HEALTH SECTOR REFORMS (HSRs) IN UGANDA: A VIABLE STRATEGY TO EFFECTIVE HEALTH CARE DELIVERY?

At the time of independence, Uganda had of the best health care delivery systems in Africa. The country's economy was also one of the most vibrant in Africa. However, the decades of misrule by Idi Amin (1971-79) and Obote II (1980-85) led to a collapse of the country's health and economic structures. By 1986, when National Resistance Movement (NRM) captured power the whole economy was in ruins with high trade deficits, debts, high inflationary levels and poor health indicators. Owing to economic difficulties, coupled by the "mystical faith" in the "free-market" paradigm after the mid 1980s, concerns started to shift away from equity issues to efficiency and sustainability. Within the realm of health care, the neo-liberal paradigm led to adoption of the health sector reforms (HSRs) as a "panacea" of all health sectors' ills. The major HSRs adopted included cost-sharing, decentralization, civil service reforms, re-organization of Ministry of Health (MoH), Partnerships with non-state actors, Health Management Information Systems and privatization. The adoption of these policies had an "inspiration" from the neo-liberal thinking through IMF and World Bank, the New Public Management (NPM), the Alma Ata Declaration as well as the Bamako Initiative. Ever since their adoption, controversy has surrounded them. Many critics argue that HSRs have created more evils by worsening the health care delivery and utilization, thus being anti-people. At the same time, protagonists argue that HSRs have increased health care quality, delivery and utilization, thus being pro-people. This research analyses the trajectory ofHSRs and their effects on health care delivery and utilization in Uganda. Indeed, the research reveals that many benefits/achievements have been registered as a result of HSRs. These include reduced distance to health units as more health units are built, efficiency in health sector management by Health Unit Management Committees (HUMes). Others include availability of drugs and auxiliary services for those who can afford; quick response to disease outbreaks by districts, integration of traditional healing and traditional medicine into main stream health care delivery system, etc. However, these benefits/achievements have been attained with "costs" to society. Some of these costs, although cannot be attributed solely to HSRs, the implementation of the programme has exacerbated its effects on Uganda. They include drug over-prescription, self-prescription and self-medication, human resources constraints, corruption, drug-leakage, consumer exploitation, informal health providers and inadequate funding. It is important to note that different segments of society have been affected differently by the reforms. It is therefore difficult to quantify the benefits and problems and put them in a continuum. However, what is clear from the research findings is that HSRs when properly implemented are a viable strategy to improve health care delivery. Implementation demands efforts at regulating the private sector as well as the public health care providers through supervision and monitoring, meaningful community participation, capacity building as well as political will and commitment.