Analyzing the influence of institutions on health policy development in Uganda: a case study of the decision to abolish user fees.
BACKGROUND
During the 2001 election campaign, President Yoweri Museveni announced he was abolishing user fees for health services in Uganda. No analysis has been carried out to explain how he was able to initiate such an important policy decision without encountering any immediate barriers.


OBJECTIVE
To explain this outcome through in-depth policy analysis driven by the application of key analytical frameworks.


METHODS
An explanatory case study informed by analytical frameworks from the institutionalism literature was undertaken. Multiple data sources were used including: academic literature, key government documents, grey literature, and a variety of print media.


RESULTS
According to the analytical frameworks employed, several formal institutional constraints existed that would have reduced the prospects for the abolition of user fees. However, prevalent informal institutions such as "Big Man" presidentialism and clientelism that were both 'competing' and 'complementary' can be used to explain the policy outcome. The analysis suggests that these factors trumped the impact of more formal institutional structures in the Ugandan context.


CONCLUSIONS
Consideration should be given to the interactions between formal and informal institutions in the analysis of health policy processes in Uganda, as they provide a more nuanced understanding of how each set of factors influence policy outcomes.
Health Policy PhD Program, McMaster University, Ontario, Canada. moatka@mcmaster.ca
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Abelson
D005249:Fees and Charges; D006291:Health Policy / Q000191:economics; D006801:Humans; D019982:Organizational Case Studies; D011050:Policy Making; D011057:Politics; D011635:Public Health Administration / Q000191:economics* / Q000331:legislation & jurisprudence; D036301:Qualitative Research; D014454:Uganda