Determining the Relationship between Political Decentralization and the Quality of Maternal Health Services in Uganda, Sheema Municipality, Sheema District.

Determining the Relationship between Political Decentralization and the Quality of Maternal Health Services in Uganda, Sheema Municipality, Sheema District.

Dr. Nuwatuhaire Benard; Dr. Ainomugisha Andrew

Ankole Western University (AWU)

DOI: https://doi.org/10.51244/IJRSI.2024.1104031

Received: 19 February 2024; Accepted: 07 March 2024; Published: 09 May 2024

ABSTRACT

The study investigated the relationship between political decentralization and the quality of maternal health services in Uganda, Sheema Municipality Sheema District. cross-sectional and correlational research designs were adopted on a sample of 235 respondents. Quantitatively data was analyzed by use of descriptive statistics, frequencies and percentage tables and qualitatively, by thematic content analysis. Inferential analysis results indicated that political decentralization had a strong positive significant relationship with quality of maternal health services. Therefore, it was concluded that political decentralization as a component of decentralization policy implementation is essential for quality of maternal health services. The study recommended that the Government of Uganda should implement political decentralization policy in the health sector by granting local government powers and authority to manage and run the health facilities in order to improve the quality of maternal health services.

Key words: Political Decentralization and Quality of Maternal Health Services

INTRODUCTION

Improving the quality of maternal and newborn baby health care is critical if maternal and newborn health outcomes are to improve further. This will necessitate a shift in global focus. According to World Health Organization statistics from 2017, 303 000 women die during labor, childbirth, or the postnatal period, 2.6 million infants are stillborn, and 2.7 million babies die within one month after birth. The majority of these deaths occur in low- and middle-income areas and are avoidable (United Nations Report, 2017) and in Political decentralization dispensation which is the transfer of authority to a sub national body this should not be the case. (Makara, 2000).

THEORETICAL REVIEW

The study was anchored on the participatory theory. This theory was introduced in the development arena in the   early 1980’s by Robert Chamber‘s Rapid Rural Appraisal Methodology. Participatory Theory served as the study’s main point of reference for assessing the impact of decentralization policy implementation on the quality of maternal health service delivery.  The theory assumes that the participation of stake holders will cause decision making processes to be more inclusive and therefore instigate ownership over development processes and services which in turn lead to more sustainable impact. According to Brett (2018), participatory theory may be used to manage services and programs for maternal health in underdeveloped nations.

REVIEW OF RELATED LITERATURE

Political Decentralization and Quality of Maternal Health Services

The transfer of more political and administrative authority to local health facility executives is a crucial component of decentralizing health care, yet it may also open up opportunities for abuse (Gilson and McIntyre, 2011). Because of this aspect, the system is more susceptible to corruption, especially when lucrative service contracts are given to friends, family, clan members, and others who pay bribes. If clear efforts are not taken to prevent it, corruption may result in the marginalization of minorities such as the poor, women, the disabled, and others who are less politically powerful. The relative appropriation of the democratic process by special interest groups at the national and local levels of government is one of the major concerns addressed in the literature on decentralization.

A study on the decentralization of health systems in Ghana, Zambia, Uganda, and the Philippines was conducted by Sumah, Baatiema, and Abimbola (2016). The study’s findings show that local communities are involved in mobilizing resources to build health centers and seek to understand how the mobilized resources have been utilized. Political decentralization has since resulted in better resource mobilization for the provision of maternal health care in underdeveloped nations. The significant financial gains that districts saw after decentralization serve as proof of this. The public services are now more accountable as a result of decentralization. This is so that they can readily see whether the planned actions are carried out as they are the ones involved in executing and planning. Using experiences from Zambia and Uganda, Jeppsson and Okuonzi (2018) looked at the vertical or holistic decentralization of the health sector. The findings highlight that political decentralization entails the local population acting as a watchdog over the system and ensuring that public officials provide high-quality goods and services. This is due to the fact that choices about the distribution of resources are made in consultation with the local communities. Decentralization has therefore resulted in increased accountability for the provision of maternal health services in Africa. This is because they can readily observe if the planned actions are being carried out as they are the ones involved in executing and planning. For instance, everyone may see the income and expenses at the Municipality level on the notice board. Decentralization promotes good governance by empowering the local populace and giving them a voice in decisions that have an impact on their daily life. This enables the local populace to monitor the system and make sure that public servants provide high-quality goods and services. This is due to the fact that choices about the distribution of resources are made in consultation with the local communities.

