The aim of this study was to assess the political and social dynamics resulting from the rapid change in user-fee reforms in Uganda and the effects on service delivery for malaria control. Using political mapping and political risk analysis techniques, the study analysed qualitative and quantitative data obtained from secondary data sources and key actors in the policy arena. The results have shown that the feasibility of user-fees in Uganda was undermined by the absence of strong central government leadership and strategies to manage the politics of the reforms. The resultant rapid change in policy adversely affected the recurrent expenditures of health units that previously relied heavily on cost sharing, which led to a chronic shortage of malaria drugs and undermined the ability of health facilities to hire and motivate staff. The study results demonstrate that in order to contribute positively to healthcare delivery goals for malaria control in endemic countries, user-fees require full ownership and strong political leadership by the central government. Decentralization, when merely used as a strategy to navigate the political risks associated with user-fees, is unlikely to succeed without a centrally coordinated and managed process of policy formulation and acceptance involving wider consultations and political management of interest groups.
The introduction of user-payment for health services is frequently followed by concern about the impact on equity of access for poor people. Decentralizing governments often try to remedy the created inequities by putting in place safety nets in the form of exemptions and waivers in the user-fee systems. However, where user payments merely operate as local government strategies for health financing, without national policy they are likely to be self-defeating, as local governments are frequently more interested in raising revenue to meet recurrent costs of devolved services than in promoting equity. Thus guidelines put in place by the central government to operationalize safety nets are seen by local governments as being contradictory to this goal, and are thus ignored or altered to suit the district revenue aims. This study was carried out to investigate the context and the constraints in implementing exemption schemes. Data were collected in two selected administrative districts of Uganda (Mbarara and Mukono). Qualitative approaches to data collection were adopted, namely focus group discussions and key informant interviews with policy-makers, health administrators, service providers and community members. These methods were combined with document review. We found little evidence of safety-net guidelines initiated by decentralized/local governments, since district local governments had little motivation to extend exemptions, waivers or credits. The conclusion is that safety nets such as waivers and exemptions will only be effective if they are backed by a national health financing policy, they reconcile the often competing demands of local government revenue needs, and are strictly enforced and supervised by both the local and central governments. The implications of the findings for remedying the tension between the needs for cost recovery and for attainment of equity goals through exemption policies for the poor and indigent are discussed.
Local government in South Africa, or ‘developmental local government’ as the lowest tier of government is often called (RSA 1998), carries the mandate of executing national development priorities of the country, as empowered by the constitution (RSA 1996), and by local government policy and legislation such as the White Paper on Local Government (RSA 1998) and the Municipal Systems Act (RSA 2000), that spell out the roles and responsibilities of local government. In terms of this mandate, local government is categorized into metropolitan, district and local municipalities, and has the responsibility of providing basic services such as water and sanitation, housing, and roads within those municipal jurisdictions, based on local integrated development plans (IDPs).
Sub-Saharan African (SSA) countries have the highest rates of HIV prevalence in the world accounting for an estimated 71% of all new infections (UNAIDS 2010
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