Barriers to Equitable Public Participation in Health-System Priority Setting Within the Context of Decentralization: The Case of Vulnerable Women in a Ugandan District

Document Type : Original Article

Authors

1 Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada

2 Department of Health, Aging and Society, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada

3 Department of Health Research Methods, Evidence, and Impact (HEI), Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada

4 Department of Health Research Methods, Evidence, and Impact (HEI), McMaster Health Forum, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada

Abstract

Background
Decentralization of healthcare decision-making in Uganda led to the promotion of public participation. To facilitate this, participatory structures have been developed at sub-national levels. However, the degree to which the participation structures have contributed to improving the participation of vulnerable populations, specifically vulnerable women, remains unclear. We aim to understand whether and how vulnerable women participate in health-system priority setting; identify any barriers to vulnerable women’s participation; and to establish how the barriers to vulnerable women’s participation can be addressed.
 
Methods
We used a qualitative description study design involving interviews with district decision-makers (n = 12), subcounty leaders (n = 10), and vulnerable women (n = 35) living in Tororo District, Uganda. Data was collected between May and June 2017. The analysis was conducting using an editing analysis style.
 
Results
The vulnerable women expressed interest in participating in priority setting, believing they would make valuable contributions. However, both decision-makers and vulnerable women reported that vulnerable women did not consistently participate in decision-making, despite participatory structures that were instituted through decentralization. There are financial (transportation and lack of incentives), biomedical (illness/disability and menstruation), knowledge-based (lack of knowledge and/or information about participation), motivational (perceived disinterest, lack of feedback, and competing needs), socio-cultural (lack of decision-making power), and structural (hunger and poverty) barriers which hamper vulnerable women’s participation.
 
Conclusion
The identified barriers hinder vulnerable women’s participation in health- system priority setting. Some of the barriers could be addressed through the existing decentralization participatory structures. Respondents made both short-term, feasible recommendations and more systemic, ideational recommendations to improve vulnerable women’s participation. Integrating the vulnerable women’s creative and feasible ideas to enhance their participation in health-system decision-making should be prioritized.

