the contribution of non-governmental organizations … boboya... · the data from the field was...

1

THE CONTRIBUTION OF NON-GOVERNMENTAL ORGANIZATIONS IN DELIVERY OF

BASIC HEALTH SERVICES IN PARTNERSHIP WITH LOCAL GOVERNMENT:

A CASE STUDY OF YEI CIVIL HOSPITAL AND MARTHA PRIMARY

HEALTHCARE CENTRE IN YEI RIVER COUNTY

SOUTH SUDAN

A DISSERTATION SUBMITTED TO THE EAST AFRICAN SCHOOL OF

DIPLOMACY, GOVERNANCE AND INTERNATIONAL STUDIES DEPARTMENT OF

GOOD GOVERNANCE AND PEACE STUDIES IN PARTIAL FULFILMENT OF THE

REQUIREMENTS FOR THE AWARD OF MASTER OF LOCAL

GOVERNANCE AND HUMAN RIGHTS OF UGANDA

MARTYRS UNIVERSITY

BOBOYA JAMES EDIMOND

2011-M083-10004

JULY 2014

iii

DEDICATION

I dedicate this piece of work to my father Edimond T Gogo, My Mother Sabina Moriba, my

Sister Betty Night, my grandmother Maria Kakune and my family, for all their efforts in making

this work possible.

iv

ACKNOWLEDGEMENT

Compiling this Research work was not an easy venture. It was however made manageable by the

assistance of several people who helped me to go through it. I wish to acknowledge all those

whose help has enabled me to succeed in this work. I am deeply indebted to my supervisor

Assoc. Professor Dr. Maximiano Ngabirano, Head of the Department of Good Governance and

Peace Studies for his assistance and advice he gave me towards the transformation of this report

from the draft stage to completion. Mr. Denis Musinguzi a lecture his help was of much value to

me. He gave me much confidence even when the going got difficult and offered me practical

suggestions for improvement.

I am also grateful to Mrs. Nina Pedersen of Norwegian People Aid Civil Society Development

Programme for her tireless support for me to be able to obtain this qualification, Mr. Jonas Anuar

who acted as my career Guardian and served as my mentor throughout the course period until

completion, Dr. Moris Ama and Sanyangi Wangi for their support in making me understand

some of the Medical and health issues addressed in this research and Mr. Mawa Seme who acted

as my research assistant his help contributed a lot to this final research.

I extend Appreciation to all the lecturers and the non-academic staff at the East Africa School of

Diplomacy, Governance and International Studies especially the Department of Good

Governance and Peace Studies, for their daily support to me during my course of study.

I acknowledge all the people who participated in this study, especially the respondents that were

interviewed, NGO officials, Church official, Health officials, patients and Local Government

officials whose clearances enabled me to move freely throughout Yei town.

Finally I would like to acknowledge and appreciate Konrad-Adenauer-Stiftung for the

scholarship support that helped me develop the skills and knowledge I needed to complete my

dissertation and to be a successful professional.

May the Almighty God reward all of you abundantly

v

TABLE OF CONTENTS

DECLARATION ........................................................................................... Error! Bookmark not defined.

APPROVAL .................................................................................................. Error! Bookmark not defined.

DEDICATION ............................................................................................................................................. iii

ACKNOWLEDGEMENT ........................................................................................................................... iv

TABLE OF CONTENTS .............................................................................................................................. v

LIST OF TABLES ..................................................................................................................................... viii

LIST OF FIGURES ..................................................................................................................................... ix

LIST OF ABBREVIATION ......................................................................................................................... x

ABSTRACT ................................................................................................................................................ xii

CHAPTER ONE: GENERAL INTRODUCTION ............................................................................1

1.0 Introduction ............................................................................................................................................. 1

1.1 Background of the Study ........................................................................................................................ 3

1.2 Statement of the Problem ........................................................................................................................ 6

1.3 Objectives of the Study ........................................................................................................................... 8

1.3.1 Main Objective ..................................................................................................................................... 8

1.3.2 Specific Objectives .............................................................................................................................. 8

1.4 Research Questions ................................................................................................................................. 8

1.5 Scope of the Study .................................................................................................................................. 9

1.6 Significance of the Study ........................................................................................................................ 9

1.7 Justification of the study ....................................................................................................................... 10

1.8 Definition of Key Terms ....................................................................................................................... 10

1.9 Conceptual Framework ......................................................................................................................... 12

CHAPTER TWO: LITERATURE REVIEW ........................................................................................ 15

2.1 Introduction ........................................................................................................................................... 15

2.1.1 Partnerships in the Health Sector ....................................................................................................... 15

2.1.2 Concepts of NGOs ............................................................................................................................. 17

2.1.3 Categories of NGOs ........................................................................................................................... 20

2.2 Activities of NGOs in the Health Sector ............................................................................................... 21

vi

2.3 Beneficiaries‟ Satisfaction on the Health Services ............................................................................... 23

2.3.1 Primary Health Care Policy ............................................................................................................... 28

2.4 Challenges Faced by the NGOS in the Delivery of Health Care Support ............................................. 30

2.5 Ways for Effective and Efficient Delivery of Health Services ............................................................. 35

Patient-Centered Outcomes Research ......................................................................................................... 40

2.9 Conclusion ............................................................................................................................................ 41

CHAPTER THREE: RESEARCH METHODOLOGY .................................................................. 43

3.0 Introduction ........................................................................................................................................... 43

3.1 Research Design .................................................................................................................................... 43

3.2 Area of Study ........................................................................................................................................ 44

3.3 Study Population ................................................................................................................................... 44

3.4 Sampling Size and Selection ................................................................................................................. 45

3.5 Sampling Techniques ............................................................................................................................ 46

3.6 Research instruments ............................................................................................................................ 47

3.7 Quality control ...................................................................................................................................... 48

3.8 Research procedures ............................................................................................................................. 48

3.9 Data presentation and analysis .............................................................................................................. 48

3.9 Ethical considerations ........................................................................................................................... 49

3.10 Anticipated limitations of the study .................................................................................................... 49

CHAPTER FOUR: PRESENTATION, ANALYSES AND DISCUSSION OF FINDINGS ............. 50

4.0 Introduction. .......................................................................................................................................... 50

4.1 Demographic Information on the Respondents. ................................................................................... 50

4.1.1 Age Groups of the Respondents......................................................................................................... 51

4.1.2 Education Levels of the Respondents ................................................................................................ 52

4.1.3 Occupation ......................................................................................................................................... 53

4.1.4 Monthly Earnings of Respondents ..................................................................................................... 54

4.2 Activities carried out by the Non-Governmental Organizations in Yei Civil Hospital ........................ 56

4.3 The beneficiaries‟ level of satisfaction by the health services provided by the Non- ........................... 58

4.3.1 Performance of Martha Primary Health Care Centre ......................................................................... 60

vii

4.3.2 The Performance of Yei Civil Hospital from 1997-2004 .................................................................. 63

4.3.3 The Performance of Yei Civil Hospital from 2005-2013 .................................................................. 65

4.3.4 Showing Performance of Yei Civil Hospital from 1997-2004 and Performance of Yei ................... 69

4.4The Challenges Faced By the NGOs in the Delivery of Health Care Support in Yei............................ 71

4.5 Suggested Ways for Effective and Efficient Delivery of Health Services ............................................ 75

4.6 Summary of overall Satisfaction of beneficiaries with the health service ............................................ 75

Table 6: Cross Tabulation for the Overall beneficiaries‟ appreciation of the health services .................... 77

CHAPTER FIVE: SUMMARY, CONCLUSION AND RECOMMENDATIONS .......................... 80

5.0 Introduction ........................................................................................................................................... 80

5.1 Summary of Findings ............................................................................................................................ 80

5.1.1 Activities carried out by the Non-Governmental Organizations in Yei Civil Hospital ..................... 80

5.1.2 Appreciation of the health services provided by the Non- Governmental ......................................... 85

5.1.3 The challenges faced by the NGOs in the delivery of health care support in Yei ............................. 86

5.1.4 Suggested ways for effective and efficient delivery of health services in Yei River ......................... 89

5.2 Conclusion ............................................................................................................................................ 91

5.3 Recommendations ................................................................................................................................. 91

References ................................................................................................................................................... 97

Appendices:............................................................................................................................................... 103

Questionnaire 1 A ..................................................................................................................................... 103

Questionnaire 1 B ..................................................................................................................................... 107

Questionnaire 2 ......................................................................................................................................... 111

Interview Guide for the Beneficiaries ....................................................................................................... 121

Interview Guide for, Health and Local Government Officials.................................................................. 122

Observation guide at the hospital and the primary health care to asses important ................................... 122

Introductory letter ..................................................................................................................................... 123

Work Plan ................................................................................................................................................. 124

viii

LIST OF TABLES

Table 3.1: Sample Size Determination Table ............................................................................................. 46

Table 1: Age of Respondents ...................................................................................................................... 51

Table 2: Highest Level of Education .......................................................................................................... 52

Table 3: Whether the services are available when ever needed .................................................................. 55

Table 4: Whether Respondents have ever experienced any problem from the health sector ...................... 59

Table 5: Overall satisfaction of beneficiaries with the health service ......................................................... 60

Table 6: Cross Tabulation for the Overall beneficiaries‟ appreciation of the health services .................... 77

ix

LIST OF FIGURES

Figure 1 Conceptual framework ................................................................................................... 13

Figure 2: Current Occupation ....................................................................................................... 53

Figure 3: Monthly Earnings of Respondents ................................................................................ 54

Figure 4: Showing Performance of Yei Civil Hospital from 1997-2004 and Performance of ..... 70

x

LIST OF ABBREVIATION

BPHS Basic Package of Health Services

CES Central Equatorial State

CF Conceptual Framework

CHD County Health Department

CMS Church Missionaries Society

CPA Comprehensive Peace Agreement

DRC Democratic Republic of Congo

ECS Episcopal Church of Sudan

FBO Faith Based Organization

GOSS Governmental of South Sudan

HUMCs Health Unit Management Committees

JAM Joint Assessment Mission

JMS Joint Medical Stores

KM Kilometer

LG Local Government

LGA Local Governmental Authority

M&E Monitoring and Evaluation

MoH Ministry of Health

NGO Non-Governmental Organization

NMS National Medical Stores

NPA Norwegian People‟ Aid

xi

PHCC Primary Health Care Centre

PPP Public Private Partnership

RSS Republic of South Sudan

SA Strongly Agree

SD Strongly Disagree

SMoH State Ministry of Health

UD Undecided

UK United Kingdom

UN United Nations

UNICEF United Nations Children Education Fund

WB World Bank

WHO World Health Organization

YD Yei Diocese

YRC Yei River County

xii

ABSTRACT

The study “the contribution of non-governmental organizations in delivery of basic health

services in partnership with local government” was aimed at assessing the contribution of non-

governmental organizations in the delivery of basic health services in Yei River County through

collaboration with the Local Government. The study was guided by the following objectives; to

identify the various activities carried out by the Non-Governmental Organizations in Yei Civil

Hospital and Martha Primary Health Care Centre; establish the beneficiaries‟ appreciation of the

health services provided by the Non- Governmental Organizations in Yei Civil Hospital and

Martha Primary Health Care; assess the challenges faced by the NGOs in the delivery of health

care support in Yei River County and suggest ways for effective and efficient delivery of health

services. The study used a case design study which employed both qualitative and quantitative

techniques. The study used questionnaires and interview guides to collect primary data and then

the data from the field was analyzed by using Statistical Package for Social Scientists (SPSS)

version 17.0 software.

The study revealed that that, NGOs make successful contributions to health in certain

circumstances. NGOs have made significant contributions to reproductive and sexual health in

many areas in the Yei River County. The research also found that effectively run NGO

reproductive and child health services have decreased child and maternal mortality in Martha

Primary health care and to some extent Yei Civil hospital. The importance of (NGOs) in the

delivery of services have gained recognition in Yei River County in terms of filling gaps in

government programmes, the research also established that the contribution of Non-

governmental Organizations has also provided Yei River community with a choice of service

outlets and to create an effective voice in respect of service needs and expectations.

Suggested ways forwarded were making of better resources to the health facilities so that clinical

staff (doctors, nurses, midwives) could improve on their full potential. Improve on the

availability of equipment for health care. Need for recruitment of adequate skilled medical

personnel at all categories i.e. from nursing, midwives, lab technicians and doctors. There should

be provision of modern medical equipment to Yei Civil Hospital and Martha Primary health Care

Centre to help in the investigation and management of health care cases.

1

CHAPTER ONE

GENERAL INTRODUCTION

1.0 Introduction

For many countries such as New Zealand , United Kingdom ,Sweden , Iceland Norway , Japan ,

Southern European and Netherlands, it is the responsibility of the government to assure health

care provision for the whole population. But the public health agenda has become so large that

the governments of these countries have been unable to provide adequate health care (Buse and

Waxman, 2001). This has led organizations outside the government to assume part of that

responsibility. Moreover, there is a growing recognition by government and international

organizations that the involvement of all stakeholders is needed if health services are to reach the

poor (Korten 1991; World Bank 1998; WHO 2001a). Further, continued bilateral relationships

between donors and non-governmental organizations (NGOs) have created a window of

opportunity for government–NGO collaboration (Begum 2000; WHO 2001a; Zafar Ullah 2002;

Management Sciences for Health (2004). Research evidence by Management Sciences for Health

2004 indicates that working in isolation can result in duplication of efforts and failure to

accomplish health goals, whereas collaboration among health care providers can generate

synergy and facilitate the flow of information (World Bank 1996; UNICEF 1999; Begum 2000;

Barkat and Islam 2001; Thomas and Curtis 2001; Hurtig et al. 2002; WHO 2003; Gomez-

Jauregui 2004; Mercer et al. 2004; Newell et al. 2004).

In some developing countries, such as South Sudan, Democratic Republic of Congo, Central

African Republic and Somalia, non-government stakeholders cover a major component of health

care (Green 1987; Magagula et al. 1997). In order to avoid clashes, it is necessary for the health

http://en.wikipedia.org/wiki/New_Zealand

http://en.wikipedia.org/wiki/United_Kingdom

http://en.wikipedia.org/wiki/Sweden

http://en.wikipedia.org/wiki/Iceland

http://en.wikipedia.org/wiki/Norway

http://en.wikipedia.org/wiki/Japan

http://en.wikipedia.org/wiki/Southern_Europe

http://en.wikipedia.org/wiki/Netherlands

http://heapol.oxfordjournals.org/content/21/2/143.full#ref-13
























2

care providers in these countries to collaborate. In South Sudan, for instance, the government and

NGOs collaborate to a certain degree to provide health care, especially to vulnerable populations

such as women, children and the poor. Within such collaborations, the government retains

ownership in the areas of policy formulation and implementation, human resource development

and budgetary control. NGOs concentrate on facilitating the activities within national policies

and strategies (MOHFW 1998).

NGOs provide quality services (NTP 2003; Guda et al. 2004; Mercer et al. 2004) in accordance

with the national policy guidelines, but lack deliberate plans to build the capacity of government

services. Moreover, there is no set process to encourage governments to move from restrictive

bureaucracy towards creating a facilitating policy environment for collaboration. For example, in

Papua New Guinea, a project was implemented and the vital part of the project is to establish

partnerships between the provincial governments and the NGOs and civil society to effectively

conduct health promotion activities in local communities which was an attempt to facilitate a

policy environment for collaboration. The initiative was designed to enhance the capacity of the

government in developing and implementing community health policies; enhance the capacity of

the government in developing and implementing community health policies and formalizing

partnerships between the government and non-state service providers including churches and

NGOs to develop and implement ways to monitor and evaluate the community health outcomes.

In order to develop consistent and workable policy, clear understanding of the nature, principles,

strengths and weaknesses, and challenges of the existing government–NGO collaboration is

essential. This study, therefore, attempts to assess the contribution of Non-governmental

organizations in delivery of basic health services in partnership with local government in Yei





3

River County, South Sudan., in the light of movement towards wider collaboration to achieve

national health goals.

1.1 Background of the Study

A collective action in search for a good society is a universal part of human existence. Millions

of people across the globe find it inspiring to pull together available resources in their struggle

for a better world. Most successful civilizations have effectively found it rewarding if these

efforts are aligned in a collective manner. Michael Edwards (2005) has noted that groups have

often successfully come together, to pull resources to save others or each other. In today‟s world,

the lives of people are in the hands of heath care system. People in different countries seek

protection on their health systems (World Bank 1993; Abedin 1997; MOHFW 1998; WHO

2003).

The United Nations Charter on Right to Development, Article 8 states that, every person has a

right to health care. Without good health systems development cannot be realized at a high level

since it begins with people but not with goods.

Today there are many governments failing to provide adequate public services, particularly for

poor communities. Some may recognize the importance of non-state providers to fill the gaps,

and the need to collaborate in order to improve services. A research was conducted by the

University of Birmingham UK (2009) examined a wide range of providers of health service in

six countries – Bangladesh, India, Malawi, Nigeria, Pakistan and South Africa. The research

stated that Non-state providers of basic services, which include for-profit firms, local

entrepreneurs, individual practitioners, community and faith-based organizations and non-

governmental organizations, have a lot to offer.






4

In Africa especially sub-Saharan Africa, there are so many diseases and this has affected the

continent in terms of economy. Poor health is one of the worst things because it causes pain and

suffering, reduces human energy and makes millions of Africans not to catch up with life hence

destruction of human capital. One of the most challenges today facing many developing

countries is how to provide health services. In many low-income countries, non-governmental

organizations (NGOs) deliver basic health services in particular areas or among certain

populations. Their effectiveness in establishing sustainable primary health care (PHC) systems

has been linked with promotion of community participation, having close links with the poor,

being flexible and having committed staff (Gellert 1996). The comparative advantage of non-

governmental organizations might be assessed in terms of efficiency, innovation, quality of

services, ability to mobilize resources, contribution to the sustainability of the local health

system and coverage of grass-roots communities (Gilson et al. 1994; Matthias and Green 1994;

Stefanini 1995).

