Civil Service Institute

Department of Public Administration

Assessment of the challenges and opportunities in decentralized

primary health care in Somaliland the case of borama local
government
By

Siham Abdillahi Ali

CSI/64//2016

Advisor

Mawlid Abdillahi

A Research Proposal/Thesis Submitted to the Department of Public

Administration, Civil Service Institute, in Partial Fulfillment of the
Requirements for the Award of Bachelor Degree in Public Administration

September, 2019

Hargeisa, Somaliland

1
 DECLARATION

Declaration page
I, Siham Abdillahi Ali, hereby declare that this submission is my own work and that, to the best
of my knowledge and belief, it contains no material previously published or written by another
person nor material which has been accepted for the award of any other degree or diploma of the
university or other institute of higher learning, except where due acknowledge has been made in
the text and reference list.

Name of the student______________________ Signature:___________ Date:_______

This is to certify that this thesis is the bonafide work of (Siham Abdillahi Ali), carried out under
my supervision.

Name of the Advisor______________________ Signature _____________Date:_____

2
 APPROVAL
Approval

This is to certify that thesis entitled “assessment of the challenges and opportunities in
decentralized primary health care in Somaliland the case of borama local government”
Submitted by Ms. Siham Abdillahi Ali to Civil Service Institute towards partial fulfillment of the
requirements for the award of the bachelor degree of arts in Public Administration.

Name of the Advisor: ________________________ Signature_____________________

Name of the External Examiner: _______________ Signature_____________________

3
 ABSTRACT
Decentralization has been defined and understood in multiple ways. Although typically defined
in public planning, management and decision-making as the transfer of authority and power
from higher to lower levels of government or from national to subnational levels, it frequently
has different characteristics for different writers. Decentralization has often been evaluated
according to Rondinelli, four-part classification of delegation, de-concentration, devolution and
privatization. Delegation transfers responsibility to a lower organizational level, de-
concentration to a lower administrative level, devolution implies transferring authority to a
lower political level and privatization takes place when tasks are transferred from public into
private ownership.

This study aims to examine and assess the challenges and opportunities of decentralized
Primary Health Care in Borama district, Somaliland. This study will look into some specific
questions which are; generally what is the role of the decentralization of primary health care in
borama? What are the challenges of the decentralization of Primary Health Care in borama
district? And also what are the opportunities it has?

The objectives of this study is to identify the role of decentralization of Primary health care in
borama district, to assess the challenges of decentralized primary health care in borama district
and to examine the opportunities of decentralized primary health care in borama district.

This study will used a descriptive study design. The research approach of this study will be both
a quantitative approach and qualitative approach. Probability sampling will used especially
stratified sampling in order to classify their characteristics. Probability sampling will used
especially stratified sampling in order to classify their characteristics. The source of population
of this study is the health district, MCH, and the health post. And the target will be the stuff of
MCH, district health section, and health post. The total number of the target population is 164
and the sample size of this population, which will be interviewed, is 49respondents. Used the
rule of thumb formula.

In question one 48% of the respondents agreed and other 10% strongly agreed that the
decentralization of primary healthcare in borama district is fully implemented, while 38% of
them disagreed that it is fully implemented. So this indicates that the majority of the respondents
agreed that the decentralization of Primary health care in borama is fully implemented. And in
the interview section the majority of the respondents said that the decentralization of primary
health care in borama works as it was intended, some other minority said it works smoothly but
no as it was intended.

Question one shows that one of the major challenges of decentralization of primary health care
in borama is the lack of local government support to the implementation process of the
decentralization system, 54% agreed and 6% strongly agreed, and it show that the majority

4
agrees that there is no local government support to implement the decentralization system which
is a major challenge to the primary health care.

AKCNOWLEDEMENT
The success of this study would not have been possible without the help, guidance and
contribution of the teachers, family, well- wishers and all dear ones. I would like to express my
gratitude to all those who gave us their blessings and support to complete this book. At the outset
I am deeply indebted to Allah, the almighty, for bestowing his grace and blessings upon me day
after day especially throughout this study.

I would also like to thank with sincere gratitude and respect to my supervisor Mawlid Abdillahi
for his inspiring guidance, valuable suggestions, timely advice, constant encouragement and
support for the completion of this study. Words are not sufficient to acknowledge his guidance
without which it would not have been possible to complete this work. I am deeply indebted to
my beloved parents. I owe my success to them who made this task possible through their
constant prayers, unconditional support and encouragement.

Any work will only bring about success when he or she is being supported by others. With a
great sense of gratitude I owe deep heartfelt thankfulness to all those who have paid the coin of
support and guidance to the successful completion of this study.

