By Judith K Mutabazi
Population is looked at both as a ‘driver’ of development, as well as the ‘beneficiary’ of the development outcomes. A competitive and productive labor force is a driver of investment decisions that are key to a country’s development outcomes. Secondly, the population with high purchasing power can provide market for domestically produced goods and services. This is key to both domestic and foreign investment.
For the population to meaningfully contribute to economic development – it must be of the right quality both in terms of demographics, knowledge and skills. Uganda has already experienced and is still experiencing the demographic transition – outlined by declining fertility and mortality. It has been reported that fertility rate has dropped further to 5.4 children per woman from 5.8 in 2014 and 6.2 in 2002. Likewise, infant mortality has declined to 43 per 1000 live births in 2016 from 83 per 1000 live birth in 2002.
Declining fertility is a window of opportunity in that it facilitates the change in the structure of the population – from the one with more young children who just consume to more of working-age adults who produce more than what they consume. In other words, a rise in economic support ratio (ESR) as the measure of the declining burden of dependence on the working population. A larger working-age population can enable a country to increase GDP and raise incomes. However, it’s not automatic that this window of opportunity availed by declining fertility would pave way to more meaningful development – demographic dividend has to be harnessed to realize economic transition by strategically investing in human capital.
Uganda Vision 2040 and NDPII prioritized human development in order to harness the population so as to drive/deliver desired development outcomes. Uganda’s high fertility resulting in high population growth rate and unfavorable age structure are key hurdles in the realization of the Vision. Consequently, the current second National Development Plan (NDPII) prioritized Human Capital Development as one of the pillars for transformation towards middle-income status. More specifically, the NDPII focused on harnessing the country’s demographic dividend (DD) as a key development strategy to achieve the middle-income status.
The big proportions of young people will also undermine the country’s development efforts since much of the resources will be spent on young people’s care, which subsequently slows down the speed of economic growth. Family Planning (FP) is a foundation for reducing maternal and infant deaths and preventing unintended pregnancies once services are made affordable and available under Universal Health Coverage (UHC). In Uganda, FP is currently prioritized under Primary Health Care (PHC) that is aimed at ensuring Universal Health Coverage (UHC).
The demographic dividend refers to the economic benefit a society enjoys when fertility and mortality rates decline rapidly and the ratio of working-age adults significantly increases relative to young dependents. The DD provides an opportunity for economic growth and development that arises as a result of changes in population age structure. When fertility rates decline significantly, the share of the working-age population increases. And a larger working-age population can enable a country to increase GDP and raise incomes.
Family planning has remained a major strategy to contribute to smaller and healthier families. In 1995, the Government of Uganda (GOU) created its first national population policy and is in the process of reviewing it. There have also been various interventions like developing the FP Cost Implementation Plan 2015–2020 (FP-CIP). As a consequence, the country has registered significant progress in family planning over the years, with Modern Contraceptive Prevalence (MCPR) increasing from 18.2 percent in 2001 to 35 percent in 2016.
Currently, 58 percent of the total demand for family planning is being met, almost entirely by modern methods. If this remains the case, Uganda will continue to have a largely youthful population; current estimates put the population of those below the age of 15 years at 48 percent.
The unmet contraceptive need is one of the greatest long-standing threats to women’s health in the country. Uganda’s unmet need for family planning is 28 percent. This means that one in every three women who would like to space or stop childbirth, are not accessing contraception, and this is more pronounced among young women and girls (15-19 years), and who have the highest unmet need at 30.4%. This explains the high teenage pregnancy rate at 25 percent. Furthermore, the unmet needs in rural areas is higher at 30.1 percent than urban at 22.8 percent.
Reduction of unmet need has significant outcomes on population growth. Evidence shows that fulfilling unmet need helps couples achieve their reproductive intentions and improve broader social, economic, and developmental measures. Secondly, satisfying unmet need can directly contribute to reductions in maternal and child mortality.
Although MCPR has equally improved over the years, the change is not significant enough to affect the reduction of Total Fertility Rate (TFR). Despite the reduction in TFR from 7.4 children per woman in 1988-89 to 5.4 children per woman in 2016, it still remains higher than the Sub Saharan Africa average of 4.98 births per woman.
This means that investments to improve on the delivery of quality family planning services to meet our target of 50 percent of CPR as per the FP-CIP 2020 are critical. The focus within the FP-CIP is on (i) improving FP commodities supplied, (ii) access to FP commodities, (iii) strengthening systems; and iv) increasing advocacy levels with key partners while ensuring all relevant stakeholders are involved in the delivery of FP services.
A drive towards UHC without prioritizing FP is not sustainable in the long run. Investment in FP potentially leads to sustainable attainment of UHC, particularly in financing requirements. This arises due to the fact that a managed population can be sustainably covered under UHC. Investing in UHC with an FP focus can provide better FP outcomes.
