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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Given a) the recent increases in the volume of aid for scaling up health interventions, b) the introduction of new aid modalities, and c) the growing interest to move towards a more results-oriented approach to deliver aid, this research seeks to better understand the relationship between Government and donors by assessing: - The nature of the incentive structures embedded in the new aid mechanisms and how they are structured by the monitoring and compensation schemes (penalties and rewards); - The motives (objective functions) of the organisations and individuals and how those shed light on the behaviours of the parties in the aid environment in Uganda; - The appropriateness of thinking embedded in economics, particularly the agency theory framework when applied to understand the aid contract. This investigation made use of qualitative methods (interviews, participant observation and documentary analysis) and a case-study approach. Key findings were: - Monitoring capacity and ability to assess performance was weak; - There was a lack of high level commitment towards improvement of monitoring from Government and donors; - Performance assessment was based on a subjective system and presented inefficiencies, which allowed for the distortion of the compensation scheme as penalties and rewards failed to be applied by donors vis-ä-vis the Government; - There were inter- and intra-organisational conflicting goals. Comparing stated and revealed motives, I found that there was less commitment towards health systems development by Government and aid effectiveness by donors than asserted by the parties. This thesis contributes to knowledge by providing an in-depth understanding of the relationship between Government and donors in a country-specific setting. It shows that agency theory is a useful framework to analyse the motives of the parties as well as the incentive structures embedded in the aid contract (albeit with some limitations).

This is a study of the experiences and perspectives of the users and providers of primary health care. The study analyses the users and the providers' experiences and perspectives with regards to the decentralization policy and its impact on the quality of primary health care delivery in the rural district of Pallisa in Uganda since its implementation in 1990s-2005. This is mainly a qualitative study in which both users and providers were interviewed although quantitative data was applied to add meaning where necessary. The study has shown that decentralization in Uganda is a new form and means of service delivery. The planners aim at getting every segment of the population to participate in all aspects of service delivery. There is evidence to show that the policy has had a positive impact on the structure of the health sector as a whole. However, the systematic processes of cost containment measures has resulted in the general economic hardship in the operationalization of the decentralization policy in Uganda and has resulted in varied experiences and the way decentralization is viewed in Pallisa. The study noted that hardships have resulted from increasing responsibilities given to lower level of government amidst declining state support in terms of funding and manpower development. The study notes that the apparent changes brought by the overall restructuring of health services have resulted in the 'commercialization of social relations which has changed the way people live and view public goods which also contributes to hardships in service utilization. This study shows that although health service delivery and its quality in rural Pallisa is an old problem, there are feelings among the users and providers that these problems have worsened in the recent past transforming health care consumers and providers into a new category of social actors who have taken different approaches to survive a midst poverty, exclusion and the declining state support system. Although this study does not recommend a return to a centralization system of service delivery in the health sector, it does however, find implementation problems which will have to be addressed if the intended benefits are to be realized.