Health Coverage and Financial Protection in Uganda: A Political Economy Perspective

Document Type : Original Article

Authors

1 Department of Economics and Management, University of Florence, Florence, Italy

2 Doctors with Africa CUAMM, Padova, Italy

Abstract

Background 
As countries health financing policies supporting progress towards Universal Health Coverage (UHC), an analysis of these policies is particularly relevant in Low and Middle-Income Countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme.
 
Objective 
This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition. 
 
Methods 
The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 Key Informant Interviews in the health sector.

Results 
We find that the current political situation is not yet conducive for implementing a universal health coverage system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship.
 
Conclusion 
By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.

Highlights

 

Commentaries Published on this Paper

 

  •  Beyond “Lack of Political Will”: Elaborating Political Economy Concepts to Advance “Thinking and Working Politically”; Comment on “Health Coverage and Financial Protection in Uganda: A Political Economy Perspective”

        Abstract | PDF

 

  •  How to Achieve Universal Health Coverage: A Case Study of Uganda Using the Political Process Model; Comment on “Health Coverage and Financial Protection in Uganda: A Political Economy Perspective”

        Abstract | PDF

 

  • Health Financing Reforms in Uganda: Dispelling the Fears and Misconceptions Related to Introduction of a National Health Insurance Scheme; Comment on “Health Coverage and Financial Protection in Uganda: A Political Economy Perspective”

        Abstract | PDF

 

  • COVID-19 Aftermath: Direction Towards Universal Health Coverage in Low-Income Countries; Comment on “Health Coverage and Financial Protection in Uganda: A Political Economy Perspective”

        Abstract | PDF

 

  • A Historical Legacy for Universal Health Coverage in the Republic of Korea: Moving Towards Health Coverage and Financial Protection in Uganda; Comment on “Health Coverage and Financial Protection in Uganda: A Political Economy Perspective”

        Abstract | PDF

 

  •  Comparative Politics, Political Settlements, and the Political Economy of Health Financing Reform; Comment on “Health Coverage and Financial Protection in Uganda: A Political Economy Perspective”

        Abstract | PDF

 

  • Advancing Empirics and Theory for a Deeper Political Economy Analysis; Comment on “Health Coverage and Financial Protection in Uganda: A Political Economy Perspective”

        Abstract | PDF

 

