Introduction: By the late 1980s, Uganda’s health system had been devastated by two decades ofconflict and mismanagement. At the same time, public-funded and run health systems hadbegun to be viewed as inefficient and undesirable. Uganda’s attempt to rehabilitate its destroyedhealth infrastructure was blocked by donors in favour of reform. Introduced as pre-conditions ofaid, market-based health sector reforms (HSRs) were eventually embraced by the government ofUganda as part of the wider globalized free-market policy to provide market solutions to healthsector problems. The reforms were driven by ideology; they were untested and not based onevidence.Theoretical framework: The research develops a conceptual framework for critical analysis ofHSRs as a policy of the free-market system, and uses policy analysis framework of Hogwoodand Gunn, which starts from policy agenda setting and ends with policy maintenance,succession or termination. Where a policy fails or becomes irrelevant, it is succeeded by anotherpolicy and terminated. It also employs Raskin et al’s transition-and-trend prediction of thefuture; that uncontrolled free-market capitalism is hungry for markets, resources andinvestment opportunities with dire consequences of social polarization, terrorism,environmental degradation, climate change and breakdown of welfare, such as health care. Twopossible scenario options are predicted: either to reform the free-market policy or develop a newcivilization.Aim and objectives: The aim of the study was to explore the implications of market-basedhealth sector reforms in Uganda for the development of sustainable health systems. Theobjectives were to 1) analyse the genesis, formulation and implementation of HSRs in Uganda;2) to evaluate the performance of the health sector under HSRs; 3) to evaluate HSRs collectivelyand individually; and 4) recommend a framework for sustainable health systems.Methods: Four main methods were used in the study: a) Several evaluation studies of HSRs inUganda were done. Ugandan studies were done in thirteen pilot health reform project districts.Evaluation studies included several separate thematic sub-studies. Most studies employedinterviews, focus-group discussions, and structured observation; b) A study was done tocompare Uganda’s reform with those in other countries under a bi-country study and through areview of multi-country studies; c) Systematic reviews and analyses of various household andhealth-facility surveys were carried out; and d) A sub-district health systems survey was carriedout to assess health system inputs, functions, outcomes and efficiency.Results: Health indicators stagnated or deteriorated during the period under study. Only slightimprovements have occurred recently but are associated factors outside the health sector. Of thetwenty reforms, only two achieved success: setting up private facilities and community-baseddistribution of health commodities. Eight failed to achieve individual objectives (user-fees,pricing of health care, defining and implementing an essential health package, hospitalautonomy, decentralization, contracting out, sector wide approaches, and restructuring ofministry of health). Seven reforms were not sustainable or feasible (revolving drug funds,prepayment schemes, social-health insurance, income generation for health care, paymentincentives, hospital trusts and autonomy or privatization of National Medical Stores). Threereforms were found to undermine health sector objectives, especially that of equity (user-fees,privatization, and decentralization). Factors complicating HSRs include aid, macroeconomicSam Okuonzi12policy, policy on economic growth, corruption, inadequate internal management capacity, andad hoc nature of reforms in general.Discussion: The failure of market-based HSRs to achieve collective and individual objectives inUganda is a trend also documented in other countries. The characteristics of a good healthsystem (such as equity, solidarity, evidence-based decisions, government leadership and control,and regulation) cannot be achieved through privatization and market forces. Moreover, HSRsare linked to a much wider and entrenched socio-economic global system established anddriven by free-market capitalism. Health systems crises cannot therefore be addressedindependently of the wider global economic order. Either there has to be policy reform withinthe prevailing framework of the free-market, focussed on addressing perpetual crises as theyemerge, or a new world order based on different values has to be defined and the human societyhas embark on the path of a new civilization. It is envisioned that only when the values uponwhich the free-market is based (such as materialism, winner-takes-it-all, individualism, anddomination of others) are replaced with other values (such as equity, solidarity, mutualexistence, and shared responsibility), will there be a suitable environment for sustainable andequitable health systems development.Conclusions, lessons and recommendations: The health system crisis in Uganda is due to freemarketpolicy, introduced through and driven by donor aid and its poor management. It wasalso due to poor leadership and governance in Uganda. Market-based approaches need closecontrol and regulation to protect social welfare and the environment. To address the crisiscaused by HSRs, Uganda requires counter-reforms in the economy, health policy, social services,leadership and governance. But globally, the market has to be controlled in favour of humandevelopment, peaceful coexistence and sustainable use of resources. Ultimately, a newcivilization in which the market is fully controlled and is not the mechanism for health servicedelivery needs to be established.
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