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 Table of Contents
DECLARATION.............................................................................................................................2

APPROVAL....................................................................................................................................3

ABSTRACT....................................................................................................................................4

AKCNOWLEDEMENT..................................................................................................................5

List of Tables and Figures...............................................................................................................8

ABBREVIATIONS.........................................................................................................................9

CHAPTER ONE: INTRODUCTION........................................................................................10

1.1. Background.....................................................................................................................10

1.2. Problem Statement........................................................................................................12

1.3. Research Objectives......................................................................................................13

1.3.1. General objectives..................................................................................................13

1.4. Significance of the study...............................................................................................13

1.5. Scope of the study..........................................................................................................13

1.5.1. Geographical scope................................................................................................13

1.5.2. Theoretical scope...................................................................................................13

1.5.3. Content scope.........................................................................................................14

1.6. Description of the study area.......................................................................................14

1.7. Limitations.....................................................................................................................14

CHAPTER TWO: LITERATURE REVIEW...........................................................................16

2.1. Theoretical literature....................................................................................................16

2.2. Empirical literature......................................................................................................17

CHAPTER THREE: RESEARCH DESIGN............................................................................19

3.1. Variable definitions.............................................................................................................20

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 3.1.1. Sample frame...............................................................................................................21

3.1.2. Sampling techniques..............................................................................................21

3.2. Source of data..................................................................................................................22

3.3. Data collection instrument..............................................................................................22

3.4. Data presentation tools....................................................................................................22

3.5. Data analysis and interpretations....................................................................................22

3.6. Ethical consideration.......................................................................................................23

CHAPTER FOUR: RESULTS AND DISCUSSION................................................................23

CHAPTER FIVE: CONCLUSION AND RECOMMENDATIONS......................................38

References......................................................................................................................................39

Appendix 1: QUESTIONNAIRE...............................................................................................41

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 List of Tables and Figures
Table 1 :.....................................................................................................................................................21
Table 2: ....................................................................................................................................................21
Table 3:.....................................................................................................................................................22
Table 4:.....................................................................................................................................................23

Figure 1: ...................................................................................................................................................25
Figure 2:....................................................................................................................................................26
Figure 3:....................................................................................................................................................27
Figure 4:....................................................................................................................................................28
Figure 5.....................................................................................................................................................29
Figure 6.....................................................................................................................................................30
Figure 7.....................................................................................................................................................31
Figure 8.....................................................................................................................................................32
Figure 9:....................................................................................................................................................33
Figure 10...................................................................................................................................................34
Figure 11...................................................................................................................................................35
Figure 12...................................................................................................................................................36

8
ABBREVIATIONS

9
 CHAPTER ONE: INTRODUCTION
1.1. Background

This chapter focuses on the background problem statement, objectives, scope of the study and
content scope, geographical scope, theoretical scope, time scope, as well as significance of the
study and lastly limitations.

Decentralization has been defined and understood in multiple ways. Although typically defined
in public planning, management and decision-making as the transfer of authority and power from
higher to lower levels of government or from national to subnational levels, it frequently has
different characteristics for different writers. (Collins, 1994), (Anne Mills, 1990)

Decentralization has often been evaluated according to Rondinelli, four-part classification of

delegation, de-concentration, devolution and privatization. Delegation transfers responsibility to
a lower organizational level, de-concentration to a lower administrative level, devolution implies
transferring authority to a lower political level and privatization takes place when tasks are
transferred from public into private ownership. (Rondinelli, 1983)

Decentralization is a difficult concept to pin down. Different scholars view it through a variety of
diverse, often inconsistent, sometimes overtly contradictory, analytic lenses. This divergence is
compounded by differences between those writing about decentralization as it applies in the field
of public administration generally, in contrast to those seeking to apply decentralization
specifically to the health sector. A range of additional questions arise when one seeks to assess
the actual outcomes of decentralization on pressing policy issues within health systems – its
impact on the capacity to provide long-term care, for example, or to construct integrated care
networks. It thus appears that decentralization covers the full range of possible judgments, with
what seem to be broadly positive outcomes to some authors or in certain contexts, becoming
broadly negative to other authors or in other contexts. (Richard B. Saltman, 2007)

The notion of community involvement in healthcare has a long tradition, but it is only in the past
ten years or so that community involvement in health care has emerged as a systematic approach
to the subject. Community involvement in healthcare is widely acknowledged to be essential to
the development of health services, particularly in developing countries, where the process of

10
involving community in other aspect of development, such as agriculture has already began. A
number of publications are now available which seek to explain the concept of community
involvement in health and it has begun to influence the health sector through, for example,
Primary health care (PHC), tropical disease control and clean water supply. (Oakley, 1989)

The authority delegated to different levels will vary from one country to another. Special purpose
area agencies can be on a wide range of scales and involve different types of recruitment, often
used in combination. The concept of deconcentration encompasses officials of the Ministry of
Health with widely varying levels of authority and status, such as District Medical Officers and
village health workers. The analysis of decentralization needs to recognize the variations
possible in each of the broad categories. (SMITH, 1997)

The decentralization of Ghana’s health sector began in 1988 with the World Health
Organization-supported Strengthening District Health Systems project and has led, most
recently, to the 1996 enactment of a comprehensive program of administrative deconcentration
and delegation. This program of fiscal decentralization within the MOH has already had
significant results in reallocating health resources toward district-based services and primary
care. The second principal element of the current reform program is the establishment of a
Ghanaian Health Service (GHS), autonomous from the Ministry of Health. Under the proposed
reforms, not fully implemented as yet, the MOH’s role will be reduced to one of policymaking
and regulation, while delegating health service delivery functions to the GHS. (Thomas Bossert,
2000)

