Finding Alternative Pathways for Contraceptive Commodities to Reach Users
Publication date: 2015
advancefamilyplanning.org an evidence-based advocacy initiative In Uganda, the private sector provides the majority (60%) of contraceptive services. The ability of the private sector to meet users’ needs depends upon the strength of the public supply chain system. Until recently, private sector facilities experienced frequent stock-outs. Supply chain operations favored public sector needs, and private sector access to supplies was limited. Beginning in 2011, with technical support from Advance Family Planning and others, family planning stakeholders came together to address the supply chain bottleneck. Together with the Ministry of Health (MoH) and donors, they developed an innovative strategy called “alternative distribution” to provide supplies more consistently and efficiently to private sector facilities. At first the system worked well, but with no formal agreement in place, by 2014 its’ future looked uncertain. A sustained advocacy effort over a period of six months led to a Memorandum of Understanding (MOU) between the Government of Uganda and the Uganda Health Marketing Group (UHMG) to formalize the alternative distribution strategy. The MOU is a critical step in validating roles and responsibilities to ensure the program continues, commodities remain available, and Uganda is able to meet the demand of its contraceptive users. Why was an Alternative Distribution System Needed? In 2010, Uganda’s private sector faced a contraceptive supply crisis. Restrictions imposed by the National Medical Stores (NMS) on access to contraceptive commodities threatened private-sector family planning service delivery. NMS management had decided to concentrate on the public sector only and not supply to the private sector. In addition, the other major supplier, Joint Medical Stores, did not handle family planning commodities due to religious principles. These factors contributed to a critical gap in access for the private sector.1 The six largest service delivery organizations— Marie Stopes Uganda (MSU), Reproductive Health Uganda (RHU), Program for Accessible Health Communication and Education (PACE), FHI360, Pathfinder International, and UHMG—came together UG AN DA Finding Alternative Pathways for Contraceptive Commodities to Reach Users November 2015 CASE STUDY 2 advancefamilyplanning.org November 2015 ADVANCE FAMILY PLANNING I UGANDA to form the Uganda Family Planning Consortium (UFPC) to address this and other issues. The consortium prioritized bottleneck issues. Emphasizing the scope of their coverage, members advocated the government for change. “We used figures and numbers, showing the reach of each player and presenting a case that…a mechanism [for the private sector] was needed,” explained one member. “We had to persuade the MoH and other stakeholders, including comforting the NMS that we weren’t creating a competitor.” As a result of these efforts, the government agreed to an alternative distribution system in 2011 [see Box 1]. The system established a separate supply channel to distribute subsidized contraceptive commodities to drug shops, pharmacies, and private clinics. An important aspect of the new alternative distribution strategy involved providing alternative national, regional, and district-level storage facilities for access by service delivery organizations. The system established a framework for cooperation between district governments and implementing partners to increase the availability of commodities. By 2014, the alternative distribution strategy was deemed a success. Between January 2012 and December 2014, more than 4 million couple years of protection were provided in family planning commodities under the alternative distribution strategy. An evaluation of the UNFPA country program noted that “the alternative distribution mechanism helped avail the [family planning] commodities to non- state actors… and this has increased access to [family planning] services under the NGO programmes” [UNFPA 2014]. The system also saved time as obtaining supplies from NMS, when this was possible, was a lengthier process compared with the alternative distribution system. However, the solution was short-lived; later that same year, the system encountered a serious setback that required additional advocacy. Why was an MOU Important? Beginning in 2014, when handling and storage bills for the UHMG warehouse were due, the Solicitor General would not endorse payments because there was no official document indicating the government’s responsibility. In July and August 2014, UHMG partners met together with the UFPC to strategize on how to move forward to address the payment problem. AFP partners Reproductive Health Uganda (RHU) and Partners in Population and Development Africa Regional Office (PPD ARO) held a strategic retreat with other family planning stakeholders to develop an advocacy plan using AFP SMART: A Guide to Quick Wins. During the retreat, consortium members realized that a formal MOU was a priority. They engaged NMS, MoH, UNFPA, the World Bank, and other stakeholders, but they faced a number of bureaucratic hurdles and challenges in trying to get an MOU endorsed through the NMS. RHU, PPD ARO, UFPC and the MoH subsequently decided to engage