FISCAL DECENTRALIZATION AND HEALTH SERVICE DELIVERY IN ,

BY NUWAHEREZA SETH 1153-06404-02557

A RESEARCH DISSERTATION SUBMITTED TO THE COLLEGE OF HUMANITIES AND SOCIAL SCIENCES IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF A BACHELOR’S DEGREE OF PUBLIC AI)MINISTRAT1ON OF INTERNATIONAL UNIVERSITY

OCTOBER, 2018 DECLARATION I, NUWAHEREZA SETI-I declare that this research dissertation on the “Fiscal Decentj’aljzatjon and Health Service Delivery in Lyantonde District, Uganda” is my original work and to the hcst of my knowledge, has not been submitted for an~ award at any academic institution.

Student: NUWAHEREZA SETH

Reg. No: 1153-06404-02557

Signed: Date: .~ APPROVAL

This is to confirm that this research dissertation on ~Fiscal Decentralization and Health Service Delivery in Lyantonde District, Uganda” is under my supervision and is now ready for submission to the College of 1-lumanities and Social Sciences of Kampala International University.

Signaturc Date

SUPERVISOR: Ms. Tusiime Rhobinah K

III DEDICATION

I would like to dedicate this piece of work to my dear parents for their endless support both financially and morally during my academic career without forgetting my brothers and sisters For their contributions. May the Almighty God bless you all.

iv ACKNOWLEDGEMENT

I thank the Almighty God for strength and good health which has enabled me to come this way and achieve the long dream of accomplishment of the degree. I acknowledge my supervisor br her great support critical and professional support and guidance throughout my whole research.

TABLE OF CONTENTS

DECLARATION APPROVAL DEDICATION iv ACKNOWLEDGEMENT TABLE OF CONTENTS LISTOFTABLES LIST OF ACRONYMS ABSTRACT Chapter One Introduction I I. Background of the Study I .2 Statement of the problem I .3 General Objective 1.4 Objectives of the Study 3 1.5 Research questions 3 1.6 Scope of the Study 3 1 .6. I Geographical Scope I .6.2 Content Scope 4 1.6.3 T~ime Scope 4 I .7 Significance of the Study 4 I .8 Conceptual Framework S Chapter Two 7 Literature Review 7 2.0 Introduction 7 2.1 Theoretical Review 7 2.2 Contributions of Fiscal Decentralization in Lyantonde District. Uganda 8 2.3 Effect of Fiscal Decentralization on I-lealth Service Delivery in Lyantonde District, Uganda

v~ 2.4 Relationship between Fiscal Decentralization and Health Service Delivery in Lyantonde District, Uganda 12 2.5 Empirical studies 5 Chapter Three I 7 Methodology 17 3.0. Introduction 17 3. I Research Design I 7 3.2 Population 7 3.3 Sample 18 3.4 Sampling procedures 18 3.5 Sources of data 19 3.5.1 Primary Data 3.5.2 Secondary Data to 3.6 Data Collection Instruments 9 3.7 Data analysis 3.8 Ethical Considerations Chapter Four 2 I Data Presentation, Interpretation and Analysis 2 I 4. 0 Introduction 2 I 4. I Description of respondents’ background information 2 I

4. I . I Respondents by Gender 2 I 4. I .2 Respondents by Level of Education 22 4. 1 .3 Respondents by Age 23 4.2 Findings on contributions of Fiscal Decentralization in Lyantonde District 23 4.2. 1 Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency 23 4.3 Findings on effect of fiscal decentralization on health service delivery in Lvantonde Districi 27 4.4Findings on relationship between fiscal decentralization and health service delivery in Lyantonde District, Uganda Chapter Five 36 Findings, Conclusions and Recommendations

vU 5.1 Summary of findings and discussions .~6 5.1 .1 Contributions of Fiscal Decentralization in Lyantonde District .~6 5.1.2 Effect of fiscal decentralization on health service delivery in Lyantonde District. Uganda 38 5.1.3 Relationship between fiscal decentralization and health service delivery in Lyantonde District, Uganda 5.2 Conclusion 41 5.2.1 Contributions of Fiscal Decentralization in Lyantonde District, Uganda 41 5.2.2 Effect of fiscal decentralization on health service delivery in Lyantonde District, Uganda 42 5.2.3 Relationship between fiscal decentralization and health service delivery in Lyantonde District, Uganda 43 5.3 Recommendations 43 5.4 Suggestions for further research 44 REFERENCES APPENDICES 47 Appendix I: Questionnaire $7

VIII LIST OF TABLES

Table 4. 1 : Gender of respondents . 21 Table 4. 2: Level of Education 22 Table 4. 3: Age of respondents 23 Table 4. 4: Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency 24 Table 4. 5: Fiscal decentralization can also ameliorate efficiencies by fostering stronger accountability 25 Table 4. 6: Decentralization gives voters more electoral control over the authorities 26 Table 4. 7: Fiscal decentralization can worsen public service delivery if scale economy is important 27 Table 4. 8: Fiscal decentralisation helps to improve the quality of decisions/decision-making at the top level management in relation to health service delivery 28 Table 4. 9: Fiscal decentralized system delivery facilitates diversification of activities 29 Table 4. 10: Decentralized health service delivery makes decision-making quicker and better.. 30 Table 4. II :Decentralizing health service delivery provides opportunity to learn by doing Table 4. 12: Health status of the people of urban and rural communities in Uganda is poor Table 4. 13: Attention to the state in which the national (public) health system components exist in the local jurisdictions Table 4. 14: Some of the private health care providers operate without registration Table 4. 15: Health care services are inadequate both quantitatively and qualitatively

ix LIST OF ACRONYMS

CBR Crude Birth Rates

CDR Crude Death Rate

GDP Gross Domestic Product

MoH Ministry of Health

NGO Non-Governmental Organization

TBA5 Traditional Birth Attendants

TFR Total Fertility Rate

WB World Bank

x ABSTRACT

The study sought to examine Fiscal Decentralization and Health Service Delivery in Lyantonde District, Uganda. The study objectives were; to establish the contributions of Fiscal Decentralization in Lyantonde District, Uganda, to examine the effect of fiscal decentralization on health service delivery in Lyantonde District, Uganda and to determine the relationship between fiscal decentralization and health service delivery in Lyantonde District. Uganda. This study was used descriptive research design. The purpose of employ this method was to describe the nature of a situation, as it exists at the time of the study and to explore the causes of particular phenomena. The descriptive approach was also quick and more practical. The population of Lyantonde District was 18000 people (Uganda Demographic Survey. 2016). The research population of 130 as a target population representing district development officers. community leaders, peasants and District health officials. The study used Sloven’s formula to determine the sample size of the actual respondents and the sample size is 98 respondents. 1 he researcher used varieties of sampling which included: Purposive and random sampling. Data \\flS collected from primary and secondary sources using questionnaires and interviews. After collecting data. the researcher organized well-answered questionnaire. data was edited and sorted for the next stage. The data was presented in tabular form. pie charts and bar graphs \\ iii frequencies and percentages. It was found out that fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency where by 20 (20.4%) respondents strongly disagreed. The results presented in the table above show that Fiscal decentralization can improve the efficiency of public service delivery throu~h preference matching and allocative efficiency where by 21 (2 1.4%) respondents disagreed. The study concludes that fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency. Local governments possess better access to local preferences and. consequently. have an informational advantage over the central government in deciding which provision of goods and services would best satisfy citizens’ needs. There needs to he more discussion and agreement on the degree of balanced distribution of fiscal resources among different regions. The study recommends that the revenue—sharing formula should be transparent. Furthermore, there is need to create some incentives for the development of own-source revenue at the regional and local level.

xi Chapter One

Introduction

1.1 Background of the Study

In the last quarter of the 9~ Century. countries the world over have attempted to implement decentralization by transferring responsibilities of the state to lower tiers of government. Significantly, most of these lower government administrative units have been established to provide for administrative, fiscal and political aspects under decentralization strategy (World Bank Policy Research Paper, May 2015).

In Africa, the issue of decentralization has been hotly debated in Nigeria for the past decade.

Following the collapse of the military dictatorship in I 991 . few Somalis open lv advocate for the return to a centralized authoritarian state that monopolizes power in Mogadishu. For many Nigerians, some form of decentralization is necessary (Akin, Hutchinson & Strump[ 2001).

In Uganda, rural development structures gradually moved from local authorities to more legitimate and representative structures after 1995 constitution, and resulted in a rural development law at the end of 2001 and while elections of councilors and mayors were held in 16 districts in 2002 (Asfaw, Frohberg, James &Juting, 2004). Of these elected district councils. 14 were reportedly changed their executive committee, the Mayor, Deputy Mayor and Executive Secretary more than once over the last 5 years. Progress in decentralizing administrative functions has been slow and little achievement has been made with regards to Fiscal Decentralization. Sources of local revenue include land registration and annual property fees, store licensing fees, livestock taxes and customs taxes at ports (Oates, 2001).

Just like in most developing countries, in Uganda. Fiscal Decentralization has been embraced in order to improve on the rural development in terms of improved literacy and levels of employment, etc (Banting, 2002). This is because it has been termed as any act in which a central government formally cedes powers to actors and institutions at lower levels in a political administrative and territorial Ii ierarchy.

