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Decentralization and National Health Policy Implementation in Uganda - a Problematic Process.

Jeppsson, Anders LU (2004)
Abstract
The Ugandan Government has aimed at creating a needs-based and cost-effective health care system. The means to carry out this aim have been 1) a decentralization of the health sector in order to increase lower-level responsibility, accountability, and participation, and 2) a strong national policy formulation capacity, facilitating needs assessment and cost-effective prioritization.



Aim



The aim of this study is to investigate the process of ascertaining goal achievement with regard to needs-based health care services and national health policy implementation in the decentralized health care system of Uganda.



Population and method



The health sector of Uganda is... (More)
The Ugandan Government has aimed at creating a needs-based and cost-effective health care system. The means to carry out this aim have been 1) a decentralization of the health sector in order to increase lower-level responsibility, accountability, and participation, and 2) a strong national policy formulation capacity, facilitating needs assessment and cost-effective prioritization.



Aim



The aim of this study is to investigate the process of ascertaining goal achievement with regard to needs-based health care services and national health policy implementation in the decentralized health care system of Uganda.



Population and method



The health sector of Uganda is examined from the national to the district level. Focus is on the process of decentralization, which includes a more efficient mechanism for implementing policy goals throughout the decentralized system, since traditional hierarchical methods of directing institutions become obsolete. The concepts of diffusion and translation have been adopted from the theoretical framework of new institutionalism in organizational theory, and are used as tools in the analysis.



Results



Financial decentralization was studied under the assumption that districts would prioritize health care financially in implementing the new national health policy. It was, however, observed that this was not the case.



As the Sector-Wide Approach Process (SWAP) was studied, it was observed that, while the policy formulation capacity of the Ministry of Health (MOH) (which is no longer supposed to focus on detailed health systems planning as in the past) became stronger, the central level had difficulties in maintaining efficient interaction with those responsible for implementation. This had resulted in an increasing gap between the centre and the periphery.



The adoption of new policies, paradigms, and strategies, such as SWAP, the restructuring of the MOH, and the formulation of a new health policy, has strengthened ties with the global institutions. Sharing paradigms and values has probably further promoted the independence of the MOH. Also studied was the application of two normative rationalist instruments, Burden of Disease (BOD) and Cost-Effectiveness (CE), intended to implement national health policy priorities at a district level. This application was a failure.



Discussion



The increasing decentralization of the health care system in Uganda during the period studied has not been followed promptly by the implementation of a global national health policy necessary for a decentralized system. It appears as if the government assumed that new health policies could be implemented by means of a fairly uncomplicated process of diffusion. However, an analysis of the near total failure of the BOD/CE initiative shows that implementation of policy in the decentralized system in Uganda is complex and must be understood as a misdirected translation process whose prerequisites were lacking.



The main factors that have inhibited the adoption of a new policy and have crated a gap between centre and periphery have been different values, the absence of a common frame of reference, and the lack of government support. As a result, local obligations and local accountability have been the main factors guiding the translation. (Less)
Abstract (Swedish)
Popular Abstract in Swedish

Ugandas regering har strävat efter att skapa en behovsbaserad och kostnadseffektiv hälso- och sjukvård på två olika sätt: hälsosektorn har decentraliserats för att öka ansvarstagande och medverkan på lägre nivåer. Kompetens har byggts upp för att kunna utveckla en nationell policy, och därigenom kunna bedöma sjukvårdsbehov och för att göra kostnadseffektiva prioriteringar.



Syfte



Syftet med denna avhandling är att undersöka processen med att genomföra en nationell hälsopolicy i Ugandas decentraliserade hälso- och sjukvårdssystem .



Population och metoder



Hälsosektorn i Uganda har undersökts från nationell nivå ner till... (More)
Popular Abstract in Swedish

Ugandas regering har strävat efter att skapa en behovsbaserad och kostnadseffektiv hälso- och sjukvård på två olika sätt: hälsosektorn har decentraliserats för att öka ansvarstagande och medverkan på lägre nivåer. Kompetens har byggts upp för att kunna utveckla en nationell policy, och därigenom kunna bedöma sjukvårdsbehov och för att göra kostnadseffektiva prioriteringar.



Syfte



Syftet med denna avhandling är att undersöka processen med att genomföra en nationell hälsopolicy i Ugandas decentraliserade hälso- och sjukvårdssystem .



