Determining policy adequacy and levels of implementation for the attainment of the millennium health goals: the case of Malaria control in Uganda

Abstract

Uganda and Sub-Saharan African (SSA) countries in general, are not making headway in achieving the health related Millennium Development Goals (MDGs) and especially reducing the under-five child mortality. While there are different ways to mitigate this problem including improving the economic growth of countries, policy choices are considered critical in determining improvement of social welfare and achieving sustainable development. This study investigated whether disease control policy was adequate to achieve the desired social goals. This was done by studying the household illness/disease experiences and health care system implementation experiences. Implementation experiences were used to interrogate policy because the two are iterative elements in a continuous loop each informing the other. Implementation success depends on the robustness of a policy; and, therefore, a need to determine the elements that inform an adequate policy. Malaria control in Uganda was used as the case of study for extrapolation to other common diseases that afflict children in SSA. Because of the iterative relationship between policy and implementation, malaria control implementation guidelines were broadly considered as policy.

The study used the Implementation Theory, the Life Model Theory, the Human Rights Perspective, the Health Belief Model, and Community Organization concepts as analysis tools. Qualitative and quantitative methods, theories, and data were triangulated in a complementary and integrative manner within a cross-sectional retrospective design. The study of the implementation experiences was carried out in Mukono and Mpigi districts of Uganda covering a sample of 543 of rural and urban households and 138 health workers and other significant people. Data was collected using personal interviews with child carers, unstructured interviews with key informants, and document reviews. A critical discourse analysis of the policy documents was done to understand the key ideas, the underlying theories, the values, assumptions and the extent it addressed the households’ illness/disease control needs, and values. The needs and values were distilled from the household illness, management, and service utilization experiences.

Findings have revealed that the disease control policy does not have the capacity to control and prevent the most prevalent diseases in SSA because it of its inadequacy, deficient implementation of the curative, preventive and promotive services, and poor household, community and institutional organization for disease control. The main reasons for policy inadequacy are: - a) the limited scope in problem construction with a tendency to use the biomedical model which emphasizes the individual level risk factors relegating the environmental factors; b) failures to fully address the implementation challenges and threats pertaining to curative and preventive strategies; c) inability to support the different health care systems in accordance with their availability, capacities, comparative advantage to manage uncomplicated and severe conditions, and people’s health care seeking values and preferences of a health care provider. Policy does not also adequately provide for social organization, social capital development and empowerment of the health care systems including the households – which factors were found to be risk factors in the sustainance of high morbidity, mortality and disability. Implementation efforts are directed at the provision of curative care and less at primary prevention and health promotion. Incidentally, curative care is beset with many problems hampering its ability to avert many preventable deaths.

One major underlying explanation for the policy inadequacy is the top-down perspective used to construct the problem. This perspective fails to fully address the constructions of the sufferers of the problem which construction slightly differs from that of the experts. Subsequently, the restricted problem construction ends up limiting the social responses, the actors, the processes, and finally the outcomes. The policy tends to focus attention more on disease and less on health; on individual health and not population health. The disease focus tends to engage more the health workers and less other professions and social service sectors contrary to primary health care (PHC) and health sector reform (HSR) precepts. Communities are less likely to participate in improving their own health because the problem construction does not give them the opportunity. Local governments are less likely to be committed to ensuring people’s right to health, and feel accountable for each child’s death because of the perception that illness is a personal problem. The study recommends that there is need to combine the top-bottom and bottom-up approaches during policy formulation processes. It also provides very specific recommendations which are packaged in a framework for designing an adequate policy. The framework consists of content elements, processes, values and an underlying community organization theory for designing a new policy and reformulation of an existing policy. The framework suggests a bigger role for other professionals especially the social workers with an ability to contribute to problem construction with the public health workers; community organization, behavioural and attitude change of service beneficiaries. However, this framework needs to be tested out with other common health problems to assess its validity and reliability in relation to achieving certain outcomes.