1 In Lyantonde District, Fiscal Decentralization is concerned with distributing services in rural areas such as education, health services and infrastructural development to people in the lower administrative units. This has significantly improved on the social wellbeing of the people in the District. The top authorities of Lyantonde District have embraced Fiscal Decentralization as a tool to deliver services to the people quickly especially in rural areas hence boosting rural development (Oates, 2001).

Through decentralizing revenue raising and/or expenditure of moneys to a lower level of government while maintaining financial responsibility, Lyantonde District Council has managed to develop its rural areas hence improving on the welfare of the people (Oates. 2001). This has been achieved through user fees, user participation through monetary or labor contributions, expansion of local property or sales taxes, intergovernmental transfers of central government tax monies to local governments through transfer payments or grants, and authorization of municipal borrowing with state government loan guarantees. It was in this regard that the researcher attempted to examine the impact of Fiscal Decentralization on rural development in urban areas particularly in Lyantonde District.

1.2 Statement of the problem

Fiscal Decentralization simply concerns the degree of fiscal autonomy and responsibility gi\en to the local government who sets and collects taxes, which makes expenditures. and how an~: vertical imbalance’ or “horizontal imbalance” is corrected (Mahal, 2000). Currently. although a great deal of development has taken place in Lyantonde District Councilin different spheres of life including Health Service Delivery. However, the district still lags behind in terms of Health Service Delivery especially in Lyantonde District. For instance.most District health centres lacks modern equipments which has significantly affected the delivery of health services to the people (Oates. 2001).

The failure of the local government authorities to effectively and efficiently render better health services in the rural areas has led to the question on whether the decentralization policy can redeem the country from its development challenges and lead it to the attainment of MDGs by 201 5 through infrastructure development or not? It is based on this state of affairs that this study attempts to unearth the implementation process of decentralization policy in relation to Health

2 Service Delivery in Lyantonde District, Uganda with an aim to suggest possible solutions to the underlying local development challenges.

13 General Objective

The general objective of the study was to examine the Eflècts of Fiscal Decentralization on Health Service Delivery in Lyantonde District, Uganda.

1.4 Objectives of the Study

The Specific objectives of the study were to:

i. To find out the contributions of Fiscal Decentralization in Lyantonde District, Uganda. ii. To examine the effect of Fiscal Decentralization on Health Service Delivery in Lyantonde District, Uganda. iii. To determine the relationship between Fiscal Decentralization and Health Service Delivery in Lyantonde District, Uganda.

1.5 Research questions

i. What are the contributions of Fiscal Decentralization in Lyantonde District, Uganda? ii. What are the effect of Fiscal Decentralization on Health Service Delivery in Lyantonde District, Uganda? iii. What is the relationship between Fiscal Decentralization and Health Service Delivery in Lyantonde District, Uganda?

1.6 Scope of the Study

1.6.1 Geographical Scope

The study was carried out in Lyantonde District. The area was located in Lyantonde District in central region of Uganda. It was the main municipal, administrative and commercial center of Lyantonde District. The district was named after the town. Lyantonde District covers a total area of 1,680 square kilometers with a population of 540,939 people (Population and Housing census

3 Analytical Report). it was composed of Lyantonde Municipal council. This geographical scope was studied because of its proximity to the researcher.

1.6.2 Content Scope

The study focused on the contributions of Fiscal Decentralization in Lyantonde District. Uganda. effect of Fiscal Decentralization on Health Service Delivery in Lyantonde District, Uganda and relationship between Fiscal Decentralization and Health Service Delivery in Lyantonde District. Uganda.

1.63 Time Scope

It focused on the period 2000 — 2017, as during this period several reforms and studies have taken place in respect of fiscal decentralization and health service delivery.

1.7 Significance of the Study

The following are the anticipated beneficiaries and ways through which the parties will benefit:

This research finding will enlighten the Ministry of Local Government as it provides ihe challenges faced by the local government in the implementation of decentralization in the area. This will therefore enable them to review the existing policy as regards to its implementation in various districts in Uganda.

The study findings will also be beneficial to Local Government Administrators. Since the recommendations forwarded in this study will enable them to try to focus on the challenges they are facing in the implementation of the policy and address them so that the implementation process can be effectively and strategically done to the benefit ofthe communities they serve.

The study findings will also help the Community Based Organizations. Civil Society as well as NGO bodies operating in the district to provide adequate interventions in the areas of accountability and transparency such that community members can begin to realize the benefits that come along with decentralization.

4 The research findings in the case of Lyantonde District in Uganda will also provide new to the existing literature in the area of decentralization. This will help future researchers in carrying out their researcher as they may use the findings in this study as literature.

The research will be of great significance to the researcher, as it will enable him to acquire more skills in research methodology and data analysis.

1.8 Conceptual Framework

The conceptual framework diagrammatically shows the relationship between the different variab!es in the study. The independent variable was perceived as the decentralization and dependent variable was Health Service Delivery

Independent variable Dependent Variable

Fiscal Decentralization Health Service I)eI iverv

• Effectiveness in health service Expenditure assignment delivery Revenue assignment • Transparency levels • Intergovernmental o Health Service satisfaction trans fers • Access to health services

Source: Researcher (201 8)

Intervening variable

• Government policy/ i nte rye fl t lOll

The conceptual frame work shows that the independent variable in this study was Fiscal Decentralization which was conceptualized as Expenditure assignment. Revenue assignment and

5 Intergovernmental transfers whereas the dependent variable is Health Service Delivery which concerns; effectiveness in Health Service Delivery, transparency levels, health Service satisfaction and access to health services and the intervening variable is government policy! intervention.

6 Chapter Two

Literature Review

2.0 Introduction

This chapter deals with discussions drawn from the subject matter of decentralization and its relation to health service delivery. It begins with a review of the existing literature from books relevant to the study.

2.1 Theoretical Review

The study was based on the Local development theory. The theory was developed by Romer P in 1987. The local development theory is a relatively young theory in social sciences based on the identification and use of the resources and endogenous potentialities of a community, neighbourhood, city, municipality or equivalent (Rondinelli & Nellis, 2000). The local development theory considers the endogenous potentialities of territories. Economic and non economic factors influence local development processes. Among the non-economic factors. social, cultural, historical, institutional, and geographical aspects can be decisive in the process of local economic development

In the year 2000 a multidisciplinary team of social scientists from several European countries argued, in a joint article published in Sociologia Ruralis (2000). that rural development basically was practiced without theory (Ploeg et al, 2000) . Since then, rural development processes in Europe have gained considerable momentum and resulted in a dazzling array of new practices characterized by new dynamics and unanticipated impacts. Nevertheless, in 2006 the OECD again referred to the need for “a new research agenda in rural development” (2006: 19). implying that the nature, dynamics and heterogeneity of rural development processes, as they unfold in practice, were inadequately expressed in new theoretical frameworics. At the same time. rural development policies have continued to develop at supra-national, national, regional and local levels and, in the social sciences there have been some major shifts (away from earlier and. in retrospect, too limited and inflexible, models) that allow for a better understanding of a rapidly changing world. The theory can usefully be drawn together to study rural change and the best

7 ways to achieve desired objectives. Additionally, the specialist expertise of natural and biological scientists, engineers, as well as education and health professionals are clearly essential in dealine with the challenges of rural development.

Local Development Theory emphasizes the need to promote desirable change which requires good co-ordination between the various actors involved in rural development (farmers. rural residents, government organisations, NGOs and other civil society organisations, donors, rural development professionals, researchers, private firms and businesses etc) (Ploeg et al. 2000).

2.2 Contributions of Fiscal Decentralization in Lyantonde District, Uganda

Fiscal decentraization can improve the efficiency of public service delivery through preference matching and allocative efficiency. Local governments possess better access to local preferences and, consequently, have an informational advantage over the central government in deciding which provision of goods and services would best satisfy citizens’ needs (flack. 1945: Tiehout. 1956; Musgrave, 1969). When provided by the jurisdiction that has the control over the minimum geographic area, costs and benefits of public services are fully internalized, which is expected to improve allocative efficiency (Oates, 1972).

Fiscal Decentralization can also ameliorate efficiencies by fostering stronger accountability. Geographical closeness of public institutions to the local population (final beneficiaries) fosters accountability and can improve public service outcomes, particularly in social sectors such as education and health (Ahmad. Brosio. and Tanzi, 2008: Cantarero and Pacual Sanchez. 2006). Local accountability is expected to put pressure on local authorities to continuously search for ways to produce and deliver better public service under limited resources. leading to “productive effeciency.” Accountability can foster larger spending in public investment and in gro~~ th enhancing sectors, such as education and health (Keen and Marchand. I 997; Arze del Granado and others, 2005; Bénassy-Quere and others. 2007: Kappeler and Valila. 2008: Fredrikscn. 2013). Local accountability can be strengthened through a direct election of local authorities by the local population.

Furthermore. Fiscal Decentralization can improve efficiency through the “voting with one’s feet” hypothesis. Decentralization gives voters more electoral control over the authorities (Seabright.

8 1996; Persson and Tabellini, 2000; Hindriks and Lockwood, 2005). It encourages competition across local governments to improve public services; voters can use the performance of neighboring governments to make inferences about the competence or benevolence ol their o’~ n local politicians (Bordignon and others, 2004). Fiscal Decentralization may lead to a decrease in lobbying by interest groups, distorting policy choices and increasing waste of public funds.