Ensuring access to a full range of health services including promotion, prevention, treatment, rehabilitation, and palliative care remains the other pathway to harnessing the DD. Among the services include family planning, whose benefits cannot be overemphasized. Universal access to family planning is not only helping Uganda’s efforts in accelerating socio-economic transformation through accelerating fertility decline and enhancing investments in family planning but also reducing the unmet need to family planning to 10 percent and increase modern contraceptive prevalence rate among married women to 50 percent by 2020.
However, the utilization of family planning services has remained low because many people cannot afford to meet the cost for these services especially the poorest of the poor. The aim of Universal Health Coverage (UHC) is to ensure that “all people obtain the health services they need without suffering financial hardship when paying for them”. Ugandans spend 41 percent of their earnings on health care, according to the National Health Accounts Report (2013-2014). The low health financing has also led to high out-of-pocket expenditure in a country where 69 per cent of households depend on subsistence farming as their main source of livelihood (UBOS, 2014).
Uganda is making progress towards UHC by implementing diverse policies designed to improve individuals’ access to healthcare without the fear of financial hardship. And therefore, attaining the DD through providing FP in UHC requires addressing the challenges of availability, affordability, and access during implementation. The focus should be on addressing the following:
- Availability – mostly low-cost family planning services have been covered and made available at all public facilities. In some instances; clients experience long waits, commodity stock outs, lack of trained providers who can provide a full range of services including the LARC (long-acting reversible contraceptives) and permanent methods.
- Access – this still remains low in rural areas and among the youth, largely because of the distance to the health centers and reproductive behavior change respectively.
- Unaffordability – Government is prioritizing financial protection over service coverage and population coverage—leading to diminished coverage of family planning services, especially lower-cost, short-acting methods.
Changing the population age structure where labour growth is relative to population growth to allow higher rates of savings and investments can be achieved by advocating for targeted investments in FP; reproductive health, especially of young people; economic and governance reforms with higher multiplier effects; and above all, educate the girl child/women. In addition, capacity has to be strengthened in research, training, and management of population and development programmes, reproductive health commodity security and in the provision of family planning plus other reproductive health services.
Delivery of FP quality services in UHC – Key areas of focus: A drive towards UHC without prioritizing FP is not sustainable in the long run. Investment in FP potentially leads to sustainable attainment of UHC particularly in financing requirements. This arises due to the fact that a managed population can be sustainably covered by UHC. Secondly, government needs to re-emphasize its commitment by increasing the family planning budget by 30 percent and its allocation for family planning supplies growing from US $3.3 million to US $5 million. Technical leadership in the country is also critical in coordinating the planning, implementation of FP interventions and enforce FP mainstreaming into national, sectoral and subnational development and budget frameworks.
Implementing Family Planning has to be a demand driven approach that is people need to be at the center of planning to address their needs. As we deliver the Quality services, we need to address the unmet need and the people who are not satisfied (48%) by modern methods of FP. Government is generating demand for family planning through counselling, cater to the people’s need for contraception, ensure easy access to services, and bring about changes in reproductive-health behavior among target groups.
Furthermore, integration of FP can be accelerated using a multi-sectoral approach than the current idea of being handled as a health sector issue. It is an innovative approach to provide maternal and child health; and family planning services. Evidence is required to support and guide policy discussion and compelling arguments on the various policy scenarios.
Additional interventions should be to the need to ensure increased years of schooling especially for the girls, awareness creation on RH services between clients and providers services; Increase the focus of FP investments and interventions towards men; develop a FP communication strategy; addressing cultural and religious beliefs or misconceptions that have hindered use and access to FP services and advocate for Political ownership. Increased policy advocacy by targeting parliamentarians and providing advocacy skills to be able to lobby for supportive policies and resources for the population and Sexual and Reproductive Health (SRH) programs is key in the FP drive.
Uganda has made progress in attaining FP and it continues to learn about the innovative ways on what works well to address the sexual reproductive health programmes. However, there is still a lot that needs to be done in increasing access to quality family planning services, reducing unmet needs for family planning, improving women’s status and integrating population factors into development planning, and ultimately slowing the population growth rate. We all need to enforce the law to fight teenage pregnancy and early marriages because it is true that most of the victims are married off at an early age.
Going forward, the focus should be on addressing the issues to attain the FP target and the unmet need for FP. This is a role of all of us; Government, Faith-Based Organizations, cultural leaders and the Civil Society. This has to be supported by providing the leadership in planning, budgeting and prioritizing of sexual reproductive health, family planning and the demographic dividend in the country development frameworks.
- UBOS (2014). National Population and Housing Census
- MOH (2016). Family Planning Costed Implementation Plan 2015-2020
- NPA (2018). Harnessing the Demographic Dividend for Uganda Report
Judith K. Mutabazi is a Senior Planner/Population, Gender and Social Development at the National Planning Authority and Project Officer under SPEED.