2015 Gap Analysis for Uganda Family Planning Costed Implementation Plan, 2015–2020

Publication date: 2015

HEALTH POL ICY P R O J E C T 2015 GAP ANALYSIS FOR UGANDA FAMILY PLANNING COSTED IMPLEMENTATION PLAN, 2015–2020 August 2015 Overview The Uganda Family Planning Costed Implementation Plan, 2015–2020 (FP-CIP), published by the Ministry of Health, was launched in November 2014. Its objective is to reduce unmet need for family planning to 10 percent and to increase the modern contraceptive prevalence rate among married women to 50 percent by 2020. The plan includes strategies to improve demand creation; service delivery and access; contraceptive security; policy and enabling environment; financing; and stewardship, management, and accountability. The cost of the total plan is US$236 million between 2015 and 2020, which will increase the number of women in Uganda using modern contraception from approximately 1.7 million in 2014 to 3.7 million in 2020.1 The FP-CIP was developed with technical assistance from the USAID-funded Health Policy Project (HPP) and partners to assist the country in fulfilling its FP2020 commitments. To further support the government and partners to identifying activities that were well-covered (to prevent duplication resources) and areas and activities that needed additional resource mobilization efforts, HPP worked with the government of Uganda (GOU) to conduct a detailed activity-based gap analysis in 2015. Uganda Family Planning Costed Implementation Plan, 2015–2020 The FP-CIP provides a guide for all family planning (FP) programming in Uganda across all sectors including government, the donor, civil society, and private sectors. As a consensus-developed document, the FP-CIP ensures a unified approach to FP programming in Uganda, as long as the plan is well-implemented and regularly monitored. The Uganda FP-CIP includes detailed programmatic activities and inputs for 2015–2020. The activities include cost-specific information and an implementation strategy. Costs fall under seven thematic areas: ƒ Contraceptives: The costs of procuring contraceptive commodities and directly related supplies (e.g., surgical supplies for sterilization, contraceptive implants) ƒ Demand creation: The costs for activities to increase demand for FP services in Uganda, including developing and implementing targets, and a holistic and evidence-based social and behavior change communication program ƒ Service delivery and access: The costs of training and equipping healthcare workers and facilities to Brief Nichole Zlatunich, Taryn Couture Health Policy Project Photo by Cristin Marona 2 August 2015 ensure that FP services are available, accessible, equitable, and voluntary throughout the country ƒ Contraceptive security: The costs for the processes, equipment, and management to quantify, procure, and distribute contraceptives and related supplies ƒ Policy and enabling environment: The costs for activities to ensure that national and local policies, guidelines, and policymakers support the goal of universal FP access ƒ Financing: The costs for activities to raise awareness and develop momentum for increasing the national FP budget for FP commodities and programming ƒ Stewardship, management, and accountability: The costs to ensure that coordination, management, and monitoring and evaluation efforts are in place at the national and district levels for all FP activities Rationale and Use for the Gap Analysis This gap analysis was prepared to help Uganda’s Ministry of Health (MOH) better implement the FP-CIP, to plan and manage future funding, and to understand what activities and thematic areas in the FP-CIP are fully, partially, or underfunded. Knowledge of the FP-CIP’s financial gaps will allow the government and partners to 1. Plan budgets and determine key activities for funding: The gap analysis provides financial coverage information for the full six years of Uganda’s FP- CIP (2015–2020), as of the first quarter of 2015. For budget planning purposes, the gap analysis provides insight into the actual funding situation of the country’s agreed-on priorities. 2. Encourage discussions between development partners and the government: The gap analysis contains information on financial gaps for the consensus-driven priority areas by year. Priority financial gap information can help facilitate the discussion and re-evaluation of planned funding for future years. 