However, Fiscal Decentralization can worsen public service delivery if scale economy is important. Devolution of public service delivery to a small-scale local government can decrease efficiency and increase costs if economies of scale are important in the process of production and provision of some specific public goods. For instance, shifting the production and provision of public services to a municipality with a small size of government officials (producers and providers) and a small population (beneficiaries) can reduce efficiency.

Fiscal Decentralization can also hinder public service delivery if accountability is loose. If accountability is not broadly anchored in a local democratic process. but instead is based on rent- seeking political behavior, local governments would be tempted to allocate higher decentrali,cd expenditure to non-productive expenditure items (such as wages and goods and services instead of capital expenditure). This can hinder efficiency, economic growth, and overall macroeconomic performance (Davoodi and Zou. 1998; Woller and Phillips. 1998: Zhang and Zou, 199$; Rodriguez-Pose and others. 2009; Gonzalez Alegre, 2010: Grisorio and Prota. 2() II

Through local financial self-sufficiency and marketization, Fiscal Decentralization plays a very significant role in the promotion of standards of living (Dolores .Jiménez I. Peter C, Smith. 2005). The rural standards of living is more sensitive to the decentralization and marketization of local finance, the expenditure of science; education. culture and public health also has a very significant positive correlation with the standards of living expenditure. It is suggested to periCct the matching mechanism of between rights and responsibilities of fiscal expenditure. improving the local financial self—sufficiency, transforming government functions, and promoting marketization level.

Fiscal Decentralization can also obstruct the redistribution role of the central government. To guarantee a minimum level of public service and basic needs (or standard of living) for the entire population (regardless of their geographical location). the central government often carries out

9 equalization transfers, which would be disrupted in cases of insufficient leverage on resources (Ter-Minassian, 1997). When a large share of revenue and expenditure is shifted to local governments, the central government does not possess sufficient resources to ensure a minimum equity across the entire territory.

Since the Indonesia reform 1998, there has been a significant increase in indigenous- population importance in Indonesian societies, especially in the eastern part of Indonesia. which has generated slightly better employment conditions and gains in political po~~er For these groups. Such changes have yielded favorable effects on their standard of living and political incorporation. At the same time, however, the said positive effects are not homogenous across regions and sectors of the economy. While many native Papuans are able to obtain better jobs tin the private and public sectors) due to changes in labor market participation. many still suffer chronic unemployment and job turnover: high labor market segmentation keeps man\ members of the indigenous community working in informal labor markets (Suebu. 2007)

More than 8O% of Papuan households are still living in the poverty line, even some of them are in the category of absolute poverty’ (Suebu. 2007). This study chose the Papua province as the research object is based on several reasons. i.e., firstly, the disintegration threat as the result of long territorial—ownership dispute betvveen Indonesia and Netherland for more than 18 years (1945-1963) has made the Papua’s economic development is politically limited. Secondl. it is the deep—economic inequality between Papua. as one of the biggest financially contributors to the central government, and other regions in Indonesia.

Improving the standard of living is the main aim of the market economy. I Io~\ experience sho\\ s that to solve social problems at the local level, is much more effective than at the state level. This demands carrying out Fiscal Decentralization, the consequence of which is the transFor and delegation of spending powers, the creation of the financial base of local and regional self government, the development of solutions to local problems. It is precisely because part of the economic reforms, Fiscal Decentralization serves in Ukraine. Under the financial decentralization should be understood not only the transfer of flnancial resources. It also invol~ es the transfer of powers in the financial sector (expenditure. revenue, tax). The local budget of Ukraine in 201 6 are deficient in because the expanded powers and means to implement them are

10 absent. Therefore many social programs are threatened (financing and maintenance of vocational schools, the solution of environmental problems. and others.).

Suebu, (2007) proposed non-standard sources of funding local budgets taking into account the potential of the region. As these sources is considered issue of local securities, provision of sob loans, subventions. For this it proposed the establishment of a regional investment hank. ~xhich can raise funds, including foreign investors. Proposed calculation of the regional budget revenues per resident, which allows estimating as an opportunity in the social development of the region and the need for subventions improve production efficiency

2.3 Effect of Fiscal Decentralization on Health Service Delivery in Lyantonde District, Uganda

Akin .1. (2001) argues that fiscal decentral isation helps to improve the quality of decisions/decision—making at the top level management in relation to Health Service Delivery. Decentralisation of authority among other executives at all levels in the district relieves the top executive of the excessive burden saving his valuable time. which he can devote to more important and long—term problems. This is hound to improve the quality of his decisions regarding such problems and this helps to boost developmental projects ~ ithin the district and hence leading to increased Gross Domestic Product (GDP) thus better Health Service Delivery.

According to Asfaw A, (2004), fiscal decentralized system delivery facilitates diversification of activities, it is a matter of common experience that a district with departmentation on the basis of activities and operations. Administrators of semi-autonomous product divisions are able to utihze their skills and experienced judgment and thus such policy creates self—sufficient units under overall co-ordination of top level management and hence increased productivity with in the district. This also further increases the Gross Domestic Product thus socio economic development.

Banting K, Corbett S (2002) note that fiscal decentralisation also encourages development of managerial personnel. This provides wide exposure to personnel or administrators and hence that gives an opportunity to grow and to have self-development and thus the more talented and capable persons learn and improve and qualify themselves for higher managerial positions within

11 the district and thus improves on the performance thus contributes to better Health Service Delivery. This is because a decentralized system of administration also allows its personnel adequate freedom to try new ideas, methods or techniques and thus increases of levels of employment and thus achievement of better Health Service Delivery.

According to Dolores Jimënezl. (2005), decentralized system of administration also impro\ es motivation. Research conducted by social scientists has proved that the organizational structure itself exercises some influence on the motivation of the people working within it. An Organisation structure which facilitates delegation. communication and participation also provides greater motivation to its managers for higher productivity and thus leads to better Health Service Delivery.

Khalegh ian. p (2003) stresses that decentralized Health Service Deli very makes decision-making quicker and better. Since decisions do not have to be referred up through the hierarchy, quicker and better decisions at lower levels can be taken. Divisional heads are motivated to make such decisions that will create the maximum prolt because they are held responsible lbr the efk~ct of their decisions on profits. Thus decentralisation facilitates quick and result—oriented decisions b~ concerned persons and thus also helps the administrators to boost the literacy levels through making progressive educational programmes \\ thin the locality.

Mahal A, (2000) suggests that decentralizingHealth Service Delivery provides opportunity to learn by doing. Decentralisation provides a positive climate where there is freedom to make decisions, freedom to use judgment and freedom to act. It gives practical training to middle level managers and facilitates management development at the enterprise level.

2.4 Relationship between Fiscal Decentralization and health Service Delivery in Lyantonde District, Uganda

Whereas. in viex~ of the power and authority wielded h~ government to make decisions and establish law and order in society, the MoH (2003) acknowledges the central role of government as: best placed to undertake and play certain roles in the broad political economy, as well as in the individual social service sectors, including health care. These roles are never static, as they shift in accordance with changes in political. economic and

12 social situations. The need to re-examine the traditional roles of government is not unique to Uganda. Many other countries have recently begun to re-define the roles of government in health.

The World Bank Development Report (World Bank, 1997) has a comprehensive analysis on the changing roles of government, not j list in health issues, but in other sectors as well. The report emphasizes the need for government to focus its attention on the provision of public

goods, protection of the pool’ and in regulating the private sector. Yet Lip to—date. decentralized health care service provision units in some areas in Uganda have only one health care service structure that has not been completed; it is situated at the headquarters and the working conditions have not improved since the l960s despite the relative peace prevailing and implementation of decentralization policies that started in 1993 in a few districts.

The district health situational analysis in the MoH-l-JSSP (2003) reveals that the health status of the people of urban and rural communities in Ugandaa is poor. Poverty, illiteracy (mainly of females (68.2%) are rampant. High ièrtility with Crude Birth Rates (CBR) of 5.6% and a Total Fertility Rate (TFR) of 6.62% respectively. Corresponding with this, a low contracepti\ c prevalence rate of 4.7% are associated with high morbidity and mortality rates. A national average for Crude Death Rate (CDR) is 20.8 per 1000, while life expectancy at birth is 50 years for females and 44 for males. These population indicators place Uganda among the poorest nations of the world, with a sign iticant need for quality health provision.

The critical view of the MoH—HSSP (2003) draws attention to the state in which the national (public) health system components exist in the local jurisdictions. Of concern are the principles guiding and driving health care provision in practice; how health care is practiced in a decentralized mode helps communities respond to health needs. The “Community as Client” model earlier presented advances the ability of health systems, communities and individuals to effectively respond to health needs through the application of primary health care principles.

Private providers are on their own and. save certiflcation for operating private practice unils. have virtually no link to the urban local government or NGO services particularly in monitoring their performance. Some of the private health care providers operate without registration. Traditional healers are not formally recognized as important actors in health care provision. By

13 now there is a change as the MoH through the districts have provided some training to the traditional birth attendants (TBAs) and traditional healers on safety measures (UNFPA. Uganda 1995). Also the MoH provided delivery kits to the trained TBAs.

Health care services are inadequate both quantitatively and qualitatively. QuantitativeI~ there is only one health unit in the local jurisdictions, giving a health unit to population ratio of 13,674. which is far greater than the national average of I I .953 (M0H. 2000).

