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

Document Type : Original Article

Authors

1 Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda

2 Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

3 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

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.

Keywords


  1. Okuonzi SA, Macrae J. Whose policy is it anyway? international and national influences on health policy development in Uganda. Health Policy Plan. 1995;10(2):122-132. doi:10.1093/heapol/10.2.122
  2. Colenbrander S, Birungi C, Mbonye AK. Consensus and contention in the priority setting process: examining the health sector in Uganda. Health Policy Plan. 2015;30(5):555-565. doi:10.1093/heapol/czu030
  3. Crichton J. Changing fortunes: analysis of fluctuating policy space for family planning in Kenya. Health Policy Plan. 2008;23(5):339-350. doi:10.1093/heapol/czn020
  4. Grindle MS, Thomas JW. Policy makers, policy choices, and policy outcomes: the political economy of reform in developing countries. Policy Sci. 1989;22(3):213-248. doi:10.1007/bf00136320
  5. Smith MP. Elite theory and policy analysis: the politics of education in suburbia. J Polit. 1974;36(4):1006-1032. doi:10.2307/2129404
  6. Anyebe AA. An overview of approaches to the study of public policy. Int J Polit Sci. 2018;4(1):8-17. doi:10.20431/2454-9452.0401002
  7. Agyepong IA, Kodua A, Adjei S, Adam T. When 'solutions of yesterday become problems of today': crisis-ridden decision making in a complex adaptive system (CAS)--the Additional Duty Hours Allowance in Ghana. Health Policy Plan. 2012;27 Suppl 4:iv20-31. doi:10.1093/heapol/czs083
  8. Uganda Bureau of Statistcs (UBOS), ICF. Uganda Demographic and Health Survey 2016: Key Indicators Report. Kampala, Uganda: UBOS, ICF; 2017.
  9. Mbonye AK. Risk factors associated with maternal deaths in health units in Uganda. Afr J Reprod Health. 2001;5(3):47-53. doi:10.2307/3583322
  10. Mbonye AK, Asimwe JB. Factors associated with skilled attendance at delivery in Uganda: results from a national health facility survey. Int J Adolesc Med Health. 2010;22(2):249-255. doi:10.1515/ijamh.2010.22.2.249
  11. Mbonye AK, Asimwe JB, Kabarangira J, Nanda G, Orinda V. Emergency obstetric care as the priority intervention to reduce maternal mortality in Uganda. Int J Gynaecol Obstet. 2007;96(3):220-225. doi:10.1016/j.ijgo.2006.12.017
  12. Benova L, Dennis ML, Lange IL, et al. Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys. BMC Health Serv Res. 2018;18(1):758. doi:10.1186/s12913-018-3546-3
  13. Fehling M, Nelson BD, Venkatapuram S. Limitations of the Millennium Development Goals: a literature review. Glob Public Health. 2013;8(10):1109-1122. doi:10.1080/17441692.2013.845676
  14. Government of Uganda. Local Governments Act 1997. Uganda: Government of Uganda; 1997.
  15. Government of Uganda. The Republic of Uganda: A Guide to Policy Development & Management in Uganda. Kampala: Cabinet Secretariat, Government of Uganda; 2009.
  16. Ministry of Health (MOH). Guidelines for Governance and Management structures. http://library.health.go.ug/publications/leadership-and-governance-governance/guidelines/guidelines-governance-and-management. Published 2013.
  17. Gilson L. Introduction to Health Policy and Systems Research. Geneva, Switzerland: WHO; 2012.
  18. Birkland TA. An Introduction to the Policy Process: Theories, Concepts, and Models of Public Policy Making. 4th ed. Routledge; 2015. doi:10.4324/9781315717371
  19. Shearer JC, Abelson J, Kouyaté B, Lavis JN, Walt G. Why do policies change? institutions, interests, ideas and networks in three cases of policy reform. Health Policy Plan. 2016;31(9):1200-1211. doi:10.1093/heapol/czw052
  20. Miller DT. The norm of self-interest. Am Psychol. 1999;54(12):1053-1060. doi:10.1037/0003-066x.54.12.1053
  21. Tullock G. The Vote Motive: An Essay in the Economics of Politics, With Applications to the British Economy. London: Institute of Economic Affairs; 1976.
  22. Krassilov V. On pragmatism, life, and evolution. Int J Philos. 2014;2(6):72-79. doi:10.11648/j.ijp.20140206.11
  23. Kwemarira G, Munene KJC, Ntayi JM. Public Interest in Government Institutions. In: Farazmand A, ed. Global Encyclopedia of Public Administration, Public Policy, and Governance. Cham: Springer; 2020. doi:10.1007/978-3-319-31816-5_3926-1
  24. Barasch A, Levine EE, Berman JZ, Small DA. Selfish or selfless? on the signal value of emotion in altruistic behavior. J Pers Soc Psychol. 2014;107(3):393-413. doi:10.1037/a0037207
  25. Sriram V, Topp SM, Schaaf M, et al. 10 best resources on power in health policy and systems in low- and middle-income countries. Health Policy Plan. 2018;33(4):611-621. doi:10.1093/heapol/czy008
