LOCAL GOVERNMENTS AND SERVICE DELIVERY IN UGANDA: A CASE STUDY OF HEALTH SERVICES IN LIRA DISTRICT

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LOCAL GOVERNMENTS AND SERVICE DELIVERY IN UGANDA: A CASE STUDY
OF HEALTH SERVICES IN LIRA DISTRICT
BY
ALWOCH LYDIA
REG NO: 12/U/3462/EVE
SUPERVISOR: PROF.MURINDWA RUTANGA
A RESEARCH DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE AWARD OF THE DEGREE OF BACHECLOR OF ARTS
IN SOCIAL SCIENCES OF MAKERERE UNIVERSITY
SEPTEMBER 2015

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CHAPTER ONE
1.1 Introduction
The main focus of this study is to explore the performance measure of health service
decentralization in the Local Governments in addressing the needs of the community members,
particularly in the case of Adekokwok sub-county, Lira District, it has stepped to take up the role
of caring for the local community and great enhancement of better health service delivery in Lango
sub-region.
1.2 Background to the Study
The World Bank defines service delivery as the manner in which public officials and public
institutions acquire and exercise authority to provide goods and services, including the delivery of
basic services, infrastructure, and a sound investment climate. According to the Local Government
Management and Service Delivery Program (LGMSD), service delivery encompasses the
activities for which the government provides to the public for the betterment and livelihood of the
public. Local Governments are responsible for providing key public services including health,
education, water, education, and agricultural services. In other words, the locals are the
beneficiaries (Tomkinson, 2007).
Decentralization in Uganda started in 1993/94 with the main objective of building a more
democratic government that is responsible and accountable to the public to promote capacity
building at the local level and introduce local choice into service delivery fostering a sense of the
local ownership. The 1995 Constitution of the Republic of Uganda provided a decentralization
system of governance with the districts on top of the administrative units. This is also governed by
the Local Government Act of 1997. Subsequent constitutional and legal reforms established
districts and sub-counties as key pillars of Local Governments through which effective service
delivery and local governance is to be attained. Schedule 2 of the Local Government Act 1997
gives mandate to Local Governments to take financial decisions and accounting regulations 1998
guide of the financial operations and specifies decentralization policies, rules and regulations.

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In relation to the above, article 176(2) of the Republic of Uganda 1995, schedule 2 of the Local
Government Act (1997) and sections 97 and 98 of Local Governments were to offer services
including and not limited to the education, medical and health services, sporting facilities while
using their local accountability forces which Ms. Cotilda Mbabazi secretary for finance on June
12, 2009 said that they contribute 0.9% funding their budget which helps to achieve services
delivery in Local Government.
According to Advocates Coalition for Development and Environment, ACODE (2010), Uganda
adopted a decentralization policy that sought to establish a system of governance underpinned by
strong Local Governments. Subsequent constitutional and legal reforms established Districts and
sub-counties as key pillars of Local Government through which effective service delivery and local
governance is to be attained. Although decentralization has been pursued over the past two
decades, there is wide spread consensus that the performance of local government is less than
desirable. The quality of service provision is also below the citizens’ expectations with key
services such as health care, water, sanitation, education and agricultural advisory services
remaining dismal yet there is no evidence that the citizens who are the intended beneficiaries of
the decentralized system are demanding better performance from their elected leaders. This is
evidenced by the local government councils’ score card initiative (LGCSCI). Similar challenges
are reported in Uganda media of how service delivery in many parts of the country are in poor
state, for instance, Mbale municipal council failed to provide essential services such as, garbage
collection (Ssalongo,2011).
In Uganda, the delivery of health service is undertaken through a National Health System whose
actions have a primary purpose of delivering and sustaining good health. At national level, the
healthcare delivery system is composed of seven levels ranging from health centers namely; village
health teams (HCI), parish (HCII), sub-county (HCIII), sub-district (HCIV), and district hospitals
(HCV) all managed by district local governments. The central government is directly responsible
for the management of the 13 regional referral hospitals (Citizen Manifesto, 2010). At the top of
the of Uganda’s NHS is the National public referral hospital Mulago (Markle, 2007). This delivery
system comprises of both the public and the private health delivery system (NHP, 2009). The
private health delivery system comprises of Private not-for profit and the for-profit providers called

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Private Health Practitioners. Owing to the need to achieve universal access to millennium health
care packages as well as equitable and sustainable financing mechanisms, government of Uganda
drafted a National Policy on PPPH where government and development partners agreed to provide
funding. The policy provided a framework for linkages of the public and private sectors where
user fees charged by private hospitals/health centers were subsidized by disbursing funds to private
hospital health units on a quarterly basis through the district after accountability for previous funds
released have been accounted for. However, while the structures for coordination are in place at
the central level, they are weak at the district level (NHP, 2010).
According to the Auditor General’s Annual Report (2003/2004), there was rampant malpractices
in the accountability from authorities in Uganda with most of their operations characterized by
non-compliance with policies and procedures, misuse use of resources and funds manipulations,
among other cases. In Mubende district, for insistence, funds were released to NGO health units
without checking the correctness of accountability for the previous releases (NHP, 2006). While
development assistance continues to play a major role in financing the health services, a bigger
proportion of this is off-budget and MOH has information on general budget/project support to the
health sector and not off budget support (MOH, 2010). In financial year 2008/2009, off-budget
funding constituted USD $440 million, while the overall health budget stood at USD $628 million
(MOFPED, 2009). MOH has difficult of tracking donor off budget support to health sector and
there is wide spread discontent among the populace mainly relating to lack of basic facilities like
drugs and equipment (Uganda country profile report, 2009).
Adekokwok Sub County Local Government budget is said to have been dominated by health,
according to Secretary of Finance Ms. Cotilda Mbabazi on June 12, 2009, 95 per cent funding
were expected from government transfers, 4.1 per cent from donors and NGO’s co-sponsor.
However it’s said that poor accountability and transparency are the leading cause of poor health
delivery in Lira district which can be measured by poor quality health service delivery. Although
health services are being provided by Lira District Local Government, Adekokwok sub-county is
also consider an alternative provider of health services to the local community. Consequently, this
study sought to investigate the contribution local government enhance to the delivery of health
services to the local community.

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1.3 Statement of the Problem
Uganda, like many other developing countries embarked on decentralization (constitution of
Uganda, 1995) for a democratic, participatory, decentralized local government system that could
sustain development and deliver health services efficiently to the people. Despite of the policies
being implemented on health service delivery, there is no study that have been put in place to
investigate health service delivery in Local Governments. However, allegations are made that,
there has been insufficient public health service delivery due to poor management, performance
and lack of accountability. Attempts are made by the government to rectify the problem through
the increase in the conditional and unconditional grants that seems to have no impact has many
local government are still performing poorly in health service delivery. Understanding the gap that
are left unfilled by the State in bringing about better health service delivery, thus, this has
necessitated the investigation of health service delivery in Adekokwok Sub-County Local
Government that is sought to enhance performance in health service delivery to the wider
community.
The study sought to investigate on these key research questions; how health services is accessible
to the people of Adekokwok Sub-County? What are the quality of health services delivered by
Adekokwok Sub-County local government to the community members? What are the suggested
ways of improving health service delivery in Adekokwok Sub-County local government?
Therefore, these research questions will form part of the investigation regarding the health service
delivery in Adekokwok Sub-County, Lira District.
1.4 Objective of the Study
General objective
The overall objective of the study is to investigate health service delivery in Local Governments
with a specific focus on Adekokwok sub-county in Lira District.
The study was further guided by the following specific objectives:
1) To examine the accessibility of health services offered by Adekokwok sub-county, Lira District.

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2) To explore the quality of health services delivered by Adekokwok sub-county, Lira District.
3) To analyze ways of improving health service delivery in Adekokwok sub-county, Lira District.
1.5 Scope of the Study
1.5.1 Geographical scope
The research has been specifically conducted in Adekokwok sub-county Lira District. The choice
of Adekokwok sub-county was because of easy access to information, and geographical location
close to the central business district where services are expected to be good.
1.5.2 Content scope
Equally important, in terms of subject scope, the study is to establish the performance of health
service delivery in Adekokwok sub-county, Lira District. Service delivery in terms of accessibility,
quality and how to improve health service provision.
1.5.3 Time scope
Most significantly, the research was carried out in July 2015 to August 2015 while collecting data
from Adekokwok sub-county Local Government, Lira District.
1.6 Significance of the Study
The results of the study was useful to Lira District Local Government in improving the quality of
health services delivered hence attaining the best use of the available resources. This is because
the findings was used as standards for measuring performance of local government that ensure the
desired health service delivery and value for money.