the Solicitor General directly, Box 1: The Uganda Alternative Distribution Strategy Goal: Increased access to reproductive health commodities across the country Objectives: • Increased uptake of contraceptives and other reproductive health commodities at the public- private service delivery points by 50% annually • Reduced number of service delivery points experiencing stock outs of contraceptives and other selected reproductive health commodities in both the public and private sector to less than 30% in five years 3 advancefamilyplanning.org November 2015 ADVANCE FAMILY PLANNING I UGANDA rather than waiting for support from NMS. AFP partners included a representative from the MoH in advocacy meetings with the Solicitor General, which helped to reassure the Solicitor General that the MOU was in line with government programs. By January 2015, the Solicitor General had agreed to sign the MOU on behalf of the government; the document was signed on January 30th. “Signing the MOU guarantees the future of the alternative distribution channel and its benefits of scaling up access to family planning commodities,” says Jackson Chekweko, chairperson of the UFPC and Executive Director of RHU. Where Are We Now? A July 2015 meeting of over 100 stakeholders noted that alternative distribution was functioning well despite a few setbacks. Through UHMG’s regional hubs, 31 implementing partners are now distributing the commodities to users and the payment issue is resolved. Partners are now developing guidelines for the alternative distribution channel. The guidelines will clarify inclusion of other partners in the alternative distribution channel, such as religious groups like the Church of Uganda and private for-profit groups like drug stores. Ensuring that the alternative distribution strategy functions well is the next challenge and requires building institutional and human resource capacity; strengthening monitoring, evaluation and coordination mechanisms; scaling up demand creation; and branding of selected contraceptives and reproductive health commodities. Lessons Learned • Formalization is essential: Creating a legal document helped ensure a sustainable and accountable system. • Join efforts with partners and competitors: The UFPC is unusual. Although members sometimes compete for the same funding, they The Ministry of Health and the Uganda Health Marketing Group signed the Memorandum of Understanding on Jan. 30, 2015. set competition aside and join forces to tackle key issues collectively. • Involve government officials as collaborators: Having support within the Solicitor General’s office helped overcome bureaucratic resistance. In addition, the involvement of the MoH, particularly Dr. Collins Tusingwire, was key to the advocacy effort’s success. Working hand-in-hand with the MoH was essential in showing that this strategy was fully supported by the government. • Determine the decisionmaker and messengers: In this case the Solicitor General was best placed to move the MOU forward. Enlisting colleagues such as Dr. Jotham Musinguzi from PPD ARO, MoH officials, and donors contributed greatly to the success of the effort. 4 advancefamilyplanning.org November 2015 ADVANCE FAMILY PLANNING I UGANDA Acknowledgments AFP appreciates the efforts of the Uganda Family Planning Consortium, the Uganda Health Marketing Group, the Ministry of Health, National Medical Stores, Partners in Population and Development Africa Regional Office, Reproductive Health Uganda, Samasha Medical Foundation, UNFPA, the World Bank, and Julie Solo. Additional support for this effort was provided by the Reproductive Health Supplies Coalition Innovation Fund. AFP is supported by the Bill & Melinda Gates Foundation, the David & Lucile Packard Foundation, and The William and Flora Hewlett Foundation Reproductive Health Uganda Plot 2 Katego Road Tufnell Drive Off Kira Road Kamwokya, Kampala, Uganda Tel: +256 414 540 665 Email: firstname.lastname@example.org www.rhu.or.ug Advance Family Planning Bill & Melinda Gates Institute for Population and Reproductive Health Johns Hopkins Bloomberg School of Public Health 615 N. Wolfe Street, Ste. W4503 Baltimore, MD 21205 Tel: +1 (410) 502 8715 Email: email@example.com www.advancefamilyplanning.org References Interviews with Jackson Chekweko, Reproductive Health Uganda (2014); Emily Katarikawe, Uganda Health Marketing Group (2014); Richard Mugenyi, Reproductive Health Uganda (2015); Kenneth Mugumya, Uganda Family Planning Consortium (2014); Dr. Jotham Musinguzi, Partners in Population and Development Africa Regional Office (2015); and Moses Muwonge, Samasha Medical Foundation (2014). 1. Uganda Ministry of Health. 2012. Uganda Alternative Distribution Strategy for Contraceptives and selected Reproductive Health Commodities in Public and Private sectors 2012–2016. Kampala, Uganda. 2. Memorandum of Understanding between Ministry of Health and the Uganda Health Marketing Group. January 30, 2015. 3. Uganda Ministry of Health and Uganda Health Marketing Group. The Annual Alternative Distribution National Stakeholders Meeting. July 7, 2015. Hotel Protea, Kampala. 4. UNFPA and Republic of Uganda, Country Programme Evaluation 2010-2014, Uganda. Final Report March 20, 2014. Cover photos by Geoff, Adam Cohn, Malcwicky; page 4: Trust for Africas Orphans (TAO).