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Daring to Change Embracing the FutureThe Story of The Family Planning Association of UgandaFrom FPAU to Reproductive Health Uganda1957 to 2007 and beyondBirth of the Daring Advocate: 1957-1969 Consolidation and Expansion: 1990-2000 This Journey to ensuring universal access to SRH has just begun. IntroductionThis website presentation presents highlights of the fifty years of the Family Planning Association of Uganda (FPAU’s) service to the people of Uganda. It shows the journey that we in the family planning movement have traveled from 1957 to 2007. For a long time FPAU was limited to issues related to information and access to family planning services. FPAU has always strongly believed that the right to information on family planning methods is a fundamental human right. This right is reflected in several international human rights instruments, for example, the Convention on Civil and Political rights. Within that understanding, FPAU has promoted the right to make free and informed decisions about fundamental aspects of one’s life and whether and when to have children. Realizing that access to information is vital to allowing individuals to make decisions about the size and wellbeing of their families FPAU has for the last fifty years concentrated on giving that information. Today, FPAU is a lead organization in the provision of sexual and reproductive health services in Uganda. The last two decades have seen a paradigm shift from family planning to reproductive health and rights. This has especially happened after the International Conference on Population and Development (ICPD) held in Cairo in 1994. After the ICPD there came a paradigm shift from family planning to total reproductive health and rights (SRHR) which has resulted in FPAU’s making efforts to ensure it meets the unmet need of women, men and especially young people to access a wide range of reproductive health services and contraceptive choices in a broader framework of sexual and reproductive health and rights. Barriers that block the practice of family planning and enjoyment of sexual health have been of much concern to FPAU which has spent the last decade unblocking these barriers with considerable successes. FPAU has reached the most difficult to reach categories of people like the commercial sex workers and the market vendors and its successes can not be underestimated. As we celebrate the fifty years of our existence in Uganda, we also rejoice our successes. We commemorate our efforts and contribution towards the advancement of the understanding of reproductive health and rights in our country. We also celebrate the fact that our efforts have been appreciated nationally and internationally and because of this, we have and will continue to exist as a leader in reproductive health in Uganda. Our commitment to work with partners who include the Government of Uganda and the International Planned Parenthood Federation (IPPF) is limitless. Our gratitude to them and all the others who have made us exist goes beyond the skies. We have been happy to enjoy the monopoly of being identified as “family planning” but we have to move with the times for we believe that society changes with place and time. Since the 21st century has come with more concerns than just family planning, we have also changed to match those concerns. These anniversary cerebrations will therefore see us change our identity from Family Planning Association of Uganda (FPAU) to Reproductive Health Uganda (RHU). Lastly, I take this opportunity to thank all those who have contributed to FPAU during the last fifty years: founders, trustees, volunteers, staff, supervisors and donors. In a special way I would like to once again thank our key partner, IPPF for their continuous support. Without your efforts FPAU would not be celebrating fifty years of its existence. I also take this opportunity to thank the Government of Uganda for their support, financial, material, technical, legal etc. over the years. To all I can say: Please continue standing with us, for the journey is just beginning. In the 1950s when Uganda like many other African countries was agitating for independence from colonialism; in tandem was another wave of campaign led by family planning (FP) advocates. These courageous advocates were selling the concept of family planning to African countries as a practical way of striking a balance between population and development. They were daring because at that particular time, most Africans were pronatalists who did not believe in family planning. Even after they got independence and were in control of instruments of power, most African governments gave little attention to family planning. Uganda was not an exception. The history of family planning in this country dates back to the 1950s and is closely linked with the visit of Edith Gates, Executive Director of Pathfinder International, an organization that was robustly advocating for the right of couples to decide the number and spacing of children. Pathfinder had sent Mrs. Gates to sub-Saharan Africa to explore the possibilities of introducing modern family planning services in Uganda, Kenya, Ethiopia, Ghana, and Liberia, among other African countries. The organization wanted to establish family planning associations in several African countries to help confront three pertinent concerns: the high population growth that threatened to outstrip economic growth; high maternal mortality resulting from unplanned pregnancies, and poor health of women. Indeed, when Gates landed in Uganda, she was dismayed by the state of prevailing poverty, high maternal deaths, closely spaced children, malnutrition and the poor health of women, which in turn had a negative socio-economic impact on the people. Hence, to reverse this trend, she urged progressive Asian and African women of Mothers’ Union to form an association that would advocate for family planning. Those who embraced the idea, formed the association, and took charge of it leadership. Her visit had another tremendous effect: it stimulated and emboldened those who believed in family planning to start speaking about it openly and with confidence. At this time, the biggest challenge was getting the government and public approval to propagate messages about its benefits to individuals, community, and the country at large. Individuals who were expected to undertake this work proposed by Gates were to be volunteers. Interest in the movement was therefore not driven by monetary considerations but a firm belief in and passion for family planning. Using mediaTo win the hearts of the people, these volunteers had to rely on other strategies such as lobbying for public support through radio and print media as well as home visits and public functions. Gate’s visit therefore led to growing interest in family planning among women in Uganda. But initially only Asian, a few European and African women from affluent families, embraced the idea. Because of this, it remained almost an exclusive practice among women who could afford the services provided in private health facilities at a fee. According to the 72-year old Mrs. Ferry Kikonyogo of Kawempe II Parish-Ttula Zone, the first African midwife to work for FPAU in the 1960s, the Association started as a club of Asian women, operating to serve their interests and that of a few rich people. But to have the impact they wanted, the women decided to transform this club of like-minded individuals into something that would later prove very formidable. That is when they founded the Family Planning Association of Uganda (FPAU) in 1957 with the first clients being attended to at the Aga Khan Health Centre. Key among the founders were Mrs. Saxton, the Association’s first president in the 1960s, and her husband Dr. Saxton, an expert in population and family planning, with Sugra Visram as the main funder. Visram also served as a Member of Parliament and was highly regarded among Kampala residents. With this unregistered organization, she and other promoters of family planning offering services as well as nutritional lessons to clients. At this time, Kikonyogo recalls that family planning devices provided to women included foaming tablets, pills, Intra Uterine Contraceptive Device (IUCD), diaphragm, jells, and condoms. To help run these programmes, the Association had established a relationship with International Planned Parenthood Federation (IPPF). Although not a member of IPPF then, the Federation helped fund the procurement of these devices and run the Association’s family planning services. Other funds were raised locally. RegistrationAfter six years in operation the Association decided to gain legal status. In 1963, FPAU was registered as an NGO under the National Council of Voluntary Social Services. It was also around this time when the providers of the services started targeting African women. In 1964, the Association opened its first clinic and the number of those seeking family planning services took a steady rise. According to a 1966 clinical report signed by Anne K. Saxton and presented during the Annual General Meeting, the total number of visits by clients rose from 118 in 1963 to 648 in 1964 to 1,670 in 1965. Of the 532 new clients who visited the clinic in 1965, 71 per cent choose IUCD on their first visit, 17 per cent opted for pills, 10 per cent diaphragm and 2 per cent settled