In a research titled “Combating the Crisis in Government Accountability,” Mookherjee (2016) found that by giving DLGs control over formerly central government-held responsibilities, political decentralization can help achieve the HSSP’s goals for systematic maternal health care service supply. This was created to provide stakeholder involvement in the planning and financial decision-making process, enabling customers to hold decision-makers and service providers responsible for the caliber of services offered. In a study on the decentralization of the health sector in sub-Saharan Africa, Naidoo (2017) found that political decentralization makes it possible for communities, particularly mothers, to take charge of their own maternal health and well-being and actively participate in the management of their local maternal health services. The Government of Uganda has started a number of initiatives under decentralization, including: developing guidelines for community capacity building for effective participation in resource mobilization and in monitoring health activities; promoting the establishment of health committees with an appropriate gender balance at each of the different levels of the local government system; establishing management boards for all publicly owned tertiary hospitals with extensive delegating powers; and establishing a health information technology (HIT) infrastructure (Landman & Henley, 2017).

According to Lubanga (2018)’s investigation of Uganda’s democratic decentralization process, decentralization enhances government responsibility for the provision of maternal health services, particularly for the underprivileged. On the other hand, academics contend that increasing funding for public services without improving the accountability incentive system is unlikely to result in larger development benefits for the underprivileged. The ability of the intended recipients to hold the persons accountable is necessary if service supply is to benefit the clients, highlighting the significance of accountability as a social relationship at the local level. These arguments assume the presence of citizens who are fully informed and capable of making their own decisions.

Decentralization within a larger framework is to bring political power closer to local communities, to address local needs, to create local capacity, and to promote accountability, according to Green’s (2017) study of district construction and decentralization in Uganda. Decentralization policy is specifically linked to improvement in the health sector, including increased use of maternal health services, better access to maternal health services, greater population coverage for essential services, higher-quality maternal healthcare, and ultimately a decrease in the rate of maternal mortality, illness, and death (Jeppsson and Okuonzi, 2018). Jeppsson and Okuonzi (2018) contend that the statistics currently available do not demonstrate any increase in social services or people’s quality of life throughout the reform era. In reality, a lot of the indications have either gotten worse or stayed the same. The criteria used by MOH to assess the performance of the various districts were criticized by Asiimwe (2012) in an analytical work not based on an empirical investigation as being inaccurate and deceptive. He noted that the majority of the data used for the ranking came from facility health management information system reporting forms, which were submitted to the MOH without triangulation with other sources. He noted that these indicators were primarily facility and management indicators derived from Uganda’s first health sector strategic plan.

Chandana (2016) investigates the relationship between decentralisation and DPT318 and measles vaccination coverage rates in 140 poor and medium income countries from 1980 to 1997. The primary measure of fiscal decentralisation employed in this study is a binary variable defined as subnational authorities having taxing, spending, or regulating authority. To double-check the results, two further decentralisation variables were used: the proportion of subnational expenditures on total government expenditures and the share of health spending on total subnational expenditures. Several control variables were also incorporated in the model (GDP per capita, illiteracy rate, democracy score, ethnic tension). According to the data, decentralisation boosts coverage rates only in low-income nations.

Mills and Tabizadeh (2016) investigated health system decentralization, concerns, issues, and country experience, and their findings show that geographical proximity to healthcare providers has increased as a result of the decentralisation policy, as has been stated by other research efforts in this area. This is shown in the percentage of the population who have physical access to health care services. Physical access has increased throughout the years, which has been primarily due to major development and investment in health infrastructure. This rise, however, does not appear to be accompanied by an increase in the use of modern providers for curative treatment. This is a major matter for worry because it appears that a growing number of people are opting to self-treat or do nothing. Montoya and Vaughan (2015) did a research on Decentralization and Local Management of the Health System in Developing Countries Division of Strengthening of Health Services, and the results show that the decentralization strategy has increased access to maternal health services. Access to maternal health care refers to the public’s availability, accessibility, and affordability of maternal health care facilities, or the capacity to use such services because an organization feels that maternal health is both a fundamental human right and a crucial concern (WHO, 2018). Improving access to maternal health care is thus a critical problem that should be attributed to decentralisation. According to the WHO (2018) research, a woman’s risk of dying or being handicapped during pregnancy and childbirth is significantly related to her social and economic status.