The Health Facilities Inventory (2000) indicates that the population within 5km (I hour walking distance) from one health unit in the A\\dal region is only 33% compared to the national a\erage of 49%. Even the health centre ratio of 2,352 persons per centre is too high compared to the national average of 760 persons.

In its analysis of one the smaller municipalities of Uganda UNICEF(2003) revealed that accessibility and use of safe and adequate water coverage in Awdal Region by district has an estimated improvement over the 1993 status of 25% and a 53% increase in decentralized health service provision units. About 85% on average are I 1 meters or more away from the house in

which people live. The common problems reported h\ locals to the NICFE study team k~r tot constructing latrines at all are: hard rock, lack of digging tools and lack of cover materials, all of which have a direct implication on the poverty status of the local communities in the A~~dal Region.

A comparative study of the experiences of Zambia and Uganda ~ ith l)ecentrali,at ion of he I Iealth sector (Jeppsson and Okuonzi 2000) describes the structural and governance reforms in Uganda’s health services and provides an assessment of its performance. The study—\vhich used a range of data sources, including a study tour to Zambia, extensive document revie\\, interviews with key informants in the healthcare system. and many years of flrst-hand experience by the authors with the sector—found that prior to the I 990s. Uganda had a highly centralized healthcare system with considerable differences in health services standards between urban and rural areas (Jeppsson and Okuonzi 2000). After decentralization. the central government. through the MinistrY of Health (MOH). is responsible lhr resource allocation and hospitals. I lo\\e\ er. it has devolved much of the i’esponsibility of operating the Io\\er health units. such as health centers and dispensaries, to lower levels of local government under the Ministry of Local

14 Government. Health facilities run by faith-based organizations, which constitute 40 percent of the country’s healthcare facilities, offer better services than non-faith-based facilities (Jeppsson and Okuonzi 2000).

2.5 Empirical studies

According to Banting (2002), decentralization is the process of redistributing or dispersing functions, powers. people or things away from a central location or authority. While centralization, especially in the governmental sphere, is widely studied and practiced, there is no common definition or understanding of decentralization. The meaning of decentralization may vary in part because of the different ways it is applied. fvlahal (2000) defines Fiscal Decentralization as a form of decentralization where local governments and private organizations are tQ carry out decentralized functions effectively, they must have an adequate level of revenues —either raised locally or transferred from the central government— as well as the authority to make decisions about expenditures. Fiscal Decentralization can take many forms, including self—financing or cost recovery through user charges. co—financing or co—production arrangements through which the users participate in providing services and infrastructure through monetary or labor contributions: expansion ol local revenues through property or sales taxes, or indirect charges; intergovernmental transfers that shift general revenues fi’om taxes collected by the central government to local governments br general or speci tic uses; and authorization of municipal borrowing and the mobilization of either national or local government resources through loan guarantees. In many developing couniries local governments or administrative units possess the legal authority to impose taxes. but the tax base is so weak and the dependence on central government subsidies so ingrained that no attempt is made to exercise that authority.

Fiscal Decentralization is also defined by Robert chambers (2008) as the public finance dimension of intergovernmental relations. It specifically addresses the reform of the system of expenditure functions and revenue source transfers from the central to local governments. It is a key element of any decentralization programme. Without appropriate fiscal empo~~ erment. ihe

15 autonomy of local governments cannot be substantiated and, in this way. the full potential of decentralization cannot be realized.

According Oate (2001), rural development is the process of improving the quality of life and economic well-being of people living in relatively isolated and sparsely populated areas. Rural development has traditionally centered on the exploitation of land-intensive natural resources such as agriculture and forestry. However, changes in global production networks and increased urbanization have changed the character of rural areas. Increasingly tourism, niche manufacturers, and recreation have replaced resource extraction and agriculture as dominant economic drivers. The need for rural communities to approach development from a wider perspective has created more focus on a broad range of development goals rather than merely creating incentive for agricultural or resource based businesses.

According to Khaleghian (2003) rural development is a process that aims at improving the standard of living of the people living in the rural areas. Rural development may be defined as overall development of rural areas to improve the quality of life of rural people. It is an integrated process, which includes social, economical, political and spiritual development of the poorer sections of the society

According to Akin, Hutchinson & Strumpf (2001), rural development can be defined as. helping rural people set the priorities in their own communities through effective and democratic bodies. by providing the local capacity; investment in basic infrastructure and social services, justice. equity and security, dealing with the injustices of the past and ensuring safety and security of the rural population, especially that of women.

According to Robert chambers (2008). rural development is a strategy to enable a specific group of people, poor rural women and men, to gain for themselves, and their children more of what they want and need. It involves helping the poorest among those who seek a livelihood in the rural areas to demand and control more of the benefits of rural development. The group md tides small scale farmers, tenants and the landless.

16 Chapter Three

Methodology

3.0. Introduction

This chapter deals with practical procedures that were used for carrying out the study and how data was collected and analyzed. It portrays an explicit description of the research design, the survey procedure, sampling design. sampling procedure. sample size, data collection methods and instruments that were used by the researcher.

3.1 Research Design

This study used descriptive research design. The purpose of employ this method was to describe the nature of a situation, as it exists at the time of the study and to explore the causes of particular phenomena (Creswell, 1994). The descriptive approach is also quick and more practical. Moreover, this method allowed for a flexible approach, thus, when important new issue and questions arise during the duration of the study, further investigation may be allowed. The study opted to use this kind of research considering the goal of the study to obtain 1~rst hand data so as to formulate rational and sound conclusion and recommendations for this study.

The quantitative pattern was used in that it utilized techniques and measurement that generated numerical or quantifiable data and statistical tools utilized for analyze (Mugenda and Mugenda. 2003), on the qualitative part the study employed in order to obtain in-depth point of view of the respondents (Amin, 2005), According to Sanders, Lewis (2003), the design enabled the researcher to carry out in—depth investigation in to the subject matter.

3.2 Population

The population of Lyantonde District is 18000 people (Uganda Demographic Survey, 2016). The research population was 130 as a target population representing district development officers (5). community leaders (12), peasants (105) and District health officials (8).

17 3.3 Sample

The study used Sloven’s formula to determine the sample size of the actual respondents. Sloven~s

formula states: n = N 1+N(z)2

Where; n = sample size; N = target population; and x = 0.05 level of significance

130 n = 1 + 130(0.05)2

130 n — ~ + 130(0.0025)

130 n — 1 + 0.325

n = 98 respondents

Table 1: Showing Research Population

Type of population Population Sample Sample Procedure Target Size

District development officials 5 3 Purposive sampling -~ Community leaders 12 9 Random sampling Local peasants 105 78 Random sampling District health officials 8 8 Purposive sampling Total 130 98

3.4 Sampling procedures

The researcher used both purposive sampling and simple random sampling. The purposive sampling was used to select district development officials and District health officials. Simple random sampling was used to select community leaders, peasants. This was intended to give each one of them equal opportunity to participate in the study. The researcher also used random sampling method. The Community leaders, Local peasants and District health officials were randomly selected

18 to give each an equal chance of representation. All respondents were assumed to have vital information on the subject matter of the research. Respondents who were willing to participate i~ere approached. The study used both primary and secondary sources of data. The Primary data collected using questionnaires and interview guide. The secondary data include reviewed annual reports of the ministry of education Uganda annual Government reports. journals, dissertations, newspapers. text. books and internet materials.

3.5 Sources of data

3.5.1 Primary Data

The researcher used both primary and secondary data. Primary data ~as collected through direct interactions ~sith the respondents in one form or through personal intervie~is as ~sell as observation.

3.5.2 Secondary Data

Secondary data was obtained from various publications of the central and Local Governments. technical and trade journals, books, magazines and newspapers. published records and statistics. historical documents and other sources of pul~lished information.

3.6 Data Collection Instruments

Questionnaire

A Semi-Structured questionnaire was used in the stud> and targeted all respondents. Mugenda and Mugenda (2005) states that questionnaires are used to obtain vital information about the population and ensure a wide coverage of the population in a short time. In addition Sekaran (2003) states that questionnaires are an efficient data collection mechanisms where the researcher knows exactly what is required and how to measure the variables of interest. He further asserts that administering questionnaires to number of interest simultaneously is less expensive and time consuming and does not require much skill tq administer as compared to conducting interviews.

Closed ended question was used with detailed guiding instructions as regards the manner in which respondents were required to fill them independently with minimal supervision. I his

1.9 made it possible due to the fict that majority of the respondents are able to read and write and in instances where the respondents were illiterate, a research assist trained by the researcher was used to translate questionnaire into the local language and fill them according to the responses provided by the respondents. Closed ended questionnaire had pre-coded answers according to themes from which respondents were asked to choose the appropriate responses. Respondents was given sample time to fill and return questionnaires later when they are through.

3.7 Data analysis

The raw data that was collected from the field, scrutinized, and analyzed by editing, coding and employing descriptive statistics in order to give more meaning to the data. The data was edited in order to screen the relevant data from the raw data that would carry meaning to the study. During this process, the researcher translated the data into numerical figures to add meaning and easy understanding of the data. The results then were presented in form of percentages. frequency tables and graphs for easy comprehension and later deductions were made from the analyses.