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The study was also useful in the attainment of a university degree since it was submitted in partial
fulfillment of the requirements for the award of Bachelor of Arts in Social Sciences of Makerere
University.
The findings is to help future researchers who may wish to explore health service delivery in Lira
District Local Government or other areas in the country since it’s used as a basis for further
research.
1.7 Conceptual Framework
The study was conceived within a framework that presumes performance of health service delivery
is a function of accessibility and quality of the services offered. This performance could be possible
be improved in various ways. However, there are some factors such as, political interferences,
staffing that can result into the failure of health service delivery in the local government.
Independent variable Intervening variable Dependent variable
Independent variable
C
Figure 1: Conceptual Framework
1.8 Justification of the study
According to Mugenda and Mugenda (1999), justification of the study highlights the reasons for
conducting the study as well as the importance of carrying it out. The most dangerous problem the
health sector faces is the declining role of the state and the changes in donor funding from the
public to the private sector which has led to poor basic health service delivery in the past 20 years.
This prompted the researcher to investigate health service delivery in local governments with a
specific focus on Adekokwok sub-county in Lira District. The research has helped the health policy
-Accessibility
services
-Quality of services
-Ways of improving
services delivery
Health service
delivery
-Political interference
-Staffing

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makers to review their risk policies in order to reduce on the level of health service delivery
challenge.
CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
This section focuses on literature linked to health service delivery in Local Government especially
in Uganda along three major themes, namely; accessibility of health services offered by the Local
Government, quality of health services delivered by the Local Government, and the ways of
improving health service delivery in the local government. Equally important, the literature
available is still scanty, only limited to journals, online Google search and few text books. Several
studies have been there in relation to health service delivery in developing countries, Uganda
inclusive and little has been found out about Local Governments.
2.2 Accessibility of Health Services Offered by the Local Governments
Uganda’s decentralization policy provided for the transfer of powers and functions from the central
Government Ministries and Departments to Local Governments. The mandate is embedded in the
1995 Constitution of the Republic of Uganda. The provision of basic services such as, water and

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sanitation, health care, primary education, feeder roads and agricultural extension services are left
to the Local Governments. The adoption of decentralization policy in 1992, and the associated
subsequent reforms, placed the delivery of primary education, health, rural roads, water and
sanitation, community services, and agriculture extension services, among others, in the hands of
Local Government (GoU, 1993).
Accessibility of health services in the Local Government is a broader issue that doesn’t only refer
to disease and illness but anything which impairs the social functioning of an individual. It
therefore includes physical, social, economic, mental and psychological factors that affect the
individuals social functioning. The 1995 Constitution of Republic of Uganda decentralized service
delivery to Local Governments. The current policy structure within that context proposed the
establishment of a health sub-district as a way of further decentralization of health services within
each district. The health sub-district is aimed at improving access to basic services by the
population by ensuring community involvement in community health care planning and delivery.
However, there is also under utilization of health services in Uganda. This is because some of the
health services are rather inaccessible and those that are accessible are in poor state or unequipped.
In some parts of Uganda, some groups of people still perceive formal health negatively, and
therefore prefer the traditional services. For instance, only 41.1 percent births are attended by
skilled professionals; immunization against measles stands about 68.1 percent, contraceptive
prevalence stands at 64.5 percent (Uganda Demographic and Health Survey, 2006).
The UNHS (2010) indicates that a high proportion of the population still relies on services of
TBAs. In Kampala it is 33.4 percent; Central region; 48.3 percent; Eastern; 72.5 percent; Northern;
87.1 percent and Western; 69.8 percent. Some areas have easy access to health and other support
services while others don’t. For instance, in rural areas 70 percent of the population accesses
improved water sources compared to 90 percent in urban areas. The national average in terms of
geographical access to health care is about 60 percent compared to 99.3 percent access in Kampala.
2.3 Quality of Health Services Delivered by the Local Government
Various experts have defined quality as “fitness for use” “conformance to requirements” “freedom
from variation.” And so on. The American society of quality control defines quality as “the totality

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of features and characteristics of the product or service that bears its ability to satisfy stated or
implied needs.” Whatever definition is used, the central focus should be on meeting the customers’
requirements indeed, and Kotler (1999) observes that there is an intimate connection between
service quality and customer’s satisfaction. He asserts that, the higher levels of quality results,
higher level of customer’s satisfaction. However, customer’s satisfaction is often not fully fulfilled
because of gaps in the delivery of health services.
Brown and Coulter (1983) argued that the past decades there have been two convergent and an
independent mode of analysis in measuring the performance of public health service delivery. The
first mode of analysis involves measuring health service delivery performance characteristics using
data from official archives of public agency. Sometimes called objective measures, these indicators
are used to document such performance criteria as effectiveness, efficiency and equity of policy
inputs, out puts and outcomes. Sometimes closely associated with production model, the objective
performance measurement is arguably the most popular approach used in measuring the
organizational performance of public health sector agency.
Most Local Government in Uganda, strives basically towards quality health service delivery to
illustrate, Sub-Counties provides quality traditional health service with the involvement of the state
in respect of the fundamental or basic human needs, in fact, these traditional health services which
are provide to improve the general welfare of the people. Notwithstanding, high quality provision
of health services are made to specific groups of people who are vulnerable, especially the orphans
and vulnerable children, women, persons with disability, internally displaced people in IDP
Camps, elderly and those with special needs. However, tremendously most Local Governments,
are attempting to deliver quality health services though most parts of the country are still
experiencing poor quality health service delivery especially rural areas.
According to the Uganda Particulars Assessment Process Wakiso District Report (2001), it was
indicated that people are unhappy with the health service provision. The locals are much concerned
about the quality of health service yet most of the poor are scared of inaccessible health services,
the quality of health service delivery for instance are mentioned to the poor, and consultants

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attribute the poor health service delivery to mismanagement of public funds, lack of transparency,
accountability and consultation from the poor people who never get to know of the health services
provided and participate little or not in planning for their funds. Thus from that above discussion,
there’s need for Local Governments to provide enough information concerning quality health
service delivery to the residents.
2.4 Ways of Improving Health Service Delivery in the Local Government
A rapidly changing development management scenario is the context in which NGOs must
function. Notably, these include the adoption of a private sector led growth strategy, a shift to
decentralized modes of governance, and increasing regional disparities in access to development
services. The changes and challenges are inevitably affected by the ongoing conflict, which
imposes not only heavy economic and financial costs, but also social costs on a development
system that is under pressure to perform comprehensively in order to ensure long-term economic,
social and political stability (Institute of Policy Studies, 2001).
In recent years NGOs have come under intense scrutiny by donors, clients, and the countries in
which they work. This scrutiny has fostered a debate regarding the merits of NGOs, specifically
related to their performance, impact, and accountability. Health NGOs have been criticized,
because despite the tremendous amount of money they receive, little is known about their overall
contributions to health.
Health facilities are required to compile financial summaries, on a monthly basis, indicating funds
received and funds spent in the categories of PHC wage, PHC non-wage, PHC development, local
governments, credit lines (medicine), donor projects, and others (to be specified). In the
management of medicines, health facilities are supposed to use stock cards to track the movements
and balance of all medicines in the health unit and the extent of (monthly) stock outs. However, a
problem of incomplete or irregular data was found. Use of data for planning purposes was found
to be low. Most of the health facilities do not complete the sections on medicines stock outs, health
facility management and funds received and used. This problem was largely attributed to low
motivation and under-staffing (Economic Policy Research Centre, 2010).
Applying economic theory to health care is an effort to address the issues of allocating physical,
human and financial resources and setting priorities in the budget decision-making process. The