Keywords

References

  1. Jeppsson A, Okuonzi SA. Vertical or holistic decentralization of the health sector? Experiences from Zambia and Uganda. Int J Health Plann Manage. 2000;15:273-289.
  2. Mills A. Decentralization and accountability in the health sector from an international perspective : what are the choices ? Public Adm Dev. 1994;14:281-292.
  3. Mogedal S, Steen SH, Mpelumbe G. Health sector reform and organizational issues at the local level: Lessons from selected African countries. J Int Dev. 1995;7(3):349-367. doi:10.1002/jid.3380070304
  4. Gilson L, Mills A. Health sector reforms in sub-Saharan Africa: lessons of the last 10 years. Health Policy. 1995;32(1-3):215-243. doi:10.1016/0168-8510(95)00737-d
  5. Kapiriri L, Norheim OF, Heggenhougen K. Public participation in health planning and priority setting at the district level in Uganda. Health Policy Plan. 2003;18(2):205-213. doi:10.1093/heapol/czg025
  6. Local Governments Act 1997. Kampala: Government of Uganda; 1997.
  7. Constitution of the Republic of Uganda. Government of Uganda; 1995.
  8. Bossert TJ, Beauvais JC. Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space. Health Policy Plan. 2002;17(1):14-31. doi:10.1093/heapol/17.1.14
  9. Mulumba M, London L, Nantaba J, Ngwena C. Using Health Committees to Promote Community Participation as a Social Determinant of the Right to Health: Lessons from Uganda and South Africa. Health Hum Rights. 2018;20(2):11-17.
  10. Namusobya S. Citizen Participation in Local Government Service Delivery Processes in Uganda. Kampala: ISER; 2018.
  11. Kirunga Tashobya C, Ssengooba F, Oliveira Cruz V. Health Systems Reforms in Uganda: Processes and Outputs. Kampala: Institute of Public Health, Makerere University; 2006.
  12. Government of Uganda. Health Sector Strategic Plan III 2010/11-2014/15. Kampala: Government of Uganda; 2010.
  13. Bolsewicz Alderman K, Hipgrave D, Jimenez-Soto E. Public engagement in health priority setting in low- and middle-income countries: current trends and considerations for policy. PLoS Med. 2013;10(8):e1001495. doi:10.1371/journal.pmed.1001495
  14. Mukasa N. Uganda Healthcare system profile: Background, Organization, Polices and Challenges. Journal of Sustainable Regional Health Systems. 2012;1(1):2-10.
  15. Nabyonga Orem J, Mugisha F, Kirunga C, MacQ J, Criel B. Abolition of user fees: The Uganda paradox. Health Policy Plan. 2011;26 Suppl 2:ii41-ii51. doi:10.1093/heapol/czr065
  16. Kapiriri L, Razavi D. How have systematic priority setting approaches influenced policy making? A synthesis of the current literature. Health Policy. 2017;121(9):937-946. doi:10.1016/j.healthpol.2017.07.003
  17. Bruni RA, Laupacis A, Martin DK. Public engagement in setting priorities in health care. Can Med Assoc J. 2008;179(1):15-18.
  18. Florin D, Dixon J. Public involvement in health care. BMJ. 2004;328(7432):159-161. doi:10.1136/bmj.328.7432.159
  19. Charles C, DeMaio S. Lay participation in health care decision making: a conceptual framework. J ournal Heal Polit Policy Law. 1993;18(4):23-24. doi:10.1215/03616878-18-4-881
  20. Daniels N, Sabin J. The Ethics of Accountability in Managed Care Reform. Health Aff. 1998;17(5):50-64. doi:10.1377/hlthaff.17.5.50
  21. Abelson J, Forest PG, Eyles J, Smith P, Martin E, Gauvin FP. Deliberations about deliberative methods: Issues in the design and evaluation of public participation processes. Soc Sci Med. 2003;57(2):239-251. doi:10.1016/S0277-9536(02)00343-X
  22. Makundi E, Kapiriri L, Norheim OF. Combining evidence and values in priority setting: Testing the balance sheet method in a low-income country. BMC Health Serv Res. 2007;7(152):1-12. doi:10.1186/1472-6963-7-152
  23. Renn O, Webler T, Rakel H, Dienel P, Johnson B. Public participation in decision making : A three-step procedure. Policy Sci. 1993;26:189-214.
  24. Mitton C, Smith N, Peacock S, Evoy B, Abelson J. Public participation in health care priority setting: A scoping review. Health Policy. 2009;91(3):219-228. doi:10.1016/j.healthpol.2009.01.005
