DECENTRALIZATION AND SOCIAL SERVICE DELIVERY: A COMPARATIVE

CASE STUDY OF THE HEALTH AND SOCIAL WELFARE DEPARTMENTS IN

BUDADIRI COUNTY SIRONKO DISTRICT UGANDA

BY

BPA/40524/151JDU

WAMUNGA JOHN

A RESEARCH DISSERTATION SUBMITTED TO THE COLLEGE HUMANITIES

AND SOCIAL SCIENCES OF IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE AWA1Th OF BACHELOR’S DEGREE

IN PUBLIC ADMINISTRATION OF KAMPALA

INTERNATIONAL UNIVERSITY

MAY, 2017

DECLARATION

I Wamunga John declare that this research dissertation is a result of my own efforts. To the

best of my knowledge it has never been submitted to any university or institution or any

academic award.

al

16 /otjZcYJ7

APPROVAL

This is to confirm that this research dissertation by Wamunga John entitled decentralization and

social service delivery: A comparative case study of the health and social welfare departments in

Budadiri County Sironko District Uganda is under my supervision and is now ready for

submission to the College of Humanities and Social Sciences with my approval.

1~ •°5i~ia)]~

DEDICATION

I wish to dedicate this research proposal to my dear parents my dady Mr. Nabubolo J.

Wamunga, mum Negesa Firista. My sisters Carl Robinah Wasagali, Ester Masagali and my

beloved brothers John, Muzenze Rogers, Charles, for all their support and encouragement.

More so I dedicate this report to my supervisor Mrs. Turnwejukye Ruth for the tireless effort

which has enabled me to accomplish this research.

I would like to also take this opportunity to thank all my friends at Kampala International

University and outside particularly Justine Munuulo and Ronald for their guidance rendered to

me when preparing this research proposal.

Lastly, I dedicate this research proposal to all members of the College of Humanities for their

prayers which have enabled me overcome all the challenges faced during my studies.

I pray that God blesses them.

III

ACKNOWLEDGEMENT

First I would like to acknowledge the divine presence of my Almighty God to whom this

research study would not have been successful without his guidance, love, care and protection.

All the Glory belongs to Him.

Special thanks and gratitude go to my parent’s dad Mr. Nabubolo J. Wamunga, mum Negesa

Firista for approving me with all the support towards my studies. I also thank to my brothers and

sisters for their support. This has opened more chances especially the fact that I am now in

position to make a reasonable contribution to nation building.

I acknowledge all the efforts and support of the entire madam Rose Bisikwa, Carol and staff of

the College of 1-lumanities and Social Sciences for their contributions towards the success of my

studies in the University.

My special thanks go to my supervisor Mrs. Tumwejukye Ruth for the insight and answering a

number of inquiries I put to her without forgetting the very valuable suggestions and comments.

Indeed, her procurement perspectives were very constructive. I thank you all and God bless you.

Finally I thank all those who contributed to the outcome of this piece of work whose names

would not appear here because of space and am grateful and appreciative to you all, and may the

almighty God bless you abundantly.

iv

TABLE OF CONTENTS

DECLARATION

APPROVAL ii

DEDICATION

ACKNOWLEDGEMENT iv

TABLE OF CONTENTS V

LIST OF TABLES ix

LIST OF FIGURES X

LIST OF ABBREVIATIONS xi

ABSTRACT xiii

CHAPTER ONE xiii

1.0 Introduction 1

1.1 Background of the Study 1

I .2 Statement ofiheProblern 4

1.3 Objectives ofthe Study 4

1 .4 ResearchQuestions 5

1.5 Scope of the study 5

1.6 Significanceofihe Study 5

1.7 Definition of terms 6

CHAPTER TWO 8

LITERATURE REVIEW 8

2.0 Introduction 8V

2.1 Conceptualizing Decentralization. 8

2.2 Types of Decentralization 9

2,3 Objective of Decentralization 11

2.3.1 To describe how decentralization can promote service delivery at the local level 11

2.3.2 To identify there a sons for state institutions to be decentralized earlier than others

strategies 1 3

2.3.3 ToidentifyareasofcollaborationandcOordinatiOnbetWeentheDepartmentsofHealth and

Social Welfare in the provision of services 16

2.4 Decentralization and Service Delivery 17

2.5 Decentralization, Health Care and Social Welfare Service Delivery in Uganda 18

2.5.1 Social Welfare Service Delivery in Uganda 19

2.5.2 Health Care Service Delivery in Uganda 21

2.6 Conclusion 23

CHAPTER THREE 25

METHODOLOGY 25

3.0 Introduction 25

3.1 Research Design 25

3.2 Study population 25

3.3 Sample size 25

3.4 Sampling procedure 26

3.5 Instruments of data collection 27

3.6 Sources of data 27

vi

Primary Data. 27

Secondary Data 27

3.7 Data Analysis 28

3.8 Ethical issues 28

CHAPTER FOUR 29

STUDY FINDINGS, INTERPRETATION AND DISCUSSION 29

4.2 Personnel respondents’ distribution by Health Sub-district (HSD), unit ownership and unit

level 34

4.3 Effect of decentralization on job expectation 36

4.4 Performance facilitation: the constraints to effectiveness and the quality, quantity and

accessibility of personnel 37

4.4.1 Effect of decentralisation on improving personnel job knowledge and skills 37

4.4.2 Performance Feedback: re-focusing personnel for better quality 39

4.4.2.1 Nature ofjob performance feedback 40

4.4.2.2 Perceived effect of decentralization on performance feedback 40

4.4.5 Working space 42

4.5.1 State of working space 42

4.5.2 Effect of decentralization on improving workspace at health facilities 42

4.5.3 Organisational support 43

4.5.4 Relationship between politicians and health personnel 44

4.5.5 Effect of decentralization in improving job incentives 44

vU

4.6 Quality of service: expressing satisfaction or dissatisfaction with performance of

personnel

4.6.1 Treatment satisfaction 45

4.6.2 People’s perception of personnel performance 46

4.6.3 Effect of decentralisation to personnel output 47

CHAPTER FIVE 49

DISCUSSION OF THE FINDINGS, CONCLUSIONS AND RECOMMENDATIONS.... 49

5.0 Introduction 49

5.1 Discussions of the findings 49

5.2 Conclusions 53

5.3 Recommendations 56

REFERENCES 58

APPENDICES 60

APPENDIX I: QUESTIONNAIRES 60

APPENDIX II: TIME FRAMEWORK 63

APPENDIX III: BUDGET 64

VIII

LIST OF TABLES

Table 1: Showing age of the respondents. 30

Table 2: Showing Sex of the repondents 30

Table 3: Showing level of education 31

Table 4: Showing the duration in service 3 1

Table 5: Showing the positions held by personnel respondents 33

Table 6: Showing the unit ownership of the respondents 34

Table 7: Showing the health unit level 35

Table 8: Showing respondents’ perception of how decentralisation has improved their job

expectation knowledge 36

Table 9: Showing the effect of decentralisation on improving job knowledge and skills 38

Table 10: Showing the reported effect of decentralisation on personnel performance feedback. 41

Table 11: Showing the effect of decentralisation on improving workspace at health facilities. .43

Table 12: Showing the effect of decentralisation in improving job incentives 45

Table 13: Showing the exit clients’ prescribed drugs received from health unit 46

Table 14 : Showing the personnel views on the effect of decentralization to their job output 47

ix

LIST OF FIGURES

Figure I: Showing level of education 31

Figure 2: Showing the duration in Service 33

Figure 3: Showing the unit ownership of the respondents 35

Figure 4: Showing the effect of decentralisation on improving job knowledge and skills 39

LIST OF ABBREVIATIONS

AIDS Acquired Immune Deficiency Syndrome

CHSWT County Health and Social Welfare Team

CHVs Community Health Volunteers

CM Community Member

DSW Department of Social Welfare

EPI-IS Essential Package of I-Iealth Services

EPI Expanded Program on Immunization

EPR Emergency Response Program

EPSS Essential Package of Social Services

Fl-ID Family 1-Iealth Division

GoL Government of Uganda

HE I-Iealth Education

I-IHPs Household Health Promoters

HIV Human Immunodeficiency Virus

HO Health Officer

HP Health Promotion

JFKMC John F. Kennedy Medical Center

LAC Ugandan Agricultural Company

LAMCO Ugandan American Mining Company

LIBINC Ugandan oil palm plantation Incorporated

LIMINCO Ugandan Mining Company

xi

LISGIS Uganda Institute of Statistics and Geo-Information Services

MOHSW Ministry of Health and Social Welfare

MoLG Ministry of Local Government

NACP National AIDS and STI Control Program

NDPC National Development Planning Commission

NDU National Diagnostic Unit

NGO Non-Governmental Organisation

NHU National Health Promotion Unit

NLTCP National Leprosy and Tuberculosis Control Program

NMCP National Malaria Control Program

NTDs Neglected Tropical Diseases

OPDOut Patient Department

PBC Performance-Based Contracting

PCU Program Coordination Unit

PHC Primary Health Care

SWO Social Welfare Officer

TB Tuberculosis

TTMs Trained Traditional Midwives

UNDP United Nations Development Programme

xi

ABSTRACT

Decentralization has been viewed widely by many in Uganda as the panacea to the challenges

of development in Uganda. With close to five years of the decentralization of the Ministry

of Health, the study sought to examine the services delivery of the Departments of Health and

Social Welfare; comparing the progress challced by both Departments and the challenges that

are experienced in the process of decentralization in the Departments. Employing a qualitative

research method, in-depth interviews wcre held with selected participants who included

Ministry officials and Community Leaders. The study found that even though the Ministry had

started the implementation of the decentralization program, the Department of Health had

advanced far greatly than the Department of Social Welfare. There were great disparities in

the implementation of the decentralization program between the two Departments. The Health

Sector was better funded, had more logistics and staff than the Social Welfare Sector. The study

also found that Health officials tended to lead in every sphere of the Ministry’s operations,

relegating the welfare staff to the background. There was very minimal collaboration between

the Departments of I-Iealth and Social Welfare. Overall, even though the decentralization

program has had some positive impact on the service delivery in the Ministry of Health and

Social welfare, there is much to be done in order for the people at the local level to have the

real benefits of the program. It is therefore recommended that the government takes steps to

stem the fragmentations in social services delivery in the country, provide the needed funding

for Social Welfare service delivery and in the medium to long term, detach the Department of

Social Welfare from the Ministry of Health and create an all new Ministry to encompass Social

V~1elfare and allied agencies in the country.

XIII

CHAPTER ONE

1.0 Introduction

This chapter explains how the research was to be carried out, It covered background to the

study, statement of the problem, research objectives, research questions, scope, and significance

of the study and definition of terms.

1.1 Background of the Study

Decentralization was one of the essential institutional reform efforts pursued in developing

countries and was intended to bring numerous improvements.

It was also considered that decentralization can contribute to further democratization, more

efficient public administration, to more effective development, and to good governance, (Saito,

2001).

Decentralization therefore, allows for the reconsideration of local government as more than just

a technical or administrative extension of the central government and br a bureaucratic structure

with new autonomous powers and functions, (McCarney, 1996 as cited Hope, 2000).

“Decentralization was the process whereby management support systems are dc-concentrated

so that national government was relief of a variety of repetitive tasks and functions which can be

more effectively accomplished at the local levels where those task and functions are

occurring”, (Ministry of Health and Social Welfare [MOHSWJ, 2008:1). When Decentralization

took place, it gave the central government or institution time to concentrate more on policy

formulations. carryout strategic planning, mobilize resources that will facilitate

implementations, conduct effective monitoring and evaluations of policy implementations and

ensure coordination between the county government and its citizens, (MOHSW, 2012).

