Health Coverage and Financial Protection in Uganda: A Political Economy Perspective

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.

Advancing Empirics and Theory for a Deeper Political Economy Analysis Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

At its core, political economy analysis involves examination of the relationship between the state and the market. A number of country case studies have emerged in recent years that aim to identify political economy factors facilitating or impeding health sector reforms towards universal coverage. In this commentary, we expand Nannini and colleagues' analysis to elaborate on how political economy analyses can better inform policy design towards more successful reforms in low- and middle-income countries (LMICs) by drawing more heavily on improved research design and theory. We suggest three ways that political economy studies could make deeper claims by historicizing analyses, going comparative and/or by grounding findings more deeply in theory.

Comparative Politics, Political Settlements, and the Political Economy of Health Financing Reform Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

Nannini et al analyze barriers to national health insurance reforms in Uganda using a political economy approach primarily rooted in stakeholder analysis. This approach is valuable, not only for its clear description of the interest-based politics at play, but also for its extension of stakeholder analysis to include consideration of the role of ideas and institutions in the policy process. However this analysis, and others like it, could be further strengthened by adding insights from two different sources. The first is the comparative politics literature on the Ugandan regime. The second is a related approach which analyzes public service delivery in the context of a country's underlying "political settlement." Stakeholder-based approaches to health financing reform emphasize interest group conflict about the contents of policy reforms. By contrast, these complementary approaches imply distinct barriers to successful implementation of national health insurance in Uganda, rooted in the regime's de-industrialization and the personalization of politics and resource allocation. They also suggest possible leverage points or avenues for progress which differ from those suggested by stakeholder analysis.

A Historical Legacy for Universal Health Coverage in the Republic of Korea: Moving Towards Health Coverage and Financial Protection in Uganda Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

Since 2001, when Uganda abolished user fees to improve the accessibility of healthcare, out-of-pocket costs still account for 42% of total health expenditure. Even if universal health coverage (UHC) is achieved on the demand-side, government authorities face political and economic challenges due to soaring burden of diseases. Therefore, this study aimed to re-analyze the implementation process according to three pillars by World Health Organization (WHO) based on Korean UHC-related articles. In terms of breadth, the national health insurance (NHI) in Korea UHC was established from 1977 for employees to 1989 for self-employed. In terms of depth, benefit packages in Korea UHC have expanded from essential medical services to expensive care (ultrasono, computerized tomography, etc) including benefit period. Finally, in terms of height of coverage, the government has tried to relieve financial burden of households with catastrophes and enhance benefit plan for major diseases till now. This historical legacy for UHC in Korea can pose lessons to policy-makers in developing countries including Uganda and Ghana.

Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa

BACKGROUND

Lack of political will is frequently invoked as a rhetorical tool to explain the gap between commitment and action for health reforms in sub-Saharan Africa (SSA). However, the concept remains vague, ill defined and risks being used as a scapegoat to actually examine what shapes reforms in a given context, and what to do about it. This study sought to go beyond the rhetoric of political will to gain a deeper understanding of what drives health reforms in SSA.

METHODS

We conducted a scoping review using Arksey and O'Malley (2005) to understand the drivers of health reforms in SSA.

RESULTS

We reviewed 84 published papers that focused on the politics of health reforms in SSA covering the period 2002-2022. Out of these, more than half of the papers covered aspects related to health financing, HIV/AIDS and maternal health with a dominant focus on policy agenda setting and formulation. We found that health reforms in SSA are influenced by six; often interconnected drivers namely (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) policy diffusion.

CONCLUSION

Political will is relevant but insufficient to drive health reform in SSA. A framework of differential reform politics that considers how the power and beliefs of policy elites is likely to shape policies within a given context can be useful in guiding future policy analysis.

COVID-19 Aftermath: Direction Towards Universal Health Coverage in Low-Income Countries Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

Progressive realization of universal health coverage (UHC) requires health systems capacity to provide quality service and financial risk protection which supports access to services without financial hardship. Government health spending in low-income countries (LICs) has been low and heavily relied on external donor resources and out-of-pocket payment. This has resulted in high prevalence of catastrophic health spending or foregone care by those who cannot afford. Under fiscal constraints posed by pandemic, reforms in LICs should focus on efficiency through health resource waste reduction. Targeting the poor even with low level of health spending can make a significant health gain. Investment in primary healthcare and health workforce is the foundation for realizing UHC which cannot be postponed. Innovative tax on health hazardous products, conditional debt relief can increase fiscal space for health; while international collaboration to accelerate coronavirus disease 2019 (COVID-19) vaccine coverage can bring LICs out of acute phase of pandemic.

Health Financing Reforms in Uganda: Dispelling the Fears and Misconceptions Related to Introduction of a National Health Insurance Scheme Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

Uganda introduced health financing reforms that entailed abolition of user fees, and in due process planned to introduce a National Health Insurance Scheme (NHIS). This paper accentuates a contextual and political-economic analysis that dispels the fears and misconceptions related to introduction of the insurance scheme. The Grindle and Thomas model is used to depict how various factors affect decision making by policy elites concerning a particular policy at a particular time. Drawing lessons from the sub-Sahara region and in particular, Ghana and Rwanda's experience, it is clear that the political will of the executive led by the president in many countries is a key determinant in bringing about health reforms. In this paper, we provide insights based on contextual and political-economic analysis to countries in similar setting that are interested in setting up NHISs.

How to Achieve Universal Health Coverage: A Case Study of Uganda Using the Political Process Model Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

How can resource-deprived countries accelerate progress towards universal health coverage (UHC)? Here we extend the analysis of Nanini and colleagues to investigate a case-study of Uganda, where despite high-level commitments, health system priority and funding has shrunk over the past two decades. We draw on the Stuckler-McKee adapted Political Process model to evaluate three forces for effecting change: reframing the debate; acting on political windows of opportunity; and mobilising resources. Our analysis proposes a series of pragmatic steps from academics, non-governmental organisations, and government officials that can help neutralise the forces that oppose UHC and overcome fragmentation of the pro-UHC movement.

Beyond "Lack of Political Will": Elaborating Political Economy Concepts to Advance "Thinking and Working Politically" Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

Political economy analysis (PEA) has been advanced as critical to understanding the political dimensions of policy change processes. However, political economy (PE) is not a theory on its own but draws on several concepts. Nannini et al, in concert with other scholars, emphasise that politics is characterised by conflict, contestation and negotiation over interests, ideas and power as various agents attempt to influence their context. This commentary reflects how Nannini et al wrestled with these PEA concepts - summarised in their conceptual framework used for PEA of the Ugandan case study on financial risk protection reforms. The central premise is that a common understanding of the PEA concepts (mainly structure-agency interactions, ideas, interests, institutions and power) forms a basis for strategies to advance thinking and working politically. Consequently, I generate several insights into how we can promote politically informed approaches to designing, implementing and evaluating policy reforms and development efforts.