for either condoms, foam tablets, or jells. The tremendous successes of 1965 were again replicated the following year, with 2,596 clients seeking family planning, an increase of 55 per cent above the 1965 figure. During this year, 81 per cent went for IUCD, 11 percent pills, 5 per cent diaphragm and 4 percent preferred condoms, foam tablets or gels. Between 1963 and 1966, the Association had carried out 1,200 insertions of IUCD performed by Dr. Serwadda and Dr. Saxton. Majority of the women may have preferred IUCD because they could use it secretly without their partners knowing. It was also long-term method. Besides family planning services, women were offered pap smears for cervical cancer, free of charge. The tests were done by Mr. Ziegler and other staff at the Cytology Laboratory at Makerere Medical School. In 1966, another milestone was realized: FPAU was registered as a member of IPPF. This development opened doors for further financial assistance. But since these funds were not sufficient, the Association had to bridge the gap using resources raised from local contributions and other fundraising activities. With these resources, the Association was able to provide contraceptive services, Information, Education and Communication (IEC) materials, as well as open up branches across the country. As this was taking place, the Association got a further boost in its campaign. In May 1968, the 21st World Health Assembly, under Resolution WHA 21.43, recognized family planning as an important component of basic healthcare service. The resolution however restricted this assistance to only those programmes established within the framework of health services. Nevertheless, this global proclamation made many national governments including Uganda to start giving serious consideration to family planning. Stiff oppositionBut even as the Association gained this status, events were not progressing as smooth as those at the organization’s helm would have wished. Several huddles stood in their way. Efforts by volunteers to explain the benefits of family planning to the authorities and the public encountered a hostile reception. From the 1960s onto the 1970s, opponents of family planning maintained a sustained campaign to discredit the practice. This made it extremely difficult for those who had decided to adopt and propagate the message about the practice to do so. As a result, not every woman or couple who wanted to benefit from the family planning services could do so. Several huddles stood in the way. Kikonyogo recalls how the services were restricted to married women, who were in addition required to have letters from their husbands authorizing them to practice family planning. Moreover, childless women or those with less than three children were not allowed to use family planning. The main desire by most couples and the community was to have large families; and giving family planning services to women was seen as defeating this purpose. Thus, convincing men to allow their wives to come for family planning encountered stiff resistance. Some men even resorted to violence to stop their women from utilizing these services “Because this increased gender based violence, women in need of family planning had to come secretly to us and we kept it highly confidential,” says Margaret Seruyange, who joined the family planning movement as a midwife in 1968. Similarly, advocates of family planning had to contend with stiff opposition from traditional, political and religious leaders who believed large families were an asset and ‘a fulfillment of God’s teachings’. “The Catholic Pope made things difficult for us when he asked people to reject family planning services. Yet, the majority of the clients we served were Catholics,” recalls Seruyange. Worse still, the Catholics doctors brought their beliefs and values into the workplace. At Mulago hospital, Dr. Ignatius James Batwala, who practiced as an obstetrician/gynaecologist in the 1970s, says most of the doctors in his department were Catholics. “When we were doing tubal ligation, my professor, a Catholic, participated in all surgical procedures, except severing of the fallopian tube, which he said was against his beliefs,” recalls Dr. Batwala. While at the hospital, Dr. Batwala, currently one of FPAU Trustees, remembers the numerous times they attended to women with ruptured uteruses caused by closely spaced births. “We sent a passionate appeal to politicians and the public warning them about this.” Still, politicians and traditional leaders would not heed this desperate call. They continued to argue that family planning information and devices were going to encourage promiscuity and make women infertile. These opponents further averred that Uganda had huge, unfilled tracts of land to accommodate everybody. Consequently, they did not see the need to limit the number of children a woman should have. From a cultural perspective, family planning was considered against the beliefs of many African communities who maintained that having many children was a source of wealth and future investment. Most people therefore rejected family planning. Misconceptions“There were a lot of misconceptions and misinformation about family planning, with many people rejecting it in the belief the practice stopped women from giving birth,” said the 67-years-old Seruyange. The condoms were said to cause cancer in women whose husbands or partners used the device during sexual intercourse, which ultimately, would result in a huge number of women dying. To many Africans, family planning was also seen as a hidden agenda to reduce the African population by the colonialists, while theirs grew, as a strategy to continue ruling our country. But this belief did not correspond with what was happening at the time, as most of those who adopted family planning were European and Asian women trying to have smaller and manageable families. With all these perceptions and misconceptions, those who promoted family planning were harassed, intimidated, and became unpopular. Their arguments were not translated into government policies, programmes or projects. In spite of the harsh environment, their determination never waned. To convince women about the benefits of family planning, those offering the service had to lead by example. “Convincing women about something you as provider or volunteer was using became easy,” says Seruyange. A mother of six, Seruyange admits to have successfully used injection for four and half years and the coil for 11 years. Other devices she used included condoms, pills and the barrier method. The service providers also, started talking directly to some men about the benefits of child spacing. In addition to these two initiatives, other innovative ways of offering these services to women who desperately needed them were devised. At one point, service providers resorted to operating within organisations whose names were widely accepted by the public, to offer the services. Dr. Sarah Ntiro, a Trustee member with FPAU, recalls how they operated under umbrella organisations such as the Young Women Christian Association (YWCA), whose mandate did not include offering family planning services. But which offered a safe haven for them when going about their work. Although their operations raised eyebrows, they were able to advance their cause because the YWCA’s leader at that time was a pastor’s wife, who supported family planning. She was therefore used in awareness-creation programmes due to the respect she commanded from the public by virtue of being a pastor’s wife. Mass media campaigns to eradicate the misconceptions about family planning were used as well. Influential peopleFPAU also encouraged influential individuals in society to become members of its board. Among those enlisted as volunteers were government officers who privately supported family planning. Respected individuals in rural areas were also recruited to propagate family planning messages in some of the most hostile areas. This strategy was very useful in the 1960’s and 1970s, as it helped reduce the resistance as well as influence the government to develop favourable policies for family planning. Similarly, Dr. Ntiro and other advocates recruited the beneficiaries of their services as volunteers and used them in advocacy work. These volunteers later became the bedrock and key to the sterling performance of family planning programmes during those difficult times. To date, they remain at the heart of success of association’s programmes. The vital role of volunteers was captured by Dr. Ntiro when she said: “Since Uganda lacked a legal policy framework to support and guide African couples interested in family planning, it meant those who worked for the government and were willing to promote family planning had to do so on voluntary basis.” And added: “This forced them to create time after their paid jobs to go and offer the family planning services, sometimes in nondescript places like the YWCA.” She and 64-year-old Mr. Kalegama Topher, a former FPAU volunteer, concur that voluntarism was at the heart of the success of the association. “Were it not for voluntarism, we would not have progressed this far. The passion of the people who volunteered during those exigent times united and strengthened our resolve and cause,” says Topher. However, they faced an uphill task in recruiting volunteers to help in evangelising the