Attitudes and perceptions of stakeholders on decentralization of health services in Uganda: the case of Lira and Apac districts

Abstract

Background: In Uganda, the decentralization of administrative functions, management, and responsibility for health care to districts, which began in 1994, resulted in fundamental changes in health care delivery. Since the introduction of the policy in Uganda, little information has been available on stakeholders' perceptions about the benefits of the policy and how decentralization affected health care delivery.

Objectives: To identify the perceptions and beliefs of key stakeholders on the impact and process of decentralization and on the operations of health services in two districts in Uganda, and to report their suggestions to improve future implementation of similar policies.

Design: We used qualitative research methods that included focus group discussions with 90 stakeholders from both study districts.

Setting: The sample population comprised of 12 health workers from the two hospitals, 11 district health administrators, and 67 Local Council Leaders.

Main outcome measures: Perceptions and concerns of stakeholders on the impact of decentralization on district health services.

Results: There was a general consensus that decentralization empowered local administrative and political decision-making. Among stakeholders, the policy was perceived to have created a sense of ownership and responsibility. Major problems that were said to be associated with decentralization included political harassment of civil servants, increased nepotism, inadequate financial resources, and mismanagement of resources.

Conclusions: This study elicited perceptions about critical factors upon which successful implementation of the decentralization policy depended. These included: appreciation of the role of all stakeholders by district politicians; adequate availability and efficient utilization of resources; reasonably developed infrastructure prior to the policy change; appropriate sensitisation and training of those implementing policies; and the good will and active involvement of the local community. In the absence of these factors, implementation of decentralization of services to districts may not immediately make economic and administrative sense.