A rapidly changing development management scenario is the context in which non-governmental

organizations must function. Notably, these include the adoption of a private sector led growth

strategy, a shift to decentralized modes of governance, and increasing regional disparities in

access to development services. The changes and challenges are inevitably affected by the

ongoing conflict, which imposes not only heavy economic and financial costs, but also social

costs on a development system that is under pressure to perform comprehensively in order to

ensure long-term economic, social and political stability which is apparently the case in South

Sudan (South Sudan Integrated Disease Surveillance and Response Assessment Report 2007).

Thus, the imperatives of good governance, poverty reduction, social harmony and political

5

stability comprise the nexus of challenges and opportunities for non-governmental organizations

in becoming an efficient agent for development services and an effective partner in development.

South Sudan has witnessed the longest civil war in modern Africa, spanning from 1955 to 2005

with the signing of the Comprehensive Peace Agreement (CPA) that paved its independence in

July 2011. The country has been through civil war for many years. The civil war practically

destroyed the whole infrastructure and social fabric of the country along with deaths and

displacement of over four million people. The public health system along with every other sector

virtually collapsed leaving Non-Governmental Organizations/Faith Based Organizations

(NGOs/FBOs) responsible for providing the majority of health services to the population. Due to

limited capacity of non-governmental organizations to cover the vast expanse of the country and

insecurity, only a limited proportion of population (estimated at less than 25%) could be reached

(Government of South Sudan Ministry of Health Strategic Plan 2011-2015). Most of the

intervention by non-governmental organization has taken place in the Equatoria region of which

Yei River County is part.

Promotion of good health by overcoming disease requires strong interventions and proper

attention on the activities in the health sector. There has been evidence now over a period of

many years that the public sector in South Sudan is lacking in capacity in the context of delivery

and management of health services (for South Sudan Health Services Report 2006). Moreover,

there are issues of the quality, efficiency and coverage of these services. The dynamics of health

planning in the history of South Sudan and Yei County in particular have been predominantly

influenced by either the strong political agendas or manifestos or by the civil war corruption and

poor governance. The contribution of non-governmental organizations providing health services

6

in Yei Civil Hospital and Martha Primary Health Care Centre has not been assessed in terms of

contributions to the society.

In line with the decentralization policy of the Interim Constitution of South Sudan (2011) and the

Local Government Act (2009), the Ministry of Health operates a decentralized structure. The

Ministry of Health is in-charge of the health sector policy, guidelines, regulations, and standards

development; quality assurance, monitoring &evaluation, health financing and health sector

partner coordination at the country level. It provides stewardship and guidance to the sector,

manages the tertiary (teaching) hospitals and executes a supportive role to the State Ministries of

Health (SMoH). The State Ministries of Health provide leadership for health service delivery and

management at State level. The County Health Department (CHD) oversees the delivery of

primary health care services in their respective County. Specific community health institutions

are envisaged to ensure community participation and oversight; however, at present these

structures are not operational.

1.2 Statement of the Problem

The declining role of the state and the changes in donor funding from the public to the private

sector have led to a dramatic increase in the number of non-governmental organizations in the

past 20 years (Edwards, 2004: 21; Vakil, 1997 & Fruttero & Gauri, 2005). It has been estimated

that there are over 40,000 internationally operating Non-Governmental Organizations majority of

these organizations have been providing health services around the world (Anheier, Glasius, &

Kaldor, 2001). Many Services that are provided by governments, such as health, education, are

now commonly supported by Non-Governmental Organizations (Fruttero & Gauri, 2005).

7

Today, Non-Governmental Organizations play a central role in the provision of health services to

people in the developing world (Pfeiffer, 2003; WHO; 1995; & UNICEF, 1996). This is due to

the fact that many countries in the developing world possess weakened health care systems

(Akukwe, 1998). Health care systems in the developing world are often faced with a tremendous

amount of disease burden and a low availability of trained medical professionals, equipment, and

drugs. Thus the basic health care needs of people in the developing world often go unmet. The

fragile health care systems of the developing world can lead to higher levels of disease burden

and human suffering. As a result, there has been a dramatic increase in funding for Non-

Governmental Organizations working in the health sector in developing countries such as South

Sundan from bilateral and multilateral actors, such as USAID and the World Bank (USAID,

1995).

Overall access to sustained quality health care is poor, with very few communities living within

the reach of the most basic health services in Yei and South Sudan at large. The material

resources and managerial expertise for administering the sector are insufficient and largely

dependent on external financial and technical assistance. Existing health infrastructure and

equipment are extremely poor, with many hospitals and health centers either dilapidated or only

have the capacity and characteristics of lower-level facilities. Given the fact that there has been a

lot of support from the international donors to the health sector in Yei, the contribution of Non-

Governmental Organizations in delivery of basic health services in partnership with Local

Government is something which has not been examined.

Non-Governmental Health Organizations have been criticized, because despite the tremendous

amount of money they receive, little is known about their overall contributions to health. Thus,

there is a need for research investigating the contribution of Non-Governmental Organizations

8

working in the health sector specifically in Yei Civil Hospital and Martha Primary Health Care

Centre.

1.3 Objectives of the Study

1.3.1 Main Objective

The main objective of this study is to assess the contribution of non-governmental organizations

in the delivery of basic health services in Yei River County through collaboration with the Local

Government.

1.3.2 Specific Objectives

1. To identify the various activities carried out by the Non-Governmental Organizations in

Yei Civil Hospital and Martha Primary Health Care Centre

2. To establish the beneficiaries‟ level of satisfaction of the health services provided by the

Non- Governmental Organizations in Yei Civil Hospital and Martha Primary Health Care

3. To assess the challenges faced by the NGOs in the delivery of health care support in Yei

River County

4. To suggest ways for effective and efficient delivery of health services.

1.4 Research Questions

1. What are the various activities carried out by the Non-Governmental Organizations in

Yei Civil Hospital and Martha Primary Health Care Centre?

2. What are the beneficiaries‟ levels of satisfaction of the health sector in Yei River County

through the support provided by the non-governmental organizations and the local

government?

9

3. What are the challenges faced by the NGOs in the delivery of health care support in Yei

River County?

4. What are the ways for effective and efficient delivery of health services?

1.5 Scope of the Study

The study was carried out in the two health institutions of Yei Civil Hospital and Martha Primary

Health Care Centre in Yei River County. The study placed focus on the contribution of non-

governmental organizations in delivery of basic health services in Yei River County through

collaboration with the Local Government and also identified challenges and how delivery of

health care services can be improved.

The study covered the period 1997 to 2013.However, some consideration was put by the

researcher to look at the period between 1997 – 2004 which was a war period and from 2005 –

2013 a period of relative peace. These two periods have witnessed activities of non-

governmental organizations in delivery of basic health services in Yei River County and in

addition these periods falls during the years of the signing of the Comprehensive Peace

Agreement (CPA) in January 9, 2005, enactment of South Sudan Local Government Act 2009

and Declaration of South Sudan independence on 9th

July 2011.

1.6 Significance of the Study

The study will provide information related to health service improvement in the health sector

which will bring accessibility to health care in the entire community.

Little or nothing has been done on the contribution of non-governmental organizations in

delivery of basic health services in partnership with local government in South Sudan. This

10

research has bridged the existing gap. The study will create an opportunity to supplement the

little existing knowledge in the field of local governance and human rights and acted as a basis

for further research which will lead to the effective health service delivery in the entire health

sector and the country at large.

The study will provide the health sector in Yei River County with some information that can be

shared with donors and government for better collaboration in the health sector and contribute to

advancing effective service to the beneficiaries in Yei, Central Equatoria State.

1.7 Justification of the study

According to Mugenda and Mugenda (1999), justification of the study highlights the reasons for

conducting the study as well as the importance of carrying it out. The most dangerous problem

the health sector faces is the declining role of the state and the changes in donor funding from the

public to the private sector which has led to poor basic health service delivery in the past 20

years. This has prompted the researcher to assess and analyze the contribution of non-

governmental organizations in delivery of basic health services in partnership with local

government. The research will help the health policy makers to review their risk policies in order

to reduce on the level of health service delivery challenge.

1.8 Definition of Key Terms

Health Systems: The World Health Organization (WHO) defined health systems as "all the

organizations, institutions, and resources that are devoted to producing health actions" in its

World Health Report of the year 2000. This definition includes a full range of players engaged in

the provision and financing of health services including public, non-profit, and for-profit private

11

sectors, as well as the international and bilateral donors, foundations, and the voluntary

organizations involved in the funding or implementing health activities(Improving performances.

Geneva; 2000).

Health System Strengthening (HSS) is defined as any array of initiatives and strategies that

improve one or more functions of the health system, leading to better health through

improvements in the access, coverage, quality and safety (World Bank and Oxford University

Press, New York; 2006). Importance of strengthening of the public, private and community

health systems has been emphasized in a variety of documents by various international, regional

and national bodies concerned with the health care such as WHO, USAID, Global Fund.

Weaknesses and gaps in the health systems limit the achievement of desired outcomes from the

interventions at various levels and therefore impede the attainment of the broader national and

international health care goals.

Efficiency, a much broader concept, is the relationship between the level of resources invested in

the health care system and the volume of services, or, what amounts to the same thing,

improvements in health achieved.(Rheault (1990), p. 2.)

Local Government: An administrative body for a small geographic area, such as a city, town,

county, or state. A local government will typically only have control over their specific

geographical region, and cannot pass or enforce laws that will affect a wider area.

Local governments can elect officials, enact taxes, and do many other things that a national

government would do, just on a smaller scale.

Healthcare sector: Is the medical and healthcare goods and services category of stocks. This

category also includes companies that are involved in the management of hospitals, health

http://publications.gc.ca/Collection-R/LoPBdP/BP/bp350-e.htm#(6)

12

maintenance organizations (HMOs), biotech firms, and other companies that are involved with

medical related products and services. This category of stocks is considered to be defensive in

nature due to the fact that most medical products and services are essential.

1.9 Conceptual Framework

In this conceptual framework, the key research variables and their inter-relationships were given.

The purpose was to show the main concepts that underpin the study and how this was useful in

guiding the analyses of the study findings, conclusions and recommendations. The key concept

here was the non-governmental organizations‟ contribution in providing services related to the

heath sector and what significant contribution they have made to the sector.

13

Figure 1 Conceptual framework

Non Organizations’ Contributions

Proper payment of health

workers

Capacity building of health

personel

Maintainance and building of

new health infrastructures

Strenthening of the health

system

Reduction in death cases related

to basic health cases

Basic Health Services

Improved Health (Level &

Equity)

Responsiveness

Social and financial Risks

protection

Improved Efficiency

Adquate delivery of health

services

Increased community access to

health care

Reduced mortality rates

Intervening factors

Government policies

The political climate

Existence of peace and security

in the health areas

Cooperation and coordination

Church/ diocesan policies

Donor policies and regulation

Population trends

Donor funding

Donor relationship

Local government

Health service systems

Funding from the local

government

Sustainability of services

by local government

The NGOs policies by the

local government

Local government

budgetary planning

14

According to the framework in figure 1, the independents variables were the actual contribution

rendered by NGOs. On the other hand the actual benefits accruing from NGO support were the

dependent variables. In other words for someone to know that the NGOs have contributed it is

when the dependent variables such as adquate delivery of health services, proper payment of

health workers, capacity building of health personel, maintenance and building of new health

infrastructures, strengthening of the health system and reduction in death cases related to basic

health cases were met.

The local government partnership with NGOs contributes to the basic health services through;

Health service systems, Funding from the local government, Sustainability of services by local

government , The NGOs policies by the local government , Local government budgetary

planning. This has smoothened the role and contribution of NGOs in improving the basic health

service delivery in Yei Civil Hospital and Martha Primary Health Care Centre in South Sudan.

There were other factors which were considered having effect on the non-governmental

organization contribution to the health sector; these were called intervening factors and they

included: government policies, political climate, existence of peace and security in the health

areas, cooperation and coordination, church/diocesan policies, donor policies and regulations,

population trends, donor funding, donor relationship, sustainability of services by government,

and availability of funds from government. The study focused on the relationship between the

independent and dependent variables, but much consideration was put to the intervening facts

because they had an attachment to the whole process.

15

CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

This chapter presents and reviews the relevant literature that has been documented by various

scholars and authors in the area of the study. The literature was reviewed in accordance with the

major themes of the study as identified in the specific objectives.

2.1.1 Partnerships in the Health Sector

Health systems are expected to serve the population needs in an effective, efficient and equitable

manner. Therefore, the importance of strengthening of public, private and community health

systems has been emphasized time and again (BMC, Health Services Research 2011). In most of

the developing countries, certain weaknesses and gaps in the government health systems have

been hampering the achievement of improved health outcomes. Public sector in Pakistan has

been deficient in the capacity to deliver equitable and quality health services and thus has been

grossly underutilized.

The Basic Package of Health Services report, (2006), highlighted that, there was weak capacity

of the Central Equatoria State Ministry of Health and the Yei County Health Department to

manage and deliver health services and that there are very few functional government health

facilities. Given these reasons the government contracted out the management and delivery of

health services to non-governmental organizations. Some Lead Agencies were contracted to

manage and deliver health services in a number of states including Yei in Central Equatoria

State. The non-governmental organizations have been providing advice, capacity building and

16

management support to the health sector but at the central government level and at the level of

local government through the County Health Departments. Since many years, international and

local non-governmental organizations (NGOs) have endeavored to fill the gaps in health service

delivery, research and advocacy (BMC Health Services Research, 2012). Non-governmental

organizations have relatively performed better and achieved the results because of the flexible

planning and the ability to design population based projects on health education, health

promotion, social marketing, community development and advocacy.

There is an increasing interest by governments and major donor agencies to work together with

non-governmental organizations (NGOs). While this is encouraging, it is recognize that greater

collaboration may require compromises in development strategies. Non-governmental

organizations have their own development philosophies, and cannot simply be used as

contractors to implement pre-designed and pre-packaged projects. At the same time, non-

governmental organizations have been flexible in adopting development strategies which meet

the local needs of the country and population which they are assisting (BMC Health Services

Research, 2012).

In 1993 the World Health Assembly called on WHO to mobilize and encourage the support of all

partners in health development, including Non-governmental organizations and institutions in the

private sector, in the implementation of national strategies for health for all (WHO, 2001).

Subsequently, interaction with the commercial sector has broadened and deepened. WHO‟s

Director-General has stated that it was necessary to be more innovative in creating influential

partnerships and that progress was being made in building partnerships with nongovernmental

organizations and the private sector. Partnering is outlined in WHO‟s corporate strategy as a core

function that can help to bring about health for all.

http://www.google.co.ug/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&cad=rja&ved=0CC0QFjAB&url=http%3A%2F%2Fauthormapper.com%2Fsearch.aspx%3Fq%3Dequity%2Bhealth%2Band%2Bhuman%2Bdevelopment%26val%3Djournal%253ABMC%2BHealth%2BServices%2BResearch%26size%3D20%26P%3D2&ei=HYbAUeCmH8nWPO_kgbAF&usg=AFQjCNEUhaTeidm6iDYAbQJF8qI9qVVoSw



17

2.1.2 Concepts of NGOs

NGOs are legally constituted corporations created by natural or legal people that operate

independently from any form of government. The term originated from the United Nations, and

normally refers to organizations that are not a part of a government and are not conventional for-

profit businesses. In the cases in which NGOs are funded totally or partially by governments, the

NGO maintains its non-governmental status by excluding government representatives from

membership in the organization. In the United States, NGOs are typically non-profit

organizations. The term is usually applied only to organizations that pursue wider social aims

that have political aspects, but are not openly political organizations such as political parties

(World Bank, 1994).

The World Bank defines NGOs as “private, not-for-profit organizations that pursue activities to

relieve suffering, promote the interests of the poor, protect the environment, or undertake

community development” (Hecht and Tanzi, 1993 cited in Waters, 1995). Green defines NGOs

as “non-profit-making organizations outside of direct state control” (Green, 1987). These

definitions fit the literature that were reviewed for this research work, especially in regards to

their non-profit status and their social mission to serve the poor, deliver health services and

under-served populations. NGOs that fit these definitions include religious organizations (e.g.,

church-run hospitals), social welfare organizations (e.g., women‟s groups), and unions and trade

or professional associations.

Since the early 1980s, many governments have regarded the role of NGOs as that of facilitators

of change whose contributions are essential to the achievement of development goals. Many

governments have highlighted the indispensability of collaboration between government and

http://en.wikipedia.org/wiki/Natural_person

http://en.wikipedia.org/wiki/Government

http://en.wikipedia.org/wiki/United_Nations

http://en.wikipedia.org/wiki/Non-profit

http://en.wikipedia.org/wiki/Society

http://en.wikipedia.org/wiki/Politics

18

NGOs and encouraged the formation of community-based organizations (CBOs) and village-

level participation in development efforts (Cousins 1991).

It is believed that the involvement of the Non-Governmental Organization (NGOs) in the health

field in the developing countries, which started in the 18th century, was initiated by the

evangelical missionary work (Ahmed, 2004). These missionaries concentrated their work, in

addition to their main religious activities, on health services provision through un-trained clerks.

Then after, they started to involve the trained health cadres.

The engagement of the non-religious NGOs in health activities in the developing countries is

recent – although dating for about 100 years. Nevertheless, the post- World War II period

represented the era when the number of NGOs increased significantly in the developing

countries. Their work was firstly restricted to the emergency and disaster times and in supporting

and rehabilitating war victims (Red Cross, Oxfam, 1985). Next to that, most of these NGOs

started developmental activities, including health aspects, although some of them continued to

restrict their activities to emergency.

