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State Effectiveness and Political Will: the Case of Malaria Control in Uganda and Rwanda by Hussein Kasim a Thesis Submitted To

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State Effectiveness and Political Will: The Case of Malaria Control in Uganda and Rwanda By Hussein Kasim A thesis submitted to the Faculty of Graduate and Postdoctoral Affairs in partial fulfillment of the requirements for the degree of Doctor of Philosophy In Public Policy Carleton University Ottawa, Canada @Hussein Kasim, 2018 Abstract Employing a comparative case study and using state effectiveness as a conceptual framework, this research explores malaria and its control in Uganda and Rwanda. These two neighbouring countries, which share a significant number of socio-economic characteristics, have been implementing the malaria control policies widely recommended by the World Health Organization (WHO). Despite their similarities, and the implementation of comparable malaria control policies, the two countries have experienced divergent outcomes: a reduction in malaria-related hospital admission and death rates in Rwanda, and an overall increase in malaria-related hospitalizations and deaths in Uganda during the same 2000-2015 period. During fieldwork in both countries over the span of several months, data was collected using key informant interviews; observation at four sites; and examination of government documents. The key findings suggest that the variation in malaria policy outcomes is due largely to political factors including the role of political leaders and institutions (i.e. the Presidency, the ruling party and parliament), and not to technical factors, as most of the literature suggests. The politicization of malaria and its control in Rwanda (i.e. putting responsibility for malaria control in the hands of political leaders), and the de- politicization of malaria control in Uganda explains the divergence in malaria control outcomes. ii Acknowledgements I am grateful to a number of individuals who have made the completion of this dissertation possible. I would like to thank the study participants in both Uganda and Rwanda, who have not only shared key insights about the two countries, but also connected me to key informants and provided me with access to documents. Some of these participants took personal risks to contribute to this research. I have been privileged to have Professor Lisa Mills as my stalwart dissertation supervisor. Without Dr. Lisa Mills’ unwavering support and guidance, this project would not have been completed. Dr. Mills is undoubtedly the best thesis supervisor any doctoral student could wish for. Similarly, I have enormously benefitted from the support and inputs of my dissertation committee members Valerie Percival, Christopher Stoney, and Anil Varughese. Professor Saul Swartz, the director of the PhD program, also kept believing in me. He provided advice and a much needed push to complete this project. I have been blessed and humbled by the steadfast support of my loving wife, Sahra Abdikadir. Her devotion to the success of this project and dedication to care for our lovely three kids, when I have been swamped with PhD life is towering. My kids, Aisha, Layla and Hashi, have been truly patient with me. I am grateful for your understanding and support for all those years. I am also grateful for other members of the family who have always been there for me including my mom, Aisha Yusuf, my brothers Ismail Kasim, Mohamed Kasim, and Abdirisak Kasim. My cousins Fowsia Abdulkadir, Sahra Abdulkadir, Nafisa M. Dahri and Abdullahi M. Hussein, Kamil Hussein, Idil Abdulkadir and Awo (Adar) Abdulkadir provided support and encouragement through the process. I would like to thank a number of people whose support was instrumental in completing this project. They include my friends Salah Jama and Dr. Hodan Shafie Mohamed who have read and critiqued my work. Other friends including Amin Mahdi, Mustafe iii Muhumed (Cagjar), Abdiwasa Mahdi, Gamal Hassan, Naima Elmi, Dr Hamdi Mohamed, Prof. Afyare Elmi, Professor Abdi I Samatar, Ikram Jama, Farrah Hussein, Daud Abdi, and Dr Abdiwasa Bade made the process of writing and rewriting the dissertation more pleasant. I wou like to thank Mulugeta Gebru, everyone’s favorite Carleton University librarian for his continues support arguably at Carleton’s main corrdior of knowledge - the MacOdrum library. I would like to thank my colleagues at work including Marieke Denissen, Abdullahi Gabho, Karen Mahy, Mathew Bryden, Abdihakim Yusuf, Mukhtar Omar, and Suleiman Mohamed who made sure I got the space and time I needed to finalize the dissertation. Lastly, many thanks to my incredible editor, Lyndal Neelin. iv Table of Contents Abstract ................................................................................................................................ ii Acknowledgements ............................................................................................................ iii Table of Contents ................................................................................................................ v List of Tables .................................................................................................................... viii List of Figures ..................................................................................................................... ix List of Abbreviations ........................................................................................................... x CHAPTER I .........................................................................................................................1 INTRODUCTION ..............................................................................................................1 Similar policies, different outcomes: Malaria control in Uganda and Rwanda .......................... 1 Research problem and question .................................................................................................. 2 Argument ..................................................................................................................................... 8 Approaches to understanding malaria and its control ............................................................... 10 The biomedical science approach to malaria and its control. ................................................................... 11 The socio-economic approach to malaria and its control. ........................................................................ 13 The behavioural/cultural approach to malaria and its control. ................................................................ 16 The need for a political approach to malaria and its control. ................................................................... 18 Analytical framework: Assessing state effectiveness .................................................................. 21 Research design and methodology ............................................................................................ 23 Primary research question. ............................................................................................................................. 23 Methodology: Comparative case study. ........................................................................................................ 24 Why a small N case study and why Uganda and Rwanda?........................................................................ 25 Data collection and analysis. .......................................................................................................................... 27 Contributions of the research .................................................................................................... 32 Structure of the thesis ................................................................................................................ 34 CHAPTER II .................................................................................................................... 38 ANALYTICAL FRAMEWORK ........................................................................................ 38 The State defined ....................................................................................................................... 39 The role of the state in development and health ....................................................................... 39 Unpacking state effectiveness ................................................................................................... 45 State autonomy and health. ............................................................................................................................ 46 State capacity and health. ................................................................................................................................ 56 Political will and health. .................................................................................................................................. 63 The interconnectedness of political will, state autonomy and capacity. .................................................. 68 Conclusions ............................................................................................................................... 69 CHAPTER III .................................................................................................................... 71 COMBATTING MALARIA: THE EVOLUTION OF THE INTERNATIONAL POLICY RESPONSE AND ITS POLICY IMPLICATIONS FOR UGANDA AND RWANDA ........................................................................................................................... 71 Malaria: An ancient killer disease in Uganda, Rwanda, and the world ....................................
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