List of acronyms

AVSI- international service voluntary association

CAO – chief administrative officer

DHO/DDHS- District health officer/district director of health services

Et al: And others

GoU: - Government of Uganda

HC: - Health center.

HRH: Human resource for health

HSD- Health sub district.

HSSP- Health Sector Strategic Plan

LC: – Local council

MDG: Millennium development goal

NGO- Non Governmental organization

NHP:- National health policy

NRH:- National referral hospital

MoH:- Ministry of health

PHPs- private health practitioners

PNFPs- Private not for profit facilities

PPPH: private public partnership for health.

RRH- Regional referral hospital

UNOCHA- united nation office for coordination of humanitarian affairs.

WHO- world health organization

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List of tables

Table one ………………………………………………………………………….18

Table two ………………………………………………………………………….22

Table two ………………………………………………………………………….22

List of figures

Fig 1………………………………………………………………………………….10

Fig 2………………………………………………………………………………….15

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Chapter one: INTROUCTION.

1.1 General introduction

This chapter will highlight the basic information about the study area and

also describe briefly what is meant by NGOs; there mandates and their

contributions in primary health care activities in the world and most

importantly in Uganda. A conceptual framework for the study has also been

presented herewith.

Defining the concept NGO.

The concept NGO is quite amorphous and obtains what it is not rather than

what it is. Green 1997, defined NGOs as organizations that are outside the

direct control of the state, he further says NGOs are non profit making and

welfare promoting. Green’s definition however has some limitations as some

NGOs are controlled directly or indirectly by the state

In NGO literature, the umbrella term ‘non-governmental organization’ is

generally used throughout, although the category ‘NGO’ may be broken

down into specialized organizational sub-groups such as ‘public service

contractors’, ‘people’s organizations’, ‘voluntary organizations’ and even

‘governmental NGOs’ or ‘grassroots support organizations’ and

‘membership support organizations’ (Lewis, 2006)

NGOs are defined by the World Bank as "private organizations that pursue

activities to relieve suffering, promote the interests of the poor, protect the

environment, provide basic social services, or undertake community

development" -NGO research council 2007

Non-governmental organizations (NGOs) as we know them today are

generally thought to have come into existence around the mid-nineteenth

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century, at least about 1839. It has been estimated that by 1914 there were

1083 NGOs already.

It was only about a century later that the importance of NGOs was officially

recognized by the United Nations. At the UN Congress in San Francisco in

1968, a provision was made in Article 71 of the Charter of the United

Nations framework that qualified NGOs in the field of economic and social

development to receive consultative status with the Economic and Social

Council.

The development of modern NGOs has largely mirrored that of general

world history, particularly after the Industrial Revolution. NGOs have

existed in some form or another as far back as 25,000 years ago. Since

1850, more than 100,000 private, not-for-profit organizations with an

international focus have been founded. The growth of NGOs really took off

after the Second World War, with about 90 international NGOs founded

each year, compared with about 10 each year in the 1890s. Only about 30

percent of early international NGOs have survived, although those

organizations founded after the wars have had a better survival rate. Many

more NGOs with a local, national or regional focus have been created,

though like their international counterparts, not all have survived or have

been successful.

The growth and development of NGOs has been related to specific events in

the world history as they have unfolded, from the aftermath of the Industrial

Revolution to the World Wars and through the aftermath of the Cold War.

According to global civil society 2001, there are about 4,000 international

NGOs operating worldwide, the highest numbers being in India and Russia

with 33,000 and 40,000 local and international NGOs respectively while

Uganda had about 3,000 NGOs by the end of 2009.

According to UNOCHA Kitgum district by the end of 2009 had 50 different

NGOs both international and local operating in areas of health, education

and social welfare.

4

Rational for NGOs intervention in health service delivery.