3.8 Ethical Considerations

To ensure ethical considerations in undertaking the study and the safety, social and psychological well-being of the respondents involved in the study, the researcher got an introductory letter from the College of Humanities and Social Sciences, Kampala International University. On the other hand to ensure the safety of the person and/or community involved in the study the researcher would get their consent of the respondents before they fill in the questionnaires. The study would also ensure the privacy and confidentiality of the information provided by the respondent which was solely used for academic purposes.

20 Chapter Four

Data Presentation, Interpretation and Analysis

4. 0 Introduction

This chapter dealt with the presentation and analysis of the major findings from the research instruments that were used for collecting the data with specific emphasis on the speci 1k objectives of the study.

4.1 Description of respondents’ background information

The section focused on the aspects of gender, age. marital status and level of education filled on the questionnaire.

4.1.1 Respondents by Gender

Respondents were asked to indicate their gender. This sought to ensure proportionate representation in the study by both the male and female respondents. Data collected is presented in Table 4.1 below

Table 4. 1 : Gender of respondents

Response Frequency Percent Male 73 74.5 Female 25 25.5 Total 98 100.0 Source: Primary Data (2018)

According to Table 4.1. males whose frequency is 73 secured 74.5% and the lèmale respondenis whose frequency is 25 secured 25.5%. This concludes that the number of males were higher than that of females. This shows that there is gender discrimination in the study area, 25 (25.5%) were females. This implies that majority of the respondents were male since men are believed to he more hardworking and capable of ensuring better health service delivery with regard to fiscal decentralization.

21 4.1.2 Respondents by Level of Education

Respondents were asked to indicate their education level. This was aimed at enabling the researcher to describe the level of education of the respondents which could also affect health service delivery in fiscal decentralization. In this study. age was 22ategorized into: Primary. Secondary. certificate. diploma, degree and Master~s Degree.

‘fable 4. 2: Level of Education

Response Frequency Percent Primary school 12 12.2 Secondary school 13 13.3 Certificate 10 10.2 Diploma 17 17.3 Degree 37 37.8 Masters Degree 9 9.2 Total 98 100.() Source: Primary data (201 8)

According to Table 4.2. the education level ol respondents ~~as as fol lo\\ s: prima~ school respondents who frequency is 12 scored 1 2.2%. secondary school respondents ~ ho frequency is 13 scored 13.3%, certificate respondents who frequency is 10 scored 10.2%. diploma respondents whose fi~equency is 1 7 secured 1 7.3%, degree whose frequency is 37 scored 37.8% and masters respondents whose frequency is 9 scored 9.2%. This further concludes that most of respondents were relatively highly educated and thus had better understanding of the role of fiscal decentralization on health service delivery.

22 4.1.3 Respondents by Age

Respondents were asked to indicate their ages. In this study, age of respondents was categorized as follows; 20-35, 3649, and 50 and above.

Table 4.3: Age of respondents

Response Frequency Percent 20-35 years 16 16.3 36-49 years 37 37.8 50 years and Above 45 45.9 Total 98 100.0 Source: Primary data (2018)

Table 4.3 shows respondents whose responses were as follows; those who where 20-3 5 years had a frequency of 16 and scored 16.3%, those who were 3649 years had a frequency of 37 and scored 37.8%, those who were 50 years and above had a frequency of 45 and scored 45.9%. This shows that most respondents were old aged and thus showing that most of the respondents 45.9% were highly experienced personnel in matters regarding fiscal decentralization and health service delivery.

42 Findings on contributions of Fiscal Decentralization in Lyantonde District

42.1 FIscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency

This sought to examine how Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency. Based on a five-point Likert Scale (Strongly Disagree, Disagree, neither agreed or disagree, Agree and Strongly Agree), respondents were presented with a number of items to measure that extent.

23 ‘[able 4. 4: Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency

Response Frequency Percent Strongly Disagree 20 20.4 Disagree 21 21.4 Neutral 39 39.8 A~xree 9 9.2 Strongly Agree 9 9.2 Total 98 100.0 Source: Primary data (2018)

Table 4.4 shows respondents whose responses are as follows: those who strongly disagreed had a frequency of 20 and scored 20.4%, disagreed had a frequency of2l and scored 2 1.4%, those who were neutral had a frequency of 39 scored 39.8%, agreed had a frequency of 9 and scored 9.2% and those who strongly agreed had a frequency of 9 and scored 9.2 too. The results presented in the table above show that Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency where by 21 (21 .4%) respondents disagreed. The table 4.4 shows that Fiscal decentralization can improve the efliciency of public service delivery through preference matching and allocative efficiency whereby 39 (39.8%) were respondents neutral about the statement. The findings indicated in the table above show that Fiscal decentralization can improve the efficiency of public service delivery through preleretice matching and allocative efficiency where by 9 (9.2%) respondents agreed. The results shown in the table 4.4 above reveal that Fiscal decentralization can improve the efficiency of public service delivery through preference matclTing and allocative efficiency whereby 9 (9.29/o) respondents strongly agreed. This shows that the majority of the respondents 39.8°/b were not sure whether Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency. This further shows that a lot needs to he done to sensitize the public about such issues.

24 Table 4. 5: Fiscal decentralization can also ameliorate efficiencies by fostering stronger accountability

Response Frequency Percent Strongly Disagree 41 4L8 Disagree 30 30.6 Neutral 12 12.2 Agree 8 8.2 Strongly Agree 7 7.1 Total 98 100.0 Source: Primary data (201 8)

Table 4.5 shows respondents whose responses are as follows~ those who strongly disagreed had a frequency of 41 and scored 41 .8 %, disagreed had a frequency of 30 and scored 30.6%, those who were neutral had a frequency of 12 scored 12.2%. agreed had a frequency of 8 and scored 8.2% and those who strongly agreed had a frequency of 7 and scored 7. 1% regarding the statement that Fiscal decentralization can also ameliorate efficiencies by fostering stronger accountability whereby 30 (30.6%) of the respondents disagreed. It was also indicated that Fiscal decentralization can also ameliorate efficiencies by Ibstering stronger accountability where by 2 (12.2%) the respondents were neutral. According to the results shown in the table above, Fiscal decentralization can also ameliorate efficiencies by fostering stronger accountability whereby 8(8.2%) of the respondents agreed with the statement. The table 4.5 shows that Fiscal decentralization can also ameliorate efficiencies by Ibstering stronger accountability. v~hercb\ 7 (7.1%) respondents strongly agreed. This implies that most of the respondents were not a~~are that political parties make policies on national security and other issues.

25 ‘Fable 4. 6: Decentralization gives voters more electoral control over the authorities

Response Frequency Percent Strongly Disagree 7 7.1 Disagree 4 4.1 Neutral 63 64.3 Agree 16 16.3 Strongly Agree 8 8.2 Total 98 100.0 Source primary data (201 8)

It was revealed in the table 4.6 above that respondents whose responses are as tbllows~ those who strongly disagreed had a frequency of 7 and scored 7. I %, disagreed had a frequency of 4 and scored 4. 1%, those who were neutral had a frequency of 63 scored 64.3%, agreed had a frequency of 16 and scored 16.3% and those who strongly agreed had a frequency of 8 and scored 8.2% regarding the statement that decentralization gives voters more electoral control over the authorities 63(64.3%) of the respondents were neutral. The study results presented in the table above show that Decentralization gives votelEs more electoral control over the authorities whereby 16 (16.3%) of the respondents agreed. According to the table above, it was discovered that decentralization gives voters more electoral control over the authorities whereby 8(8.2%) respondents strongly agreed. The study findings revealed that most of the respondents were not sure that Decentralization gives voters more electoral control over the authorities.

26 Table 4. 7: Fiscal decentralization can worsen public service delivery if scale economy is important

Response Frequency Percent Strongly Disagree 12 12.2 Disagree 21 21.4 Neutral 43 43.9 Agree 14 14.3 Strongly Agree 8 8.2 Total 98 100.0

Source: Primary Data (2018)

The research study of findings in table 4.7 show that respondents whose responses are as follows; those who strongly disagreed had a frequency of 12 and scored 12.2%, disagreed had a

frequency of 21 and scored 2 1.4%, those who were neutral had a tlequency o143 scored 43.9%. agreed had a frequency of 14 and scored 14.3% and those who strongly agreed had a frequency

of 8 and scored 8.2% regarding the statement that fiscal decentralization can worsen public service delivery if scale economy is important. This implies that the majority of the respondents were not aware about the above mentioned statement hence this illustrates that a lot still needs to be done to improve health service delivery.

4.3 Findings on effect of fiscal decentralization on health service delivery in LyantOn(le District, Uganda

This sought to examine how effect of fiscal decentralization on health service delivery in Lyantonde District, Uganda. Based on a five-point Likert Scale (Strongly Disagree. Disagree. neither agreed or disagree, Agree and Strongly Agree), respondents were presented with a number of items to measure that extent.