Population och metoder



Hälsosektorn i Uganda har undersökts från nationell nivå ner till distriktsnivå. Fokus har riktats mot decentraliseringsprocessen, som också förutsätter en effektivare mekanism för att genomföra policymål genom hela det decentraliserade systemet sedan de traditionella hierarkiska styrningsmetoderna blivit föråldrade. För att studera genomförandeprocessen har nyinstitutionalismen inom organisationsteorin används som teoretisk ram. De olika uppsatserna i avhandlingen behandlar perspektiv som är viktiga för att förstå förutsättningarna för policygenomförande i ett decentraliserat system. Den sista uppsatsen bedömer och tolkar också ett fullskaligt genomförandeförsök mot bakgrund av de föregående studierna. Diffusions- och översättningsbegreppen från nyinstitutionalismen används som verktyg i analysen. Som övergripande metod har deltagande observation använts. Intervjuer, enkäter, fokusgruppdiskussioner och dokumentstudier har nyttjats för att samla in data.



Resultat



Den finansiella decentraliseringen studerades, och det antogs att distrikten skulle prioritera hälso- och sjukvård ekonomiskt, för att därigenom följa den nationella hälsopolicyn. Så befanns emellertid inte vara fallet.



När ”Sector-Wide Approach (SWAP)” studerades, framgick det att medan förmågan att utveckla policies blev starkare i hälsoministeriet hade den centrala förvaltningen samtidigt svårigheter att upprätthålla en effektiv samverkan med distriktsnivån. Detta ledde till att en klyfta skapades mellan centrum och periferi.



Omstruktureringen av hälsoministeriet studerades, och det noterades att medan hälsoministeriet nu mer fokuserar på policyformulering än på detaljstyrning av hälso- och sjukvårdssystem, finns det ändå en växande klyfta mellan centrum och periferi.



Fastställandet av nya policies, paradigm och strategier, som t. ex. SWAP, omstruktureringen av hälsoministeriet och framtagandet av en ny hälsopolicy, har förstärkt relationen mellan hälsoministeriet och globala institutioner genom att värderingar och paradigm är likartade. Emellertid har denna process sannolikt också bidragit till att hälsoministeriets lokala förankring har minskat.



Tillämpningen av normativa och rationalistiska verktyg som Burden of Disease (BOD), kombinerat med kostnadseffektivitet för att genomföra den nationella hälsopolicyn på distriktsnivå studerades. Detta tillämpningsförsök bedömdes som ett misslyckande.



Diskussion



Den ökade decentraliseringsgraden av hälsosektorn i Uganda har under studieperioden inte åtföljts av ett välbehövligt och framgångsrikt genomförande av en övergripande nationell hälsopolicy som ledstjärna för ett decentraliserat hälsosystem. Det förefaller som om beslutsfattare antagit att nya hälsopolicies skulle kunna genomföras genom en tämligen okomplicerad diffusionsprocess. Emellertid visar vår analys av det misslyckade försöket att använda BOD/kostnadseffektivitet som budgetallokeringsredskap, att genomförande av en policy i det decentraliserade systemet i Uganda är av komplex natur och att detta snarare bör förstås som en översättningsprocess i en oönskad riktning, dvs. att förutsättningar saknades för en översättningsprocess i önskvärd riktning.