On the other hand Somaliland government practices decentralization in primary health care with
the Ministry of Health (MOH). Like a few other government Ministries, MOH has been
decentralizing its functions and power to lower levels. The country currently has six regions. A
Region is headed by a Regional Medical Officer, who is appointed by the DG of MOH. The
structure of the regions mimics that of the Central MOH but mainly focuses on support to the
district health program. Each region has a Regional Health Board whose composition represents
the community. They are usually seven and have oversight functions on all health institutions in
the region including the hospitals, the regional health office, health centers, etc. However, they
have been known to fully support fund raising, especially for the hospital. As they are usually
from the business community, they are unable to provide clinical oversight required for the

11
hospital‘s clinical work. The regional health system is further divided into districts. Districts are
governed by the Executive Committee which comprises of an elected mayor and the deputy and
an executive secretary that is appointed by the Ministry of Interior. The electoral districts also
have elected council members who have been elected since 2003. District Medical Offices are
functional in a few of these districts. In general, district management capacity is still very limited
in many districts: leadership, management and specialist skills are in short supply at all levels of
health care. Community participation is also weak. (MoH, 2011)
1.2. Problem Statement

In Somaliland the Regional team and the District Health Teams supervise service delivery at
government health facilities at the Primary care level. However, challenges exist: supervision
and monitoring visits are irregular and poorly documented; there is a lack of tools and human
resource to conduct supervision especially in newly created districts; lack of supervisory skills at
district and regional levels; lack of transport for supervisory and monitoring visits; and
inadequate budgets. Efforts at national level to organize and support clinical supervision of the
Regional hospitals have not been very successful. In general, technical supervision is weak and
this has affected the quality of service. (MoH, 2011)

To date, studies evaluating the impacts of decentralization on PHC services in developing

countries provide mixed result. Positive results are more rational and unified health services that
cater for local needs and preferences, a reduction of health inequalities, community involvement
and improved intersectoral coordination. Negative results include capacity constraints (finances,
functionaries and staff) at local levels, poor support or direction from the center, a lack of clarity
about the role and responsibility of managing local services in the new set-up, and poor
coordination between central government and local authorities. Similarly, the impact of
decentralization on health services management and on service delivery has rarely been assessed.
Despite the widespread process of decentralization, little is known about the role that the health
sector plays in this process or vice versa. This gap in the impact of decentralization on the local
culture and circumstances needs to be addressed. (Krishna Regmi, 2009)

This study aims to examine and assess the challenges and opportunities of decentralized Primary
Health Care in Borama district, Somaliland. This study will look into some specific questions
which are; generally what is the role of the decentralization of primary health care in borama?

12
What are the challenges of the decentralization of Primary Health Care in borama district? And
also what are the opportunities it has?

1.3. Research Objectives

1.3.1. General objectives

The general objective of this study will be assessing the challenges and opportunities in
decentralized primary health care in Somaliland the case of borama local government.

The specific objectives of this study is to find out:

1. The identify to role of decentralization of Primary health care in borama district

2. To assess the challenges of decentralized primary health care in borama district.
3. To examine the opportunities of decentralized primary health care in borama district.

1.4. Significance of the study

This study will be a good source of information for health and public researchers to use it as a
primary source, it will also be a great recommendation for policy makers and national authorities
to act upon the results of this research whether it is a positive result to promote or a negative
result to change.

1.5. Scope of the study

The theoretical scope of the study will determine the challenges and opportunities in
decentralized primary health care in Borama district

1.5.1. Geographical scope

Borama is situated in a mountainous and hilly area. It has green meadows and fields, and

represents a key focal point for wildlife. The town's unusual fertility and greenery in the largely
arid countryside has attracted many fauna, such as gazelles, birds and camels.

1.5.2. Theoretical scope

This study will identify and assess the challenges and opportunities of decentralized primary
healthcare in Borama, it will also find out the outcomes of decentralization of primary healthcare
and at same time it will identify its challenges and limitations.

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1.5.3. Content scope

Content scope of the study will intend to describe the decentralization of primary health care and
its challenges and opportunities.

The study period started in April and will end November 2019.

1.6. Description of the study area

Borama is the regional capital of the region and has the largest population in the region. The
exact figure of the total inhabitants that live Borama town is uncertain, however, it is estimated
that total population of not less than 450,000 to 750,000 live inside Borama. Borama population
has greatly increased since the collapse of the former regime of Siad Barre due to IDPs from
Somalia in 1991 and returnees from refugee camps in Ethiopia and Djibouti. Borama is Grade
"A" district and is one of the six districts under the provision of Joint Program for Local
Governance (JPLG) program. Five UN agencies (UNDP, UN-HABITAT, UNICEF, NCDF,
and ILO) work close with the local government to carry out their responsibilities. Each of the
five UN agencies involves in a distinct role different from those of the other four. Some of the
areas in the JPLG program include financial management, planning and management of projects,
local counci's parliamentary procedures and leadership. Despite the important roles that
Somaliland constitution has assigned to local governments to plays in socio-economic
development of its constituency, Borama Local Government is not without challenges.