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first issue, related to the concept of efficiency, is to determine the optimum amount to be allocated
to health care; this depends on the extent of resources to be allocated to meeting society's other
needs. In addressing this issue, we must make a choice: what portion of the budget is to go to
health care and what portion to other, equally important, public investments such as education, job
creation, and research and development. The second issue, also related to efficiency, is how to
allocate resources among the various components of health care, for example, preventive care,
curative care and medical research. The third issue is to identify activities considered effective and
for which funding assistance is to be provided, taking into consideration the limitations determined
and priorities set in addressing the two preceding issues. Before assessing the system's efficiency
from a macroeconomic point of view, we should identify the activities that are effective from a
microeconomic perspective.
Assessing effectiveness in health sector consists of measuring the effects of medical practices and
techniques - therapeutic, diagnostic, surgical and pharmacological - on individuals' health and
wellbeing. This must take into consideration not only observed improvements in health but also
side effects and iatrogenic effects (Government of Quebec, 1990) .In its pure form, assessing
effectiveness compares two things that have the same effect or the same purpose. If two drugs are
each used to treat a particular illness, the more effective drug will be the one that treats the illness
more quickly with fewer side effects; it is called the more clinically effective drug. Here the
researcher looked at effectiveness in terms of the level of NGOs contribution to the health sector.
Broadly applied, effectiveness combines both the clinical and economic aspects of health care.
Assessing effectiveness makes it possible to determine the medical practices and techniques that,
first, actually help improve health and, second, make good use of resources (Springer-Verlag,
1990). Since resources allocated to health care are limited, only effective practices and techniques
should be used.
As a corollary, the clinical and economic assessment of health care allows us to determine which
services are ineffective or inappropriate. A service is considered clinically ineffective if it does not
have the desired effect, such as treating or detecting illness or improving health. A service is
considered economically ineffective if it produces only a minimal improvement in health for its
cost. A medical procedure is considered inappropriate if it has no beneficial effects, or even has

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undesirable effects, on the patient's health. Health care expenditures can be controlled better when
we stop funding inappropriate or ineffective services (University of Toronto Press, 1992).
The purpose of efficiency is to maximize results effectively, or services delivered, given a
particular budget. According to this concept, each service must be delivered at the lowest possible
cost, have benefits of value equal to or greater than its cost, and make optimum use of the resources
invested. Efficiency is distinct from effectiveness in that it considers costs in relation to benefits.
The goal of transformation is to move from where we are to where we want to be in terms of
having effective and efficient delivery systems to meet health needs across communities. Much of
the change needs to happen locally, with assistance and investment in key system-wide areas at
the state and national levels. Coordination and open communication across levels are essential.
Areas requiring and benefiting from attention include both infrastructure and incentives (Katz el
at, 2010).
Human resources are the most important component of the health care delivery infrastructure.
While the U.S. health care workforce is well-educated and well-trained, there is relatively little
national attention to workforce strategy and few policy levers outside of payment by which to spur
desired changes (Katz el at, 2010). It is not clear that resources are always deployed in ways
conducive to establishing effective and patient-oriented health care delivery systems in Yei South
Sudan. Notably, the system offers far greater financial rewards to those physicians who hone
relatively narrow specialties instead of a general practice focusing on primary care and prevention
by the NGOs (South Sudan Health Report, 2012).
Further, medical education and training programs have not traditionally emphasized the teamwork
approach that is increasingly recognized as a critical feature of effective health care delivery. It is
difficult to retool practice and sustain change if practitioners are unprepared to practice in new
ways (World Bank, 1994). Also, the use of the broader range of health care professionals and the
scopes of their practice vary significantly across states and communities, suggesting that there is
untapped potential to deliver care more efficiently without compromising effectiveness.

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After decades of paying lip service to the need to integrate automated information management
and communications technology into health care delivery, remarkable progress on this front has
been made quite recently like in USA, Germany and UK. Information technology provides the
capacity to access patients‟ clinical information in the course of a treatment episode, to make
relevant and up-to-date evidence and protocols more readily available, to share information across
providers, to facilitate patients‟ self-management and shared decision-making, to extend care to
patients living in areas with limited local provider availability, and to engage in real-time
monitoring of quality and safety. Thus, strengthening the infrastructure and fostering its use
continue to be among the most essential goals of delivery system transformation in the short term
(Center for Studying Health System Change, 2010).
Accountability is very important in the improvement of health service delivery. Accountability
refers to ability to account for allocation use and control of public money, assets and properties
from beginning to the end (Glynn and Murphy, 1996). Accountability to both central and local
government is measured by financial and non-financial performance measures. A recent service
delivery survey and tracking of public expenditure study for education and health sectors by
Economic Policy and Research Centre (EPRC) (1998), revealed that 64 per cent of the budget
expenditure was diverted and only 36 per cent of the funds actually reached the targeted
beneficiaries of Economic Development Institute (EDI) 1997, of the World Bank also revealed
that only 11 per cent of the household surveyed had any contact with an agricultural extension
agent that a third of the grants meant for the one. Institutional materials and non-wage items in
primary education actually reach schools. Such results stressed the need for government to
progress, greater emphasis on improving performance, transparency and accountability in a public
sector through Results Oriented Management (ROM). If monitoring and evaluation were done
effectively and efficiently, there could be improved performance and accountability hence health
service delivery. Results Oriented Management was part of a comprehensive public sector or
reform programs (PSRP) being implemented by government of Uganda, which was initiated back
in 1995, the districts included Iganga, Mpigi, Mukono, Rakai and Rukungiri which after spread to
other districts, especially Lira District. Accountability as result into proper allocation of public

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funds, assets and properties into better use for the provision of health services to the local
community enhance impacting quality health service delivery in the local government. Ministries
included Agriculture, animal industry and fisheries, works transport and telecommunications,
Health education and the judiciary. The lessons learnt from pilot phase were shared with another
13 districts and provided the basis for implementation of results oriented management in 45
districts and 18 ministries, including the judiciary. The use of results oriented management in local
government was to control performance through timely and accurate accountability for the
resources used in order to ensure value for money. Performance information was necessary for the
discharge of accountability, financial and accounting information was often emphasized in
determining accountability. Performance measurement was therefore important for internal and
external accountability. The success of implementing Results Oriented Management within
departments depended on the relationship of the Chief Administrative Officer, the Head of
Department and designated Results Oriented Management Officer. Each department selected a
Results Oriented Management Co-coordinator who would take the lead in the implementation
process.
According to Mutahaba (1989) and Rondinelli (1984), decentralization, is defined as the “spatial
relocation of decision making, that’s the transfer of some responsibility or authority from higher
to lower levels within the central government ministries or agencies. We have 5 types of
decentralization and they include; deco-centration, devolution, delegation, partnerships and
privatization. Decentralization which includes new system for inter-governmental transfer,
financial regulations and accounting and budgeting procedures. The Local Government Finance
Commission Report number 1 of February 1995-December 1996 states that the mission of
financial decentralization as to “assist Local Governments to achieve sound financial autonomy
through efficient and effective mobilization of own resources and practicing accounting,
transparency, accountability and responsible legal framework both in the 1995 constitution of
Uganda (article 152,191(1) and (196), financial and regulation of 1998.
Decentralized Local Governments possess authority to levy taxes not levied by the central
authorities and collect one from the local sources and decide how to spend it. When badly done,
decentralization, however may increase regional imbalances, jeopardize macro-economic stability

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and lead to economic inefficiency. Fiscal decentralization with little or no adequate institutions
like a strong system at all levels of government, clear rules governing revenues and expenditure
assignments and a well-designed system of transfers between different levels reduces fiscal
accountability and leads to macro-economic and allocation of problems that may lead to severe
economic crises.
Accordingly, coupled to improvement of health service delivery in the Local Government, the
rationale for the provision of the social health services are aimed at improving on human welfare
thus the general human quality of life in the social, political and economic aspects. Most
significantly, it’s a social contract between the citizens and the government because the people pay
taxes and expect health services in return, to promote equality among individuals since inequality
has subversive effects like exploitation, more so, to respect human rights i.e. the fundamental
human rights and freedom with accordance to the 1995 constitution of the republic of Uganda
which is the supreme law of the land, chapter four i.e. Acts 20-58 (protection of the fundamental
human rights and freedom). In addition, to increase productivity to illustrate, educational services
to ensures better entrepreneurial skills, health care services ensuring good health free from illness
and disease hence increasing the levels of productivity of individuals. (Porter, 2000). Quality of
health service delivery is the most significant and enduring strategy in ensuring survival of
organizations and a fundamental route to business excellence and extending market share of health
care organizations (Lindquist, 2007). In a hospital setting, he said that primary health service
delivery can be discerned from; health care providers who are professional, facilities that are well
functioning, well stocked with drugs and supplies, and well governed with managers that are fully
accountable.
According to Brown (1998), financial accountability is the assessment of value for money and
acceptance by individuals of personal responsibility for their actions in relation to quality of their
outputs and decisions. Practically, all approaches adapted to getting health systems perform better
through partnerships and increased competition in service delivery emphasize accountability as a
core element in implementing health reform/improving system performance (Brinkerhoff, 2003).