importance of family planning. Many people recoiled from supporting a practice that was unpopular at that time. Even then, the spirit of determination and the conviction of those who had volunteered never died. And they were encouraged when they started seeing the fruits of their efforts. Government softens to Family PlanningThe environment improved towards the late 1960s, when the government allowed family planning advocates to promote the practice in government health facilities. Seruyange, who first worked at Katwe Community Centre and then Fort Portal clinic, said they were allowed to move round government clinics, addressing women and men on family planning. “Although the government was not offering the service, it allowed us to give talks in its clinics, especially to women who had come for antenatal clinic,” recalls Seruyange. At that time, the administration feared being seen, publicly, supporting a service which was unpopular among its electorate. Indeed, the issue became political, especially at a time when those in government wanted to win the acceptance and support of the population at a time when they were trying to craft a viable state. Facilitating the work of family planning personnel without being seen to be active players was therefore a win-win situation for the government. Dr. Batwala noted that doctors working in government hospitals were also allowed to propagate the merits of family planning, but mainly outside government hospitals. What this therefore means is that even before it had put in place a population policy to guide family planning, those in government believed the practice was good for the country. “Slowly, we started seeing more women space their children, with a very small number, especially in urban centres, started families when they a little older. We had started recording success, albeit in a small way,” said Seruyange, with a broad smile. Family planning advocates realized they could use immunization programmes to reach many women since they had their husbands’ support. “During immunization programmes, we would ask for permission from authorities in government or local councils to allow us talk to women about child wellbeing and nutrition,” explained Seruyange. “But this was a strategic move to teach the women about family planning.” When attending such clinics, the family planning providers would teach women about nutrition and child care, and then tactically educate them on how to plan their families. “Presenting these things as a package convinced women that family planning was good,” recalled Mrs. Kikonyogo. Indeed, immunization programmes became an easier way to reach some women who would not have managed to get near those offering such services. Even in the late 1980s, similar strategies had to be used to get women to come to family planning forums. Joyce Mpanga, who served as the Minister for Women Development in the President’s office between 1989 and 1990, recalls how they used to rally women to bring their children for de-worming and nutrition lessons. They would then use this opportunity to provide family planning information and give contraceptives to those who wanted them. But as they made these inroads, it painfully dawned on them that women living outside urban centres suffered as they could not access these services. This led to family planning providers, in the late 1960s, to start outreach visits outside towns as a strategy of taking services close to those underserved. But this approach was restricted to areas near the urban centres due to lack of resources to venture deep in the hinterland and the hostility towards family planning in those areas.
Verbatim from the Diary-1965The main clinic and office of the Association is now 9, South St. in the Arvind Industries Building in Kampala. Our activities were moved to these premises on 14th November, 1964, when we began to rent three rooms there, one with running water, and situated next to a private toilet. We were then able to schedule three clinics weekly for the first time, as follows: Monday morning, Wednesday and Friday afternoons from 3.00-7.00pm. In mid-February, 1965, a fourth clinic as started on Thursday mornings. A midwife continued to attend the City Council Health Centre on Wednesday afternoons, as in the past, until mid-March, 1965. Then we found we were no longer able to provide personnel and transport for two clinics simultaneously, and found it more efficient to concentrate all consultations in the new premises. Regretfully, then we discontinued our visits to the City Council Health Centre. A similar advice clinic at Makerere College for junior staff wives was not well enough attended to make it worth continuing after the end of April. On the other hand, the Naguru Child Welfare Centre at one of the older housing estates continues to be a good place to contact interested mothers three Tuesday mornings each month in an advice clinic given by one of our midwives. The Aga Khan Health Centre was renovated in 1964, leaving one large room and no privacy for conducting a family planning type of clinic. Space was given for this work in the dental room which had running water and privacy. A special examining cot combined with built-in storage space was designed and built to fit in this small space. However, after four months of concentrated effort to make this clinic function it was deemed necessary from a medical point of view to give advice only and refer patients to the South St. Clinic for actual prescribing and fitting. Many thanks are due to the City Council Health Centre and the Aga Khan Health Centre where the first family planning work started in 1957, and we regret – and at the same time rejoice – that our work has outgrown their facilities. Outside Kampala, essential instruments and medicines and stationery supplies were purchased for the Fort Portal and Jinja clinics and both have gotten under way with one clinic weekly. Doctors in other parts of Uganda are also able to care for family planning patients and especially our Intra-Uterine plastic coil patients, if they need help. Signed Anne K. Saxton General Secretary – Family Planning Association of UGANDA Back to TopTroubled Times: 1970-19794Videosoft iPod Manager 3.1buy software in canadamiddle ages world history worksheetsblank letter of credible coverage1STEIN CodedColor PhotoStudio Pro 5.8Flaming Pear India Ink 1.97 for Adobe Photoshopadobe illustrator cs4 serial numberZoho ManageEngine EventLog Analyzer 6.0 x32shafford raspberry hand painted tea cupsAudio Recorder Titanium 7.1free legislative branch vocabulary worksheetswright 3 by blue worksheetsJoboshare DVD Copy 2.7RAR Password Recovery Magic 6.1cut and paste kid worksheetPentaware PentaSuite Pro 8.54U M2TS Converter 2.0 MultilingualeBook: Adobe Photoshop CS2 Classroom in a Book(Adobe Press)adobe illustrator cs5 keygenNETGATE Registry Cleaner 1.0spanish worksheets with tener idiomsAplus DVD Ripper 8.7 The 1970’s will remain etched in the minds of supporters of family planning as the most difficult period. When Idi Amin took control of the country after a military coup, he banned family planning, arguing it went against African culture. “The former government did not realize the serious implications of high population growth in this country, and turned a blind eye to the voluntary activities being conducted by FPAU,” remarked Dr. E.G.N Muzira, the Permanent Secretary/Director of Medical Services, during FPAU’s 23rd Annual General Meeting held on 18th November 1979. “Consequently,” added Dr Muzira, “the then political government did not accept FPAU to open and run clinics in government hospitals and institutions and prohibited tutors and lecturers from giving family planning lectures to medical students and other paramedics.” As a result, during Amin’s rule, the country was isolated and became an international pariah. “Interaction with donors and other players remained very limited. People’s lives were disrupted, with many not taking any interest in family planning,” said Emmanuel K. Sekatawa. Sekatawa, who at the time of writing this book was a member of FPAU’s Programme Committee, said the 1970s saw the gains made in the 1960s on the family planning front being eroded systematically and at a very painful and rapid rate. So bad was the situation that even Mr. Michael Sozi, the then International Planned Parenthood Federation-Africa Region (IPPFAR) Regional Director, could not return to his home country to assess FPAU’s work. This is evident in the Board of Directors meeting held on 6/10/79 in which Mr. Sozi “expressed happiness that he had been able to come to Uganda for the first time to meet the board formally.” Mr. Sozi explained to the board that he could not do so earlier because of the prevailing political situation in the country before the liberation. Besides Sozi, other highly educated figures who were behind FPAU activities had to flee to other countries because Amin was said to have targeted educated individuals likely to oppose his leadership. Within the organization, the difficult times also saw it experience some of the worst managerial and administrative challenges in the running of the association. The board in the 6/10/79 minutes complained of how some FPAU officials took advantage of this confusion in the country to mismanage the Association. This was made worse by the looting of the Association’s clinics; it was noted in the minutes. “Some of