International Journal of Health Policy and Management

International Journal of Health Policy and Management

Generating Political Priority for the Health Needs of the 21st Century: A Qualitative Policy Analysis on the Prioritization of Rehabilitation Services in Uganda

Document Type : Original Article

Authors
Rachel Neill 1
Elizeus Rutebemberwa 2
Raymond Tweheyo 2
Sam Tukei Ojulo 2
Gerald Okello 2
Abdulgafoor M. Bachani 1
Yusra Ribhi Shawar 3, 4
1 Johns Hopkins International Injury Research Unit, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
2 College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
3 Department of International Health, Johns Hopkins University Blomberg School of Public Health, Baltimore, MD, USA
4 Paul H. Nitze School of Advanced International Studies, Johns Hopkins University, Washington, DC, USA
10.34172/ijhpm.8347
Abstract
Background 
Few low- or middle-income countries (LMICs) have prioritized the expansion of rehabilitation services. Existing scholarship has identified that problem definition, governance, and structural factors are influential in the prioritization of rehabilitation. The objective of this study was to identify the factors influencing the prioritization and implementation of rehabilitation services in Uganda.

Methods 
A case study design was utilized. The Prioritization of Rehabilitation in National Health Systems framework guided the study. Data sources included 33 key informant interviews (KIIs) with governmental and non-governmental stakeholders and peer-reviewed and grey literature on rehabilitation in Uganda. A thematic content analysis and concept map were conducted to analyze the data.

Results 
Rehabilitation is an unfunded priority in Uganda, garnering political attention but failing to receive adequate financial or human resource allocation. The national legacy of rehabilitation as a social program, instead of a health program, has influenced its present-day prioritization trajectory. These include a fragmented governance system, a weak advocacy coalition without a unified objective or champion, and a lack of integration into existing health systems structures that makes it challenging to scale-up service provision. Our findings highlight the interactive influences of structural, governance, and framing factors on prioritization and the importance of historical context in understanding both prioritization and implementation.