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CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Introduction
This section focused on the methods and procedures to use in the process of data collection for the
study. These included: research design, interview schedules, observation and sampling design
among others.
3.2 Research Design
The study used a case study design for conducting research as the researcher analyzed the
information given by the respondents so as to interpret the conceptual framework and study
objectives in such a way that both past and current information on a case study which is going to
be done in Adekokwok Sub County, Lira District and the research was done to obtain a deeper
understanding of the problem under investigation and tremendously contributory to enhance
performance measure. Quantitative approach was used to collect data from Adekokwok sub-
county Local Government using the information that are already existing on health service delivery
in Adekokwok sub-county and this helped the researcher to make comprises. On the other hand,
Qualitative approach was used so as to develop a rich and comprehensive understanding of health
service delivery in Adekokwok sub-county.
3.3 Target Population
The target population were, the Chief Administrative Officer since he/she is the accounting officer
of the district. Secondly, Sub County Chief who is responsible for implementation of service
delivery policies. Moreover, Sub-accountants, prepares accountability reports. Equally important,
the community members who comment on the quality of services provided. Additionally,
Politicians since they set priorities needs.
3.4 Sampling Design
A stratified random sampling design was used in selection of respondents due to the homogeneity
of the sample population especially the community members. However purposive sampling was
used to select the local Government officials and local council leaders who was interviewed during

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the study. Therefore, the researcher intends to purposely select a sample with the intention of
getting respondents who are well conversant with the services provided by the Local Government.
Most significantly, here I approached the ministry of local government officials, Chief
Administrative Officer, and Sub County Chief.
3.4.1 Sample Size
The sample size attributed 60 respondents, they were identified to fill the questionnaires. This
comprised of, Adekokwok Sub County as the service delivery providers. A Systematic Sampling
Technique was used to sample the respondents. In this method a sampling frame was determined
using the formulae.
Systematic sample Selection Interval (I) = N/n (Casley and Kumar 1992)
Where: N = Total number of the sample population in the Local Government
n = the number of people desired per the sampler (20)
I = the Selection Interval.
Suppose the total number of informants in the Sub County is 97,
Then N: 97/20 = 5 (Selection Interval).
This calculation was done for each group. The rationale for the sample size was to enable the
workers in the local government staffs, politicians and community members with equal
opportunity to provide their experiences they meet at the Organization Waa.
The sample size was as below;
Table 1: Sample Size Distribution
Planned Available numbers Sample
Chief Administrative Officer 1 1
Sub-county chief 10 8
Health workers 10 8

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Community members 50 30
Politicians 26 13
Total 97 60
Source: Lira District Council Minutes (2011-2012).
3.4.2 Data Sources
Basically two sources of data were used in this research which included;
1. Primary data. Here, fresh data were collected from the field through observations and interviews.
2. Secondary data. This involved data from internal and external sources. Internal data included
service delivery report, and external sources involved the use of newspaper articles and internet.
3.5 Data Collection Methods and Research Instrument
Key informant interview schedules and semi structured Interview, in-depth interview and
observation among others were all used.
3.5.1 Methods of Data Collection
Key informants interview methods was used to collect qualitative data, where the Local
Government staffs, were all purposely selected and interviewed and semi structured were also
administered through questionnaires which was used to collect data from community members
interviewed. Most significantly, Survey method: This involved data which was collected from the
entire population or large sample. This was used due to its wider coverage and in addition it permits
the comparison and generation of findings in a cross section of the study area.
In addition, face to face in depth interviews was conducted to collect data from Adekokwok Sub
County and other respondents. This involved designing schedules on which respondents met in
Local Government in Lira. This helped to close down the gap that was left by the survey method.
Lastly, through observation method, the researcher used the naked eyes to see and record data that
helped in gathering data thus, involving going out to the field and seeing the level of service
delivery.
3.5.2 Research Instrument

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Here questionnaires were used to collect data. Structured and short form questions were extended
to respondents which need short and precise answers. The questionnaires were prepared and
distributed to the respondents requiring them to fill short and precise answers about the subject
under study.
3.6 Data Processing and Analysis
3.6.1 Editing
Qualitative data collected was analyzed through editing so as to help the researcher cross check
and get rid of errors so as to ensure accuracy, eligibility, consistency in the data that was gathered.
This exercise was done immediately or on-spot and after the interview and it ensure that all
questions have been answered and recorded.
3.6.2 Coding
This was used in open ended questions and for individual interviewed with questions. Thus,
enabling the researcher to classify different answers or responses into meaningful categories as it
was given by the respondent during actual field work and coding them down.
3.6.3 Tabulation
This helped to table quantitative data. Tabulation involved transferring coded data into tables and
also the tables were presented on the basis of the study variables in a frequency distribution.
3.6.4 Data Analysis
After data have been processed, it was then analyzed in the following ways;
Quantitative data was categorized and coded using numerical codes. After that statistical
techniques was used to analyze the data. This involved descriptive data analysis. Under this
descriptive statistics was used which included measure of central tendency example mean, median,
mode and measure of variability examples standard deviation, variance, and range. Also
inferential/confirmatory analysis was used with the help of statistical outcomes. Inferential
statistics was used to measure relationship, correlation between the variables. This was done with
the help of Statistic Package for Social Sciences.

22. 22
Qualitative data was analyzed through conceptualization. Under this data was analyzed through
quantifying methods which involves categorization, utilization (where individual response are
allocated to category that it fits best), recognition of relationship and testing relationship to reach
conclusion. Also none quantifying method was used which involved making direct conclusion.
3.7 Ethical Considerations
Ethical consideration refer to the morality, uprightness and justification of the researcher’s conduct
in carrying out research. The researcher was guided by the following main considerations. Certain
information such as the respondents’ names was kept confidential on special request by officials.
It was also prudent to document information from archives only with the consent of respondents.
The researcher acknowledged all published sources of literature used in the study.
3.8 Limitations of Study
The research encountered a number of constraints, particularly related to the resources like
financial constraints especially in typing, printing and maintenance costs but this was overcome
through using a very tight budget and spending sparely which enabled the researcher to complete
the study successfully.
Furthermore, transport means from home to Anyangatir Health Centre ||| to search for available
related literatures presented great limitation because the researcher had to foot but this was
overcome and managed through perseverance.
3.9 Conclusion
The purpose of this chapter was to provide an in-depth discussion of the following issues: research
design, data collection methods, sampling techniques and analysis methods. In this study, the
researcher made use of qualitative research because one cannot understand human behavior
without understanding the framework within which subjects interpret their thoughts, feelings, and
actions. Qualitative research is a broad approach that seeks to study social phenomena and gain a
deep understanding of the activities and perceptions of people. The chapter also highlights the
validity and reliability of using a case study approach encompassing qualitative and quantitative

23. 23
methodology. The methods of data collection used were in-depth interviews, key informant
interviews and questionnaires. For the analysis of the outcomes, the chapter used semantic analysis
to gain a deeper understanding of the themes emerging from the research. This chapter was the
basis of the data gathering and analysis which the researcher undertook. The next chapter is the
data analysis of health service accessibility to community members of Adekokwok, quality of
health services offered by Adekokwok Sub-County, Lira District and ways of improving health
service delivery in Adekokwok Sub-County.