the looting was suspicious,” commented Sozi during the board meeting. It is this situation which forced the IPPF Executive Committee in 1979 to ask Mr. Sozi to manage FPAU without the board. In executing this decision, Sozi suspended the board and appointed an advisory committee of volunteers to work with the administrator, Mr E.M Mugoya. Amin’s time was the most difficult for the Association as Dr Jane Bosa, Director, Makerere University Hospital and FPAU board member, observed: “Many things went into limbo as the prevailing political environment made it difficult to publicly propagate family planning.” Similar sentiments were expressed during a 1974 FPAU special meeting held at Imperial Hotel, Kampala, where the chairman, Mr. Kyeyune noted with dissatisfaction that “although the Association had started as long as those in Kenya and Tanzania, it was sad to note that those two countries were doing better than Uganda.” Indeed, it is during this troubled period the total fertility rate and maternal mortality increased to levels that threatened attainment of safe motherhood and threw the population-economic balance into disarray. The only heartening thing is while Amin effected this ban, he did not ban FPAU, making it possible for the Association to continue with operations as evidenced by the meetings it held and the services it continued to deliver covertly. Advocates of family planning remained resilient and refused to allow what they had toiled for over the years to go down the drain. They went underground and continued to offer services to those in need. They had also to rely on other strategies to survive. In some instances, they leaned on people close to Amin for support. In one such case, 72-year old Mrs. Ferry Kikonyogo of Kawempe II Parish-Titula Zone remembers the Association inviting Amin’s wife Sarah during one of their , anniversaries, as a strategy to win political support. But as they struggled to remain afloat, the reputation of the country they were operating in had suffered a great deal. Donors were hesitant to support FPAU programmes in such a hostile environment. Only IPPF stood with the Association, sustaining it during these trying times. However despite the hostile environment, the Association registered some success. The Association’s persistent and consistent advocacy led the Ministry of Health to accept child spacing as an essential component of primary healthcare. In 1975, the Ministry instructed all of its medical units to work with FPAU in offering child spacing information and commodities as an integrated part of primary health care and maternal and child health services. The Ministry had realized that family planning was integral to improving the health of the families. This government directive however hit a snag. Most of the government hospitals lacked trained personnel trained in family planning, equipment and contraceptives. The Association started by training government midwives and assistant health visitors on family planning at the Makerere Institute of Public Health and providing contraceptives. In 1975, FPAU in collaboration with IPPF, influenced Makerere University to start a course on population research and demography. The following year, the Association was made a full member of IPPF after the Regional Council meeting held in Ibadan, Nigeria. As this happened, Dr. Charles Lwanga, FPAU’s representative to the IPPF Africa Regional Council, had worked hard to secure research funds and get Uganda selected as a training centre for infertility and sub-fertility problems in sub-Saharan Africa. By 1977, as these impressive developments took place, the Association’s clinics rose to four. Besides this, FPAU also operated in another 13 clinics located within government hospitals, bringing the total to 17. Human resource capacity and provision of contraceptives to the populace had been greatly enhanced by this time. During one of the meetings in 1977 that was attended by various stakeholders and members of the public, the FPAU took the opportunity to spell out some its objectives as:
Such appeals that involved explaining its objectives were to safeguard the gains the Association had made since its formation, including retaining the number of acceptors (term used to describe those who accepted family planning). Statistics of 1977 indicate why such explainations were very dear to the Association. According to Board of Directors minutes of 4/3/77, the total number of acceptors hit 20, 214, by that year, with 7,918 being new acceptors, translating into an 80 percent increase over the 1975 figure. Hence, while the 1970s will go down in history as the most painful times for FPAU, they will also be remembered as a period when the Association withered many challenges to record remarkable developments. The overthrow of Amin by Tanzanian troops and Ugandan exiles saw the Association consolidate these gains as it enjoyed renewed recognition. In the words of Dr E.G.N Muzira, the “then military government proposed that FPAU should be the main agent for implementing family planning in collaboration with Ministry of Health.” Speaking at FPAU’s 23rd Annual General Meeting held on 18th November 1979, he added: “FPAU was required to expand its staff, clinics, and facilities in order to propagate the benefits of family planning.”
Source: Board of Directors minutes of 4th/March/1977, Report to the 20th Annual General Meeting held at Jinja Town Hall. Development Phase: 1980-1990This decade began with a flurry of activities and new developments that later shaped FPAU’s service delivery. The sterling performance registered since its inception was taking shape, and by 1980, the Association had 60 clinics. Twenty-three of these were owned and run by FPAU, while the rest being housed within government and mission health units. However, the outbreak of the civil war in 1981 started eroding FPAU's gains as some health facilities were destroyed. In 1981, the government adopted the maternal and child health programmes, effectively bringing on board family planning services. The following year, FPAU celebrated its Silver Jubilee. The committee in-charge of the celebrations included Mr. J. Mandu, the chair; Hon. Henry Ssewanyanna; Mr. Y. Gwayambaddle, Mr. Machyo and Mr. Sebadukka. The Jubilant mood was amplified in 1983 when the management of FPAU, which had been conducted directly by IPPFAR Regional Director, Mr Sozi, for two and half years, was restored because of the improved situation within the Association. But as they celebrated this development, the Association was aware much needed to be done. In his speech at the FPAU’s General meeting held on 16/1/82 at the Institute of Public Administration, the then Minister for Health enumerated several challenges that FPAU had to confront as follows:
It is perhaps this and other concerns that made the government in 1983 to take over from FPAU, provision of family planning services in government hospitals and other health units. Such a move was made possible because UNFPA and several other donors had come in to support the government’s population agenda. With this development, FPAU had to make a strategic decision. The Association left these clinics and concentrated on creating awareness and motivating more people to accept family planning. It also opened more branches across the country and initiated models of intervention that would enable it reach the underserved groups like the youths, slum and rural dwellers. Communities resistant to family planning due to their cultural or religious leanings were also targeted. Some of the interventions adopted at this time included the introduction of community based distribution services, outreach visits, and satisfied user programmes. Others were development and dissemination of Information, Education and Communication (IEC) materials that aimed at promoting services at different sites and linking agricultural analogies to reproductive health. Integration of sexual and reproductive for the youth was also done in all FPAU service outlets. This elaborate infrastructure resulted in more clients patronizing the clinics, exerting pressure on the limited resources the Association had. At this time FPAU was the only organization, apart from the government, the ordinary people could turn to for reproductive health services. Since the government was only offering such services in its health facilities, the Association decided to take an innovative route. In 1983, community based delivery of services, was started to take services closer to underserved people. Since then, the growth of the outreach visits has been steady and impressive. At present, the Association has 19 clinics, each conducting a minimum of four outreach visits every week. “We allow our branches to be innovative in the way they conduct their outreach programmes. The visits can be in the markets, churches or any other place they consider will have the greatest impact,” said Elly Mugumya, FPAU’s Executive Director. With President Yoweri Museveni taking power in 1986, FPAU began to thrive once again. Several new organizations also started working in the field of family planning and other reproductive health issues. In response, FPAU redirected resources from the areas where the new organizations were operating. “The entrance of these organizations relieved us of some pressure. And since we did not want to compete in offering the same services to the same people, we had to change tact,” said Mugumya. Resources re-channeled from these settings were then invested in other locations and activities where maximum impact would be realized. Similarly, the coming on board of other organizations made FPAU to look at new horizons. Around 1987, the Association started, albeit in a small way, to integrate HIV/AIDS in their work. It is also during this period the organization began witnessing more donor funds flowing in to finance its programmes. By 1990, for the first time, the budget hit one billion Uganda shillings, sending a strong signal all was well as the organization worked hard to take more services to deserving populations. Diversification of sources of donor funds, notes Emmanuel K. Sekatawa, who served as FPAU’s Program Director from 1990 to 1994, was instrumental in this regard. These good tidings were a harbinger of impressive times expected in the next 10 years from 1990 to 2000.  