This article explores how USAID’s Advancing Partners & Communities (APC) project, led by FHI 360 in Uganda (July 2014 to July 2019), implemented a multisectoral approach to family planning. APC found that helping district leaders appreciate the evidence creates ownership of problems and commitment to solutions, and that multisectoral partnerships are both possible and powerful.
Efforts to expand ownership of family planning (FP) programs to other sectors and to share resources and services have been challenging. The World Health Organization (WHO) notes that barriers to multisectoral and intersectoral action include lack of political will or commitment, lack of resources and coordination, and entrenched siloed thinking. However, WHO also asserts that a systematic multisectoral approach to FP can help address conflicting interests among sectors, power imbalances, and competition for resources. At the community level, providing political, religious, and cultural leaders with information about the importance of FP, and building the capacity of technical leaders to coordinate and structure multisectoral approaches, will help increase uptake of available services.In Uganda, for many years the government has addressed FP as a high priority and committed itself to meeting the ambitious national goal of 50% modern contraceptive use by 2020. The total fertility rate (TFR) in Uganda, however, remains high at 5.4 children per woman—among the highest in the world (DHS Program STATcompiler). This rate is driven by various factors, including high percentages of unintended and teenage pregnancies, which average over 25% in various regions of the country. The modern contraceptive prevalence rate (mCPR) has grown significantly (up to 35%, from 18.2% in 2001), but at current growth rates in mCPR, the country will not meet its FP2020 goals. Therefore, much work remains to be done.
The Government of Uganda has recognized that increasing uptake of FP services requires addressing an array of underlying determinants, many of which lie beyond the health sector. The government, together with FP stakeholders, determined that one strategic priority in the 2015–2020 Uganda Family Planning Costed Implementation Plan (CIP) was to “mainstream implementation of family planning policy, interventions, and delivery of services in multisectoral domains to facilitate a holistic contribution to social and economic transformation” (CIP Strategic Priority Number 4). The multisectoral nature of the CIP and the roles of different institutions are clearly defined, with the Office of the Prime Minister coordinating implementation of the CIP with assistance from the National Population Council. This underlines the need for all FP programs to effectively engage other sectors and stakeholders who may influence both the quality of and the demand for services.
The multisectoral approach also aligns well with USAID’s new strategic direction, the Journey to Self-Reliance, which emphasizes cross-sectoral approaches, including engaging with the private sector.
The APC project in Uganda worked in five high-fertility (hot spot) districts (Figure 1) to address teenage pregnancy and barriers to uptake of FP. The project started by exploring social norms to identify factors that drive high fertility, teenage pregnancy, and low contraceptive use. Given the multidimensional nature of the factors identified―including economic, religious, and cultural factors; quality and access to FP services; and gender issues―the project applied a multisectoral approach at the district level to build ownership across sectors. Through partnership with the National Population Council, APC conducted a landscape analysis using FHI 360’s SCALE+ methodology (Figure 2) to identify stakeholders that would support FP interventions.
Key district leaders were trained on the Resources for the Awareness of Population Impacts on Development (RAPID) model, originally developed by Avenir Health with support from USAID’s Health Policy project. This training helped the districts understand the consequences of high fertility on different sectors―like education, health, and production—to increase awareness about the negative impact of high fertility on the country’s overall development. District multisectoral working groups were then formed, and they identified ways to address gaps in each of the FP CIP’s thematic areas. For instance, in Agago, the district planner championed the allocation of a budget line for FP in the district’s annual health budget. At one meeting, he indicated that he would not approve a budget without an FP line, because he was convinced about the contribution FP would make to the district’s development. He said he had “been transformed by APC and its programming.”
APC rallied key community influencers and non-health stakeholders―such as local political leaders, religious leaders, and farmers’ groups―to commit to helping reduce barriers to FP uptake and to reduce teenage pregnancy/early marriage through “Family Planning Charters,” their term for concrete actions. For instance, some local village chairmen used their routine meetings to invite a midwife from a nearby facility to talk about and demonstrate FP methods and services to attendees.
APC monitored referrals to FP services made by non-health stakeholders at the community level, such as politicians and religious leaders who helped develop the FP Charters. Between January and May 2019, 1,169 completed referrals to FP services were made through stakeholders like these (Figure 3).
Figure 3. Completed referrals made to FP services by multisectoral working group members
When members of the multisectoral FP working groups used the RAPID model to relate FP to the development challenges in other priority sectors, such as education and crop production, it reduced their negative biases toward FP use by women and transformed them into FP champions. Subsequently, all five districts developed collaborative FP Charters with practical commitments, such as allocation of budget and resources for FP in the district work plan and using radio airtime accorded to political leaders to mobilize people to use FP services.
Multisectoral efforts are still new in Uganda, and APC’s initial positive outcomes are important for convincing local governments of the potential for multisectoral efforts to improve the health and wellbeing of communities. FHI 360’s multisectoral approach has provided a forum for community representatives and empowered them to push district leadership to help solve community issues. This approach has brought about a change in attitudes about FP among many cultural and religious leaders. In Butaleja district, for example, when the Pentecostal Bishop attended the first FP working group meeting, he told members that he could not be part of a team that “goes against God’s commands.” At the next meeting, however, after participating in the RAPID exercise, he returned with a different mindset and contributed strategies about how FP can be promoted among religious leaders—saying he had been convinced that FP is beneficial to his congregation.
All the districts identified means to support the quarterly multisectoral FP working group meetings beyond the life of the project. In one district, funding for the meetings is being sustained through a community-based organization that belonged to the group. In another, the district health office has included the meetings in its budget. The remaining three districts plan to meet either before or after regularly scheduled local council meetings and/or district planning meetings.
The five districts that the APC project worked with can potentially be used as learning sites for other implementing partners in Uganda and beyond who may be interested in scaling up this multisectoral engagement approach.
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