The work of these Red Cross and Oxfam in the health sector was influenced by the ideological

and philosophical changes accompanying the evolution of this sector: while Primary Health Care

(PHC) concepts reigned, over-marking the period 1980s, in which it was focusing on the

concepts of equity, community participation, linking development and health and redirecting

health resources towards health aspects other than the curative medicine services; we also notice

that the period of 1990s witnessed the concentration on the concepts of health system

reconstruction, which directly influenced the work of NGOs - due to the frustration from the

weak public sector performance in regard to medical services provision, in addition to the

19

diminishing resources available for this sector and the structural adjustment of policies

dominating that period of time. All these factors influenced the work of NGOs and gave them the

great opportunity to be presented as a substitute for the public sector in services provision,

particularly in health fields.

Closely related to the above, we can recognize the imposition of the New Policy Agenda (NPA),

which concentrated on the necessity to move for the policies of open market, privatization and

community openness as basic pre-requisites for sustainable development (Pfeifer, 2002). This led

in turn to prosperousness of NGOs work in the developing countries, especially in the last two

decades.

This verity is recognized also when considering the financial support the developing countries

receive from donor countries and organizations, which reached approximately 55.1 billion US

dollars (1992-1996). Reflecting this fact, the external support represented 10% of the GDP of the

Sub-Saharan African countries according to the statistics of the early 1990s (Walt, Pavignani,

Gilson & Buse, 1999).

Since the 1980s, NGOs and other civil society organizations have grown exponentially and

climbed the centre stage of the development arena. For some, development NGOs are a magic

bullet that can be fired in any direction and would still find its target, while for others they are

the most overestimated actors on the national and international political stage (Van Sant 2003;

Nuscheler 2001). Carbone (2003) describes their increasing importance as an “association

revolution”, comparable in importance with the rise of the nation state in the nineteenth century.

Other non-governmental organizations which are not dealing with health activities also

contributed to improvement of the health status of the population in Yei and South Sudan in

20

general. Sectors like agriculture, animal industry, water, education, community development

contributed significantly to the improvement of the health status of the population. The

Ministries of Health at central, state and county levels therefore collaborate with all health

related sectors in order to harness the significant contribution to health that reside in these other

sectors. The Ministry of Health, Government of South Sudan, through the inter-ministerial

committee and other channels, advocates to all these sectors to effectively carry out their

constitutional mandates, roles and responsibilities some of which result in improving the health

status of the population (South Sudan Development Plan 2011-13).

2.1.3 Categories of NGOs

Due to their diversity, NGOs are often classified in terms of their attributes. For example,

Gordenker and Weiss (1995) classify NGOs as private, self-governing, formal, nonprofit

organizations. The omission of the word “voluntary” from this classification reflects the

increasing professionalism of the NGO sector (Vakil, 1997). In fact it is the „organizational‟

attributes of NGOs that distinguishes them from social movements or other forms of collective

action like public protests (Martens, 2002). NGOs possess an organizational structure, such as

permanent offices, members, employees, and a constitution (Uvin & Weiss, 1998; 213). One of

the main distinctions of NGOs is their self-governing attribute.

NGOs are private, autonomous organizations made up of individuals with similar social

interests, and are not controlled by any government body (Malwaski, 1993). They are typically

not composed of government representatives, and not interested in seeking governmental power

(Martens, 2002). However, many NGOs have ties to the national governments of the countries in

which they work, and they often receive funding from and work in conjunction with government

21

agencies (Martens, 2002). In sum, NGOs are formal, professionalized, independent societal

organizations whose primary purpose is to promote a common goal at the national or

international level (Martens, 2002).

Several other attributes of NGOs are important to note: level of operation and sector. NGOs are

often classified according to their level of operation. Many NGOs are considered transnational

organizations; meaning they operate in many countries around the world (Collingwood, 2006).

The level of operation often differs among NGOs, and can vary depending on factors such as its

size, structure, and purpose. Vakil (1997) identified four levels of operation: international,

regional, national, and local. Additionally, NGOs can be classified according to the sector in

which they work. There is little consensus regarding the number and type of sectors in the NGO

literature. The present study focuses on NGOs working in the health sector; however before

discussing health NGOs the researcher discussed the relevant discourse and research on the NGO

sector.

2.2 Activities of NGOs in the Health Sector

The World Health Organization (WHO) defines service delivery as the way inputs are combined

to allow the delivery of a series of interventions or health actions (WHO 2001b). As noted in the

World Health Report 2000, “the service provision function of the health system is the most

familiar; the entire health system is often identified with just service delivery.” The report states

that service provision, or service delivery is the chief function the health system needs to perform

(WHO, 2000).

There are many different activities carried out by different organizations in the health sector in

the world, Sub Saharan-Africa and South Sudan. In the past 20 years there has been a dramatic

increase in the number of non-governmental organizations (Edwards, 2004: 21; Fruttero &

22

Gauri, 2005). Although non-governmental organizations are not a new phenomenon, they are

now seen as the preferred vehicle for service provision (Lavelette & Ferguson, 2007). In many

areas of the world Non-Governmental Organizations (NGOs) are considered the key providers of

human services, and the NGO sector currently constitutes a 1.1 trillion dollar industry (Edwards,

2004; 21). As the non-governmental organizations sector has grown in power and presence in the

world today.

Non-governmental organizations are the major providers of health services in South Sudan. After

the collapse of the public health care system during the many years of conflict, non-

governmental organizations played a major role in the health sector by providing a range of

services in accessible areas. In the post-war South Sudan, non-governmental organizations

continue to provide the bulk of health services. It is estimated that non-governmental

organizations are providing about 80% of health services in South Sudan. The non-governmental

organizations involved in health service delivery include international non-governmental

organizations, faith-based organizations and local non-governmental organizations (Government

of Southern Sudan Health Strategic Plan (2011 – 2015).

In recent years, non-governmental organizations have become key players in promoting health in

developing countries (Pfeiffer, 2003). Health non-governmental organizations are seen as

alternatives to government run health care services because they are considered less hampered by

bureaucratic constraints and inefficiencies (Gilson, Sen, Mohammed, & Mujinja, 1994). Health

non-governmental organizations are extremely diverse in terms of their origins, motivations, and

overall contribution to health.

23

Health non-governmental organizations provide a range of services: basic health services;

provision of medical or health supplies; health promotion and exchange; health policy setting;

resource mobilization and allocation; health advocacy; and monitoring the quality of health care

services (WHO, 2001).

2.3 Beneficiaries’ Satisfaction on the Health Services

At the center of non-governmental organizations debate is the issue of non-governmental

organizations performance or impact. Many terms are used interchangeably in the non-

governmental organizations literature to describe impact, such as performance, effectiveness, or

success. All of these terms refer to the organizational outputs of the non-governmental

organizations. Non-governmental organizations are thought to provide services more efficiently

and effectively than governments, to give better value for money, and reach the poorest

communities (Sollis, 1992; Vivian, 1994).

There is some evidence suggesting that non-governmental organizations make successful

contributions to health in certain circumstances. Non-governmental organizations have made

significant contributions to reproductive and sexual health in many areas in the developing world

and South Sudan in particular. Mercer, et. al, (2004) have shown that effectively run non-

governmental organizations reproductive and child health services have decreased child and

maternal mortality. Non-governmental organizations primary health care programs were found to

expand coverage for reproductive and child health services, and decrease child and maternal

mortality.

Non-governmental organizations programs in Bangladesh increased contraceptive use by 78%,

child immunizations by 67%, and antenatal care by 78% (Paxman, Sayeed, Buxbaum, Huber, &

24

Storver, 2005). In terms of customer satisfaction, non-governmental organizations run health

facilities received higher marks than government run facilities. A study in Mexico found that

women attending non-governmental organization services reported more satisfaction than

women who attended public clinics (Gomez-Jauregui, 2001). Leonard (2004) found that the

African rural poor viewed non-governmental organizations health services to be of higher quality

and more attractive despite the fees they charged.

Over the last few decades, health has attained worldwide recognition as a crucial component of

human development and poverty eradication. This recognition springs, in part, from the

realisation that one third of the world population lacks access to essential medicines. This

critically contributes to further poverty, mortality, morbidity and indebtedness (WHO, 2004).

The 2009 Report of the Special United Nations Rapporteur on the Right to Health, for example,

observes that the diseases of the poor – that is, communicable, maternal, prenatal, and nutritional

diseases – still account for 50 percent of the burden of disease in developing countries (nearly 10

times higher than in developed countries). Secondly, improving access to medicines alone could

save 10 million lives a year – four million in Africa and six south Asia. Third, the right to health

is an inclusive right, which extends not only to the timely delivery of medicines, but also the

underlying determinants of health. These include things like sanitation and access to clean water;

proper nutrition; the availability of highly motivated health workers; and auxiliary infrastructure

such as housing for health workers, access to roads, and solar equipment to keep vaccines in

rural health centers at the right temperatures. In this study focus was made on the delivery

mechanisms of health service in Yei River County South Sudan. But the underlying determinants

of good health were not forgotten.

25

The human right to health means that everyone has the right to the highest attainable standard of

physical and mental health, which includes access to all medical services, sanitation, adequate

food, decent housing, healthy working conditions, and a clean environment. The human right to

health care means that hospitals, clinics, medicines, and doctors‟ services must be accessible,

available, acceptable, and of good quality for everyone, on an equitable basis, where and when

needed. The design of a health care system must be guided by the following key human rights

standards and principles (Article 25 of the Universal Declaration of Human Rights 1948)

There are various references in international human rights documents to a right to health care.

The Universal Declaration of Human Rights for example vouches for everyone's 'right to a

standard of living adequate for the well-being of himself or herself and of his or her family,

including (amongst others) medical care' (Article 25(1). Article 12(1) of the International

Covenant on Economic, Social and Cultural Rights the states parties to the Covenant " recognize

the right of everyone to the enjoyment of the highest attainable standard of physical and mental

health' and this inter alia impels them to create conditions 'which would assure to all medical

service and medical attention in the event of sickness' (Article 12(2) (d)). It must be borne in

mind that the Covenant has the legal force of a treaty for the states that are parties to it.

Article 16(1) of the African Charter on Human and Peoples' Rights states that 'every individual

shall have the right to enjoy the best attainable state of physical and mental health' while Article

16(2) requires from states that are parties to the Charter to 'take the necessary measures to protect

the health of their people and to ensure that they receive medical attention when they are sick.

The coming on board by the NGOs is not just for granted but is to realize the right to health as

highlighted in the various charters and universal declaration. The Constitution of the Republic of

http://www.nesri.org/resources/the-universal-declaration-of-human-rights

26

South Sudan of 2011 also provides for Public Health Care to its people. The Constitution call for

all levels of government which local government is part of to promote public health, establish,

rehabilitate and develop basic medical and diagnostic institutions and provide free primary health

care and emergency services for all citizens. The aim of many health non-governmental

organizations is to improve access to and coverage of health services to the poorest communities,

and they are often the primary service providers for vulnerable groups such as the disabled,

women, and children (Gilson, et al., 1994; Jareg & Kaseje, 1998). NGOs often provide local

health care systems with resources such as health care training, financial support, medical

supplies, and drugs (Gilson et al, 1994). In addition, they may establish and run local health

clinics or hospitals.

United Nation Charter on Right to Development calls for States to undertake, at the national

level, all necessary measures for the realization of the right to development and shall ensure,

inter alia, equality of opportunity for all in their access to basic resources, education, health

services, food, housing, employment and the fair distribution of income. Effective measures

should be undertaken to ensure that women have an active role in the development process.

Appropriate economic and social reforms should be carried out with a view to eradicating all

social injustices.

The importance of non-governmental organizations (NGOs) in the delivery of services is gaining

increasing recognition not only to complement government programmes, but also to provide

people with a choice of service outlets and to create an effective voice in respect of service needs

and expectations. The World Health Organization (WHO) report of 2010 has recognized the

need for concerted inter-sectoral action with the participation of all actors in health development.

Accordingly an analysis of the current situation in regard to Non-Governmental Organizations

27

participation and partnership in health development is considered to be timely and relevant to

initiate strategies to promote and enable non-governmental organizations to engage meaningfully

in collective action for health development. Such collaboration could have a positive impact on

the form and substance of health governance.

The failure of the economic development process to lead to rapid improvement in the living

standards of the poor in developing countries led, in the 1960s and 1970s, to a reconsideration of

the aims and methods of development policy and development aid. A growing consensus

emerged that the objectives of economic development - an improvement in the living standards

of the population at large - should be the more immediate target of socio-economic policy, rather

than that it should be the incidental consequence of policies geared towards economic growth.

Put differently, it came to be widely accepted that it was not appropriate to wait for the benefits

of economic growth to trickle down to the whole population, but that a more direct route should

be followed in terms of the type and nature of growth itself. This came to be known as a basic

needs approach. (Streeten et al. 1981; Streeten 1979; Stewart 1985) More recently, a so-called

human development approach has been adopted by some international development institutions.

In essence, this does not fundamentally differ from the basic needs approach.

In accordance with the basic needs strategy, a set of core basic needs are identified which should

take precedence in terms of the provision of public goods and the implementation of

development strategies. These core basic needs, often identified with the more basic needs in

Maslow's hierarchy, include nutrition, housing, sanitation, clean water, health, basic education,

and energy for cooking and heating purposes. (Streeten 1979; Streeten et al.1981). Though there

is some disagreement about precisely which needs are to be considered core needs, there is no

28

doubt that health is such a basic need. But, as was pointed out above, health is not purely an

outcome of the volume or quality of health care, but also reflects many other aspects of well-

being, such as housing, nutrition, clean water, sanitation, and even education. Health is thus an

outcome of a very complex interaction of social service provision, community structures and

individual behavior.

Since many years, international and local non-governmental organizations (NGOs) have

endeavored to fill the gaps in health service delivery, research and advocacy. NGOs have

relatively performed better and achieved the results because of the flexible planning and the

ability to design population based projects on health education, health promotion, social

marketing, community development and advocacy (BMC Health Services Research 2011). This

paper captures the need and the opportunity of public private partnership in Pakistan and presents

a framework for a meaningful engagement of the government and the private and nonprofit

NGOs.

2.3.1 Primary Health Care Policy

In many low-income countries, non-governmental organizations (NGOs) deliver basic health

services in particular areas or among certain populations. Their effectiveness in establishing

sustainable primary health care (PHC) systems has been linked with promotion of community

participation, having close links with the poor, being flexible and having committed staff (Gellert

1996). The comparative advantage of NGOs might be assessed in terms of efficiency,

innovation, quality of services, ability to mobilize resources, contribution to the sustainability of

the local health system and coverage of grass-roots communities (Gilson et al. 1994; Matthias

and Green 1994; Stefanini 1995).

29

The role of NGOs in the health sector was impacted by changes in the thinking regarding

development and health policies in the last two decades (Green & Mathais, 1997). One such shift

was the introduction of primary health care policy. Primary health care (PHC) was launched by

the World Health Organization in the 1987 Alma Ata declaration with the goal of improving

health for all by 2000 (WHO, 1978). The Alma Ata declaration transformed the traditional

understanding of health by recognizing health as a human right, and overhauling the service

delivery system to incorporate all stakeholders in health (Jareg & Kasaje, 1998). Primary health

care policies shifted the focus of health care from the biomedical model and placed priority on

combating all the causes of poor health by engaging sectors outside of health care (Green &

Mathais, 1997).

Primary health care policies are based on several principals: health as a human right (universal

health care for all people), community participation, and inter-sectoral coordination (WHO,

1978). PHC draws attention to the link between poor health and under-development. This

reflects the view that health is affected by social determinants such as poverty, illiteracy, and

sanitation; and that health improvements occur through social, economic, and cultural changes in

a community (Green & Mathais, 1997; King, 2001). Thus, PHC stresses the importance of

community involvement and development as a mean of improving health. It also reflects the

belief that long term improvements in health can be achieved by giving people more choices and

control over the determinants of their health (Frankish, 2006).

Lastly PHC policies address the resource wastage historically associated with the health sector

by shifting the bulk of funding from large urban hospitals that focus primarily on curative care,

to primary care facilities that focus on both curative and preventative measures (Green &

30

Mathias, 1997). While the Alma Ata declaration did not single out NGOs in particular, many

health NGOs quickly adopted these ideas into their operations. NGOs are now considered key in

the implementation of PHC policies because they are accustomed to working within

communities, and partnering with organizations in other sectors (Jareg & Kaseje, 1998).

The goal of the health policy in South Sudan is to improve the health of the people through

strengthening the health system at all levels and in particular ensuring the universal coverage of

an essential package of health services.

2.4 Challenges Faced by the NGOS in the Delivery of Health Care Support

The major challenges facing NGOs at the moment include creating an environment for

cooperation. Governments have not moved fully to create a positive environment for cooperation

with NGOs. But NGOs must also contribute to creating a new environment. Those NGOs who

have long believed that the Government is the problem need to understand that sustainable

development to reduce poverty will require cooperation. NGOs should avoid being perceived as

adversaries and competitors of the Government (Drucker, 1990).

Mobilizing local resources is the recent policy of privatization and liberalization calls upon the

NGOs to take heed of the emerging private enterprise sector. Partnerships with the private sector

could be a strategy for achieving the organizational and financial sustainability of the NGOs, an

issue of critical concern. Local NGOs need to generate income through local resource

mobilization. Drucker (1990) points out that non-profit organization themselves know that they

need management all the more, because they do not have a conventional 'bottom line'! They need

to know how to use management as their tool lest they be overwhelmed by it. Easo (2004) points

out that today there is a stronger emphasis on "doing well" while "doing good".

31

Health NGOs have encountered a number of common problems with government support. These

include delays or even non-payment of grants and reimbursements, which is increasingly a

problem as economic conditions decline in a number of countries, low and inflexible

reimbursement rates (e.g., for bed grants), the lack of flexibility in the use of earmarked funds,

and unacceptable conditions tied to the granting of funds. For instance, in Zimbabwe the

government prescribes fees in church-run hospitals that the missions consider too high (Gilson et

al, 1994).