Youth issues at the heart of FPAU workContrarily to what people may think, Family Planning Association of Uganda (FPAU) started addressing issues of youth seriously in the 1970s as one of the association’s key objective. In the 1977 minutes of the Annual General Meeting, for instance, one of the association’s objectives highlighted in the report reads: Promotion of responsible family life amongst adults and youths, particularly in rural areas. But the only difference with today is there were no specific programmes targeting young people. This meant the youth were lumped together with other groups and not addressed as a unique cohort, in terms of programming. Such an approach resulted in missed opportunities. Likewise, even with this recognition, there were limits to the sexual and reproductive health (SRH) content and commodities the youth could access and at what age. Some of this restrictions and the absence of youth friendly reproductive health service providers and health outlets, did more harm than good to the young people. As the Association entered into the 1980s, matters relating to young people were still being addressed within other programmes. But after the adoption of IPPF Vision 2000 in 1992, and the 1994 International Conference on Population and Development in Cairo, both of which focused on adolescents and youth in an elaborate way, the Association’s programming around this area took a different shape as well. Specific programmes targeting youth and which concentrate on their sexual and reproductive health needs have been developed and implemented. This has brought immense benefits in the lives of young people because their unique SRH needs have been tackled in manner they like. In the past 10 years, tremendous progress has further been made in coming up with initiatives that address these needs. The partnership between FPAU and African Youth Alliance, for instance, was designed to implement a project whose objectives were: Promote the adoption of safer sex attitudes and practices; increase utilization of SRH services, and delay the initiation of sex by young people. This project was implemented in seven districts of Uganda: Kapchorwa, Mbale, Iganga, Kampala, Kabarole, Kamwenge, and Kyenjojo. In 2003, FPAU started implementing the Youth Club Cascade Model in Luwero district using funds from German Foundation for World Population-Uganda. The model targeted in and out of school youth who were recruited into clubs, with the purpose of reaching them with SRH information, as a first step to egg them on to utilize reproductive health services. Around the same time, there was another project targeting students in three institutions of higher learning: Makerere University, Kampala; Kyambogo University, and Makerere University Business School, Nakawa. The aim of the project was to facilitate easy access to Youth Friendly SRH services including life skills development. Young people in Internally Displaced Persons camps have been on FPAU’s radar as well. The focus has been on young people in Displaced Peoples Camps in Gulu, northern Uganda. This group of young people is assaulted with a myriad of problems, yet there are no broad based interventions to respond to their reproductive health plight. Sexual violence, low condom use, and high HIV prevalence are some of the problems in these camps. In response to this, FPAU trained Peer Educators within the camps on SRH matters. It is these educators who continue to offer invaluable assistance to their fellow young people in such distressing circumstances. Establishment of youth friendly services to improve access to SRH services has also been in high gear in the past couple of years. In 2006, FPAU established such services in various parts of Uganda like in Bushenyi and Hoima. A major paradigm shift had therefore been undertaken. Consolidation and Expansion: 1990-2000The 1990s can be described as one of the periods in which FPAU was confronted with many opportunities and challenges that called for urgent strategic thinking and actions if its future programmes were to succeed. Some of the landmark developments within IPPF and on the international scene required a paradigm shift in the way the Association conducted its business. The reproductive health indicators were not impressive. Maternal and infant mortality stood at 500/100,000 and 101/1,000 respectively. These challenges required innovative approaches to address them. It started at the International Planned Parenthood Federation, where serious reflection on family planning and other SRH issues was taking place. The reflection centred on how to confront challenges and utilize opportunities in order to register maximum benefits in the new millennium which was approaching. IPPF was also marking its 40 anniversary, and those at the helm of the Federation believed such reflection in the 1990s was critical in confronting the challenges of new millennium. This process led to the development of Vision 2000, a strategic plan that focused on: • Empowerment of women • Meeting the unmet need for family planning • Reduction or elimination of unsafe abortion • Promoting and protecting sexual and reproductive health and rights • The SRH services for the Youth • Quality of Care The Plan was adopted in 1992 during the Members Assembly held in New Delhi, two years before the 1994 International Conference on Population and Development (ICPD) in Cairo, Egypt. A 20-year Programme of Action (PoA) adopted by the Conference to guide the implementation of what was agreed upon touched on various fundamental issues that also defined FPAU programming and response to SRH matters. Key areas of the the PoA included:• Ensuring universal access to quality and affordable sexual and reproductive health services including family planning. • Empowering couples to make real choices about family size through a series of social investments including expansion of education opportunities, particularly for girls and improvement of women socio-economic status. • Improving child survival. • Reducing maternal mortality. • Ensuring the right of individuals to make decisions free of discrimination, coercion, and violence. In addition to these landmark developments, other major developments which defined FPAU’s work during this period: the Uganda National Population Policy launched in 1995 and the New Constitution promulgated in the same year. While the Policy emphasized the quality of life of the population through provision of comprehensive SRH services; the new constitution emphasized promotion of the status of women, youth and the disabled. The policy on decentralization and devolution of power and resources to the local authorities, another milestone registered in this period, witnessed the trickling down of resources to finance SRH services at the local level. Likewise, it is at this time FPAU had to respond to the increasing number of non-governmental organizations (NGOs) and donors such as DISH, Plan International, CARE International and Maries Stopes, among others, who were getting into the Ugandan SRH arena. All these developments made the Association to assess how to re-position itself and strategically on how to operate within this environment. In 1997, the Association developed its first five year Strategic Plan, 1997-2001, which continues to help in scanning the environment to know what the issues are; predicting the future; measures the Association’s competence; and helps to take advantage of alliances. The Plan had three core goals: • Increase service delivery. • Increase advocacy for reproductive health. • Build institutional capacity to manage reproductive health programmes. Similarly, this plan reflected a major paradigm shift with the delivery of SRH services being done from a right-based approach in line with the IPPF Vision 2000 and the ICPD spirit. The idea behind this concept was and is “to empower claim holders to demand rights from the holders of these rights,” said Elly Mugumya, FPAU Executive Director. The strategic plan also ensured FPAU broadened its scope from an organization that offered family planning only to a provider of broader sexual and reproductive health and rights. However, this shift had its positive and negative effects. One of the positive aspects was the integration of services that enabled the Association to minimize costs and take advantage of opportunities. Clients were able to access services under one roof, without having to hop from one centre to