Keywords


  1. Cotlear D, Rosemberg N. Going Universal in Africa: How 46 African Countries Reformed User Fees and Implemented Health Care Priorities. Universal Health Coverage Studies Series No. 26. Washington, DC: World Bank; 2018.
  2. Agyepong IA. Universal health coverage: breakthrough or great white elephant? Lancet. 2018;392(10160):2229-2236. doi:1016/s0140-6736(18)32402-4
  3. Kutzin J. Anything goes on the path to universal health coverage? No. Bull World Health Organ. 2012;90(11):867-868. doi:2471/blt.12.113654
  4. Dye C, Reeder JC, Terry RF. Research for universal health coverage. Sci Transl Med. 2013;5(199):199ed113. doi:1126/scitranslmed.3006971
  5. Barroy H, Kutzin J, Tandon A, et al. Assessing fiscal space for health in the SDG era: a different story. Health Syst Reform. 2018;4(1):4-7. doi:1080/23288604.2017.1395503
  6. McIntyre D, Meheus F, Røttingen JA. What level of domestic government health expenditure should we aspire to for universal health coverage? Health Econ Policy Law. 2017;12(2):125-137. doi:1017/s1744133116000414
  7. The Lancet Global Health. Gravitating towards universal health coverage in the new WHO era. Lancet Glob Health. 2017;5(7):e633. doi:1016/s2214-109x(17)30224-3
  8. Yates R. Universal health care and the removal of user fees. Lancet. 2009;373(9680):2078-2081. doi:1016/s0140-6736(09)60258-0
  9. Xu K, Soucat A, Kutzin J, Brindley C, et al. Public Spending on Health: A Closer Look at Global Trends. Geneva: World Health Organisation; 2018.
  10. Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ. 2013;91(8):602-611. doi:2471/blt.12.113985
  11. Swanson RC, Atun R, Best A, et al. Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions. Global Health. 2015;11:5. doi:1186/s12992-015-0090-3
  12. Savedoff WD, de Ferranti D, Smith AL, Fan V. Political and economic aspects of the transition to universal health coverage. Lancet. 2012;380(9845):924-932. doi:1016/s0140-6736(12)61083-6
  13. North D. Institutions, Institutional Change and Economic Performance. Cambridge: Cambridge University Press; 1990:1-36.
  14. Fox AM, Reich MR. The politics of universal health coverage in low- and middle-income countries: a framework for evaluation and action. J Health Polit Policy Law. 2015;40(5):1023-1060. doi:1215/03616878-3161198
  15. Gilson L, Raphaely N. The terrain of health policy analysis in low and middle-income countries: a review of published literature 1994-2007. Health Policy Plan. 2008;23(5):294-307. doi:1093/heapol/czn019
  16. Stuckler D, Feigl AB, Basu S, McKee M. The Political Economy of Universal Health Coverage. Background Paper for the Global Symposium on Health Systems Research. Geneva: WHO; 2010.
  17. Chemouni B. The political path to universal health coverage: power, ideas and community-based health insurance in Rwanda. World Dev. 2018;106:87-98. doi:1016/j.worlddev.2018.01.023
  18. Croke K, Mohd Yusoff MB, Abdullah Z, et al. The political economy of health financing reform in Malaysia. Health Policy Plan. 2019;34(10):732-739. doi:1093/heapol/czz089
  19. Hsiao WC, Li M, Zhang S. Universal Health Coverage: The Case of China. Working Paper 2014-15. Unrisd. 2014. http://www.unrisd.org/80256B3C005BCCF9/%28httpAuxPages%29/E15A4915BFDBEE8AC1257D9E0033BACE/$file/Hsiao et al.pdf.
  20. Lavers T. Towards universal health coverage in Ethiopia's 'developmental state'? the political drivers of health insurance. Soc Sci Med. 2019;228:60-67. doi:1016/j.socscimed.2019.03.007
  21. Pisani E, Olivier Kok M, Nugroho K. Indonesia's road to universal health coverage: a political journey. Health Policy Plan. 2017;32(2):267-276. doi:1093/heapol/czw120
  22. Reich MR, Harris J, Ikegami N, et al. Moving towards universal health coverage: lessons from 11 country studies. Lancet. 2016;387(10020):811-816. doi:1016/s0140-6736(15)60002-2
  23. Shiffman J. Political context and health financing reform. Health Syst Reform. 2019;5(3):257-259. doi:1080/23288604.2019.1633894
  24. Sparkes SP, Bump JB, Özçelik EA, Kutzin J, Reich MR. Political economy analysis for health financing reform. Health Syst Reform. 2019;5(3):183-194. doi:1080/23288604.2019.1633874
  25. Campos PA, Reich MR. Political analysis for health policy implementation. Health Syst Reform. 2019;5(3):224-235. doi:1080/23288604.2019.1625251
  26. Schmidt VA. Does discourse matter in the politics of welfare state adjustment? Comp Polit Stud. 2002;35(2):168-193. doi:1177/0010414002035002002
  27. Averill C, Marriott A. Universal Health Coverage: Why Health Insurance Schemes Are Leaving the Poor Behind. Oxfam International; 2013.
  28. Gheorghe A, Straehler-Pohl K, Nkhoma D, et al. Assessing the feasibility and appropriateness of introducing a national health insurance scheme in Malawi. Glob Health Res Policy. 2019;4:13. doi:1186/s41256-019-0103-5
  29. World Health Organization (WHO). Arguing for Universal Health Coverage. WHO; 2013.
  30. Reich MR. Reshaping the state from above, from within, from below: implications for public health. Soc Sci Med. 2002;54(11):1669-1675. doi:1016/s0277-9536(01)00334-3
  31. Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ. 2013;91(8):602-611. doi:2471/blt.12.113985
  32. Mathauer I, Carrin G. The role of institutional design and organizational practice for health financing performance and universal coverage. Health Policy. 2011;99(3):183-192. doi:1016/j.healthpol.2010.09.013
  33. 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:ii41-51. doi:1093/heapol/czr065
  34. Ministry of Health Uganda. Health Sector Strategic & Investment Plan. 2010. http://ec.europa.eu/priorities/jobs-growth-and-investment/investment-plan_en#actions.