The United Nations Habitat Agenda (1996) recognizes the fact that in order for any country to

obtain successful human settlements development, it should be done through an effective

decentralization of management, policy, responsibilities, decision making authority and

allocation of sufficient resources inclusive of revenue collection authorities to the local

authorities who are believed to be closest to the people and also representatives of

constituencies.1

The trend towards the development of elected forms of local government that do not just have

vertical accountability, butalsowhosepublicservicedeliveryroleanddirectaceountabilitytoits

citizens are effective has become a global issue. Alcpan, (2007) presumes that lower levels of

government, for example, a local government, is better placed at perceiving the desires and

demands of its constituents for public services than a distant centralized government.

Uganda being a developing country has had the administration and governance of the country

controlledbyinstitutionsandstructuresthroughacentralizedprocess, as far as its history is

concerned.Thiskindofsystemhinderedtheparticipationoflhelocalgovermnentinhelping in the

formulation and implementation of policies that will meet the needs of the vulnerable

population. It also led to the gaps in equal access in the provision of public goods and services

throughout the country, (Governance Commission, 2010).

According to the Uganda National Policy on Decentralization and Local Governance (201 0),the

absence of decentralization has slowed the overall economic growth and development and

democratization processes. His has effectively led to under investment in human resources and

human wellbeing throughout the country. The Government of Uganda, thus, realized that there

was a need for the Ugandan people themselves to participate in any process of development that

will yield equal distribution of public goods and services. This can be achieving through the

promotion of the use of the country resources and international contributions. This realization by

the Government of Uganda through the administration of President Ellen Johnson-Sirleaf,

deemed it necessary to formulate the National Policy of Decentralization and Local Governance,

with the intent to share political, administrative and fiscal powers with the county authorities in

the fifteen counties. Five governmental institutions were named as the first agencies to initiate

the decentralization processes, amongst which was the Ministry of Health and Social Welfare.

The Ministry of Health and Social Welfare is divided into two main service delivery

departments namely:

The Department of I-Iealth Services and the Department of Social Welfare. They both benefit

from the functions of the Department of Administration and the Department of Planning,

Research and Development. While it is true that the Ministry emphasizes decentralization, the

Department of Social Welfare is yet to decentralize its services as compared to the Department

2

of Health. Through observation, it is seen that the Department of Health has advanced in terms

of human resources, finding and logistics as compared to the Department of Social Welfare.

The Department of Health is found to be functioning in all fifteen counties through its County

Health and Social Welfare Teams, which is the decentralized administrative branch. On these

Teams, there is ones lot allocated for the Department of Social Welfare occupied by the Social

Welfare Supervisor. The Social Welfare Supervisor presently is responsible to carry out all

functions of the Department. The Department of Health on the other hand has over twenty — one

staff on each of the fifteen County Health and Social Welfare Teams excluding staff assigned to

facilities and communities, with specific functions.

Looking at the situation in Uganda, the Department of Health has attracted much attention as

compared to the Department of Social Welfare. Interestingly, the Ministry is called, The

Ministry of Health and Social Welfare, but both have separate policies and plans. The

Department of Health has decentralized its services unlike the Department of Social Welfare

which is yet to decentralize its services.

In the case of human resources, the Department of Health has many staff ranging from medical

doctors to community health volunteers and the Department of Social Welfare has staff with

limited qualifications and also insufficient staff Logistically, the Department of I-lealth has

many vehicles to help in its service delivery unlike the Department of Social Welfare that barely

has three.

Decentralization of services and sustainability of development are important in addressing the

issues of rebuilding and governing in a country like Uganda which has gone through devastating

conditions. According to the Uganda National Policy on Decentralization and Local

Governance, (201 0),centralization limits the functions of the local authorities, thus creating an

environment where in they have to depend wholly and solely on central government for both

policy formation and the implementations,

3

1.2 Statement of the Problem

Uganda in implementing its structural adjustment program [SAP] it resulted into

decentralization of services and health inclusive which was extended to the district level, July

1994. This was aimed at improving on the quality of health services and pharmaceutical supplies

in the hospitals and health IV [units], with resultant increase in the level of utilization of health

services in Budadiri County Sironlco District Uganda. In the health sector, this has not been

successful due to inadequacy of funds to extend health services supervision. This was coupled

up with poor supervision and improper monitoring of health centres, corruption, inefficient

utilization of the resources available and worse of it inappropriate delivery of health services in

the town council.

According to the Uganda Bureau of statistics, in the town council health programmes on the

effectiveness of health service delivery of community information system 2009, statistics show

that the percentage distribution of health services is still low and vulnerability risks are high and

sanitation and clean water accessibility is still not well addressed, the working population is low

showing a risk of poverty in the community. Therefore the problem statement is focused to find

to find out why there is still poor performance in the delivery of health services through

“decentralization policy” in place which gives and attributed with community participation.

There is a need to understand the decentralization strategies used by the Department of Health to

meet its service delivery. It is also necessary to identi& the gaps and constraints within the

Social Welfare Department that is causing delays in its decentralization policy implementations.

It is also important to identify a point of collaboration and coordination between the Health and

Social Welfare Departments along with other implementing partners to improve service delivery

in Uganda.

1.3 Objectives of the Study

The research specifically aimed at addressing the following objectives:

I. To describe how decentralization can promote social service delivery at the local level In

Budadiri County Sironko District Uganda.

2. To identify the reasons for institutions being decentralized in Budadiri County Sironko District

Uganda.

4

ToidentifyareasofcollaborationandcoordinationbetweentheDepartrnefltsOf Health and Social

Welfare in the provision of services in Budadiri County Sironko District Uganda.

1.4 Research Questions

The above problem was examined with the hope of addressing the following research questions:

1. How does decentralization promote service delivery in Budadiri County Sironko District

Uganda?

2. Why do state institutions decentralize in Budadiri County Sironko District Uganda?

3. How can the Departments of Health and Social Welfare collaborate and coordinate to

improve service delivery in Budadiri County Sironko District Uganda?

1.5 Scope of the study

1.5.1 Geographic scope

The study was carried out in Budadiri which is located approximately 13 kilometres (8.1 mi), by

road, southeast of Sironko, the district headquarters. It is located within Mount Elgon National

Park.

1.5.2 Content scope

The research study is to study on decentralization and service delivery in Budadiri County

Sironko District Uganda, and also finding out the possible solutions to the problem statement

and finally the conclusion and recommendations.

1.5.3 Time scope

This research will be carried out in a period of four months that is from January to May 2017.

1.6 Significance of the Study

This research looked at how the Republic of Uganda can have an effective decentralized health

and social welfare system that will help in alleviating some of its social problems.

5

It was also intended to identify the point at which the Departments of Health and Social Welfare

can collaborate their services for the best interest of its population. The inability of the Social

Welfare for each the vulnerable population in the fifteen counties had the tendency to increase

the rates of social problems within the country, thus having an unhealthy country.

The findings from this research will add to the stock of knowledge on decentralization and

social service delivery specifically taking in to account the importance of the level of

collaboration and coordination between the Departments of Health and Social Welfare.

This study also gave strength to the definition of health by the Constitution of World Health

Organization (2006) emphasizing that health was not only the absence of diseases but also the

state where one has physical, mental and social well-being. In most cases the Social Welfare

Department was ignored by politicians not taking in to consideration that when the social

issues are handled, it has the tendency to improve economic growth and sustainable

development.

This study intended to inform and influence policy makers of the importance of social welfare

service provision to the nation.

It was also to help non-governmental organizations and community-based organizations focus

on the total wellbeing of the vulnerable population.

This study was also providing knowledge too there countries in helping to strengthen their health

and social welfare services to meet the wellbeing of the population for a sustainable

development.

1.7 Definition of terms

Decentralization: “Decentralization is the process whereby management support systems are

dc-concentrated so that national government is relief of a variety of repetitive tasks and

functions which can be more effectively accomplished at the local levels where those task and

functions are occurring

Social welfare services: are as the cornerstone of the new Ugandan National Social Welfare

case delivery strategy.

6

Service Delivery; can be usefully conceptualized as the relationship between policy makers,

service providers, and consumers of those services and encompasses both services and their

supporting systems.

Social Service Delivery System:

The social service delivery system refers to the transfer of goods and services from one source to

the other; from producers to consumers. It also refers to the organizational arrangements among

distributors and between distributors and consumers of social welfare benefits in the context of

the local community (Gilbert and Terrell, 1998).

7

CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter of the study focuses on their views of relevant literature. Their view is conducted

underthemeswhichhavebeenformulatedinlinewiththeobjectivesofthestudy and in a bid to seek

answers to questions that have been raised by the study. Their view begins by loolcing at the

concept of decentralization, its challenges and solutions. This is followed by a consideration of

decentralization as implemented in various countries across the world with special emphasis on

developing countries. There is then are view of literature on decentralization on health care and

social welfare service delivery in Uganda. The chapter ends with a conclusion by the researcher.

2.1 Conceptualizing Decentralization

Even though decentralization is not a new concept, having been used since the 1950s (European

Commission, 2007); According to Crawford (2004),it has become an increasingly widespread

and significant dimension of political and administrative form in many developing countries.

The coming in to prominence of the concept according to Crawford (2004) began in the late

1980s and has been strongly supported by a variety of actors ranging from international

development agencies through national governments to non-governmental and grass roots

organizations.

Decentralization is invariably defined by various authorities. Though the definitions vary, at the

core of the concept is devolution of power from the center to the local levels. The World Banlc

(2001) characterized decentralization as a complex multifaceted concept embracing a variety of

perceptions which must be carefully analyzed in any particular country before determining if

projects or programs should support reorganization of financial, administrative or service

delivery systems. The World Bank (2001) defines the concept as “the transfer of authority and

responsibility for public functions from central government to intermediate and local

government or quasi-independent government organizations and/or the private sector”. On the

other hand, the UNDP (2004) defines the concept of decentralization as a restructuring of

authority so that there is a system of co-responsibility between institutions of governance at the

central, regional and local levels according to the principle of subsidiarity. This definition by

8

UNDP connotes a sharing of power between the central government and the local authority

which otherwise was a preserve of the central government. This diverts slightly from the World

Bank’s definition which seems to suggest an outright transfer of power from the central to the

local government. The UNDP (2004) espouses that based on the principle of decentralization

functions or tasks are transferred to the lowest institutional or social level that has the potential

of completing them. The French Corporation (2009) characterizes decentralization as being part

of democratic governance which is intended to give local authorities their own resources and

responsibilities separate from those of central government.

The above definitions of the concept of decentralization can be summarized as any act in which

a central government formally relinquishes powers to actors and institutions at lower levels in a

political-administrative and territorial hierarchy (Mawhood 1983; Smith 1985, as cited by Ribot

2001)

2.2 Types of Decentralization

Generally, there are three types of decentralization, which are fiscal, political and administrative

decentralization (Falleti, 2004; Scott, 2009; World Bank, 2001).Fiscal decentralization entails

the transfer off financial resources in the form of grants and tax-raising powers to the sub-

national units or local governments (Scott, 2009; World Bank, 2001).This kind of

decentralization gives the local level authorities autonomy to appropriate the resources in

manners deemed necessary.

On the other hand, administrative decentralization, which may be sometimes be referred to as

de- concentration, connotes a situation where the functions performed by the central government

are transferred to geographically distinct administrative units (European Commission, 2007;

French Corporation, 2009; Scott, 2009; World Bank, 2001).

The European Commission (2007) indicates that this type of decentralization seeks to transfer

decision-making authority, resources and responsibilities for the delivery of a select number of

public services or functions from the central government to other levels of government, agencies

or field offices of central government line agencies.

Shah and Thompson (2004) concords with the definition of administrative decentralization but

also simplifies it by stating that an effective administrative decentralization requires lack of any

9

exante controls over the decision to hire, fire and set terms of employment of local staff. To

improve tax collection or the delivery of local public services, local government should have the

freedom to contract own taxing and spending responsibilities. Furthermore, local governments

should have the authority to pass by laws in their spheres of responsibility without having to

obtain prior clearance from the higher level government. The European Commission explains

that administrative decentralization has three possible variants which come with different

characteristics. These variants include de-concentration, delegation and divestment.