Non-Governmental Organizations (NGOs) have equipped themselves

adequately and come up enthusiastically in providing services like relief to

the displaced, disadvantaged and helping the government in , TB and HIV,

malnutrition, water and sanitation ,mother and child health care, including

family planning programs among others. (A.Chitra 2009)

As a result, all concerned have realized the potential of NGOs and their

considerable merit compared to the public/private health sectors because of

their staff’s motivation, dedication and sympathy for the deprived sections

of our society and their personalized approach towards the solution of

problems. (A.Chitra 2009)

The Health sector strategic support plan 2010 (HSSP III) and National

Health Policy (NHP 2) 2009, states that there should be greater

involvement of NGOs in the implementation of health care services in the

country. In recognition of the crucial role played by them, Government of

Uganda started granting financial aids to some NGOs for various schemes.

(NH policy 2009/HSSP III 2010)

The important role played by the various national and regional level NGOs

in Uganda is briefly documented in the ‘The national health inventory 2009’

where special mention has been made of such organizations like The AIDS

Information center(AIC), the AIDS support organization (TASO) Family

Planning Association of Uganda (FPAU), Uganda Medical Association

(UMA), AVSI, Action contrẽ la faim/action against hunger (ACF) among

others, the Greater roles of the NGOs was seen to ensure Health for All

through the primary health care approach. Their role was also considered

as most crucial to translate the concept of ‘People’s Health in People’s

Hands’ bestowed in the Uganda’s health policy into action.

1.1.1 Area of study.

The study shall be conducted in kitgum district in Northern Uganda.

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1.1.2 Historical background

When the Imperial British East Africa (IBEA) was trying to establish

authority and control in Uganda, it initially intended to form two

administrative units in areas occupied by the Acholi-speaking ethnic group.

The first district called Acholi was to occupy present-day Gulu district and

extend up to Nimule in today’s Southern Sudan.

The second district should have been called Chua with its headquarters in

Dibolyec in present-day Lokung sub-county, Lamwo County, Kitgum district.

The advance team of colonialists led by Corporal Musa and his soldiers

brought to Acholi aspects of Kiganda culture, including having all men

concede that the Buganda Kabaka would take any of the Acholi wives at

will. The Acholis treasured wives because they earned them in exchange for

ivory.

Corporal Musa began to build a fort at Dibolyec (meaning an arena of

elephants) using forced local labour. He was an agent of Semei Kakungulu,

the colonialist’s chief agent in the country, who was still in Eastern Uganda.

The fundamental mistake they made was that while the able-bodied men

were working on the fort Corporal Musa and his soldiers was busy raping

the wives of the men working on the fort. The locals learnt of that dirty act

and hatched a plan to kill Corporal Musa and all his soldiers. Indeed Musa

was killed during a pre-arranged Otole dance at Dibolyec.

That history is well recorded in one Otole dance song: "Lugot oneko Musa

nyong; Odong Kakungulu." meaning, “It is good the people from the

mountain (read hills) have killed Corporal Musa indeed. We are left with

Kakungulu”.

The survivors retreated to a small hill, about 50km further south of Dibolyec

in present day Kitgum town. Acholi call this hill "Kidi Guu". Colonialists

could not pronounce ‘Kidi Guu’ so they instead called it Kitgum.

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When finally demarcating the boundary between Imperial British East

Africa (IBEA) and Anglo-Egyptian Rule in 1926, the colonial masters

decided to cut away part of northern Acholiland and make it part of Sudan.

This area included volcanic soil-rich Upper Talanga, Katire, Palutaka,

Parjok, Owiny-Kibul, Opari and Nimule.

Two reasons can be advanced for: One was to punish the Acholi ethnic

community for resisting colonialism. Many leaders like Rwot Awich (Payira)

Rwot Ogwok (Padibe) and Rwot Olyaa (Atiak) are known to have fought

colonialism. The second reason was to divide the Acholi and reduce their

resistance to colonial authority.

At independence on 9th October 1962, there was one Acholi district in

Northern Uganda. A second chunk of Acholi speaking ethnic group occupied

the immediate borderline in Southern Sudan.

During the reign of Idi Amin (1971-1979) East Acholi district, later renamed

Kitgum was curved out of a united Acholi district during the Idi Amin of

1971-1979. The name kitgum come from ‘kidi Guu’- (Guu Hills) . West

Acholi district was later renamed Gulu, and remained west of Aswa River

which flows through the two districts. On December 4th 2001, Pader

district was curved out of Aruu and Agago counties of Kitgum district.

