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Foreign Aid, Child Health, and Health System Development in Tanzania and Uganda, 1995-2009

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Foreign Aid, Child Health, and Health System Development in Tanzania and Uganda, 1995-2009 FOREIGN AID, CHILD HEALTH, AND HEALTH SYSTEM DEVELOPMENT IN TANZANIA AND UGANDA, 1995-2009 by Kevin Croke July 2011 Baltimore, Maryland A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy © 2011 Kevin Croke All Rights Reserved Abstract As donors have scaled up efforts to improve health in sub-Saharan African, African countries have diverged sharply in their health performance: Some countries have made rapid progress while others have stagnated. Yet the reasons for these divergences are often not well understood. In this dissertation I present in-depth case studies of two such divergent countries, Tanzania and Uganda, over the 1995-2007 period. Over this period, Tanzania reduced its under-5 mortality rate by 35%, while Uganda’s mortality rate decline was less than half as rapid; between 12% and 15% over virtually the same period. This occurred despite the fact that both countries received similar amounts of foreign aid for health, implemented virtually identical health sector reforms, and saw comparable rates of growth in GDP per capita and similar trends in other socioeconomic indicators. Explanations for such differences often vary by academic discipline. Public health scholars often focus on coverage levels of critical child health interventions, while political scientists emphasize variation in the quality of governance institutions. I show that coverage of child survival interventions did indeed differ between Tanzania and Uganda, particularly in the area of malaria control, but that the ultimate determinant of these differences can be traced to political economy factors. Specifically, regime maintenance dynamics and the differing composition of political patronage coalitions in the two countries determined the relative success of health sector programming in Tanzania and Uganda. ii In addition to outcomes such as under-5 mortality, I also analyze the results of broader health system strengthening efforts in Tanzania and Uganda over the 1995-2009 period. To structure this comparison, a new theoretical framework for health system performance is developed and tested, based on previous theory developed by Pritchett and Woolcock (2002) and Fukuyama (2004). The same political economy dynamics that contributed to Tanzania’s stronger performance on child mortality reduction also enabled its greater progress on health system strengthening. Furthermore, Tanzania’s experience demonstrates the potential for “second best” strategies for health system strengthening that can be implemented in conditions of relatively low state capacity. Primary dissertation advisor: Professor Francis Fukuyama Second advisor: Professor Peter Lewis Additional readers: Professor Joshua Michaud, Professor Tanvi Nagpal, Dr. Nandini Oomman iii Abstract ........................................................................................................................................... ii Table of Figures and Tables ............................................................................................................ v Acknowledgements ....................................................................................................................... vii Introduction ..................................................................................................................................... 1 Chapter 1: Methods and Case Selection ......................................................................................... 8 Chapter 2: Theory and Literature Review .................................................................................... 28 Chapter 3: Child health programs and child survival in Tanzania, 1995-2009 ............................ 74 Chapter 4: Health sector reform and health system development in Tanzania, 1995-2009 ....... 105 Chapter 5: Child health programs and child survival in Uganda, 1995-2009 ............................ 164 Chapter 6: Health sector reform and health system strengthening in Uganda, 1995-2009 ........ 219 Chapter 7: Conclusion................................................................................................................. 280 References: .................................................................................................................................. 300 Vita .............................................................................................................................................. 320 iv Table of Figures and Tables Figure 1.1 GDP per capita in Tanzania and Uganda, constant 2000 US dollars………...18 Figure 1.2: Health system and population health indicators for Tanzania, Uganda and sub-Saharan Africa……..