HEALTH SERVICES DELIVERY DECENTRALIZATION STRATEGY, OND HEALTH

CARE OF MOTHERS AND CHILDREN INSOMALIA,

PhD Thesis Defense

By:
HDC 422-C004-1643/18
IBRAHIM ABDI HASSAN

Supervisors:
Prof. MAURICE SAKWA
Prof. FLORENCE ONDIEKI-MWAURA
Background of the Study

•Effective health service delivery is a vital component of any healthcare system and it is no gain saying that good health service delivery is
crucial to mother and child health in Somalia (WHO, 2010).

•Women's health is very important, based on their roles in the family, the community, and nation-building at large.

• Women are regarded as home builders, thus issues about their health cannot be overemphasized.

•Ensuring the availability of health services that meet a minimum quality standard and securing access to them are key health system functions
(WHO, 2010).

•Over the past years, the majority of the world's mother and child healthcare systems have been in a dismal situation.

•The World Health Organization (WHO) reported in 2017 that 810 women pass away each day from pregnancy- and childbirth-related causes.

•The majority of maternal fatalities occurred in low- and middle-income countries between 2000 and 2017.

•86% of the deaths in 2017 were in southern Asia and sub-Saharan Africa, totaling more than 250,000.

•This shows a depressing and unsettling pattern.

•While Southern Asia and sub-Saharan Africa were responsible for the majority of these fatalities, it was also noted that Southern Asia had a
general drop in fatalities, (WHO (2017).
Background of the Study Cont..
•The majority of maternal deaths have been linked to disparities in access to healthcare, with low- and high-income
economies showing different trends.

•For instance, according to the WHO report, maternal mortality rates in low-income economies were 460 for every
100,000 live births, compared to 11 for every 100,000 in high-income economies.

•The majority of communities, particularly those in rural areas, must deal with subpar maternal and pediatric healthcare.

•The WHO study from 2017 makes clear that there are more pregnancies among women in the least developed nations
than in developed nations.

•The majority of deaths in women are due to complications, however, with a proper healthcare system, these
complications can be avoided.

•According to the World Health Organization (WHO) in 2017), the majority of maternal mortality occurred in developing
and middle- countries between 2000 and 2017.
Background of the Study
•Globally, 3 million newborns die each year and there are 2.6 million stillbirths, with Africa accounting for more than half of both
numbers

•India has made significant progress since its Independence through improvement in life expectancy, reduction in infant mortality
and crude death rates, effective eradication of diseases such as small-pox and polio, and so on (Patel et al. 2015).

• Life expectancy has increased by almost four years over the last ten, from 64.4 years in 2005 to 68.3 years in 2015. The rate of
infant mortality has declined from 57 deaths per 1,000 live births in 2005 to 37 deaths per 1,000 live births currently.

•India’s human development index has improved from 0.494 in 2000 to 0.624 in 2015, with the country ranking at 131 out of a total
of 188 countries in 2015 - an improvement of 4 ranks from the corresponding 2010 figure (UNDP, 2016).
• Thailand, despite many impressive successes in health system development, the country implemented the decentralization
policy slowly although it was clearly stated in the Constitution since 1997.
• From 1999 to 2012, the share of the local government (LG) budget in the central government budget increased from 9% to
26.8% although it was targeted at 35% by 2006.
• According to the Decentralization Action Plan for health care, there was a need to transfer all public health facilities to the local
government LG.
• However, there were only 28 health (HCs), which accounted for only 0.3% of total HCs being devolved to local government
LGs in 2007–2008 (Pongpisut & Jaruayporn, 2012).
 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).
 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).
•The situation of access to medical care by mothers and children in Somalia is currently undergoing a rapid shift as access to health
care is improved as a result of the decentralization of health services to local governments.
•Although Somalia's government has approved a constitution to empower citizens, setting the way for accessible access to health care,
more has to be done in terms of assessing the role of decentralization in health service delivery (MOHDPS, 2013).
Statement of the Problem
•Somalia, faces a pressing and complex challenge concerning the health of mothers and children.

•Despite global efforts to improve maternal and child health, this region continues to grapple with high rates of maternal and child
morbidity and mortality.

•The intersection of socio-economic, political, and healthcare system challenges creates a multifaceted problem that demands urgent
attention and targeted interventions (Reliefweb, 2021).

•Somalia witnesses alarmingly high maternal mortality rates, with many mothers succumbing to preventable complications during
pregnancy and childbirth.

•Limited access to quality prenatal and obstetric care, compounded by a shortage of skilled healthcare professionals, exacerbates the
vulnerability of pregnant women.

• Cultural factors, including traditional birthing practices, often contribute to delays in seeking medical assistance, putting mothers at
increased risk (Somali Health Advisory Board , 2015).

