‘Writing budgets for meetings and teas?’: a multitheoretical analysis of intragovernmental coordination for multisectoral action for health in Uganda

Abstract

IntroductionCoordination across policy domains and among government agencies is considered critical for addressing complex challenges such as inequities, urbanisation and climate change. However, the factors influencing coordination among government entities in low-income and middle-income countries are not well known. Although theory building is well suited to explain complex social phenomena, theory-based health policy and systems studies are limited. This paper examined the factors influencing coordination among government entities at the central government level in Uganda.MethodsThis theory-based case study used a qualitative approach. Primary data were collected through 26 national-level key informant interviews supplemented with a review of 6 national strategic and policy documents. Data were analysed abductively using a multitheoretical framework combining the transaction cost economics theory, principal–agent theory, resource dependence theory and political economy perspective.ResultsComplex and dynamic interactions among different factors, both internal and external to the government, were found. Interdependencies, coordination costs, non-aligned interests, and institutional and ideational aspects were crucial factors. The power dynamics within the bureaucratic structures and the agency of the coordinated entities influence the effectiveness of coordination efforts. New public management principles promoted in the 1990s by donor institutional strengthening projects (characterised by agencification and setting up of independent agencies to circumvent ineffective big line ministries) created further fragmentation within the government. The donors and international agendas were occasionally supportive but sometimes counterintuitive to national coordination efforts.ConclusionThe multitheoretical framework derives a deep analysis of the factors that influence organisational decision-making to coordinate with others or not. Achieving intragovernmental coordination requires more time and resources to guide the software aspects of institutional change—articulating a shared vision on coordination across government. Shaping incentives to align interests, managing coordination costs and navigating historical-institutional contexts are critical. Countervailing political actions and power dynamics should be judiciously navigated.

What are the tools available for the job? Coordination instruments at Uganda’s national government level and their implications for multisectoral action for health

“…Central-level agencies such as the OPM and NPA were constrained, despite clear mandates, by limited technical capacity and non-material resources such as legitimacy. This is consistent with other assessments (Secretariat, 2013;A et al, 2016;Roberts and Ssejjaaka, 2017;Ssennyonjo et al, 2022) and with literature from LMICs emphasising the importance of relational and technical factors (Hongoro, Akim J and Kembo, 2012;Zaidi et al, 2018;Mahlangu, Goudge and Vearey, 2019).…”

“…Our study revealed that market-based tools were generally absent at the central government level, despite recent global trends such as the pursuit of result-based management approaches in Africa underpinned by neoliberal market logic (African Development Bank 2017, Oxman andFretheim 2009). The Ugandan context (like other LMIC) is characterized by challenges in performance measurement, risk-averse principals, weak capacity to monitor, high transaction costs, strong interdependence, high complexity and uncertainty (Roberts and Ssejjaaka, 2017;Uganda Ministry of Public Service, 2017;Mukuru et al, 2021;Ssennyonjo et al, 2022). These features favour dominance of tools based on hierarchical and network-based mechanisms as per the TCE and PAT theories ( (Rossignoli and Ricciardi, 2015) Additionally, lack of market based tools can be explained by notions of the path-dependence in institutional change (Thelen, 1999).…”

“…This study is part of a broader PhD project focusing on coordination within the public sector to harness MSA for health improvements. The government focus is motivated by the limited attention to internal government dynamics in health policy and systems research on multisectoral collaboration (Shankardass et al, 2018;Glandon et al, 2019;Ssennyonjo et al, 2022). The focus on national government coordination is inspired by this government level being the principal custodian of national development efforts.…”

Examining the influence of health sector coordination on the efficiency of county health systems in Kenya

“…The framework focuses on coordination within government and between government and non-state actors such as donors. The framework assumes that poor coordination occurs when there is (1) misalignment, (2) duplication, or (3) fragmentation of institutional structure and implementation processes in the health sector [13,[17][18][19]. Misalignment occurs when multiple health system structures or processes do not yield coherent incentives and outcomes.…”

Examining the Influence of Health Sector Co-ordination on the Efficiency of County Health Systems in Kenya

“…The framework focuses on coordination within government and between government and non-state actors such as donors. The framework assumes that poor co-ordination occurs when there is 1) misalignment, 2) duplication, or 3) fragmentation of institutional structure and implementation processes in the health sector [13,[17][18][19].…”