Abstract
Over the years, Uganda’s health policy frameworks and strategic plans have guided steady progress in various health indicators including increased access and utilisation of healthcare. However, health inequality in access and utilisation persist as a majority of citizens do not have access to quality health services due to poor services at most public health facilities resulting from inadequate health staff, drugs and equipment. This study reveals that socio-cultural, income and gender dynamics at household levels are critical determinants of healthcare access. Health system efficiency is fundamental factor; in Uganda, this remains challenging. The decentralisation policy introduced to improve public service has not resolved the historical institutional failures as expected due to weak local governments with limited fiscal and administrative authority to improve utilisation and quality of care for the citizens. Hitherto, primary healthcare remains the main component that benefits majority of citizens but it does not receive adequate funds as significant health budget remains at national level. The behavioural and organisational efficiency models offer government some leeway to customise its health priorities; especially the balance between expansion, improving quality of care and strengthening of local capacity at district level to achieve results but success depends on flexibility in planning and budgeting. This study argues that strong local health structures at facilities and community levels, and increased resource allocation to districts would make the health system work because the existing focus on district health teams alone has excluded individuals from taking part in health activities that is critical. This would bolster bottom-up relationships vital for health institutional functioning, accountability and decision-making that would improve quality health services leading to equitable access and utilisation.
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