•Thus, mother and child mortality rates remain a significant concern in Somalia, but many practitioners believe that health decentralization
can improve the health of mothers and children.
 Statement of the Problem Cont.
•Factors such as malnutrition, inadequate immunization coverage, and a lack of access to basic healthcare
services contribute to the vulnerability of young children.
•Infectious diseases, exacerbated by challenges in medical access, unsanitary living conditions and insufficient
water and sanitation infrastructure, pose persistent threats to the health and well-being of the youngest members
of the community (OCHA, 2021).
•In contrast, India’s infant mortality has declined from 57 deaths per 1,000 live births in 2005 to 37 deaths per
1,000 live births currently. Somalia is among the 15 countries that WHO marked as very high alert countries for
maternal deaths as it has one of the worst maternal conditions in the world (Adam, Magan, & Ali Omar, 2021).
•Decentralization may be implemented to stimulate economic growth, reduce rural poverty, strengthen civil
society, deepen democracy or to delegate responsibilities onto lower-level governments.
• However, decentralization reforms are bound to have varying levels of success in achieving their intended
effects on health systems, such as equity in population health outcomes, health system efficiency, and health
system resilience, including how community engagement influences these effects (Seye, Leonard, & Maryam,
2019).
•Thus, there still exist a gap in health services delivery in Somalia, thus, this study seeks to fill that gap by
establishing the moderating effect of decentralization policy on the relationship between health service
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.
 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.
 Significant of the Study
• Healthcare Professionals and Providers
• Community Members and Local Authorities
• Policy Makers and Government Authorities
• Development Organizations and NGOs
• Researchers and Academics
Scope of the Study
• Variables - decentralization policy, health services decentralization delivery strategy,
health of mothers and children in Somalia.
• Five general hospitals in the five federal member states in Somalia
• Fiscal decentralization strategy, administrative decentralization strategy, procurement
decentralization strategy, decentralization policy and the health of mothers and children
in Somalia.
• The study will be carried out in the month of June and July 2024.
 Theoretical Review

• Participatory Rural Appraisal Approaches

Participatory rural appraisal is a citizen-centred method of development. The concept of
PRA has evolved overtime since, “as a development tool, it cannot just stop with
committing the people in appraising and analysis their problems...rather, it must go
beyond that and extend into analysis, planning and action
• Community Development Theory
Community development theory is a framework that provides explanations and
understanding of people's behavior in the context of community life and social and
economic change
• The Souffle theory of Decentralization
The soufflé theory of decentralization" attempts to bring together the dimensions of
decentralization and to relate them to a set of intermediate outcomes that are likely to
have an important impact on overall rural development outputs and outcomes
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

Administrative Decentralization Strategy

 Decentralization of support staff hiring
 Decentralization of staff training


Decentralization of hiring midwifes
Decentralization on hiring medical doctors
Health of Mothers and Children
 Number of mothers receiving health care
 Mothers who had receiving prenatal care
 Mothers who had receiving postnatal care
Procurement Decentralization Strategy  Number of children receiving vaccinations
 Authority for local purchases
 Engaging local suppliers
 Percentage of procurement authority
Independent Variables
 Authority for local tendering

Community participation Decentralized Policy

 Community participation in social programs  Fiscal policy
 Community participation in running the hospitals  Administrative policy
 Community participation in decision making  Procurement policy
 Community participation policy
Independent Variables Moderating Variable
 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== = 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
Cluster/ State General Target population/ Sample Size/ Target Sample Size/ Mothers

Hospitals Doctors Doctors population/

Mothers

Puntland Gerowe 9 7 35 15

South West Baydoba 18 15 133 58

Gal-Mudug Dhusamareb 15 12 57 24

Hir-Shabelle Jowhar 5 4 23 10

Jubaland Kismayo 50 40 249 117

97 78 497 224
Grand total 411
• Pilot study – 28 questionnaires in health centers in Somalia
• Valility and validity will be tested
• Reliability test- Cronbach Alpha – recommended score >.7
• Validity Test - Content validity by supervisor, convergent validity by Factor Analysis
• Data Collection Procedures –Introduction letter from JKUAT, permit from NACOSTI
Data collection will be administered through drop and pick method.
• Data Processing - edited, cleaned, coded and tabulated and correct any errors
• Data Analysis -Statistical Package for Social Sciences (SPSS) software version 25.
• Descriptive statistics –mean, standard deviation, Skewness and Kurtosis
• Inferential statistics –Moderated multiple linear regression, Pearson’s moment
correlation, ANOVA and model summary will be generated
 Model Specification of the Study
Before moderation
Y = β0 + β1X1 + β2 X2 + β3X3 + β4X4+ɛ …………………………….………………..(eq. 3.1)
Y= Health of Mothers and Children in Somalia
X1= Fiscal decentralization strategy
X2 = Administrative decentralization strategy
X3 = Procurement decentralization strategy
X4 = Community participation decentralization strategy
Ɛ: Error term, β0: Intercept.
βi: coefficient of the independent variable i which measures the responsiveness of Y to changes in i.
With moderation;
Y = β0 + β1X1*DP+ β2 X2*DP+ β3X3*DP+ + β4X4*DP + ɛ ………………………………..(eq. 3.2)
Y= Health of Mothers and Children in Somalia
X1= Fiscal decentralization strategy
X2 = Administrative decentralization strategy
X3 = Procurement decentralization strategy
X4 = Community participation decentralization strategy
DP = Decentralization policy
MLR assumptions: Normality, Linearity, Multicollinearity, Heteroscedasticity test will be done
Thank you.