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

ABSTRACT

INTRODUCTION: Coordination 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. METHODS: This 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. RESULTS: Complex 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. CONCLUSION: The 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.