24. 24

25. 25
CHAPTER FOUR
PRESENTATION, ANALYSIS AND INTERPRETATION OF FINDINGS
4.1 Introduction
This chapter presents in detail the findings and interpretations on Local Government and service
delivery in Uganda with specific focus on Adekokwok sub-county, Lira District. This has been
done basing on the specific objectives including the demographic characteristics of community
members.
4.2 Demographic characteristics of respondents
In demographic characteristics of respondents, the researcher was primarily concerned with the
sex (gender), age bracket, source of income and educational level. These characteristics were
obtained from health workers and community members. The study was conducted in Anyangatir
Health Centre III in Adekokwok Sub – County, Lira District.
4.2.1 Gender of Respondents
The study included both sexes (males and females) to be gender sensitive and gather as much
opinions as needed. Males perceive issues differently from females.
Table 1: Distribution of respondents by gender
Gender Frequency Percentage
Male 18 60
Female 12 40
Total 30 100
Table 1, show that majority of the respondents (60%) were males compared to 40% who were
females. This was not done deliberately since the respondents used random sampling. However, it
was helpful in terms of gathering diverse views.
4.2.2 Age Group of Respondents

26. 26
This section presents the age bracket of respondents obtained from the health workers and
community members. The age bracket of respondents were grouped into five age groups to enable
easy categorization of respondents. The age groups were divided by an interval of 5 ranging from
25 years, 25 – 30 yeas, and 31 – 35 years, 36 – 40 years and above 40 years.
Table 2: Distribution of respondents by age group
Age group Male Female Total Percentage
Below 25 years 5 4 9 30
25-30 years 0 3 3 10
31-35 years 1 2 3 10
36-40 years 2 2 4 13.3
Above 40 years 10 1 11 36.7
Total 18 12 30 100
The table shows that the majority of the respondents (36.7%), male and female, were aged above
40 years. This age was particularly reflective of working age group. The owners of means of
production and those with more pushing factors to work and seek medical checkup and treatment
than those in other age brackets because of family responsibilities. 30% were aged below 25 years
and 13.6% were aged between 36 to 40 years. The least number of respondents (10%) were aged
between 25 to 30 years and 31 to 35 years respectively.
The empirical evidence from fieldwork reveals that the highest number of respondents seeking
medication were in the age group above 40 years constituting 36.7 percent of the total population.
Thus, the findings clearly shows that the adults and elderly people are most acquiring health
services in Anyangatir health Centre iii, Adekokwok sub – county.
Particularly focus was put on ascertaining the reason for low rate of participation by youth (25 –
30 and 31-35 age bracket) in the delivery of quality health services, this is because most youth fear
to seek medical advice since the result may embarrass them.
4.2.3 Source of income

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The source of income for livelihood is vital as far as accessing quality health service is concerned,
as well as management of the family well-being.
The researcher was interested in the source of income because it gives the researcher an
understanding which group of the community has most access at the health service.
Table 3. Distribution of respondents by source of income
Source of income Male Female Total Percentage
Paid employment 5 4 9 30
Farming 11 7 18 60
Trade 1 1 2 6.7
Self-employed 1 0 1 3.3
Total 18 12 30 100
The table above shows that 30% of the respondents get their source of income through paid
employment, 60% were farmers, 6.7% were traders and 3.3% self-employed. This implies that the
majority of respondents in the study were peasants (farmers) whose income was low hence
appropriate for the study objectives. Since most community members are farmers, this make it
very hard for them to attain quality. This makes most people fail to attain high quality health
service delivery in Adekokwok sub-county, Lira district.
Available evidence suggest that majority of the community members are peasant farmers
constituting 60 percent. The overwhelming number of have-nots barely eke out a living from the
land from which they derive their income from relying heavily on subsistence rather than
commercial farming. Relatively, 30 percent of the respondents tracing their source of income from
paid employment with such great margins of income disparity, many poor farmers seek heath
service of Adekokwok sub – county Local Government.
4.2.4 Educational level

28. 28
The findings which emerge from this study suggest that education is an important key component
in the social well-being of the population and is a vital weapon in fighting poverty. Therefore, the
respondents in Adekokwok Sub – County have different educational level.
Table 4: Distribution of respondents by education
Level of education Male Female Total Percentage
No formal education 2 2 4 13.3
Primary 3 2 5 16.7
Secondary 6 5 11 36.7
Tertiary 7 3 10 33.3
Total 18 12 30 100
As table 4, show the majority of the respondents (36.7%) had attained only secondary school
education and are living rural peasant life, with agriculture as their main source of livelihood. It
was because of this low level of education that some respondents could not clearly measure the
impact of health service delivery due to existence of on-going various programs and projects in
their area. The low level of education means that some respondents are uninformed or unaware of
their role and the degree to which they ought to participate in delivery of quality health services.
Also table 4, show that 33.3% of the respondents had tertiary level of education within post-
secondary vocational studies, certificate, diploma and degree. They are also engaged in agriculture
as their main source of livelihood.
The smallest number of respondents (13.3%) comprised those with no formal education and also
16.7% of primary educational level. Additionally, the respondent’s educational status influences
people’s decisions whether to seek medical treatment or not.
The social demographic characteristics of respondents such as gender, age bracket, source of
income and educational level provide a foundation for the next analysis which provided detailed
discussion. The accessibility of health services offered by Adekokwok Sub – County, Lira District.
4.3 Accessibility of health services offered by Adekokwok Sub – County, Lira district

29. 29
In this objective, the researcher examine whether people access health services offered by the
Local Government. In this section, the discussion on the accessibility of health service will be
classified into three sub – sections namely: The different kinds of health services provided, health
services easily and not easily accessible to the community and finally factors that facilitate and
hinders access to health services.
4.3.1 Different kinds of health services provided
Adekokwok Sub-County provides numerous health services to the community members of
Adekokwok. This health services are witnessed in Anyangatir Health Centre III and these services
has helped in the improvement of standards of living of the local community hence a healthy living.
Figure 1: Bar graph representing kinds of health services in Anyangatir Health Centre III
Source: Primary data
The figure above indicates the various health services provided in Anyangatir Health Centre III,
these include, dental services constituting 25 %,maternity (26.2 %),pharmacy (28.6 %),minor
surgery ( 6.0 %),lab investigation ( 6.0 %),Out Patient Discharge ( 1.2),immunization (3.6
0
5
10
15
20
25
30
35
Percentage
HEALTH SERVICES
A BAR GRAPH REPRESENTING KINDS OF HEALTH SERVICES
INANYANGATIRHEALTH CENTREIII

30. 30
%),Family Planning (1.2 %),and HIV testing and Counseling ( 2.4 %).According to the statistics
from the field study, pharmacy (28.6 %) and maternity (26.2 %) were the highest health services
utilized in Anyangatir Health Centre III. This is so, because drugs are given to the patients who
seek medical treatment in the Health Centre and the Local Government provide drugs to
Anyangatir Health Centre III. Besides that, Anti-retroviral care (maternity) is also of high
percentage because maternity wards are made available to the community members of
Adekokwok.
The findings from this study reveals that Adekokwok sub – county Local Government provide
various kinds of health services including anti – retroviral care ( maternity) services provided to
women such as anti – natal care, post – natal care, delivery services offered for safe delivery and
prevention of infant mortality and maternity mortality. Secondly, offering minor surgery for
instance safe male circumcision, surgery of physically disabled orphans, fixing broken limbs
(upper and lower limbs) among others. Thirdly, pharmacy to illustrate providing drugs to patients,
diagnosis of infectious diseases, immunization of children and HIV/AIDS testing and counselling.
More to this, dental treatment services introduced and offered by Anyangatir health Centre III.
Including nutritional services, maternal and child health services. Intensifying health education to
people to promote preventive, curative and rehabilitative behavior. Reproductive health services,
family planning, laboratory investigation and lastly out – patient services.
By implication, from the participants responses, it’s evident that Adekokwok sub – county Local
Government provides different kinds of health services that promote good health to the people and
the health education offered is making residents of Adekokwok take charge ( control) of their own
life, hence health care provided enables people to maintain good health condition

31. 31
4.3.2 Health services easily and not easily accessible to the community member
Source: Field study
Empirical evidence reveals that the widely and easily accessible health services were anti –
retroviral care (maternity) services to women constituting 80%, minor surgery services (50%) and
pharmacy (70%), immunization of children (50%) and lastly laboratory investigation to illustrate
testing for malaria. On the contrary, the health services not easily accessible to the community
members were found to be pathology (5%), optical (eye care) constituting 5%, orthopedic (10%)
and prosthetic aids, physiotherapy (20%) and dental services (30%) including treatment of HIV
positive patients with ARV drugs.
“ Anyangatir health Centre III is providing anti – retroviral care to women and there are special
wards (maternity wards ) for the women for delivery care with this at hand, it makes maternity
services easily accessible and in Anyangatir health Centre iii ARV drugs are not being supplied
hence making it inaccessible to HIV positive patients.” (In depth interview) No.1
0
10
20
30
40
50
60
70
80
90
percentage
Health services
Bar graph representing health services easily and not easily
accessiblein Ayangatir health Centre iii