Conclusion 
Our findings demonstrate challenges in prioritizing emerging, multi-sectoral health areas like rehabilitation. Strategic considerations for elevating rehabilitation on Uganda’s policy agenda include generating credible indicators to quantify the nature and extent of the population’s need and uniting governmental and non-governmental actors around a common vision for rehabilitation’s expansion. We present opportunities for strengthening rehabilitation, both in Uganda and in similar contexts grappling with many health sector priorities and limited resources.
Keywords
Health Policy
Health Systems
Disability
Rehabilitation
Africa
Uganda
  1. Vos T, Lim SS, Abbafati C, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204-1222. doi:1016/s0140-6736(20)30925-9
  2. Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease Study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2021;396(10267):2006-2017. doi:1016/s0140-6736(20)32340-0
  3. World Health Organization (WHO). Rehabilitation. WHO. https://www.who.int/health-topics/rehabilitation#tab=tab_1. Accessed April 20, 2021. Published 2021.
  4. Gimigliano F, Negrini S. The World Health Organization "rehabilitation 2030: a call for action". Eur J Phys Rehabil Med. 2017;53(2):155-168. doi:23736/s1973-9087.17.04746-3
  5. Seventy-Sixth World Health Assembly. Strengthening rehabilitation in health systems. Agenda item 13.4.
  6. World Health Organization (WHO). World Rehabilitation Alliance. https://www.who.int/initiatives/world-rehabilitation-alliance. Accessed January 25, 2024. Published 2024.
  7. Neill R, Shawar YR, Ashraf L, et al. Prioritizing rehabilitation in low- and middle-income country national health systems: a qualitative thematic synthesis and development of a policy framework. Int J Equity Health. 2023;22(1):91. doi:1186/s12939-023-01896-5
  8. Bickenbach J, Cieza A, Kleinitz P, Marks E, Mills JA. Access to Rehabilitation in Primary Health Care: An Ongoing Challenge. Geneva: World Health Organization; 2018.
  9. Walt G, Gilson L. Can frameworks inform knowledge about health policy processes? Reviewing health policy papers on agenda setting and testing them against a specific priority-setting framework. Health Policy Plan. 2014;29 Suppl 3:iii6-22. doi:1093/heapol/czu081
  10. Maher A, Sridhar D. Political priority in the global fight against non-communicable diseases. J Glob Health. 2012;2(2):020403. doi:7189/jogh.02.020403
  11. Heller O, Somerville C, Suggs LS, et al. The process of prioritization of non-communicable diseases in the global health policy arena. Health Policy Plan. 2019;34(5):370-383. doi:1093/heapol/czz043
  12. Hyder AA, Hoe C, Hijar M, Peden M. The political and social contexts of global road safety: challenges for the next decade. Lancet. 2022;400(10346):127-136. doi:1016/s0140-6736(22)00917-5
  13. Iemmi V. Establishing political priority for global mental health: a qualitative policy analysis. Health Policy Plan. 2022;37(8):1012-1024. doi:1093/heapol/czac046
  14. Shawar YR, Crane LG. Generating global political priority for urban health: the role of the urban health epistemic community. Health Policy Plan. 2017;32(8):1161-1173. doi:1093/heapol/czx065
  15. Bartlett JA, Shao JF. Successes, challenges, and limitations of current antiretroviral therapy in low-income and middle-income countries. Lancet Infect Dis. 2009;9(10):637-649. doi:1016/s1473-3099(09)70227-0
  16. Kapiriri L, Lee NM, Wallace LJ, Kwesiga B. Beyond cost-effectiveness, morbidity and mortality: a comprehensive evaluation of priority setting for HIV programming in Uganda. BMC Public Health. 2019;19(1):359. doi:1186/s12889-019-6690-8
  17. Colombini M, Mayhew SH, Lund R, et al. Factors shaping political priorities for violence against women-mitigation policies in Sri Lanka. BMC Int Health Hum Rights. 2018;18(1):22. doi:1186/s12914-018-0161-7
  18. Colombini M, Mayhew SH, Hawkins B, et al. Agenda setting and framing of gender-based violence in Nepal: how it became a health issue. Health Policy Plan. 2016;31(4):493-503. doi:1093/heapol/czv091
  19. Pelletier DL, Menon P, Ngo T, Frongillo EA, Frongillo D. The nutrition policy process: the role of strategic capacity in advancing national nutrition agendas. Food Nutr Bull. 2011;32(2 Suppl):S59-S69. doi:1177/15648265110322s203
  20. Abimanyi-Ochom J, Mannan H. Uganda's disability journey: progress and challenges. Afr J Disabil. 2014;3(1):108. doi:4102/ajod.v3i1.108
  21. Institute for Health Metrics and Evaluation. WHO Rehabilitation Need Estimator. https://vizhub.healthdata.org/rehabilitation/. Accessed February 8, 2024. Published 2024.