Decentralization refers to “a process in public administration in which a field office or official or

a central department or ministry acquires some degree of delegated authority to make decisions

or otherwise regulate operations” (European Commission, 2007, p.1 7).

Delegation on the other hand is said to refer to a more extensive form of administrative

decentralization and involves a redistribution of authority and responsibility to local units of

government or agencies that are not always necessarily branches or local offices of the

delegating authority (European Commission, 2007). The final variant of administrative

decentralization is divestment which the European Commission posits is a finance term but has

been co-opted into the field of public administration. According to the European Commission

(2007), divestment “occurs when planning and administrative responsibility or other public

functions are transferred from government to voluntary, private or non-governmental

institutions” (p. 17).

Political decentralization is the third type of decentralization and refers to the situation where

powers and responsibilities are devolved to elected local governments (Scott, 2009; World Bank,

2001).

The European Commission (2007) corroborates the definition of political decentralization by

Scottand World Bank and further explains that political decentralization normally involves a

partial transfer of power and authority with the central government reserving greater amount of

power and control.

Although, it is widely accepted that there are three types of decentralization, there are a few

instances of divergence.

10

The French Corporation (2009) in its clarification of decentralization presents the original three,

fiscal, administrative and political decentralization, but goes to add a fourth, divestment.

This is in sharp contrast to the views of the European Commission (2007)

Who indicates divestment as a variant of administrative decentralization?

Therefore, according to the French Corporation, there are four types of decentralization: fiscal,

administrative, political and divestment which involves the devolution of public functions to

voluntary, private or non- governmental institutions.

2.3 Objective of Decentralization

2.3.1 To describe how decentralization can promote service delivery at the local level

According to Francis [1996] in his suggestion, he found out that decentralization is untimely

called for the service delivery survey [SDS] which has enabled effective delivery of social

services to the local people for example in pursuit of this goal, the service delivery mostly social

services to the local level.

Despite, the service delivery survey had produced information to be used as baseline on the

delivery of health services for example, provision of drugs in the health center, giving of

mosquito nets to people, water and sanitation to the local people i.e. Malcara S [1 998],in his

book political and administrative relations in decentralization, he said that decentralization

policy has compelled the local council governments to be concerned with the questions of

efficiency outcomes and outputs while they have the responsibility for their delivery of health

services to areas under their jurisdictions. Though this was done, but the outcomes of

decentralization policy in its attempt to foster effective delivery of health and social services at

the local level is still questionable.

Francis L [1996] further reported and revealed that decentralization has worlced effectively on

the delivery of health services of people, this was then the government of Uganda through

institutional capacity building programme borrowed funds to establish the system and training to

implement the results oriented management.

11

However, even if it was true that the government of Uganda borrowed funds with the purpose of

enabling decentralization policy to work effectively on its attempt to deliver health services to

the local centers but there is still little improvement on the delivery of social services such as

road network mostly on the local level hence leading to absence of delivery of social services at

the local level.

1-lowever, the management structures at the health service delivery level remain unclear and are

at present supported by no central guidelines; the town clerk council has been established and is

operational in all centers. The planning capacity of the town council in different districts and

even within one district varies greatly.

That still there are also regional variations in the status of health infrastructure and staffing

pattern. The more affluent regions are found in and the capital of Kanipala, whereas the north

eastern part of the country was least developed. On average 45% of all households live with 5

kilometers walking distance of health care, but this number ranges from 8% in Kitgum to almost

100% in Kampala. Most town councils had at least one health care unit but only 40% of parishes

in the town council have a health facility within their boundaries. The infrastructure at most

peripheral health facilities are in deplorable state.

In practice, the health facility staffing does not meet the established standards. A study in 1999

indicated that only 34% of the existing positions were filled by qualified staff. In general, health

centers from II to IV have no access to electricity, but also depend primarily on firewood, gas

and charcoal, so as to meet their energy requirements for sterilization, lighting, and refrigeration

of vaccines.

District and referral hospital on the other hand were usually connected to the country’s main

electrical grid or had generators to supply their needs, consequences of decentralization for the

health sector with the shift of managerial responsibility, disciplining the recruitment and

dismissal of staff was a task of body within the respective districts and the district commission

service.

Recently, the central ministry of health [MOHJ is responsible for deployment of health sector

staff to the district despite the fact that ministry processed an overview of needs the country’s

distribution of staff is very uneven and peripheral districts went largely understaffed.

12

But with the decentralization the other hand, posts are now advertised and districts seek out

officers by recruitment process. However, the inquiry between peripheral and central districts

remains a major problem.

2.3.2 To identify the reasons for institutions to be decentralized with strategies

According to Apollo Nsibambi, the NGOs have played significant roles in the implementing of

health programmes. Such NGOs include: UNICEF, Plan International, Action Aid Uganda,

TASO, Marie Stopes among others have improved the PHC in the areas of immunization, latrine

coverage sensitization, informing people on prevention of STDs, AIDS and many more, for

example Plan International has donated health facilities and equipment’s such as beds,

mattresses, drugs, vaccine, sponsored health personnel training. All the above mentioned

activities have been done to improve on the performance of the health sector in delivery of

services.

According to Pierre land eli mill 1987, giving them a voice to demand more accountable in it is

beneficial for development especially in terms of efficiency resource mobilization and

sustainability participation in consultation, identification, selection, implementation,

management utilities are some of the aspects highlighted. However, there is for example

community participation in the health sectors the degree of community participation varies from

one NGO to another in some cases, for example priority activities are selected by the NGOs

while in other cases the task is left to the community or their leaders.

According to Betty Kwagalana, the failure of official administrative instruments to deliver

health services to the population in Uganda demonstrated among other issues the absence of

good governance. NOOs and the local authorities however, have been instrumental in filling up

the gaps.

The NOOs community and the central government are closely interlinked and constitute some of

the indispensible services for human survival. More emphasis is laid on the rural areas since in

comparison to urban areas, they are poorly served.

Samuel Paul [1989) has noted that it is difficult to incorporate community participation in

service delivery when the setting does not have a supportive social tradition. NOOs are known

13

as a key catalyst to community participation and are expected to eventually strengthen civil

society and the populace.

According to Francis L, democratic decentralization in Uganda revealed that the local

government has a challenge of incompetence among the staff that existed in the town council for

example the commonest qualifications among many staff had been ordinary level school

certificate hence affecting health services in most local levels thus affecting the delivery of

health services due to the result of the policy.

1-lowever, Francis L stated that ‘decentralization policy had contributed a lot towards the decline

on the delivery of social services still in most town councils, the delivery of health services and

social services are still very low. It was due to these that most council had lagged behind due to

poor supervision, recruitment and corruption thus the challenges faced by the local government.

Francis L further asserted that “for the public services standing orders for the purpose of

uniformity, issues by the central government, still given the conditions service country wide at

the district level. The central government continues to provide block grants to districts for

services planned for and delivered by the district to the council. These block grants have

replaced a system of earmarked votes determined by the ministry of finance. These were

introduced in a phased manner and since the fiscal 1996-1997, and all districts received them.

Therefore, several conditional! stringed grants have been instituted for specific purposes like

primary health care [P1-IC].

In practice, the allocation of funds to the districts does not correspond to the actual commitment

made by the central government on behalf of the district. Out of the recurring national budget for

fiscal 1997-1998, only 34.9% was allocated to the districts. In addition to that, the relative size

of the conditional grants declined from 25.6% of the local budgets in 1996-1997 to 22.8% in

1998-1999 ULLA [1998].

According to Apollo Nsibambi in his book “Decentralization and Civil society”, he pointed out

that local government is faced with a challenge in the recruitment of unqualified staff and

unstable staff In many schools for example Apollo Nsibambi cited Masaka district where

graduated nurses were employed without the knowledge of mixing drugs for patients.

14

However, to a bigger extent, it was true that the government had failed to extend health and

social services that were of quality standards due to the challenges of its activities to recruit

unqualified and unstable staff as told by Apollo Nsibambi in his book. It was because of this that

many hospitals and health centers failed to improve on the performance. He went further and

stipulated that decentralization had a challenge on the delivery of health services to the local

centers therefore; the local government faced a problem of receiving similar financial transfers

from the central government thus made the policy to fail to catch up on the delivery of social

services like health to the local centers.

However to a larger extent, this was true because many health centers at the local levels had

failed to buy the required equipment’s so as to increase on their performance due to small

percentage of the finance extended to them. This was associated with a lot of corruption among

the officials who used the money for meeting their personal gain and interest than using the

money for the interest focused on delivering services to the people in the local level [parameter].

However, central decentralization still has fiscal power that affects the districts, leaving a

considerable discrepancy between the formal powers given to the districts by the local

government Act” and the financial means to exercise them. The local revenue base is also very

small as the lion’s share of the income from the local revenue is also very small as the lion’s

share of the income from the central government.

There has been a very significant reduction in infant and material mortality 1990’s. Data from

the indicators of health status and health service delivery compared to the situation of 5 years

earlier.

Infant mortality and malaria morbidity are on the increase, and maternal maternity remains

constant at high level estimated at 506 details per 100,000 live births. The proportion of fully

immunized children has declined from 47% to 37% and a tetanus oxide TT immunization

pregnant woman shows a decline from 54% to 42%.

In 1995 to 1996 a burden of diseases study was carried out in 13 of the districts of Uganda the

unit selected for measuring disease burden was discounted life years lost due to the discounted

life years reduced to 10 preventable diseases with five of them according for approximately 60%

of the total burden.

15

According to Onyach — 099 [2003] said that the capacity to implement decentralized system is

several limits the politicians hence perpetuating the problem of coordination between the initial

stages of decentralization has caused perpetuated in the level of development especially at the

district.

Furthermore, the capacity problem had been increased due to the lack of essential data that could

be used for monitoring, planning and evaluating at the local levels.

The magnate of the capacity outcome is generally muffed by the general tendency to over eat the

ability of the local goverm~ent council leaders to the priorities, plan and implement local

development programs in some cases poorly implemented. Decentralization has also led to the

delegation of natural resources thus leading to over exploitation of forest resources and this can

be proved with the early stages of Uganda’s decentralization process where a reality prompted a

recentralization of the country’s forest management.

I-Ic also went ahead and analyzed the challenges of decentralization into the structural

constraints and capacity constraints where he said that donor’s assistance to Uganda has taken

the form on general budget support and project Aid.

The general budget support is often times earmarked by donors to finance as project Aid; it has

been channeled directly to local government by passing the local government. This has

fragmented local development structures resulting in the exacerbation of the problem of

coordinating and monitoring local development activities, more so it has undermined the

institutional growth of local government system weakened community linkages.

Also pointed that in the system of decentralization and devolution conflicts emerge. A clash

between resident district commissioners and the district chairman is case in point. These

Authorities often belong to opposing political groups resulting in division and inefficiency in

public sector management and development.

2.3.3 To identify areas of collaboration and coordination between the Departments of

Ficaith and Social Welfare in the provision of services

According to the local government act of 1997, decentralization refers to the shifting of power

planning, decision making and administrative authority from the center [central government] to

the local government.16

This term can also be used to refer to the system of government in which power is provided to

the local authorities of financial management, decision making, planning and so forth.

Local governments are sub — national bodies and body cooperates that can sue and be sued

under their cooperates names “local government” and they perform functions on behalf of the

state [national government].

And their system of governance is categorized into four types that are devolution,

decentralization, delegation and privatization.

According to Apollo Nsibambi, the NRM government before it attained power in 1986, one of

its manifestations was to empowering local governments through decentralization with an aim to

enable the locals to participate in decision, administration, planning and control of financial

management in their local units.

Service delivery, it is the process where the required non tangible demands are made recently

available for the clients (consumers) to receive and check upon their cun~ent situation & desires.

And health services are delivered by those working (employed) in the department of health.

Uganda in implementing its structural adjustment program (SAP) it resulted into

decentralization of services and health inclusive which was extended to the district level, July

1994. This was aimed at improving on the quality of health services and pharmaceutical supplies

in the hospitals and health center units.