1.1.3 Geographical background

Kitgum is one of the most remote districts in Uganda, lying on the border

with the Republic of Sudan, with Kotido District to its East, Pader District to

the South and Gulu District to the West. Its land area measures about 7,557

square kilometers.

The district receives average annual rainfall of 1330mm. Rain starts in late

March or early April and ends in November. Rainfall is bimodal with peaks

in April and August. It is dry-hot and windy from December to mid March.

The average monthly maximum temperature is 270 c and average monthly

minimum temperature is 170 c.

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1.1.4 Physical features

The land is semi-arid but about 80% of it is classified as arable. The

vegetation is predominantly savannah and the relief generally flat in most of

the district except toward the border with Sudan, where there are hills with

gentle slopes. Kitgum District experiences dry and rainy seasons.

Population, morbidity and mortality (demographic) background.

Kitgum has a projected population of 228,900 in 2010, according to the

2002 housing and population census, kitgum district had a population of

283,546 people. There were 137,186 males and 144,188 females. Of these,

42493 inhabitants were in kitgum Town council, Lamwo county (now

Lamwo district had 114,168) Chua county including town council (now

kitgum district) had a population of 168,378.

According to the Kitgum district population office 2003, the population of

kitgum was reflecting a relatively low population density of 29 persons per

square kilometers. Its annual population growth rate, estimated to be at

3.6% per annum, is just above the country’s average.

Kitgum district has two hospitals, one public and the other one is private

(missionary hospital), one health center IV, eight health center III and eight

health center II and with three other non functional health units.

The district has a total of 22 health facilities, out of these, 19 (80%) are

functional; while 3 (20%) of the units are non functional. Most of the non

functional health units have either just been completed and not yet opened

or have no health staff posted to run tem

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Accessibility to health care, defined as the proportion of the population

within a radius of 5km of a Health Centre III, was in 2010 estimated at only

37.4%, against a national average of 49% (UNOCHA 2010).

The burden of disease consists mostly of communicable diseases, including

malaria, diarrhea, Acute Respiratory Infections (ARIs), intestinal worms,

trauma and injury.

The HIV prevalence rate in north-central Uganda, where Kitgum District

lies, averages about 8.2%, significantly above the national average of 6.7%.

The infant mortality in Kitgum is estimated at 274/1000, more than three

times the national average rate of 88/1000. At the height of the insurgency,

malnutrition among children, was acute in the affected areas, affecting up

to 31% of under-fives and was a major underlying cause of their high death

rate.

The district had cholera outbreak that was considered the longest outbreak

ever in the history of the nation with 1,714 cases with 31 deaths

(cumulative fatality rate (CFR) = 1.6%) below the recommended level 5% in

complex emergencies. Then later, hepatitis E outbreak. And now yellow

fever disease (District health office kitgum 2010)

Political background

The district has only one administrative county i.e. Chua, and further

subdivided into smaller administrative units: 10 sub-counties (including

kitgum town council) and 50 parishes.

Under Uganda’s decentralized administrative structure, most of the

government funded services are provided at the level of the district, which

is administered by an elected Chairperson, his/her cabinet and a quasi-

legislature formally known as Local Council Five (LC V). The LC V is

constituted by elected representatives of sub-counties.

The second most important level of service delivery in the local government

hierarchy is the sub-county (Local Council III), with an administrative setup

similar to that at the district level.

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It’s at this point that most policies, planning and allocation of public fund in

provision of social services are done. It’s responsible for the

implementation, coordination and monitoring of other stakeholders in

service delivery.

1.2 Statement of the problem

In an attempt to improve health sector performance, Uganda pursued a

variety of health sector reforms, including decentralization.

Decentralization has been touted as the key management strategy in the

countries’ health policies of the last two decades. One of the components

the strategy seeks to address is the participation of the non-governmental

organizations in helping the government to achieve stated national health

objectives. Within the framework of decentralization, the extent to which

the strategy has been implemented can be seen as an indicator of progress

towards the health goal through giving opportunity for the participation of

NGOs in providing health services

1.3 Purpose of the study

The study will be conducted to establish the challenges facing NGOs in the

implementation of primary health care service delivery in kitgum district

with the view of offering some practical solutions as well as literature for

future researchers in the same field.