32. 32
It is quite clear from the above figure 2 that there are some health services offered by Adekokwok
sub – county Local Government in Anyangatir health Centre iii that are more easily accessible
such as maternity, minor surgery, pharmacy, dental other than some inaccessible health services
of major surgery, pathology, optical, orthopedic, physiotherapy among others.
Similarly, in concurrence with rating accessibility of health services, a significant 63.3 percent of
health services are moderately accessed by people ,23.3 percent of health services are highly
accessible, 6.8 percent of services are lowly accessible and 6.6 percent of services are inaccessible
by Adekokwok community members.
The findings which emerge from this study suggest that factors that facilitates community
members access to health services were short distance to the health Centre, that is not exceeding 5
kilometers , professional – staff such as nurses, mid – wives, drug availability at the health Centre
and quick services offered to patients. Notwithstanding, the factors hindering people’s access to
health services were discovered to be inadequate ( few) staffs and health workers acerbated by
residing far away from the health Centre , at times inadequate drug as a result of the Local
Government delay to supply the drugs, high cost since some community members are farmers and
cannot afford to pay medical bills. Moreover, overcrowded population of patients in Anyangatir
health Centre iii and a challenge of health worker’s absenteeism.
This chapter was a reflection on social demographic characteristics of community members.
Adekokwok sub – county Local Government’s staff and on the accessibility of health services
offered by Adekokwok sub – county, Lira District. Integrating issues of the need for participation
in health issues analysis that Adekokwok sub – county is playing prominence role in the support
of patient health and superficial care.
Global research has found that decentralization of service delivery to Local Government has
created access of health services to many rural poor (WHO 1993) demonstrates. It has been shown
by the people. Therefore, Adekokwok sub – county Local Government holistically strives to its
best. That its demographic population have accessibility to necessary health services delivered by
the government to them at community level.

33. 33
In addition, as ascertain from the interviews, these findings were interpreted and discussed within
the framework of the existing literature as presented in chapter two of this study. As discussed in
chapter one, this inquiry has attempted to investigate the Local Government and service delivery
in Uganda. A case study of health in Lira District and on the ways of improving health service
delivery in the sub – county. Utilizing views of sub – county staffs, health workers and community
members thus responses gathered from in depth interviews, key information interviews and
questionnaires.
4.4 Quality of health services offered by Adekokwok Sub-County, Lira District
4.4.1 Introduction
Having previously presented the accessibility of health services offered by Adekokwok Sub –
County and social demographic characteristics of health workers and community members.
Has it follows in a sequence, chapter four presents the most sensitive part of this study. The
prominence of Local Government in playing prominent role in service delivery in Uganda.
4.4.2 High quality health services
Concerning health services being provided by Anyangatir Health Centre III, there are services of
high and low quality services in place. Despite of that, the Health Centre is quite known for
providing high quality health services with great support of Adekokwok Sub- County.
Table 5: High quality services in Adekokwok Sub-County
High quality services Frequency Percentage
Dental 3 4.3
Maternity 23 32.9
Minor surgery 4 5.7
Pharmacy 21 30
HIV testing counseling 1 1.4
Lab investigation 1 1.4
Immunization 17 24.3

34. 34
Total 70 100
Source: Primary data
In table 5 health services of high quality include, anti-retroviral care (maternity) constituting 32.9
%, pharmacy (30 %), and immunization (24.3 %).These services are of high quality because they
are easily accessible by the local community of Adekokwok. As statistics reveal, the low quality
services are, dental (4.3%), and HIV testing and counseling (1.4 %), and lab investigation (1.4
%).The services are of low quality because there are limited medical equipment to operate these
services to the required services.
Empirical evidence from fieldwork reveals that Adekokwok sub-county delivers high quality
health services. The high quality health services has resulted into improvement of the lives of the
local masses. Here, high quality health services offered to community members of Adekokwok
includes; pharmacy, anti – retroviral care (maternity), pharmacy and immunization. In response to
the provision of high quality services in Adekokwok, one informant said,
“Adekokwok had been experiencing very low quality health service delivery due to inadequate
drug supply and few staffs, but as a result of the massive support from the Local Government,
there is increment in drug supply hence drug stock-out at Anyangatir health Centre III and more
staffs are recruited. With this at hand, there is provision of quality health services for instance
there are many outreaches of immunization within the village settings and this has helped to
improve on the attainment of immunization within the community.” (In – depth interview) no.2
With regards to this, Adekokwok Local Government had been providing low quality services to
the community members. Due to the recruitment of more staffs and increment in drug supply,
Anyangatir health Centre iii in Adekokwok is providing high quality health services to the
community.
However, not all services provided are of high quality, some of the health services as well are of
low quality and these are HIV testing and counselling, dental, physiotherapy, orthopedic and major
surgery. Evidence from fieldwork shows that dental services are of low quality because it was
initiated a few weeks ago and most people are not aware of it and in response to HIV testing and

35. 35
counselling, most youths fear to go for testing and they are ignorant about the dangers of HIV
virus.
4.4.3 Rate of quality health services delivered by Adekokwok Sub – County
In line with the quality of health services delivered. A healthy population is productive and
functional for development therefore health as one of the services is most vital to general
population chimney of Uganda and particularly to the host population of Adekokwok Sub –
County, Lira District. Thus, these necessitates quality health services delivered by Adekokwok
Sub – County to its inhabitants.
Figure 3: Illustrate the rate of quality health services in Adekokwok
In accordance to fieldwork 83.3 percent of the population (respondents) admit that the rate of
health service delivery is moderate in Adekokwok, 10 percent revealed there is high quality health
services, 3.4 percent also talked of very low quality health services in Adekokwok being delivered
to the local community.
83.3
10
3.4 3.3

36. 36
4.4.4 Factors that facilitate provision of quality health services
Table 6: Factors facilitating provision of quality health services
Factors facilitating Frequency Percentage
Strong leadership 20 21.7
Good facilities 13 14.1
Quick service 16 17.4
Low population 2 2.2
Professional staffs 23 25
Drug availability 18 19.6
Total 92 100
In Adekokwok, the provision of quality health services is high and moderate as a result of the
recruitment of professional staffs. These staffs helped in the provision of quick services to the
available patients at the health Centre hence solving the problem of time wastage. Prior to that,
there is strong leadership by the administration and in this case, the administration work as a team
hence promoting team work. Here, the administration, health workers work together with the
community members, hence fighting embezzlement of funds by corrupt government officials.
Apart from that, drug availability also facilitate provision of quality health services in Adekokwok.
Here, Adekokwok sub – county Local Government ensures continuous supply of more drugs to
Anyangatir health Centre iii. This has made most of the local community members to seek for
medical treatment and care.
4.4.5 Factors hindering the provision of quality health services
Table 7: Factors hindering provision of quality health services
Hindrance Frequency Percentage

37. 37
Corruption 17 20
Few health workers 26 30.6
High cost 1 1.2
High population 19 22.4
Unprofessional staffs 11 12.9
Drugs unavailability 11 12.9
Total 85 100
Generally there are a number of factors that hinders the provision of quality health services in
Adekokwok. These factors has resulted into the provision of low quality health service delivery in
Adekokwok and this include; corruption, in this case, most government officials are very corrupt
in a way that they embezzle public funds for their own use and benefit such as drug theft. Not only
has that, few health workers also hindered the provision of high quality health services.
“Anyangatir health center iii in Adekokwok has got few staffs to attend to patients and yet the
population of Adekokwok is high. As a result of this, there is poor time management by the staff
members hence hindering the provision of high quality health services in Anyangatir health Centre
iii.” (A female mid – wife of Anyangatir health Centre iii).
The population of Adekokwok is very high and this makes it very hard for them to seek for medical
treatment in – time since Anyangatir health Centre iii has inadequate number of staffs. Due to this,
there is poor time management hence hindering the provision of high quality health services.
Important to note, poverty also hinders the provision of quality health services in a way that, most
people in Adekokwok are very poor hence experiencing financial problems. Due to this, most
people often fail to seek medical check – up and treatment because they cannot afford. Evidence
from fieldwork show that most people don’t have enough money to pay their medical bills. In this
case, some of the medication are of high cost and this discourages the locals to attain quality health
services hence they resort to traditional ways of medical treatment which is very harmful since
some people end up losing their lives at the end.