The NGOs may disclose sources of their funding at their own discretion. In reality, most NGOs

are generally unwilling to disclose their funding sources and actual expenditures to anybody

outside their governing board or executive body, not even to researchers (Kwesiga 2000). A

study published in June in 2004 by an international consulting company on Sustainability,

concluded that an "Accountability squeeze" was one of the major challenges facing non-profit

organizations (Christensen, 2004).

The power and presence of non-governmental organizations has increased significantly over the

past few years and they are now considered significant players in world affairs (Martens, 2002).

However, this increase in prestige has been a double edge sword for many organizations. Non-

governmental organizations are now expected to be accountable for their finances, as well as

demonstrate the effectiveness of their programs and services. This focus on accountability comes

at a time when there is a debate regarding the merits of non-governmental organizations,

specifically related to service provision, cost effectiveness, and their overall contribution to civil

society.

32

Health systems in countries emerging from conflict are often characterized by damaged

infrastructure, limited human resources, weak stewardship and a proliferation of non-

governmental organizations. These conditions result in the disrupted and fragmented delivery of

health services. One increasingly popular response to improve health service delivery in post-

conflict countries is for the country government and international donors to jointly contract non-

governmental organizations to provide a Basic Package of Health Services like USAID, UNDP

and CIDA. This approach is being applied in Afghanistan, South Sudan and in the Democratic

Republic of Congo. The approach is novel because it is intended as the only primary core service

delivery mechanism throughout the country, with the available financial health resources

primarily allocated to it. Although the aim is to scale up health services rapidly, including sexual

and reproductive health services, there are a number of implications for such sub-sectors.

Provision of Payment and Other Misaligned Incentives is Misalignment of financial and other

incentives is perhaps the largest obstacle to be surmounted in reforming health care delivery. Too

often, provider payment systems unintentionally reward duplication of services, use of services

that may not be clinically necessary or appropriate, and other cost-escalating activities, while

failing to create incentives and compensate providers for their contributions to desired outcomes

(including disease prevention) and their care decisions to appropriately use fewer and less

intensive services (Springer-Verlag, 1990).

Incentives to develop delivery innovations for better management of high-cost patients so as to

achieve desired outcomes are countered by the reality that such patients serve as an important

source of provider revenue. Experts agree that the fee-for-service payment system needs to

evolve and give way to more sophisticated arrangements that offer global or bundled payments

33

that are tied to acceptance of responsibility for care episodes and outcomes. Experimentation

with alternative payment arrangements is one of the most important areas of ongoing reform.

Provider payment is not the only area in which misaligned incentives pose obstacles to health

care delivery reform. Throughout the health system there are tensions and conflicts of interest

that can create barriers to change. While the burden of high and rising health care costs affects

everyone, the health sector is also a thriving economic sector that serves as a job creator and

center for lucrative opportunities that have played a vital role in the nation‟s economy. Deep-

seated cultural, financial, and institutional vested interests constitute hurdles to recognize and

overcome. Addressing these challenges will require leadership, creativity, and sustained

commitment (New Health System, 2001).

Searching NGOs is a daunting task for several reasons. First, the sheer number of and diversity

among NGOs makes it difficult for researchers to examine the impact of these organizations.

NGOs are highly diverse in terms of their organizational characteristics, such as size, resources,

age, services and the number of sectors in which they work. This diversity also extends to the

environments in which NGOs operate. Many NGOs operate on an international level, and work

in countries with vastly different social, economic, and political landscapes. These factors make

it difficult for researchers to measure and compare the outputs of NGOs working in different

countries.

However, research conducted by Tendler (1982) and Riddell and Robinson (1992) found that

non-governmental organizations are not automatically more cost effective than the public

sectors. In fact, there is no one study which demonstrates that non-governmental organizations

services are cheaper than government services (Edwards & Hulme, 1996). Though some

34

evidence suggests larger non-governmental organizations are more cost effective than

governments (Edwards & Hulme, 1996). In terms of reaching the poor, some evidence indicates

that non-governmental organizations perform better than governments (Smillie & Helmich,

1993; Farrington, Bebbington, Wells, & Lewis, 1993).However Hashemi (1992) found that

larger non-governmental organizations in Bangladesh strive to achieve breadth rather than depth,

and as a result often failed to reach the poorest of the poor.

In addition, non-governmental organizations are often less inclined to maintain a presence in the

more remote and poorer communities (Barr & Fafchamps, 2006). Additionally researchers found

that non-governmental organizations programs were not related to community need, and that

NGOs did not strive to avoid the duplication of services (Fruttero & Gauri, 2005). Much of

research on non-governmental organizations has focused on organizational behaviors,

specifically those behaviors that are thought to influence impact. Several organizational

characteristics have been found to influence non-governmental organizations efficiency,

longevity, and success.

The power and presence of NGOs has increased significantly over the past few years and they

are now considered significant players in world affairs (Martens, 2002). However, this increase

in prestige has been a double edge sword for many organizations. NGOs are now expected to be

accountable for their finances, as well as demonstrate the effectiveness of their programs and

services. This focus on accountability comes at a time when there is a debate regarding the

merits of NGOs, specifically related to service provision, cost effectiveness, and their overall

contribution to civil society. NGOs are criticized for possessing weak accountability

mechanisms, and poor institutional learning (Mebrahtu, 2002).

35

Critics cite numerous studies that demonstrate a lack of evidence from which to establish the

impact of NGO services (Edwards & Hulme, 1996; Kelly, Kilby, & Kasynathan, 2004). These

studies indicate that NGOs often fail to monitor and evaluate their programs, and thus are unable

to demonstrate the impact of their work. Instances of scandals and misdeeds concerning the use

of donor funds have also contributed to the criticism of NGOs. NGOs are also charged with

possessing hidden agendas, and being heavily influenced by donors (Lister, 2003; Logister,

2007).

On the other hand, proponents of NGOs argue they are effective vehicles of service delivery,

reach the poorest communities, and are more cost effective than governments (Fruttero & Gauri,

2005). NGOs are under pressure to show that their organizations are efficient, effective, and

accountable for their actions. Demonstrating achievement has been cited as the first step to

establishing NGO legitimacy (Fowler, 1997:183). The NGO debate has sparked a significant

amount of scientific research into the NGO sector.

In the face of growing criticism, NGOs have been called to scale up the impact of their programs

(Edwards and Hulme, 1992). Scaling up refers to „expanding‟ the impact of NGO services (Uvin,

Jain, & Brown, 2000). Even when NGO programs are successful the research indicates that their

impact often remains small (Uvin, et. al., 2000). NGOs can scale up impact by: increasing their

size and coverage; increasing their activities; networking other organizations; and enhancing

organizational sustainability.

2.5 Ways for Effective and Efficient Delivery of Health Services

A rapidly changing development management scenario is the context in which NGOs must

function. Notably, these include the adoption of a private sector led growth strategy, a shift to

decentralized modes of governance, and increasing regional disparities in access to development

36

services. The changes and challenges are inevitably affected by the ongoing conflict, which

imposes not only heavy economic and financial costs, but also social costs on a development

system that is under pressure to perform comprehensively in order to ensure long-term economic,

social and political stability (Institute of Policy Studies ;2001).

In recent years NGOs have come under intense scrutiny by donors, clients, and the countries in

which they work. This scrutiny has fostered a debate regarding the merits of NGOs, specifically

related to their performance, impact, and accountability. Health NGOs have been criticized,

because despite the tremendous amount of money they receive, little is known about their overall

contributions to health.

Health facilities are required to compile financial summaries, on a monthly basis, indicating

funds received and funds spent in the categories of PHC wage, PHC non-wage, PHC

development, local governments, credit lines (medicine), donor projects, and others (to be

specified). In the management of medicines, health facilities are supposed to use stock cards to

track the movements and balance of all medicines in the health unit and the extent of (monthly)

stock outs. However, a problem of incomplete or irregular data was found. Use of data for

planning purposes was found to be low. Most of the health facilities do not complete the sections

on medicines stock outs, health facility management and funds received and used. This problem

was largely attributed to low motivation and under-staffing (Economic Policy Research Centre,

2010).

Applying economic theory to health care is an effort to address the issues of allocating physical,

human and financial resources and setting priorities in the budget decision-making process. The

first issue, related to the concept of efficiency, is to determine the optimum amount to be

allocated to health care; this depends on the extent of resources to be allocated to meeting

37

society's other needs. In addressing this issue, we must make a choice: what portion of the

budget is to go to health care and what portion to other, equally important, public investments

such as education, job creation, and research and development. The second issue, also related to

efficiency, is how to allocate resources among the various components of health care, for

example, preventive care, curative care and medical research.

The third issue is to identify activities considered effective and for which funding assistance is to

be provided, taking into consideration the limitations determined and priorities set in addressing

the two preceding issues. Before assessing the system's efficiency from a macroeconomic point

of view, we should identify the activities that are effective from a microeconomic perspective.

Assessing effectiveness in health sector consists of measuring the effects of medical practices

and techniques - therapeutic, diagnostic, surgical and pharmacological - on individuals' health

and wellbeing. This must take into consideration not only observed improvements in health but

also side effects and iatrogenic effects (Government of Quebec, 1990, p. 104.) In its pure form,

assessing effectiveness compares two things that have the same effect or the same purpose. If

two drugs are each used to treat a particular illness, the more effective drug will be the one that

treats the illness more quickly with fewer side effects; it is called the more clinically effective

drug. Here the researcher looked at effectiveness in terms of the level of NGOs contribution to

the health sector.

Broadly applied, effectiveness combines both the clinical and economic aspects of health care.

Assessing effectiveness makes it possible to determine the medical practices and techniques that,

first, actually help improve health and, second, make good use of resources (Springer-Verlag,

38

1990, p. 41-50.). Since resources allocated to health care are limited, only effective practices and

techniques should be used.

As a corollary, the clinical and economic assessment of health care allows us to determine which

services are ineffective or inappropriate. A service is considered clinically ineffective if it does

not have the desired effect, such as treating or detecting illness or improving health. A service is

considered economically ineffective if it produces only a minimal improvement in health for its

cost. A medical procedure is considered inappropriate if it has no beneficial effects, or even has

undesirable effects, on the patient's health. Health care expenditures can be controlled better

when we stop funding inappropriate or ineffective services (University of Toronto Press, 1992,

p. 89-98.).

The purpose of efficiency is to maximize results effectively, or services delivered, given a

particular budget. According to this concept, each service must be delivered at the lowest

possible cost, have benefits of value equal to or greater than its cost, and make optimum use of

the resources invested. Efficiency is distinct from effectiveness in that it considers costs in

relation to benefits. The goal of transformation is to move from where we are to where we want

to be in terms of having effective and efficient delivery systems to meet health needs across

communities. Much of the change needs to happen locally, with assistance and investment in key

system-wide areas at the state and national levels. Coordination and open communication across

levels are essential. Areas requiring and benefiting from attention include both infrastructure and

incentives (Katz el at, 2010).

Human resources are the most important component of the health care delivery infrastructure.

While the U.S. health care workforce is well-educated and well-trained, there is relatively little

39

national attention to workforce strategy and few policy levers outside of payment by which to

spur desired changes (Katz el at, 2010). It is not clear that resources are always deployed in

ways conducive to establishing effective and patient-oriented health care delivery systems in Yei

South Sudan. Notably, the system offers far greater financial rewards to those physicians who

hone relatively narrow specialties instead of a general practice focusing on primary care and

prevention by the NGOs (South Sudan Health Report, 2012).

Further, medical education and training programs have not traditionally emphasized the

teamwork approach that is increasingly recognized as a critical feature of effective health care

delivery. It is difficult to retool practice and sustain change if practitioners are unprepared to

practice in new ways (World Bank, 1994). Also, the use of the broader range of health care

professionals and the scopes of their practice vary significantly across states and communities,

suggesting that there is untapped potential to deliver care more efficiently without compromising

effectiveness.

After decades of paying lip service to the need to integrate automated information management

and communications technology into health care delivery, remarkable progress on this front has

been made quite recently like in USA, Germany and UK. Information technology provides the

capacity to access patients‟ clinical information in the course of a treatment episode, to make

relevant and up-to-date evidence and protocols more readily available, to share information

across providers, to facilitate patients‟ self-management and shared decision-making, to extend

care to patients living in areas with limited local provider availability, and to engage in real-time

monitoring of quality and safety. Thus, strengthening the infrastructure and fostering its use

continue to be among the most essential goals of delivery system transformation in the short term

(Center for Studying Health System Change, September 2010).

40

Patient-Centered Outcomes Research

Information and evidence from research on effective health care delivery, in terms of both

treatments and models, are another essential part of the health care delivery infrastructure which

brings about health care service accessible. Recent investments in developing the information

base have resulted from debates that highlight the large gaps in knowledge needed to deliver care

effectively and to arm patients with the ability to participate in informed and shared care

decision-making. Such investments are also critical to achieving a better balance between the

promotion of beneficial innovation and the pressures to rapidly diffuse unproven technologies

that serve as a driver of rapid escalation in health care costs and the contribution of NGOs and

Government in the health arena.

The Quality Improvement a focus on quality of care, particularly when it is accompanied by

investments in the quality measurement and improvement infrastructure, can create incentives

for health care delivery reforms. An early and ongoing focus on patient safety issues, such as

medication errors, has expanded to include national attention to problems such as avoidable

hospital readmissions, inadequate management of chronic conditions, and poor transitions across

health and long-term care delivery settings. Furnishing providers with data on relative

performance across quality metrics can and does spur innovation in deliver health care that can

provide models for others seeking to improve.

In South Sudan the National Health System comprises of all the resources, institutions, structures

and actors whose actions have the primary purpose of achieving and sustaining good health. It is

made up of the public and private sectors. The public sector includes all Government health

institutions under the Ministries of Health (MoH-GoSS and SMoHs) and other ministries

(especially Defense and Internal Affairs). The private health delivery system consists of Non-

41

Governmental Organizations (NGOs) (private not for profit), private health practitioners (PHP),

the traditional healers and the communities (Health Policy – Government of Southern Sudan

(2007-2011)

The functions of a health system are: stewardship (leadership, governance or oversight); health

financing (collecting, pooling and purchasing); generation and management of health resources

(human and physical resources); and provision of health services (Health Policy – Government

of Southern Sudan (2007-2011). These functions are carried out by different aspects of the health

system including government (public) and private; central and local government; and national,

bilateral and multi-lateral partners.

A framework for coordinating donors in the health sector needs to be worked out expeditiously

to avoid disruption of National Medical Stores activities. One way of doing this is by National

Medical Stores creating a special unit to handle medicine supplies by “third parties”. A clear

procurement and distribution calendar of medicines supplied by third parties is necessary

(Economic Policy Research Centre, 2010).

2.9 Conclusion

The importance of Non-governmental Organizations (NGOs) in the delivery of services is

gaining increasing recognition not only to complement government programmes, but also to

provide people with a choice of service outlets and to create an effective voice in respect to

service needs and expectations.

In brief, health service delivery is not only a national problem but also a global problem and it

has persisted despite several initiatives directed to reduce it below acceptable figures at least

according to Millennium Development Goals. Although many researchers have emphasized on

42

the contribution of Non-Governmental Organization to service delivery, little consideration is

given to health service. This study therefore looked at the Contribution of Non-Governmental

Organizations in Delivery of Basic Health Services in Partnership with Local Government in Yei

River County.

43

CHAPTER THREE

RESEARCH METHODOLOGY

3.0 Introduction

This chapter presents a description of the research design, study population, sample and

sampling techniques, research instruments, the quality control, research procedures and

techniques of data presentation and analysis.

3.1 Research Design

The research design adopted in this study was a cross-sectional case study research design. Case

studies emphasize detailed contextual analysis of a limited number of events or conditions and

their relationships. The purpose for choosing a case study research design was to identify the

various activities carried out by the Non-Governmental Organizations in Yei Civil Hospital and

Martha Primary Health Care Centre, establish the beneficiaries‟ level of satisfaction of the

health services provided by the Non- Governmental Organizations in Yei Civil Hospital and

Martha Primary Health Care, assess the challenges faced by the NGOs in the delivery of health

care support in Yei River County and suggest ways for effective and efficient delivery of health

services in South Sudan so as to find out whether Non- Governmental Organizations has a

significant contribution basic health service delivery. On case study research designs, Mugenda

and Mugenda (1999) says “The investigation therefore makes a detailed examination of a single

subject, group or phenomenon.” The researcher employed both quantitative and qualitative

research techniques. These are considered the best strategies for this kind of study. The

quantitative research was used for descriptive purposes, and through this approach, the

researcher was able to describe the population characteristics as well as understand the impact of

the variables of the study on each other. It was possible to gather more information through this

44

technique and further use numbers to describe the extent of the variables of interest. It enabled

the researcher to make comparisons of the findings from different population groups.

Qualitative technique helped the researcher to collect information that was not easy to be

captured through structured instrument that could find out any hidden information. Descriptive

research has been recognized as a very important method because it makes people understand the

characteristics of a group in a given situation, thinking systematically about aspects in a given

situation, offering ideas for hidden information and research that make certain simple decisions

(Sekran, 2003). Case study was used to study a phenomenon in depth and find out further

information through descriptive studies.

3.2 Area of Study

The study was conducted at Yei Civil Hospital and Martha Primary Health Care Centre in Yei

River County. Yei is a medium-sized town in South Sudan's southwest. It lies close to the

borders of two of the country's trading partners, Uganda and the Democratic Republic of Congo.

It is a business hub, attracting traders and customers from all three countries. The town of Yei is

located in Yei River County, Central Equatoria State, southwestern of Juba, the capital of South

Sudan, close to the international borders with the Democratic Republic of the Congo and the

Republic of Uganda. It is approximately 160 kilometers (100 miles), by road to Juba. They are

seven health centres and one hospital in Yei River County.

