Healthcare markets in post-conflict settings : experiences of formal private-for-profit healthcare organisations in Gulu District, Northern Uganda

There is a paradox between the post-conflict setting and the healthcare market in Northern Uganda. While there is a strong missionary sector and apparent ongoing rehabilitation of the government facilities, the popularity of the formal private for-profit sector has steadily increased in Gulu municipality, northern Uganda, which has a high poverty-afflicted population. Therefore, there is need to understand why and how we can leverage the potential of the formal private for-profit providers (FPFPs) to accelerate Universal Health Coverage (UHC) goals. The study explored the experiences of the FPFPs based in Gulu municipality regarding the market in which they operated during and after the conflict. In particular, the study sought to understand the characteristics of and changes in FPFPs over time, as well as the challenges, coping strategies, opportunities, and linkages with others in the market. This was a case study using mixed methods with a quant-qual sequential approach. The methods included organisational survey, life-history interviews, key informant interviews and observation. This study utilised the New Institutional Economics (NIE) theory as an analytical lens. Data analysis was conducted using SPSS, ATLAS.ti ver. 7.0 and UCINET ver. 11.0 software. The findings suggest that FPFPs increased in number and experienced internal changes within individual businesses across the conflict periods. Conflict provides the context in which the FPFP businesses started and operate (d) and explains their survival patterns and the emergent regulatory context. The FPFPs were faced with diverse challenges embedded in the active conflict that further complicated operational costs and regulatory mechanisms. Notably, some of the coping strategies compromise the quality of the services provided. There is a dense relational network for FPFPs in Gulu municipality, and these numerous relational links have positive implications for the broader coverage of the goal for UHC, the reduction of transaction costs as well as their continued relevance in the market. FPFPs were continuously faced with a dilemma of balancing optimization of their incomes with their altruism objectives. In the period following conflict, FPFPs attempted to implement various mechanisms to ensure that the poor could access health care. The mechanisms were enabled by the managers’ ad hoc judgements as well as partnerships with the local government and NGOs in the area. These ranged from price exemptions and reductions to price discrimination and breaking down doses. The study concludes by noting that FPFPs play a critical role in service provision in post-conflict northern Uganda. However, they cannot be ‘exclusively’ pro-poor, given that they are formed with a profit maximization objective. Some coping strategies and some mechanisms to enable the poor to access services may compromise quality. Hence, the government needs to enforce regulations to control the number of FPFPs opening business as well as quality. There is evidence of partnerships between the government and FPFPs. This needs to be continuous and expanded to include more FPFPs if UHC goals are to be achieved.