Seabright (2018) examines the implications of decentralization on access to public services. Using a survey of local agencies, this study discovered that both local and central service providers in Bolivia were falling short in terms of providing an adequate quantity and quality of services, but local agencies were more successful in being accessible to citizens, particularly for the poorer demographics. Because decentralization is still a work in progress (in this nation and others), improved results in access to services for the poor may be a precursor to future improvements in ultimate outcomes such as newborn mortality rates, as the poor are the most susceptible. However, this is only the beginning of determining the consequences of decentralization on public services (WHO, 2018).

Scott-Herridge (2016) investigated whether decentralization delivered good governance and better services in Uganda, and the findings show that decentralization requires raising knowledge about the importance of maternal health through sex education and civic education. Decentralization is recognized with informing grassroots communities about the availability of free maternal health care through district, county, subcounty, and village health representatives, as well as powerful government officials. Women may be drawn into the advocacy arena by potential and present advocates of maternal health supplies, professional associations, and other practicing health care providers who are exposed to the issues of maternal health care on a daily basis. Those with community power, such as religious leaders, political leaders, and cultural leaders, can help (World Bank, 2018).

Kisakye (2015) According to her research on Health systems determinants impacting maternal health service delivery, there is still a significant gap between the implementation of health care programs and the delivery of services itself. She attributes this to a lack of suitable resources to enable successful policy guidelines distribution at lower levels, as well as the restricted capability of health facilities closest to communities. It is important to highlight that, despite the implementation of decentralisation policies in service delivery and its related contributions to the enhancement of maternal health service quality, consumers are nonetheless dissatisfied since they are frequently sent to private clinics to obtain medications. The above literature demonstrates that researchers have made great efforts to study the link between political decentralization. For instance, all the studies were based outside Uganda. These gaps make it imperative for this study to be carried out in Uganda to seek to establish the relationship between political decentralization and quality of maternal health services in Uganda specifically in Sheema district.

METHODOLOGY

The cross-sectional and correlational research designs were used in the investigation. A cross-sectional study design, according to Sekara (2003), is one in which data is gathered just once over a period of days, weeks, or months in an effort to address a research issue. The cross-sectional design made it possible to gather data using a variety of methods, including face-to-face interviews and self-administered questionnaires (Lavrakas 2008). However, because the research was cross-sectional, the data collected reflected what was happening at a specific point in time, enabling the collection of valuable data in a relatively short amount of time and at a lower cost (Moule& Goodman 2009). Regarding the correlational design, this involves investigating the relationship between the effectiveness of the decentralization strategy and the standard of maternal health (Ingham-Broomfield, 2014). By correlating the independent and dependent variables, statistical inferences were made using quantitative data as the foundation. By giving specific information in the form of remarks from interviews for in-depth examination, qualitative data complemented quantitative data. The study conducted an in-depth investigation and statistical conclusions using both the quantitative and qualitative methodologies (Bernard 2012).

Sample Size and Sampling Technique

The sampling techniques used to select the respondents were simple random and purposive sampling. The simple random offers detailed information on all or most elements in the population involving all the total of a small population. This allowed the use of a questionnaire to collect information (Lavrakas, 2008). Simple random method was used to select the Maternal health users/beneficiaries because although a small population, they were sufficient for providing questionnaire survey data necessary for generalisation of the findings. With purposive sampling, this was used to select particular people to provide in-depth views since the study was both quantitative and qualitative. The method of purposive sampling used was intensity purposive sampling. Intensity sampling allows the researcher to select a small number of rich cases that provide in depth information and knowledge of a phenomenon of interest (Palinkas et al., 2015). As shown in table 1 below.