3.3 Study Population

The study consisted of chosen group of communities which comprised of clients, health

management committees which were beneficiaries related to Yei Civil Hospital and Martha

http://en.wikipedia.org/wiki/South_Sudan

http://en.wikipedia.org/wiki/Uganda

http://en.wikipedia.org/wiki/Democratic_Republic_of_Congo

http://en.wikipedia.org/wiki/Central_Equatoria



http://en.wikipedia.org/wiki/Democratic_Republic_of_the_Congo

http://en.wikipedia.org/wiki/Republic_of_Uganda

http://en.wikipedia.org/wiki/Juba,_South_Sudan

45

Primary Health Care Centre. The study also considered the Local government officials, medical

officials within local government and church leaders.

3.4 Sampling Size and Selection

A sample is a section of the population chosen to represent the whole population. The essence of

sampling is to obtain data from a smaller particular sample which in turn increases efficiency by

allowing generalisations to deduce about the population without necessarily having to examine

every member.

From the population shown, the sample size consisted of seven categories of groups that; 5

Church officials, 5 health officials 5 local government officials, 5 County health department

officials, 30 NGOs officials, 40 participants within the local population and others 10. In total the

numbers of respondents was one hundred (100). The study involved these groups of people

because of their key roles that they played in their various capacities as key stakeholders. The

selection of the sample size for the study was done using a sample size determination table

developed by Morgan and Krejcie (1970). This table was scientifically designed such that the

bigger the population size, the bigger the corresponding sample size as shown in table 3.1 below.

46

Table 3.1: Sample Size Determination Table

Category Population Sample size Technique

Clients 2000 40 Simple Random Sampling

Local government officials 7 5 Purposive Sampling

Health official 6 5 Purposive Sampling

NGOs officials 30 30 Purposive Sampling

County health department 7 5 Purposive Sampling

Church official officials 8 5 Purposive Sampling

Others 80 10 Simple Random Sampling

Total 2138 100

Morgan and Krejcie (1970)

3.5 Sampling Techniques

There were several sampling techniques that are employed in determining the sample to be used

in the research. These include cluster sampling, stratified sampling, proportionate sampling,

purposive sampling and simple random sampling among others. For this study however, Simple

random sampling technique and purposive sampling were employed in the study to select the

sample for 40 clients or beneficiaries and purposive sampling was used for the 60 key

informants. This technique was preferred because according to Oso and Onen (2005:35), it

selects samples without bias from the accessible population. It also ensures that each member of

the target population has equal and independent chance of being included in the sample. This

technique was used to control some extraneous variables like political climate. For Yei civil

hospital and Martha primary health care Centre administrators, however, purposive sampling

was employed. This was because the researcher considered them central in having the

information he required on contribution of non-governmental organizations in delivery of basic

47

health services in partnership with local government. As noted by Amin (2005:242), in purposive

sampling, the researcher selects a sample based on the knowledge that respondents have the

information required.

3.6 Research instruments

In this study, the researcher used questionnaires and interviews guide as primary sources of

gathering data. The two tools were preferred because they were the best in determining the

affective domain of the respondents. As noted by Touliatos and Compton (1988), they are the

best tools for getting views, perceptions, feeling and attitudes of respondents.

(a) Questionnaire

The questionnaires were both open and close-ended, designed in appropriate structured

questions. Some sections of the questionnaire were open ended. Structured questions were

preferred because they provided standardized sets of questions that represented varying degrees

of agreement. The researcher used questionnaire for 40 clients or beneficiaries because it was a

reliable and dependable instrument for collecting information from respondents who were

scattered in a vast area as noted by Ghosh (2000:241).

(b) Interview Guide

The researcher used interview guide as a tool to obtain first hand information from the

respondents on their perception about the contribution of non-governmental organizations in

delivery of basic health services in partnership with local government, the methods of collection

and their convenience. As noted by Amin (2005:178), interview was an appropriate data

collection tool because the researcher was able to explain and clarify the questions were asked. It

assisted the researcher to analyze in depth information on the contribution of non-governmental

48

organizations in delivery of basic health services in partnership with local government,

performance and service delivery. Responses were compared with those from questionnaires.

The method had a number of advantages. According to Amin, (2005), it ensures interaction and

social situated-ness, are motivational to both the interviewer and the interviewee. It also gives

chance for getting highly personalized data, eases probing and gives a good return rate.

3.7 Quality control

This refers to the way how the researcher measured the validity and reliability of instruments.

The researcher used a number of techniques to ensure that the instruments were both valid and

reliable.

3.8 Research procedures

Introductory letter was obtained from Uganda Martyrs University. The researcher drew a work

plan which guided him carry out planned activities of meeting respondents, distributing

questionnaires and conducting interviews as well as reporting to the supervisor for more review.

After data collection, the researcher did data analysis by: editing, coding and entering of data and

analysis of variables. The outcomes from the analysis were then compiled into a report for

onward submission to examiners.

3.9 Data presentation and analysis

After successful retrieval of filled –in questionnaires and conducting of interviews, raw data was

entered into a statistical package known as Statistical Package for Social Scientists (SPSS) and

variables were analyzed. Outcomes were presented as percentages using tables as a primary

analysis.

49

3.9 Ethical considerations

Ethical considerations refer to the morality, uprightness and justification of the researcher‟s

conduct in carrying out research. The researcher was guided by the following main

considerations. Certain information like the names of respondents was kept confidential on

special request by officials. It was also prudent to document information from archives only with

the consent of respondents. The researcher acknowledged all published sources of literature used

in the study.

3.10 Anticipated limitations of the study

The researcher encountered but solved the following problems. The researcher was faced with

methodological problems as in interviewing Yei civil hospital and Martha primary health care

Centre employees, who in any case were suspicious of ill motives by the researcher. An honest,

intimate relationship was developed to overcome this by requesting respondents to advise

accordingly on how he/she can be questioned. Questionnaire retrieval, leave alone filling it, took

a lot of time and patience, which delayed the whole research process. The benefits of such an

exercise were explained to the respondents for easy cooperation.

50

CHAPTER FOUR

PRESENTATION, ANALYSES AND DISCUSSION OF FINDINGS

4.0 Introduction.

This chapter presents the findings of the study on assessing the contribution of non-governmental

organizations in the delivery of basic health services in Yei River County in collaboration with

the Local Governments.

This chapter therefore covers the presentation, analysis and interpretation of the findings the

researcher obtained from the field based on the general and specific objectives of the study

shown in chapter one. Before addressing the objectives, background information about

respondents is given to contextualize the study. The background information was about

demographic information on the respondents, age groups of the respondents, education Levels of

the Respondents and respondents Occupation. It is against this analysis that the researcher

established conclusions and recommendations

The study was carried out in two health facilities; in Yei Civil Hospital and Martha Primary

Health Care Centre.

4.1 Demographic Information on the Respondents.

The distribution of the respondents and selected characteristics of the respondents was organized

into different variables selected from the study. The selected variables were from Church

officials, health officials, local government officials, County health department officials, NGOs

officials participants within the local population. The demographic characteristics were

51

considered because of their key roles that they played in their various capacities as key

stakeholders. The respondent‟s age was looked into because age is the determinant in each level

of appreciation of service offered. The demographic characteristics of the respondents which

were considered are shown below.

4.1.1 Age Groups of the Respondents

The researcher investigated about the age groups of the Respondents. The age composition of the

respondents was by grouping the respondents‟ ages in different age groups. Studying the age

composition of the respondents was deemed necessary because it was thought that people of

different age groups determine the level of satisfaction the health services provided by the Non-

Governmental Organizations in Yei Civil Hospital and Martha Primary Health Care. By studying

age groups thus balanced views were achieved on the different factors that determine level of

satisfaction and whether Non- Governmental Organizations contribution is appreciated.The

results are presented in Table 1.

Table 1: Age of Respondents

Frequency Percentage

Valid 18-24 12 30.0

25-30 16 40.0

Over 30 years 12 30.0

Total 40 100.0

Source: Primary Data

52

The statistics in Table 1 above indicate that the larger number of the respondents was between 25

– 30 years that is 40% followed by those over 30 years and then those who were between 18 – 24

were also 30%. The statistics shows the respondents were drawn from different categories of age

groups. Therefore, this provided chance of balanced opinions about the level of beneficiaries‟

appreciation of the health services provided by the Non- Governmental Organizations in Yei

Civil Hospital and Martha Primary Health Care.

4.1.2 Education Levels of the Respondents

The researcher was interested in the level of education to find out the perceptions of respondents

regarding the contribution of NGOs in delivery of basic health services in partnership with local

government. The responses were shown as below;

Table 2: Highest Level of Education


Valid Primary and Below 14 35.0

Secondary and above 24 60.0

Never been/Went to school 2 5.0

Total 40 100.0


According to Table 2, the larger number of the respondents 60% had attained secondary and

above, 35% had attained primary and below and 5% had never been/went to school. Looking at

the data in the Table the majority of the respondents had attained an education level of secondary

and above. This provided the researcher the opportunity of collecting dependable data as these

53

with the help of researcher could give informed data about the issues under study. In the

researcher‟s opinion information was valid because people of secondary and above in a city

setting like Yei ought to have used the health services provided by the Non- Governmental

Organizations in Yei Civil Hospital and Martha Primary Health Care.

4.1.3 Occupation

The researcher was interested in in the occupation because it gives the researcher an

understanding which group of the community is most accessing the health services.

Figure 2: Current Occupation


From figure 3 above, shows that 2% of the respondents were business/trade workers, 72% were

farmers, 32% were salaried employees and 16% unemployed. This implies that majority of

respondents in the study were peasants (farmers) whose income was low and hence appropriate

for the study objectives.

2%

72%

10% 16%

Business/Trade Farming (crop/animal) Salaried Employment Others (Un employed)

Current Occupation

54

4.1.4 Monthly Earnings of Respondents

The researcher was also interested in the monthly earnings of respondents because it wanted to

establish what level of income respondents earn monthly and also if the respondents were able to

access the health services appropriately based on the level of their earning and expenditures.

Figure 3: Monthly Earnings of Respondents


From figure 4 above shows that, 22% of the respondents were earning monthly income of below

South Sudanese Pounds (SSP) 60, 58% were South Sudanese Pounds (SSP) 61 – 120, 8% were

South Sudanese Pounds (SSP) 121 – 250 and 13% were of South Sudanese Pounds (SSP) 250

plus. This implies that the respondents‟ standards of living are poor which lead them to attend

public clinic regardless of the quality of service delivered and hence determining the level of

satisfaction in the health services provided by the Non-Governmental Organizations in Yei Civil

22%

58%

8% 12%

£ 60 £ 61 - 120 £ 121 - 250 Above £ 250

Monthly Earning

55

Hospital and Martha Primary Health Care. This was because at Martha Primary Health Care

Centre there is no referral to private clinics and cost sharing is cheap.

4.1.5 Availability of Services

The figure below is to give some analyses on whether the services are available whenever

needed by patients and it was to test the level at which respondents have satisfied with the health

services provided by the Non-Governmental Organizations in Yei Civil Hospital and Martha

Primary Health Care

Table 3: Whether the services are available when ever needed


Valid Yes 7 17.5

No 23 57.5

Sometimes 10 25.0

Total 40 100.0


Table 5 shows that majority of the respondents 23 (57.5%) said that the services are not available

when ever needed in the hospital, 10 (25%) revealed that sometimes they are available while

only 7 (17.5%) agreed by saying that yes the services are available when ever needed. The above

findings indicates the level of access by beneficiaries is very low due to poor health services

provided by the Non-Governmental Organizations in Yei Civil Hospital and Martha Primary

Health Care

56

4.2 Activities carried out by the Non-Governmental Organizations in Yei Civil Hospital

and Martha Primary Health Care Centre.

The study set out to identify the various activities carried out by the Non-Governmental

Organizations in Yei Civil Hospital and Martha Primary Health Care Centre. The findings below

show various activities carried out by the Non-Governmental Organizations in Yei Civil Hospital


The research findings revealed that there are various activities and services offered by Non-

Governmental Organizations (NGOs) in Yei civil hospital and Martha Primary Health care

Centre Primary Health care Centre. The quality and range of services offered depend on the type

of Non-governmental Organizations. Both Yei Civil hospital and Martha Primary Health care

Centre offers curative inpatient and outpatient services.

According to the findings from the Yei County Health Department are that (Non-Governmental

Organizations (NGOs) offering health services and support in Yei Civil Hospital which includes

Winchester UK, Population Services International (PSI), Handicap international, Malteser

International, Across Health Program, United Nation Children Education Fund (UNICEF),

United Nation Development Programme (UNDP) to mention but a few.

One of the key informants from the Local Government officials revealed that;

“The services offered in Yei Civil hospital are maternal, minor operations,

Tuberculosis treatment, surgical services, tooth ache and fracture management. At

Martha Primary health care and Yei civil hospital services offered are treatment of

malaria and warms which are higher, other services includes provision of anti-

57

retroviral drugs for HIV/AIDs, voluntary counseling and testing of HIV and other

STDs and treatment of treatable STDs by the NGOs. Data obtained from the Yei

Civil hospital Matron office.”

Primary health care programmes which have direct linkages with the centers and units in the

Payams and Bomas in the greater Yei also refer their patients to Yei civil hospital. NGO such as

Winchester UK is helping clinicians in Yei Civil hospital to develop their skills by teaching,

demonstrating and assisting in their professional work.

NGOs also supported the renovation of people with disability Centre and training of community

health workers on prevention and care of disability and support. The government of Central

Equatoria State was also financing the renovation of the Main wards at the Yei civil hospital.

Handicap International (HI) an International organization is providing Yei civil hospital with

anti-malaria drugs, giving basic rehabilitation care for persons with disability, distribution of

mobility devices like elbow crutches auxiliary crutches, wheel chairs, tricycles to assist people

with disability to access services and also establishment of efficient referral system for people

with disabilities.

The Winchester –Yei Link support Yei civil hospital which is an initiative from United Kingdom

and Yei Local government have been providing services such as diagnosed patients by doctors

who came from the UK. Winchester –Yei Link also provides technical help to medical staff and

equipment to Yei Civil hospital. Family planning services and immunization programs are also

offered by NGOs supporting Yei civil hospital.

58

Consultation services/ curative, in patient services (admission) ANC, PMTCT, Delivery services,

Emergency obstetric care/ surgery TB, HIV Aids Care, Sleeping sickness care, treatment of

under-five/ grown monitoring service and EPI services are both offered at Yei civil hospital and

Martha Primary health care Centre.

At Yei civil hospital most of services are done in medical ward, surgical ward, pediatric ward,

Gynae ward, maternity ward, sleeping sickness ward, TB ward, ART Centre and there is

laboratory services.

World health Organization is supporting the TB and sleeping sickness Programme in Yei civil

hospital and it also supply drugs and reagents.

Interview with the Director of the Anti-Retroviral Treatment Centre reveal that, UNFPA is

supporting the PMTCT at Yei Civil hospital by supplying test kids. A local organization known

as Widows Orphans and People Living with HIV/ AIDS (WOPHA) provided volunteering

testing and counseling to substitute the services of Family Health International (FHI) which

brought complains from the community in Yei that services are needed.

4.3 The beneficiaries’ level of satisfaction by the health services provided by the Non-

Governmental Organizations in Yei Civil Hospital and Martha Primary Health Care.

The study set out to establish the beneficiaries‟ appreciation of the health services provided by

the Non- Governmental Organizations in Yei Civil Hospital and Martha Primary Health Care.

Table 5-8 show the results of the key findings.

59

Table 4: Whether Respondents have ever experienced any problem from the health sector

in Yei


Valid Yes 26 65.0

No 14 35.0

Total 40 100.0


Table 4 shows that majority of the respondents 26 (65%) have ever experienced any problem

from the health sector in Yei, while 14 respondents (35%) have never experienced any problem

from the health sector in Yei. This implies that to certain extent the beneficiaries of Yei satisfied

with the services provided by health sector in Yei. According to the responses from the

respondents who were interviewed, it was because of; there is free medical service and do not

need paying money to go to private clinic, availability of electricity and ambulance, response to

patients is good, no referral to private clinics, adequate drugs and qualified medical staff at the

health Centre. The researcher therefore went further to note that much as the health Centre looks

beautiful but when lacking free medical service, good prescription of drugs, adequate drugs and

qualified medical staff, availability of electricity and ambulance and good relationship with

between patients and the medical staff.

60

Table 5: Overall satisfaction of beneficiaries with the health service


Valid Yes fully 26 65.0

Not at all 8 20.0

Fair 6 15.0

Total 40 100.0


From the descriptive statistics in table 5 above indicates that 26 (65%) of the all the respondents

acknowledged that beneficiaries are satisfied with the health service, 8(20%) said that they were

not satisfied while the minority 6 (15%) said fairly they were satisfied with facility. The findings

there imply that fairly the beneficiaries appreciate the health services provided by the Non-

Governmental Organizations in Yei Civil Hospital and Martha Primary Health Care. This was

because of adequate drugs and qualified medical staff at the health Centre and those who were

not satisfied was due to their income levels compared to the cost that are incurred in receiving

the health services.

4.3.1 Performance of Martha Primary Health Care Centre

An interview with those who receive the medical service at Martha primary health care centre, it

was established that the centre is properly managed by the NGOs and the church. The

beneficiaries who receive the health services were asked why they prefer to receive their health

services at Martha Primary health Care Centre than any other health Centre or even Yei civil

hospital their response is that they prefer Martha primary health care Centre because they can

access medicine and they are not referred to buy medicine from the private clinic which reduces

child and mortality. Non-governmental organizations primary health care programs were found

61

to expand coverage for reproductive and child health services, and decrease child and maternal

mortality.