  25. Kamuzora P, Maluka S, Ndawi B, Byskov J, Hurtig A. Promoting community participation in priority setting in district health systems: experiences from Mbarali district, Tanzania. Glob Health Action. 2013;1(22669). doi:10.3402/gha.v6i0.22669
  26. Razavi SD, Kapiriri L, Abelson J, Wilson M. Who is in and who is out? A qualitative analysis of stakeholder participation in priority setting for health in three districts in Uganda. Health Policy Plan. 2019;34(5):358-369. doi:10.1093/heapol/czz049
  27. Luna F. Identifying and evaluating layers of vulnerability - a way forward. Dev World Bioeth. 2019;19:86-95. doi:10.1111/dewb.12206
  28. Rogers W, Mackenzie C, Dodds S. Why bioethics needs a concept of vulnerability. Int J Fem Approaches Bioeth. 2017;5(2):11-38. doi:10.3138/ijfab.5.2.11
  29. Anderson PS. Autonomy, Vulnerability and Gender. Fem Theory. 2003;4(2):149-164. doi:10.1177/14647001030042004
  30. UNDP. Uganda Human Development Report 2015. Kampala: UNDP; 2015.
  31. Wong JQ, Uy J, Haw NJL, et al. Priority Setting for Health Service Coverage Decisions Supported by Public Spending: Experience from the Philippines. Health Syst Reform. 2017;4(1):19-29. doi:10.1080/23288604.2017.1368432
  32. Kapiriri L, Norheim OF, Heggenhougen K. Using burden of disease information for health planning in developing countries: the experience from Uganda. Soc Sci Med. 2003;56(12):2433-2441. doi:10.1016/S0277-9536(02)00246-0
  33. Ministry of Health. Health Sector Development Plan 2015/16-2019/20. Uganda: Ministry of Health; 2015:110.
  34. Ministry of Health. The Second National Health Policy: Promoting People’s Health to Enhance Socio-Economic Development. Kampala: Ministry of Health; 2010.
  35. Development E. Poverty Eradication Action Plan (2004/5-2007/8). Kampala: Ministry of Finance, Planning and Economic Development; 2004.
  36. Luna F. Elucidating the Concept of Vulnerability : Layers Not Labels. Int J Fem Approaches Bioeth. 2009;2(1):121-139.
  37. Loftspring RC. Inheritance rights in Uganda: How equal inheritance rights would reduce poverty and decrease the spread of HIV/AIDS in Uganda. Univ Pennsylvania J Int Econ Law. 2007;29(1):243-263.
  38. Bell S, Aggleton P. Social influences on young people’s sexual health in Uganda. Health Educ. 2013;113(2):102-114. doi:10.1108/09654281311298795
  39. Ministry of Health. Uganda One Health Strategic Plan 2018-2022. https://www.health.go.ug/cause/uganda-one-health-strategic-plan-2018-2022/.Published January 2018.
  40. Morgan R, Ayiasi RM, Barman D, et al. Gendered health systems: Evidence from low- and middle-income countries. Healt Res Policy Syst. 2018;16(1):1-12. doi:10.1186/s12961-018-0338-5
  41. Mac-Seing M, Zinszer K, Eryong B, Ajok E, Ferlatte O, Zarowsky C. The intersectional jeopardy of disability, gender and sexual and reproductive health: experiences and recommendations of women and men with disabilities in Northern Uganda. Sex Reprod Heal Matters. 2020;28(2). doi:10.1080/26410397.2020.1772654
  42. Parikh SA. “ They arrested me for loving a schoolgirl” : Ethnography, HIV, and a feminist assessment of the age of consent law as a gender-based structural intervention in Uganda. Soc Sci Med. 2012;74(11):1774-1782. doi:10.1016/j.socscimed.2011.06.037
  43. Rutakumwa W, Krogman N. Women’s health in rural uganda: problems, coping strategies, and recommendations for change. Can J Nurs Res. 2007;39(3):105-125.
  44. Devereux S, Ntale CL, Sabates-Wheeler R. Phase I Report: Vulnerability Assessment & Review of Initatives Chapter 3. Analysis of Vulnerability in Uganda. Brighton; 2002.
  45. National Gender Policy. Government of Uganda; 1997.
  46. Manafò E, Petermann L, Vandall-Walker V, Mason-Lai P. Patient and public engagement in priority setting: A systematic rapid review of the literature. PLoS One. 2018;13(3):1-18. doi:10.1371/journal.pone.0193579
  47. Hunter DJ, Kieslich K, Littlejohns P, et al. Public involvement in health priority setting: future challenges for policy, research and society. J Health Organ Manag. 2016;30(5):796-808. doi:10.1108/JHOM-04-2016-0057
  48. Denhardt J, Terry L, Delacruz ER, Andonoska L. Barriers to citizen engagement in developing countries. Int J Public Adm. 2009;32(14):1268-1288. doi:10.1080/01900690903344726