1.4 General objectives

The overall objective of this study is to establish the challenging facing

NGOs in health service delivery in kitgum district.

1.5 Specific objectives

1. To establish the challenges within the NGOs themselves (internal)

facing NGOs in the delivery of health services in kitgum district.

2. To establish the external challenges facing NGOs in the delivery of

primary health care activities in Kitgum district.

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3. To establish environmental challenges facing NGOs in the delivery of

primary health care .

1.6 Research question

1) What are internal challenges facing NGOs in the delivery of primary

health care activities in kitgum district?

2) What are the external challenges facing NGOs in the delivery of

primary health care activities in kitgum district?

3) What are the environmental challenges facing NGOs in the delivery of

primary health care activities in kitgum district?

1.7 Scope of the study

1.7.1 Geographical scope

The study shall be conducted in Kitgum district. The district is located in

northern Uganda. It is bordered by Lamwo district from the north, Pader in

the south, Kotido in the east and Gulu in the south east. Kitgum district has

two hospitals, one public and the other one is private (missionary hospital),

one health center IV, eight health center III and eight health center II and

with three other non functional health units.

The district has coverage of 37% of the population within areas covered by

operational health center within 5km, and with 32 out of 50 parishes

without any health center. Kitgum has a projected population of 228900 in

2010, according to the 2002 housing and population census, kitgum district

had a population of 283,546 people. There were 137,186 males and 144,188

females. Of these, 42493 inhabitants were in kitgum Town council, Lamwo

county (now Lamwo district had 114,168) Chua county including town

council (now kitgum district) had a population of 168,378.

Content scope

This study will concentrate in finding out the major challenges facing NGOs

in the delivery of primary health care in district especially the internal,

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Extraneous Variables Attitudes Cultural practices (tradition) Incomes levels among the populationPolitical influence

INDEPENDENT VARIABLES Structures and functionsDistrict level Management /Health service Delivery (hospital) Sub County Level health service delivery (Heath Centre)Parish Level Health service Delivery (Clinic)Village level health Service delivery (Village Health teams) Outreach workers of NGOs

DEPENDENT VARIABLEEfficient and effective health service delivery Functional structures of the health structures Transparent and accountable health service delivery Healthy Population in Kitgum Districts.

Planning and Budgeting Lower level inputsPrioritized service delivery Adequacy of the services

NGOs

external and environmental challenges in the delivery of health services in

kitgum district.

1.7.3Time scope

The scope will be conducted between December 2010 to June 2011.

Significance of the study

Primary health care Service delivery under NGOs system seems to be far

from reaching its intended primary purpose, increasing efficiency and

effectiveness while popularizing local participation, staff involvements,

compliance with local laws and increasing sense of ownership and

responsibility at the same time while reserving the sense of meeting the

universal human rights to access health service and attaining MDGs is a big

challenge and yet its of focus.. The study will therefore

1. Provides an opportunity to Kitgum District Local government to

deepen learning on the dynamics surrounding the health service

delivery under NGOs systems and harness such lessons to deliver

quality but also easily accessible health services by all.

2. Provides insights into other related studies that may be taken for

academic interest and or for pragmatic actions by stakeholders at

various levels in the decentralized system of governance.

3. Offer firsthand experience for the researcher to understand the

dynamics of PHC research.

fig1. Conceptual framework of NGOs involvement in health service delivery

in Kitgum district.

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Chapter two: LITERATURE REVIEW.

2.0 Introduction

This chapter will explore theories relevant to the study. It will deepen the

understanding of the concept of NGOs participation in health service

delivery with particular emphasis on the functionality of the various

stakeholders in the system, planning frameworks, accountability

mechanisms and participation of all the key players in the system.

2.1 Health service delivery in Uganda

The delivery of health services in Uganda is done by both the public and

private sectors with GoU being the owner of most facilities. GoU owns 2242

health centers and 59 hospitals compared to 613 health facilities and 46

hospitals by PNFPs and 269 health centers and 8 hospitals by the PHPs.

Because of the limited resource envelope with which the health sector

operates, a minimum package of health services has been developed for all

levels of health care for both the private and the public sector and health

services provision is based on this package.

