'Writing budgets for meetings and teas?': a multitheoretical analysis of intragovernmental coordination for multisectoral action for health in Uganda

Policy analysis of the Global Financing Facility in Uganda

BACKGROUND

In 2015, Uganda joined the Global Financing Facility (GFF), a Global Health Initiative for Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH). Similar initiatives have been found to be powerful entities influencing national policy and priorities in Uganda, but few independent studies have assessed the GFF.

OBJECTIVE

To understand the policy process and contextual factors in Uganda that influenced the content of the GFF policy documents (Investment Case and Project Appraisal).

METHODS

We conducted a qualitative policy analysis. The data collection included a document review of national RMNCAH policy documents and key informant interviews with national stakeholders involved in the development process of GFF policy documents (N = 16). Data were analyzed thematically using the health policy triangle.

RESULTS

The process of developing the GFF documents unfolded rapidly with a strong country-led approach by the government. Work commenced in late 2015; the Investment Case was published in April 2016 and the Project Appraisal Document was completed and presented two months later. The process was steered by technocrats from government agencies, donor agencies, academics and selected civil society organisations, along with the involvement of political figures. The Ministry of Health was at the center of coordinating the process and navigating the contestations between technical priorities and political motivations. Although civil society organisations took part in the process, there were concerns that some were excluded.

CONCLUSION

The learnings from this study provide insights into the translation of globally conceived health initiatives at country level, highlighting enablers and challenges. The study shows the challenges of trying to have a 'country-led' initiative, as such initiatives can still be heavily influenced by 'elites'. Given the diversity of actors with varying interests, achieving representation of key actors, particularly those from underserved groups, can be difficult and may necessitate investing further time and resources in their engagement.

Demands for Intersectoral Actions to Meet Health Challenges in East and Southern Africa and Methods for Their Evaluation

OBJECTIVES

Focusing on the East, Central, and Southern African region, this study examines both regional and country-level initiatives aimed at promoting multisectoral collaboration to improve population health and the methods for their economic evaluation.

METHODS

We explored the interventions that necessitate cooperation among policymakers from diverse sectors and the mechanisms that facilitate effective collaboration and coordination across these sectors. To gain insights into the demand for multisectoral collaboration in the East, Central, and Southern African region, we presented 3 country briefs, highlighting policy areas and initiatives that have successfully incorporated health-promoting actions from outside the health sector in Zimbabwe, Uganda, and Malawi. Additionally, we showcased initiatives undertaken by the Ministry of Health in each country to foster coordination with national and international stakeholders, along with existing coordination mechanisms established for intersectoral collaboration. Drawing on these examples, we identified the primary challenges in the economic evaluation of multisectoral programs aimed at improving health in the region.

RESULTS

We illustrated how decision making in reality differs from the traditional single-sector and single-decision-maker perspective commonly used in cost-effectiveness analyses. To ensure economic evaluations can inform decision making in diverse settings and facilitate regional collaboration, we highlighted 3 fundamental principles: identifying policy objectives, defining the perspective of the analysis, and considering opportunity costs. We emphasized the importance of adopting a flexible and context-specific approach to economic evaluation.

CONCLUSIONS

Through this work, we contribute to bridging the gap between theory and practice in the context of intersectoral activities aimed at improving health outcomes.

Examining the influence of health sector coordination on the efficiency of county health systems in Kenya

BACKGROUND

Health systems are complex, consisting of multiple interacting structures and actors whose effective coordination is paramount to enhancing health system goals. Health sector coordination is a potential source of inefficiency in the health sector. We examined how the coordination of the health sector affects health system efficiency in Kenya.

METHODS

We conducted a qualitative cross-sectional study, collecting data at the national level and in two purposely selected counties in Kenya. We collected data using in-depth interviews (n = 37) with national and county-level respondents, and document reviews. We analyzed the data using a thematic approach.

RESULTS

The study found that while formal coordination structures exist in the Kenyan health system, duplication, fragmentation, and misalignment of health system functions and actor actions compromise the coordination of the health sector. These challenges were observed in both vertical (coordination within the ministry of health, within the county departments of health, and between the national ministry of health and the county department of health) and horizontal coordination mechanisms (coordination between the ministry of health or the county department of health and non-state partners, and coordination among county governments). These coordination challenges are likely to impact the efficiency of the Kenyan health system by increasing the transaction costs of health system functions. Inadequate coordination also impairs the implementation of health programmes and hence compromises health system performance.

CONCLUSION

The efficiency of the Kenyan health system could be enhanced by strengthening the coordination of the Kenyan health sector. This can be achieved by aligning and harmonizing the intergovernmental and health sector-specific coordination mechanisms, strengthening the implementation of the Kenya health sector coordination framework at the county level, and enhancing donor coordination through common funding arrangements and integrating vertical disease programs with the rest of the health system. The ministry of health and county departments of health should also review internal organizational structures to enhance functional and role clarity of organizational units and staff, respectively. Finally, counties should consider initiating health sector coordination mechanisms between counties to reduce the fragmentation of health system functions across neighboring counties.

What are the Tools Available for the Job? Coordination Instruments at Uganda's Central Government Level and Their Implications for Multisectoral Action for Health

Managing sectoral interdependences requires functional tools that facilitate coordinated multisectoral efforts. The pursuit of multisectoral action (MSA) for health is intrinsically linked to broader efforts in many governments to achieve greater internal coordination. This research explores the nature of coordination instruments for MSA at the national level in Uganda and the complexities of how these tools play out in implementation. Data was collected through 26 purposive in-depth interviews with national-level stakeholders, including government officials and non-state actors, and a review of selected government strategic documents. An adapted framework by Bouckaert and colleagues (2010) was used to establish a typology of coordination instruments (CIs) and break them down into structural and management tools, and infer their underlying coordination mechanisms based on their design and operational features. A multitheoretical framework guided the analysis of the factors influencing the implementation dynamics and functioning of the tools. The study found that the government of Uganda uses a range of structural and management instrument mixes mutually influencing each other and mainly based on hierarchy and network mechanisms. These instruments constitute and generate the resources that structure interorganisational relationships across vertical and horizontal boundaries. The instrument mixes also create hybrid institutional configurations that generate complementary but at times conflicting influences. This study demonstrated that a contextualized examination of specific coordination tools can be enhanced by delineating the underlying institutional forms of ideal type mechanisms. Such an approach can inspire more complex analysis and comparisons of CIs within and across government levels, policy domains or issues over time. Health policy and systems research needs to pay attention to the instrument mixes in government systems and their dynamic interaction across policy issues and over time.

The Government Budget: An Overlooked Vehicle for Advancing Strategic Health Purchasing

The most effective way to finance universal health coverage (UHC) is through compulsory prepaid funds that flow through the government budget. Public funds-including on-budget donor resources-allow for pooling and allocation of resources to providers in a way that aligns with population health needs. This is particularly important for low-income settings with fiscal constraints. While much attention is paid to innovative sources of additional financing for UHC and to implementing strategic purchasing approaches, the government budget will continue to be the main source of health financing in most countries-and the most stable mechanism for channeling additional funds. The government budget should therefore be front and center on the strategic purchasing agenda. This commentary uses lessons from Tanzania and Uganda to demonstrate that more can be done to use the government budget as a vehicle for making health purchasing more strategic, across all phases of the budget cycle, and for making greater progress toward UHC. Actions need to be accompanied by measures to address bottlenecks in the public financial management system.