PhD defence Aloysius Ssennyonjo

Supervisors

• Prof. Dr. Em. Bart Criel (ITM) 

• Prof. Dr. Sara Van Belle (ITM)

• Prof. Dr. Kristof Titeca (Institute of Development Policy, University of Antwerp, (IOB/UA))

• Prof. Dr. Freddie Ssengooba (Makerere University School of Public Health (MakSPH))

Abstract

Introduction: Advancing a multisectoral approach to universal health coverage in Uganda and similar settings is crucial for improving the population’s overall health and wellbeing. A multisectoral approach involves coordination among various policy domains such as health, education, economy, agriculture, and trade to address the multiple determinants of health comprehensively. This PhD takes a government perspective premised on the limited exploration of intragovernmental coordination (i.e. internal coordination among public sector organisations such as ministries, departments and agencies from various policy sectors) to advance a multisectoral approach to health and other development aspirations. Intragovernmental coordination refers to the voluntary or forceful alignment of different government entities’ actions, resources and efforts to address many contemporary development goals and challenges. However, achieving such coordination is an ongoing challenge. The government is often considered a homogeneous entity without unpacking its unique structural, organisational and functional complexities. Using the case of the national government in Uganda, this thesis investigates intragovernmental coordination over the 2015-20 period to inform the country’s multisectoral efforts towards health Sustainable Development Goals (SDGs) espoused under universal health coverage.

Methods: This study evolved as an interdisciplinary, iterative and theoretical-empirical exploration comprising three related work strands: a) theory development, b) empirical inquiry and c) synthesis of findings to draw insights to inform policy, practice and future research. The theory development stream entailed the development of conceptual and theoretical tools (through narrative reviews focused on different topics and expert feedback) that were applied during the empirical phase. The main tools included a) a multidimensional coordination framework for government action, b) a typology of coordination instruments, and c) a multitheoretical framework (combining the transaction cost economics theory, principal-agent theory, resource dependence theory and political economy perspective). The empirical inquiry involved a single-embedded case study of Uganda’s national government. The study deployed a majorly qualitative research strategy comprising a narrative review approach, stakeholder engagements and observations during the 2015-20 period, 26 in-depth interviews with national-level stakeholders and a document review. The findings were later synthesised into lessons, implications and recommendations to enhance IGC and advance the multisectoral approach to UHC and other development goals.

Results: Intragovernmental coordination manifests as a relational, multidimensional and multilevel phenomenon comprising external-internal and vertical-horizontal interorganisational relationships towards short-term, medium-term or long-term outcomes. The national government is a multiorganisational entity, and each government entity is multilayered. In its merit, each entity is and exists in an intricate web of vertical-horizontal and internal-external relationships that must be managed judiciously.

The complex and dynamic interactions among multiple factors and actors, internal and external to the government, influenced the coordination process. Interdependencies, coordination costs, non-aligned interests, and institutional and ideational factors were crucial to the coordination process. The power dynamics within the bureaucratic structures and the agency of coordinating entities influence the coordination efforts. The functioning of the bureaucracy is influenced by historical path-dependent features such as public sector reform processes and broader factors such as neopatrimonialism, political settlements and colonial legacies, which are also characteristics of other African states. New Public Management principles promoted in the 1990s by institutional strengthening projects of donors, characterised by agencification and the setting up of independent agencies to circumvent ineffective big line ministries, created further fragmentation within the government. Dissatisfaction with the new public management promise has instigated counter-reforms such as increased (re)centralisation and use of political appoints to ensure more political control over the bureaucracy. The donors and international agendas were occasionally supportive but sometimes counterintuitive to national coordination efforts.

Other findings indicate that coordination in government entails activating several structural and management instrument mixes based mainly on hierarchy and network mechanisms. However, the market logic linked to neoliberalism that underpins many aspects of the political, social and economic life in Uganda plays a fundamental role. The instruments’ functionality depends on the inherent mechanisms, (counter-)interactions with each other and the broader contextual factors that shape actors’ behaviours. On a related note, horizontal coordination between health and other sectors was shaped by technical and political factors such as lopsided framing of (inter)dependence, actor opportunism and asymmetrical interests. The structural-institutional factors existent at the intrasectoral level interact with the broader national context to shape internal and external coordination.

Conclusion: Pursuing a multisectoral approach to universal health coverage and other development goals is inseparable from the (national) government’s efforts to coordinate its affairs. This thesis underscores that domains of knowledge such as public administration, organisational theory, public policy, political science and development studies, where thinking on coordination within and across government entities has advanced over time, can enrich multisectoral efforts towards public health issues. An iterative process of theory development and empirical inquiry is pertinent to an emerging area of study and essential for understanding how and why coordination takes place. The thesis affirms that the coordination process requires time and resources to guide the software aspects of institutional change—articulating a shared vision of coordination across government. Policy actions and implementation arrangements should promote incentives to align interests, manage coordination costs and navigate historical institutional context, countervailing political actions and inherent power dynamics. Understanding the interactive dynamics among coordination instruments is vital. The role of the health sector in leading or supporting multisectoral efforts for health advancement should be contingent.