  22. Development Initiatives. Uganda’s Disability Data Landscape. https://devinit.org/resources/uganda-disability-data-landscape-economic-inclusion-persons-with-disabilities/governance-disability-inclusion-and-data-uganda/. Accessed February 17, 2021.
  23. Claussen J, Kandyomunda B, Jareg P. Evaluation of the Community Based Rehabilitation Programme in Uganda. Oslo, Stockholm: Norwegian Association of the Disabled; 2005. https://www.norad.no/globalassets/import-2162015-80434-am/www.norad.no-ny/filarkiv/ngo-evaluations/evaluation-of-the-community-based-rehabilitation-program-in-uganda.pdf. Accessed January 25, 2024.
  24. Atim P, Loum CS, Okello TR, et al. Prevalence of Major Limb Loss (MLL) in post conflict Acholi sub-region of Northern Uganda: cross sectional study. bioRxiv [Preprint]. May 14, 2020. https://www.biorxiv.org/content/10.1101/2020.05.14.095836v1.full.
  25. Okello TR, Magada SM, Atim P, et al. Major Limb Loss (MLL): an overview of etiology, outcomes, experiences and challenges faced by amputees and service providers in the post-conflict period in Northern Uganda. J Glob Health. 2019;3:e2019028. doi:29392/joghr.3.e2019028
  26. Brydges C, Munro LT. The policy transfer of community-based rehabilitation in Gulu, Uganda. Disabil Soc. 2020;35(10):1596-1617. doi:1080/09687599.2019.1702505
  27. Murindwa G, Tashobya CK, Kyabaggu JH, Rutebemberwa E, Nabyonga J. Meeting the challenges of decentralised health service delivery in Uganda as a component of broader health sector reforms. In: Tashobya CK, Ssengooba F, Cruz VO, eds. Health Systems Reforms in Uganda: Processes and Outputs. London: Health Systems Development Programme, London School of Hygiene & Tropical Medicine; 2006:97-108.
  28. World Bank Group. Uganda Public Expenditure Review 2022-23 Module III(B) Efficiency, Effectiveness, and Equity in Health Spending. Washington, DC: World Bank; 2023.
  29. Yin RK. Case Study Research: Design and Methods. 4th ed. Thousand Oaks: SAGE Publications; 2009.
  30. O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-1251. doi:1097/acm.0000000000000388
  31. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:45. doi:1186/1471-2288-8-45
  32. Heidari S, Babor TF, De Castro P, Tort S, Curno M. Sex and Gender Equity in Research: rationale for the SAGER guidelines and recommended use. Res Integr Peer Rev. 2016;1:2. doi:1186/s41073-016-0007-6
  33. Roberts K, Dowell A, Nie JB. Attempting rigour and replicability in thematic analysis of qualitative research data; a case study of codebook development. BMC Med Res Methodol. 2019;19(1):66. doi:1186/s12874-019-0707-y
  34. NVivo. NVivo (Version 12). https://lumivero.com/. Accessed January 25, 2024. Published 2017.
  35. Bacchi C, Goodwin S. Making politics visible: the WPR approach. In: Poststructural Policy Analysis: A Guide to Practice. New York: Palgrave Macmillan; 2016:13-26. doi:1057/978-1-137-52546-8_2
  36. Birt L, Scott S, Cavers D, Campbell C, Walter F. Member checking: a tool to enhance trustworthiness or merely a nod to validation? Qual Health Res. 2016;26(13):1802-1811. doi:1177/1049732316654870
  37. Birks M, Chapman Y, Francis K. Memoing in qualitative research: probing data and processes. J Res Nurs. 2008 Jan;13(1):68-75. doi:1177/1744987107081254
  38. Daley BJ. Using concept maps in qualitative research. In: Concept Maps: Theory, Methodology, Technology. Pamplona, Spain: Dirección de Publicaciones de la Universidad Pública de Navarra; 2004:1-7.
  39. Ligita T, Nurjannah I, Wicking K, Harvey N, Francis K. From textual to visual: the use of concept mapping as an analytical tool in a grounded theory study. Qual Res. 2022;22(1):126-142. doi:1177/1468794120965362
  40. Serrat O. The five whys technique. In: Knowledge Solutions: Tools, Methods, and Approaches to Drive Organizational Performance. Singapore: Springer; 2017:307-310. doi:1007/978-981-10-0983-9_32
  41. Learning, Acting, and Building for Rehabilitation in Health Systems. Consensus Workshop on Integrating rehabilitation into Primary Care. Gulu: Johns Hopkins University; 2021.
  42. ReLAB-HS. Gap Analysis. Baltimore; 2021.
  43. Smith ER, van de Water BJ, Martin A, et al. Availability of post-hospital services supporting community reintegration for children with identified surgical need in Uganda. BMC Health Serv Res. 2018;18(1):727. doi:1186/s12913-018-3510-2
  44. Abbo C, Mwaka AD, Opar BT, Idro R. Qualitative evaluation of the outcomes of care and treatment for children and adolescents with nodding syndrome and other epilepsies in Uganda. Infect Dis Poverty. 2019;8(1):30. doi:1186/s40249-019-0540-x