According to the Uganda Bureau of Statistics, in the town council health programmes on the

effectiveness of health service delivery of community information system 2009, statistics show

that the percentage distribution of health services is still not well addressed; the working

population is low showing a risk of poverty in the community.

2.4 Decentralization and Service Delivery

Akpan (2007) opinesth at decentralization may result in better service delivery. Heal so stressed

that the decentralization of the provision of social services such as education, health, water and

sanitation may improve service delivery. Ahmed, Devarajan, Khemani and Shah (2005)also

corroborates with Akpan that a country can have a successful and sustainable service delivery if

thegovernmentintervenesandprovidethenecessaryresourcesandtechnicalassistanCetolower-tier

17

governments.(Republic of Rwanda, 2006) emphasizes that a sound intergovernmental system is

grounded on a clear definition of spending and revenue responsibilities between each level of

government. Failing to clarify assigned responsibilities will surely result in in efficiency and

instability of service delivery.

Darmawan (2008) Opinesal so that decentralization and service delivery can be achieved if

financial resource autonomy is given to local authorities and later inter-governmental transfers

and grants are established to address some specific problems such as fiscal gap or vertical

imbalance between expenditure and revenue at sub-national government level. Furthermore, the

transfers are important to correct fiscal inequality among the sub-national governments, improve

the fiscal efficiency across jurisdictions, overcome spillovers and establish fiscal harmonization.

2.5 Decentralization, Health Care and Social Welfare Service Delivery in Uganda

The Ugandan governance and public administration has since the country’s independence in

1847 remained highly centralized in the country’s capital, Monrovia (Governance Commission,

2010).

Thus, the governance and public administration of Uganda had been controlled largely by

institutions and structures of the central state. This situation according to the Governance

Commission indicates that it did not allow adequate legal opportunities for the establishment of

a system of participatory local governance.

Further, the Governance Commission espouses that the centralized nature of the governance and

public administrative structures of the country had impeded popular participation and local

initiatives, especially in regards to the provision of public goods and services. The consequent

effects of this system as hinted by the Governance Commission include potential gaps in

economic growth and development, equal access to social and economic opportunities and

human wellbeing between the center, Monrovia, and the rest of the country.

Ultimately, the Governance Commission laments that the situation had contributed greatly to a

slowdown in the country’s overall economic growth and development, as well as the

democratization processes and under investment in human resources and human wellbeing

throughout the Republic. Such challenges with a centralized system of governance and

18

administration as gaps in development and service delivery are factors that informed the

formulation and implementation of the decentralization program in Uganda.

The new National Health and Social Welfare Policy and Plan which covers a ten year span,

starting 2011 and folding 2021 entrusts the responsibility of the execution of the Ministry’s

decentralization program in the hands of the County Health and Social Welfare Teams

(CHSWT)-a combined team of health and social welfare personnel.

This Team is responsible for the delivery of services to the people of Uganda at the grassroots

level. According to the Ugandan National Health Policy and Plan (2008-2011), the County

Health and Social Welfare Teams was responsible to manage all Ministry-owned facilities,

Ministry-employed human resources and Ministry-provided material resources. The National

Health Policy and Plan,(2008-201 1, p. 10) intended that the center will gradually allocate and

transfer resources to the county It is expected that the County Health and Social Welfare Teams

were to strategize and respond to the local health and social welfare issues within their

communities.

2.5.1 Social Welfare Service Delivery in Uganda

The Government of Uganda’s Social Welfare Policy (2009) describes social welfare services as

the cornerstone of the new Ugandan National Social Welfare case delivery strategy. The

Department of Social Welfare, under the Ministry of Health and Social Welfare has the mandate

to deliver social welfare services in the Republic of Uganda (Ministry of Health and Social

Welfare,EssentialPackageofSocialServices,2O 11-2021 ).TheEssentialPackageof Social Services

indicates that the Department of Social Welfare is charged with the responsibility to provide

“equitable and high quality services targeting persons, families and communities, and strengthen

the modalities to enhance the voice of the vulnerable in defining priority needs and influencing

the character and content of service delivery” (p.7). However, the National Health Policy and

Plan (2007) portrays the Social Welfare Department as fragmented and under resourced, and

thus, unable to address the enormous needs of the Ugandan population.

According to the Essential Package of Social Services, (2011-2021), in order to ensure the

effective social welfare service delivery in Uganda, the Department of Social Welfare introduced

the Social Welfare Policy in 2011 to provided direction for reforming the Social Welfare

Department in line with the principles of the National Decentralization Policy.19

The objectives of their forms in the Social Welfare Department focus on improve deficiency and

effectiveness among the various actors in the Department, increased accountability and probity,

and an enhanced ability to support vulnerable persons.

The main aim of their forms in the Social Welfare Department in particular was to redirect the

operations of the Social Welfare Department “towards a developmental social welfare approach”

which would focus specifically on the establishment of a demand-driven, community-focus

social welfare response with strengthened institutions capable of delivering quality services

(Social Welfare Policy, 2009).

Three key achievements are targeted by the Social Welfare Department with regards to their

form efforts and these include the ability of the Department of Social Welfare to enable a better

coordination of social welfare service delivery; the ability of the Department to strengthen the

influence of vulnerable groups in decision-making in society; and finally, the ability of the

Department to enhance the socio-economic conditions of vulnerable groups in the country

(Social Welfare Policy, 2009). Thus, at the heart of the Social Welfare Policy that was

formulated in 2009, is a two —point aim of strengthening the Social Welfare Department as well

as protecting vulnerable groups. In the long-term, however, the Social Welfare Policy aimed at

three things: the first being the decentralization of social welfare services and there enforcement

of partnerships to effect the decentralization process; the second, the strengthening of

community social capital and family and extended family networks; and finally, the enabling

systems and Structures that allow the effective and equitable access to social services among the

populace who are most vulnerable and in need (Social Welfare Policy, 2009).

The delivery of social welfare services in Uganda should be organized into four divisions

according to the Essential Package of Social Services (2011-2021).The first of the divisions is

the Community Welfare Division which entails basic community services, psychosocial support

and services for the elderly. The second is the Family Welfare Division which involves the

promotion of family-base care, family reunification, and services for separated or orphaned

children, and children in contact with the law.(MOHSW’5EP55201 1 -2021, p.8).

There are fourtiers of care delivery in the Ugandan social service delivery system (EPSS,20l 1-

2021).

20

These follow the political structure of the country. The first tier is the community level which is

the lowest level. This is the level that involves community case workers, community outreach

volunteers and trained social service providers. Staffs at this level are supposed to work directly

with the people and thus, the direct link between the people and the chain of authorities. These

condtier is the district level workers who at this level serve as facilitators for case workers at the

community level. The social welfare supervisors at this level are responsible for the supervision

and monitoring of the community level. County level officers form the third tier officers of the

Department of Social Welfare. Officers at this level are supervisors and case managers. They

provide supervision for all county social welfare activities and are responsible for the training

andre training of staff of the Department of Social Welfare in their respective counties.

The final tier in the social welfare service delivery in the Republic of Uganda is the national

level. This refers to the central administration of the Department of Social Welfare and officers

here are senior members of the Department who have the responsibility to ensure that social

welfare services are render in gat the community level and it should be done through the county

social workers. Officers at this level are responsible for policy formulation and implementation.

2.5.2 Health Care Service Delivery in Uganda

The Essential Package of Health Services [EPHSI of the Ministry of Health and Social Welfare,

2011, indicates that the responsibility of ensuring that the Ugandan people are healthy and enjoy

good quality health care is entrusted to the Department of Health Services. Uganda’s health

services like many other sectors of the economy have been severely disrupted by years of

conflict and looting (MOHSW, 2007).Jhpiego (nd). Jhpiegoreite rates that the key among the

challenges included weak logistics, transportation and communications systems, as well as in

sufficient access to care and poor referral networks, particularly in remote rural areas.

The EPHS (2011) indicates maternal health care as one of the priority areas for the MOHSW

and Jhpiego (nd) indicates that maternal mortality in Uganda is among the highest in the world

and only 40% of the population has access to health services. This calls for frantic and pragmatic

efforts after building the Department through the building of infrastructure, workforce and the

utilization of all available services. In this regard, Jhpiego (nd) acknowledges that the efforts so

far taken by the Government of Uganda as it opines that within a short period, the MOHSW has

taken bold steps to transition from an emergency relief model of health care to a functioning,

21

decentralized health care system. Jhpiego (nd) acknowledges that there is still a long way to go

even though all fifteen counties of the country have begun operational management of health

services. It is important to note however that the countries are still operating under the direction

and support of the central Ministry of Health and Social Welfare (Jhpiego, nd).

The Government of Uganda’s National Health and Social Welfare Policy which was first

introduced in 2007, revised in 201 land billed to span up to 2021, spells out the modalities for

the delivery of health care services in Uganda. However, in order to ensure that services reach

the lowest level of the Ugandan population, and in line with the principles of the National

Decentralization program, the EPHS (2011) indicates that the Ugandan health care sector like the

social welfare sector is organized into three levels. The first level is primary is primary level

which includes community healthcare systems. This level is made up off our types of service

providers. The first of them is Community Level Services such as set standards for outreach,

health promotion and referral services for communities that are more than one hour walk (5km)

from the nearest health facility. This activity is the responsibility of the Community Health

Volunteers including Household I-lealth Promoters, Trained Traditional Midwives, and general

Community Health Volunteers. These categories of personnel are responsible for primary health

care education at the grass roots level. These condtier within the primary care system is the

Primary I-Iealth Care Clinic Level 1. This refers to community clinics that operate Out Patient

Department services. These clinics are opened eight hours a day from Monday to Friday. These

level covers cluster communities that are isolated from major settlement. Such communities

usually have a population of up to 3,500. The penultimate tier within the Primary Level health

care system is the Primary I-IealthCare Clinic Level 2 which covers catchments that are made up

of populations between 3,500 and 12,000. In addition to providing OPD services eight hours a

day from Monday to Friday, PHC Level 2 clinics also provide outreach services oportions of

their catchment population outside of a 5 km radius. The outreach program constitutes the last

but

Not leas to f the primary level care an dischristened the Integrated Outreach Program (EPHS,

2011).

The next level of health care in Uganda after primary health care is Secondary Care which is

referring to as District Level HealthCare System. It is the first provider of secondary health care

22

and focuses on maternal and child health care. Secondary health care is the referral point for the

community systenL

This system provides health care services for catchments with populations ranging between

25,000 and 40,000. A facility that provides services at this level includes Health Centers and

District Hospitals. County Health System is an advanced healthcare system in the secondary

healthcare system which provides expanded services within the secondary level of care. It

consists of county hospitals which are responsible for receiving referrals from the community

and district health systems. Such county hospitals provide general surgeries, pediatrics, general

medicine, obstetrics and gynecological services and are open twenty-four hours every day.

Tertiary Care, that is, the National Health System is the final level. This level consist of two

types of hospitals: Regional Hospitals and one National Hospital, John F. Kennedy Medical

Center (JFKMC).Regional Hospitals serve a catchment area of three to five counties and receive

referrals from County Hospitals. The National Hospital is the final referral point for cases in the

country.

Despite such a comprehensive structure of the health care system in the country, the

Decentralization Guidelines (2008) empowers county health authorities to manage county health

facilities, including county hospitals.

The Decentralization Guidelines indicates that proper administrative structures and

management tools would be introduced at county level, to make health authorities truly

autonomous. It further iterates that county health authorities would be given responsibility for

financial and asset management and personnel, and would be fully accountable to local

constituencies, as well as to overseeing public bodies. The Decentralization Guidelines (2008)

establishes a County Health Team which is entrusted with the responsibility of management of

county health service delivery. The Team is made up of senior staff and general members.

Senior staff on the Team includes the county health officer, the county health department

director, the county hospital medical director, the county health services administrator, the

county pharmacist, and the county laboratory supervisor.