The regional governor office is in Borama, the regional capital. It was built during colonial
administration and had been the office of the then Borama District Commissioner. The building
is very old and made of mud bricks and is one of the few public offices not occupied by
squatters. It is a historic place and that could be a reason squatters got ashamed of its occupation
or it might have been prevented from occupation by patriotic individuals. Whatever the reason
might have been, it is a historic icon for the region

1.7. Limitations

There might be some limitations that can face during the conduction of this study, which are the
following; respondents may refuse to answer the interview questions due to their circumstances,
there also can be a language barrier which respondents may not understand the terms that are

14
used in this study. There also can be an attendance barrier which respondents may be absent
from the hospital at the time of interview which will be leading to postponing and delay of time.

15
 CHAPTER TWO: LITERATURE REVIEW
2.1. Theoretical literature

This study provides preliminary case studies of primary health care decentralization in
Somaliland. It looks at the ways in which decentralization affects local health sectors and its
decision makers and the range of choice available to them. It also analyzes the effect of
decentralization on performance of the health system in providing equity, efficiency, quality, and
financial soundness.

In the last two decades, health sector decentralization policies have been implemented on a broad
scale throughout the developing world. Decentralization, often in combination with health
finance reform, has been touted as a key means of improving health sector performance and
promoting social and economic development (World Bank, 1993). The preliminary data from the
field, however, indicate that results have been mixed, at best. In some cases, these limitations
have resulted in a backlash against the reforms and an initiative for recentralization. We believe
that this rejection is often premature or misplaced, and that the issue at hand is how to better
adapt decentralization policies to achieve national health policy objectives. In this context, it
becomes increasingly important to adequately understand the dynamics of health sector reform
processes in diverse contexts, to draw both general and case-specific lessons, and to formulate
effective strategies for future research and policy making.

The term “decentralization” has been used to connote a variety of reforms characterized by the
transfer of fiscal, administrative, and/or political authority for planning, management, or service
delivery from the central MOH to alternate institutions. These recipient institutions may be
regional or local offices of the same ministry, provincial or municipal governments, autonomous
public service agencies, or private sector organizations. (Prudhomme, 1995).

The range of policies grouped under the rubric of “decentralization” is quite diverse with respect
to objectives, mechanisms, and effects. This report make use of widely accepted terminology
developed by Rondinelli, who identifies three principal categories of decentralization:
deconcentration, delegation, and devolution. Deconcentration is generally the most common and
limited form of decentralization, and involves the transfer of functions and/or resources to the

16
regional or local field offices of the central government agency in question. Within a
deconcentrated system, authority remains within the same institution (e.g., the ministry of health)
but is “spread out” to the territorially decentralized instances of this institution. Delegation
implies the transfer of authority, functions, and/or resources to an autonomous private, semi-
public, or public institution. This institution assumes responsibility for a range of activities or
programs defined by the central government, often through the mechanism of contracting.
Devolution is the cession of sectoral functions and resources to autonomous local governments,
which in some measure take responsibility for service delivery, administration, and finance.
(Rondinelli, 1983),

2.2. Empirical literature

In many countries, decentralization is often undertaken as part of a sectoral reform process. In

this context, the world Development Report of 1993 states that a policy that can improve both
efficiency and responsiveness to local needs is decentralization of the planning and management
of government health services (World Bank, 1993). In reality, health system decentralization
takes many different forms, depending not only on overall governmental political and
administrative structures and objectives, but also on the pattern of health system organization
prevailing in the particular country (Anne Mills, 1990). It is generally believed that the
3decentralization of health sector would result in greater community participation in local health
activities, which, in turn, will lead to improved service quality and coverage. The following
advantages are generally cited as justification for decentralization of health care services: -

- A more rational and unified health services that caters to local preferences
- Improved implementation of health programmes
- Reduction in duplication of services as the target population are defined more specifically
- Reduction of inequalities between rural and urban areas
- Greater community financing and involvement of local groups
- Greater integration of activities of different public and private agencies
- Improved inter-sectoral co-ordination (Mills, 1994) (Yan Wang, 2002) (Kolehmainen-
Aitken, 1999).

17
On the other hand, according to Prud’homme, Decentralization has been predicted to improve
primary health care performance in a number of ways, including the following: (1) improved
allocative efficiency through permitting the mix of services and expenditures to be shaped by
local user preferences; (2) improved production efficiency through greater cost consciousness at
the local level; (3) service delivery innovation through experimentation and adaptation to local
conditions; (4) improved quality, transparency, accountability, and legitimacy owing to user
oversight and participation in decision making; and (5) greater equity through distribution of
resources toward traditionally marginal regions and groups. At the same time, fears have been
raised about potential macroeconomic destabilization and the aggravation of interregional
disparities in wealth and institutional capacity as a result of decentralization. (Prudhomme,
1995)

It is, thus, an accepted fact that health care cannot be achieved only through the department of
health services. Experiences all over the world suggest that one precondition for enhancing
health status is community participation. This, to a great extent, can be ensured through the
active involvement of the civil society including nongovernmental organizations (NGOs), locally
elected leaders in health programmes as well as private service providers. Decentralized
governance and local level participation can contribute to improving the health care facilities
through better monitoring and supervision of the functioning of the health system at the local
level. The small jurisdiction of decentralized local bodies allows the communities to adjust to
local social and cultural particularities while the adoption of short and simple administrative
process facilitates quick and focused responses to immediate needs. (Sekher, 2001)