Most of the interviewed beneficiaries 80% also reported that the Martha primary health care

Centre has established a mechanism of cost sharing this is to help in the sustainability of the

health Centre as the NGOs think is the best strategy. According to the beneficiaries the payment

of the cost sharing is appreciated and the cost is not high compared to services in the private

clinics and Yei civil hospital. The beneficiaries said they get good health services and

encouraged the cost sharing to be continued. This is in line with Sollis (1992) & Vivian (1994)

who assorted that Non-governmental organizations are thought to provide services more

efficiently and effectively than governments, to give better value for money, and reach the

poorest communities.

Two pregnant mothers who came to receive antenatal care at the time when the research was

under way reported that Martha primary health care has a good handling of patients more

especially the children and pregnant mothers. The way in which the Martha primary health care

is managed by the church, health Centre staff and the NGOs reported to suggest that more

emphasis have been put on core values.

The Health Centre values such as were reported to the love of human being by creator of God,

faith in God acted as a motivation save humanity. The Martha primary health care officials also

conduct prayers which aided the motto of Martha which says we treat but the lord heals.

62

Martha primary health care Centre is managing 45 health staff four (4) of whom are paid partly

by the ministry of health through the local government county health department. The staff at

Martha primary health care Centre based on the researcher observations suggest that they are

motivated, interested and are ready to provide services which contributed to better performance

of Martha primary health care. The Centre is now referred as the best Centre under the church in

Yei River County.

The performance of the health system at Martha primary health care Centre is also link to issues

related to NGOs and the church policy on well fare where Martha is now providing breakfast,

lunch to the health officials. The existences of the staff management team and the health

committee under the ECS Diocese is said to be an important factor to the better performance of

the health system at Martha primary health care. Reporting structures are said to be very clear

reducing on bureaucratic red tape which normally hinder the performance of any sector.

The performance of Martha primary health care is because of the capacity building where health

officials are trained and are able to discover new ideas, skills and knowledge that are

immediately utilized on patients leading to improved health service performance.

Most of the beneficiaries interviewed stated that they prefer Martha primary health care Centre

because of the presence of NGOs support and the management of the health Centre by the NGOs

which they said has resulted in to quick and prompt services; no insult of patients like the one

witnessed in the public hospital such as Yei civil hospital. Some beneficiaries reported that the

health services are cheaper than the Government and private clinic.

63

4.3.2 The Performance of Yei Civil Hospital from 1997-2004

Most interviewed persons who used to be beneficiaries (65%) receiving health services from Yei

hospital highlighted that the hospital used to be very good when the NGOs were fully and

comprehensively running and managing it. Most respondents referred to the period between

2000 and 2005 as the period when the health services in Yei civil hospital were well performed.

Beneficiaries who were interviewed having received health services in 1998 and the period

beyond 2000s reported that the health services offered by the NGOs in Yei civil hospital were

well maintained they reported that the wards were well maintained there was an NGO hospital

Ambulance that was well maintained and could help to pick critical and patients emergency from

Rural areas to the main hospital.

There was running electricity in the hospital during the NGOs managing the hospital. It was

reported that the provided electricity for 24 hours a day is due to the support from Norwegian

People‟s Aid (NPA) and Africa Action Africa Help South Sudan (AAH). There were three

Doctors managing patients and conducting operations on need be basis and there services were

appreciated by the beneficiaries. The information obtained from one old hospital official

suggested that there were few cases of complications resulting from patients operations.

The NGOs used to support the hospital staff with meals by 1997 - 2004 which also increases the

motivation of medical staff and has also helped in time wastage where the staffs eat in the

hospital instead of travelling to their homes for food and some do not later come back for

service.

64

Hospital officials reported that they were well paid and their salaries comes on regular basis by

the Norwegian peoples Aid (NPA) where the officials reported that this NGOs has performed

despite limited resources and pressure of challenges during the war time in South Sudan.

The hospital was relatively well staffed with 3 physicians, 2 medical assistants, 33

nurses, 4 midwives, 3 traditional birth attendants and 6 laboratory technicians.

(Report from Yei civil hospital)

Most of the interviewed beneficiaries who received medical services during the time when the

NGOs were fully running the hospital stated that during the war period 1997 to 2004 there were

only private commercial clinics this suggest that there was no chance of sending a patient to a

private clinic to acquire medical service the hospital had almost all the facilities that patients

enjoy most.

Hospital officials also reported that NGOs recruited well qualified Doctors, Clinical officers and

Nurses which contributed to better health services and addressed the poor health cases which

were persistent by then and cases of improved transparency and accountability were in the core

front of the health management based on the nature of NGOs principal of inputs as a basis to

provide out puts and outcomes.

The respondents in diferent groups said that Yei civil hospital health services fall short of health

standards right from the time the NGOs handed over the running, management and intensive

support to the hand of government. The diferent groups of the interviewed beneficiaries referred

to the period of 1997 to 2005 as period where they think the health services in Yei civil hospital

65

where the health services were properly managed and NGOs‟ contribution to the health sector

was appreciated.

4.3.3 The Performance of Yei Civil Hospital from 2005-2013

The performance of Yei civil hospital was reported by interviewed beneficiaries who received

health services in the facilities between 2005-2013 most interviewed beneficiaries suggested that

the falling of the hospital health services standard was between years 2005 to 2007. This is the

period where NGOs were in transition to rapidly hand over the management and running of the

hospital responsibilities to the government.

The researcher randomly selected 10 beneficiaries who received health services in Yei civil

hospital, 5 beneficiaries of whom were interviewed to give data on the performance and ways in

which the health services in Yei civil hospital can be improved. The beneficiaries were people

who have received health services either in 2005, 2007, 2008 and 2012. The other 5 beneficiaries

were randomly selected at the time when the research was under way and it was particularly

when the researcher visited Yei civil hospital the beneficiaries took the interview right after

receiving the health service.

The findings established that the Yei civil hospital is not doing to the best standards that brought

about unsatisfactory by the beneficiaries despite the fact that government is running the hospital

and some NGOs are filling the gaps.

Most interviewed hospital staff and beneficiaries 74% reported that the hospital health services

has fallen sort of standards, government structures has not supported issues to do with

transparency and accountability. Most beneficiaries reported that health officials do their health

66

job with impunity due to lack of check and balances. This has scared some patients and now they

decided to go to private clinics.

The health personnel are supposed to follow the principle of Acceptability and Dignity: Health

care institutions and providers must respect dignity, provide culturally appropriate care, be

responsive to needs based on gender, age, culture, language, and different ways of life and

abilities. They must respect medical ethics and protect confidentiality.

"Health centres are employing unqualified people who at times give wrong dosage

or even may give wrong drugs that can kill people especially children."(a Patient

in Yei Civil Hospital 15th

October 2013.

Even though the government is reported to be doing what it can to ensure improved quality

delivery of the health services. There were cases of government lack of capacity and the fact that

many qualified medical personnel has gone out of the hospital which has left the hospital with a

big gap. Among the most pressing issues raised by hospital staffs and beneficiaries suggest that

drugs are not available in the hospital patients are often referred to private clinics to procure

drugs. Low and inconsistent salaries is also reported to be responsible for the deteriorating health

services in Yei civil hospital.

“Look, since Martha is supported by NGOs they pay relatively better salaries to

their staff. We here in Yei civil hospital receive insistence salary of 250 South

Sudan Pounds per month and those at Martha Primary care receive 500 South

Sudan Pounds per month and it is paid promptly (one hospital official told the

Researcher 12th

October 2013)”.

67

The research also established that patients who visits Yei civil hospital were handled in a harsh

way and at times insulted by hospital officials. Despite this challenge, patients still come to Yei

civil hospital because they believe that the hospital offers best diagnosis compared to private

clinics and most patients visited the hospital because of poverty, they cannot afford the

expensive health services from the private clinics.

The research findings established that most of the patients coming to the Yei civil hospital are

only there to get prescriptions of which sickness they are suffering from and which medicine are

they supposed to take and later they go to the private clinic to purchase them. 70% of the

interviewed respondents indicated that they need the hospital prescriptions to avoid going to the

private clinic and pay for consultations fee and prescription services fee which the hospital does

not charge for.

"Sometimes treatment given by private health centres causes swellings that turn

into pus and removing the pus needs more money". (A Patient at Yei Civil

Hospital 10th

October 2013)

The research findings has established that both patients who come to the hospital because they

do not have money to go to the private clinics and those who can afford the private clinic

services do not receive the health services easily. Health beneficiaries has reported that receiving

services in the hospital affects 3-7 hours at most this was not the case when the NGOs were

managing the hospital.

68

"In health centres, the prices of drugs are not constant, so you are forced to keep

roaming from clinic to clinic in search of cheaper drugs yet the disease is

increasing." (A Patient at Yei civil hospital 7th

October 2013)

60% of respondents interviewed also reported that no patient has the authority to tell the hospital

staff to provide service to the patient. One respondent stated that one time his wife was to give

birth and he was told to come to the hospital with most of the basic medical items that are related

to delivery of mothers and then they only receive the expertise of the medical staff to ensure that

the delivery is done. When the NGOs were managing the hospital these services were readily in

place and available no need of a patient coming with medical equipment‟s.

The falling of the hospital standards is connected to work load due to the increased population

and pressing health need within Yei River County. The staffs were subjected to stress population

which affected the performance of the health sector. The health services in Yei civil hospital also

went down due to abrupt pulling out of NGOs. Treatment of HIV/AIDS from the ART Centre

was reported by both beneficiaries and health officials to be fairly good. This is because the

supply of the drugs is done by UNDP which is independent of drug supply than the government

channel.

The poor performance of the hospital is link to the poor partnership between the government and

NGOs. Since these NGOs are international in nature, they prefer to report to the national

government and the state government instead of the local government. This has made it difficult

for local government to ensure that the NGOs are able to fill the gaps and it has also hindered

issues of accountability by the NGOs hence poor health performance.

69

The health officials have indicated that so long as the government of South Sudan is not

economically stable and viable it is important for the NGOs to continue filling the gaps; the

supply of drugs and provision of specialized expertise for further improvement of the health

services in Yei civil hospital.

4.3.4 Showing Performance of Yei Civil Hospital from 1997-2004 and Performance of Yei

Civil Hospital from 2005-2013

The figure below shows the performance of the Yei civil hospital from the years indicated. The

researcher was interested in these years because these years have witnessed activities of non-

governmental organizations in delivery of basic health services in Yei River County and in

addition these periods falls during the years of the signing of the Comprehensive Peace

Agreement (CPA) in January 9, 2005, enactment of South Sudan Local Government Act 2009

and the declaration of South Sudan independence on 9th

July 2011. The results are presented in

figure 4 below.

70

Figure 4: Showing Performance of Yei Civil Hospital from 1997-2004 and Performance of

Yei Civil Hospital from 2005-2013


From figure 8 above it was revealed that before (1997-2004 before the partnership between

NGOs and government), the performance of Yei civil hospital was so much better but after the

partnership (2005-2013) there has been a decline in service provision of the health sector.

Therefore, NGOs have taken it as an importance aspect of making the public, private and

community health systems stronger during the war time (1997-2004). It was stated in the BMC,

Health Services Research 2011 that in most of the developing countries, certain weaknesses and

gaps in the government health systems have been hampering the achievement of improved health

outcomes. Local Government has deficient in the capacity to deliver equitable and quality health

services and thus has been grossly underutilized.

52%

10%

16% 12%

20%

14%

36%

30%

Better Some how Poor Worse

Performance of Yei Civil Hospital from 1997-2004

Performance of Yei Civil Hospital from 2005-2013

71

4.4The Challenges Faced By the NGOs in the Delivery of Health Care Support in Yei River

County

The study also assessed the challenges faced by the NGOs in the delivery of health care support

in Yei River County. And also to look at the general challenges facing the health sector in Yei

River County and the local government health department. This was established below.

One challenge NGOs have revealed to the researcher is that most donor funding for health care

often comes with complex requirements and expectations. Failure to meet these requirements can

result in the loss of funding. Therefore NGOs often find themselves in a situation in which they

are more likely to succumb to the demands of external forces. The price of obtaining resources

from donors can put the NGO‟s mission, activities, and purpose at risk.

Another challenge is that due to the nature of NGOs work, NGOs are highly dependent on the

flow of resources from external providers. This dependency can create a situation in which

donors have power over the NGO. For example the Basic Services Funds where the donor

detects on which services were to be delivered at Martha Primary health care. It does not

provided for flexibility for appropriate health delivery.

Interviews results show that when the interests of the funding agency conflict with the interests

of the organization, NGOs are left with two options: seek funding from other sources, or make

the necessary changes in order to obtain funding reference was made to why Family Health

International (FHI) was not able to secure funding from donors due to conflict of the interests.

NGOs with higher levels of dependency may be forced to make these changes in order to ensure

their survival.

72

The local government health official has stated as a local government, a lot of challenges find

themselves registered in working with NGOs. Lack of proper coordination, undermining of the

county health department, poor communication and lack of transparency have challenged the

NGOs in health service delivery. The researcher has established that most NGOs operating in

Yei are social sector NGOs but in most cases they at times work independently without liaising

with the county sector units, this way the local government would be able to bring NGOs to

liaise with the Programme of the government.

Activities which are jointly funded by international NGOs and Government were reported to

delay because of the bureaucracy in government departments for example the cost shared salaries

for Martha Primary health care Centre officials. This affects release of government counterpart

funds which in most cases is a pre-requisite for release of funds from some NGOs.

The Challenges Facing the Health Sector in Yei River County

Mushrooming of clinics in Yei town without proper ascertaining and accreditation by the

Ministry of Health have left both South Sudanese and foreigners who are medically qualified to

practice upon the Yei people leading to deaths and several complication especially after a

patients has been operated.

The health services in Yei River County are inadequate and inequitable. There is Rural Urban

migration due to poor medical services and other social services in the rural areas of greater Yei

hence leading to increase of population. In 2011, the South Sudan Relief and Rehabilitation

Commission (SSRRC) estimated the population of Yei at about 185,000 but during the research

local government estimated the population to have double to 400,000. This population is said to

73

be giving pressure to the health services in Yei civil hospital and other organizations offering

health services in the greater Yei.

As a results of the Rural Urban migration respondents have reported that this factor has let to

increase of private clinics in Yei town by non-medical professionals. Many people in Yei have

taken the weaknesses of government to establish the said unprofessional private clinics resulting

in to loss of many people‟s lives due to this action in Yei River County.

Partnership between NGOs and the Local government County Health Department

There were several partnership arrangements with the NGOs and the local government county

health department. The partnerships includes; Regular coordination meetings involving county

health department staff in some of the Programme activities and specially in supervision and

provision of technical training to local health staff, development of Memorandum of

Understanding with Local government and NGOs.

The partnership between NGOs and the Local government on the issue of NGOs sharing their

activities with Local government, NGOs Present their budget, activities plan achievement and

challenges to the Local government. NGOs are trying to work with county health department

sharing expertise and identifying service gaps and suggesting ways of improving the health

services in Yei River County.

The achievements of the health sector in Yei River County

County health department is beginning to work together; arranging meetings for health partners,

and there is also evidence that some health officials from Martha Primary health Care Centre are

receiving salaries four (4) Martha staff is on the county health department pay role.

74

Martha Primary health Care have reported high patients number, over 800 children admitted to

the health Centre between January to June 2013 No death case in the children words have been

noticed Martha Primary health care Centre has good record keeping and their reports being

handed over to the County Health department.

The Non –governmental organizations and the county health department is collaborating in terms

of training of some staff. Cases of Diarrhea have reduced due to rapid awareness programmes

done by across, Immunization of mothers and children were seen during the research in Yei

River County.

Improvement in the health care particularly maternity, adequate prevention of child hood illness

through regular vaccination, Reduction in infant and maternal morbidities, Provision of anti-

retroviral drugs (ARV) for HIV patients and Rover diseases surveillance.

Improvement of existing structures through renovation buildings, frequent health service offered

such as EPI service, Existence of the number of NGOs, Reduction in malaria cases through free

provision of mosquito nets , Low mortality rate among children below 5 years and mass

distribution of mosquito nets in Yei River County by Population Services International (PSI).

Health official from Martha Primary care have revealed that, the donor funds have been managed

by Action Africa Help International and needs to be available to support providing good health

care. Martha has trained more than 50 health staff at all levels and continue to do this to ensure

continuation if high quality health care.

75

4.5 Suggested Ways for Effective and Efficient Delivery of Health Services

The fourth objective was to suggest ways for effective and efficient delivery of health services.

The findings were revealed as below;

According to the suggestion by the respondents from Yei Civil Hospital and Martha Primary

Care Centre., the following ways for effective and efficient were forwarded; the health centers

should work with county health department sharing expertise and identifying service gaps

Proposal writing is happening to ensure health service delivery because without the help of Small

UK organization the health service will suffer.

The health official at Martha proposed that a large children words is needed for which the NGOs

supporting Martha Primary Health Care Centre is trying to fund raise Martha needs the Ministry

of Health support for more salaries to be paid and good supplies of drugs to be received this is

important for the good and smooth continuation of the health services offered. Martha has

trained more than 50 health staff at all levels and continue to do this to ensure continuation if

high quality care.

There is a link between a UK hospital (Royal Hampshire County hospital Winchester) and Yei

civil Hospital and Martha Primary Health Care Centre. The link is facilitated by Church the link

lead to training to Yei civil hospital and Martha Primary Health Care Centre and the Yei

National Medical Training Institute. HIV is on increase the number of new infection is on raise

funding for HIV is not massive donors are failed away.