2.6 Conclusion

According to Apollo Nsibambi, the NRM government before it attained power in 1986, one of

its manifestations was to empowering local governments through decentralization with an aim to23

enable the locals to participate in decision, administration, planning and control of financial

management in their local units.

Note: Service delivery, it is the process where the required non tangible demands are made

recently available for the clients (consumers) to receive and check upon their current situation &

desires. And health services are delivered by those working (employed) in the department of

health.

Uganda in implementing its structural adjustment program (SAP) it resulted into

decentralization of services and health inclusive which was extended to the district level, July

1994. This was aimed at improving on the quality of health services and pharmaceutical supplies

in the hospitals and health center (IV) units.

24

CHAPTER THREE

METHODOLOGY

3.0 Introduction

This chapter explains the methods that were being used in this research including the research

design, the study population and area of study sampling techniques, sources of primary and

secondary data, data collection instruments, data processing of presentation of research findings

and limitations of this research.

3.1 Research Design

The study employed a descriptive design because of the qualitative nature of the study. Both

quantitative and qualitative approaches were being used in data collection and analysis and

general information on the subject matter was collected from the different departments of the

Sironko district among employees. Qualitative design was being involved in-depth interviewing

of the departmental managers. On the other hand, the quantitative design was to involve use of

close-ended questionnaires which was to be issued to the employees in the different departments

as the method was convenient for them to fill during thier free time.

3.2 Study population

The population of the study was to be 100 got from all departments, these include the

Administrators, the I-Iuman Resource, Supervisors, because they knew what decentralization was

and how it affects social service delivery.

3.3 Sample size

The researcher was to use the Solven’s formula to determine the sample size out of study

population of 100 members, 80 respondents were being selected from the study population.

25

Solvens Formula is applied as follows,

N= 1 + N(e)2

Where n simple size

N= population of the study

1 constant

e = marginal error (0.05)

100— 1 + 100(0.05)2

100— 1 + 100(0.0025)

100

— 1 + 0.25

1001.25

= 80 respondents.

3.4 Sampling procedure

The respondents for the study were being selected using Simple random and purposive

sampling. The researcher was to sample the participants using the judgment that the participants

had the knowledge, experience and information that will require for the study.

Purposive sampling

Purposive sampling was to be used as respondents were to be grouped according to departments.

50 workers were interviewed while 20 supervisors and 10 Administrators were chosen in the

sample population. This procedure was less costly and time saving.

Sampling random sampling

The simple random sampling refers to a technique that selects a sample without bias from the

target/accessible population. The researcher was to ensure that each member of the target

population has an equal and independence chance of being included in the sample. Each

respondent was to have an equal chance of being selected.

26

3.5 Instruments of data collection

These are the tools that were being used in collecting data from the respondents and these were

to include the following;

Questionnaire

The researcher used questionnaires as one of the tools for data collection. This method was to

help the researcher to attain information from different respondents. The respondents were being

given questionnaires to fill in. The reason for opting for this instrument is because, it is simple

to administer and it gave respondents time to think about what they should answer. The

questionnaires were to be answered by the Employees and Administrators themselves and later

collected by the researcher;

A pre-test was to be conducted to ensure the clarity of questions, their effectiveness the time was

being required to complete the questionnaire and to make sure that the questionnaire measures

what it intended to measure, the researcher assessed its content validity and reliability. In depth

interviews were also to be used especially for top managers that will be human resource for

accurate information.

Interviews

This method was to be used to obtain primary information from respondents, mainly the key

informants. The tools were to help the researcher to asic questions about the decentralization and

social service delivery in Sironko district in Uganda. The reason for the use of interviews was

that the respondents were to be few, meaning that it would be easy to interview them; and

interviewing them would result into the collection of in-depth

3.6 Sources of data

There are two general sources of data, which include primary and secondary (Hair et al 2003).

Primary Data

This was data that provided first-hand information in research (Hair, et al 2003) primary data

which included questionnaires and interviews.

Secondary Data

Secondary data was to be collected and assembled for some research problems or opportunity

situation other than the current situation (Hair et al 2003) secondary data was useful for it

27

formed the baseline and starting point for the research study. It included document analysis

observation and focus group discussions.

3.7 Data Analysis

Data was to be continuously analyzed during data collection. The data categories was being

identified and edited with a view of checking for completeness and accuracy. Qualitative data

was being attributed to numerical codes so that it could be analyzed statistically.

3.8 Ethical issues

The researcher kept her word on the confidentiality of the respondents and none of their details

and opinions was shared with a third party.

The researcher was honest to the respondents by telling them the truth about the research.

The researcher kept her integrity by always presentable and professional in conducting of this

research.

28

CHAPTER FOUR

STUDY FINDINGS, INTERPRETATION AND DISCUSSION

4.0 Introduction

Chapter four presents and discusses the results of the study. Information was handled in the

order of respondents’ background characteristics, job expectations/performance definition,

performance facilitation, performance encouragement and quality of service. This arrangement

was picked because it presents the systematic flow of performance as earlier supported by

Cascio (1986, p.423) and outlined in chapters 1 and 2 above.

4.1 Background characteristics of respondents

A total of 150 Budadiri County Sironko District Uganda I-Iealth personnel and 60 exiting

patients/caretakers were interviewed by questionnaire from four of the Health Sub-districts of

Budadiri County Sironko District Uganda. Additionally, 10 focus group discussions were held in

Wakiso Health Sub-districts (the furthest and nearest to the district headquarters) targeting

female and male adolescents (10-19 years), female and male adults (20 years and above) and

community leaders. Key informant interviews were administered to 10 respondents who were

associated with the Budadiri County Sironko District Uganda Health Directorate 31 work,

including politicians and bureaucrats from the government and non-government health sector of

the district.

4.1.1 Background characteristics of personnel respondents

Table 3 below shows the summary of background characteristics of personnel respondents.

Starting with the age and sex of personnel respondents

29

Table 1: Showing age of the respondents

Age No of respondents Percentage

20-29 27 34

30-39 17 21

40-49 23 29

50-59 09 11

60- and above 4 5

Total 80 100Source: Primary Data 2017

The table: 1 show that age range of 20 to 29 years (31%) had the largest number of respondents

and age range 60 to 69 (3%) had the smallest number.

Table 2: Showing Sex of the repondents

The female constituted the largest number with 52% while the male were at 48%. This is

because it is the female who are most affected.

Source: Primary Data 2017

30

Table 3: Showing level of education

Level of education No of respondents Percentage

Primary 12 15

Secondary 41 51

Post-secondary 21 26

University 4 5

Others 2 3

Total 80 100Sourcc: Primary Data 2017

The majority of health personnel interviewed had attained

postsecondary (26%) and University (5%). Primary leavers were

they had never gone to school. This implies that most people had

Secondary education (62%),

(15%). Only (2%) reported that

less education.

The majority of health personnel interviewed had attained

postsecondary (26%) and University (5%). Primary leavers were

they had never gone to school. This implies that most people had

Secondary education (62%),

(15%). Only (2%) reported that

less education.

Figure 1: Showing level of education

31

Table 4: Showing the duration in Service

Duration of Service No of Respondents Percentage

itolO 37 46

llto2O 22 28

21to30 16 20

31to40 4 5

41to50 1 1

Total 80 100

Source: Primary Data 2017

As for duration in service, over half of the respondents had worlced for a duration of 1 to 10

years (46%) a possible indication of new staff recruited during years of decentralisation, they

were followed by (28%) for 11 to 20 years’ service range, (20%) for 21 to 30 years, (5%) for 31

to 40 years and lastly (1%) for 41 to 50 years of service.

32

Figure 2: Showing the duration in Service

37

rn~Tr

~ -~ Irt Ir --

~_~

S 16-

- --

L~~ I_____

1- -~ —__

Source: Primary Data 2017

According to figure above as per duration in service, over half of the respondents had worked

for a duration of 1 to 10 years (46%) a possible indication of new staff recruited during years of

decentralisation, they were followed by (28%) for 11 to 20 years’ service range, (20%) for 21 to

30 years, (5%) for 31 to 40 years and lastly (1%) for 41 to 50 years of service.

Table 5: Showing the positions held by personnel respondents

Position held No of respondents PercentageNursing assistant 18 23Nurse/midwife 17 21Support staff 13 16in-charge 12 15Others officers 08 09Vaccinator 4 5Clinical officer 3 4Laboratory 3 4Medical officer 2 3Total 80 100Source: Primary Data 2017

33

Positions held by personnel respondents constituted nursing assistants forming the biggest

proportion of the respondents interviewed (23%), followed by nurses/midwives (2 1%), support

staff (16%) and unit in-charges (15%) who included nursing assistants, nurses, midwives and

clinical officers. Other officers (9%) (Comprising of dispensers, dental, radiography and

orthopaedic officers), vaccinators (5%), clinical officers (4%), laboratory (4%) and medical

officers (3%).

4.2 Personnel respondents’ distribution by Health Sub-district (HSD), unit ownership and

unit level

Table 2 below shows the distribution of personnel respondents by HSD, health units’ ownership

and health unit levels. Budadiri County Sironko District Uganda HSD,

Table 6: Showing the unit ownership of the respondents.

Unit ownership No of respondents Percentage

Government 17 21

Non-government organization 43 54

Private 20 25

Total 80 100

Source: Primary Data 2017

In the above table 21% of personnel interviewed were from Government units, 54% personnel

came from NGO health units, while 25% were interviewed from private units. This is because

non-government organizations are the ones which were so much involved in the study as

compared to other units.

34

Figure 3: Showing the unit ownership of the respondents.

— —43 ~——— —————— —

r__-~~--—

~ >~r~

---- -j~ir--~-

1 20

~ I r—-~ F

——.—~ 1__~_.__________~ I

1 1-- ~- —- - —~

- -

Source: Primary Data 2017

In the above figure 21% of personnel interviewed were from Government units, 54% personnel

came from NGO health units, while 25% were interviewed from private units.

Table 7: Showing the health unit level.

Unit ownership No of respondents Percentage

Hospital 10 13

HCII 25 31

I-IC III 29 36

I-ICIV 16 20

Total 80 100Source: Primary Data 2017

Personnel interviewed as by health unit level were 13% at hospital level, 31% at HCII, at HCIII

were 36% and 20% from HCIV.

35

4.3 Effect of decentralization on job expectation

On whether the current system of decentralisation is helping health personnel to clearly know

what they are expected to do on their jobs, according to table 4 below, the majority of the

personnel (72%) answered that it had helped them, 17% reported that it had no effect and 11%

could not tell.

Of the personnel who had worlced for more than 10 years in service (44% - 65/148) or joined

service before decentralisation, 71% (46/65) reported that decentralisation had helped improve

personnel’s Ic owing what they are expected to do, 25% reported that there was no improvement

and only 5% could not tell. When asked to give ways through which decentralisation had helped

them to clearly know what they were expected to do, of those respondents who reported

decentralisation had helped them, the biggest proportion of 45% (48/106) reported it was

through support supervision, 19% (20/106) by organizing short term trainings, while 11%

(12/106) reported having powers to plan and budget in relation to job descriptions. Others

included knowing whom to report to, easy communication with supervisors and administrative

units at lower levels.

Table 8: Showing respondents’ perception of how decentralisation has improved their jobexpectation knowledge.

Duration years in Personnel reported effect of Total

service decentralization on job expectation

Improved Not improved Could not tell

1 to 10 60% 40% 80% 60%

(30) (6) (12) (48)

11 + 40% 60% 20% 40%

(20) (09) (3) (32)

Total 100% 100% 100% 100%

~___________________ (50) (15) (15) (80)

Source: Primary Data 2017

Budadiri County had improved majority of the Health personnel’s ability to know what is

expected of them on their jobs thereby improving their quality and job performance.

36

4.4 Performance facilitation: the constraints to effectiveness and the quality, quantity and

accessibility of personnel

Performance facilitation section presents results on the staffing status, action on elimination of

roadblocks to performance and provision of adequate resources for making easy personnel tasks.

