International Journal of Health Policy and Management

International Journal of Health Policy and Management

“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
Moses Mukuru 1
Suzanne N. Kiwanuka 1
Lucy Gilson 2, 3
Maylene Shung-King 2
Freddie Ssengooba 1
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
10.34172/ijhpm.2020.230
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
Policy Elites
Millennium Development Goals
Maternal Health
Uganda

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International Journal of Health Policy and Management
Volume 10, Special Issue on Analysing the Politics of Health Policy Change in LMICs
The HPA Fellowship Programme 2017-2019
July 2021
Pages 388-401

  • Received Date 15 April 2020
  • Revised Date 10 July 2020
  • Accepted Date 07 November 2020
  • First Published Date 23 November 2020
  • Published Date 01 July 2021