A Comparative Analysis of Health System Governance and its Impact on Maternal Health Care in Post-Conflict Northern Uganda and Non-conflict East Central Uganda

Abstract

Background: Northern Uganda is recovering from a 23-year civil war that was largely confined to the region. During this period the rest of Uganda enjoyed a rapid GDP growth rate following wide-ranging macroeconomic reforms by the Ugandan government and its development partners. A post-recovery programme was implemented for Northern Uganda; however, the region still has the worst health status. This contributed to the country’s failure to attain MDG five for maternal health. Limited research has been conducted to determine which national and health system governance factors influence performance and affect access and utilisation of health care in countries like Uganda that have witnessed the dual context of conflict and non-conflict. A better understanding of the governance and policy development process in such settings is required if health policy adoption and implementation is to be more appropriate to the needs of the country’s entire population. Methods: A Political Economy Analysis framework was applied to compare governance factors at national and sub-national level in post-conflict Northern Uganda and in non-conflict East Central Uganda that had influenced the provision and utilisation of maternal health care. An analysis of constitutional, economic and health policies determined contextual factors, while data collected through in-depth interviews and focus group discussions with decision-makers, implementers and communities determined the institutional and agency features. The features were used to access power and accountability relationships and incentives that drove the actions of health system stakeholders in central government, health ministry, district local government and civil society as well as in the local communities during the post conflict period in the Northern and East Central Uganda. Findings: The post-conflict period in Northern Uganda coincided with evidence of increased national political commitment to addressing the healthcare needs of Northern Uganda. However, the President, International Funding Institutions and Finance Ministry technocrats who were the dominant governance stakeholders pursued an approach to economic development that prioritised funding for the development of energy, transportation and defence sectors over that for healthcare. Women parliamentarians emerged as maternal healthcare policy champions but played a limited role in highlighting the special health needs of Northern Uganda. The Health Ministry lacked the political and technical capacity to adapt and implement maternal health care policies to specific sub-national needs. NGOs focused on human rights advocacy in Northern Uganda that enhanced the community’s demand for appropriate healthcare while in East Central Uganda they mainly addressed supply-side issues. Political patronage at national and sub-national levels negatively influenced supply and demand for healthcare. In Northern Uganda donor funding, district-based development partner presence, and CSO health system demand-side activities moderated a more positive influence. Conclusion: Decentralisation offers greater opportunities for health system recovery in settings of confined conflict but is prone to elite capture and corruption in peaceful settings within the same national context. Women leaders are critical in the development of a national health system where there is confined conflict, but political and traditional norms limit their role in the promotion of universal healthcare coverage. Despite the presence of factors that portended better maternal healthcare in the post-conflict setting, the limited involvement of the health ministry in the recovery process diminished the impact. CSOs in collaboration with communities play an important role in enhancing the responsiveness of the health system but are prone to political intrusion. The comprehension of policies, economic processes and social institutions of a country recovering from confined conflict enables the identification of variables which, if addressed, will lead to versatile, equitable health systems for all citizens.