  26. Reith S. Money, power, and donor–NGO partnerships. Dev Pract. 2010;20(3):446-455. doi:10.1080/09614521003709932
  27. Bochel C, Bochel HM. The UK Social Policy Process. Basingstoke: Palgrave Macmillan; 2004.
  28. Lehmann U, Gilson L. Actor interfaces and practices of power in a community health worker programme: a South African study of unintended policy outcomes. Health Policy Plan. 2013;28(4):358-366. doi:10.1093/heapol/czs066
  29. Koduah A, van Dijk H, Agyepong IA. The role of policy actors and contextual factors in policy agenda setting and formulation: maternal fee exemption policies in Ghana over four and a half decades. Health Res Policy Syst. 2015;13:27. doi:10.1186/s12961-015-0016-9
  30. Shiffman J. Agency, structure and the power of global health networks. Int J Health Policy Manag. 2018;7(10):879-884. doi:10.15171/ijhpm.2018.71
  31. Shiffman J. Knowledge, moral claims and the exercise of power in global health. Int J Health Policy Manag. 2014;3(6):297-299. doi:10.15171/ijhpm.2014.120
  32. Fischer SE, Strandberg-Larsen M. Power and agenda-setting in Tanzanian health policy: an analysis of stakeholder perspectives. Int J Health Policy Manag. 2016;5(6):355-363. doi:10.15171/ijhpm.2016.09
  33. WHO. Health policy. https://www.who.int/topics/health_policy/en/.  Accessed June 4, 2020.
  34. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  35. Chen YY, Shek DT, Bu FF. Applications of interpretive and constructionist research methods in adolescent research: philosophy, principles and examples. Int J Adolesc Med Health. 2011;23(2):129-139. doi:10.1515/ijamh.2011.022
  36. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:45. doi:10.1186/1471-2288-8-45
  37. Damian RS, Zakumumpa H, Fonn S. Youth underrepresentation as a barrier to sexual and reproductive healthcare access in Kasulu district, Tanzania: a qualitative thematic analysis. Int J Public Health. 2020;65(4):391-398. doi:10.1007/s00038-020-01367-6
  38. Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893-1907. doi:10.1007/s11135-017-0574-8
  39. Robinson M. The political economy of governance reforms in Uganda. Commonw Comp Polit. 2007;45(4):452-474. doi:10.1080/14662040701659910
  40. Tangri R, Mwenda AM. Elite corruption and politics in Uganda. Commonw Comp Polit. 2008;46(2):177-194. doi:10.1080/14662040802005336
  41. Shearer JC. Policy entrepreneurs and structural influence in integrated community case management policymaking in Burkina Faso. Health Policy Plan. 2015;30 Suppl 2:ii46-ii53. doi:10.1093/heapol/czv044
  42. Koduah A, Agyepong IA, van Dijk H. Towards an explanatory framework for national level maternal health policy agenda item evolution in Ghana: an embedded case study. Health Res Policy Syst. 2018;16(1):76. doi:10.1186/s12961-018-0354-5
  43. Moat KA, Abelson J. Analyzing the influence of institutions on health policy development in Uganda: a case study of the decision to abolish user fees. Afr Health Sci. 2011;11(4):578-586.
  44. Forest PG, Denis JL, Brown LD, Helms D. Health reform requires policy capacity. Int J Health Policy Manag. 2015;4(5):265-266. doi:10.15171/ijhpm.2015.85
  45. Buse K, Mays N, Walt G. Making Health Policy. Maidenhead: Open University Press; 2005.
  46. Kjær AM. Political settlements and productive sector policies: understanding sector differences in Uganda. World Dev. 2015;68:230-241. doi:10.1016/j.worlddev.2014.12.004
  47. Kjær AM, Therkildsen O. Elections and landmark policies in Tanzania and Uganda. Democratization. 2013;20(4):592-614. doi:10.1080/13510347.2012.659019
  48. Koduah A, Agyepong IA, van Dijk H. ‘The one with the purse makes policy’: power, problem definition, framing and maternal health policies and programmes evolution in national level institutionalised policy making processes in Ghana. Soc Sci Med. 2016;167:79-87. doi:10.1016/j.socscimed.2016.08.051
  49. Wallace LJ, Kapiriri L. Priority setting for maternal, newborn and child health in Uganda: a qualitative study evaluating actual practice. BMC Health Serv Res. 2019;19(1):465. doi:10.1186/s12913-019-4170-6
  50. Bennett S, George A, Rodriguez D, et al. Policy challenges facing integrated community case management in sub-Saharan Africa. Trop Med Int Health. 2014;19(7):872-882. doi:10.1111/tmi.12319
  51. Fischer F, Miller GJ. Handbook of Public Policy Analysis: Theory, Politics, and Methods. CRC Press; 2006.
  52. Dye TR. Understanding Public Policy. Pearson New International; 2013.
  53. Bakke Ø, Endal D. Vested interests in addiction research and policy alcohol policies out of context: drinks industry supplanting government role in alcohol policies in sub-Saharan Africa. Addiction. 2010;105(1):22-28. doi:10.1111/j.1360-0443.2009.02695.x