another. As this happened, the association increased its coverage area, improving service reach and delivery. The number of people served per year started to rapidly move towards the half a million mark. But the broader scope of work stretched available staff to the limit. Specialized equipments, doctors and additional staff, were some of the key ingredients that remain a headache to date in an effort to cope with the ever increasing demand. Counting the SuccessesSince it was founded in 1957 and upon registration by government in 1963, Family Planning Association of Uganda (FPAU) has been making significant contribution in the area of SRH. Many of these efforts have redefined the SRH landscape in Uganda. Areas where FPAU has registered sterling performance include: Policy Development and MonitoringFPAU worked extremely hard to influence major policy changes in Uganda. Some of the key ones include: • The registration of FPAU in 1963 opened doors for other NGOs. • FPAU’s sustained advocacy made the Ministry of Health in 1975 to allow child spacing as a component of primary health care. • In 1984, FPAU successfully lobbied the Government to introduce community based services. • In 1995, FPAU’s immense knowledge on population matters resulted in the association being selected to participate in the development of the 1995 Uganda Population Policy. The association contributed to the process by providing facts, reviewing documents, and undertaking research, among other things. • The association has provided key contribution during the development of the Gender Policy, Adolescent Reproductive Health Policy, The Domestic Relations Bill, and Private Partnerships for Health Policy guidelines. • The association is currently monitoring the Implementation of Kapchorwa Female Genital Cutting by-law. • Has consistently, in collaboration with the media, highlighted the restrictive abortion laws. • As a member of Reproductive Health Committee, FPAU helps to review the status of reproductive health issues in Uganda. Rights Awareness• Since ICPD adopted the right-based approach to SRH issues, FPAU has never wavered in this regard. The association continues to apply a range of strategies to ensure the SRH rights of underserved groups such as the youths and marginalized groups are addressed. A breakthrough in this direction has been realized through the use of young peer educators and youth clubs, the media, FPAU staff at the national, district, and community, and other community mobilization strategies. • Advocacy work of FPAU in collaboration with other organizations has witnessed local government in Kapchorwa change its by-laws on Female Genital Cutting (FGC). Since then, young girls in this area are less likely to agree to FGC. • Participated in the Presidential Initiative on HIV/AIDS for in-school youth. • FPAU boasts of bringing-up the abortion debate on the national agenda as a human rights issue. • The Association has continuously campaigned for the rights of the displaced persons. • For the longest time, the association has continued to mobilize communities on rights and rights violations, conduct research on the same, and then share the findings with other stakeholder through the media. • Rights-based information and education materials for young people both in and out of school have been developed. Forging PartnershipsPartnerships remain one area that has and will continue to define the success of FPAU programmes. In realization of this, the Association has given the area the attention it deserves. Some of the highlights on this front are: • FPAU works with other stakeholders or initiates the formation of networks, coalitions or alliances to address topical issues like abortion, female genital cutting and dowry. These alliances are critical in advocacy work as well as helping the association disseminate SRH information. • The Association is a member of NGO Track, which brings together NGOs involved in population and RH activities that are supported by UNFPA. • Partnerships with religious and community leaders and goodwill ambassadors have helped to reduce resistance to SRH services in some communities. • FPAU works with several government ministries- Ministry of Health, Ministry of Finance, and Ministry of Planning and Economic Development. On the international scene, the Association works closely with United Nations Population Fund, Plan International, DFID, CARE International, United Nations Children Fund, USAID, GTZ, European Development Fund and World Bank. Volunteers: The heart of FPAUIf there is one thing that remains at the heart of survival and success of FPAU, it is the spirit of the Association’s volunteers. It is the volunteers who started and kept the family planning movement alive during some of the most difficult times. From a handful of them in the 1960’s, the association now boasts of a membership of 4,000 volunteers with diverse backgrounds and located in FPAU’s 29 branches. The volunteers are critical in FPAU’s advocacy work and service delivery. The volunteers cut across all the sectors of society and sections of the population: the youth, women, internally displace persons, private sector, among others. They are key in the Association’s strategy to minimize costs while at the same time offering quality and affordable services. They also bring with them immense knowledge, experience, and spirit of hard work. This has been so critical in enabling FPAU implement programmes within different communities with fewer challenges since the volunteers understand better and are known within their respective societies. Accordingly, to ensure volunteers and community development and health workers deliver quality SRH services as well as help in programme implementation, the association improves their skills through trainings on a regular basis. Relationship with the GovernmentFrom somewhat frosty relationship with the government in early years of its formation, FPAU has over the years won the respect and attention of the administration, which now works closely with the Association on SRH matters. This rosy relationship is manifested in various ways: • Through the NGO Track, FPAU benefits from technical and funding assistance the government’s Population Secretariat extends to this group. • FPAU is a member of the National Reproductive Health Committee, and the Private not-for-profit. • The Association participated in the health sector strategic plan development and is involved in the review process. • The commissioner of government’s Reproductive Health has co-opted FPAU as member of the board that advises the government on SRH issues. • FPAU is one of the five NGOs that receive direct cash grants from the government’s Poverty Alleviation Fund hosted by Ministry of Health. • Ministry of Health outlets are used by FPAU as referral centres by the Association’s clinics. • FPAU has a representative in the government’s district health planning committees and advisory boards. This is vital as it enables the association to synchronize its programmes with those of government as well as benefiting from the district decentralized health support funds. • Government district officials are some of the volunteers within FPAUs district branch committees • The Association was the lead agency for Management of Global Fund on HIV/AIDS, Malaria, and Tuberculosis, private sector component in 12 districts of Central and Eastern Uganda. Recognition Phase: 2000 And BeyondThe dawn of the New Millennium opened new opportunities and possibilities as well challenges. It presented the opportunity to do things differently in confronting the myriad sexual and reproductive health challenges facing Uganda. While the Association had in the past focused on family planning, it was now required it to consolidate, crystallize and develop programmes that addressed the ICPD Programme of Action. At this particular time, issues of sexual and reproductive health were immense. Teenage pregnancies, high maternal and child mortality, unplanned pregnancies, unsafe abortion, and limited access to reproductive health information and commodities, were the order of the day. HIV and AIDS was an additional challenge, threatening to wipe-out the gains made since independence. In fact, in 2000, the HIV prevalence rates in Uganda were 6.9 per cent among women and 5.6 per cent among men, according to Aidsmap. Well designed and targeted interventions were therefore a requisite if the Association was to intervene effectively in this prevailing environment. At the IPPFAR level, a paradigm shift was taking place as well. In 2004, IPPFAR developed its five year Strategic Plan (2005 to 2009) that focused on five key areas also known the Five As – Adolescents, Advocacy, Access to Family Planning, Safe Abortion and Safe Motherhood, and HIV/AIDS. The advocacy component was critical as a lot of such processes were needed to have new SRH laws formulated, restrictive ones abolished or widened to increase greater enjoyment of SRH rights. Increased allocation of resources to SRH programmes was also going to be realized through aggressive advocacy. To ensure consistent and unity of purpose, each IPPFAR affiliate Member Association adopted this Strategic Plan, which they used as a framework to design programmes and activities around issues of priority within their respective countries. FPAU too adopted this new strategic plan, which currently guides and defines the