  45. Kett M, Bailey-Athias D, Gelders B, Kidd S, Peebles-Brown A. Situational Analysis of Persons with Disabilities in Uganda. 2020. https://www.developmentpathways.co.uk/wp-content/uploads/2020/09/Webready-DP1294-ESP-Disability-Uganda-Sept-2020.pdf. Accessed January 25, 2024.
  46. Committee on the Rights of Persons with Disabilities. Concluding Observations on the Initial Report of Uganda. New York: OHCHR; 2016.
  47. Mugisha J, Ssebunnya J, Kigozi FN. Towards understanding governance issues in integration of mental health into primary health care in Uganda. Int J Ment Health Syst. 2016;10:25. doi:1186/s13033-016-0057-7
  48. Zziwa S, Babikako H, Kwesiga D, et al. Prevalence and factors associated with utilization of rehabilitation services among people with physical disabilities in Kampala, Uganda. A descriptive cross sectional study. BMC Public Health. 2019;19(1):1742. doi:1186/s12889-019-8076-3
  49. Ministry of Health , Clinton Health Access Initiative (CHAI). Assistive Technology Country Capacity Assessment. 2020.
  50. Seymour N, Geiger M, Scheffler E, Dorman R, Seymour N. Community-based rehabilitation workers’ role in wheelchair service provision. In: Layton N, Borg J, eds. Global Perspectives on Assistive Technology. Geneva: World Health Organization; 2019:113-125. http://apps.who.int/bookorders.
  51. Republic of Uganda. Ministry of Health Strategic Plan 2020/21-2024/25. Kampala. http://library.health.go.ug/monitoring-and-evaluation/strategic-plan/ministry-health-strategic-plan-202021-202425.
  52. Smith ER, van de Water BJ, Martin A, et al. Availability of post-hospital services supporting community reintegration for children with identified surgical need in Uganda. BMC Health Serv Res. 2018;18(1):727. doi:1186/s12913-018-3510-2
  53. World Health Organization (WHO). Global Health Expenditure Database. https://apps.who.int/nha/database. Published August 17, 2022. Accessed August 16, 2022.
  54. Negrini S, Selb M, Kiekens C, et al. Rehabilitation definition for research purposes. A global stakeholders' initiative by Cochrane Rehabilitation. Eur J Phys Rehabil Med. 2022;58(3):333-341. doi:23736/s1973-9087.22.07509-8
  55. Rehabilitation in Uganda: A Call to Action. 2023. https://relabhs.org/resources/policy-brief-rehabilitation-in-uganda-a-call-to-action/. Accessed November 6, 2023.
  56. Scarr JP, Buse K, Norton R, Meddings DR, Jagnoor J. Tracing the emergence of drowning prevention on the global health and development agenda: a policy analysis. Lancet Glob Health. 2022;10(7):e1058-e1066. doi:1016/s2214-109x(22)00074-2
  57. 57 Shiffman J. Generating political priority for maternal mortality reduction in 5 developing countries. Am J Public Health. 2007;97(5):796-803. doi:2105/ajph.2006.095455
  58. Pelletier DL, Frongillo EA, Gervais S, et al. Nutrition agenda setting, policy formulation and implementation: lessons from the Mainstreaming Nutrition Initiative. Health Policy Plan. 2012;27(1):19-31. doi:1093/heapol/czr011
  59. Chipendo PI, Shawar YR, Shiffman J, Razzak JA. Understanding factors impacting global priority of emergency care: a qualitative policy analysis. BMJ Glob Health. 2021;6(12):e006681. doi:1136/bmjgh-2021-006681
  60. World Health Organization (WHO). International Classification of Functioning, Disability and Health (ICF). https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health. Accessed February 8, 2024. Published 2024.
  61. Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet. 2007;370(9595):1370-1379. doi:1016/s0140-6736(07)61579-7
  62. Shawar YR, Shiffman J. A global priority: addressing violence against children. Bull World Health Organ. 2021;99(6):414-421. doi:2471/blt.19.247874
  63. Schön D, Rein M. Frame Reflection: Toward the Resolution of Intractable Policy Controversies. New York: Basic Books; 1994.
  64. Koon AD, Hawkins B, Mayhew SH. Framing and the health policy process: a scoping review. Health Policy Plan. 2016;31(6):801-816. doi:1093/heapol/czv128
  65. Shiffman J, Shawar YR. Framing and the formation of global health priorities. Lancet. 2022;399(10339):1977-1990. doi:1016/s0140-6736(22)00584-0
  66. World Health Organization (WHO). Framework on Integrated, People-Centred Health Services. Geneva: WHO; 2016. http://apps.who.int/iris/bitstream/10665/174536/1/9789241564977_eng.pdf?ua=1.
  67. De Groote W. Concept changes and standardizing tools in community-based rehabilitation. Phys Med Rehabil Clin N Am. 2019;30(4):709-721. doi:1016/j.pmr.2019.07.013
International Journal of Health Policy and Management
Volume 13, Issue 1
2024
Pages 1-14

  • Received Date 16 November 2023
  • Revised Date 23 March 2024
  • Accepted Date 12 June 2024
  • First Published Date 15 June 2024
  • Published Date 01 December 2024