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The Political Economy of Child Mortality Decline in Tanzania and Uganda, 1995–2007

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Abstract

This article identifies political economy factors that help explain dramatic differences in the pace of child mortality reduction between Tanzania and Uganda from 1995 to 2007. The existing literature largely explains divergence in basic health outcomes with reference to economic variables such as GDP per capita. However, these factors cannot explain recent divergence across African countries with similar levels of GDP per capita, rates of economic growth, and levels of health funding. I argue that institutional and governance divergences between Tanzania and Uganda can be linked directly to differing coverage levels of key child health interventions (especially related to malaria control), and thus to differing child health outcomes. These institutional differences can be explained in part by historical factors, but more relevant causes can be found in recent political events. In Tanzania, there was an unusually effective project of institution building in the health sector, while in Uganda, by contrast, there was a negative political shock to the health system. This was driven by the repatrimonialization of the Ugandan state after President Yoweri Museveni’s decision to eliminate term limits in the 2001–2006 period. This repatrimonialization process reversed previous health sector institutional gains and had particularly negative effects on child health service delivery in Uganda over the period in question.

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Notes

  1. Excluding six northern war-affected districts in Uganda, the under-5 mortality rate was 156.

  2. Uganda’s 2011 DHS preliminary results show 90 deaths per 1,000 live births, compared Tanzania’s 2010 figure of 81 deaths per 1,000 live births (Uganda Bureau of Statistics and ICF International 2012).

  3. Author’s calculations from the institute for Health Metrics and Evaluation’s under-5 mortality dataset.

  4. The under-5 mortality rates measured in Demographic and Health Surveys are average mortality rates over a 5-year period. This means that, for example, the Uganda 2006 survey measures under-5 mortality over the 2001–2005 period.

  5. Ross (2006) shows that when censored data is accounted for and time and period fixed effects are included, democracy has no independent effect on infant or child mortality.

  6. While this paper compares Uganda to mainland Tanzania (i.e., excluding Zanzibar), it should be noted Tanzania’s “partly free” Freedom House rating is likely at least in part due to developments in Zanzibar, where partisan politics over the period in question were markedly less consensual than on the mainland. More detail on fundamental similarities of Tanzanian and Ugandan political economy (as low income, largely neopatrimonial states with reasonably free civil society and open elections but completely dominant ruling parties) as well as key institutional differences is provided in the concluding section of this article.

  7. Tanzania and Uganda are both among the top five total recipients of health sector aid since 1990, according to data from the Institute for Health Metrics and Evaluation.

  8. For estimates of the size of malaria-linked mortality reductions, see Eisele et al. (2012).

  9. The 13 interventions are: ITN coverage, exclusive breastfeeding, availability of malaria and pneumonia treatment, coverage of measles and Hib vaccines, birth in a clean delivery location, complementary feeding of infants, intermittent preventive treatment for malaria during pregnancy, prevention of mother-to-child transmission of HIV, access to clean water, coverage of vitamin A supplementation, and use of oral rehydration therapy for diarrhea.

  10. While findings from sentinel sites are not nationally representative, their positive findings are illustrative, especially in the case of Dar es Salaam, which contains roughly 10 % of Tanzania’s population. Further evidence of progress on malaria is also apparent in other nationally representative surveys. For example, NIMR recorded a drop from 20 % parasitemia in 2005 to 14 % parasitemia in 2006, while the NATNETS survey recorded 11 % parasitemia in 2008. These surveys also largely confirmed the trends found in the DHS and THMIS surveys about bed net ownership and use, and malaria treatment practices (National Malaria Control Program 2009).

  11. The Ifakara Health Institute was started in the 1956 in rural Tanzania by researchers from the Swiss Tropical Institute, see http://www.ihi.or.tz/about-history.php.

  12. Now known as the Swiss Tropical and Public Health Institute.

  13. Interview, Ifakara Health Institute malaria researcher, December 2009, Dar es Salaam.

  14. Interview, Swiss Tropical and Public Health Institute researcher, March 31 2011, Washington DC.

  15. An example of this is when the Global Fund was ready to cancel Tanzania’s first Global Fund grant, due to bureaucratic delays in program initiation. They were persuaded not to do so when the international Roll Back Malaria ITN working group intervened (described in Ritha et al. 2009).

  16. See for example, Jakaya Kikwete, “We Must Do Better Against Malaria.” Guardian (UK), July 30 2010.

  17. Interview, World Bank July 2009, Washington DC; interview with Swiss Tropical Institute researcher, March 31 2011, Washington DC.

  18. Interview, Ifakara Health Institute, September 2009, Dar es Salaam.

  19. Interview, NMCP official, April 2010.

  20. Interview, Kampala, April 19, 2010.

  21. In both countries, this involved actual devolution of decision-making authority to district governments, rather than simply de-concentration of central Ministries to rural areas. In both countries, however, the vast majority of health funding still came from the central government (and from donors).

  22. Speech at Management Sciences for Health/SURE conference in Kampala, Protea Hotel, April 15–16 2010; author’s notes.

  23. There was one pre-existing DSS system, and one developed for the purposes of the TEHIP project.

  24. In Uganda, where the donors give general budget support (and where no district basket fund was ever instituted), the districts often complain that they are starved of resources, and indeed the increase in funding for districts in Uganda has been exclusively for the wage bill (Okwero et al. 2010).

  25. While similar in many respects, there are also several key technical differences in decentralization design between the two countries, relating both to Uganda’s lack of burden of disease data for planning purposes, and limited autonomy given to district health teams due to extensive earmarking of the district health budget.

  26. Author interview, March 30, 2010, Kampala.

  27. Author interview, MUSPH researcher, Kampala, August 2009.

  28. Author interview, April 19, 2010, Kampala.

  29. Author interview, April 21, 2010, Kampala.

  30. Similar results were seen in 2003 in a four-district drug tracking study (cited in World Bank 2004), which found that stock outs were much higher in the public sector than in private facilities, and that they were particularly high for antibiotics used to treat acute respiratory infection.

  31. By contrast, former Minister Crispus Kiyonga was an MD and had also received his MPH from Johns Hopkins.

  32. Minister of Health (at the time of writing) Stephen Mallinga was an opposition MP who received the Minister of Health post after switching parties to join the NRM, and Minister of State for Health (at the time of writing) James Kakooza was the main political mobilizer behind the third term project for Museveni.

  33. In one example, funds went to pay NRM campaign workers (Kasfir 2010), while in another, then-Vice President Gilbert Bukenya channeled funds to an NGO under his control to do voter mobilization activity in his parliamentary constituency (Etyang 2006). Deputy Minister Mukula was also found to have used Global Fund money for political travel (Etyang and Odyek 2006).

  34. Furthermore, Uganda was involved in conflict in the Democratic Republic of Congo over this period, while Tanzania was not. Even though domestic health spending increased sharply in both Tanzania and Uganda, the DRC conflict may have shifted Ugandan budgetary resources to security sectors and away from health at some margin. If so, this further underlines the point that differing political choices by Tanzania and Ugandan leaders (both internally and externally) led to differing levels of political priority and funding for health services.

  35. Besigye’s candidacy was perceived as particularly dangerous for Museveni because it signaled a split within the NRM elite, and within Museveni’s ethnic base in the Ankole region of Western Uganda.

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  1. International Development Program, School of Advanced International Studies, Johns Hopkins University, Washington, USA

    Kevin Croke

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Croke, K. The Political Economy of Child Mortality Decline in Tanzania and Uganda, 1995–2007. St Comp Int Dev 47, 441–463 (2012). https://doi.org/10.1007/s12116-012-9120-9

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