38. 38
Not only that, inadequate drug supply is one of the major hindrance of quality health service
provision. Here, when drugs are not stocked by the Local Government or health centers, sometimes
they run short of drug availability and this affects the lives of many community members. A health
worker of Anyangatir health Centre iii noted that, at times they run out of drug stock out in the
health unit due to high population and delay of drug supply by the Local Government. This make
some people to go back to their residence without medical check – up and treatment.
4.4.6 Role
Table 8: Role of respondents in delivery of quality health services
Role Frequency Percentage
Following instructions 27 35.5
Respecting health workers 23 30.3
Paying medical bills 1 1.3
Using facilities well 25 32.9
Total 76 100
In the delivery of quality health services, different roles has to be played by different people within
the community. The roles played led to the delivery of quality health services. In Adekokwok,
roles are played by the community members, local leaders, politicians and health workers.
The role of the community in the delivery of quality health services involves following
instructions. In this case, when there is a patient who is sick she/he goes to the hospital for check
– up and treatment. A health worker gives instructions such as medical prescription to be followed
by the patient. In addition to that, community members has to pay medical bills, respect health
workers and use the facilities well. This is because when the community members follow
instructions, respect health workers, use facilities well, then delivery of quality health services in
Adekokwok.

39. 39
Politicians are also considered to be very important in the delivery of health services to the
community members. The politicians play roles of supervision of health service delivery,
monitoring of drug supply, ensuring good conductive environment of health Centre and monitoring
time management of health workers. Monitoring of drug supply is very important by the politicians
because it helps to reduce on drug theft by the health officials.
Additionally, the health workers also play a big role in the delivery of quality health services in a
way that health workers should monitor their patients, manage time for work properly and also
monitor drug availability so that there is sufficient drug stock at the health Centre.
4.5 Ways of improving health service delivery in Adekokwok sub – county
Though Local Government strives to its higher limits in delivery of health services, available
evidence generated from the collected data shows clear patterns of inadequacies or challenges that
engulf (curtails) quality service delivery. Therefore, this section discusses in details ways of
improving health service delivery in Anyangatir health Centre iii, Adekokwok sub – county, Lira
District.
4.5.1 Improvement of quality health service
A tremendous effort to improvement of quality health services in Adekokwok sub – county,
Anyangatir health Centre iii has shown a far reaching impact to the lives of community members
of Adekokwok, and their health status. Evidence from fieldwork also suggest that 96 percent of
community members in Lira district agrees that quality of health services has been improved.
Likewise, they are thoughtful that the quality of health services can be improved. People in
Adekokwok access better medical treatment to illustrate health services such as immunization,
HIV/AIDS testing and counselling, diagnosis of infectious diseases, surgery of physically disabled
men and women, dental treatment among others. On this issue one respondent mentioned that:
“years ago Anyangatir health Centre iii used to be in poor shape in terms of infrastructures,
inadequate drug, facilities and welfare of nurses, but with PHC (Primary Health Care)
intervention program we now realize about of improvements in Adekokwok sub – county,

40. 40
especially in health sectors whereby there is increase in drug supply, medical health attained by
people.” (In –depth interview no.3, with the health worker of Anyangatir health Centre iii)
In light with what this respondent claimed, it is no secret that there is about on improvements in
Anyangatir health Centre iii and there is better utilization of health service by not only community
members of Adekokwok sub – county but also by people in Lira district.
Equally important, the findings from this study revealed that tireless efforts is devoted by
community members to ensure that there is improved health service delivery in Adekokwok sub
– county Local Government. In one such, the community members have contributed greatly in the
provision of land for expansion of Anyangatir health Centre iii. Moreover, with great magnitude
respecting health workers, working in teams in monitoring quality of health services, reporting
drug theft in order to safe guard their health Centre from drug shortage
4.5.2 Strategies the Local Government has done to improve health service delivery in
Adekokwok.
The main obligation of the Local Government is to fulfill that the decentralized social services
reach the grass root level that is to the local community members. The study established that
though the persistence and consistence in delivery of health services. Adekokwok sub – county
has made a tremendous contribution to accessibility of health service to its residence. At this point,
the concept of accessibility of health services is not an issue because we have discussed it
repeatedly in our previous discussion, and therefore, what is important to begin with is
understanding in details the steps, strategies the Local Government has done to improve health
service delivery in Adekokwok sub – county. Despite the fact that financial constraints still remain,
Adekokwok sub – county’s biggest challenge and hindrance to attaining the desired levels of health
service provision and growth, the Local Government have maintained continued budgetary and
health support to Adekokwok sub – county, there is realization of increased funding and similarly
the sub – county continue to demonstrate efficient utilization of all funds. Further, Adekokwok
sub – county technical staff initiatives aim at finding solutions to the problems pressing society
that is by building more blocks in the health Centre iii Anyangatir, increasing drugs and medical
equipment facilities supply and all these are in line with their strategic focus. More to this,

41. 41
Adekokwok sub – county is undoubtedly fighting corruption acts in order, the implication of such
unnerving actions not to cast them in fielding service delivery in the sub – county. In the same
way, Local Government has recruited more staff that is qualified skilled human resource such as
health professional, physicians, specialists, clinical officers, nurses, mid – wives, laboratory
technicians among other skilled man powers that are confident in rendering health services such
as diagnosis of patients in Adekokwok.
4.5.3 Non – Governmental Organization efforts to improve health service delivery.
The findings which emerge from this study suggest that non – governmental organization to
illustrate CARE Uganda has done imaginable humanitarian and philanthropic assistance in
supporting Anyangatir health Centre iii in Adekokwok sub – county Local Government.
The non- Governmental organization advocacy or lobby is one of the contribution to improve
health service delivery carried out by them which involves seeking to influence the public and
official policies regarding health service improvement to community members in Adekokwok. As
a result of inadequate budgetary financial allocation to health when the national budget on health
are designed. Innumerable Non- Governmental Organization and other donors, well – wishers
devoted themselves unconditionally by providing funds to strengthen and improve health service
delivery in Adekokwok. Eventually, available evidence shows quite clearly that Non-
Governmental Organizations have built health Centre for instance maternity ward, laboratory
equip the health Centre with medical facilities such as prosthetic, orthotic aids/appliances, wheel
chairs, clippers, laboratory equipment, vehicles (ambulance) and most significantly supplying
drugs to the health Centre that is helping in combating infectious diseases and chronic diseases
putting patient lives at stake.
Thus, Non – Governmental Organization have recruited staffs that is health workers and further
their skills by conducting several seminars with them, mentor young medical professionals
exposing them to gain experience and requisite knowledge in the fields of medicine of which this
has necessitated better health services delivered in Adekokwok sub – county.
By implication, it’s from Non – Governmental Organization efforts made to improve health service
delivery in Adekokwok sub – county Local Government that is ultimately bringing the realization

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of World Health Organization (WHO 1974) and the Alma – Mata declaration of 1978. Access of
health for all to reality to the many inhabitant of Adekokwok sub – county and Lira district. Thus,
formulated strategies and intervention taken by Non – Governmental Organization to improve
health has intensified health education to the residents of Adekokwok to promote preventive,
curative and rehabilitative health behaviors among people, hence, all these efforts id geared to
restoration of patients to whole gain in order to resume their social roles as it’s noted that a healthy
person is productive unlike unhealthy person performing the sick role parsons (1951) stressed.
From the above, it can be concluded that Non – Governmental Organization efforts in improving
service delivery supplements the Local Government activities in service delivery in Adekokwok
sub – county.
4.5.4 Suggestions to improve health service delivery.
In line with inadequacies or challenges observed by the researcher as curtailing service delivery of
Local Government, a significant percent of community members of Adekokwok sub – county
proposed suggestions stemming from challenges experienced as ways needed to improve health
service delivery in Adekokwok sub- county and these included: more funding of high levels by
government and maintaining continued support to health sectors for instance, rehabilitating
existing hospital and health Centre structure and building more health facilities to enhance quick
and better health care to the people.
More to this, increase medical equipment as well as drug supply are needed to the provision of
medical equipment such as chairs, beds, instruments for minor surgery, tables among others and
supply of drugs such as ARVS, pills for chronic diseases like diabetes, ulcers, cancer, high blood
pressure. Therefore, increase in medical equipment and drug supply are of paramount to the health
status of the population in Lira district.
In response to suggestions to improve health service delivery a number of community members
called for need of the Local Government to ensure that there are more staffs that is doctors and
nurses in the health Centre with doctor to patient ratio of 1:50 relative to standard ratio so that the
sick or ill people can be treated with enough care and attention. Additionally, the community
members and sub – county staffs propose minimization of devastating acts of unnerving corrupt

