Abstract
As countries health financing policies are expected to support 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. 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. 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 (KIIs) in the health sector. We find that the current political situation is not yet conducive for implementing a UHC 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. 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
Forty years after the Alma Ata declaration, the international community reaffirmed its commitment to ensure access to quality healthcare for the population of all countries
The adoption of a political economy perspective is relevant to enhance the understanding on the main processes shaping progress towards universal health coverage (UHC) and the usefulness of applying this analytical lens goes beyond the single case study of Uganda
Following the line of reasoning illustrated in our conceptual framework, we present the main findings by referring to the domains of “stakeholder and institutions,” “politics,” and “policy” for health financing reforms as depicted in Figure (“a,” “b,” and “c” spheres)
Summary
Forty years after the Alma Ata declaration, the international community reaffirmed its commitment to ensure access to quality healthcare for the population of all countries. Universal health coverage (UHC), defined as a situation where people who need health services receive them without undue financial hardship, received renewed attention at the global level and was embraced in the Sustainable Development Goals.[1] The objective of UHC is informed by a horizontal approach for system-level interventions and, brings about important implications for low- and middle-income countries (LMICs).[2,3] As part of the 2030 Agenda, international institutions strongly support the implementation of efficient and equitable health sector reforms for quality care, claiming, in particular, to ensure adequate financial protection for the population against the risk of financial catastrophe due to health expenditures.[4].
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