Table 1: Sample size

Category	Target Population	Selected Population  (Sample Size)	Sampling Technique
Maternal health users/beneficiaries	436	178	Simple Random Sampling
VHTs	88	36	Simple Random Sampling
DHO	01	01	Purposive Sampling
Municipality/ Town council Health Center in charges	02	02	Purposive Sampling
CAO	1	01	Purposive sampling
Mid wives	42	17	Simple Random Sampling
Total	570	235

Data Analysis

Quantitatively when data was obtained, there was Coding, Statistical Package for Social Sciences (SPSS) 24.0 computer entry, frequency table summarization to identify problems, and editing to fix errors were all steps in the processing of quantitative data (Greasley 2007). Calculating descriptive statistics and frequencies for descriptive analysis was part of quantitative data analysis. The testing of the hypothesis included correlation analysis using Pearsons Linear Correlation Coefficience and regression analysis for inferential statistics (Simpson, 2015). This generated the data required for the findings to be generalized. Quantitatively, Discursive and thematic methodologies were used to conduct the analysis (Kohlbacher 2006). The discursive approach took into account textual specifics when interpreting the material under analysis and assigning meaning. Thematic analysis, on the other hand, made sure that groups of text with comparable meanings were displayed together (Attride-Stirling 2001). Quantitative data were complemented by qualitative data, which assisted in elucidating the findings.

RESULTS AND DISCUSSION

Response Rate

At first, the researcher had 235 respondents from whom to gather data. However, 215 respondents provided complete data, which was gathered. There were 215 replies altogether (91.5% of those that were surveyed and interviewed). This response rate was enough since, according to Mellahi and Harris (2016), humanities studies only need a response rate of 50% or above. A questionnaire was used to get quantitative data from 212 respondents, and an interviewing guide was used to gather qualitative data from 3 respondents. The response rate was as presented in Table 2

Response rate

	Frequency	Percentage
Response	215	91.5%
Non response	20	8.5%
Total	235	100%

Source: Field Findings 2023

Political Decentralization and Quality of Maternal Health Services

Political decentralisation which is the first aspect of decentralisation policy implementation was studied using seven items. The results on the same were as presented in Table 3 below

Table 3 Descriptive statistics on Political decentralization

	F/%	SA	A	N	D	SD	Mean
The central government has given authority to local government to manage health sector	F	134	60	–	11	7	4.03
	%	63.3	28.3	–	5	3.3
The local government makes decision on how to manage health sector	F	124	70	–	7	11	3.87
	%	58.3	33.3	–	3.3	5
The central government gives guidelines to local government on how to implement maternal health programme	F	21	35	–	110	46	2.07
	%	10	16.7	–	51.9	21.7
The local governments are concerned on the performance of health centers in relation to provision of maternal health services	F	81	60	7	42	21	3.96
	%	38.3	28.3	3.3	20	10
There is good coordination between central government and local governments in implementing maternal health programme	F	42	35	6	20	60	3.66
	%	20	16.7	1.7	33.3	28.3
The local government gives feedback on the performance of health centers in relation to provision of maternal health services	F	120	56	–	14	21	4.02
	%	56.7	26.7	–	6.7	10
Political leaders interfere in the implementation of maternal health programmes	F	109	64	7	18	14	4.12
	%	51.7	30	3.3	8.3	6.7

 Source: Primary Data 2023

The findings in Table 3 regarding whether the central government has granted local governments authority to manage the health sector revealed that, overall, the majority of respondents (91.6%) said the central government has granted local governments authority to manage the health sector, while 8.4% said this was untrue. The results showed that respondents believed it was true that local governments had been granted authority by the federal government to handle the health sector, with a high mean of 4.03, which is near to code 4, on the scale being utilized. The respondents agreed that the local government takes decisions on how to administer the health sector since the majority (91.6%) agreed, 8.4% disagreed, and only 1.7% were indifferent. The high mean = 3.87 verified the results. Furthermore, the majority (73.6%) of respondents disagreed with the low mean = 2.07 that the central government provides guidance to local governments on how to administer the maternal health program. The finding indicated that the local governments are concerned on the performance of health centers in relation to provision of maternal health services because the majority percentage (66.6%) agreed and this was supported by the high mean= 3.87. With a high percentage (76.9%) of the respondents agreeing and a high mean = 3.66, that there is good coordination between central government and local governments in implementing maternal health programme. Furthermore, the respondents indicated that the local government gives feedback on the performance of health centers in relation to provision of maternal health services because majority percentage (83.4%) and the mean = 4.03 was high. However, with the larger percentage (60.3%) of the respondents disagreeing that political leaders interfere in the implementation of maternal health programmes with lower mean = 2.01, the results suggested that it was not true that political leaders interfere in the implementation of maternal health programmes.