3. Advocate for increased funding: The gap analysis details activity-specific financial gaps, allowing the government and partners to know what activities are funded, and which are underfunded, making it easier to conduct specific resource-mobilization efforts for priority activities identified in the plan. 4. Increase visibility and accountability: As part of the gap analysis, requests were sent to each FP stakeholder to define their planned financial commitments for FP. This not only creates space for each organization to reflect on its planned funding against the government plan, it also gives the MOH specific details on partners’ activities and when they are planned to happen. Methodology Projected activity-based financial data from 2015 through 2020 were collected and analyzed as part of this study. The cost to conduct activities is detailed in the FP-CIP costing tool; costs are based on the direct costs to conduct activities, without any overhead rate added. The costing information data on direct activity-specific costs (contraceptives, training workshops, printing, training and service delivery staff, other consumables) and indirect costs (support personnel, transport, meeting space) was collected between August and October 2014 through one-on-one communication with government officials, implementing partners, and donor organizations. In 2015, the government and development and implementing partners2 provided information on their planned FP activities between 2015 and 2020. These data were then analyzed using the CIP Complex Gap Tool developed by HPP, with additional support from the United Nations Foundation and FP2020. All funded activities were assigned the appropriate direct and indirect costs per the FP-CIP costing methodology for Uganda (without any associated overhead costs added), categorized against all of the FP-CIP activities by thematic areas (contraceptives, demand creation, service delivery and access, etc.), and specified to the country’s priority and commitment areas. Results Total Gap: Overall, Uganda has a total financial gap of about US$113 million for all six years of the FP-CIP. The total cost for the FP-CIP is US$235.8 million, which means that less than half of the activity costs in the CIP are covered by currently planned funding between 2015 and 2020. The size of the gap in Uganda differs by year; the largest gap is in 2019—US$21.8 million (see Figure 1). The larger gaps in the later years are due to a steady increase in reach of activities within Uganda, in line with the projected scale-up of demand and services for FP and the country’s goal to reach a 50 percent modern contraceptive prevalence rate among married women by 2020. In addition, government and development and implementing partners often had insufficient knowledge of what would be funded past the first few years of the FP-CIP due to funding cycles and program timelines. 3 2015 Gap Analysis for Uganda Family Planning Costed Implementation Plan, 2015–2020 Total Gap for Contraceptive Commodities: Contraceptives are a significant part of any FP program. In Uganda, the cost of commodities in the FP-CIP is significant and budgeted at about 50 percent of the total FP-CIP costs, at US$115 million between 2015 and 2020. As described in the FP-CIP, the GOU and donor organizations have made significant contributions to funding contraceptive procurement in recent years, and there is robust coordination for commodity financing. As seen in Figure 2, the gap analysis found that contraceptives are more than 100 percent funded in the first two years and remain at 95 percent or above for 2017–2020. Funding for contraceptives differs depending on the type, with implant contraceptives budgeted to receive the most funding (US$49.6 million between 2015 and 2020) due in large part to the global push to scale up Figure 3: Total Gap for Demand CreationFigure 2: Total Gap for Contraceptives access to long-acting reversible contraceptives (LARCs). Injectable contraceptives receive the second highest funding in the FP-CIP (US$40.7 million), as they are the most popular method in Uganda. Total Gap for Demand Creation: Demand creation is budgeted at US$28.3 million in the FP-CIP between 2015 and 2020. After contraceptive commodities, the gap analysis found that demand creation activities receive the most coverage from development and implementing partners: 31 percent of the FP costs are funded. However, with a total gap of US$19.3 million over the six years, demand creation remains significantly underfunded in total dollars, due to the large number and type of activities in the FP-CIP that make it a more expensive area to implement. In the first year (2015), demand Figure 1: Uganda Total Gap Contraceptives Stewardship, management, and accountability Financing Policy and enabling environment Contraceptive security Service delivery and access Demand creation 2015 2016 2017 2018 2019 2020 CIP costs Available funding CIP costs Available funding CIP costs Available funding CIP costs Available funding CIP costs Available funding CIP costs Available funding 50 45 40 35 30 25 20 15 10 5 0 2015 2016 2017 2018 2019 2020 Available fundingCIP costs 2015 2016 2017 2018 2019 2020 35 30 25 20 15 10 5 0 8 6 4 2 0 M ill io ns M ill io ns 4 August 2015 Figure 4: Total Gap for Service Delivery and Access creation receives 100 percent coverage for its activities, but that drops to 12 percent within the second year, most likely based on unknown levels of funding from development and implementing partners for future years. Nine of the 16 activities planned for the first year are overfunded, but about 44 percent of the activities in demand are not covered despite the overall thematic area being covered at 100 percent for 2015. Activities that have the highest funding levels in 2015 include introducing a mass media campaign on family planning, orienting interpersonal communication (IPC) agents