Perceptions of Decentralization in Health Services in Uganda

1. THE ATTITUDES AND PERCEPTIONS OF STAKEHOLDERS ON DECENTRALIZATION OF HEALTH SERVICES IN UGANDA: THE CASE OF LIRA AND APAC DISTRICTS Anokbonggo WW, Ogwal-Okeng JW,Ross-Degnan D, Aupont O. International Conference on Improving Use of Medicines Chiang Mai, Thailand 2004 INRUD Uganda and Makerere University Project supported as part of the Joint Initiative on Improving Use of Medicine under a grant from ARCH

2. Abstract Problem Statement: In Uganda, the decentralization of administrative functions, management, and responsibility for health care to districts, which began in 1994, resulted in fundamental changes in health care delivery. Since the introduction of the policy in Uganda, little information has been available on stakeholders’ perceptions about the benefits of the policy and how decentralization affected health care delivery. Objectives: To identify the perceptions and beliefs of key stakeholders on the impact and process of decentralization and on the operations of health services in two districts in Uganda, and to report their suggestions to improve future implementation of similar policies. Study Design and Setting: We used qualitative research methods that included focus group discussions with 90 stakeholders from both study districts. The sample population comprised of 12 health workers from the two hospitals, 11 district health administrators, and 67 Local Council Leaders. Outcome Measures: Perceptions and concerns of stakeholders on the impact of decentralization on district health services. Results: There was a general consensus that decentralization empowered local administrative and political decision-making. Among stakeholders, the policy was perceived to have created a sense of ownership and responsibility. Major problems that were said to be associated with decentralization included political harassment of civil servants, increased nepotism, inadequate financial resources, and mismanagement of resources. Conclusions: This study elicited perceptions about critical factors upon which successful implementation of the decentralization policy depended. These included: 1) appreciation of the role of all stakeholders by district politicians:; 2) adequate availability and efficient utilisation of resources; 3) reasonably developed infrastructure prior to the policy change; 4) appropriate sensitisation and training of those implementing policies; and 5) the good will and active involvement of the local community. In the absence of these factors, implementation of decentralization of services to districts may not immediately make economic and administrative sense.

3. BACKGROUND • In 1993, Structural Adjustment Programme (SAP) ACT introduced in Uganda. Decentralization policy of health care services. • District level health care admistration “Independent” from Central Admistration. District hospitals financing and operations managed by district decision-makers. • Actual impact of the decentralization policy unknown questionable by stakeholders. Overall perceptions and feedback of healthcare workers, administrators and community leaders needed for improvement

4. BACKGROUND (continued) • Initial study on impact of decentralization on health services in Uganda. focus: - Facility utilization - Prescribing patterns for common childhood illnesses - Availability of essential drugs. - In depth exploration of study findings

5. OBJECTIVES To investigate perceptions and concerns of stakeholders on impact and process of decentralization policy on health care services. Specific Objectives • To analyze and understand the advantages and challenges of the policy as perceived by the stakeholders. • To gather stakeholders’ recommendations for improvement of future implementation of similar policies.

6. METHODS Design and Setting. - Initial retrospective data collection in two district hospitals (Apac and Lira). - patients attendance, - prescribing patterns for AIR, Malaria, and Diarrhoea - Availability of essentials drugs. - Presentations of fidings and focus group discussion with 90 stakeholders: 11 district health administrators 67 local community leaders 12 health care workers - Identification of operational areas for improvement - Development of consensus recommendations

7. Results Positive aspects reported • General consensus that decentralization policy was a good concept. • Improvement in financing of NGOs’ projects and government grants to districts. • Planning and management of district health care services/ reported/perceived to be more efficient. • District drug procurement and supply improved • Improvement in local mobilization of resources

8. Results (continued) Perceived challenges • Poor management of resources. • Communication gap between district and centre. • Poor staff/community relationship • Hospital attendances affected • Workforce motivation affected by limited financial resources. - District staff not familiar with new policy.

9. Results Suggestions for improvement - Reinforcement of central administration monitoring and evaluation of district activities • Regular review of district financial operations. - Improvement of workforce by recruitment, retraining, and better remuneration. • Greater and clearer communication between central and district decision-makers • Public education and sensitisation • Improve availability of essential drugs in districts.

10. Summary • Perception of empowerment created sense of responsibility among stakeholders. • Successful implementation of decentralization policy is contingent upon local politicians’ support of the role of all stakeholders. • Financial constraints affected several aspects of decentralization policy implementation. • Lack of managerial skills at the district level hampered efficient implementation of the policy. • Inadequate preparation of the community and health care workers negatively affected the implementation of the policy.

11. Conclusion - Inspite of noticeable problems, most groups felt that decentralization had improved social service delivery to districts. - Adequate availability and efficient utilisation of resources must be ensured. - Appropriate infrastructure necessary prior to implementation of new policies - Sensitization and education of District decision-makers necessary to to ensure effective implementation of decentralisation policy.