New institutional formation in the intersection of Tanzanian decentralization and HIV/AIDS interventions

Assessments of sub-Saharan African decentralization processes often overlook change experienced and facilitated by technical institutions operating in recipient countries on behalf of major donor interventions. This change affects public service delivery at different government levels and the decentralization-oriented exchanges between those levels. This article examines these institutions as well as the change they experience and facilitate. It does so from the perspective of program implementing units (PIUs) contracted by donors to support technical public service delivery. The selected PIU cases are those contracted by the Tanzanian operations of the American President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR Tanzania played an instrumental role in the national health sector’s HIV/AIDS policy shift from a focus on prevention of and care for those with the virus to the adoption and implementation of a national treatment policy. Complicating treatment in Tanzania were expectations for homogenous national distribution of HIV/AIDS requiring extensive, consistent service support at every point of care. The government’s decentralization strategy introduced the PIUs as core HIV/AIDS service institutions. The PIUs’ resulting position in decentralization structures facilitated their own institutional change as well as change in relevant decentralization stakeholders’ exchanges that altered the government’s decentralization-by-devolution strategy.