Assessment of the influence of sustainable development goals declaration on health financing reforms for universal health coverage in Uganda : A stakeholders’ perspective

Abstract

Background Achieving universal health coverage (UHC) requires health financing reforms (HFR) in many countries. Health Financing Reforms are inherently political. The sustainable development goals (SDG) declaration provides a global political commitment that can potentially influence HFR for UHC at national level. However, how the declaration has influenced HFR discourse at the national level and how ministries of health and other stakeholders are using the declaration to influence reforms towards UHC were yet to be explored. Therefore, this thesis explored how SDG declaration has influenced health financing reforms for UHC in Uganda and proposed a framework for examining such complex processes needing multidisciplinary lens of health systems financing, health policy analysis and policy transfers. Aims and objectives This thesis aimed at exploring the influence of the SDG declaration on health financing reforms in Uganda, and to develop a theory of change for desired health financing reforms for UHC. The study objectives were: - i. Exploring changes in health system financing towards UHC in Uganda between financial years 2000/2001 and 2019/2020. ii. Examining how the SDG declaration has influenced health financing reforms for UHC in Uganda. iii. Identifying factors that have facilitated or inhibited SDGs declaration in influencing health financing reforms for UHC in Uganda iv. Developing a theory of change on how the SDG declaration influence health financing reforms for UHC.

Methods This was an exploratory and explanatory qualitative study using a case study approach, with Uganda being the case. Detailed literature reviews were conducted and in doing literature reviews, document review guides were used for data collection. Key informant interviews (KIIs) with purposely selected respondents were also conducted to enrich the findings from the literature reviews and to refine the theory of change. Relevant theories, frameworks, and concepts especially Kutzin’s health financing conceptual framework, Dolowitz and Marsh policy transfer theory and concepts from health policy analyses guided data collection and analysis. Results Uganda has had a variation in the focus of health financing policy objectives over the four strategic plan periods running between 2000/2001 and 2019/2020 financial years, from equity and mobilizing more funding to financial risk protection and UHC. The variation in policy intentions over the four strategic plan periods were informed by low level of national health sector funding, global level discussions on SDGs and UHC, and financing reform discourse focusing on establishing a National Health Insurance Fund (NHIF). However, policy objectives were not followed by the necessary structural changes in the organization of the health financing functions and thus the health financing organization architecture have not changed much over the years. Some reforms such as the abolition of user fees in public health facilities, development of National Minimum Health Care Package (NMHCP) as the benefits package, Sector Wide Approach (SWAp), movement towards performance-based financing were noticeable. The policy objective statements, and the reforms were generally aligned to World Health Organization (WHO) policy principles of reforms that advance UHC. However, given the limited structural changes in health system financing there have been very subtle progress in terms of improvement in financial risk protection. Furthermore, there have been limited studies on global to national policy transfers especially in the health sector and particular on health financing reforms. Majority of studies on health financing reforms in Uganda have focused on the technical aspects using rather rigid health financing conceptual frameworks for analysis that do not cover aspects of policy transfers. On how the SDG declaration is influencing health financing reforms in Uganda, the declaration has raised and sustained the issue of health financing high on the national agenda and provided a framework for development of policies such as national UHC roadmap and health financing strategy 2016. The declaration has also energized the process of developing National Health Insurance Fund (NHIF), with a number of stakeholders who are not traditionally involved in health financing discussion showing interest. Civil Society and Professional Associations are using the SDG declaration as a tool for engagement with other stakeholders as they seek support for health financing reforms towards UHC with a focus on NHIF. Factors favouring the SDG declaration to influence health financing reforms in Uganda include the high media attention and the reporting requirement on countries. These ensure there is continuous discussion on health financing in relation to SDGs. Having a specific indicator on UHC and therefore health financing in the declaration has also ensured the SDG declaration continues to influence the health financing discourse at the national level. Other factors include strong partnership between MOH and other stakeholders, and development partners’ support. However, the push for reforms in health financing for UHC based on the SDG declaration is tempered by factors such as limited fiscal space for health as reforms require funding, lack of relevant recent evidence grounded in country data and complexity of the health financing issues which are not well understood by the general population and other key stakeholder groups. Conclusion The SDG declaration has influenced health financing reforms in Uganda with national policy intentions aligning with proven global policy principles. However, much needs to be done to go beyond aligning policy principles to proven global reform principles to ensuring there is commensurate changes in health financing system architecture and functions. Previous reforms can provide lessons for better adaptation of the global health financing reform principles that advance UHC. In addition, use of theory-driven frameworks such as the theory of change (TOC) can provide a more comprehensive set of information to support reform drivers to design appropriate strategies for engaging stakeholders for buy-in and development of context appropriate policies.