Delegated Service Authority: Institutional Evolution of PEPFAR Health‐Based Program Implementing Units in Tanzania
| Date | 01 September 2017 |
| Author | Catherine Long |
| DOI | http://doi.org/10.1111/1758-5899.12444 |
| Published date | 01 September 2017 |
Delegated Service Authority: Institutional
Evolution of PEPFAR Health-Based Program
Implementing Units in Tanzania
Catherine Long
Istanbul Aydin University, Africa Application and Research Center Advisory Board
Member and MSF*
Abstract
The critical development literature examines donor interventions’institutions and institutional impact. Donor agencies examine
specific intervention mechanisms to improve intervention effectiveness or conformity with given development trends. Both lit-
eratures insufficiently address the potential evolution of program implementing units (PIUs) deployed by donor agencies
according to the units’respective technical capacities. This article assesses PIU evolution using specific units contracted under
the United States Government’s PEPFAR program in Tanzania. These units evolved in their respective operational space that
exists in the interactions between three stakeholder categories: (1) the contracting agency of PEPFAR; (2) relevant Tanzanian
national public institutions; and (3) local Tanzanian authorities responsible for HIV/AIDS or health service delivery. This article
examines how stakeholders’delegation of authority to PIUs for technical management and/or implementation of HIV/AIDS
prevention and treatment services drive the units’institutional evolution. This evolution is ongoing given iterative PIU-stake-
holder interaction expanding units’services along with delegated authority. In the Tanzanian case, evolved PIUs became
essential to the national health system with few institutions able to re-assume the units’services or delegated authority. They
also fostered a new domestic technocracy with transnational network connections to the global public health epistemic com-
munity offering new policy platform voice and exit opportunities.
Policy Implications
•Identify PIUs’unique institutional identity in recipient country contexts apart from the donor agencies contracting them
and the recipient countries or institutions receiving their given technical support.
•Expand the scope of research questions regarding the deployment of program implementing units (PIU) in development inter-
ventions to better reflect their operational space, inter-stakeholder interaction, and authority in recipient country contexts.
•Define processes of multi-stakeholder authority delegation by donor agencies and recipient country institutions to PIUs
and the iterative effects of that delegation over time.
•Qualify the ability of stakeholders, delegating authority to PIUs or other institutions to assume services managed or imple-
mented by the units as well as the authority for the execution of those services.
•Understand PIU-related changes in recipient country health systems in terms of new hierarchy and epistemic communities.
This article assesses the institutional evolution of program
implementing units (PIUs) using a selection of those
deployed in the Tanzanian health system for the provision
of HIV/AIDS services under cooperative agreements with the
American President’s Emergency Plan for AIDS Relief (PEP-
FAR). As a focused bilateral donor intervention led by the
United States Global AIDS Coordinator, PEPFAR underwent
substantial portfolio expansion following initial emergency
roll-out in 15 target countries
1
to become the single largest
international intervention addressing a specific disease. The
depth and breadth of this intervention made PEPFAR inte-
gral to several recipient countries’HIV/AIDS-related public
health service delivery structures within a matter of years.
By the end of its first five-year program term, PEPFAR inter-
vention in HIV/AIDS sub-sectors had expanded to entire
national health systems providing or supporting services
ranging from foundational laboratory strengthening to
enhanced health product supply chain management. PEP-
FAR therefore required a broad array of technical support
sufficiently flexible to fit the given, and often challenging,
contexts from its initial roll-out to its subsequent expansion.
PIUs served as one such source of support.
Health PIUs may be divided into two initial qualifying cat-
egories for the purposes of this article. First are those that
provide targeted, often technical, support without expanded
or entrenched integration into the given health system. Sec-
ond are those that provide such support but also undergo
institutional change related to service expansion beyond the
original contract. This expansion integrates the PIUs more
*The personal views of the author expressed in this publication do not
reflect the official position of M
edecins sans Fronti
eres (MSF).
Global Policy (2017) 8:3 doi: 10.1111/1758-5899.12444 ©2017 University of Durham and John Wiley & Sons, Ltd.
Global Policy Volume 8 . Issue 3 . September 2017 303
Research Article
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