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. CONCLUSION: 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.