  35. Zikusooka CM, Kyomuhang R, Orem JN, Tumwine M. Is health care financing in Uganda equitable? Afr Health Sci. 2009;9 Suppl 2:S52-58.
  36. USAID, Ministry of Health Uganda. Financing for Inclusive and Sustainable Health Services Uganda Health Public Expenditure Review 2013/14-2016/17. USAID, Ministry of Health Uganda; 2016.
  37. Ministry of Health Uganda. Health Financing Strategy 2015/16-2024/25. Ministry of Health Uganda; 2016.
  38. Uganda Statistical Profile. WHO; 2015.
  39. Xu K, Evans DB, Kadama P, et al. Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda. Soc Sci Med. 2006;62(4):866-876. doi:1016/j.socscimed.2005.07.004
  40. Wagstaff A, Flores G, Hsu J, et al. Progress on catastrophic health spending in 133 countries: a retrospective observational study. Lancet Glob Health. 2018;6(2):e169-e179. doi:1016/s2214-109x(17)30429-1
  41. Kjær AM, Ulriksen MS, Kangave J, Katusiimeh M. A Political Economy Analysis of Domestic Resource Mobilization in Uganda. UNRISD; 2017.
  42. Habraken R, Schulpen L, Hoebink P. Putting promises into practice: the new aid architecture in Uganda. Dev Policy Rev. 2017;35(6):779-795. doi:1111/dpr.12294
  43. Ministry of Finance, Planning and Economic Development (MoFPED). National Budget Framework Paper FY 2019/20-FY 2023/24. MoFPED; 2018.
  44. International Monetary Fund (IMF). Uganda Selected Issue. IMF Country Report No. 17/207. Washington, DC: IMF; 2017:1-86.
  45. Williamson T, Davies F, Aziz I, Hedger E. Budget Support to Uganda 1998-2012. Overseas Development Institute; 2016.
  46. Ministry of Health Uganda. Annual Health Sector Performance Report 2017/18. Ministry of Health Uganda; 2018.
  47. Odokonyero T, Mwesigye F, Adong A, Mbowa S. Universal Health Coverage in Uganda: The Critical Health Infrastructure, Healthcare Coverage and Equity. 2017. http://www.eprcug.org/research/research-series?task=document.viewdoc&id=521.
  48. Uganda Bureau of Statistics (UBOS). National Service Delivery Survey: 2015 Report. UBOS; 2015.
  49. Basaza RK, O'Connell TS, Chapčáková I. Players and processes behind the national health insurance scheme: a case study of Uganda. BMC Health Serv Res. 2013;13:357. doi:1186/1472-6963-13-357
  50. Zikusooka CM, Kwesiga B, Lagony S, Abewe C. Universal Health Coverage Assessment Uganda. Global Network for Health Equity; 2014. doi:13140/RG.2.1.1174.7683
  51. Ministry of Health Uganda. Booklet on the Planned National Health Insurance Scheme. Ministry of Health Uganda; 2019.
  52. Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. BMJ. 2000;320(7227):114-116. doi:1136/bmj.320.7227.114
  53. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. doi:1093/intqhc/mzm042
  54. Ssennyonjo A, Namakula J, Kasyaba R, Orach S, Bennett S, Ssengooba F. Government resource contributions to the private-not-for-profit sector in Uganda: evolution, adaptations and implications for universal health coverage. Int J Equity Health. 2018;17(1):130. doi:1186/s12939-018-0843-8
  55. Awor P, Bisase H, Lochoro P, Curtale F. How is the Partnership between the Public and Non-Public Sector Evolving to Strengthen Universal Health Coverage? Universal Health Coverage in Uganda; 2018:1-17.
  56. Steurs L. European aid and health system strengthening: an analysis of donor approaches in the DRC, Ethiopia, Uganda, Mozambique and the global fund. Glob Health Action. 2019;12(1):1614371. doi:1080/16549716.2019.1614371
  57. Ministry of Health Uganda. Uganda National Health Accounts. Ministry of Health Uganda; 2017.
  58. 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:1093/heapol/czz049
  59. Kwesiga B, Zikusooka CM, Ataguba JE. Assessing catastrophic and impoverishing effects of health care payments in Uganda. BMC Health Serv Res. 2015;15:30. doi:1186/s12913-015-0682-x
  60. Allotey P, Tan DT, Kirby T, Tan LH. Community engagement in support of moving toward universal health coverage. Health Syst Reform. 2019;5(1):66-77. doi:1080/23288604.2018.1541497
  61. Kjær AM. Political settlements and productive sector policies: understanding sector differences in Uganda. World Dev. 2015;68:230-241. doi:1016/j.worlddev.2014.12.004
  62. Aid and Health Sector Performance in Uganda. Cordaid; 2011.
  63. Uganda: Political Economy Analysis. UNICEF; 2018.
  64. Soors W, Devadasan N, Durairaj V, Criel B. Community Health Insurance and Universal Coverage: Multiple Paths, Many Rivers to Cross. World Health Organization; 2010.
  65. Nshakira-Rukundo E, Mussa EC, Gerber N, von Braun J. Impact of voluntary community-based health insurance on child stunting: evidence from rural Uganda. Soc Sci Med. 2020;245:112738. doi:1016/j.socscimed.2019.112738
  66. Basaza R, Criel B, Van der Stuyft P. Low enrollment in Ugandan Community Health Insurance schemes: underlying causes and policy implications. BMC Health Serv Res. 2007;7:105. doi:1186/1472-6963-7-105
  67. Biggeri M, Nannini M, Putoto G. Assessing the feasibility of community health insurance in Uganda: a mixed-methods exploratory analysis. Soc Sci Med. 2018;200:145-155. doi:1016/j.socscimed.2018.01.027
  68. Ministry of Health Uganda. Annual Health Sector Performance Report. Ministry of Health Uganda; 2012.
  69. Ministry of Health Uganda. Health Sector Development Plan 2015/16-2019/20. Ministry of Health Uganda; 2015.
  70. Wilunda C, Putoto G, Dalla Riva D, et al. Assessing coverage, equity and quality gaps in maternal and neonatal care in sub-Saharan Africa: an integrated approach. PLoS One. 2015;10(5):e0127827. doi:1371/journal.pone.0127827
  71. SPEED. Symposium on Health Financing for UHC in LMICs proceedings report. 2017.
Volume 11, Issue 9
September 2022
Pages 1894-1904
  • Receive Date: 06 August 2020
  • Revise Date: 06 August 2021
  • Accept Date: 23 August 2021
  • First Publish Date: 29 August 2021