The social services provided by local governments are financed mainly by

grants from the central government, supported by multilateral and bilateral

donors, and supplemented by local revenues. Uganda runs a liberalized

economy, where both the profit-motivated and not-for-profit private players

are also involved in the provision of social services like healthcare and

education.

The health sector in Kitgum District is headed by the District Director of

Health Services (DDHS), who chairs the District Health Team.

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Primary health care

The c o n c e p t of primary health care was defined by World Health

Organization (WHO) in 1978 September 12 at Alma-Ata as both a level of

health care delivery and an approach to health care practice. It was

estimated that 75- 85% of the population seek care at this level yearly and

therefore, it provides both the initial and majority of health care services of

a person or the population. This is in contrast to tertiary health care which

is consultative, short termed and disease oriented for the purpose Primary

health care tackles the root causes of ill health, and attacks threats to

health, better use of existing interventions could prevent 70% of the global

disease burden. (WHO 1978)

Primary Health Care (PHC) is defined as: Essential health care based on

practical, scientifically sound, and socially acceptable methods and

technology made accessible to individuals and families in the community

through their full participation and at a cost that the community and

country can afford to maintain in the spirit of self-reliance and self-

determination. (Health for All by the Year 2000, WHO 1978, Alma Ata)

Health Service Delivery is conceptualized as the relationship between

health policy makers, health service providers, and the poor people. It

encompasses services and their supporting systems that are typically

regarded as a state responsibility.

PHC is based upon the following components: Promoting good nutrition ,

Access to safe water and basic sanitation , Improving maternal and child

health care, including family planning, immunizing against major

infectious diseases, Preventing and controlling locally endemic diseases,

Fostering education on common health problems their prevention and

control measures, Treating common diseases and injuries , Access to

essential drugs(The Johns Hopkins Public Health Guide for Emergencies

2003)

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The implementation of primary health care requires a minimum of

preconditions as follows:

Availability of a sufficient number of qualified human resources for health,

Availability of adequate infrastructure according to the guidelines/norms,

Availability of financial resources, Availability and accessibility of affordable

quality essential medicines

Health Service Delivery is conceptualized as the relationship between

health policy makers, health service providers, and the poor people. It

encompasses services and their supporting systems that are typically

regarded as a state responsibility.

The broad purpose of a health system calls for many players addressing the

complexities in the system , Having many players working towards better

health, good organization is paramount; he recognized that ,the National

Policy must respond to people’s needs and expectations., Institutions need

to be well organized, facilitated, and regulated for the purposes they serve

towards better health.

Roles of the Uganda health system

A health system is Complex to define, however, a health system is taken to

include “all activities whose primary purpose is to promote, restore or

maintain Health” This definition encompasses Health actions and Non-

Health actions within and outside the Health Sector that lead to desired

health results.

According to Dr. Francis Runumi, commissioner health planning MoH

Kampala, the Uganda health system has the following roles ; Stewardship

Roles: which include Policy development and Appraisal; Standards Setting;

Accreditation; Quality Assurance; Coordination of sector players:

The Sector Wide Approach – working with Development Partners; Public

Private Partnerships in Health; Inter-sectoral Collaboration; Ensuring

community involvement; Ensuring fairness and equity to access and

financing health services; Accountability to ensure the sector is responding

to people’s needs and expectations; Health financing , developing and 15

mobilizing management of resources for health , however, this functions

have been greatly challenged by human resource crisis, leadership crisis,

low sector budgeting and low opportunities invested in training and

capacity building

There are significant barriers to access to health services Uganda by the

poor people. Quality of services, distance from health services and the cost

of using services present major obstacles. Most medical staffs are in the

hospital sector and in urban areas and productivity tend to be low.