It includes subsections on staffing, knowledge and skills, performance feedback, equipment,

supplies and workspace and organisational support.

4.4.1 Effect of decentralisation on improving personnel job knowledge and skills

Personnel explanation of how the system of decentralization had helped to improve their job

knowledge and skills were summarized in table below. The table illustrates the views of

personnel respondents on the effect of decentralisation on job knowledge and skills. In general,

the majority (74%) of all personnel interviewed reported that decentralisation had helped to

improve their job knowledge and skills while the rest (26%) reported that they had not improved

their job knowledge and skills under the decentralisation system. Of the personnel who had

worked for more than 10 years in service (65/140) or joined service before decentralisation, 75%

(49/65) reported that decentralisation had improved their job knowledge and skills and 25% said

they had not had their job knowledge and skills improved under decentralisation. On how

decentralisation had improved personnel job knowledge and skills, of those respondents who

reported improvement (104/140), 40% answered that it was through attending seminars and

workshops organized by the DDHS office, 26% was for training received, 14% through support

supervision and others included sharing knowledge with personnel from other units and

information passed on through grand rounds and radio. From the staff that gave reasons for why

they had had no improvement, the majority, 72% (15/28) argued that they had not gone for any

other training, seminar or workshop during decentralisation.

37

Table 9: Showing the effect of decentralisation on improving job knowledge and skills

Duration years Personnel reported effect of I Total

in service decentralization on knowledge and jobs

Improved Not improved

1 to 10 46% 54% 100%

(25) (14) (40)

11+ 54% 46% 100%

(29) (12) (40)

Total 68% 33% 100%

(54) (26) (80)

Source: Primary Data 2017

Information from qualitative interviews below confirms that the commonest training to

personnel is very short on-the-job type through Grand Rounds and Continuing Medical

Education (CME), whose attendance is also limited by work overload due to understaffing and

lack of transport money for staff to attend. In support of the above, key informant DI-IT officials

made the following observations:

In-depth interview information indicates that apart from the money allocated for staff training

being little, it was also diverted to improve on workspace as pointed out by a District Councillor

below.

Some little money for training comes from the Central Government although the district has

decided to use this money for construction. The reason given for this diversion of finds is that

we cannot have trained personnel who will not have where to work. And we have to get the

structures in place i.e. I-Iealth Centre Ills and us (Ku, DHC).

38

Figure 4: Showing the effect of decentralisation on improving job knowledge and skills

4______ ~—--- ---~-~--- —----------------------~ -----

--~

--— —-

44~;

17

-_-‘

- -

~:‘ -~

i;

U IE ~

I

Source: Primary Data 2017

Personnel explanation of how the system of decentralization had helped to improve their job

knowledge and skills were summarised in table below, The table illustrates the views of

personnel respondents on the effect of decentralisation on job knowledge and skills. In general,

the majority (74%) of all personnel interviewed reported that decentralisation had helped to

improve their job knowledge and skills while the rest (26%) reported that they had not improved

their job knowledge and skills under the decentralisation system. Of the personnel who had

worked for more than 10 years in service (65/140) or joined service before decentralisation. 75%

(49/65) reported that decentralisation had improved their job knowledge and skills and 25% said

they had not had their job knowledge and skills improved under decentralisation.

4.4.2 Performance Feedback; re-focusing personnel for better quality

Performance feedback addresses the continuous orientation of personnel towards what they are

expected to do to achieve total performance by regular removal of obstacles to a clear focus on

performance goals. Good performance feedback enhances personnel quality.

39

4.4.2.1 Nature of job performance feedback

The study revealed that the majority of the interviewed health personnel were getting some form

of job performance feedback. 45% of the respondents reported that they were getting job

performance feedback (reorientation to knowing they are doing what they are expected to do)

through verbal means, 37% reported that it was both verbal and written and 11% said it was by

written means only. 7% reported that they were not getting any feedback; these included a dental

officer, nurse, laboratory officer, an in-charge and a radiographer.

As regards the frequency of performance feedback, 49% indicated receiving feedback on

monthly basis, 17% quarterly, and 16% daily. However, only 8% reported receiving it annually.

Respondents under the category of “others” (11%) said that they either received feedback

weekly, rarely or did not get any feedback. When cross-tabulated with unit ownership, it was

noted that the majority of the personnel in government, NGO and private health units, reported

receiving feedback on monthly basis. From the above presentation, clearly, a big proportion of

personnel received feedback on a monthly basis, which is good for enhancing good

performance.

On the question of who assesses the personnel performance, 37% reported that they were

normally assessed by unit in-charges, 32% by Heads of Department, 18% said they were

assessed by health sub-district (HCIV) and 11% by the DDHS officials and 2% said by the

Parish Development Committee (PDC).

4,4.2.2 Perceived effect of dccentrallzation on performance feedback

Personnel were asked to explain how the system of decentralization had helped to improve their

performance feedback, their responses were summarized in table 6 below. According to the

table, the majority (23%) of the personnel respondents reported that decentralisation had helped

to improve on performance feedback, 17% said it had not improved on feedback and 9% could

not tell, these included a clinical officer, a dispenser, with the biggest proportion of 36% (9/2 5)

being nursing assistants. Of the personnel who had worked for more than 10 years in service

(65/150) or joined service before decentralisation, 27% (45/65) reported that decentralisation

had improved on performance feedback, 20% reported that there was no improvement while

40% could not tell whether there was improvement or not. On ways in which decentralisation

40

had improved on feedback, of the respondents who reported improvement (100/150), 37%

answered that it was through supervisors being nearer hence regular supervision was ensured,

19% was for information on guidelines and mistakes being given immediately and 16% said it

was because of easy access to information on performance from DDHS and HSD. Respondents

that reported that decentralisation had not improved on feedback (22/150), 32% contended it

was because the policy is not followed, 23% said that there was little effect to NGO and private

units and 18% that there is no change because the situation was as it was before decentralisation.

Table 10: Showing the reported effect of decentralisation on personnel performancefeedback.

Duration years in Personnel perception of the decentralization Total

service effect on performance feedback

Improved Not improved Could not tell

1 to 10 46% 40% 60% 100%

(23) (06) (9) (40)

11+ 54% 60% 40% 100%

(27) (09) (6) (40)

Total 100% 16.9% 16.7% 100%

(50) (15) (15) (80)

Source: Primary Data 2017

Decentralisation as a way of improving job performance feedback is further supported by reports

from key informant interviews below: A DHT official said: “Under decentralization, it is easier

to provide feedback because of the new structure introduced with it” (KI, DHT).

The in-depth interviews also revealed the weaknesses that constrain decentralisation as a way of

improving on job performance feedback. A DHT member pointed out: “The problem persisting

under decentralisation is that there is still a shortage of stationery, functional communication

means and allowances” (KI, DI-IT).

On the other hand, a former member of the DHT noted: “Most districts do not ask for the

monthly plans and monthly reports to enhance feedback. If the DHT officials insist, they can be

realized, but most times they are absorbed in attending to the councillors’ wishes” (KI, DHT).

41

Based on results presented above, performance feedbaclc in Tororo Health Directorate had been

largely improved upon as a result of decentralisation thereby farther improving on the

competence and performance of health personnel. However, meagre funds were still a hindrance

to better results.

4.4.5 Working space

4.5.1 State of working space

48% of the respondents reported that they did not have enough working space. Of those who

reported that they did not have enough space, 11/72 lacked enough room for delivery/maternity

wards, 10/72 for examination rooms, 9/72 needed injectionltreatment room and 9/72

immunisation rooms, 6 were for out-patient waiting room and 5 lacked counseling /family

planning space. The other space needed was for offices, storage, dispensary, antenatal,

laboratory, cold chain and monitoring of very sick patients.

In-depth interviews with health officials at the district further confirmed the problem of lack of

enough working space. A DHT official said: “There is lack of working space in most health

centres. Plans for construction of health centres are on paper and a few are completed. Space is

provided for as and when money is received from the Centre” (IU, DHT).

4.5.2 Effect of decentralization on improving workspace at health facilities

Personnel explanations on how the system of decentralization had helped to improve workspace

were summarised in table 7 below.

42

Table 11: Showing the effect of decentralisation on improving workspace at healthfacilities.

Duration years in Personnel reported effect of Total

service decentralization on work space status

Improved Not improved Could not tell

1 to 10 55% 57.0% 83% 100%

(18) (20) (10) (48)11+ 45% 43% 17% 100%

(15) (15) (2) (32)

Total 29.1% 100% 13.5% 100%

(33) (35) (12) (80)

Source: Primary Data 2017

The table 11 illustrated that the majority (57%) of all interviewed personnel reported that

decentralisation had not helped to improve workspace mainly due to lack of funds for

developmental purposes, 29% reported improvement, while 14% could not tell (these included

10 support staff, eight nursing assistants, a nurse and a clinical officer). Of the personnel who

had worked for more than 10 years in service (65/148) or joined service before decentralisation,

71% (46/65) reported that decentralisation had not improved on workspace, 26% reported that

there was improvement and only 3% could not tell. On ways how decentralization had improved

work space, 28% (11/43) answered that it was through new units built and completed, 15% was

for ongoing construction, 10% were for a maternity unit built, 10% a theatre built and 10% for

increase on existing space and others included partitioning existing space, renovation and

planning support for NOO units.

4.5.3 Organizational support

This section deals with the structure of Tororo district resulting from decentralisation and how it

facilitates or de-facilitates the health personnel performance. For that matter, results will be

presented on the structure, personnel supervision and the relationship between politicians and

personnel vis-à-vis service delivery.

43

4.5.4 Relationship between politicians and health personnel

The study revealed that 40% of the respondents observed that the relationship between health

personnel and politicians was not supportive to the delivery of services. However, 45% of the

respondents said that their relationship with politicians was good and that it helped to speed up

service delivery, while 14% (21/1 50) could not tell, with 13/21 working in NGO health units of

whom one was a medical officer and four were nurses. Of the 67 who praised the relationship,

57% said the politicians help in mobilising people, 15% reported that they increased supervision,

9% said that they participate in meetings for collective agreements and 8% said politicians

mobilise for drugs and equipment. From the 59 personnel that did not praise the politician-

personnel relationship for service delivery, 45 gave different reasons, of whom 29% observed

that politicians do not care about improving their relationship, 27% said that politicians did not

understand the personnel’s work but just harass them, 13% said that they take health workers as

being corrupt yet they are not, 9% said that they take long to make decisions and another 9%

said politicians only mind about their allowances.

4.5.5 Effect of decentralization in improving job incentives

Personnel were asked to explain how the system of decentralization had helped to improve their

job incentives, their responses were summarised in table 8 below, The table shows that 48% of

all personnel reported that decentralisation had not helped to improve job incentives, 35%

reported improvement while 17% could not tell, and they included mainly nursing assistants,

nurses and support staff. Of the personnel who had worked for more than 10 years in service

(65/147) or joined service before decentralisation, 54% (35/65) reported that decentralisation

had not improved job incentives, 41% said there was improvement and only 5% could not tell.

On ways through which decentralisation has improved job incentives, of the respondents who

reported improvement, 42% answered that it was through provision of incentives in form of

physical and monetary allowances, 38% was for assured rewards every month and others

included contribution to NGO staff allowances.

44

Table 12: Showing the effect of decentralisation in improving job incentives.

Duration years in Personnel reported effect of Total

service decentralization on job incentives

Improved Not improved Could not tell

1 to 10 54% 50% 83% 100%

(15) (17) (15) (47)

11+ 46% 50% 17% 100%

(13) (17) (3) (33)

Total 100% 100% 100% 100%

(28) (34) (18) (80)

Source: Primary Data 2017

Most key informants reported that personnel motivation is not good, leading to lower

performance than would be desired; this is because of low revenue to the District. For example,

a DHT official said: “Personnel motivation is poor, nothing much given apart from the salaries.