There are varying experiences reported from different countries on whether decentralization
results in improving the provisioning of health services. The experience of Botswana shows that
a strong administrative structure is needed at district level for the effective decentralization of
health services (Maganu, 1990). On the other hand, the transfer of primary care clinics to
municipalities in Chile has not resulted in extending coverage or in improving the quality of the
services, mainly due to lack of professional supervision and poor planning by the area health
services (Aguilar Montoya, 1990). The initial experience of 'trial and error method' of
introducing decentralized decision-making in Netherlands has indicated that the process is too

18
slow and too complicated because of the large number of structural changes to be implemented
(Schrijvers, 1990).

In Papua New Guinea, it is observed that decentralization has enabled the Department of Health
to become revitalized and more technically competent (Reilly, 1990). In Senegal, the strong
political will at the highest level for decentralization and community involvement in health
system management was coupled with a close integration of public and private health activities
for operational purpose (Ndiaye, 1990). Drawing lessons from Spain, (Artigas, 1990) suggests
that the decentralization process should take place slowly after creating legal framework and
autonomous administrations so that the authorities become aware of what services can be
transferred. In Sri Lanka, the decentralization process paved the way for the active participation
of non-governmental and governmental organizations in the activities of health teams at the
village level (Cooray, 1990).

The above brief review of country-wise experiences indicate that many countries (developed and
developing) at different times have felt the need to institute large-scale organizational reforms
that favor a greater degree of decentralization in the health sector for supporting the
implementation of 'primary health care' and 'health-for-all' strategies. However, the
contemporary interest in health sector decentralization in developing countries has not been
sufficiently extended to the development of decentralized systems of human resource
management, especially in the onset and process of decentralization (Yan Wang, 2002). The
underlying problematic aspects of decentralization and human resources has been the lack of
constructive policy dialogue between those responsible for the formulation and implementation
of health sector reforms and stakeholders in the field of human resources. (Kolehmainen-Aitken,
1999) Underlines the pre-requisites for decentralization of health services such as active
involvement of health managers in the decentralized design, clear national resources allocation
standards and health services norms, and regular system for monitoring. The one lesson that does
seem clear from the existing experiences is that without proper planning and acknowledgement
of the lessons from other countries, decentralization of health care can be disappointing at best
and detrimental at worst. While a few developing countries have long-term experience with
health sector decentralization its impact on the management and the services delivered has rarely
been evaluated. Many country-study evidences confirm that poorly designed and hastily

19
implemented decentralization has serious consequences for health service delivery, and so far we
do not have an analytical framework to isolate or generalize the factors behind successful and
unsuccessful decentralization (Lucy Gilson, 1994).

CHAPTER THREE: RESEARCH DESIGN

This chapter describes the variables definitions, research type, research approach, and sample
design, source of data, procedure for data collection instruments, data presentation tools also data
analysis procedure and interpretations, as well as ethical considerations.

3.1. Variable definitions

Decentralization: the transfer of authority and power from higher to lower levels of
government

Or from national to subnational levels, it frequently has different characteristics for different

Writers.

Primary Health Care: Primary health care is a whole-of-society approach to health and well-
Being centered on the needs and preferences of individuals, families and communities. 

It Addresses the broader determinants of health and focuses on the comprehensive and
interrelated Aspects of physical, mental and social health and wellbeing.

3.2. Research type

This study will used a descriptive study design,
3.3. Research approach
The research approach of this study will be both a quantitative approach. And qualitative
approach
3.4. Sample design

Probability sampling will used especially stratified sampling in order to classify their
characteristics. The researcher will also employ a non-probability sampling from the study in
particular the purposive sampling.

20
3.4.1. Population

the target population of the study are staff 9 MCH, 1 health post and district health section under
the social affairs department of local government in Borama district There are 120 staffs that
works in MCH and 12 staffs whose works a section of health district section in local government
and lastly there is 12 staffs who worked the health posts.

The source of population of this study is the health district, MCH, and the health post. And the
target will be the stuff of MCH, district health section, and health post.

3.4.2. Sample size

The total number of the target population is 164 and the sample size of this population, which
will be interviewed, is 49respondents. Used the rule of thumb formula.

Formula rule of thumb

If the people less than or equal 1000 take 30 percent

164x30/100: the sample size will be 49 respondents.

3.1.1. Sample frame

Category Population Sample size

12 7

District health section

MCH 120 36

Health post 12 6

Total 164 49

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Source primary data 2019

3.1.2. Sampling techniques

The researcher will use probability sampling including the stratified sampling from the study in
order to classify the respondents based on their characteristics. And the researcher will also use
the non-probability sampling from the study in particular the purposive sampling in order to get
factual information from the key officials of the selected institutions.

3.2. Source of data

Normally we can gather data from two sources namely primary and secondary. Data gathered
through perception or questionnaire review in a characteristic setting are illustrations of data
obtained in an uncontrolled situation.