4.6 Summary of overall Satisfaction of beneficiaries with the health service

The research also use the cross tabulation to establish the extent to which Overall Satisfaction of

beneficiaries with the health service have been. The table below provides a summary and it

76

addresses objective which is the beneficiaries‟ appreciation of the health services provided by the

Non- Governmental Organizations in Yei Civil Hospital and Martha Primary Health Care

77

Table 6: Cross Tabulation for the Overall beneficiaries’ appreciation of the health services

provided by the Non- Governmental Organizations in Yei Civil Hospital and Martha

Primary Health Care

Not satisfied satisfied Significance

Age

18-24 years 12(30%) 28(70%) p>0.05

25-30 years 16(40%) 24(60%)

Over 30 years 12(30%) 28(70%)

Highest Level of Education

Primary and Below 14(35%) 26(65%)

Secondary and above 24(60%) 16(40%) p>0.05

Never been/Went to school 2(5%) 38(95%)

Current Occupation

Salaried employment

Self employed

Unemployed

36(90%)

1(2.5%)

5(12.5%)

4(10%)

39(97.5%)

35(87.5%)

p>0.05

Monthly earnings

Below £20

11(27.5%)

29(72.5%)

£21 – 85 19(47.5%) 21(52.5%) p>0.05

£170 and above 4(10%) 36(90%)


78

From the table 9 above , health services described the care giver‟s attitude towards them as good

while 57.1% of them who had a contrary opinion of the attitude of care givers were still satisfied

with the health services provided by the Non- Governmental Organizations in Yei Civil Hospital

and Martha Primary Health Care; this was also significant(p>0.05).

The overall rating was classified into poor and good. Most respondents were satisfied with the

services given at the clinic; 81% rated the services as good while 19% were not satisfied and

stated that service was poor. Most respondents (83%) revealed that they would register in the

same health facility in subsequent sickness and would recommend the health Centre to someone

else. The findings also revealed that there is no significant association between age and

occupation of respondents under study and their appreciation services with P>0.05. This means

that parity is not a determining factor in the health services provided by the Non- Governmental

Organizations which is in contrast with the findings of Simkhada, Teijlingen, Porter, and

Simkhada, (2008) that Parity had a statistically significant negative effect on adequate

attendance. Whilst beneficiaries of higher parity tend to use health Centre less, there is

interaction with respondent's age and religion.

Significant association was found between level of education of respondents under study and

their attendance with p>0.05. This shows that beneficiaries‟ education has a positive impact on

appreciation of health services provided by the Non- Governmental Organizations in Yei Civil

Hospital and Martha Primary Health Care; this was also significant. This reflects the view that

health is affected by social determinants such as poverty, illiteracy, and sanitation; and that

health improvements occur through social, economic, and cultural changes in a community.

79

There is some evidence suggesting in this research that NGOs make successful contributions to

health in certain circumstances. NGOs have made significant contributions to reproductive and

sexual health in many areas in the Yei River County. The research also found that effectively run

NGO reproductive and child health services have decreased child and maternal mortality in

Martha Primary health care and to some extent Yei Civil hospital.

80

CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.0 Introduction

The study aimed at assessing the contribution of non-governmental organizations in the delivery

of basic health services in Yei River County through collaboration with the Local Government.

This chapter outlines the researcher‟s discussion of findings, conclusion and recommendations;

5.1 Summary of Findings

5.1.1 Activities carried out by the Non-Governmental Organizations in Yei Civil Hospital


Various NGOs have contributed to delivery of basic health services in Yei River County. All the

NGOs seemed to stress the importance of networking. By establishing partnerships with local

community members or agencies as well as working with local government, the NGOs felt they

could achieve their goals more efficiently and effectively. The NGOs acknowledged the role that

networking has in their work, and it was a key value stressed by all of the NGOs in the study.

The NGOs stressed that it was particularly important to establish these networks in the

communities that they work in. All of the NGOs favored a bottom up approach to their work.

Networking was also found to predict high levels of health contribution in the quantitative

analysis. This finding seemed to be corroborated by the results of the case study.

81

NGOs are engaged in a broad range of activities beyond the narrow definition of health.

Activities are aimed to solving specific problems as well as improving the health status and

coping ability, enthusiasm and other positive effects generated by association with one NGO,

e.g., strengthening local leadership, mobilising local development committees, and capacity

building, have the potential to spread and in the long-term, be cultivated within the community.

By targeting marginalized groups such as farmers and, especially women, NGOs give them a

greater opportunity and role to participate in development activities. This also increases

opportunities for capacity building and skills development.

The dependent variable of the quantitative phase of the study measured the health contributions

of NGOs. One of the advantages of the case description was that it allowed the researcher to

illustrate these contributions in words and give meaning to the numbers of the quantitative

component. The NGOs in the case study engaged in a variety of health related activities. The

most common were: disease prevention, maternal and child health, and counseling. Disease

prevention was perhaps the most common health related goal of the NGOs. To achieve this goal,

NGOs provided immunizations, education, and testing services. These services focused on the

prevention and treatment of such diseases as HIV/AIDs, TB, Malaria, and various childhood

illnesses. The NGOs also provided many services in the area of maternal and child health, such

as safe birth centers, mobile health clinics, nutrition programs, and treatment of childhood

diseases. Lastly, the NGOs offered a range of psychosocial and educational counseling services.

These findings provide us with a better idea of contributions NGOs are making to health in the

Yei River County which most beneficiaries are remembering them for.

82

Promotion of good health by overcoming disease requires strong interventions and proper

attention on the activities in the health sector. There has been evidence over a period of many

years that the public sector in South Sudan and Yei in particular is lacking in capacity in the

context of delivery and management of health services. NGOs as regarded as the private sector

have a significant contribution in health care provision, given the current shortage of government

resources, the thrust towards Primary Health Care, and the policy of decentralization.

The relationship between public service delivery and private service delivery

The realization that both the public and the private sectors suffer important constraints has given

credence to public–private partnerships (PPPs) as important institutional innovations. Partnership

exist where there is mutual trust, backed by a guiding policy framework; shared norms and

values; common goals or pursuits; a code of conduct; and a general agreement on the rules of

engagement. According to North (1990) and Nkya (2000), partnerships are institutional

arrangements that constitute rules defining the relationships, roles, responsibilities and

accountability mechanisms (both formal and implied) of different collaborating actors. The

overriding goal of PPPs is to meet public needs that would have been difficult to realize without

collaborative efforts.

The point of departure by the research team is that the public, the private and faith-based health

providers all serve the public, in the true sense of the word. The researcher found out that there

exist a relationship between public service delivery and private service delivery in Yei and

Central Equatoria state at large. The relationship between public service delivery and private

health service delivery is on planning where the two entities see it as very important to work

together and delivery well planned services. The relationship between public and private health

delivery are brought about by the South Sudan Health Policy 2011 where health responsibility

83

were specified between levels of governments. The state level governments render public

services through the level closest to the people (local government). The County Health

Departments and Payams are therefore responsible for health service delivery.

Public and private health services delivery also interlinked when it comes to design and

implementation of programmes so as to deliver well-structured and coordinated services this

thought do not show off concretely as Public sector in South Sudan has been deficient in the

capacity to deliver equitable and quality services compared to the capacity the privates sector

has. Due to limited capacity of the County Health Departments (CHDs) and Payams to deliver

health services and limited capacity of State Ministry of Health to support them as a result of

many years of armed conflict and the resultant collapse of the public sector, the NGOs have been

providing the bulk of health services at most cases during the research the population under

study referred the NGOs as the private sector.

There is also an evident that After the Comprehensive Peace Agreement in 2005, the public

sector through the central government Ministry of Health –Government of South Sudan entered

into formal agreements (contracts) with a number of NGOs to provide health services in Yei.

Some lead Agency such as Norwegian People‟s Aid were contracted to support Yei Civil

hospital in the management and delivery of health services. And the government only

concentrated on the stewardship role of providing oversight, policy and planning, and monitoring

and evaluation.

The research finding also established that the non-governmental organizations have been

providing advice, capacity building and management support to the health sector but the

government has not taken the capacity building very serious hence lack of stewardship role in

84

providing oversight and even monitoring and evaluating the service the private sector is

delivering. As part of the transition, the MoH-GoSS and SMoHs/CHDs are supposed to

gradually take on more responsibility of service provision but this has not taken place.

Public services most have been centered to the context of the poor and the public bodies work to

address the service delivery needs to the poor main while and private service delivery. The

institution concern with the delivery of the public service do not have the required capacity and

expertise which at most cases required them to work with the private sector and delivery needed

services of higher standards.

For the betterment of the community in Yei The framework of accountability relationships” that

was articulated in the World Development Report of the World Bank (2004) entitled: Making

Services Work for Poor People needed to used. This analytical framework has five cardinal

principles of effective service delivery, namely: delegation, financing, performance, information

and enforceability. All these must work together to maximize service delivery. For example,

decentralization in South Sudan resulted in the delegation of duties from the central Ministry of

Health to States and then to the Local Governments (LoGs). However, decentralized health

services can only work if there is (a) adequate financing (for staff, drugs, and equipment); (b)

clear performance measurements (e.g. at the health facility level such as the Yei Civil Hospital

and Primary health care centre such as Martha); (c) proper information flows (hence the

importance of the Health Management Information Systems (HMIS); and (d) effective

supervision, inspection and enforcement of performance standards.

85

Lesson learned from both the public and private sector service delivery

Public institution working with the private sector in delivery public health service need to work

together in capacity building each other so that that expertise can be drown from both sides if

very important services are to be delivered and government institution concern should take the

initiative very seriously.

.Both public and provided service delivery needs to be made to intended beneficiaries and there

must be some indication of ownership. Where a public service needed to be delivered by a

private sector the institution concern should be involved in the process, formulation and

understanding of the policy needed to successfully delivery the service.

Health systems are expected to serve the population needs in an effective, efficient and equitable

manner. Therefore, the importance of strengthening of public, private and community health

systems has to be emphasized time and again. In most of the developing countries, certain

weaknesses and gaps in the government health systems have been hampering the achievement of

improved health outcomes. Public sector in Pakistan has been deficient in the capacity to deliver

equitable and quality health services and thus has been grossly underutilized and therefore the

government of South Sudan should learn and see to it that the population it is servicing should

get the health service in an effective, efficient and equitable manner.

5.1.2 Appreciation of the health services provided by the Non- Governmental

Organizations in Yei Civil Hospital and Martha Primary Health Care Centre.

The key community health interventions mainly carried out by NGOs are: health education,

nutrition education, AIDS education, environmental education and poverty reduction. The

86

research established that most beneficiaries appreciated the services offered by NGOs and NGOs

health services were properly managed.

Respondents recognize that NGO are playing a significant role in the provision of health care in

Yei River County. The findings could be applied to other County or even states of South Sudan

in the country. NGOs were noted to have a good geographical coverage, offered relatively cheap

services, and some NGO were good at mobilizing resources and could have a strong pressure

group role to play. Some private clinics and the informal private sector offer credit facilities or

services perceived as being cheap by the community.

5.1.3 The challenges faced by the NGOs in the delivery of health care support in Yei River

County

Local NGO reported inadequate funding and the lack of facilities as major problems. A good

number of these NGOs depend on donor funding which may not be consistent or reliable. This

lack of funds affects the NGO activities because they fail to maintain equipment, and are unable

to carry out supervision due to lack of transport. The regulatory process for the NGOs is

inadequate and most cases not enforced. There was a lot of government bureaucracy involved in

implementing NGO activities. Lack of political and community support led to poor

implementation of NGO activities.

The research also found that Preventive interventions (e.g., Immunization) are seen as expensive

to some NGO institutions for they do not charge for these services. And donors have specific

objectives and are not usually flexible in funding other activities that implementers feel should

be carried out. This has some effect on the extent of positive contribution of the NGOs in the

health sector in Yei River County.

87

Some limitations in health service delivery identified include: lack funding, lack of community

support and community mobilization, inadequate staff or using untrained staff, duplication of

services in an area, and lack of flexibility in implementation of some programmes, and poor

quality services.

The relations dynamics on the public sphere that enhance or hinder health service delivery.

The protracted nature of the war in South Sudan has seriously constrained the development of a

functioning health system and has damaged the existing health facilities it will take many years

indeed to have the health sector develop to its full capacity as other countries such as Rwanda

have tried and also the people of Yei needed to be very serious in taking the development of the

health sector as their own without owning it noting will be realised.

According to a number of key-informants in the health sector the diminishing interest from

donors in supporting health provision and the lack of proper hand-over and training of local staff

upon the departure of international NGOs has further declined the current quality and quantity of

health services.

Legacy of conflict and emergent process have also hindered the delivery of the health service

delivery. The war altered the socio- political structures and relations of diferent players in the

delivery of services in Yei River County. The war has also induced poverty, displacement and

trauma; it has weakened kinship and community ties. Before the way community were active in

voluntary services which aided the quality of service it is not the case now. This dynamic have

affected both the public and provide sectors.

Government spends excessive funds on the treatment of civil servants to be treated in public and

private hospitals in neighbouring countries. Furthermore, the lack of high quality services is a

88

main restraining factor for Diaspora to return home, as is lack of education, has made well

qualified medical personnel not to come to Yei from the diaspora. Therefore, while the priority

for donors and Government should be to develop a functioning public health sector, there is

potential for private health providers to complement the public sector. Social support relations

are also affected negatively, intra communal collaboration have affected the performance of the

health sector. Health is integral and essential for reconstruction.

Corruption is also another factor that have affected the health service delivery, Drugs were stolen

and taken to private clinics for economic gain by hospital health personnel in the public health

facility. Despite the fact that Yei has developed a significant human capital which can be used to

solve the problem in Yei and given its vast natural resources, Yei remains severely impacted and

underdeveloped. The serious political and economic mismanagement has impeded any real social

development. Most public sector services have been eroded, abandoned or replaced by what

many people see as unsustainable external humanitarian relief.

Culturally determined gender based inequalities in decision-making is prevalent in the area

exacerbated by illiteracy and early (forced) marriages. Various cultural practices tend to

marginalize women by isolating them from opportunities to participate in decision-making and to

access, control and share resources. The war also added extra burden on women, as they were the

ones left behind to care for their families when the men were in the battle front. Other cultural

challenges in Yei River County as in other parts of South Sudan include:

Polygamy promoting risky behavior in the era of HIV/AIDS; Ethnic and inter-clan conflicts and

rivalries; Demand for high bride price; Conflict around grazing areas and cattle rustling; and

89

Domestic violence and conflict related injuries. These factors were also believed to have a

negative effect on the health service delivery in Yei River County.

The combination of conflict the some of the neighboring states, drought, famine, poverty and

underdevelopment has led to one of the largest displacements and migration of people in history

to Yei River County hampering the delivery of the health services. The health care is supposed

to be Available: Adequate health care infrastructure (e.g. hospitals, community health facilities,

trained health care professionals), goods (e.g. drugs, equipment), and services (e.g. primary care,

mental health) must be available in all geographical areas and to all communities.

5.1.4 Suggested ways for effective and efficient delivery of health services in Yei River

County.

The research findings conclude that there are several ways suggested for effective and efficient

delivery of health services in Yei River County.

Suggested way forward are making of better resources to the health facilities so that clinical staff

(doctors, nurses, midwives) could improve on their full potential Improve on the availability of

equipment for health care.

The State Government should build a democratic, transparent, and accountable Government,

managed by a professional and committed public service, with an effective balance of power

among the executive and legislative of the Yei Local government so as to tackle the problems

above that are hindering the enhancement of the health sector in Yei River County.

Government should make the establishment of effective and affordable Disarmament,

Demobilization and Reintegration (DDR) Programme to support transformation strategies for all

organized forces (Sudan People‟s Liberation Army (SPLA), South Sudan Police Service (SSPS),

90

prisons, fire brigade and wildlife forces) so as to make peace possible in Yei the mentality of war

and the language of war every day talked about by the youths will pose a risk in the development

of the youth contribute in the advancing the economic activities of the Yei people which the

research belief that the if the economy is boosted by youths participating it will results in the

lasting peace.

To ensure that improvements are made, public spending should be targeted so that the poorest

sections of society and the poorest regions get the greatest emphasis. Poverty audits of public

expenditure, constant monitoring of socio-economic indicators and evaluating delivery of basic

services are important to measure progress in meeting the needs of population in Yei.

Need for recruitment of adequate skilled medical personnel at all categories i.e from nursing,

midwives, lab technicians and doctors. There should be provision of modern medical equipment

to Yei Civil Hospital and Martha Primary health Care Centre to help in the investigation and

management of health care cases.

Health Staff motivation is to be taken as a key. This motivation should include good salaries that

are paid in regular bases to medical staff in Yei civil hospital and even Martha Primary health

care.

Other Suggested way forward are Regular supplier of drugs, more refresher training for health

staff to remind them of their health ethics. Ambulance provision to cater for patients in the rural

areas and the referral from primary health centers to the main Yei civil hospital. Improve the

quality of health services and establish psychotherapy service Centre and establish a regulatory

body to monitor NGOs in performance and delivery of health service

91

Key determinants of the quality of service are staff, availability of supplies and equipment, cost

of services, and client-provider relationship.

The main conclusion is that the flaws in the flow of medicines can be overcome. What is needed

is greater determination in improving the governance of the health sector; the mobilization of

adequate financial, logistical and human resources; and the effective coordination of the different

institutional actors in the health system. The challenge is big but not insurmountable.

5.2 Conclusion

Accordingly an analysis of the current situation in regard to NGO participation and partnership

in health development is considered to be timely and relevant to initiate strategies to promote and

enable NGOs to engage meaningfully in collective action for health development. Such

collaboration could have a positive impact on the form and substance of health governance.

The importance of Non-governmental Organizations (NGOs) in the delivery of services have

gained recognition in Yei River County in terms of filling gaps in government programmes, the

research also established that The importance of Non-governmental Organizations has also

provided people with a choice of service outlets and to create an effective voice in respect of

service needs and expectations. Where patients have choice to either go to Yei Civil hospital

(public facility) or privates health facility such as Martha Primary Health Care Centre or any

other health Centre.

