Professor Michael Ryan | What the Ugandan Response to HIV/AIDS Can Teach Us About Collaborative Governance

Persistent problems such as poverty, disease and hunger are of critical interest to organisation and management scholars. Developing countries often struggle with intractable social issues, including susceptibility to epidemics. The complexity of these challenges means it can be difficult for leaders to organise governance and ensure that resources and capabilities are effectively coordinated. Professor Michael Ryan looks at the case study of the HIV/AIDS response in Uganda, and asks how this can contribute to our understanding of public organisation and state capacity. In particular, he explores how Uganda was successful in using collaborative governance to manage the HIV/AIDS crisis.

What is Collaborative Governance?

Collaborative governance refers to an arrangement in which public agencies engage different levels of government, public agencies and non-state stakeholders in decision-making. This decision-making is formal, consensus-oriented, and aims to make, implement or manage public policies and programmes. In bringing various stakeholders together, it aims to aggregate resources and offer a more holistic response to a crisis.

One specific type of collaborative governance, cross-sector network governance, is particularly useful in dealing with highly complex, longstanding issues. These usually require participatory structures and experimentation, and network governance structures are often more able to be flexible and efficient.

What Affects Network Collaboration?

There are several factors that influence the nature and success of network collaborations. Firstly, antecedent conditions, such as the scarcity and need for resources, motivate and shape collaborations. There are also a number of key tensions which can influence outcomes. For example, conflicts between inter-organisational goals, practices and norms can be hard to resolve. Status and power differentials between different agents in the network can also cause issues.

Further, there can be tensions between efficiency and inclusivity. In democracies, inclusivity would normally mean citizens and representatives would be involved in collaborations, but this has not been unexplored in non-democratic contexts. The governance of collaborations and networks is also of utmost importance, as there can be challenges in terms of coordination, control, power, legitimacy, and accountability. Size, tasks, and levels of trust within the collaboration can all influence style and outcome.

The Ugandan Context

Uganda is a developing country. It is low in resources and notable for ineffective public organisation. In fact, it ranks amongst the lowest-performing African countries in terms of governance. At the time of the HIV/AIDS crisis, which started in the 1980s, the country was classified as a non-democratic personal rule autocracy.

Due to contemporary social structures and patterns of behaviour, Uganda was particularly susceptible to the HIV/AIDS epidemic. Many were employed in mines and in the military, which created migration patterns which aggregated men together. This provided a fundamental vector for HIV to spread easily and quickly. Furthermore, the Ugandan health system was weak and unable to cope with epidemics.

In the late 1980s, an estimated two-thirds of Ugandan sex workers were HIV positive. By the early 1990s, HIV/AIDs rates peaked at 18% nationally and, in some areas, up to 30%. In the West Nile district of northern Uganda, an estimated 50 out of 75 children were HIV positive. Many local people believed the disease was due to witchcraft originating from Tanzania.

Despite these numerous challenges, Uganda successfully implemented a collaborative governance system to deal with HIV/AIDS. They reduced HIV prevalence in the country dramatically, and by the 2010s, HIV/AIDS rates were down to 5% nationally. Their response has been influential in many other settings and has been called best practice by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS.

As collaborative governance in developing non-democracies has been underexplored in research, this provides fruitful ground for scholarship. Professor Michael Ryan particularly highlights the insights this can give us in terms of the tensions between efficiency and inclusivity, and social power and social legitimacy.

How Was Success Achieved?

So, how did Ugandans achieve such successful outcomes in a major health crisis? Uganda was the first country in Africa to attempt to directly address the HIV/AIDS crisis, and the first to control it. In October 1986, President Museveni established the National Committee for the Prevention of AIDS, which was composed of the ministers of health, education, defence and finance. He also set up the National AIDS Office, naming John Onwony as its lead. These organisations worked to coordinate and manage a participatory organisation model of cross-sector collaborative governance.

The network developed a recognisable identity, which gave it legitimacy to its members and the public. Regular dialogue and joint decision-making were also encouraged, which created an environment of trust. A major part of this was the leadership role taken by the National AIDS office.

Although resource-poor, Ugandan executives were able to leverage their international networks to bolster their capabilities. They drew in international donors, such as WHO, US and UK agencies for international development, Catholic Relief Charities, and the Elizabeth Glaser Pediatric AIDS Foundation. They used it to draft a five-year action plan – the first national plan of its kind. They also helped to found many local community groups and organisations around Uganda, including the AIDS Support Organization and the Pediatric AIDS Clinic of the Mulago National Teaching Hospital.

In the 1990s, public officials established a documentation and information centre, which enhanced data gathering and analysis capabilities in order to provide a better basis for decision-making. The data they collected allowed them to design public agencies to monitor and measure programme results. This was particularly useful given that Uganda was using foreign aid to fund their programs; they collaborated with international donors to establish a participatory form of accountability.

Insights from Uganda

For Professor Ryan, the successful outcomes in Uganda were due to many factors associated with collaborative governance. But what can Uganda teach us about the aforementioned tensions between efficiency and inclusiveness and social power and social legitimacy in a non-democratic context?

Within the collaborative governance structure, the Ugandan Chief Executive shared power with international donors, who did not report to the president and who controlled decisive resources and capacities. However, he still used the HIV/AIDS programmes to demonstrate and augment his power. He spoke to international donors as a protector, rather than a representative, of his people, but he backed up his words with actions that legitimated his standing with international donors.

In terms of efficiency and inclusivity, Ugandan public executives tended towards efficiency because they lacked the democratic incentives to include wider groups of people. However, their actions still gained alternative forms of legitimacy through participatory models. These insights merit further study into these tensions in a non-democratic context.

Overall, the Ugandan HIV/AIDS case study shows that, even when implemented in a non-democracy, cross-sector collaboration seems to avoid the failures that have been observed in other large social initiatives in autocratic states.