Primary source of data of this study will be from the questionnaire which will be interviewed to
the respondents. And the secondary source of data is all previous studies about this topic

3.3. Data collection instrument

Data collection instrument will be questionnaires used in this study which is consisted of an
open-ended questions and close ended questions, structured question with options which is
simple to guess and choose the right choice. And their will be a interview.

3.4. Data presentation tools

When the data collection will be done, I will check and count the questionnaire in order to
analyze it. In this study SPSS (statistical package for social science) v. 20 will be used to analyze
the collected data, and also charts (e.g. Pie and Bar) will be used for the analysis and also a short
interpretation for each chart to clarify what it is presenting.

3.5. Data analysis and interpretations

In data analysis and interpretations, I will use descriptive analysis method by using (SPSS) for
analyzing data.

22
Data will be analyzed using descriptive statistics namely frequency distributions, means, modes,
percentages and standard deviations. Data was presented in form of tables, figures, bar graphs
and charts.

3.6. Ethical consideration

The rights of the respondents, they could refuse to share their ideas, answer the questions freely
and could stop interviewing any time. One of the duties of data collectors is to explain the
objective of the study and its benefit to the intended Community.

I got a permission to carry this study from the admin the civil Service institute.

CHAPTER FOUR: RESULTS AND DISCUSSION

Age of the respondent

Valid
Frequency Percent Percent Cumulative Percent
Valid 20-25 21 41.2 42.0 42.0
30-35 15 29.4 30.0 72.0
40 and above
14 27.5 28.0 100.0

Total 50 98.0 100.0

Missing System 1 2.0
Total 51 100.0

Table 1 : shows that the majority of our respondent were 22-25 {41.2%} were {30%} were 30-
35 and while the age groups of 40 and above were {28%}

Gender
Frequency Percent Valid Percent Cumulative Percent
Valid male 19 37.3 38.0 38.0
female 31 60.8 62.0 100.0

23
 Total 50 98.0 100.0
Missin System
1 2.0
g
Total
51 100.0

Table 2: are about the sex distributions of the respondents. It is evident from this gender
frequency distribution table that the majority of respondents were female 62% while 38% were
male

Highest academic professional reached

Cumulative
Frequency Percent Valid Percent Percent
Valid Secondary 5 9.8 10.0 10.0
Diploma 12 23.5 24.0 34.0
Undergraduate 17 33.3 34.0 68.0
Postgraduate 16 31.4 32.0 100.0
Total 50 98.0 100.0
Missing System 1 2.0
Total 51 100.0

Table 3: this table shows us that the majority of the respondent 34% were undergraduate and
32% of the respondent were postgraduate 24% of the respondents were Diploma level 10% of
the respondents were secondary level

Number of years worked

Frequency Percent Valid Percent Cumulative Percent

24
Valid 1year 2 3.9 4.0 4.0
2years 10 19.6 20.0 24.0
3years 8 15.7 16.0 40.0
4years 14 27.5 28.0 68.0
5years and
16 31.4 32.0 100.0
above
Total 50 98.0 100.0
Missing System 1 2.0
Total 51 100.0

Table 4: this table is about the years that the respondent worked, the majority of the respondent
32% were worked 5years and above and 28%of them worked 4years and 20%worked 2years
and 4%of the respondent were only worked 1year.

25
Specific objective one: to identify the role of decentralization of Primary health care in
borama district.

This scale table shows the role of decentralization of primary health care in borama district. In
this table there is four questions as shown above, which are as the following:

Figure 1: in this figure 48% of the respondents agreed and other 10% strongly agreed that the
decentralization of primary healthcare in borama district is fully implemented, while 38% of
them disagreed that it is fully implemented. The sum of the respondents that strongly agreed and
the ones who just agreed is 58%, so this indicates that the majority of the respondents agreed that
the decentralization of Primary health care in borama is fully implemented. And in the interview
section the majority of the respondents said that the decentralization of primary health care in

26
borama works as it was intended, some other minority said it works smoothly but no as it was
intended.

Figure 2: In figure two describes the role of local government of borama district in the
decentralization of primary health care, 46% of the respondents agreed that without the support
of local government of borama there is no role of decentralization of primary health care, while
12% disagreed and 8% strongly disagreed to that. So that the majority (80% of agreed and
strongly agreed) show that the support of the local government of borama district plays vital role
in the decentralization of primary health care of borama district.

27
Figure 3: In figure three is related to question two, it describes the fact of whether the local
government of borama plays a vital role or not in the current time. 64% disagreed that the local
government plays a vital role in the primary health care, and 10% strongly disagreed which
indicates that the majority says; the local government do not support the decentralization of
primary health care in borama district. As it’s indicated in the previous question the
decentralization of primary health care needs and demands the support of the local government,
and this is a major challenge to the decentralization of primary heath care of borama district.

28
Figure 4: In figure four indicates the role of health education in the decentralization of primary
health care, 32% agreed that primary health education is included to the decentralization of
primary health care, and 26% strongly agreed which makes that the majority of the respondents
are agreed to it.

