Not for us, without us: examining horizontal coordination between the Ministry of Health and other sectors to advance health goals in Uganda.

The Ministry or Department of Health (M/DoH) is the mandated government agency for health in all countries. However, achieving good health and wellbeing requires the health sector to coordinate with other sectors such as the environment, agriculture and education. Little is known about the coordination relationship between MoH and other sectors to advance health and development goals in low- and middle-income countries (LMICs). Our study examined the coordination relationship between MoH and other government ministries, departments and agencies (MDAs) at the national level in Uganda. This was an embedded case study nested in a study on intragovernmental coordination at the central government in Uganda. A qualitative approach used document review and key informant interviews with government officials and non-state actors. Data were analysed thematically using a multitheoretical framework. The coordination relationship was characterized by interdependencies generally framed lopsidedly in terms of health sector goals and not vice versa. Actor opportunism and asymmetrical interests interacted with structural-institutional factors contributing to variable influence on internal and external coordination within and beyond MOH. Supportive mechanisms include (a) diverse health sector legal-institutional frameworks, (b) their alignment to broader government efforts and (c) the MOH's agency to leverage government-wide efforts. Constraints arose from (a) gaps in the legal-institutional framework, (b) demands on resources due to the 'broad' MOH mandate and (c) the norms of the MOH's professional bureaucracy and the predominance of medical professionals. This study underlines critical actions needed to improve coordination between the health and non-health sectors. Introspection within the MOH is vital to inform efforts to modify MOH's internal functioning and positioning within the broader government to strategically advance MOH's (development) aspirations. The nature of MoH's role in multisectoral efforts should be contingent. Consideration of mutual sectoral interdependencies and interactions with and within broader government systems is critical.

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

Managing sectoral interdependences requires functional tools that facilitate coordinated multisectoral efforts. The pursuit of multisectoral action for health is intrinsically linked to broader efforts in many governments to achieve greater internal coordination. This research explores the nature of coordination instruments for multisectoral action at the national level in Uganda and the complexities of how these tools play out in implementation. Data was collected through 26 purposive in-depth interviews with national-level stakeholders, including government officials and non-state actors, and a review of selected government strategic documents. A typology of coordination instruments was developed and used to break them down into structural and management tools, and infer their underlying coordination mechanisms based on their design and operational features. A multitheoretical framework guided the analysis of the factors influencing the implementation dynamics and functioning of the tools. The study found that the Government of Uganda uses a range of structural and management instrument mixes mutually influencing each other and mainly based on hierarchy and network mechanisms These instruments constitute and generate the resources that structure interorganizational relationships across vertical and horizontal boundaries. The instrument mixes also create hybrid institutional configurations that generate complementary but at times conflicting influences. This study demonstrated that a contextualized examination of specific coordination tools can be enhanced by delineating the underlying institutional forms of ideal type mechanisms. Such an approach can inspire more complex analysis and comparisons of coordination instruments within and across government levels, policy domains or issues over time. Health policy and systems research needs to pay attention to the instrument mixes in government systems and their dynamic interaction across policy issues and over time.

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

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.

Multisectoral action for health in low-income and middle-income settings: how can insights from social science theories inform intragovernmental coordination efforts?

There is consensus in global health on the need for multisectoral action (MSA) to address many contemporary development challenges, but there is limited action. Examples of issues that require coordinated MSA include the determinants of health conditions such as nutrition (malnutrition and obesity) and chronic non-communicable diseases. Nutrition, tobacco control and such public health issues are regulated separately by health, trade and treasury ministries. Those issues need to be coordinated around the same ends to avoid conflicting policies. Despite the need for MSA, why do we see little progress? We investigate the obstacles to and opportunities for MSA by providing a government perspective. This paper draws on four theoretical perspectives, namely (1) the political economy perspective, (2) principal-agent theory, (3) resource dependence theory and (4) transaction cost economics theory. The theoretical framework provides complementary propositions to understand, anticipate and prepare for the emergence and structuring of coordination arrangements between government organisations at the same or different hierarchical levels. The research on MSA for health in low/middle-income countries needs to be interested in a multitheory approach that considers several theoretical perspectives and the contextual factors underlying coordination practices.

Blood cigarettes: cigarette smuggling and war economies in central and eastern Africa.

OBJECTIVE: To analyse cigarette smuggling practices in central and eastern Africa. METHODS: Primary data were gathered during long-term qualitative field research in which about 400 interviews were conducted. Analysis of secondary sources included academic literature and reports from non-government organisations, multilateral organisations and the press. RESULTS: Our research suggests that the following factors play an important role in cigarette smuggling in eastern and central Africa: (1) government officials encounter difficulties monitoring the long and porous borders; (2) there is a general problem of corrupt government officials and particularly those who allow large-scale smugglers to operate; (3) criminal elements also play an important role in smuggling--cigarette smuggling has helped rebel groups to finance their activities, something illustrated through examples from the war economy in the eastern part of the Democratic Republic of Congo. CONCLUSIONS: Our research suggests that cigarette smuggling in this region is not primarily the result of different taxation levels in neighbouring states, but rather the outcome of weak state capacity, high levels of corruption and the activities of rebel groups. Under these conditions smuggling cigarettes becomes an attractive option as taxation is so easily avoided. This explains why in the low-income countries in this study there are high levels of smuggling in spite of low cigarette prices. Comprehensive supply control and enforcement legislation, and cooperation at national, regional and global level are needed to tackle fraudulent practices facilitated by corruption at state level, and to effectively punish interaction between cigarette traders and rebel groups.