Graduate School of Business
and Leadership

Improving the Delivery of HIV and AIDS Services in Uganda

A passion for working on people-centred programmes motivated the Head of Resource Mobilisation at the Uganda AIDS Commission, Dr Sarah Khanakwa, to conduct a study titled: Institutional Arrangements and Sustainability of HIV Control Programmes in Uganda: A Transaction Cost Economics (TCE) Analysis.

She graduated with a Doctor of Philosophy in Leadership Studies at UKZN in May.

Khanakwa employed the TCE analytical framework to identify the most cost-effective institutional arrangement(s) with the potential to sustain HIV and AIDS service delivery in Uganda. She conducted a comparative analysis of three dominant institutional arrangements for providing such services in the country, namely, contracting-out to Non-Governmental Organisations (the case of Determined, Resilient, Empowered, AIDS-free, Mentored and Safe – DREAMS), public-NGO partnerships (the case of Clinton Health Access Initiative – CHAI), and direct public sector delivery.

The study found that aligning the transaction characteristics of HIV and AIDS services with institutional arrangements minimises transaction costs, as predicted by the TCE theory. However, it revealed that the DREAMS and public sector delivery models suffered some flaws in efficiency. Contrary to the TCE prediction, DREAMS had high administrative controls, high-powered tangible incentive intensity, and intensive monitoring mechanisms. In contrast with the TCE prediction, low administrative controls in the public sector arose from the failure to invest in performance monitoring systems. The low sources of transactional costs in the CHAI arrangement arose from the utilisation of informal institutions (trust, social expectations and reputation) rather than principal-agent arms-length sanctions of administration. These results suggest that the level of transaction costs is associated with features of institutional arrangements.

Khanakwa is pleased that the useful insights from the TCE analysis could contribute to policymaking for the design of institutional arrangements to efficiently deliver HIV and AIDS services. As a health financing specialist, this is important to her as she leads the design and implementation of national HIV and AIDS financing strategies and the development of other means of achieving efficiency improvements for the HIV and AIDS response in Uganda.

During her study, Khanakwa identified capacity gaps in institutional development and sustainability approaches for HIV and AIDS and health programmes in Uganda. To address these gaps, she is putting plans in place to establish a mentoring hub for sustainable financing of HIV and AIDS, health and other social services.

Delighted to have completed her academic journey, she said: ‘This study was an opportunity to contribute to knowledge and to the prevailing debate on cost-minimising delivery mechanisms to sustain HIV and AIDS responses. I used this opportunity to the full, obtained lived experiences from experts at all levels, and reported significant findings on the importance of transaction costs and institutional arrangements in the sustainability of HIV and AIDS responses.’

Khanakwa had a pleasant journey working under the supervision of UKZN finance expert, Professor Josue Mbonigaba and health economists from UKZN’s Health Economics and HIV and AIDS Research Division (HEARD). She said: ‘The diversity of the group was hugely enriching. In conceptualising my work, I was mentored and guided by a team of experts at HEARD which included Professors Kaymarlin Govender and Jim Whitman and Dr Tim Quinlan. Their expert guidance made me walk the doctoral journey with great comfort.’ She is indebted to colleagues at the Uganda AIDS Commission, particularly the Director-General, Dr Nelson Musoba for professional and emotional support.

Her family is proud of her achievement and they are interested in seeing how this qualification will advance her career in the near future.

Khanakwa’s doctoral studies were funded by UKZN’s HEARD, a specialist division which works with research and advocacy groups as well as individuals to generate innovative ideas and ensure these translate into practical policies to overcome the enormous burden of disease in Africa.

Words: Hazel Langa

Photograph: Abhi Indarajan