"The Actor Is Policy": Application of Elite Theory to Explore Actors’ Interests and Power Underlying Maternal Health Policies in Uganda, 2000-2015

Abstract

Background: The persistence of high maternal mortality and consistent failure in low- and middle-income countries to achieve global targets such as Millennium Development Goal five (MDG 5) is usually explained from epidemiological, interventional and health systems perspectives. The role of policy elites and their interests remains inadequately explored in this debate. This study examined elites and how their interests drove maternal health policies and actions in ways that could explain policy failure for MDG 5 in Uganda. Methods: We conducted a retrospective qualitative study of Uganda’s maternal health policies from 2000 to 2015 (MDG period). Thirty key informant interviews and 2 focus group discussions (FGDs) were conducted with national policy-makers, who directly participated in the formulation of Uganda’s maternal health policies during the MDG period. We reviewed 9 National Maternal Health Policy documents. Data were analysed inductively using elite theory. Results: Maternal health policies were mainly driven by a small elite group comprised of Senior Ministry of Health (MoH) officials, some members of cabinet and health development partners (HDPs) who wielded more power than other actors. The resulting policies often appeared to be skewed towards elites’ personal political and economic interests, rather than maternal mortality reduction. For a few, however, interests aligned with reducing maternal mortality. Since complying with the government policy-making processes would have exposed elites’ personal interests, they mainly drafted policies as service standards and programme documents to bypass the formal policy process. Conclusion: Uganda’s maternal health policies were mainly influenced by the elites’ personal interests rather than by the goal of reducing maternal mortality. This was enabled by the formal guidance for policy-making which gives elites control over the policy process. Accelerating maternal mortality reduction will require re-engineering the policy process to prevent public officials from infusing policies with their interests, and enable percolation of ideas from the public and frontline.

‘Writing budgets for meetings and teas?’: a multitheoretical analysis of intragovernmental coordination for multisectoral action for health in Uganda

“… 12 This work contributes to studies that have used theories to analyse data and interpret findings. 33 36 37 86 We demonstrated how a multitheoretical approach is particularly pertinent to intragovernmental coordination. The TCE with emphasis on transaction costs, the agency theory with focus on principal–agent relationships in government, the RDT with its emphasis on interdependence and the PE theory with its attention to politics and contestation over ideas, interests and resources, each provide a partial explanation of the reasons for coordination or not.…”

“… 32 In other instances, theory-guided data analysis has been used to interprete and explain data. 33 34 There is also an interest in the number of theories used in a given research enterprise. 35 There are instances when one theory has been used to interprete empirical data in LMICs-based case studies.…”

“… 35 There are instances when one theory has been used to interprete empirical data in LMICs-based case studies. 33 36 Conversely, some HPSR scholars have used more than one theory in their inquiry. 37 The multitheoretical approach derives richer and deeper analyses by drawing on the different theoretical world views and propositions, thereby overcoming the potential slanted analysis associated with no or a single theoretical perspective.…”

Introduction to the Special Issue on "Analysing the Politics of Health Policy Change in Low- and Middle-Income Countries: The HPA Fellowship Programme 2017-2019"

“…Other policy stages are examined by Okeyo et al 12 and Mukuru et al 13 Oeyo et al 12 consider the policy adoption (formulation) process around the 'first thousand days of childhood' initiative, an intersectoral programme to improve child health outcomes, within one province of South Africa. Explicitly considering the ideas, interests and institutions influencing policy adoption, this paper considers what factors hinder moves towards policy implementation following apparently successful agenda setting processes.…”

“…The analysis raises important questions about whether and how health sectors and systems can break free of historical ideas, interests and institutions to enable the intersectoral action recognised as essential in addressing the social determinants of health. Founded in policy elite theory, Mukuru et al 13 present a detailed inquiry into how policy elites' interests and power dynamics influenced decisionmaking around maternal health policy in Uganda. The paper considers political, state and donor actors working at national level, illuminating diverse driving interests including votewinning, personal economic interests, pragmatic interests and altruistic interests.…”