No money from district local revenues that can be used to assist the personnel. The few staff

recruited goes away for other jobs because of lacic of incentives.”

4.6 Quality of service: expressing satisfaction or dissatisfaction with performance of

personnel

This section presents results on how the performance of personnel under decentralisation is

affecting the quality of service delivered and subsequently the client satisfaction. Areas

investigated included: waiting time to see health care providers, manner of handling clients’

complaints, information provision by health workers, clients’ satisfaction with treatment,

peoples’ perception of personnel performance and personnel’s overall view of the effect of

decentralisation to their job output.

4.6.1 Treatment satisfaction

Table 9 below shows how the respondents had got the prescribed drugs at health units during

two visits. On the last visit (visit to health unit by respondents before the date of interview), 60%

of the respondents indicated that they got all the drugs as prescribed, while 70% reported to have

received all the prescribed drugs on the current visit (at the time of the survey). It was, however,

45

noted that all government health units had just received new supplies of drugs from the district

and this could partly explain the increase in the number of patients who received drugs at the

time of the study time early June 2003.

Table 13: Showing the exit clients’ prescribed drugs received from health unit in Budadiricounty Sironko district.

Prescribed drugs Last visit Day of survey Total

received

All 15(42%) 24(55%) 43

Some 13 (36%) 706%) 20

None 401%) 9(20%) 13

Follow up (no drugs 4 (11%) 4(9%) 4

required)

Total 36(100%) 44 (100.0%) 80

Source: Primary Data 2017

On whether the patients were satisfied with the way they had been treated, 42% said they were

satisfied only 36% were not satisfied. Those satisfied reported that they had got treatment and

received drugs (55%), had been examined (16%), were well received and the providers were

polite (20%), that they had not waited for long before being treated (9%) and other reasons

included immunisation of children, others were because of thorough explanation, workers were

available and because they received prescriptions for buying the missing drugs. Information

from qualitative interviewees also concurred with reasons given by exit respondents, but they

added the construction of new health units and posting their staff as helping in bringing health

services closer to the people.

4.6.2 People’s perception of personnel performance

On the rating of the performance of health workers, 75% of exit respondents reported that it was

generally good, 17% said it was fairly good, while only 8% rated the performance as poor.

The study revealed that the relatively lower personnel job output was largely blamed on poor

facilitation that affects the job quality and staff morale. A former DHT member noted: “The

results are embarrassing because of the new challenges facing personnel that are not

46

proportionately facilitated (that is inadequate Ending, supplies and equipment to meet the

extended services).

Decentralisation came with benefits and liabilities” (KI, ex-DHT).

An LCIII Councilor /HCIII HUMC member also said: “Personnel output has been a bit slow.

Some workers feel sidelined. They are not very friendly because of frustration due to the fact

that they cannot effectively sustain themselves on the small salary plus allowance” (1(1, HUMC).

This was also supported by the FGD participants in the sub-counties of Butaleja and Osukuru

who noted that health workers were under-facilitated, understaffed, some were untrained,

received low salary, lacked enough drugs and the majority did not have electricity to enable

them work at night.

4.6.3 Effect of decentralisation to personnel output

Personnel explanation of how the system of decentralisation had affected their output were

summarised in table 10 below.

Table 14: Showing the personnel views on the effect of decentralization to their job output.

I)uration years Effect on personnel job input Total

in service

Improved Not improved

I to 10 53%(29) 48% (12) 100% (41)

11+ 47% (26) 52% (13) 100% (39)

Total 100% (55) 100% (25) 100% (80)

Source: Primary Data 2017

The table illustrates personnel respondents’ views on the effect of decentralization to their job

output. The majority (53%) of personnel interviewed reported that decentralisation had helped to

improve their job output while the rest (47%) said that their job output had not been improved

under the decentralisation system. Of the personnel who had worked for more than 10 years in

service (65/144) or joined service before decentralisation, 48% (46/65) reported that

decentralisation had improved their job output and 52% said they had not had their job output

47

improved upon under decentralisation. This means that though decentralisation had helped the

majority improve performance, the other lot still needed to be uplifted for better results.

48

CHAPTER FIVE

DISCUSSION OF THE FINDINGS, CONCLUSIONS AND RECOMMENDATIONS

5.0 Introduction

This chapter presents the conclusions and recommendations drawn from the findings. This study

examined the effect of decentralisation on the performance of local government in Budadiri

County Sironico District Uganda Health Directorate personnel; it assessed the personnel

performance in terms of their quantity and quality, personnel accessibility to local people, the

clients’ satisfaction of personnel services and constraints to personnel performance under

decentralisation. In the process, it followed up the personnel performance factor; that is

performance definition or job expectation, performance facilitation and encouragement, and the

quality of service. Conclusions are therefore, presented on the personnel performance factors of

job expectations, staffing, lcnowledge and skills of personnel, equipment, supplies and

workspace, organizational support, job rewards and quality of service. Through these,

conclusions based on the study objectives are drawn.

5.1 Discussions of the findings

Decentralisation was found to have improved upon the ability of health personnel in Budadiri

County Sironlco District Uganda to lcnow their job expectations and consequently improve on

their quality. Performance goals were set within preset national standards. Reminders of

performance goals were clear (written and oral), and were both regular and timely. Personnel

were able to describe their performance goals in measurable terms, and the majority of them said

they had been given job descriptions. Both staff recruited before and after decentralisation

reported improvement on knowing their job expectations as a result of decentralisation, they

reported that this improvement was mainly through support supervision, short term trainings,

having more powers to plan and budget in relation to their job descriptions. Other improvements

were knowing whom to report to, easy communication with supervisors and administrative units

at lower levels.

In an effort to take health services closer to the Budadiri County communities, decentralisation

created more health units in categories of HCII, HCIII and HCIV; however, this was not

followed by proportionate increase in the numbers of relevant manpower, subsequently

49

overloading the available personnel. This led to many health units especially those falling under

HCII and HCIII category to be headed by under-qualified staff who did not measure up to the

required performance demands of planning, implementing and evaluation of activities as

managers of Health in the district. Even at hospitals, various categories of staff were

understaffed among these were the nurses while nursing assistants were overstaffed to cope with

the shortage of nurses. The staff resisted posting to rural areas where new units were being

created, this challenges the decentralisation powers to improve on service delivery. The I-lealth

Directorate had little influence on numbers of staff in NGO and private health units, while it has

direct influence on their staff qualifications. But results showed that many personnel in NGO

and private units were under qualified for the posts they occupied. Lack of funds was found to

be the biggest roadblock to eliminating staffing gaps; the DSC that was sometimes nonexistent

probably due to political reasons made the staffing problems worse.

The majority of staff interviewed felt that their pre-service training was adequate for their jobs.

However, most clients expressed dissatisfaction with the recruitment of personnel they deemed

to be unqualified. The majority (94%) of personnel expressed the need for on-the-job-training to

improve on their performance, but almost one-third (29%) had never attended any on-the-job

training while 54% had attended within the last one year. The majority of interviewed staff

(about ¼) that had worked before and after the introduction of decentralisation in the district

reported improvement on their job knowledge and skills; this was mainly through training

received, support supervision, sharing knowledge with personnel from other units and

information passed on through Grand Rounds and radio.

The type of staff training mainly given was of a very short-term nature, but this was also

hampered by inadequacy of funds for organizing the trainings and transporting participants and

facilitators.

Worse still, the training funds were diverted to construction of new health units. The

understaffing that leaves some staff unable to attend because they do not have partners to

delegate their duties to during their absence, also blocks personnel from attending training.

Regular verbal and written performance feedback on monthly, quarterly and daily basis received

by the majority of personnel, helped to remind them to properly focus their perfonnance to the

50

right services. In-charges, Heads of Department, HSD and DDHS, in that order, were reported to

be playing a big role in performance feedback. This is an indication that managers under

decentralisation are active in guiding personnel to stick to the right performance goals.

The majority of the personnel recruited both before decentralisation (69%) and afler (65%),

reported improvement on performance feedback during the decentralisation era. Reasons given

for the improvement included supervisors being nearer hence regular supervision was ensured,

information on guidelines and mistakes being given immediately and easy access to information

on performance from DDHS and HSD. However, meagre funds were still a hindrance to

achieving better results.

Availability of equipment to personnel was very poor with almost three quarters of interviewed

personnel reporting not having the equipment needed for their work. The majority of the

requests for equipment’s were not honoured. Equipment maintenance, on the other hand, was

very good with over three quarters of personnel saying that all their equipment’s were well

maintained. The relatively low amount of revenue collected by the district and that remitted by

the Central Government was largely blamed for the unavailability of equipment’s and its poor

maintenance in some cases.

The study revealed that the majority of the personnel did not have all supplies needed for their

work, neither were all their supplies’ requests honoured. Supplies most requested but not

received were drugs and protective wears. This led to demoralisation of patients and personnel.

The low funding situation in the district was mainly blamed on lack of supplies especially the

scarcity and irregularity of drugs in health units.

About half of the personnel interviewed did not have enough working space like rooms for

maternity services, patients’ examination, injection and counselling. A large proportion of both

staff recruited before and after decentralisation introduction in Budadiri County, reported that

decentralisation had not improved on their workspace status. Construction of new buildings for

workspace improvement was very slow due to inadequate funding which was given as a major

reason for diverting money meant for staff training to workspace construction. The inadequate

workspace makes staff inaccessible to all clients due to lack of rooms to conduct their duties in

confidence leading to client dissatisfaction of personnel services.

51

There was general agreement that the structure for decentralisation of health services in Budadiri

County had extended better health management to the lower communities especially through

creation of lower administrative centres. This had helped personnel to improve on their

performance through taking supervisors closer to them, by opening up health centers at different

levels it had brought their services closer to the community, and a little more quantity of drugs

than before. On the other hand, the structure was also making it difficult for health staff to

perform effectively because of delays in responding to requisitions like for drugs, delays in

release of funds and attending to problems, delay in appointing and confirming staff leading to

personnel getting overworked and collectively become less effective. The structure had not been

fully utilized to bolster personnel performance due to poor facilitation mainly because of

inadequate staff and funds to support supervisory work and provide logistics.

The relationship between politicians and health personnel was found to be both supportive and

unsupportive to service delivery. It was supportive because politicians helped in mobilising the

people, supplies and equipment for health service, supplementing supervision and participation

in meetings. While on the other hand, it was not supportive because some politicians did not

care about improving the relationship, politicians did not understand the personnel’s work but

just harassed them, politicians took all health workers to be corrupt yet this did not apply to all

of them, politicians were taking long to make decisions and only cared about securing future

votes and getting allowances. It was noted that the gap between politicians and personnel under

decentralisation was narrowing, leading to better service delivery, whereby the two increasingly

work as a team as time goes by.

The biggest proportion of personnel respondents indicated that they were receiving salary and

allowances as job rewards. The majority were not happy with the value and amount of their job

rewards, because the rewards could not meet all their basic needs. Just over half of the

interviewed personnel were happy with the timing of their job rewards while about a-half were

not happy as they received them late. Similarly, just over half of the personnel were getting job

rewards as promised by employers, while the rest were not happy because they had not received

accumulated salary arrears, no allowances paid, lacked salary increment and promotion.

Personnel promotions were generally inhibited by scarcity of funds, limited positions for

promotion in the district and further compounded by nepotism and tribalism. Generally, just

over a half of the personnel interviewed reported improvement of job incentives during52

decentralisation. The majority of the personnel were not encouraged by their job rewards to

sustain good performance.

Most patients were taking long to see health workers; the waiting time was at an average of lhr

15 mm. Some clients were also not able to see health staff in the afternoons as the staff was

leaving early before end of working hours. This made staff unavailable and the clients

dissatisfied.

