Decentralization and the delivery of adolescent sexual and reproductive health services in Sironko District: 1990-2005
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Uganda is one of the countries in sub Saharan Africa that has embraced the system of decentralization, with the sole aim of ensuring that services move closer to the communities. Decentralisation is supposed to improve the delivery of health care services (Rama 2004). The government of Uganda has committed itself to spearheading health service delivery through a decentralized health service system that is in line with both international and national levels; particularly, reference goes to the Alma Ata declaration for health for all, the Cairo conference on Population and Development, and the National Health Policy. The current special attention devoted to the sexual and reproductive health of adolescents is justified by the sheer size of this population to the nation compared to other age groups (630 Million in Sub Saharan Africa and one third of the population in Uganda)(World Bank 2006). The primary objective of the study was to examine the effect of decentralization on the delivery of ASRH services in Sironko. The objectives were fourfold; it sought to identify ASRH concerns, which included; access to and use of ASRH services, incidence of STIs/STDs, teenage pregnancies, early adolescent marriages and abortions. It also looked into health services provided and specific attention was rendered to ASRH services. The study also examined the nature of the decentralization system undertaken in Sironko District as well as the extent of decentralization on health service delivery. The study was largely qualitative, although quantitative elements prevailed. Data was collected from different sections of the population to establish ASRH services provided. ASRH concerns and the extent to which decentralization affected health service delivery. Methods of data collection included focus group discussions, key informant interviews, documentary reviews, observations and semi-self-administered questionnaires. Two counties of Bulambuli and Budadiri were chosen to ensure representativeness and homogeneity. Population within the sub counties constituted the sampling frame. Eighty randomly selected adolescents were interviewed in addition to fifty purposely selected individuals. Findings from the study indicated that the population in Sironko which predominantly accessed health services in a decentralized framework identified ASRH as an area of concern. The state of ASRH was appalling. Close to 25% of the population aged between 15-24 had their first sexual experience by the age 15.About 5% of the women became mothers by the age of 18.Adolescents accounted for 30% pregnancy related cases and yet HIV/AIDS prevalence was high. Local administration capacity in terms of human resources and finances was insufficient to deliver the desired ASRH services to the community. The system of decentralization was found to offer potential advantages for capacity building as well overall health services delivery. However a number of challenges were hurting the implementation of programs on ASRH delivery, these included corruption and nepotism, power relations, high levels of poverty in the community as well as the insufficient human capacity in the district. The study concluded that ASRH service delivery was a significant concern to the community and to adolescents in particular. Inadequate funding and lack of a conscious plan for financing health services was creating inefficiencies in the delivery process. The study concluded that the incidence of HIV/AIDS and STIs/STDs had not been helped by the system of decentralisation. Even awareness on ASRH and denial by higher authorities in the planning process greatly contributed to the poor state of ASRH. The study recommended for more research into this area of study. It also recommended the establishment of a comprehensive strategy for ASRH which would aim at addressing human capacity needs, corruption and nepotism, effective monitoring and evaluation of ASRH programs as well as reduction in the levels of poverty. In conclusion the study established that the effective delivery of ASRH services in a district setting like Sironko was dependent on the system of decentralization in place. The concerns and services provided and factors affecting the efficient delivery of ASRH services could only be realized well by taking on a conscious, pragmatic approach. It was upon the stakeholders to remedy the current status quo.