(Health briefing IHSD)

NGO in Uganda have been pivotal in the last years, providing a unique

contribution in channeling the huge funding coming from the so-called

“western countries” and international institutions such as the International

Monetary Fund, the World Bank and the UN agencies. NGOs represent a

fundamental link in the aid chain

The NGO sector, however, still faces a number of obstacles that are

hampering its rapid development. One of the main constraints has been the

fact that they are still insufficiently organized as a sector. This limits their

ability and capacity to influence policies that affect them and the people

they serve. It has also limited their capacity to effectively interface with

government, especially at the local levels. In addition, the NGO sector in

Uganda today is struggling to assert its own identity. The challenge

however, is not so much about the differences between NGOs and

Government, but rather what collaborative relationship should exist

between the two. The challenge for NGOs now is to assert their own values

more confidently (David Kalete 2009)

Research into this area produced a number of common problems and

dilemmas that NGOs experienced. One of the most mentioned was that of

the decision-making processes. Tensions often occurred between staff and

senior managers because of the staff expectations that they would be equal

partners in the decision-making process, in addition there is governance

crisis and decision making problems (Mukasa, 2006).

16

In addition to the above, the other problem is about staff; such as;

recruitment, assignment and layoff as well as human resources

development and administration and finally everyday management of staff

(Vilain, 2006).

According to AVSI, an international NGO operating in Uganda, Cultural

barriers, political instability and limited staffing levels are among the strong

challenge facing the implementation of its project in Hoima district and in

the north, these challenges have impeded on implementation of its

programs.

The most common inter organizational weaknesses of the NGO sector

include; limited financial and management expertise, limited institutional

capacity, low levels of self-sustainability, isolation/lack of inter-

organizational communication and/or coordination, lack of understanding of

the broader social or economic context (Malena, 1995).

According to Moore and Stewart 1998, there is also structural growth

problems besides accountability, sustainability evaluation of their

performance against set goals and objectives, economy of scale challenges,

volunteer relationship as well as future needs problems as put forward by

marcuello in 2001.he argued that younger NGOs are interested

management and information advice whereas older NGOs are interested in

more paid staffs with technical expertise.

The health service delivery framework in Uganda

a) (The policy framework)

In the 1980s the government of Uganda carried out a number of reforms,

including the decentralization health services delivery to the districts and

local councils. One of the other reforms was the adaptation of the sector

wide approach (SWAP) in developing a policy with the objective of providing

an enabling environment that would allow for effective coordination of

efforts among all partners in Uganda’s national health development,

increase efficiency in resource application and ensure effective access to

essential health care. It especially aims at improving health status and

services through a coordinated framework for better use of resources.

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The SWAP approach has been used as a guiding principle in health planning

and resource mobilization, planning and management of health services by

the MoH, the districts other ministries and development partners including

NGOs.

Health care delivery services in Uganda are guided by the Uganda health

policy II emphasis on the minimum health care package (MHCP) and

detailed plans for its implimenions are outlined in HSSP III including the

monitoring system.

b) Fig 2. Institutional framework

The MoH headquarters is the leading center for management of the MoH

which was restructured with the new constitutional mandates in 1995. The

MoH is responsible for national planning, policy formulation setting

standard guidelines and protocols, capacity building and technical support

in program area as well as monitoring and evaluation in districts and others

lower level government structures. The MoH also manages the RRHs and

NRHs.

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HSD

District Health Services HQ

National Referral HOSP

Referral Facility (Public or NGO)

(HC IV or HOSPITAL)

HC II

HC II

HOUSEHOLDS / COMMUNITIES / VILLAGES

Regional Referral

HOSPITALS

HC II

HC II

HC II

HC III

HC III

HC III

MOH Headquarte

rs

DistrictHealth Services

The district health service is responsible for coordinating an equivalent

level of care as the MoH headquarter in the district. It’s headed by the

DDHS, under this is the HSD at the level of health center IV and supports

the lower levels of HC III and HC II. This structure is accountable to and is

supervised by the district authority and functionally supported by the MoH.

(MoH Kampala 2010/NHP II)

Partnership in health service delivery/roles of other actors

The MoH acknowledges the importance of each partner and considers

partnership an important guiding principle of the NHP.

This partnership recognizes the public and private sectors, other Ministries

and departments, HDPs, Civil Society Organizations (CSOs), and the

community as important players in health. The private sector includes 3

subsectors: PNFPs, PHPs and TCMPs. The contribution of each sub-sector

varies widely. With coordination structures between the MoH and the

private sector only established at national l level.