Generally, most health workers were reported to be handling patients well despite the lack of

drugs at times, and for that the clients were satisfied. But some health workers were at times

rude, careless and money minded thereby not satisfying the patients with their service. Most

health workers gave clients the information that answered their needs for which the clients were

satisfied. On the other hand, some staff were reported to be overloaded by large numbers of

patients, not free with the local languages and some were rude hence not giving the needed

information and making the patients dissatisfied. Most patients were receiving all prescribed

drugs from the health units at which they were prescribed. However, about two fifths of patients

were either receiving some or no drugs at all which made them dissatisfied with the treatment

they were receiving from health workers.

Other common reasons given by citizens dissatisfied with treatment included unavailability of

staff, rudeness of staff, lack of comprehensive explanation from staff, poor or partial

examination and staff coming to health units late and leaving before end of working day. The

people perceived the health personnel performance as generally good. They further noted that

the relatively lower personnel job output was mainly due to under-facilitation of staff, which

negatively affects the quality of output and staff morale. The majority of the personnel reported

that decentralisation had helped to increase their job output.

5.2 Conclusions

In conclusion, the study achieved its general objective of assessing the effect of decentralisation

on the performance of district personnel in Uganda and Budadiri County Sironko District

Uganda Health Directorate in particular. It further attempted to answer the specific objectives of

assessing the nature of personnel performance in terms of their quantity and quality; the extent

to which personnel were accessible to their clients; the consumers’ satisfaction of personnel

services. The study also identified key constraints affecting effectiveness of the personnel53

performance under decentralisation in Budadiri County Sironko District Uganda as specifically

laid out below:

The improvement of personnel’s ability to know what they are expected to do on their jobs

under decentralisation led to improvement in personnel quality as being focused in their

performance.

The quantity of the Health Directorate personnel in Budadiri County Sironko District Uganda

was found to be lacking leading to overloading of personnel to serve the increasing numbers of

clients and increasing numbers of health units, it also led to understaffing hence constraining

service delivery. The personnel performance was also constrained by absence of the DSC that is

the top legal body in the district that oversees the smooth functioning of personnel. Personnel

quality was also found wanting especially in lower cadres of Government, NGOs and private

units where personnel were serving in positions for which they were under-qualified. The above

coupled with the lack of funds to recruit personnel were constraints to Budadiri County

personnel performance under decentralisation.

Personnel quality was partially enhanced under decentralisation by improvement of job

knowledge and skills through mainly very short-term training. Long-term courses were limited

and nonparticipation to available training of some personnel were caused by lack of funding and

understaffing that left no time for training to improve staff quality and subsequently their

performance.

The quality of personnel was in part improved by the regular verbal and written performance

feedback from the Health Directorate managers at lower levels created under decentralisation.

But meagre funds were again a constraint to the smooth flow of feedback in terms of transport

and stationery.

Personnel quality and accessibility were negatively affected by the general lack of equipment.

Staff without the essential equipment is viewed by the local people as inferior; and staffs are

also forced not to attend to clients when they lack the necessary equipment. The lack of

equipment and the funds that would purchase equipment were therefore major constraints to

personnel performance and contributed to some of the clients’ dissatisfaction.

54

Necessary supplies, especially drugs were scarce and irregular as a result of the poor financial

capacity of Budadiri County Sironlco District Uganda. Little amounts of drugs were purchased

as and when funds became available; this was a constraint to personnel performance leading to

the dissatisfaction of the local people who sometimes blamed staff for the situation based on

mere allegations. Lack of drugs is a major source of dissatisfaction among service users.

Workspace as venue for confidential personnel-client interaction was lacking to many personnel

thereby constraining health workers and making them not easy to access ending into

dissatisfaction of clients. On the other hand it is worth noting that an almost equal number of

personnel had their workspace made better under decentralisation. The lack of enough finds was

blamed for the inadequate and slow pace of workspace improvement.

Accessibility of health workers was improved upon through the creation of the health services

decentralisation structure that brought nearer more qualified cadre of personnel form hospitals to

lower health units, the same also partly improved health management at lower levels thus

enhancing personnel quality. But the structure was also found to be unhelpful when it came to its

inability to do away with the personnel constraints of poor staff appointment and confirmation,

and delayed in responding to calls for staff facilitation. The politicians were, on the one hand,

helpful to health workers in improving performance where they mobilised people and resources,

while on the other hand they constrained personnel performance especially the selfish ones, but

they were found to be progressing for better as time went by.

Personnel performance was constrained by poor job rewards, this made personnel less accessible

whenever they sought supplementary income activities (like gardening in the mornings) as an

alternative survival strategy and consequently dissatisfied the citizens. Personnel were not happy

with the value and amounts ofjob rewards that were not meeting their basic needs; the rewards

were sometimes received late, while promotions were inhibited by scarcity of funds, limited

positions in the district, nepotism and tribalism.

The clients expressed dissatisfaction with the way some personnel delivered services; clients

took long to see health workers, the personnel were sometimes unavailable, staff were

overloaded and could not avail enough time with patients, some were rude and others were not

conversant with the local languages. Sometimes, dissatisfaction was also directed to personnel

whenever patients did not receive the prescribed drugs. However, clients were satisfied with

55

some personnel labouring to handle patients carefully and giving thorough explanations

concerning patients’ ailments despite poor facilitation in terms supplies (drugs) and equipment.

All in all, the study revealed that decentralisation has helped to improve on personnel

perfonnance and is still beneficial to service delivery, but there is urgent need for proportionate

facilitation of the system to appropriately deliver the decentralised services.

5.3 Recommendations

In order to improve the quality of personnel, there is need to strengthen the lower administrative

units at the HCIV, HCIII and HCII to increase the reminders to personnel of performance goals

in written and oral form at timely and regular intervals. This will enhance the personnel’s ability

to know their job expectations or performance definitions thereby improving their service

delivery.

To enhance the personnel quantity, quality and accessibility, urgent action is required to

proportionately recruit personnel to fill the current 70% health personnel gap in Budadiri

County. Similarly, there is urgent need to allocate personnel to perform duties for which they are

qualified to give citizens the quality of service for which they pay taxes. In particular, urgent

action should be directed towards recruitment of enrolled comprehensive nurses and clinical

officers Grade I who are needed across all health facilities to head HCII and HCIII respectively

and to provide lead and supportive treatment elsewhere. Enrolled comprehensive nurses gap was

100%. while that of clinical officers Grade I was 85%.

Personnel quantity, quality and accessibility improvement requires to have a functional DSC,

which is operational at all times. This will allow it to perform its duties of ensuring adequate and

satisfied personnel for the district to fulfill its service delivery to the citizens. The Budadiri

County Sironko District Uganda Council should be made to realise the importance of the

existence of the DSC in personnel performance and go out to ensure its existence.

The need to regularly update the quality of personnel requires that the personnel office should

ensure that all personnel get equal chances of attending timely and regular on-the-job-training to

keep up with changes for better performance. In addition, more funds should be mobilised to

enable staff to attend longer-term training sessions. Health workers should also be encouraged to

56

expeditiously learn local languages of their areas of operation to communicate fully with their

clients.

Performance feedback should target all personnel to help them focus their performance to the

right goals. There is need to invest more in performance feedback activities like regular

meetings with stafi, supervisory visits and confidential discussion of individual appraisal forms.

To supplement personnel quality, availability and raise client satisfaction, more funds should be

mobilised for procurement of equipment and its maintenance, for regular and adequate purchase

of supplies of drugs, protective wears and others like stationery. Under the current

decentralization system, the Central Government takes biggest responsibility of securing Thnding

to districts as it retained the most lucrative revenue generation sources.

For better accessibility of personnel, extra funds should be mobilised to expedite construction of

new rooms and maintenance of existing workspace. The workspace status should always ensure

upholding of the principle of confidentiality for areas like the examination of patients, injection,

counselling and maternity services.

To reduce constraints resulting from poor relationships between politicians and personnel,

continuous team building between the two factions should be organised and most especially with

every new batch of politicians to cement the working relationship towards better performance

for service delivery. Roles for politicians and bureaucrats need to be clearly understood during

these team-building sessions for them to avoid confusion in the process of working alongside

each other as is required under decentralisation.

To minimize constraints to performance of personnel due to poor job rewards, there should be a

deliberate effort to significantly improve the job rewards given to personnel so as to encourage

them to continuously aim at better performance. The improvement should address the value and

amount of job rewards, timely release of all promised rewards, salary increment and promotion

of personnel.

Putting in place and implementing a system that ensures availability of personnel at the work

place for all the time they are supposed to be there should complement the improved rewards.

57

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Ahmad, J., Devarajan, S., Khemani, S. &Shah, S.(2005).Decentralization and service delivery.

World Bank Policy Research Working Paper 3603. World Bank

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African Economic Research Consortium. Nairobi: AERC

Crawford, G.(2004). Democratic decentralisation in Ghana: issues and prospects. POLlS

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Monrovia: MOHSW

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APPENDICES

APPENDIX I: QUESTIONNAIRES

Part 1 Background Information

Dear Respondents,

I am Wamunga John Reg No, BPA/40524/151/DU a final year student of the above named

institution, conducting a research on the topic ‘decentralisation and social service delivery; A

study of students of Kampala international University Uganda.

I humbly request your assistance in filling the questionnaire. All information gathered shall be

used purely for research purpose and shall be treated with confidentiality.

Yours faithfully

Researcher

Section A: Blo data

I. What is your sex?

Male DFemale D2. What is your age bracket?

18-24 D25-31 D32-38 D39-40 D

60

SECTION B

Please tell me your name and present position in the Ministry of I-Iealth and Social Welfare

Tell me about your roles and responsibilities within the Ministry

How long have you worked with the Ministry?

Part 2 Decentralization and Service Delivery

What informed the Ugandan Government’s decision to decentralize its ministries and agencies?

In the cases of the departments of Health and Social Welfare, How has the process been

successful in bringing about improvement in the areas of health and social welfare in the country

especially at the local level?

With the introduction of the decentralization process, what challenges do you still face as a

department?

Has the decentralization of the Ministry of Health and Social Welfare contributed in any way to

the resource fullness or other wise of the staff of the department at the local levels? Please throw

more light on this.

How many Social Welfare/Health officials are in atypical CHSWT at the local level?

On the average, how many health worker and DSW workers is one expected to find at the county

and district levels in Uganda?

How do the departments of health and social welfare fund their operations?

Part 3 Reasons for Disparity between the Departments of Health and Social Welfare

Kindly describe how services are delivered in the Department of Health / Social Welfare

There is an apparent disparity in the decentralization process between the Department of Health

and that of Social Welfare. What might have accounted for this disparity in your view?

What do you suggests makes it possible for the health department to have advanced in the

decentralization process compared to the DSW?

61

Do you think the slow pace of decentralization in the DSW has something to do with their

internal operational mechanisms?

Part 4 Promotion of Wellbeing by Collaboration through Decentralization Process

What is the level of collaboration between the Health and Social Welfare Departments in

delivery of services to meet the well-being of the population?

What do you think account for the low/high levels of collaboration?

What would be some of the areas of collaboration between our department and that of DSW in

your quest to fully decentralize?

Community leaders

F In time of sickness, how do you get to the nearest health facility?

Can you explain the kind of services that are provided?

When there are social problems like child abuse, domestic violence, old age people, etc. how do

you deal with them?

Who are those that provide you with social welfare services in your community?

I-low was service delivery in terms of health and social services some five years ago?

Decentralization is expected to bring services closer to you. What do you think about the health

and social welfare services?

What are some social problems in the community that you think can be handled by social welfare

and health?

62

APPENDIX II: TIME FRAMEWORK

Proposal writing

Submission and

approval

Collection of

literature

Instrument Design

Month Activities March April May June July

Pilot test

Corrections

Data Collection

Data analysis and

Report writing

Approval and

submission

63

APPENDIX III: BUDGET

Items Unit Cost In Total Cost

Typing and Printing 200 per page 50000

Binding 8000 per copy x 3 24000

Transport 30000 50000

Communication — 10,000

Data collection 100,000

Meals 30000 30000

Stationeries 20000 20000

Miscellaneous 40000 40000

Grant Total 324,000

64