to integrate FP communication into the communities, and support for peer educator training and outreach activities. Total Gap Service Delivery and Access: Service delivery and access is costed at US$46 million between 2015 and 2020 in the FP-CIP. It is the second most expensive thematic area in the FP-CIP, after contraceptive procurement. It has the largest gap in funding among all of the thematic areas—only 3 percent of projected activity costs are funded in the first year, and funding levels drop to about 1 percent for the following years. The Service Delivery and Access thematic area is expensive as many of its activities require significant funding. These expensive activities include scaling up mobile clinics, retraining all Village Health Teams (VHTs), and creating youth corners at health facilities. Scaling up mobile clinics and retraining of all VHTs are also among the highest-funded activities; however, no activity in this thematic area is fully funded in line with the FP-CIP projections. Total Gap for Contraceptive Security: Despite contraceptive security being the third least-expensive activity in the FP-CIP (US$9.3 million between 2015 and 2020), this thematic area is only funded at 6 percent in 2015 and 7 percent over the full six years. However, two activities in the contraceptive security thematic area are fully funded: conducting a study that tracks the available commodities and reviewing and developing two government strategies. Total Gap for Policy and Enabling Environment: Between 2015 and 2020, the thematic area of Policy and Enabling Environment is estimated to need US$3.5 million. However, only 20 percent of the activities in this thematic area are funded, with a total gap of US$2.8 million. In 2015, 69 percent of the costs are covered by the government and development and implementing partners; this drops to 6 percent in 2016 and 2 percent in 2017. In 2015, five of the 19 activities described in the FP- CIP are overfunded; with support for FP champions and support for implementing task-sharing activities receiving significant overfunding of approximately US$375,000 and US$18,600, respectively. Figure 5: Total Gap for Contraceptive Security Figure 6: Total Gap for Policy and Enabling Environment 2015 2016 2017 2018 2019 2020 Available fundingCIP costs 2015 2016 2017 2018 2019 2020 Available fundingCIP costs 2015 2016 2017 2018 2019 2020 Available fundingCIP costs 8 6 4 2 0 10 2.5 2 1.5 1 0.5 0 800 600 400 200 0 M ill io ns M ill io ns Th ou sa nd s 5 2015 Gap Analysis for Uganda Family Planning Costed Implementation Plan, 2015–2020 Total Gap for Financing: Financing is the least expensive area of the FP-CIP, with a budget of approximately US$500,000 between 2015 and 2020. The total financial gap for financing over the six years is about US$381,000, with total funding of 19 percent against the budget. Within the first year (2015), financing is almost fully covered with no projected financial gap. In 2015, activities that are funded include advocating with parliamentarians for increased FP funding, developing an advocacy strategy that will target development partners, and organizing a meeting with corporate officers on corporate social responsibility for family planning. However, available funding for financing activities falls significantly in subsequent years with no funding dedicated to activities in the Financing thematic area in any of the remaining years. Total Gap for Stewardship, Management, and Accountability: Stewardship, management, and accountability is the third most expensive thematic area in the FP-CIP, at US$33.2 million. However, it is the second least-funded thematic area with about 2 percent coverage over the six years. The total financing gap for stewardship, management, and accountability for the six years is US$32.6 million. In 2015, 5 percent of the activities under stewardship, management, and accountability are covered, but funding for this thematic area drops to an average of one percent funding coverage between 2016 and 2020. Strategic Priority Area Gaps: Five priorities were identified as part of Uganda’s FP-CIP: ƒ Priority #1: Increase age-appropriate information, access, and utilization of family planning among young people ages 10–24 years ƒ Priority #2: Promote and nurture change in social and individual behavior to address myths and misconceptions, side effects, and improve acceptance and continued use of family planning to prevent unintended pregnancies ƒ Priority #3: Implement task-sharing to increase access, especially for rural and under-served populations ƒ Priority #4: Mainstream implementation of FP policy, interventions, and delivery of services in multisectoral domains to facilitate a holistic contribution to social and economic transformation ƒ Priority #5: Improve forecasting, procurement, and distribution and ensure full financing for commodity security in the public and private sectors These five strategic priorities were costed at US$77.7 million between 2015 and 2020. However, only about US$9.6 million was allocated by the government and Figure 7: Total Gap for Financing 2015 2016 2017 2018 2019 2020 Available fundingCIP costs 