About 20 years ago, the then hyperactive Population Secretariat warned President Museveni about uncontrolled population growth. The secretariat argued then that Uganda’s meager resources would not be able to provide the desired quality of social services especially in the education and health sectors.
The president’s belief was, a high population, provides a bigger market and enough human resource, thence accelerating economic development.
Fast forward, at 35 million people – with the second youngest population in the world and poor social services – Museveni at least now believes in manageable or planned family sizes.
But as the Uganda Family Planning Costed Implementation Plan 2015-2020 of the ministry of Health notes, the country faces “a tall and uphill task”. For various reasons, many women and families would like to delay, space, or limit their childbearing but they are not using family planning (FP).
‘YOUTH-(UN) FRIENDLY SERVICES’
Almost all health facilities The Observer visited in Wakiso and Kampala districts offer family planning services free-of-charge but uptake is low. Entebbe hospital is ‘overwhelmed’ by the high number of teenagers who instead opt for the antenatal section rather than the family planning section.
At the impressively-organized Nakuule health centre II in Nansana, regardless of one’s ailment or need, all patients must be in possession of a ‘book’ where patients’ medical records are registered.
Without it, no health services including family planning can be accessed. The book costs between Shs 500 and 1,000 at the nearby shops. When our undercover researcher went there, she was asked if it was her first time to seek family planning services. It was, and she wanted to know the best method.
“My dear, no one will ever tell you the best. You just need to know all of them and then make your own choice. It is our duty to guide you, but not to choose for you a particular method,” a nurse told her.
Available options included injectables, pills, tubal ligation, moon beads, and condoms. Apparently, some clients lie that they have not had sex and take injections, yet they are already pregnant.
This has forced the health facility to only administer injections to women who have just started their menstrual periods. Otherwise, one has to present a ‘negative’ pregnancy test results form.
The nurse explains that the three-month injection is administered to people without sight difficulties, goiter, abnormal monthly periods or abnormal blood pressure. Side effects include weight loss/gain, low sex drive, vaginal dryness and irregular periods in the first months.
The nurse uses the opportunity to counsel our researcher about HIV/Aids. She hands over a pack of 25 condoms and advises her to come back with her boyfriend at the next outreach family planning camp organized by Marie Stopes Uganda on November 28.
Nakibuuka Noor Musisi, the program manager for community empowerment at the Center for Health, Human Rights and Development (CEHURD), isn’t surprised at the low uptake of the ‘unfriendly’ family planning services in government facilities.
She argues that because of the pressure of civil society, government simply provides a room with an almost-inevitably-judgmental desk officer.
“Imagine if a youth goes to get a pill and she finds a 50-year-old ‘mama; do you think she will give it to her?” Nakibuuka says.
Margaret Kasolo, a nurse in charge of family planning services at Kawaala health centre III, says the most used FP methods are injectables – on average 75 women a week. The facility has a fully-fledged youth wing. Women prefer injectables because unlike pills, they don’t have to be taken every day. Others love the fact that injectables make them fat.
“Even when we tell them that they have side effects such as vaginal bleeding, delayed fertility and delayed menstruation, they want them,” Kasolo said.
The ‘safest’ method is the coil – because it has no major side effects and it’s reversible. But Kasolo says most youths, especially teenagers, have not appreciated it. Intrauterine devices (IUDs) and pills are in stock, but women don’t want them.
She claims the facility carries out outreach programmes to schools and communities twice a week.
“School visits are good because most of these teenagers are sexually-active. They fear to come for these services but when we go there, they can identify a nurse and they choose a suitable method,” she says.
Kawaala health centre III is limited by poor supplies from the National Medical Stores (NMS). The facility last received NMS supplies in June this year. She says this is supplemented by supplies from Infectious Diseases Institute (IDI).
“They [NMS] give us what they have. But this time they are reluctant on family planning. It is as if they are saying women should give birth to as many children as possible. They give us very little,” Kasolo says. “I am tired of begging government. I have served for 35 years and we have always been asking for enough supplies in vain. This [profession] is a calling and I am only serving God, not government.”
Services here are free but Kasolo says there are times when they have no plasters, gloves, or surgical blades.
“Imagine a situation where an HIV+ woman with four children comes and they need implants. What we do is ask them to raise little money to buy a plaster and surgical blade so that we can insert the implant. Does that mean we charge them?” she wonders.
NMS accepted to show us a recent listing of family planning supplies to Wakiso and Kampala, but had not done so by press time.
According to the ministry of Health Stock Status Report (SSR) of October 2016, most of the reproductive health commodities at NMS are stocked out except for Depoprovera (injectables) and Implanon that are over-stocked.
Of the 129.6 million pieces of ministry of Health/Global fund condoms; only 8.6 million pieces are available for distribution. Pipeline of 26 million male condoms are undergoing port clearance, while 56 million are expected in December 2016.
The ministry of Health’s Uganda Family Planning Costed Implementation Plan, 2015-2020 blames the top-down procurement process.
“Implementation of the Contraceptive Procurement Strategy, developed with support from partners, has led to a dramatic reduction in the percentage of contraceptive stock-outs. However, the current system for quantification, ordering, and distribution from national to district levels, and from districts to facilities and end users, faces challenges. Forecasting is not done in tandem with the budgeting cycles. Quantification is also constrained by lack of programme data on distribution, demand, and use,” the report says.
It says the private sector should be more involved in managing reproductive health (RH) supply chain management, especially at the forecasting stage. Even the Joint Medical Stores (JMS), “a channel of health commodity access for the private sector,” keeps off FP commodities on religious grounds.