29
Specific objective two: To assess the challenges of decentralized primary health care in
borama district.

This scale table is about the assessment of the challenges of the decentralization of primary
health care. This also consists four questions which are as following:

Figure 5 shows that one of the major challenges of decentralization of primary health care in
borama is the lack of local government support to the implementation process of the
decentralization system, 54% agreed and 6% strongly agreed, and it show that the majority
agrees that there is no local government support to implement the decentralization system which
is a major challenge to the primary health care.

30
Figure 6 indicates whether the lack of political support to the implementation of the primary
healthcare policies is a challenge or not, 44% disagreed and 10% strongly disagreed, which
shows us that the majority of the respondents agreed that this is not a challenge to the
decentralization of primary health care in borama district.

31
Figure 7 describes that if the local government of borama do not properly run the primary health
care of the district? 64% disagreed that the local government do not run primary health care
properly while 12% agreed, and this identifies that the local government do properly run the
primary health care of the district.

32
Figure 8 shows that the financing is one of the challenges in the decentralization of primary
health care of borama district, 58% agrees that the financing system is one of the challenges
while other 24% strongly agreed to that. So the majority is that the financial constraint is a
challenge.

There is also other challenges that the respondents mentioned in the interview, the most common
challenges are; budget or financial challenges, there is no enough or sufficient staff and mostly
they have no capacity building and there is no enough infrastructure and.

Specific objective three: To examine the opportunities of decentralized primary health care
in borama district.

This table shows about the opportunities of the decentralization of primary health care in borama
district.

33
Figure 9: In this figure the majority of the respondents agreed that the opportunities of the
decentralization of primary health care in borama district is very wide such as financing and
other opportunities, where 46% answered that they agree and 8% said that they are strongly
agree while other 42% disagreed and 4% strongly disagreed, which minor to agreed percentage.

34
Figure 10 shows that the government supports the decentralization of primary health care in
borama district, 48% agreed and 10% strongly agreed while 36% disagreed and other 6%
strongly disagreed, which means that the majority of the respondents agreed that the government
supports the decentralization of primary health care in borama.

35
Figure 11 indicates that if the decentralization has an opportunity that the civil society can play
an important role in the implementation of the decentralization process, 58% agreed and 16%
strongly agreed which makes that the majority agrees that the civil society can play an important
role in the implementation process of the decentralization of primary health care in borama
district.

36
Figure 12 shows that the training of the stuff of the local government of borama will be a great
opportunity to the decentralization of primary health care in borama district, 48% strongly agreed
and 40% agreed while the rest percentage disagreed which is a minority in this, so the majority
agreed that the training of the staff will be a great opportunity to the decentralization of the
primary health care in borama district.

On the other hand the respondents has been asked, are there any opportunities of the
decentralization of primary health care in borama, the majority answered yes, and they suggested
dome opportunities which are, there will be a better implementation and the community will
understand more about the decentralization of primary health care, and community will
participate more.

37
 CHAPTER FIVE: CONCLUSION AND RECOMMENDATIONS
In conclusion the decentralization creates both opportunities as well as challenges for
primary health care provision. However, caution needs to be taken when interpreting the
findings and generalizing to a wider population because of the limited sample size and
relatively underrepresentation of the respondents. However, I believe that this study is a
valuable contribution to the policy debate of better health services by focusing of an under
researched group both in Borama and regional context. Evidence from this study noted that
active involvement of services providers, and development of partnerships between
government, civil society Organizations and the private sector, with clear and effective
policy and regulation, would bring changes in people’s health status.

An ongoing system of service delivery monitoring by local bodies, making the outcomes
available to the public including service users, is suggested for promoting equity and quality
and for improving efficiency. The study has also noted some discrepancies in service
delivery, and lack of capacity building in local authorities—services management
committees and intersectoral coordination among different authorities. Therefore, this study
suggests that decentralization should be taken as a ‘mission’—ensuring that the public’s
interest is at the center of the planning and decision making process, and that decentralization
should be based on evidence-based principles of what works best where and in what context
for improving the quality of, access to and utilization of district health services in meeting
the needs of the community.

I recommend to the local government, public authorities and service providers to develop
policies regarding the decentralization of primary health care to promote primary health care
delivery and access to the individuals, I also recommend to develop strategies and solutions
to overcome and solve every single challenge to strengthen the effectiveness of the
decentralization of primary health care and also to make new plans to use the mentioned
opportunities for the development of the decentralization of the primary health care in
borama. I recommend to the central government to widen and spread the decentralization in

38
primary health care to all other districts of the country specially districts of hargeisa the
capital city.

