2. Background of the Study
• Sub-Saharan Africa accounted for 86 percent of all deaths, resulting in over 250,000 deaths.
• This depicts a depressing and concerning trend. While Sub-Saharan Africa and Southern Asia accounted for the majority of
these deaths, the WHO (2017) also noted that deaths in Southern Asia had decreased by about 38% overall.
• The sustainable development goals (SDGs) aim to reduce maternal mortality to less than 70 deaths per 100,000 live births by
2030, but the main barrier to achieving this goal is the inadequate status of maternal and child health care systems which can only
be improved on through vigorous reforms in the health care delivery mechanism.
• In Africa health service delivery accounts for a big chunk of global maternal deaths, in 2013 about 289,000 women
worldwide died during pregnancy or childbirth, and of those deaths, 62% occurred in sub-Saharan Africa.
• Trends in Maternal Mortality: 1990 to 2013. The report adds that in 2013, the maternal mortality ratio in developing
countries was 230 women per 100,000 births, versus 16 women per 100,000 in developed countries
• Demographic Health Survey (2008/09) noted that in Kenya, maternal mortality remains high at 488 maternal deaths per
100,000 live births.
• While this is below the Sub-Saharan average of 640 deaths per 100,000, Kenya experiences a very slow progression in
maternal health. Many of these deaths could have been averted if women had timely access to skilled attendance and essential
obstetric and neonatal care. UNFPA (2015) a recent analysis by the University of Nairobi showed that 98 per cent of these deaths
are concentrated in just 15 of the country’s 47 counties (Okoth Joshua Odhiambo, 2021).
• In Uganda, Child and maternal mortality rates remain high with 90 under-five child deaths per 1,000 live births and 438
maternal deaths per 100,000 live births.
• Among children under 5, more than a third are stunted and under-nutrition contributes to four in 10 deaths. A particular
challenge in Uganda is inconsistent service coverage along the continuum of care and low uptake of reproductive and child health
services in public health facilities (UNICEF, 2018).
3. Background of the Study
• Somalia is among the 15 countries that WHO marked as very high alert countries for
maternal deaths. Somalia has one of the worst maternal conditions in the world (Adam, Magan,
& Ali Omar, 2021).
• The Maternal Mortality Ratio (MMR) is 692/100,000 live births where 1 in 20 women
would die from pregnancy-related causes during their reproductive lifetime.
• Four in 100 Somali children die during the first month of life, eight in 100 before their first
birthday, and 1 in 8 before they turn five. Many die or suffer near misses due to lack of access or
lack of knowledge of health services (Adam, Magan, & Ali Omar, 2021).
• Delay in seeking medical care is one of the most significant factors contributing to maternal
deaths in Somalia.
• This is largely due to cultural beliefs and practices, a lack of knowledge about complications
and the benefits of modern healthcare services, and women's low status in society (Reliefweb,
2021).
• Somalia is dealing with health issues, including malaria in children, tuberculosis in adults,
and cholera outbreaks.
• Furthermore, the healthcare quality provided to individuals is very low, and the number of
maternity services accessible is limited in comparison to the population, resulting in a severe
shortage.
• Consequently, due to a lack of availability of high-quality food and balanced diets, there is a
low rate of immunization among newborns with severe malnutrition (MOHDPS, 2013).
4. General Objective
• The General objective of this research will be to establish the moderating effect of
decentralization policy on the relationship between health services delivery decentralization
strategies and the health of mothers and children in Somalia.
Specific Objectives
i. To determine the effect of fiscal decentralization strategy on the health of mothers and
children in Somalia
ii. To establish the effect of administrative decentralization strategy on the health of mothers and
children in Somalia
iii. To assess the effect of procurement decentralization strategy on the health of mothers and
children in Somalia
iv. To find out the effect of community participation decentralization strategy on the health of
mothers and children in Somalia
v. To establish the moderating effect of decentralization policy on the relationship between
decentralization strategy and the health of mothers and children in Somalia.
5. Research Hypotheses
i. Fiscal decentralization strategy has no significant effect on the health of mothers and children in
Somalia
ii. Administrative decentralization strategy has no significant effect on the health of mothers and children
in Somalia
iii. Procurement decentralization strategy has no significant effect on the health of mothers and children in
Somalia
iv. Community participation decentralization strategy has no significant effect on the health of mothers
and children in Somalia
v. a. To establish the moderating effect of decentralization policy on the relationship between fiscal
decentralization strategy and the health of mothers and children in Somalia.
b. To establish the moderating effect of decentralization policy on the relationship between administrative
decentralization strategy and the health of mothers and children in Somalia.
c. To establish the moderating effect of decentralization policy on the relationship between procurement
decentralization strategy and the health of mothers and children in Somalia.
d. To establish the moderating effect of decentralization policy on the relationship between community
participation decentralization strategy and the health of mothers and children in Somalia.
6. Independent Variables
Administrative Decentralization
Strategy
Decentralization of support staff hiring
Decentralization of staff training
Decentralization of hiring midwifes
Decentralization on hiring medical doctors
Procurement Decentralization
Strategy
Authority for local purchases
Engaging local suppliers
Percentage of procurement authority
Authority for local tendering
Decentralized Policy
Fiscal policy
Administrative policy
Procurement policy
Community participation
policy
Fiscal Decentralization Strategy
Autonomy on local revenue collection
Autonomy in local revenue spending
Autonomy in local health care budgets
Autonomy in local social program budgets
Health of Mothers and
Children
Number of mothers receiving
health care
Mothers who had receiving
prenatal care
Mothers who had receiving
postnatal care
Number of children receiving
vaccinations
Community participation
Community participation in social
programs
Community participation in running the
hospitals
Community participation in decision
Independent Variab
7. RESEARCH METHODOLOGY
• Research Philosophy -Positivism philosophy -to help the researcher operationalize the concepts,
formulate hypotheses which will be tested and provided the empirical explanations to the causes and
effects relationship between variables
• Research Design – Explanatory Research Design -explore and establish causal relationships between
variables.
• Target Population – 594 (97 doctors and 497 walk in mothers) staff and walk in mother patients in
hospitals somalia
• Sampling Frame – Hospitals of the federal states of Somalia.
• Sample Size- Yamane, (1973) formulae - 411
n=
𝑁
1+𝑁(𝑎)²
=
594
1+594(0.05)²
= 411
• Where: N = Total population, n = Sample population, α = Sampling error which is 0.05
• Sampling Technique –
• cluster sampling – doctors and mothers; purposive sampling method – identify the doctors
• Simple random sampling method- to ensure each member of the population has an equal chance of
being selected – walk in mothers
• Unit of analysis – Hospitals in Somalia
• Unit of observation – doctors and walk in mother patients
• Data Collection Instruments - unstructured questionnaire- capture opinion of respondents