27 4. 8: Fiscal decentralisation helps to improve the quality of decisions/decision-making at the top level management in relation to health service delivery

Response Frequency Percent Strongly Disagree 23 23.5 Disagree 46 46.9 Neutral 10 10.2 Agree 10 10.2 Strongly Agree 9 9.2 Total 98 100.0 Source: Primary data (201 8)

The table 4.8 shows that 23 (23.5%) respondents strongly disagreed. The research findings presented in the table above show that Fiscal decentralisation helps to impro\ e the qualit\ a! decisions/decision—making at the top level management in relation to health service delivery whereby 46(46.9%) the respondents disagreed. According to the results presented in the table above, Fiscal decentralisation helps to improve the quality of decisions/decision-making at the top level management in relation to health service deliver\ ~~hereb~ I 0(10.2 0 o) \\ere respondents were neutral. It was indicated in the table above that Fiscal decentralisation helps to improve the quality of decisions/decision—making at the top level management in relation to health service delivery whereby 10 (10.2%) were respondents agreed. The findings above show that the Fiscal decentralisation helps to improve the quality of decisions/decision-making at the top level management in relation to health service deliver\ whereby 9 (9.2%) respondents strongly agreed. This implies that most respondents noted that fiscal decentralization helps to improve the quality of decisions/decision—making at the top level management

28 Table 4. 9: Fiscal decentralized system delivery facilitates diversification of activities

Response Frequency Percent ~ongIy Disagree 12

~ ,- ~ Disagree 64 N~tral 8 Agree 8 8.2 ~ongly Agree 6 Total 98 100.0 Source: Primary data (2018)

According to the study findings shown in table 4.9, Fiscal decentralized system delivery facilitates diversification oF activities whereby 12 (12,2%) respondents strongly disagreed. The results presented in the table above showed that Fiscal decentralized system delivery facilitates diversification of activities whereby 64 (65.3%) were respondents disagreed. Findings shown in the above table reveal that Fiscal decentralized system delivery facilitates diversiFication ol’ activities whereby 8(8.2%) respondent were neutral and 8(8.2%) the respondents were agreed. Results illustrated in the table above show that Fiscal decentralized system delivery Facilitates diversification of activities whereby 6(6.1%) respondents strongly agreed. This farther implies that most of the respondents generally disagreed with this statement since they were ignorant about how fiscal decentralized system delivery facilitates diversification of activities

29 Table 4.10: DecentralIzed health service delivery makes decision-making quicker and better

Response Frequency Percent Strongly Disagree 8 8.2 Disagree 6 6.1 Neutral 23 23.5 Agree 55 56.1 Strongly Agree 6 6.1 Total 98 100.0 Source: Primary data (2018)

1’he table 4.10 above that general public is made aware of their voting rights whereby 8(8.2%) of the respondents strongly disagreed. It was revealed in the table above that Decentralized health service delivery makes decision-making quicker and better whereby 6(6.1%) the respondents disagreed. According to the table above. Decentralized health service delivery makes decision- making quicker and better whereby the 23(23.5%) of them respondents ~sere neutral. The stud> findings showed that Decentralized health service delivery makes decision-making quicker and better whereby 55(56.1%) were respondents agreed. As the study revealed that Decentralized health service delivery makes decision-making quicker and better whereby the remaining 6(6.1%) the respondents strongly agreed. This shows that the majorit> of the respondents ~cre aware of decentralizing health services helps in making quicker decisions and thus impro~cd health services

30 Table 4. 11:DecentraliZiflg health service delivery provides opportunity to learn b~ doing

The study findings revealed that decentralizing health service delivery provides opportunity to learn by doing 17(17.3%) respondents strongly disagreed. It was also indicated in the above table that Decentralizing health service delivery provides opportunity to learn by doing 53 (54. respondents disagreed. The table above shows that Decentralizing health service delivery provides opportunity to learn by doing 9(9.2%) of the respondents were neutral. The table Ondings above illustrate that Decentralizing health service delivery provides opportunity to learn by doing 9(9.2%) respondents agreed. The results presented in the table above sho\\ that Decentralizing health service delivery provides opportunity to learn by doing 10 (I 0.2%) respondents strongly agreed.

31 4.4Plndings on relationship between fiscal decentralization and health service delivery in Lyantonde District, Uganda

Table 4.12: Health status of the people of urban and rural communities In Uganda is poor

Response Frequency Percent Strongly Disagree 13 13.3 Disagree 14 14.3 Neutral 45 45.9 Agree 9 9.2

Strongly Agree 17 — —— 17.3 100.0

Source primary data (2018)

The results presented in the above table. Health status of the people of urban and rural communities in Uganda is poor whereby 13(13.3%) respondents strongly disagreed. The above table shows that Health status of the people of urban and rural communities in Uganda is poor ~~hereby 14(14.3%) were respondents disagreed. It was showed in the table above that political parties in more than one way unite, simplify and stabilized the political process of the country whereby 45(45.9%) were respondents ~~ere neutral. According to the table above. Ilealth status of the people of urban and rural communities in Uganda is poor whereby 9(9.2%) respondents agreed. The results presented in the above table show that Health status of the people of urban and rural communities in Uganda is poor whereby 17(17.3%) respondents strongly agreed. This implies that most of the respondents were not aware that health status of the people of urban and rural communities in Uganda is poor

32 Table 4. 13: Attention to the state in which the national (public) health system components exist in the Local jurisdictions

Response Frequency Percent Strongly Disagree 6 6. I Disagree Neutral 70 71.4 AL~ree 7 7.1 Strongly Agree 7 7.1 Total 98 lOOM Source primary data (2018)

According to the study flndings in table 4. 13. attention to the state in ~ Inch the national (pubIc) health system components exist in the local jurisdictions 6(6.1%) respondents strongly disagreed. The results presented in the above table show that Attention to the state in which the national (public) health system components exist in the local jurisdictions whereby 8(8.2%) of the respondents disagreed. The table above illustrates that Attention to the state in which the national (public) health system components exist in the local jurisdictions whereby 70(71 .4%) of the respondents were neutral. The study findings illustrated in the above table show that Attention to the state in which the national (public) health system components exist in the local jurisdictions whereby 7(7.1%) were of the respondents agreed. The table sho\\ ed above revealed that Attention to the state in which the national (public) health system components exist in the local jurisdictions whereby 7(7.1%) respondents strongly agreed. This implies that the majority of the respondents were ignorant about state in which the national (public) health system components exist in the local jurisdictions

33 Table 4. 14: Some of the private health care providers operate without registration

Response Frequency Percent

Strongly Disagree 9 9.2 Disagree 35 35.7 Neutral 35 35.7 Agree 9 9.2 Strongly Agree 10 10.2 Total 98 100.0 Source: Primary data (2018)

The study findings presented in the table 4.14 above show that some of the private health care providers operate without registration whereb) 9(9.2%) respondents strongly disagreed. 1 he table above shows that some of the pri~ ate health care pros iders operate isithout registration ~ihereby 35(35.7%) of the respondents disagreed. The results presented in the above table sho~~ that some of the private health care providers operate without registration whereby 35(35.7%) of respondents were neutral. It was also revealed that some of the private health care providers operate without registration whereby 9(9.2%) respondents agreed. The table above also further shows that some of the private health care providers operate without registration whereby 10(10.2%) respondents strongly agreed. This implies that most of the respondents in this stud> were generally not sure whether some of the private health care providers operate without registration

34 TabLe 4. 15: health care services are inadequate both quantitatively and qualitatively

Response Frequency Percent Strongly Disagree 6 6. 1 ,, 1-~ Ii.., Disagree 61Li 62.2 Neutral —To- 10.2 Agree 8 8.2 Strongly Agree 98 io~o~:o~ Total

Source primary data (2018)

The stud) findings illustrated in the table above show that Health care services are inadequate both quantitatively and qualitatively whereby 6(6.1%) respondents strongly disagreed. It ~as further noted that Health care services are inadequate both quantitatively and qualitatively whereb) 13(1 3.3%) were respondents disagreed. ~I he table above re~ ealed that I lealth care services are inadequate both quantitatively and qualitatively where by 61(62.2%) of the respondents were neutral. It was also shown in the table above that Health care services are inadequate both quantitatively and qualitatively whereby 10(10.2%) of the respondents agreed. According to the table above, Health care ser~ ices are inadequate both quanhitati\ el\ and qualitatively whereby 8(8.2%) respondents strongly agreed.

35 Chapter Five

Discussion of Findings, Conclusions and Recommendations

In this last chapter of the thesis, a summary of findings is provided, conclusions are drawn and recommendations made based on the findings of the study. The section begins with a summary ofthe findings of this study.

5.1 Discussion of findings

5.1.1 Contributions of Fiscal Decentralization in Lyantonde District

it was Ibund out that fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency where by 20(20.4%) respondents strongly disagreed. The results presented in the table above show that Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency where by 21 (21.4%) respondents disagreed. The table 4.4 shows that Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency whereby 39 (39.8%) were respondents neutral about the statement. The findings indicated in the table above show that Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency where by 9(9.2%) respondents agreed. The results shown in the table 4.4 above reveal that Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency whereby 9 (9.2%) respondents strongly agreed. This shows that the majority of the respondents were not sure whether Fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency. This further shows thai a lot needs to be done to sensitize the public about such issues. This is in line with Hayek (2011) who noted that fiscal decentraization can improve the efficiency of public service delivery through preference matching and allocative efficiency. Local governments possess better access to local preferences and, consequently. have an informational advantage over the central government in deciding which provision of goods and services would best satisfy citizens’ needs. When provided by the jurisdiction that has the control over the minimum geographic area. costs

36 and benefits of public services are full> internalized. which is expected to improve allocathe efficiency.