References
Aguilar Montoya, V. P. (1990). Decentralization and Local Management of the. In A. Mills,
Health System Decentralization: Concepts,. Geneva: WHO.
Anne Mills, J. P. (1990). Health system decentralization, concepts issues and country experience
. Geneva: WHO.
Artigas, J. (1990). Health Services Decentralization in Spain. In A. Mills, Health System
Decentralization: Concepts, Issues and Country Experience. Geneva: WHO.
Collins, C. a. (1994). Decentralization and primary health care: some negative. International
Journal of Health Services, 459–75.
Cooray, N. (1990). Decentralization of Health Services in Sri Lanka. In A. Mills, Health System
Decentralization: Concepts, Issues and Country Experience. Geneva: WHO.
Kolehmainen-Aitken. (1999). Decetralization of the Health Sector. In J. Litvack,
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system decentralization : concepts, issues and country experience. Geneva: World Health
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Mills, A. (1994). Decentralization and accountability in the health sector from an international
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292.
MoH. (2011). National Health Policy . Hargeisa : Ministry of Health .
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Decentralization: Concepts, Issues and Country Experience. Geneva: WHO.
Oakley, P. (1989). Community Involvment in Health Development . Geneva : WHO.
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Reilly, Q. (1990). Experience of Decentralization in Papua New Guinea. In Anne Mills, Health
System Decentralization: Concepts, Issues and Country Experience. Geneva : WHO.
Richard B. Saltman, V. B. (2007). Decentralization in health care. England : World Health
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Bank.
Schrijvers, G. (1990). The Decentralization of the Netherlands Health Services. In A. Mills,
Health System Decentralization: Concepts, Issues and Country. Geneva: WHO.
Sekher, T. V. (2001). Health Care for the Rural Poor: Decentralization of Health Services in
Karnataka, India. Bangalore, India: Institute for Social and Economic Change.
SMITH, B. C. (1997). The decentralization of health care in developing countries: organizational
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Thomas Bossert, J. B. (2000). Decentralization of Health Systems: Preliminary Review of Four
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40
 APPENDECIES

QUESTIONNAIRE

Dear Respondents,

I am carrying out this study to graduate B.A in public administration from Civil Service Institute.

The study title is “assessing the challenges and opportunities in decentralized primary
health care in Somaliland the case of borama local government.

”As your opinion in this study, may I request you to answer this questionnaire?

I Will appreciate if you give more consideration to answer all the questions and return as soon as

Possible.

Please note that your data will be used only for academic purpose and I will promise you that I

Will not use it for another purpose. Furthermore, the information you provide will be treated as a

Confidentiality.

I extremely appreciate your time you spent to fill this questionnaire.

Thank you very much indeed

Yours truly,

Siham Abdillahi Ali

B.A Candidate in Public Administration

Civil service Institute, Hargeisa Somaliland

41
Section A: Socio demography

Name. ………………………………………………….

Organization. ………………………………………….

Title. ……………………………………………………

1. Age
a. 20 – 25
b. 25 – 30
c. 30 – 35
d. 35 – 40
e. 40 and above
2. Gender
a. Male
b. Female
3. Highest academic professional reached
a. Primary
b. Secondary
c. Diploma
d. Undergraduate
e. Postgraduate
4. Number of years worked at this hospital/ health center
a. 1 year
b. 2 years
c. 3 years
d. 4 years
e. 5 years and above

42
Section B: choose one of the four scaling options for each one of the following questions.

Specific objective one: to identify the role of decentralization of Primary health care in
borama district.

Scale Strongly Agree Disagree Strongly

agree disagrees

1. The decentralization of primary health care in

borama district is fully implemented.

2. The decentralization of primary health care of

Borama has no role without the support local
government.

3. The decentralization of the local government of

Borama plays a vital role the primary health care of
the district.

4. The role of local government in the

decentralizations also includes the primary health
education.

Specific objective two: To assess the challenges of decentralized primary health care in
borama district.

Scale Strongly Agree Disagree Strongly

agree disagrees

1. The major challenges of decentralization include

lack of local support to the implementation process

43
 of the decentralization system.

2. There is lack of political support with the

implementation of the primary health care policies
in Borama district

3. The local government of Borama does not

properly run the primary health care of the district.

4. A financial constraint of the donors was one

challenge, which trapped the smooth running of the
decentralization of primary health care of Borama.

Specific objective three: To examine the opportunities of decentralized primary health

care in borama district.

Scale Strongly Agree Disagree Strongly

agree disagree

1. The opportunities of the decentralization of

primary health care in Borama district is very wide
such as financing.

2. The government supports the decentralization of

primary health care in Borama district.

3. The civil society plays important role in the

implementation of the decentralization process

4. The training of the staffs of local government in

Borama will be a great opportunity the
decentralization of primary health care in borama
district.

Section C: Interview questions

1. How does the decentralization of primary health care works in Borama district?
………………………………………………………………………………………………………
………………………………………………………….
………………………………………………………………………………………………………
………………………………………………………….

44
………………………………………………………………………………………………………
………………………………………………………….………………………

2. What do you think the challenges, which faced the implementation of decentralization of
primary health care in Borama district?

………………………………………………………………………………………………………
………………………………………………………….
………………………………………………………………………………………………………
………………………………………………………….
………………………………………………………………………………………………………
………………………………………………………….
………………………………………………………………………………………………………
………………………

3. Are there any opportunities for the decentralization of primary healthy care in Borama
district? If the answer is yes explain them?

………………………………………………………………………………………………………
………………………………………………………….
………………………………………………………………………………………………………
………………………………………………………….
………………………………………………………………………………………………………
………………………………………………………….
………………………………………………………………………………………………………
………………………

4. Does the decentralization of primary health care works as it intended by the government
in the Borama district?

………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………

45
46