150 120 90 60 30 0 Th ou sa nd s Figure 8: Total Gap for Stewardship, Management and Accountability 2015 2016 2017 2018 2019 2020 Available fundingCIP costs 6 5 4 3 2 1 0 M ill io ns Figure 9: Percentage of Funding Coverage for Strategic Priority Areas 80% 60% 40% 20% 0 100% Priority 1 Priority 2 Priority 3 Priority 4 Priority 5 2015 Gap Analysis for Uganda Family Planning Costed Implementation Plan, 2015–2020 6 The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. HPP is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. Contact Us Health Policy Project 1331 Pennsylvania Ave NW, Suite 600 Washington, DC 20004 www.healthpolicyproject.com policyinfo@futuresgroup.com its development and implementing partners to actualize these strategic priorities. Thus, available funding for the priority areas covers less than 13 percent of the strategic priority costs detailed in the FP-CIP between 2015 and 2020. Priority #1 is the most funded, with US$3.6 million from 2015 to 2020 (48%), and is the only priority to be overfunded in 2015. Priority #3, to implement task- sharing, is the least funded, with 0.2 percent funding dedicated to task-sharing activities detailed in the FP-CIP. Discussion Only through significant financial investments can Uganda implement the activities detailed in the FP-CIP. The priority areas defined in the FP-CIP are meant to help guide the government and development partners in determining what activities are essential to meet the country’s goals. However, there are significant gaps in the projected funding for FP programs in Uganda, meaning that it is unlikely the country will be able to achieve its goals of reducing unmet need for family planning to 10 percent and increasing the modern contraceptive prevalence rate among married women to 50 percent by 2020. The gap analysis provides clear evidence that the Ugandan government and in-country development partners are focusing significant effort on financing the purchase of contraceptives. However, evidence has shown that for FP interventions to be effective, financial support and efforts must be dedicated to providing a holistic, rights-based FP program that includes demand- generation efforts; improvement in the quality of service provision; supply chain improvements; strong policies and financing; and coordinated planning, management, and supervision at the national and decentralized levels. However, as illustrated in the gap analysis, Uganda’s FP financing is not aligned to the consensus-developed FP-CIP strategy. It is crucial that funding be increased in all of the thematic areas that are significantly under- resourced to build an effective national program aligned with principles of rights and empowerment in FP information and services: agency and autonomy; availability; accessibility; acceptability; quality; empowerment; equity and non-discrimination; informed choice; transparency and accountability; and voice and participation.3 Next Steps As this gap analysis has better data for the first few years, an annual re-evaluation and assessment of the financial gap is the best way for Uganda to continue to plan and create harmonized national annual workplans for all stakeholders. Financial analysis of funding priorities provides an opportunity for discussion and re-evaluation of the country’s evolving priorities for family planning. A yearly re-assessment of the priorities should be done in conjunction with annual work planning and the gap analysis exercise to ensure that the country is addressing the areas that will support progress, even within a constrained financial resource environment. Additional technical support to the Ministry of Health, to guide coordination and monitoring of the FP-CIP, is essential to supporting the transition from strategy document to implementation; the first activity of the Stewardship, Management, and Accountability section of the FP-CIP provides details on hiring an FP-CIP Coordinator at the ministry to fill this essential role. In addition, the Ugandan government and development and implementing partners should regularly reassess their joint priorities, review the annual government budget for the MOH and National Medical Stores, and call on development partners to increase financial resources and better align the available financial resources to the country’s plan to prevent duplication of efforts and focus resources on the areas of greatest priority and need. Notes 1. For the full FP-CIP (including the list of FP2020 commitments made at the 2012 London Summit on Family Planning) please see: Ministry of Health, Uganda. 2014. Uganda Family Planning Costed Implementation Plan, 2015–2020. Kampala: Ministry of Health, Uganda. Available at: http://www.healthpolicyproject.com/index.cfm?ID=topics- FP2020. 2. DFID, FHI360, Marie Stopes Uganda, PACE, Pathfinder, PPD ARO, Reproductive Health Uganda, Uganda Ministry of Health, Uganda Population Secretariat, UHMG, UNFPA, USAID, and the World Bank. 3. FP2020. 2014. Family Planning 2020: Rights and Empowerment Principles for Family Planning. Available at: http://www.familyplanning2020.org/resources/4697.

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