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actors by having a battle that they have no choice to fight a aforementioned corruption problem
that disables the provision of health service delivery in the Local Government.
4.6 conclusion.
The empirical findings discussed in this chapter suggest that there has been a vacuum created by
the state despite the major efforts the state is accomplishing to deliver the quality health services
to the general population of Uganda and that the Local Government has emerged as alternatives in
decentralizing services from the district (regional level) to grass root level (community level). The
main argument here is that, despite of deregulation and inadequacies of Adekokwok sub – county,
it has played a primary role in delivery of health services.
The various aspects of the model which were derived from empirical evidence gathered in chapter
four and five are better service delivery by the Local Government in Uganda to the people. The
accessibility of health services, quality of services and improving health services has contributed
to the growing importance of the Local Government in health service delivery.
Empirical evidence also suggests that there is proper coordination of Adekokwok sub – county
with its community members. In terms of participatory development, accessing the views of the
community members from Adekokwok themselves from the narrative descriptions that these
chapters made use of, rather than second hand accounts from other acknowledges the need of the
local community members to participate in relevant decision making and social processes and to
gain insights of how they view the obligation of Anyangatir health Centre iii by extending good
health services to the people thus, respecting their versions of reality that is access for health, hence
this provided a framework for examining the quality of services offered by the Local Government.
This study therefore, necessitates the understanding of various health services delivered from the
perspective of Adekokwok sub – county. The crucial significance of using or multidimensional
approach of data collection assisted to tap the bottom-up views of the services of Adekokwok sub

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– county in Lira district. Having discussed the empirical evidence gathered from the study, the
following chapter will conclude this study.
CHAPTER FIVE
SUMMARY, CONCLUSION AND RECOMMENDATIONS
5.1 introduction.
This chapter presents the summary of the study and its findings; it also presents the conclusions
drawn from the study and recommendations to Adekokwok sub – county Anyangatir health Centre
iii, Local Government and government, and also future studies. Concurrently, the chapter reveals
how the study examined the Local Governments and service delivery in Uganda, a case study of
health in Lira district. Major focus was put on the accessibility of health services offered by
Adekokwok sub – county, social demographic characteristics of community members and the
quality of services delivered and then, finally the ways of improving health service delivery in
Adekokwok sub – county, Lira district.
5.2 Summary and reflection on the findings.
The findings of the study reveal that the Local Government is accomplishing powerful works in
service delivery in Lira district. Undoubtedly, Adekokwok sub – county has made maximum
efforts of coordinating services from the district level to the community level. The sub – county is
delivering not only health services but a variety of social services to meet the different interest of
its demographic population and in accordance of gender sensitivity with fairness thus equality and
equity.

45. 45
The findings also shows that the accessibility of health services offered by Adekokwok sub –
county, Lira district is outstanding demonstration efficiency and effective utilization of health
services. The services within the health Centre are moderately accessible, quick and easily
accessible by its presumed beneficiaries (the host population of Adekokwok) and from
visualization of health services accessed by the people, it is worth noting that the services are of
great significance in the lives of poor community members to which they look up to or count on
to broaden their life expectancy period.
As regards to the quality to the quality of services delivered by Adekokwok sub – county. It is
ultimate to denote that, health services of extremely higher quality standards to illustrate anti-
retroviral care (maternity), pharmaceutical and medicine, minor surgery among others delivered
to the community members of Adekokwok. Particularly it was acknowledge that with the provision
adequate services, these was sought to restore the good health status of the people to enable them
be as productive humans that will work to improve the sub – county and their own standards of
living. The findings shows that the quality health services provided is to enable the ordinary
community members live a normal life, with happiness and comfort rather than some sick patients/
people resuming the sick role that exempts them from performing their daily activities.
Though Adekokwok sub – county is playing prominent role and performing powerful works in
health service delivery to community members in Adekokwok and Lira district. Empirical
evidence also shows some loop holes (inadequacies) in service delivery by Adekokwok sub –
county that at one point curtail accessibility of services by community members and these
included: inadequate staffs and health workers, inadequate drugs due to delayed supply, inadequate
medical facilities and equipment, overcrowded patient dilemma, and health workers absenteeism,
not forgetting inaccessibility of ARVS drugs by the people living with HIV/ AIDS virus.
Another objective of the study was to analyze ways of improving health service delivery in
Adekokwok sub – county, Lira district that also influence the Local Government service delivery
in Uganda. As shown in results and discussion. Chapter five from the findings, the community
members they themselves have done great things to improve health service delivery for instance,
providing land for the health Centre expansion, respecting health workers, reporting drug theft and

46. 46
maintaining “Esprit de corps” spirit of togetherness that is in unity there is strength of working,
monitoring and ownership of their health Centre. Most significantly, the Local Government thus,
Adekokwok sub – county has made tireless efforts and has strategic focus to improve health service
delivery by increasing funding to the health Centre, constructing more health Centre infrastructure,
increasing drugs and medical equipment supply, recruiting more skilled health workers and
fighting aforementioned corruption problem. Additionally, Non – Government Organization
humanitarian and philanthropic assistances such as, constructing health Centre, supplying medical
equipment and drugs, equally important advocacy for Anyangatir health Centre iii are sought to
improve health service delivery in Adekokwok sub – county, Lira district.
In addition to this, as for suggestion to improve health service delivery, the sub – county and its
community members called for the need of more funding of higher levels by government,
increased medical equipment and drug supply, most important supply of ARVS drug to HIV/AIDS
positive patients, increased number of health professionals to represent standard doctor-patient
ratio of 1:50 and lastly having a battle that we have no choice to fight corruption problem. It’s a
crucial concern that these strategies should be taken into consideration by the government, if there
is need for us Ugandans to achieve the Millennium Development Goal (MDG) that is,
Goal 4: reduce child mortality. Goal 5: improve maternal health, and goal 6: combat HIV/AIDS,
malaria and other diseases. And of which sadly, in September 2007, the secretary general of the
United Nations, Ban Ki Moon, announced that halfway to the deadline, sub- Saharan Africa is
unlikely to meet even a single goal (United Nations Development Program, 2008)
5.3 Conclusion.
This chapter has presented the major findings of the study. The decentralization of service delivery
by the government from central government to Local government have enhanced service delivery
to reach the entire population in the country. Therefore, the results confirm that the significance of
the local government has evolved accordingly, necessitating the activities of Adekokwok sub –
county in health service delivery in Lira district. The integrated model presented a platform for
analysis of how contributory Adekokwok sub – county delivers health services in Anyangatir
health Centre iii to the community members, and it acknowledge that, in order for the health Centre

47. 47
to promote good health to the people, the sub – county needs to make their community members
the Centre of their programs that is participatory development.
Ultimately, the narrative description in this study assisted in drawing attention to the concerns
about the local government service delivery of which a variety of health services are made
accessible to the local people. In relation to the empirical data gathered underpinning the study
results also confirms that communities surrounding the sub – county staffs, having good
relationship with the health workers and other people.
Undoubtedly, the study was a multidimensional approach and for quantitative data questionnaires,
key informants interview schedules, and analysis of existent documents at the sub – county were
used to collect data, code and later tabulate it. For quantitative data, an in – depth interview
schedule were used together with observation method to gather experiences and was semantically
analyzed through editing to supplement quantitative data.
5.4 Recommendations.
In line with the findings presented in this inquiry, related recommendations are made. The aim of
this section is, essentially , to propose strategies that may enhance provision of better health service
delivery in Anyangatir health Centre iii, Adekokwok sub – county.
The government needs to increase on their source of funding at higher levels. This means the
government of Uganda should establish good mutual understanding with other outside countries
such as U.S.A, UK, Denmark so that, there is continuous support given or provided to the
government of Uganda.
Local government should construct accommodation for the health workers within the health units.
This helps the health workers to maintain proper time for work and also encourages them to do
their work diligently till the required time since they stay within the health Centre.

48. 48
Local government should improve and renovate health Centre and equip them with the necessary
medical equipment and facilities such as beds, tables, chairs among others. This is to ease work at
health Centre and also avoid overcrowding in over populated area.
5.5 Recommendations for future Research.
This study investigated the local government and service delivery. A case study of health in Lira
district. Based on the strength of this study with its comprehensive conceptual framework and
analysis of primary data, other future researchers can use this study as their guide. The result of
this study were derived from the emic perspective of the sub – county staffs, health workers and
community members of Adekokwok in Lira district. Future researchers need to focus on how
politicians influence health services in local government. This will increase the body of knowledge
that will allow future researchers to analyze the factors influencing distribution of health services.
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