This thesis focuses on the HIV/AIDS pandemic, and seeks to understand why Uganda as the only country in Southern Africa, has managed to turn the trend and greatly reduced the number of infected. HIV/AIDS statistics and studies show a reduction in HIV/AIDS prevalence rates, in stigmatisation/discrimination, in addition to increased awareness and changes in sexual behaviour. Simultaneously the Ugandan government with partners has in a political "zero-party system" implemented a variety of programmes. The thesis pose three questions: What characterises the Ugandan HIV/AIDS programmes? How can we explain the relative success of Uganda in fighting HIV/AIDS? To what extent do existing Western implementation theories need to be supplemented in order to grasp the challenges of health and service delivery in developing countries? Theoretical point of departure is classic public policy implementation theory: the “top-down” and the “bottom-up” approach. The five factors examined were: political will and commitment, support of government officials, involvement and support of civil society, resource allocation and decentralisation.
Findings from national level and Masaka district show that the HIV/AIDS programmes have involved a wide variety of public and private actors. External donors have greatly financed these activities, but government has also contributed. From starting out as fairly centralised programmes, the programmes increasingly became more decentralised involving more of civil society.
The factors which can explain Uganda’s relative success in fighting AIDS have contributed in a concerted action of “an environment of openness” about the disease. The most important factor is “political will and commitment” primarily from the President who early addressed this issue and “opened up” the society, creating an environment for actors like civil society to become involved. The President spearheaded the cooperation between government and civil society through various forums at all levels. "Political will and commitment" also triggered mobilisation of resources from external and internal donors. “Resource allocation” has been important for all actors to carry out programmes. However, this factor seems to be largely the cause of other factors such as political commitment and involvement of civil society. “Involvement and support of civil society” appears to be the second most important factor. The creation of the “environment of openness” would not have been possible without the inclusion of People Living with HIV/AIDS and their organisations. They have given the “epidemic a face”, which has increased the target groups' reliance in information. Civil society through NGOs, FBOs and CBOs has been extremely important to distribute information to the grassroots as people trust them. They also have more capacity and knowledge and use more innovative measures. However, involvement of civil society has been even more important as they have supported government interventions. “Support of government officials” at national and district level can be observed through the support to, and collaboration with, civil society. This collaboration has been extremely important, increasing both human and financial resources, to reach more people. However, “support of government officials” looses some effect as there are indications of some lack of support at national level through especially delay of funds. “Decentralisation” appears to have had a certain effect as more local level responsibility has supported other important factors such as the collaboration between government and civil society and to some extent also local political support. In addition, districts now have more of an opportunity to “tailor” the programmes according to local needs.
Findings from the Ugandan HIV/AIDS programmes in general support the “top-down” more than the “bottom-up” approach since many actors have supported the programmes and formal actors like politicians have been decisive. As initiatives came primarily “from above”, this also supports the “top-down” approach. However, this approach seems to pay too much attention to formal actors such as government officials and their “control”, and too little attention to the freedom of e.g. civil society organisations to contribute with their capacities. The involvement of these “street-level bureaucrats” has provided the programmes with innovative and flexible measures spoken for by the “bottom-up” approach. In combination with more local level control over the programmes, this seems to have been decisive.
Classic implementation theory does not, however, seem to grasp the importance of the cooperation between government and civil society. Hence, we need to supplement this theory by development and health theoretical approaches. These theories place more of an emphasis on the role of politicians and point at the importance of the collaboration between public and private sector to increase resources. In addition, these theories also point at the need for external resources contrary to implementation theory which only focuses on internal. However, none of the theoretical approaches examined can help us understand the widespread importance of the President’s commitment, the importance of the “environment of openness” and the involvement of People Living with HIV/AIDS.