To overcome this private sector gap, an alternative distribution channel strategy was formed but is yet to be institutionalised.
Cehurd’s Nakibuuka suggests that local governments should get powers to change their budgetary priorities to buy the required reproductive health supplies, instead of relying on centralized procurement.
RHU’S EXPERIENCE
Alex Craig Kiwanuka is the youth officer at Reproductive Health Uganda (RHU) which takes pride in being the ‘pioneers of family planning in Uganda’. He says they provide FP following ministry guidelines that demand rigorous counseling and knowledge of a client’s medical and physical history.
“So, we do not just dish out because there are certain family planning methods that [will not work],” Kiwanuka says. “A case in point is when you are taking certain ARVs like nevirapine, some hormonal contraceptives will not work. There are people who are already pregnant; so, there is no sense administering the family planning method. Then there are those who are taking epilepsy drugs, hormonal contraceptives will not work”.
Although young people are supposed to go to the RHU clinic, Kiwanuka says they have a youth centre with FP services – and reduced risk of a youth queuing up behind his/her mother or other adult relative.
“We have young people who are empowered to capacitate fellow young people,” he says. “We do not only provide information but show the different family planning methods.”
RHU is offering a self-administered injectable – Sayanapress – to youths in Kampala and Gulu.
MIXED MESSAGES
Kiwanuka thinks there’s a lot of ‘contraceptive stigma’ out there, fueled by the conspiracy of culture, religion, myths, and limited male involvement.
“If you gather young people and you bring the topic of contraceptives, young people would love to listen. But there is a gap in who has the right information” he says. “When a youth goes for family planning services, they will instead start telling them about morals. That is the reason why family planning [supplies] are expiring in government health facilities. The health centres are not creating a lot of awareness about the existing services within the health centres, contraceptives inclusive.”
Although the reception at Wakiso Epicenter health centre III in Ttemangalo advertises ‘youth-friendly’ family planning methods, including IUDs, pills, coils, implants, condoms and injectables, Sister Amisa Muhammad, the nursing officer in charge of family planning, says they only offer two methods.
“We only offer injections and implants because those are the only supplies we get from NMS. In fact the implants are given to us by Mildmay,” she says.
Because of limited capacity and resources, they do outreaches twice a month, usually done on days when they go out for immunization drives. But she says the youth response is very low, with most shunning the outreach programmes and those that attend never take on the methods.
She, however, says men are very responsive, usually collecting condoms from the facility. The facility has a catchment area of three parishes of Bukasa, Nakabugo and Lukwanga.
About the low response to outreach programmes, Nakibuuka calls for creativity in packaging of FP messages and proactive efforts by government and service providers – for instance why not resume reproductive health school debates, plays and other co-curricular activities?
“Every lady who comes for antenatal visits must have counseling on family planning. That should be the procedure just like HIV; you can never take antenatal without an HIV test,” Nakibuuka says. “Maybe let it be a must if it should – because at the end of the day, it is going to help the nation. You come in you for a one-on-one counseling.”
CONFLICTING IDEOLOGIES
According to Margaret Kasolo, most women on family planning at Kawaala are doing it without the consent of their men, which sometimes puts health workers in a tricky position.
“A man came here and asked us to remove the implant from his wife,” Kasolo said. “But the woman begged us to hide it inside her thighs. We did it because we were protecting her life; she was HIV+.”
But conflicting messages over FP play out at a much higher level, leaving a nation confused. While the ministry of health wants sex education to start early, the ministry of gender late this year banned it from schools altogether.
“That is the problem we have, because the president speaks something different, the Kabaka speaks something different, the Nnabagereka speaks something different, then the church also has an influence. The Kabaka says muzaale mwale (produce and fill the earth) but the Nnabagereka says you must use family planning,” Nakibuuka says.
With different interests, it is perhaps asking too much to think that these influential people will ever speak the same language but early age-appropriate sex education by the parents themselves is necessary.
“My four-year-old knows it is me, aunt (maid) or daddy who showers her, she is not bought sweets by ‘uncle’, they are bought by me or her dad. That is the appropriate age to start sex education. If she wants money, she has to ask daddy or mummy. Now that is age-appropriate information. At nine to 14 years, a child should know that when you engage in sex, this and this happens because one; we have phones that we don’t regulate or have access to but our children have access”, she adds.
PATIENTS CHARTER
Almost all patients and even some health workers interviewed are unaware of the contents – never mind the existence of a Patients Charter published in October 2009.
The charter spells the rights of patients including unconditional emergency care without the need to pay any fees or deposits prior to medical care. It also calls for non-discrimination or harassment of patients.
Dr Martin Sendyona from the Quality Assurance department at the ministry of health, recently admitted that they published just a few copies but have not distributed it amongst health facilities. According to its foreword, the charter will educate patients about their rights and responsibilities.
Although some analysts have described the charter as just a ‘persuasive’ document that is not legally-binding, Nakibuuka echoes the World Health Organisation, saying the charter is important, but only if people are sensitized about its existence and particulars.
“If people knew what is in the Patients’ Charter, I think we would have a better [health] system,” she says. “You would not see a service provider being negligent of their roles and responsibilities”.
Health minister Sarah Opendi says the charter will soon be printed and distributed because it is an important document that would sensitise patients about their rights and responsibilities.
For many reproductive health rights activists, this couldn’t come soon enough.
Additional reporting by Joseph Kimbowa.
This work is a product of The Watchdog, a centre for investigative journalism at The Observer. Research for this article was facilitated by Center for Health, Human Rights and Development (CEHURD).