Association’s work in 29 branches spread across the 86 districts of Uganda. In addition to this Strategic Plan, the dawn of the Millennium had other trappings of success. In 2005, FPAU was accredited to IPPF and in 2005 was awarded the Quality of Care Certificate by IPPFAR. This was an indication of the strides the Association had made in improving its services. FPAU Executive Director, Elly Mugumya, attributes this success to improved image, technical competence, confidence and ability to deliver, account and share best practices with other stakeholders. Indeed, one of the SRH stakeholders, the government, acknowledges this. Assistant Commissioner for Reproductive Health, Dr Anthony K. Mbonye was full of praises for FPAU’s role in complementing the government’s SRH programmes. “The partnership with the Association has been instrumental in implementing basic SRH services such as family planning, putting in place gender sensitive policies, distribution of contraceptives and treatment of the cancer of the cervix.” On other fronts, FPAU intensified its efforts to build alliances and coalitions as a strategy in strengthening the its bargaining power on some of the essential SRH issues. Efforts in this regard have resulted in the Association working in partnership with the Network of African Women Ministers and MPs (NAWMP),Uganda Chapter. The Association is also working closely with Parliamentary Committee on Food Security and Population; and Parliamentary Forum on HIV/AIDS. In addition to partnerships, integration of HIV/AIDS in SRH programmes, was another major achievement registered. Incorporation of gender as a cross-cutting issue in all the programme areas has witnessed not only bringing of women into the fold of SRH management, but also addressing women’s specific and unique needs in a more focused manner. Putting a smile on the poor peoples facesChildren with rheumy eyes and running noses cling tightly on the backs of their mothers, who have formed along twisting queue that ends in a garage. Many of them seem oblivious of the punishing sun as they wait to be attendant to. It is around noon, and this is the homestead of a local councilor, which has been transformed into a makeshift health centre. The compound is teeming with people of all ages, some chatting excitedly. Others with sullen faces seem indifferent to what is happening around them, only eager to get treatment and go home. The councilor and his wife, both members of the village health team, have given out the garage and their compound to the Family Planning Association of Uganda, which is carrying out a treatment outreach programme. The two also help the Association in mobilizing people before such outreach visits take place. Young, pregnant women and mothers with toddlers, mill around the compound. There are those who have come for HIV Voluntary Counseling and Testing (VCT) and other SRH services, antenatal care, immunization and de-worming, or treatment of other ailments. In their midst, a man with a hand-held loud speaker goes around the sea of humanity directing them to different locations where services are being offered. “Here you will get HIV testing, there your child will be weighed, and on my right in that room you will see the doctor,” he says. Majority of the expectant women on this day are teenagers. They are said to have ended up like this because they engage in sex to earn a living. For others, the teeming poverty makes them an easy prey for older men who offer food and small gifts in exchange of sex. “The high teenage pregnancy here is a disturbing phenomenon. And our role on days like this is to offer counseling to the young girls on how to prevent it from happening again,” says Peter Ibembe, FPAU’s National Programme Manager. A day like this also offers opportunity to the service providers to advise other young girls who are not yet mothers, but who come with other needs, on issues around SRH. Like in other outreach visits ran by the association, women in Kyebando are also educated about long-term methods of family planning. These young girls and women are among the more than 300 people in this poor setting of Kyebando who have turned up to benefit from health services being offered by FPAU. This is one of the outreach sites being run by the Association, in an effort to reach the poor of the poorest. The programme being implemented here is part of what is called Children Millennium Project, which is supported by Plan Uganda, using funds from Canadian International Development Agency. FPAU comes to this site twice a week and uses an integrated model to offer services ranging from family planning, VCT, antenatal, to treatment of malaria, screening for sexually transmitted infections (STIs), immunization, and health education. “Patients with major or complicated ailments are referred to FPAU clinic at the headquarters or to the government’s Mulago National Referral hospital,” said Linda Birungi, FPAU service provider in-charge of Kyebando Outreach site. Those who test HIV positive are too referred to Mulago hospital or other centres where CD4 count test and free antiretroviral programmes are available. The clients here are overwhelmingly poor, living on less than a dollar a day. Public health facilities in this area are non-existent, with few private clinics, mostly manned by non-professionals, who charge exorbitantly. But the outreach programme provides the services free of charge. Even for those where charges are levied, they are heavily subsidized, explaining the huge turn-out whenever there is an outreach visit. As one of the client put it: “Whenever a person falls sick, you just persevere until the day the Association will be offering treatment.” But attending to the huge numbers during the outreach visits is not easy. At the Kyebando outreach centre, for instance, there is only one nurse and two other staff members who are expected to attend to the 300 clients on a hectic day like this. On less busy days, the client load ranges between 80 and 100. “This work is so draining that by the time I am through, I am dead-beat,” said Birungi. Such workload vis-à-vis constraining human resource, is likely to affect the quality of services delivered. To attend to everybody, Ms Birungi and her team are forced to spend few minutes with every patient as they struggle to clear the queue. She thinks recruitment of more personnel would help manage the heavy workload that confronts them during the outreach visits. “At the moment we are spread thinly on the ground, but managing the situation,” said Ibembe. Similar problems face other outreach visits run by the Association and which are currently offering immense and immeasurable benefits to poor Ugandans. Two to three FPAU personnel manning each outreach site are on many occasions overwhelmed with the numbers they have to deal with. While the Association acknowledges human resource constraints as a major issue they have to deal with, lack of financial resources to employ more people or offer refresher training to the existing ones, remain the biggest drawback. A huge percentage of the funding they receive goes into services, with little being left to hire more staff. This means the Association will have to either mobilize resources from donors for this purpose or explore other innovative ways of raising funds for salaries and other incentives. In addition to human resource, there are other infrastructural challenges. At Kyebando, the garage the association has turned into a consultation and examination room is one of them. There is lack of confidentiality since the patient is forced to discuss intimate matters in the earshot of other patients. The situation becomes complicated if the patient needs physical examination. The service providers have to request the garage owner to allow then to use one of his bedrooms to do so. Observes Birungi: “This is very cumbersome and inconveniences us and the house owner, especially when we are forced to keep asking for permission for the many patients.” Alternatively, to ensure privacy and confidentiality, clients are referred to the FPAU clinic at its headquarters. Unfortunately, many of them do not go to the clinic due to lack of bus fare. A part from Kyebando, FPAU does outreach programmes on a daily basis in various parts of the country, according to Dr. Ibembe. In the rural areas, community based reproductive health volunteers distribute contraceptives to compliment efforts of outreach programmes. Likewise, during outreach visits, children under five years and pregnant women receive free insecticide treated nets to protect them from malaria. Prevailing EnvironmentAs FPAU redefines itself to remain relevant and ensure its leadership position in sexual and reproductive health and rights, the task ahead requires innovative approaches in tackling existing challenges. The country faces overwhelming SRH challenges. Assistant Commissioner for Reproductive Health, Dr Anthony K. Mbonye cites a number of these challenges which he says have to define how FPAU, the government, and other stakeholders, design their programmes in the next 20 years or so. Currently, family planning unmet need stands at 41 per cent, according to the 2006 Uganda Demographic and Health Survey (UDHS). Two in five married women in Uganda have unmet need for family planning. About 25 percent of these women need family planning to space their births compared to 16 percent who