Decentralization and National Health Policy Implementation in Uganda – a Problematic Process

Background: The Ugandan Government has aimed at creating a needs-based and cost-effective health care system. The means to carry out this aim have been 1) a decentralization of the health sector in order to increase lower-level responsibility, accountability, and participation, and 2) a strong national policy formulation capacity, facilitating needs assessment and cost-effective prioritization. Aim: The aim of this study is to investigate the process of ascertaining goal achievement with regard to needs-based health care services and national health policy implementation in the decentralized health care system of Uganda. Population and method: The health sector of Uganda is examined from the national to the district level. Focus is on the process of decentralization, which includes a more efficient mechanism for implementing policy goals throughout the decentralized system, since traditional hierarchical methods of directing institutions become obsolete. In order to study the implementation process, the theoretical framework of new institutionalism has been employed. The several papers in this thesis focus on understanding the prerequisites of policy implementation in a decentralized system. In the final paper, the outcome of a full-scale policy implementation trial is assessed and interpreted against the background of the previous studies. The concepts of diffusion and translation have been adopted from the theoretical framework of new institutionalism in organizational theory, and are used as tools in the analysis. The methods employed for data collection in different parts of the study have been interviews, questionnaires, focus group discussions, and document analysis. Results: Financial decentralization was studied under the assumption that districts would prioritize health care financially in implementing the new national health policy. It was, however, observed that this was not the case. As the Sector-Wide Approach Process (SWAP) was studied, it was observed that, while the policy formulation capacity of the Ministry of Health (MOH) (which is no longer supposed to focus on detailed health systems planning as in the past) became stronger, the central level had difficulties in maintaining efficient interaction with those responsible for implementation. This had resulted in an increasing gap between the centre and the periphery. The adoption of new policies, paradigms, and strategies, such as SWAP, the restructuring of the MOH, and the formulation of a new health policy, has strengthened ties with the global institutions. Sharing paradigms and values has probably further promoted a the independence of the MOH. Also studied was the application of two normative rationalist instruments, Burden of Disease (BOD) and Cost-Effectiveness (CE), intended to implement national health policy priorities at a district level. This application was a failure. Discussion: The increasing decentralization of the health care system in Uganda during the period studied has not been followed promptly by the implementation of a global national health policy necessary for a decentralized system. It appears as if the government assumed that new health policies could be implemented by means of a fairly uncomplicated process of diffusion. However, an analysis of the near total failure of the BOD/CE initiative shows that implementation of policy in the decentralized system in Uganda is complex and must be understood as a misdirected translation process whose prerequisites were lacking. The main factors that have inhibited the adoption of a new policy and have crated a gap between centre and periphery have been different values, the absence of a common frame of reference, and the lack of government support. As a result, local obligations and local accountability have been the main factors guiding the translation. © Anders Jeppsson, 2004 Printed in Sweden. Media-Tryck, Lund, 2004.