Sub-Saharan African countries have diverged sharply in health status in recent years: Some have reduced premature mortality rapidly while others have made little progress, despite significant health-oriented foreign aid. This article identifies political economy and institutional factors that help explain dramatic differences in the pace of child mortality reduction between Tanzania and Uganda from 1995-96 to 2006-07. The existing literature largely explains divergence in basic health outcomes like child mortality with reference to economic variables such as GDP per capita, or in terms of inputs such as the level of public sector health spending. However, these factors cannot explain recent divergence across African countries with similar levels of GDP per capita, rates of economic growth, and levels of health funding. I argue that in addition to economic factors, governance-related variables can play a large role in determining health outcomes. I argue that institutional and governance divergences between Tanzania and Uganda can be linked directly to differing levels of coverage of key child health interventions (especially related to malaria control), and thus to differing child health outcomes. These governance-related divergences are found in the institutional dynamics of malaria control, in the degree of meritocracy and bureaucratic autonomy found atthe Ministry of Health, in the political economy of health sector decentralization, and in corruption levels in the pharmaceutical supply chain. These institutional differences can be explained in part by historical factors, but the more relevant causes can be found in recent
years. In Tanzania, there was an unusually effective project of institution-building in the health sector, centered on malaria policy and research institutions, and on district-level reforms driven by use of demographic surveillance systems. In Uganda, by contrast, there was a negative political shock to the health system, driven by the repatrimonialization of the Ugandan state after President Yoweri Museveni’s decision to eliminate term limits in the 2001-2006 period
and embark on the “president-for-life project.” This repatrimonialization process reversed previous health sector institutional gains and had particularly negative effects on child health service delivery in Uganda.