Mathauer, Inke
(2001)
Institutional pluralism and interorganisational relations in local health care provision in Uganda: Institutionalised pathologies or healing organisations?
PhD thesis, London School of Economics and Political Science.
Abstract
This thesis is an examination of health care provision in Uganda by means of a case study in Kamuli District. In Uganda, the response to political and economic breakdown in the 1970s has been the spontaneous, decentralised emergence of a pluralist, but fragmented system made up of public, private and voluntary sector providers. While theorists and policy-makers previously placed almost exclusive emphasis on state health care provision, they now favour a system of institutional pluralism. This approach attempts to use the particular advantages attributed to each type of provider to meet diverse needs and conditions. The thesis undertakes a comparative performance analysis of each sector in relation to access, efficient use of resources and quality of care to determine each provider's relative strengths. While the public sector performs worst, the other two sectors also suffer from performance gaps. An institutional analysis is used to explain the differences in (mal-)performance. First, the thesis assesses the intraorganisational institutional mechanisms of each provider type and their ability of ensuring accountability, financial responsibility and appropriate staff incentives. Secondly, it examines the nature of interorganisational interactions and the effectiveness of the governance mechanisms for the co-ordination and regulation of the system as a whole and illuminates how these affect organisational performance. The study demonstrates that the intraorganisational institutional set-up, the governance mechanisms and the interorganisational interactions are characterised by a lack of accountability and therefore are constantly distorted through the operation of perversive incentives. These institutionalised pathologies, especially in the public sector, affect performance negatively. It is argued that a system characterised by institutional pluralism is superior. However, to benefit from its full potential and to heal organisations and put them in a position to heal, it is necessary to manage the intraorganisational and interorganisational dimensions simultaneously and to strengthen accountability mechanisms and the actors' capacities and willingness to co-operate.
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