It was also revealed that Decentralization gives voters more electoral control over the authorities whereby 7(7.1%) respondents strongly disagreed. The table 4.6 indicates that Decentralization gives voters more electoral control over the authorities whereby 4(4.1%) of the respondents disagreed. The findings showed in the table above reveal that Decentralization gives voters more electoral control over the authorities 63(64.3%) of the respondents were neutral. The study results presented in the table above show that Decentralization gives voters more electoral control over the authorities whereby 16 (16.3%) of the respondents agreed. According to the table above, it was discovered that Decentralization gives voters more electoral control over the authorities whereby 8(8.2%) respondents strongly agreed. The study findings revealed that most of the respondents were not sure that Decentralization gives voters more electoral control over the authorities. This is in line with Lock” ood. (2005) “ho noted that fiscal l)ecentralitation can improve efficiency through the sbvoting with on&s feet’ hypothesis. Decentralization gives voters more electoral control over the authorities. It encourages competition across local governments to improve public services; voters can use the performance of neighboring governments to make inferences about the competence or benevolence of their o~~n local politicians. Fiscal Decentralization may lead to a decrease in lobbying by interest groups. distorting policy choices and increasing waste of public funds.

The research study of findings revealed that Fiscal decentralization can ~~orsen public sen delivery if scale economy is important whereby 12(122%) respondents strongly disagreed. The results presented in the table above shows that the Fiscal decentralization can worsen public service deliver> if scale econom> is important where 21 (2 1.4%) respondents disagreed. According to the table above, the Fiscal decentralization can worsen public service deliver) if scale economy is important whereby 43 (43.9%) were respondents neutral. The table shows that the Fiscal decentralization can worsen public service delivery if scale economy is important whereby 14 (14.3%) were respondents agreed. It was also revealed in the table above that the Fiscal decentralization can worsen public service delivery if scale economy is important whereby 8(82%) respondents strongly agreed. This implies that the majority of the respondents were ‘lot aware about the above mentioned statement hence this illustrates that a lot still needs to be done

37 to improve health service delivery. This is in line with Prota, (2011) who noted that Fiscal Decentralization can worsen public service delivery if scale economy is important. Devolution ni public service delivery to a small-scale local government can decrease efficiency and increase costs if economies of scale are important in the process of production and provision of some specific public goods. For instance, shifting the production and provision of public services to a municipality with a small size of government officials (producers and providers~ and a small population (beneficiaries) can reduce efficiency.

5.1 .2 Effect of fiscal decentralization on health service delivery in Lyantonde District, Uganda

It was found out that Fiscal decentralisation helps to improve the quality of decisions/decision- making at the top level management in relation to health service delivery where by 23 (23.5%) respondents strongly disagreed. The research findings presented in the table above show that Fiscal decentralisation helps to improve the quality of decisions/decision-making at the top level management in relation to health service delivery whereby 46(46.9%) the respondents disagrecd. According to the results presented in the table above. Fiscal decentralisation helps to improve the quality of decisions/decision-making at the top level management in relation to health service delivery whereby 10(10.2 %) were respondents were neutral. It was indicated in the table above that Fiscal decentralisation helps to improve the quality of decisions/decision-making at the top level management in relation to health service delivery whereby 10 (10.2%) were respondents agreed. The findings above show that the Fiscal decentralisation helps to improve the quality of decisions/decision—making at the top level management in relation to health service delivery whereby 9 (9.2%) respondents strongly agreed. This implies that most respondents noted that fiscal decentralization helps to improve the quality of decisions/decision-making at the top level management. This is in line with Akin J. (2001) who argued that fiscal decentralisation helps to improve the quality of decisions/decision—making at the top level management in relation to Health Service Deliver. Decentralisation of authority among other executives at all evels in he district relieves the top executive of the excessive burden saving his valuable time, which he can devote to more important and long-term problems. This is bound to improve the quality of his decisions regarding such problems and this helps to boost developmental projects within the

38 district and hence leading to increased Gross Domestic Product (GDP) thus better Health Service Delivery.

It was discovered that fiscal decentralized system delivery facilitates diversification of acti\ ities wherebyl2 (12.2%) respondents strongly disagreed. The results presented in the table above showed that Fiscal decentralized system delivery facilitates diversification of activities whereby 64 (65.3%) were respondents disagreed. Findings shown in the above table reveal that Fiscal decentralized system delivery facilitates diversification of activities whereby 8(8.2%) respondent \\ere neutral and 8(8.2%) the respondents were agreed. Results illustrated in the table above show that Fiscal decentralized system delivery facilitates diversification of activities whereby 6(6.1%) respondents strongly agreed. This further implies that most of the respondents generally disagreed with this statement since they were ignorant about how fiscal decentralized system delivery facilitates diversification of activities. This is in line with Asfaw A, (2004) who notcd that fiscal decentralized system delivery facilitates diversification of activities. It is a matter of common experience that a district with departmentation on the basis of activities and operations. Administrators of semi-autonomous product divisions are able to utilize their skills and experienced judgment and thus such policy creates self-sufficient units under overall co ordination of top level management and hence increased productivity with in the district. This also further increases the Gross Domestic Product thus socio economic development.

It was lbund out that general public is made a\\arc ol’ their oting rights hereby 8(8.2%) o~ l~ respondents strongly disagreed. It was revealed in the table above that Decentralized health service delivery makes decision-making quicker and better whereby 6(6.1%) the respondents disagreed. According to the table above, Decentralized health service delivery makes decision- making quicker and better whereby the 23(23.5%) oF them respondents ~~erc neutral, The sluJ\ findings showed that Decentralized health service delivery makes decision-making quicker and better whereby 55(56. 1%) were respondents agreed. As the study revealed that Decentralized health set~vice delivery makes decision—making quicker and better whereby the remaining

6(6. 1%) the respondents strongly agreed. This shows that the majority of the respondentc \\ crc a~~are of decentralizing health services helps in making quicker decisions and thus impro\ ed health services

39 5.1.3 Relationship between fiscal decentralization and health service delivery in Lyantonde District, Uganda

It was also revealed that health status of the people of urban and rural communities in Uganda is poor whereby 13(13.3%) respondents strongly disagreed. The above table shows that Health status of the people of urban and rural communities in Uganda is poor whereby 14(14.3%) ~sere respondents disagreed. It was showed in the table above that political parties in more than one way unite, simpli~ and stabilized the political process of the country whereby 45(45.9%) were respondents were neutral. According to the table above. Health status of the people of urban and rural communities in Uganda is poor ~~hereby 9(9.2%) respondents agreed. I he results presented in the above table show that Health status of the people of urban and rural communities in Uganda is poor whereby 17(17.3%) respondents strongly agreed. This implies that most of the respondents were not aware that health status of the people of urban and rural communities in Uganda is poor. This is in line with the Molt (2003) ~~ho ackno’~ ledges the central role ni government as: best placed to undertake and play certain roles in the broad political economy, as well as in the individual social service sectors. including health care. These roles are never static. as they shift in accordance with changes in political, economic and social situations. The need to re-examine the traditional roles of government is not unique to Uganda. Many other countries have recently begun to re-define the roles of government in health.

The study found out that attention to the state in which the national (public) health system components exist in the local jurisdictions 6(6.1%) respondents strongly disagreed. The results presented in the above table show that Attention to the state in which the national (public) health system components exist in the local jurisdictions whereby 8(82%) of the respondents disagreed. The table above illustrates that Attention to the state in which the national (public) health system components exist in the local jurisdictions whereby 70(71.4%) of the respondents ~sere neutral. The study findings illustrated in the above table show that Attention to the state in which the national (public) health system components exist in the local jurisdictions whereby 7(7.1%) t~ere of the respondents agreed. The table sho~ed above revealed that Attention to the state in which

the national (public) health system components exist in the local jurisdictions whereby Ri. I” n) respondents strongly agreed. This implies that the majority of the respondents were ignorant

40 about state in which the national (public) health system components exist in the local jurisdictions. This is in line with MoH-HSSP (2003) who drew attention to the state in which the national (public) health system components exist in the local jurisdictions. Of concern are the principles guiding and driving health care provision in practice; how health care is practiced in a decentralized mode helps communities respond to health needs. The “Community as Client” model earlier presented advances the ability of health systems, communities and individuals to effectively respond to health needs through the application of primary health care principles.

The study findings indicated that some of the private health care providers operate without registration whereby 9(9.2%) respondents strongly disagreed. The table above shows thai some of the private health care providers operate without registration whereby 35(35.7%) of the respondents disagreed. The results presented in the above table show that some of the private health care providers operate without registration whereby 35(35.7%) of respondents were neutral. It was also revealed that some of the private health care providers operate without registration whereby 9(9.2%) respondents agreed. The table above also further shows that some of the private health care providers operate without registration whereby l0(l0.2%) respondents strongly agreed. This implies that most of the respondents in this study were generally not sure whether some of the private health care providers operate without registration. This is in line with UNFPA (1995) who noted that private providers are on their own and, save certification lbr operating private practice units, have virtually no link to the urban local government or NGO services particularly in monitoring their performance. Some of the private health care providers operate without registration. Traditional healers are not formally recognized as important actors in health care provision. By now there is a change as the MoH through the districts have provided some training to the traditional birth attendants (TBAs) and traditional healers on safety measures.

