Policy genesis
This thesis focuses primarily on the evaluation and succession of HSRs as policy, but this is the end-tail of the analysis. It is essential to discuss first the genesis, policy development and policy implementation. In Uganda, HSRs were initiated and propelled by five factors (Paper I), most of which are common to other developing countries. First, Uganda in mid 1980’s was coming out of civil war, which had left much of the health infrastructure devastated. There was a dire need for major health infrastructure rehabilitation. Second, there had been economic decline for 10 years during and following the political mismanagement of the country under dictator Idi Amin. Uganda’s economy had been contracting, not expanding.
Service delivery
Third, the contracting economy was worsened by the global economic crisis arising from the increase in oil prices in 1970s. With the advantage of hindsight, this appears to have been the major factor behind Uganda’s accelerated economic decline in 1970’s. Even peaceful and politically stable countries, such as Tanzania and Kenya, eventually suffered similar degrees of economic decline in 1990s. Fourth, there was widespread dissatisfaction with PHC as a vehicle for health-care delivery among both politicians and health-care professionals. Even ordinary people, already disillusioned with the deteriorating health services, did not view PHC as a positive strategy. Instead, many people mistakenly associated the worsening health services with the introduction of PHC. Finally, the World Bank had asserted its strong views through the publication of the World Development Report 1993, and subsequently assumed the leadership of the health sector. WHO, which was championing PHC and viewed as failing, was “pushed aside” to leave way for the World Bank which seemed to have revolutionary ideas that struck deep cords in politicians and ministries of finance in low income countries.
The usual process of policy discussion, issues-definition and forecasting of policy which should normally take place internally in a country among different interest groups (Hogwood and Gunn, 1984) did not happen. Some discussions initiated by the media and civil society were held, but these were peripheral and did not affect the content of HSR agreed between the GoU and the World Bank and other donors (Paper 1). The GoU wanted funding and the donors had a duty to promote their domestic policies through aid. Many HSR policies were extensions of domestic policies of donor countries and business interests supporting multi-national corporations of the donor countries. For the World Bank, the clear aim was to remove all barriers to a free-market global economy and ensure that all systems, including health systems, conformed to and became compatible with free-market principles.
Policy development
Health policy development in Uganda was ambivalent (Paper 1). It was driven by national political leaders on the one hand who wanted a genuine health sector development based on the usual agreed health-sector objectives. On the other hand, it was controlled by donors, led by the World Bank, which ignored most of the policy proposals made by Ugandan politicians and health professionals. A typical example is the “Three-Year Health Plan Frame 1993-1996”
developed by World Bank consultants posted to the Ugandan MOH. Subsequent policies developed by MOH were shelved and they largely remained unimplemented.
Only selected elements of the health policy (generally those market-oriented initiatives) were funded by the Bank and other donors under the Bank’s Poverty Reduction Strategy Papers (PRSP) (Paper II). Similar parallel policies were thus developed every year under different names and funded through the Ministry of Finance. The Ministry virtually became an extension of the Bank in the country, acting as its agent. Broad policy frameworks were set by the Ministry of Finance and all sectoral policies had to fit within this framework. Thus, while health policy was progressive, its implementation was subjected to market-based economic policy framework known as the Medium Term Expenditure Framework (MTEF). This framework set arbitrarily low and unrealistic ceilings for health and other social services. In the end, donors triumphed.
Only donor-selected policies (the HSRs) were funded and implemented.
Table 24: How the National Health Policy did not fulfil implementation preconditions
Conditions Comments External factors do not impose
crippling constraints
Crippling constraints in form of unrealistic budget ceilings, restriction to market reforms and other management restrictions.
There is adequate time and resources NHP was devoted far less resources than was optimal. Most resources targeted donor
determined priorities, in most cases market-based interventions.
Required combination of resources is available
Mostly impossible; usually there was lack of human skills, infrastructure and drug supplies, even when other supplies such as vaccines were available.
Theory of cause and effect is valid There is some cause-effect relationship in the NHP, but no demonstrable link between market-based HSRs and health system performance Cause-effect relationship is direct True for NHP, but not HSRs.
There is an understanding and agreement on policy
True for NHP, not for HSRs.
Dependency relationship is minimal For most of the past 20 years, the health sector has depended on donor aid for 50 to 90% of its funding. So this condition was not met.
Tasks are fully specified in the correct sequence
In real life this is usually difficult to achieve. It is even more difficult in a dependency relationship.
There is perfect communication and coordination
There was no transparent communication on the HSRs, which became the de facto national health policy, displacing NHP.
Those in authority can demand and obtain perfect compliance
In real life this is not usually fully achieved, but it becomes even less achievable under dependency and non-transparent arrangements involving donors.
Source: author’s compilation Policy implementation
Implementation of the HSRs, which in Uganda doubled as the whole public-sector health service, was done through projects and NGOs. The HSRs were geared to activities with clear and immediate outputs for accountability to donors. These projects or programmes typically avoided funding health care infrastructure, health personnel, institutional development or long-term plans. The implementation of HSRs also fragmented the health system. In many cases, with the increasing participation of numerous NGOs funded by donors, the system became uncontrollable by both donors and the government. The mismanagement of Uganda’s Global Fund programme exemplifies how donor rigidity and the involvement of too many NGOs with varying and conflicting interests made the programme spiral out of control (Okuonzi, 2005).
The implementation of HSRs thus disrupted and obscured the implementation of the HSD that was envisaged in the health policies of the government. The necessary conditions to have a genuine HSD implemented in Uganda and other poor countries were not achievable with a strong HSR agenda in place. Hogwood and Gunn (1984) laid down ten conditions for perfect implementation of policy. The genuine HSD in Uganda articulated in the National Health Policy (NHP) did not fulfil most of the conditions for implementation, which are summarized in the Table 24.