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

Abstract

Background: As countries health financing policies supporting progress towards Universal Health Coverage (UHC), an analysis of these policies is particularly relevant in Low and Middle-Income Countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. Objective: This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition. Methods: The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 Key Informant Interviews in the health sector. Results: We find that the current political situation is not yet conducive for implementing a universal health coverage system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship. Conclusion: By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.

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

“…Studies have also shown the influence of market economy ideologies. The neoliberal agenda of the 1980s–1990s had adverse effects in Ghana,36 Zimbabwe24 and Uganda 78. In South Africa, the SHI lost momentum when the country adopted the neoliberal-laden Growth, Employment and Redistribution (GEAR) 40 which favoured efficiencies and control of public sector expenditure 38 39.…”

“…The desire to win or stay in government plays a major role in shaping health reforms, particularly if the opposition political parties raise reforms on the campaign plank. However, reforms that are primary driven by electoral motives are often populistic, hurried and technically weak 78 as in the case of user fee removal 132 and community health initiatives. 122 This study also found that political ideologies have a profound effect on policy reforms.…”

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"

“…15 In addition, the "free healthcare" policy was perceived as inconsistent with the introduction of premiums under NHIS-counteracting policy adoption. 4 In conclusion, this paper raises key considerations to practically change the 'rules of the game' of how PEA is deployed as both a practical and theoretical tool. First, disaggregating while carefully linking the PEA concepts increases their viability as analytical tools for researchers and policymakers to think and work politically.…”

“…2 However, defining politics and related concepts is not straightforward. 3 Nannini et al, 4 in their paper on health financing reforms in Uganda, underscore the relevance of the political economy (PE) lens in understanding the dynamics of advancing universal health coverage aspirations. The authors applied a conceptual framework with several domains, including stakeholders and institutions, politics (interests and ideologies), policy implementation and outcomes.…”

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"

“…1 Yet once attaining power, the ideology changed towards the supremacy of the market forces, without being accountable electorally. 1 At present there is a stark imbalance between the concentrated political power of the private sector in healthcare, versus the fragmented and diffuse social-forces of communities, advocacy groups, and people who would benefit from UHC. Government officials have, perhaps perversely, tended to rely on external donors for both funding and leadership, without the necessary accountability and commitment for UHC.…”