  49. Goold SD, Myers CD, Danis M, et al. Members of Minority and Underserved Communities Set Priorities for Health Research. Milbank Q. 2018;96(4):675-705. doi:10.1111/1468-0009.12354
  50. Pratt B, Merritt M, Hyder AA. Towards deep inclusion for equity-oriented health research priority-setting: A working model. Soc Sci Med. 2016;151:215-224. doi:10.1016/j.socscimed.2016.01.018
  51. McCollum R, Taegtmeyer M, Otiso L, et al. Sometimes it is difficult for us to stand up and change this: An analysis of power within priority-setting for health following devolution in Kenya. BMC Health Serv Res. 2018;18(1):906. doi:10.1186/s12913-018-3706-5
  52. Sandelowski M. What’s in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77-84. doi:10.1002/nur.20362
  53. Sandelowski M. Whatever Happened to Qualitative Description? Res Nurs Health. 2000;23:334-340. doi:10.1002/1098-240X
  54. Munk Ravenborg H, Boesen J, Sørensen A, et al. Gendered District Poverty Profiles and Poverty Monitoring Kabarole, Masaka, Pallisa, Rakai and Tororo Districts. Copenhagen: Danish Iinstitute For International Studies; 2004.
  55. Browne K. Snowball sampling: Using social networks to research non-heterosexual women. Int J Soc Res Methodol Theory Pract. 2005;8(1):47-60. doi:10.1080/1364557032000081663
  56. Marshall C, Rossman GB. Managing, Analyzing, and Interpreting Data. In: Designing Qualitative Research. Sixth Edit. Thousand Oaks: SAGE Publications, Inc.; 2016:207-235.
  57. Crabtree BF, Miller WLT. Doing Qualitative Research. Second Edi. Thousand Oaks: SAGE Publications, Inc.; 1999.
  58. Ryan GW, Bernard HR. Data Management and Analysis Methods. In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. 2nd ed. Thousand Oaks: Sage Publications; 2000:769-802.
  59. Hsieh H-F, Shannon SE. Three Approaches to Qualitative Content Analysis. Qual Health Res. 2005;15(9):1277-1288. doi:10.1177/1049732305276687
  60. Kondracki NL, Wellman NS, Amundson DR. Content Analysis : Review of Methods and Their Applications in Nutrition Education. J Nutr Educ Behav. 2002;34(4):224-230.
  61. Hennink MM, Kaiser BN, Marconi VC. Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough? Qual Health Res. 2017;27(4):591-608. doi:10.1177/1049732316665344
  62. Meetoo D. The setting of healthcare priorities through public engagement. Br J Nurs. 2013;22(7):372-376. doi:10.12968/bjon.2013.22.7.372
  63. O’Meara WP, Tsofa B, Molyneux S, Goodman C, McKenzie FE. Community and facility-level engagement in planning and budgeting for the government health sector - A district perspective from Kenya. Health Policy. 2011;99(3):234-243. doi:10.1016/j.healthpol.2010.08.027
  64. Maluka SO, Hurtig A-K, San Sebastián M, Shayo EH, Byskov J, Kamuzora P. Decentralization and health care prioritization process in Tanzania: from national rhetoric to local reality. Int J Health Plann Manage. 2011;26:e102-e120. doi:10.1002/hpm.1048
  65. Hennegan J, Shannon AK, Rubli J, Schwab KJ, Melendez-Torres GJ. Women’s and girls’ experiences of menstruation in low-and middle-income countries: a systematic review and qualitative metasynthesis. PLoS Med. 2019;16(5):e1002803. doi:10.1371/journal.pmed.1002803
  66. Maluka SO. Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania. Glob Health Action. 2011;4:1-11. doi:10.3402/gha.v4i0.7829
  67. Alonso-Garbayo A, Raven J, Theobald S, Ssengooba F, Nattimba M, Martineau T. Decision space for health workforce management in decentralized settings: A case study in Uganda. Health Policy Plan. 2017;32:iii59-iii66. doi:10.1093/heapol/czx116
  68. Jeppsson A. Financial priorities under decentralization in Uganda. Health Policy Plan. 2001;16(2):187-192.
  69. International Society for Eye Research (ISER). An Assessment of the Role and Effectiveness of Barazas in Decision Making Processes. ISER; 2018.
International Journal of Health Policy and Management
Volume 11, Issue 7
July 2022
Pages 1047-1057

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History

  • Receive Date: 31 January 2020
  • Revise Date: 08 December 2020
  • Accept Date: 09 December 2020
  • First Publish Date: 23 December 2020

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