Den främsta svårigheten förefaller vara klyftan mellan centrum och periferi, vilken innebär att man inte delar samma värderingar och referensramar, och att man lider brist på nödvändigt understöd från ömse håll. Detta innebär i sin tur att lokala förpliktelser och ansvar sannolikt kommer att bli de faktorer som främst styr policyöversättningen. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Tomson, Göran, Karolinska Institute, Stockholm, Sweden.
organization
alternative title
Decentralisering och genomförande av en nationell hälsopolicy i Uganda - en komplex process.
publishing date
type
Thesis
publication status
published
subject
keywords
epidemiology, Public health, Uganda., policy diffusion, policy translation, policy implementation, decentralization, health care systems, primary health care, health sector reform, Ministry of health, health policy, Folkhälsa, epidemiologi, Social medicine, Socialmedicin, samhällsmedicin
pages
129 pages
publisher
Department of Community Medicine, Malmö University Hospital
defense location
Jubileumsaulan, Medicinskt Forskningscentrum, Malmö University Hospital, Malmö, Sweden.
defense date
2004-10-29 09:00:00
ISBN
91-628-6247-2
language
English
LU publication?
yes
additional info
Article: I. Jeppsson A (2001). Financial priorities under decentralization in Uganda. Health Policy and Planning 16(2):187-192. Article: II. Jeppsson A (2002). SWAP dynamics in a decentralized context: experiences from Uganda. Social Science and Medicine 55:2053-2060. Article: III. Jeppsson A, Östergren PO, and Hagström B (2003). Restructuring a ministry of health: an issue of structure and process. Health Policy and Planning 18(1):68-73. Article: IV. Jeppsson A, Birungi H, Östergren PO, and Hagström B. The global/local dilemma of a Ministry of Health: a case study from Uganda. Health Policy (In press). Article: V. Jeppsson A, Okuonzi S A, Östergren PO, and Hagström B. Application of Burden of Disease/Cost-Effectiveness Analysis as an instrument for district health planning: experiences from Uganda. Health Policy (In press).
id
2c44826f-7d57-4195-911c-b7e0f15c5603 (old id 467314)
date added to LUP
2016-04-04 11:53:32
date last changed
2021-04-23 09:33:11
@phdthesis{2c44826f-7d57-4195-911c-b7e0f15c5603,
  abstract     = {{The Ugandan Government has aimed at creating a needs-based and cost-effective health care system. The means to carry out this aim have been 1) a decentralization of the health sector in order to increase lower-level responsibility, accountability, and participation, and 2) a strong national policy formulation capacity, facilitating needs assessment and cost-effective prioritization.<br/><br>
<br/><br>
Aim<br/><br>
<br/><br>
The aim of this study is to investigate the process of ascertaining goal achievement with regard to needs-based health care services and national health policy implementation in the decentralized health care system of Uganda.<br/><br>
<br/><br>
Population and method<br/><br>
<br/><br>
The health sector of Uganda is examined from the national to the district level. Focus is on the process of decentralization, which includes a more efficient mechanism for implementing policy goals throughout the decentralized system, since traditional hierarchical methods of directing institutions become obsolete. The concepts of diffusion and translation have been adopted from the theoretical framework of new institutionalism in organizational theory, and are used as tools in the analysis.<br/><br>
<br/><br>
Results<br/><br>
<br/><br>
Financial decentralization was studied under the assumption that districts would prioritize health care financially in implementing the new national health policy. It was, however, observed that this was not the case.<br/><br>
<br/><br>
As the Sector-Wide Approach Process (SWAP) was studied, it was observed that, while the policy formulation capacity of the Ministry of Health (MOH) (which is no longer supposed to focus on detailed health systems planning as in the past) became stronger, the central level had difficulties in maintaining efficient interaction with those responsible for implementation. This had resulted in an increasing gap between the centre and the periphery.<br/><br>
<br/><br>
The adoption of new policies, paradigms, and strategies, such as SWAP, the restructuring of the MOH, and the formulation of a new health policy, has strengthened ties with the global institutions. Sharing paradigms and values has probably further promoted the independence of the MOH. Also studied was the application of two normative rationalist instruments, Burden of Disease (BOD) and Cost-Effectiveness (CE), intended to implement national health policy priorities at a district level. This application was a failure.<br/><br>
<br/><br>
Discussion<br/><br>
<br/><br>
The increasing decentralization of the health care system in Uganda during the period studied has not been followed promptly by the implementation of a global national health policy necessary for a decentralized system. It appears as if the government assumed that new health policies could be implemented by means of a fairly uncomplicated process of diffusion. However, an analysis of the near total failure of the BOD/CE initiative shows that implementation of policy in the decentralized system in Uganda is complex and must be understood as a misdirected translation process whose prerequisites were lacking.<br/><br>
<br/><br>
The main factors that have inhibited the adoption of a new policy and have crated a gap between centre and periphery have been different values, the absence of a common frame of reference, and the lack of government support. As a result, local obligations and local accountability have been the main factors guiding the translation.}},
  author       = {{Jeppsson, Anders}},
  isbn         = {{91-628-6247-2}},
  keywords     = {{epidemiology; Public health; Uganda.; policy diffusion; policy translation; policy implementation; decentralization; health care systems; primary health care; health sector reform; Ministry of health; health policy; Folkhälsa; epidemiologi; Social medicine; Socialmedicin; samhällsmedicin}},
  language     = {{eng}},
  publisher    = {{Department of Community Medicine, Malmö University Hospital}},
  school       = {{Lund University}},
  title        = {{Decentralization and National Health Policy Implementation in Uganda - a Problematic Process.}},
  url          = {{https://lup.lub.lu.se/search/files/5879421/1693121.pdf}},
  year         = {{2004}},
}