Background: The Ugandan Government has aimed at creating a needs-based and cost-effective
health care system. The means to carry out this aim have been 1) a decentralization of the health
sector in order to increase lower-level responsibility, accountability, and participation, and 2) a
strong national policy formulation capacity, facilitating needs assessment and cost-effective
prioritization.
Aim: The aim of this study is to investigate the process of ascertaining goal achievement with
regard to needs-based health care services and national health policy implementation in the
decentralized health care system of Uganda.
Population and method: The health sector of Uganda is examined from the national to the district
level. Focus is on the process of decentralization, which includes a more efficient mechanism for
implementing policy goals throughout the decentralized system, since traditional hierarchical
methods of directing institutions become obsolete. In order to study the implementation process,
the theoretical framework of new institutionalism has been employed. The several papers in this
thesis focus on understanding the prerequisites of policy implementation in a decentralized system.
In the final paper, the outcome of a full-scale policy implementation trial is assessed and
interpreted against the background of the previous studies. The concepts of diffusion and
translation have been adopted from the theoretical framework of new institutionalism in
organizational theory, and are used as tools in the analysis.
The methods employed for data collection in different parts of the study have been interviews,
questionnaires, focus group discussions, and document analysis.
Results: Financial decentralization was studied under the assumption that districts would prioritize
health care financially in implementing the new national health policy. It was, however, observed
that this was not the case.
As the Sector-Wide Approach Process (SWAP) was studied, it was observed that, while the
policy formulation capacity of the Ministry of Health (MOH) (which is no longer supposed to
focus on detailed health systems planning as in the past) became stronger, the central level had
difficulties in maintaining efficient interaction with those responsible for implementation. This had
resulted in an increasing gap between the centre and the periphery.
The adoption of new policies, paradigms, and strategies, such as SWAP, the restructuring of the
MOH, and the formulation of a new health policy, has strengthened ties with the global
institutions. Sharing paradigms and values has probably further promoted a the independence of
the MOH. Also studied was the application of two normative rationalist instruments, Burden of
Disease (BOD) and Cost-Effectiveness (CE), intended to implement national health policy
priorities at a district level. This application was a failure.
Discussion: The increasing decentralization of the health care system in Uganda during the period
studied has not been followed promptly by the implementation of a global national health policy
necessary for a decentralized system. It appears as if the government assumed that new health
policies could be implemented by means of a fairly uncomplicated process of diffusion. However,
an analysis of the near total failure of the BOD/CE initiative shows that implementation of policy
in the decentralized system in Uganda is complex and must be understood as a misdirected
translation process whose prerequisites were lacking.
The main factors that have inhibited the adoption of a new policy and have crated a gap between
centre and periphery have been different values, the absence of a common frame of reference, and
the lack of government support. As a result, local obligations and local accountability have been
the main factors guiding the translation.