Political economy analysis of subnational health management in Kenya, Malawi and Uganda

Abstract

The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers’ ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N = 112) with government actors, development partners and civil societies in three districts or counties in each country (N = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach.

Perceived progress toward scale of 14 maternal, newborn, child health, and nutrition (MNCHN) assets at subnational level in Burkina Faso, Ethiopia, India, Kenya, and Nigeria

“…In this assessment, budget allocation was mentioned as a barrier more often by DHMT staff than providers (54% vs. 41%). At the subnational level, underfunded budgets and misalignment between policy, planning and budgeting sometimes occurs [30,31]. Results from an analysis of the political economy of subnational health sector planning and budgeting in three counties in Kenya revealed that while devolution has resulted in expanded participation in subnational health management, budget allocation has become more politicized so may not be directly aligned with national priorities [32].…”

Political Economy Analysis of Health Taxes (Tobacco, Alcohol Drink, and Sugar Sweteened Beverage): Case Study of Three Provinces in Indonesia

“…We used a problem-driven Political Economic Analysis (PEA) adapted from Overseas Development Institute (ODI) framework(14, 15, 43) to guide our analysis. This framework offers flexibility in analyzing specific policies across a wide spectrum of issues(44, 45).…”

“…We employed framework analysis(48, 49) using the transcribed verbatim from all the audio records of the FGD. We constructed a matrix to display the participants’ arguments against the PEA framework, from which we derived keywords to align with the themes and sub-themes outlined in the PEA for each commodity category (see Appendix S3), adopted from Rodríguez et al, 2023 (14). A cross-member checking was performed to ensure rigorous data analysis process.…”

“…The political economy of a health system shapes policy development and implementation in important ways (12). Conflicts of interests, poor interagency and multisectoral coordination, as well as excessive bureaucracy were among the most common challenges to fully institutionalizing evidence-informed health taxes policy recommendations (13)(14)(15). Public sector decentralization may hinder the health policy adoption due to challenges including limited shared understanding of health tax objectives among local authorities, political complexities, and financing issues at the sub-national level, resulting in suboptimal implementation (14,16).…”

“…Conflicts of interests, poor interagency and multisectoral coordination, as well as excessive bureaucracy were among the most common challenges to fully institutionalizing evidence-informed health taxes policy recommendations (13)(14)(15). Public sector decentralization may hinder the health policy adoption due to challenges including limited shared understanding of health tax objectives among local authorities, political complexities, and financing issues at the sub-national level, resulting in suboptimal implementation (14,16). Indonesia, as one of the largest countries with escalating concerns in the healthcare sector, primarily due to rising the NCDs epidemic (17)(18)(19).…”