The major challenge in strengthening of the public private partnership is

the fact that the PPPH policy is still in draft form and once this is passed it

will facilitate coordination and integration with the public health sector,

private sector and the NGO world.

Constraints in meeting the minimum health care package (MHCP)

the Uganda National Minimum Health Care package (UNMHCP) is divided

into four clusters namely: (i) Health Promotion, Disease Prevention and

Community Health Initiatives; (ii) Maternal and Child Health; (iii)

Prevention and Control of Communicable Diseases; and (iv) Prevention and

Control of Non-Communicable Diseases (NCDs). Emphasis during the

implementation of the HSSP II was placed on a limited set of interventions

which have been proven effective in reducing morbidity and mortality.

The achievements in these clusters was however greatly affected by

corruption and embezzlement of public funds, funding deficits, example only

31% of the districts trained VHTs, HRH crisis with about 42% of health

staffs on private and PNFP facilities besides absenteeism and poor

19

attitudes, high levels of poverty, inadequate awareness, poor enforcement

of public health bye-laws and cultural factors in some regions (e.g. in

Karamoja) are major challenges that have affected the implementation

MHCP

The above challenges therefore influenced the trends in achieving the MDG

as well as the national target example Uganda still remain at 16 th/20 most

burden TB countries in the world, HIV prevalence still remain at 6.7%

against a target of 3% and 7.4% against 4.4% among pregnant mothers

attending ANC in HSSP II, the proportion of deliveries in the health

facilities is still low at 32% against 50% in HSSP II yet maternal and child

health carry the highest total burden of disease with most HC IV yet not

able to provide a comprehensive RHS, inadequate information sharing and

research, weak supervision and monitoring of programs even so, some

programs are even not sustainable example the yellow star program meant

to enhance supervision.

Chapter three: METHODOLOGY.

3.0 IntroductionThis Chapter presents detailed descriptions of the methods that will be

deployed to collect, analyze and present data. It will entail research design,

population and sampling techniques, target population, sample size, data

collection methods, research instruments and procedures, data and

assumptions.

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3.1 Research DesignThe study envisages the use of both qualitative and quantitative methods.

Qualitatively, the study will seek to establish facts on the ground basing on

an elaborate observation and in depth interviews that may lead in non-

numerical data presentation.

Similarly, the researcher will use descriptive and exploratory research

designs. The researcher will explain and describe his findings thoroughly in

words. Quantitatively, the study will involves measurement of the problem

situation. The outputs will then be presented as statistical data in figures by

use of tables, graphs and charts.

3.2 Area of study

The study shall be conducted in kitgum district.

3.3 Population

The study population will include all NGOs staffs, patients, local

government leaders, NGOs mangers, local government mangers in the

health department.

3.4 Sample size determination The sample size will be determined by random sampling among the selected

study population above.

Below is a tabular presentation of the study population

Table 1: Study population

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DEPARTMENT Total population Sample size

Category A: district health mangers

DDHS staffs 15 03

HC in charges 08 08

HC staffs 160 30

Category B: District leaders

Administration ( technical staffs) 50 10

politicians ( elected leaders ) 25 5

Category C: Community beneficiaries

Representatives

Village Health Team 150 30

Opinion leaders (retired civil

servants, politician and NGOs

staffs)

50 10

Health inspectors 5 5

Category D: NGOs staffs

Managers 25 05

Field staffs 100 20

TOTAL 388 126

3.5 Sampling procedure A sample will be obtained by picking the 5th number out of a population of

about 400 and about 126 respondents will be picked by probability sampling

methods. However, purposeful selection will also be made where the

number of respondents seems low for probability sampling.

22

3.6 Size and selection of the study population The study is envisaged to cover 10 sub-counties that form Kitgum District.

The coverage thus is wide and will necessitate sampling procedure to

determine actual places and people that will be included for the study. Non

probability sampling will be useful. However, all the NGOs involved in

primary health care service delivery and health facilities will be included

in the study

3.7 Data Collection methods.

The study will involve the use primary and secondary sources of data. The

primary sources will be obtained by the moving out to the field and picking

first hand information directly from the various respondents. By way of

observation, some salient and required data shall be obtained from the field

as well.