require it for limiting the number of children. But they are not getting the contraceptives. Although the number of those using any method of contraceptive has increased from 23 per cent in 1995 to 24 percent in 2006, this number remains low. All this is a consequence of many factors, including rapid population growth that has led to an unprecedented increase in the number of young people who need sexual and reproductive health services. This increase, according to Dr. Mbonye, has brought more people into the bracket of family planning users, putting immense pressure on provision of services. Yet, the increase has not attracted increased funding for SRH programmes. Funds for reproductive health have been dwindling over the years, making it difficult for the government to open up new delivery points that are closer to the people. Dr. Mbonye said the government was exploring ways of intervening at the parish level where maternal and family planning services can be provided. Even if this succeeded, the government would have to grapple with another challenge: lack of trained health personnel at those levels as well as constant contraceptive stock-outs that currently bedevil the many health centres. “In most of these centres, stock-outs are due to poor management of health services, and lack of planning and forecasting skills,” lamented Dr Mbonye. The 2006 UDHS indicates that the average total fertility rate is 6.7 (4.4 children per woman in urban and 7.1 children per woman in rural areas). However, it notes that 41 per cent of married women in Uganda now want no more children or prefer sterilization; 35 per cent want to wait for two or more years before the next birth, and 16 percent want to have a child within two years. The sources where the women got their contraceptives varied. Fifty two (52) per cent of the women obtained their products from private sector, more than a third from public, and 13 per cent from other private sources. The maternal mortality ratio stood at 435 deaths per 100,000 live births, one of the highest in Africa. Such high rates could be explain by several factors lack of skilled birth attendants or access emergency obstetric care. According to the UDHS, 58 per cent of the women delivered at home, with 42 per cent in health centres. Statistics on infant and child mortality were not good either. The infant mortality was 76 deaths per 1,000 live births, with the under-five mortality rate standing at 137. These rates were higher in rural area (88 deaths per 1,000 live births) than urban areas (68 deaths per 1,000 live births). Information on the trends in the HIV/AIDS arena indicates much still need to be done. The UDHS shows that 28 percent of the men and less than two per cent of the women had had two or more sexual partners during the 12 months preceding the survey. Gender-based violence, a factor now positively correlated with HIV spread, was captured by the survey, with 70 per cent of the women reporting to have experienced physical or sexual violence. Those most affected were rural women (41 per cent) compared to their urban counterparts (31 per cent). Other challenges facing young girls are the negative cultural practices such Female Genital Cutting (FGM), polygamy, and early marriages. It is estimated that 300,000 unsafe abortions are procured every year in Uganda, with the government hospitals spending millions of shillings to attend to over 80,000 cases of post-abortion care annually. The restrictive legal regimes that allow safe abortion only when it is to save the life of the mother, is to blame for these outcomes, as it pushes women to the back streets quacks. It is within this context full of issues and inherent challenges FPAU is going to offer its services in the next two or three decades. In fact, Dr Mbonye, strongly thinks the Association is going to be very relevant in not only serving the under-served but also in offering technical support to government staff. The Association will have to bank on its 50-year–old experience and the emerging opportunities to win the battle and put a smile of the faces of many poor women, men and youth who look upon it for SRH services. OpportunitiesThe decentralized system of governance, where decisions are made at the local level makes it easier for FPAU to advocate for increased SRH resources and formulation of favourable policies by local authorities. “It is easier to advocate at the local council level than at the national level where there many interests at play,” says Peter Ibembe, FPAU’s National Programme Manager Donor support to the budget is another area of opportunity. Because donors fund up to 40 per cent of the budget, they have the power to influence the government to allocate more resources to SRH. Hence, the way forward would be to convince donors on the importance of influencing the government to do just that. Joyce Mpanga, said unlike in the past years when family planning was viewed as preventing people from giving birth, such attitudes have changed with many people now considering it a strategy to pursuing quality lives. These opportunities are some of those that are going to be critical as FPAU focuses on a future that is replete with SRH challenges. Giving hopeOn the hilly and leafy suburb of Kampala city lies an old building that has come to personify the hope of many poor Ugandan women, men and children. Every morning, women with children strapped on their backs and others tagging by, stream to this place, sure of their sexual and reproductive health needs being attended to. This is the Family Planning Association of Uganda clinic at its headquarters. For over three decades, this clinic has remained the last line of defense for the poor people who cannot afford services offered in the private sector. Inside the clinic, several services are given by the three service providers who have, with assistance of 10 support staff, to work overtime to clear the heavy caseload. This staffs say they have witnessed a major improvement in the broadening of services they offer to their clients. “From offering vertical family planning, we have transformed ourselves and are now providing a comprehensive integrated SRH services,” says Margaret Demeter Namuyobo, who is in-Charge of the clinic. Provision of long-term family planning methods and integration of HIV/AIDS into SRH delivery points are some of these major developments. With this transformation, the number of clients has increased in leaps and bounds. In the year 2006, for instance, the Katego clinic alone served over 112,000 clients – youths, adults and children. Clients who cannot come to the clinic are catered for during the outreach visits. The clinic conducts 12 outreach visits every week, eight at sites set-up in slum areas. Still, this increased workload has been accompanied with increased quality of care. Again, such tremendous work of high quality resulted in the association scooping the first position when the government did a ranking of organizations working in SRH. The clinic has also registered another first in recent times by conducting capacity building of other organizations. The Ministry of Health and other NGOs use it as a training centre for their staff. Post-graduate students from Makerere University too come to offer their services under an arrangement the Association has with the institution. Demeter attributes all this excellent performance to team work. “One of our overriding values is team work. For without it, nothing moves.” But the path towards realizing this string of successes as been replete with challenges. Ranking high on the list is lack of enough human resource. The few service providers are forced to come up with innovative ways of serving a huge clientele base. In the long-term, this is going to have negative effect on the quality of services delivered. While integration of services has improved access to healthcare, it has at the same time posed major challenges. Although the service providers are strained as they cope with the increased workload; the amount of funds flowing in, especially the ones needed to motivate staff through increased salaries, has remained static. Equipments such as the ultra-sound and a CD4 count machine, which would help in bettering the management of the HIV positive clients, are not available. Patients requiring CD4 count tests and antiretroviral drugs have to be referred to government hospitals or organizations offering these services. Of those who consulted the clinic in 2006 and 2007, about 23 per cent were referred to other centres for HIV management. In 2006 and 2007, FPAU has had to refer 33 per cent of its clients to other hospitals for ultra sound. Experience has shown that, notes Demeter, many of these patients fear confiding in other people after doing so at the clinic. Thus, they rarely end-up at the referral centres. When it came to other services, 4 percent of infertility cases, 6 percent of antenatal care and 9 percent of those requiring laboratory services were referred to other health facilities. Despite of these hiccups, FPAU staff are very optimistic about the future. To maintain its status as the leader in provision of SRH services, Demeter proposes the transformation of the clinic a fully-fledged in and out patient hospital, with a theatre.
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Clinics awash with young men 
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