What slows the progress of health systems strengthening at subnational level? A political Economy Analysis of three districts in Uganda

There is increasing recognition that without stronger health systems, efforts to improve global health and Universal Health Coverage cannot be achieved. Over the last three decades, initiatives to strengthen health systems in low-income countries have attracted huge investments in the context of achieving the Millennium Development Goals, the Sustainable Development Goals, as well as Universal Health Coverage. Yet, health system inadequacies persist, especially at the subnational level. Our paper presents a political economy analysis featuring a three-district case study in Uganda, where district-based health systems strengthening initiatives were implemented. The study sought to understand why health systems at the subnational level are failing to improve despite marked investments.   This problem-based political economy analysis draws from a document review and key informant interviews [N=49] at the central and district levels with government actors, development partners and civil society in three purposively selected districts. Available financial data extraction and analysis were used to complement qualitative data. We found that challenges in strengthening district health systems were numerous. Themes related to financing and planning broadly interacted to curtail progress on strengthening subnational level health systems.  Specific challenges included inadequate financing, mismatch of resources and targets, convoluted financial flows, as well as unwieldy bureaucratic processes. Sticky issues related to planning process-included variations in planning cycles, conflicting interests among actors, insufficient community engagement, limited decision space, and distorted accounting mechanisms.    In conclusion, the political economy analysis lens was a useful tool that enabled understanding the dynamics of decision-making and resource allocation within district health systems as well as the performance in terms of implementation of the district work plans with existing resources. Whereas it is clear that the District health teams play a big role in service program implementation, the context in which they work needs to be improved in terms of sufficient resources, setting realistic targets, widening the decision space and capacity necessary to engage with other various stakeholders and effectively harmonize the implementation of the programs. Despite playing a crucial role of compensating for local shortfalls in resources, donor resources and engagements should not happen at the cost of the subnational voice in priority setting and decision-making. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial N/ A ### Funding Statement : This study was primarily funded by the United Nations Children’s Fund (UNICEF) with funding from the Bill & Melinda Gates Foundation(contract #43297444) The views expressed in this manuscript do not necessarily reflect views of UNICEF and Bill and Melinda Gates Foundations. The findings do not represent the Official position of UNICEF Uganda. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: 1. Makerere School of Public Health Research Ethics Board. 2. Uganda National Council of Science and Technology 3. Johns Hopkins School of Public Health Ethics Review Board I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data relating to this study is available at Makerere University School of Public Health can be availed in conformity to institutional data governance policy. Data requests should be forwarded to sphrecadmin@musph.ac.ug and sengooba@musph.ac.ug.