The Researcher will also make use of questionnaires which will be in the

form of self-administered and guided questionnaires.

Secondary source of data, here the researcher will use all sorts of data

which will be collected, processed and sorted for other purposes which will

be related to the researchers’ area of interest. Such information will be

used to supplement and back up the primary data collected

The secondary source of data will include among others text books,

journals, magazines, media (radios, TV, and news papers), and study reports

of other researchers.

Specifically, the following study instruments shall be deployed throughout the process of data collection;-

3.7.1 QuestionnairesSimple questionnaire of about 5-7 pages will be developed with structured

sets of questions which will be designed and administered to appropriate

respondents. It will be in these questioners that the respondents will give

their ideas and knowledge as required to the problem on the ground.23

The respondents will be required to tick in or make explanation according

to the demand and or requirements of the questions. The use of

questionnaires will be convenience and time saving.

3.7.2 Observations

During the study, the researcher will physically be present to the people as

he asks them a few questions. This will grant him opportunity to make his

own assessments at the end of the data collection process.

3.8 Ethical ProcedureFirstly the researcher will obtain a letter of introduction from the Head of

Department Management, Faculty of Business and Development Studies

Gulu University.

In the areas of study, it will in order to gain smooth entry by passing

through authorities from the district level to the sub-county levels where

the study will be conducted. This also implies that after the study, there is

need for the researcher to share the research findings with all these

relevant authorities in the areas of study. Two to three research assistants

will be engaged to ease the process of data collection from the field as well

as the analysis of the data.

3.9 Data AnalysisDuring the process of analyzing data, the researcher will engaged in

organizing, manipulating and interpreting of data collected from the field.

Tables, charts and graph as a way of analyzing quantitative data, in the

analysis of qualitative data, the researcher will describe data collected

using words.

1.1 Delimitation of the study.

24

Time; time is one of the most crucial factor in this research in the sense that

the duration of the study is short, this will be mitigated by incorporating

activities in the work plan so that more than one activity runs at the same

time.

The other limitation in the study is financial weakness to the extend that the

researcher has to borrow a small loan to support the research assistants

who will help in data collection.

Reference

1. Kitgum district information portal; www.kitgum.go.ug accessed

1/1/2011

2. The health sector strategic support plan III 2010.

3. The Rise and fall of Transnational Civil Society: The Evolution of

International Non-Governmental Organizations since 1839. By T. R.

Davies City University London Working Paper. Steve Charnovitz, "Two

Centuries of Participation: NGOs and International Governance,

Michigan Journal of International Law, Winter 1997

4. The Uganda National health policy II 2009 draft

5. Statistical abstract 2010- Uganda bureau of statistics

6. Subcontracting Peace - The Challenges of NGO Peace building. Edited

by: Richmond, Oliver P., and Carey, Henry F. Published by Ashgate,

2005. Page 21.

25

Appendices

Budget estimate

S/

NO.

ITEMS QUANTIT

Y

RATES

EACH

TOTAL

AMOUNT(UG.SHS

)

1 Stationary

-Pen 6 200= 1,200=

-Ream of paper 2 8,000= 16,000=

-Note book 3 2,000= 6,000=

-Clip board 1 5,000= 5,000=

2 Secretarial services

-per page 60 pages 1,000= 60,000=

26

3 Flash disk 1 40,000= 40,000=

4 Binding services 3 copies 2,000= 6,000=

5 Refreshment

-Food/water - 10,000= 10,000=

TOTAL 129,800/=

Proposed work plan

S/

NO.

ACTIVITIES S O N D J F M A M J J PER.RESPN.

1 Topic formulation x Student/Richard

2 Approval of topic x x Research

committee

3 Synopsis writing x X Student/Richard

4 Draft proposal

writing

x x Student/Richard

5 Approval of

proposal

X x Supervisor/Dr.

Mshilla

6 Data collection X x x x Student/Richard

7 Data analysis and

limitation.

x x x Student/Richard

8 1st draft of research

report

x x Student/Richard

9 Correction of 1st

draft

x Student/sup.

10 Pdn. Of final

research report.

x Student/Richard

11 Approval x Supervisor/

Dr.Mshilla

Map of kitgum district

27

28