52 Conclusion

52.1 Contributions of Fiscal Decentralization in Lyantonde District, Uganda

The study concludes that fiscal decentralization can improve the efficiency of public service delivery through preference matching and allocative efficiency. Local governments possess

41. better access to local preferences and, consequently, have an informational advantage over the central government in deciding which provision of goods and services would best satisfy citizens’ needs

Fiscal decentralization can alsb ameliorate efficiencies by fostering stronger accountabilit>. Geographical closeness of public institutionS to the local population (final beneficiaries) fosters accountability and can improve public service outcomes, particularly in social sectors such as education and health

The study concludes that fiscal decentralization can improve efficiency through the “voting v~ ith one’s feet” hypothesis. Decentralization gives voters more electoral control over the authorities. It encourages competition across local governments to improve public services: voters can use the performance of neighboring governments to make inferences about the competence er benevolence of their own local politicians.

5.2.2 Effect of fiscal decentralization on health service delivery in Lyantonde District, Uganda

The study concludes that fiscal decentralisation helps to improve the quality of decisions/decision-making at the top level management in relation to health service delivery. Decentralisation of authority among other executives at all levels in the district relieves the top executive of the excessive burden sos log his saluable time. ~ hich lie can de\ etc to mire i ~ portant and long—term problems.

Fiscal decentralized system delivery facilitates diversification of activities. It is a matter of common experience that a district with departmentation on the basis of activities and operations. Administrators of semi—autonomous product divisions are able to utilize their skills and experienced judgment and thus such policy creates self—sufficient units under overall co— ordination of top level management and hence increased productivity with in the district

The study also concludes that fiscal decentralisation also encourages development of managerial personnel. This provides wide exposure to personnel or administrators and hence that gives an opportunity to grow and to have self-development and thus the more talented and capable

42 persons learn and improve and qualify themselves for higher managerial positions within the district and thus improves on the performance thus contributes to better health service delivery.

53.3 RelationshIp between fiscal decentralization and health service delivery in Lyantonde District, Uganda

The study concludes that in view of the power and authority wielded by government to make decisions and establish law and order in society, the central role of government as: best placed to undertake and play certain roles in the broad political economy, as well as in the individual social service sectors, including health care

The study concludes that the district health situational analysis in the MoH-HSSP (2003) reveals that the health status of the people of urban and rural communities in Uganda is poor.

The state in which the national (public) health system components exist in the local jurisdictions. Of concern are the principles guiding and driving health care provision in practice; how health care is practiced in a decentralized mode helps communities respond to health needs.

5.3 Recommendations

The study recommends that there needs to be more discussion and agreement on the degree of balanced distribution of fiscal resources among different regions. Furthermore, what is important is for the national government to provide a steady stream of transfers that local governments can rely on for budget purposes.

The study recommends that the revenue-sharing formula should be transparent. Furthermore, there is need to create some incentives for the development of own-source revenue at the regional and local level.

Local governments should control their own-source revenues sufficient to allow some discretion in matching the needs of citizens and the taxes paid.

It is also recommended that government of Uganda in partnership with its agencies should ensure to build capacity at lower levels of the communities through better intergovernmental transfers

43 5.4 SuggestIons for further research

The following are aspects were not tacked due to limited time. Further, there is need for research on them in order to explore them in detail.

More research needs to be done on the following;

• Administrative decentralization and service delivery in Uganda • Local revenue mobilization and service delivery in Uganda • Economic decentralization and service delivery in Uganda

44 RE1~EKMNCtb

Akin J. Hutchinson P, Strumpf K (2001) “DecentralizatIon and Government Provision of Public Goods: The Public Health Sector in L~ganda”. Carolina Population Center University ofNorth Carolina at Chapel Hill, Working Paper 01-35.

Asfaw A, Frohberg K, James KS. Juting J (2004) “ModellIng the impact of fiscal decentralization on health outcomes: empirical evidence from India”. 7FF Discussion Paper 87, Bonn.

Banting K, Corbett S (2002) “Multi-level Governance and Health Care: Health Policy in Five Federations”, paper presented to the Meetings of the American Political Science Association. Ontario.

Dolores Jiménezl, Peter C. Smith, (2005). Decentralization ofhealth care and its impact on health outcomes; University of York,Heslington. York. YOlO 5DD. United Kingdom.

Khaleghian. P (2003): “Decentralization and Public Sen’ice.s: Thc Case of Immunization”. World Bank Policy Research Working Paper No. 2989. Washington DC.

Mahal A. Srivastava V. Sanan D (2000): “Decentrali:ation and its impact on public service provision on health and education sectors: the case ofIndia” in: Dethier J (Ed.). Governance. Decentralization and Reform in China. India and Russia. Kluwer Academic Publishers and ZEF. London.

Oates. WE (2001): Fiscal Federalism. Ilarcourt L3racc Jovanovich. Nc’~ York.

Rondinelli. D.. and Nellis, J (2000) “Assessing Decentralization Policies: A Case for Cautious Optimism~, Development Policy Review LV, I (1986),

Shah. Anwar and Theresa Thompson. (2004). .‘lniplc’menting Decentralized Local Governance: Treacherous Road it’ith Potholes, Detours and Road Clawres.Policy Research Working Paper 3353. World Bank, Washington, D.C.

45 UNDP (2010) Factors to Gonsider in Designing Decentralized Governance Policies ~,;ul Programmes to Achieve Sustainable People-Centred Development, Management Development and Governance Division, February 1998.

United Nations (2011). Report of the United Nations Global Forum on Innovative Policies and Praclices in Local Governance. Gothenburg. Sweden. 23-27 September 1996

46 APPENDICES

Appendix 1: Questionnaire

Dear Respondent

My name is NUWAHEREZA SETH, 1153-06404-02557, A student of Kampala International University pursuing a “FISCAL DECENTRALIZATION AND HEALTH SERVICE DELIVERY IN LYANTONDE DISTRICT, UGANDA” as a requirement for the award oF bachelor Public Administration. I humbly request you to he one of the participants in this study and your cooperation will be oF great importance to this study. Your answers will he kept ~ ith utmost confidentiality.

SECTION A: BACKGROUND INFORMATION

1. Gender Male Female 2. Marital Status Married Single 3. 1 lighest Educational level Primary Secondary Tertiary University 4. Age. Below 20 Between 20-39 Bet~~een 40-59 60 and above

47 Direction 1: Please write your rating on the space before each option which corresponds to ~ our best choice in terms of level of motivation. Kindly use the scoring system below:

Score Response Mode Description Interpretation 5 Strongly Agree You agree with no doubt at all Very satisfactor) 4 Agree You agree with some doubt Satisfactory

3 Neutral You are not sure about any None 2 Disagree You disagree with some doubt Fair I Strongl) Disagree You disagree ~ ith no doubt at all Poor

PART 2: FISCAL DECENTRALIZATION AND hEALTH SERViCE DELIVERY

2 Contributions of fiscal decen tra liza~on in Lyantonde District L I Fiscal decentralization can iiiipm~ e the ci hclenc\ of public service delivery through preference matching and allocative efficiency -~..,.-----2 l~iscal decentralization can also ameliorate elficiencies by fostering stronger accountability.

-~---- 3 Decentralization gives voters more electoral control over the authori ties — — — Fiscal decentralization can worsen public service delivery if scale economy is important L

Effect of fiscal decentralization on health service delivery in 5 4 3 2 Lyantonde District Fiscal decentralisation helps to improve the quality of decisions/decision-making at the top level management in relation to health service delivery 2 Fiscal decentralized system delivery facilitates diversification of activities ~ - - -~ Decentralized health service delivers makes decision-making quicker

and better J —

48 4 Decentralizing health service delivery provides opportunity to learn — by doing

Relationship between fiscal decentralization and health service 5 4 3 2 Ti delivery in Lyantonde District 1 Health status of the people of urban and rural communities in Uganda is poor 2 Attention to the state in which the national (public) health system components exist in the local jurisdictions

3 ~ -

4 Health care services are inadequate both quantitatively and — qualitatively

Thank you very cooperation End

49 Ggaba Road, Kansanga* P0 BOX 20000 Kampala, Uganda 11 ~ ~ KAMPALA TcL: ~-256 701 665 699 Fax: ±256 (0) 41 501 974 INTERNATIONAL E-mail: adminakiu.ac.ug Website: http://www.kiu.ac.ug ~

COLLEGE OF hUMANITIES AN)) SOCIAL SCIENCES DEPARTMENT OF POLITICAL AND ADMINISTRATIVE STUDIES

August 14. 2018

TO WhOM IT MAY CONCERN Dear Sir/Madam.

RE: INTRODUCTION LETTER FOR NUWAHWREZA SETH REG NO. 1153-O64O4-9~O~cS~(

The above mentioned candidate is a bonafide student of Kampala International University pursuing a Bachelor’s Degree in Public Administration.

He is currently conducting a field research for his dissertation entitled, “Fiscal Decentralization and Health Service delivery in Lyantonde district, Uganda.”

Your organisation has been identified as a valuable source of information pertaining to his Research Project. The purpose of this letter then is to request you to accept and avail him with the pertinent information he may need.

Any data shared with him will be used for academic purposes only and shall be kept with utmost confidentiality.

Any assistance rendered to him will be highly appreciated.

Yours faithfully,

Geral Muzaare HOD, Political and Administrative Studies

“Exploring the Heights”