Abstract
BackgroundSeveral countries in Sub Saharan Africa have abolished user fees for health care but the extent to which such a policy decision is guided by evidence needs further exploration. We explored the barriers and facilitating factors to uptake of evidence in the process of user fee abolition in Uganda and how the context and stakeholders involved shaped the uptake of evidence. This study builds on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitating factors for knowledge translation (KT). Application of the MRT to the case of abolition of user fees contributes to its refining.MethodsEmploying a theory-driven inquiry and case study approach given the need for in-depth investigation, we reviewed documents and conducted interviews with 32 purposefully selected key informants. We assessed whether evidence was available, had or had not been considered in policy development and the reasons why and; assessed how the actors and the context shaped the uptake of evidence.ResultsSymbolic, conceptual and instrumental uses of evidence were manifest. Different actors were influenced by different types of evidence. While technocrats in the ministry of health (MoH) relied on formal research, politicians relied on community complaints. The capacity of the MoH to lead the KT process was weak and the partnerships for KT were informal. The political window and alignment of the evidence with overall government discourse enhanced uptake of evidence. Stakeholders were divided, seemed to be polarized for various reasons and had varying levels of support and influence impacting the uptake of evidence.ConclusionEvidence will be taken up in policy development in instances where the MoH leads the KT process, there are partnerships for KT in place, and the overall government policy and the political situation can be expected to play a role. Different actors will be influenced by different types of evidence and their level of support and influence will impact the uptake of evidence. In addition, the extent to which a policy issue is contested and, whether stakeholders share similar opinions and preferences will impact the uptake of evidence.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-014-0639-5) contains supplementary material, which is available to authorized users.
Highlights
Several countries in Sub Saharan Africa have abolished user fees for health care but the extent to which such a policy decision is guided by evidence needs further exploration
The ministry of health (MoH) institutional capacity to lead the knowledge translation (KT) process, the partnerships for KT, the political context and the overall government discourse impacted the uptake of evidence in the abolition of user fees for health care in public health facilities in Uganda
We noted symbolic use of evidence in the form of community complaints by the president to abolish user fees; instrumental use of evidence in the form of routine monitoring data by technocrats in the MoH to negotiate for an increase in the health sector allocation and, conceptual use of evidence in the form of survey data by the cabinet to debate the ills of user fees for health care
Summary
Several countries in Sub Saharan Africa have abolished user fees for health care but the extent to which such a policy decision is guided by evidence needs further exploration. In an effort to improve access to health services, several low income countries (LICs) have abolished user fees [5,6], but the results in the medium- to long-term have been mixed. In order to bring services closer to the people, the country undertook decentralization reform in the early 90s, redefining roles and responsibilities between the central level and local governments (districts). In the early 2000s, global actors pushed to reduce poverty in LICs. Uganda benefited from the HIPC initiative on the condition that the country invested debt relief funds into social services sectors, such as health. More funding was realized to support the implementation of the HSSP [39]
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