………………………………………………………………...19 Figure 1.3: Health sector aid to Tanzania and Uganda, 1990-2007……………………...20 Figure 2.1: Foreign aid for health per capita (log scale) and child mortality percent change (log scale), 1998-2007………………...…………………………………………28 Figure 2.2: 1996-2006 percent child mortality decline in Tanzania, Uganda, and sub- Saharan Africa.................................................................................................................................29 Figure 2.3: Causes of under-5 mortality in Tanzania and Uganda………………………33 Table 2.1: under 5 mortality estimates and standard errors in Tanzania and Uganda, 1995- 2007………………………………………………………………………………………34 Table 2.2: Child survival interventions and data coverage for Tanzania and Uganda, 1999- 2007………………………………………………………………………………………42 Table 2.3: Sectoral functions classified by specificity and transaction intensity………..57 Figure 3.1: under 5 mortality 1990-2010, all DHS point estimates……………………………….............................................................................71 Figure 3.2: Selected socioeconomic indicators in Tanzania, 1991-2010………………...77 Figure 3.3: Immunization rates in Tanzania, 1996-2010………………………………...79 Figure 3.4: prevalence of fever and parasitaemia (estimated and measured) in children under 5 years of age…………………………………………………………..…………87 Figure 3.5: Health spending by government level, 2001-2006………………………….91 Figure 3.6: under-5 mortality trends in TEHIP districts………………………………...94 Table 4.1: Family-oriented self care in Tanzania………………………………………100 Figure 4.1: quality of care for sick children and IMCI program coverage………..……102 Figure 4.2: Access, use and patient perceptions of government health services, 2001 and 2007..................................................................................................................................104 Figure 4.3: PEPFAR and Global Fund HIV/AIDS treatment spending by category…...106 Figure 4.4: essential drugs budget and MSD sales figures, 1999-2007……..………….123 Figure 4.5: Tanzania's health sector supply chain……………………………………...125 Figure 4.6: Health worker hiring and estimated attrition, district level, 2002-2008.......128 Figure 4.7: Government health spending per capita 1995-2006………………………..140 Figure 4.8: HIV/AIDS spending vs. rest of health budget……………………………..144 Figure 5.1: Under 5 mortality in Uganda and Tanzania, 1995-2007…………………...155 Figure 5.2: Poverty rates in Tanzania and Uganda……………………………………..160 Figure 5.3: Child survival in Uganda, 1992-2006……………………………………...161 Figure 5.4: Percentage of women accessing antenatal care (ANC) and delivery services in Uganda, 1995- 2006…………………………………………………………………………………….166 v Figure 5.5: Percentage of population covered by selected key child survival interventions and affected by selected conditions in Uganda, 1995-2006…………………………....167 FIgure 5.6: Percentages of under-5s with fever (1999-2010) and with malaria (2007- 2009) in Uganda and Tanzania…………………………………………………..……..172 Figure 5.7: Global Fund disbursements for malaria in Uganda, 2004-2010……….…..176 Figure 5.8: Number of districts in Uganda, 1969-2011………………………………...199 Table 6.1: Family-oriented self care in Uganda …………………………………………….206 Figure 6.1: Outpatient visits per capita and percent of population with 5km of health facility, 2000-2010…………...........................................................................................208 Figure 6.2: Sickness and choice of health care providers, 1997-2010………………….209 Figure 6.3: Number of people enrolled on antiretroviral therapy in Uganda and Tanzania …………………………………………………………………………………………..210 Figure 6.4: Quality of care for sick children and IMCI program coverage in Uganda…215 Figure 6.5: Percentage of health facilities with three major child illness treatments in stock………………………………………………….....................................................229 Figure 6.6: Percentage increase in per capita health expenditure in Uganda, 1997-2006 (1997=100).......................................................................................................................250 vi Acknowledgements A project this large could not have been completed without the help of many people. My dissertation committee played an important role throughout the process. In particular, my primary dissertation advisor Professor Frank Fukuyama has taught me most of what I know about the field of comparative politics, offered wise methodological counsel, and was a source of advice and encouragement from start to finish. Professor Peter Lewis was also a valued advisor, and generously stepped into a larger role when Professor Fukuyama moved to Stanford University in 2009. Dr. Nandini Oomman was a valuable sounding board, and had much wisdom to share on the role of HIV/AIDS programs in Africa. Professors Tanvi Nagpal and Josh Michaud graciously
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