To find out how overall how respondents rated political decentralisation, summary statistics were calculated for the items measuring political decentralisation. The results were as shown in Table 3

Table 4:  Summary of Descriptive Statistics on political decentralization

	Descriptive		Statistics	Std. Error
Political decentralisation	Mean		3.86	0.05
	95% Confidence	Lower Bound	3.52
	Interval for Mean	Upper Bound	3.94
	5% Trimmed Mean		3.89
	Median		3.91
	Variance		0.61
	Std. Deviation		0.79
	Minimum		1.00
	Maximum		5.00
	Range		3.88
	Interquartile Range		1.00
	Skewness		-0.87	0.24
	Kurtosis		0.46	0.40

 Source: Primary Data, 2023

According to Table 4 findings, the median value of 3.91 was not far from the mean value of 3.86. Therefore, the outcomes were normally distributed even though the skew was negative (skew -0.87). Due to the high mean, respondents found political decentralization to be satisfactory (high). Low response dispersion was suggested by the low standard deviation of 0.79. Area leaders were questioned about their thoughts on whether political decentralization has aided in enhancing the standard of maternal health in the Sheema district. The district leaders provided various relevant comments in their responses, indicating that political decentralization has helped over time to improve the standard of maternal health in Sheema district. One leader said;

“In the past years, leaders in communities of Sheema district showed low commitment and willingness to work towards improving the quality of maternal health. However, since the introduction of decentralization especially political decentralization there has been improvement. This has not been because of lack of avenues to make them get involved in decision making, but sensitization about the importance   and benefits of getting involved in the improving the quality of maternal health has been ongoing” (Sheema, May 2022). Another leader said;

“Although the enthusiasm for leaders in Sheema district is still low, there has been improvement. This can be seen in the increasing numbers of leaders getting involved improving the quality of maternal health. Even though the number are still low, once in a while we get some people joining the campaign of improving the quality of maternal health services” (Sheema, May 2022)

The opinions above from the respondents suggest that leaders love to improve the quality of maternal health had improved. This finding is consistent with the results of the descriptive statistics which showed that political decentralization has helped in improving the quality of maternal health for people of Sheema district were improving although it has not yet reached the required level.

Correlation of political decentralization and quality of maternal health services

To establish whether political decentralization was related to quality of maternal health services, the researcher carried out correlation analysis. The results were as given in Table 5.

Table 5 Correlation Matrix for political decentralization and quality of maternal health services

	quality of maternal health services,	Political decentralisation
quality of maternal health services,	1	0.89** 0.000
Political decentralisation		1

Source: Primary Data 2023

According to Table 5. Findings, the two aspects of political decentralization (r = 0.89, p = 0.000< 0.05) had a significant relationship with the quality of maternal health services in Sheema district. This indicates that H03 was accepted whereas the null hypotheses (H01&H02) was rejected. This suggests that the adoption of political and financial decentralization had a substantial association with the quality of maternal health care.

Regression Model for political decentralization and quality of maternal health services.

At the confirmatory level, to establish whether political decentralization affect the quality of maternal health services, a regression analysis was carried out. The results were as in Table 5 below

Table 6 Regression Results

	Standardised Coefficients	Significance
Political decentralization	0.464	0.000
R= 0.87, R2= 0.76, adjusted R2= 0.25, F =102.35, p = 0.000

 Source: Primary Data 2023

According to Table 6 findings, political decentralization ( = 0.464, p = 0.000 <0.05) has a positive impact on the standard of maternal health services. This indicates that the hypothesis was disproved was accepted. According to the magnitudes of the corresponding betas, Sheema district’s maternal health services are primarily strongly influenced by political decentralization.

CONCLUSION

Political decentralization significantly influenced quality of maternal health services and this implies that when local governments are given powers and authority to manage their health facilities, there was improvement of quality services

RECOMMENDATION

The researcher recommended that the Government of Uganda implement political decentralization policy in the health sector by granting local government powers and authority to manage and run the health facilities in order to improve the quality of maternal health services. Local councils also need to be empowered to monitor the grass root situation of maternal health service delivery especially in rural areas like Sheema Municipality.

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