5.3 Recommendations

Recommendation to the Minister of health

The research has established that technically the local government county health department is

technically having a link to the Yei civil hospital which is a good thing but administratively the

92

connectivity between the county health department and Yei civil hospital is not seen to be

existing. This disconnect of the administrative linkage is one of the factor responsible for the

lack of management, administration and supervision of the Yei Civil hospital. The Hospital is

answerable to the state ministry of health central equatorial the makes the day to day

administration of the hospital to be in question. The Ministry of Health Central Equatoria State

needs to decentralize some administrative function to the County Health Department so as to

allow them to do the day today administrative supervision to improve the health condition in Yei

Civil hospital

Government should ensure that appropriate levels of care (after the study you should be able to

specify the specifics of the appropriate levels of care) are provided. There should be quality

assurance in the hospital, health Centre, drug shops and the informal sector. The quality

assurance should be done by the Ministry of health and the County Health Department. The

quality assurance should be initiated by the Ministry of health and the ministry of should allow

the county health department.

An in-depth evaluation of the NGO and the private sector should be carried out from the

NGO/private sector perspective by the Ministry of health. It should review the key issues of

efficiency in the organizations, equity of service in the different sectors, resource mobilization,

collaboration and referral systems between NGO and private sector, community mobilization

mechanisms, and quality of service issues this evaluation will provide some mechanism of

strengthening the already assisting efficiency in the NGOs .

The research recommend that Local or State government should improve on the policies and

regulating measures to control private practitioners. Government should strengthen the

certification and licensing of all private practitioners County Health Department of health at

93

local government level should have more authority to enforce the regulations. Local Councils

committees should also be involved in enforcing regulatory measures by government on the

private practitioners.

Government should institute regulatory mechanisms make sure that some minimum standards

are in place before one is allowed to start a private clinic as the indicator in the study suggest that

the clinic are providing substandard health service. These may include ; storage facility for the

drugs; minimum qualification for the personnel working in the clinic; maximum number of

clinics a private doctor can operate; and the maximum number of private clinics and drug to

avoid overcrowding in one location. The regulation should also look at the operation of NGOs

and their area of operation to reduce inequity in access to services, and duplication of activities.

Recommendations to Yei River County Local Government

The Local Government county health department should ensure that NGOs work closely with its

departments share plans quarterly, yearly and see what gaps exists and that NGOs should fill in.

By NGOs submitting their plans and budgets will allow the local government authorities to

understand how they can direct the utilization of resources and also will address the issues which

were raised by beneficiaries that NGOs still think that local government has relax and have no

capacity to decide on which health services are priority that requires to be tackle to better the

health performance in Yei civil hospital and Martha primary health care Centre.

The local government county legislative council has a very important role to play in the over side

of the health sector given that it has a specialized committee on health. This committee through

the county legislative council needs to be encouraged and supported financially to execute its

mandate as the highest local government authority and responsible for health matters in a local

94

government jurisdiction such as Yei county. The specialized committee through the legislative

council should pay visits to the county health department, participates in the coordination

meetings organized between the NGOs and the county health department so as to give a support

for issues that might require by laws ordinances that will regulate and improve the performance

of the health sectors The county legislative council should also pay visits to the primary health

care centers.

The local government should encourage and supported to be able to carry out its responsibilities

when it comes to the health sector. There is an indication that local government sees the health

issues as an NGO issue rather than that of the community. This thinking should turn around to

local government taking the health issue as their own issue and only require the NGOs to help.

Information sharing is inadequate among the NGO/Private sector. Only the prescribed routine

information is collected and given to the County Health Department office. There is no

information flow from the NGOs to Local government and back to the NGO for use to improve

their services.

NGO staff interviewed recommended a policy which regulates the activities of politicians not to

interfere with their activities. The political leaders should take an active role in health activities

at community level and not block NGO activities.

Recommendations to the Yei Civil Hospital and Martha Primary Health Care Centre

The Yei civil hospital administration should work on the improvement of their management style

and assess the existing structure so as to reduce the bureaucratic procedures which has been seen

as hampering the performance of the hospital.

95

The available resources such as the human, financial resource and other material resources

should be better utilized to enhance the health system as this is the key factor to health services

succeeding and this is one of the concern that most people who were interviewed accessing the

hospital services reported.

Recommendation to the Non- Governmental Organizations

NGOs should work in building the capacity of the local government health department so that its

able to come up with a comprehensive strategic plan for the health sector in Yei river county the

strategic plans should cover aspects of the Yei civil hospital and the primary health care centers

and also look at issues of health concerns that are arising in Yei such as the mushrooming private

clinics that have been seen as a threat to the population. The strategic plans should also cover

capacity building needs of the local government health department in concrete terms than base

on individual personal interest.

Given the manner in which some NGOs pulled out in delivering the basic health service. It is

recommended that when NGOs are about to leave from delivering health services in Yei there

should be very clear face out plan and alternative strategies between the NGOs and the local

government considering the effects the pullout will cause to the health sector.

The NGOs should always employ advocacy and lobbying mechanisms to supplement the health

services where the National, State and Local Government cannot afford and has no capacity. The

advocacy and lobbying as a tool should be integrated in to the Local Government county health

department so as to build expertise that result in to a capacity that helps the government and

hospital staff to be able to attract other funding that contributes to enhancing the performance of

the health sector in Yei River County.

96

Research in community financing of health care should be carried out. The use of community

based NGOs in financing health care services should be explored.

NGOs should explore other financing mechanisms so that the quality of service produces is

improved.

Government should honor its commitments to NGOs so that they can improve on the services

they deliver.

Recommendations to the community accessing the health services in Yei River County

Community members should support NGOs by verifying with the precautions from the medical

staff, the government policies and the NGOs policies and this will improve the quality of health

service delivery.

Community should increase their participation and interest in community programmes especially

water and sanitation programmes which resulted into diarrhea cases. They should be able to

accommodate changes and new developments in their areas.

97

References

Akukwe, C. (1998). The growing influence of Non-governmental organizations (NGOs) in

International health: Challenges and opportunities.

Amin, M.E (2005), Social Science Research, Conception, Methodology and Analysis. Kampala:

Makerere University Printery

Andersson-Brolin, L., Ole-Memiri, B.L., Michanel, E., & Ndagala, D (1991) the Art of Survival:

Anheier, H.K., & Seibel, W. (eds). (1990). the Third Sector: Comparative Studies of Nonprofit

Organizations. Berlin, de Gruyter.

Banda, E. and Simukonda, H. 1994. “The Public/Private Mix in the Health Care System in

Malawi.” Health Policy and Planning 9(1): 63-71.

Barlett L, Mawji S, Whitehead S, Crouse C, Dalil S, Ionete D, Salama P. Where giving birth is a

forecast of death: maternal mortality in four districts in Afghanistan, 1999-2002. Lancet 2005; 5:

864-70.

Basic Package for Hospital care Services – Government of Southern Sudan, Ministry of Health –

Directorate of Curative Services – St. Mary‟s Hospital, Isle of Wight, UK (2009)

Berman, P. and Dave, P. 1996. “Experiences in Paying for Health Care in India‟s Voluntary

Sector.” International Journal of Health Planning and Management 11:33-51.

Bhushan I, Keller S, Schwartz B. achieving the twin objectives of efficiency and equity:

contracting health services in Cambodia. Manila: Asian Development Bank, 2002.

98

Brinkerhoff, D. 1991. Improving Development Program Performance: Guidelines for Managers.

Boulder, CO: Lynne Rienner Publishers Chin, S. “PVOs in Health Programs: Prospects for

Sustainability.” Three Philippine PVO Monographs.

Collingwood, V. (2006). Non-governmental organizations, power and legitimacy in international

Society.

Dave, P. 1991. “Community and Self-Financing in Voluntary Health Programmes in India.”

Health Policy and Planning 6(1): 20-31.

Davis, H. and Watt, M. 1994. “Trip Report: Preparation of Pilot Test of Sustainability Indicators

for Bangladesh CA/NGO Project, May 1-12, 1994.” Boston, MA: Family Planning Management

Development Project.

Department for International Development. Why we need to work more effectively in fragile

states. London: DFID, 2005.

Economic Policy Research Centre, (2010) governing health service delivery in Uganda: a

tracking study of drug delivery mechanisms - Research Report No. 1

Edwards, M. (1999). „Legitimacy and Values in NGOs and Voluntary Organizations:

SomeSkeptical Thoughts.‟ In D. Lewis (Ed.).International Perspectives on Voluntary

Action.London: Earthscan.

Edwards, M. (1999). Ngo performance- what breeds success? New evidence from south

Asia.World Development, 27 (2), 361-374.

Establishing Human Resources Systems for Health during Post-conflict Reconstruction -

Occasional Papers – Management Sciences for Health No. 3 (2006)

99

Family Planning Policy (July 2009) – Ministry of Health, Government of Southern Sudan

Frankish, C.J. (2006). Setting a foundation: Underlying values and structures of health promotion

in primary health care settings.Primary Health Care Research and Development, 7, 172-182

Gilson L., Sen P.D., Mohammed S. and Mujinja P. (1994): The potential of health sector non-

governmental organizations: policy options. Health Policy and Planning Vol. 9 (1), pp. 14-24.

Government of Southern Sudan – Sudan Household Health Survey (Southern Sudan Report) –

2006

Government of Southern Sudan, Health Sector, Draft Health Sector Budget Plan 2007 – 2009

Grant S. (2000): The Role of Civil Society CBOs/NGOs in Decentralized Governance; Asian

Review of Public Administration, Vol. 12 (1, January-June), pp. 15-25.

Grantmakers In Health, Implementing Health Care Reform: Funders and Advocates Respond to

the Challenge (Washington, DC: August 2010).

Health Policy – Government of Southern Sudan (2007-2011

Katz, Aaron, Amelia M. Bond, Emily R. Carrier, et al., Cleveland Hospital Systems Expand

Despite Weak Economy, Community Report No. 2, (Washington, DC: Center for Studying

Health System Change, September 2010).

Kebede E. (2004). The Participation of NGOs/CSOs in the Health Sector Development Program.

Addis Ababa: Christian Relief Development Agency (April).

Kebede E. (2004). The Participation of NGOs/CSOs in the Health Sector Development Program.

Addis Ababa: Christian Relief Development Agency (April).

100

Krejcie & Morgan in their 1970 article “Determining Sample Size for Research Activities”

Educational and Psychological Measurement, #30, pp. 607-610).

Loevinsohn B, Harding A. Buying results? Contracting for health service delivery in developing

countries. Lancet 2005; 366: 676-81.

Massachusetts Office of the Governor, Governor Patrick Announces $26.75 Billion Medicaid

WaiverAgreement, press release, December 21, 2011.

Mills A, Rasheed F, Tollman S: Strengthening health systems. In Disease control priorities in

developing countries. 2nd edition. World Bank and Oxford University Press, New York; 2006.

Milner M Jr. Unequal care: a case study of interorganizational relations in health care.New York:

Columbia University Press, 1980.

Moore, G., Beyene, M., Green, E., Leinen, G. and Robbins, M. (1998): “Evaluation of the

Essential Services for Health in Ethiopia (ESHE) Program”; Population Technical Assistance

Project, USAID (May). http://www.poptechproject.com/pdf/eshe63.pdf

Mugenda, M. Olive and Abel G. Mugenda (1999) Sample size: Research Methods Quantitative

and Qualitative Approaches, Kenya African Center for Technical Studies (ACTS)

Oregon Health Policy Board, “Coordinated Care Organizations,”

<http://health.oregon.gov/OHA/OHPB/health-reform/ccos.shtml>, accessed December 2011.

Oso, W.Y & Onen, D. (2005) A General Guide to writing research proposal and report, Kisumu,

Options Publishers overcoming Apartheid‟s legacy,” in Avirgan et al. (eds.) (2005). project

“Women in Informal Employment: Globalizing and Organizing”.

101

Republic of Kenya (2006): “Joint Program of Work and Funding: 2006/07–2009/10 for the

Kenya Health Sector”; Nairobi: Health Sector Reform Secretariat, Ministry of Health.

Review of International Studies, 32, 439-454.

Shih, Anthony, Karen Davis, Stephen Schoenbaum, et al., Organizing the U.S. Health Care

Delivery System for High Performance (New York, NY: The Commonwealth Fund, August

2008).

Southern Sudan Health Financing Study report – April 2009

Southern Sudan Malaria Strategic Plan 2007 – 2011 – Ministry of Health – Government of

Southern Sudan

Southern Sudan Maternal, Neonatal and Reproductive Health Strategy – Action Plan 2008 –

2011 - Government of Southern Sudan – Ministry of Health

The Journal for the Royal Society for the Promotion of Health, 118 (2), 107-115.

World Bank (1987): Financing Health Services in Developing Countries: An Agenda for

Reform. Washington, DC: World Bank, 1987.

World Bank (1993): World Development Report 1993: Investing In Health. Washington DC:

World Bank.

World Bank (1994): Better Health in Africa. Washington DC: World Bank.

World Bank (2000): Can Africa Claim the 21st Century? The World Bank: Washington D.C.

102

World Health Organization (1978): Declaration of Alma-Ata. International Conference on

Primary Health Care, Alma-Ata, USSR (6-12 September).

World Health Organization (1999): Commission for Macroeconomics and Health. WHO:

Geneva.

World Health Organization (2000): The World Health report 2000: Health Systems: Improving

Performance; WHO: Geneva.

World Health Organization: Everybody's business: strengthening health systems to improve

health outcomes: WHO's framework for action Geneva; 2007.

World Health Organization: World Health Report 2000 In Health systems: Improving

performances. Geneva; 2000.

http://www.biomedcentral.com/sfx_links?ui=1472-6963-11-122&bibl=B1

103

Appendices:

Questionnaire 1 A

For Health Care officials (Yei Civil Hospital) NGO

Dear respondents,

I am BOBOYA JAMES EDIMOND, a student at Uganda Martyrs University pursuing Master of

Arts in Local Governance and Human Rights. I am researching on The Contribution of Non-

Governmental Organizations in Delivery of Basic Health Services in Partnership with Local

Government. A Case Study of Yei Civil Hospital and Martha Primary Healthcare Centre in Yei River

County. Please, may you answer the below questionnaire to the best of your knowledge and

experience, and be assured that all information given will be treated with confidentiality and respect.

The data you will provide will only be used for academic purposed only.

Section A. Background information

Please tick where necessary.

1. Gender

Male ( ) Female ( )

2. Age Groups of the Respondents

18-24 ( ) 25-30 ( ) Over 30 years ( )

3. Education Levels of the Respondents

Primary and below ( ) Secondary and above ( ) Never been/Went to school ( )

4. Occupation

Business/trade workers ( ) Farmers ( ) Salaried employees ( ) Unemployed ( )

5. Monthly Earnings of Respondents

£ 60 ( ) £ 61 – 120 ( ) £ 121 – 250 ( ) Above £ 250 ( )

SECTION B. CONTENT INFORMATION

In this section, tick or fill where necessary.

104

6. Which None Governmental Organizations is supporting Yei civil hospitals?

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

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

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

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

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

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

…………………………………………………………………

7. What type of health support do these Organizations giving?

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

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

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

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

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

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

Is this health support given for free by those None Governmental Organizations?

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

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

........................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

.............................................................................................................................

8. What challenges do you faced in the delivery of health care support in Yei River

County?

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

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

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

105

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

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

9. Who are your patients?

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

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

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

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

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

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

10. Do they get referral to other health facilities?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

..................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

.....................................................................................................................................................

11. In your opinion, what are the best ways to improve the delivery of health services?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

.....................................................................................................................................................

12. How will the None Governmental Organizations improve their working relationship

with the local government?

106

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

..................................................................................................................

13. What are the achievements of the health sector in Yei River County?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

..................................................................................................................

14. What shows that you have achieved your goals and objectives?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

..................................................................................................................

15. Please provide any additional information of relevancy here

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

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

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

…………………………………………………………………………………..

Thank you

107

Questionnaire 1 B

For Health Care officials (Martha Primary Health Care Centre) Church

Dear respondents,





County. Please, May you answer the below questionnaire to the best of your knowledge and





1. Gender

Male ( ) Female ( )



2. Which organizations are supporting Martha Primary Health Care Centre?

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

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

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

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

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

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

…………………………………………………………………

3. What types of health support do those Organizations giving Martha Primary Health

Care Centre?

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

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

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

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

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

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

……………………………………

108

4. Is these health support given for free by those None Governmental Organizations?

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

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

........................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

.............................................................................................................................

5. What challenges do you faced in the delivery of health care support in Yei River

County?

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

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

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

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

……………………………………………………………………………

6. Who are your patients?

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

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

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

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

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

…………………………………………………………………………

7. Do they get referral to other health facilities?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

..................................................................................................................................

109

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

8. In your opinion, what are the best ways to improve the delivery of health services?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

..................................................................................................................

9. How will the None Governmental Organizations improve their working relationship

with the local government?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

..................................................................................................................


............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

110

............................................................................................................................................................

..................................................................................................................

11. What shows that you have achieved your goals and objectives?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................


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

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

Thank you

111

Questionnaire 2

For Local Government Officials

Dear respondents,





County. Please, May you answer the below questionnaire to the best of your knowledge and



PART 1: Data for Yei Civil Hospital (Public facility)



1. Gender

Male ( ) Female ( )



2. What types of services are offered in Yei Civil hospital?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

3. How do you know that the services have taken place in Yei civil hospital?

............................................................................................................................................................

............................................................................................................................................................

112

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

4. As a local government what are your role in Yei Civil Hospital?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

5. What have you achieved working with the NGOs supporting Yei Civil hospital?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

6. What do you do together with the NGOs to achieve results in Yei civil hospital?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

113

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

7. What are the challenges in working with the NGOs, providers and profit organizations

delivery health services in Yei River County?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

8. What are the best ways to address these challenges in order to improve health services?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

9. Which organizations support the health sector in Yei Civil Hospital and what type of

support do they give?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

114

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

10. Who are they supporting in the health sector?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

11. How are they supporting Yei Civil Hospital?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

12. What in your Opinion is a good example of the collaboration with the NGOs in the

delivery of the basic health services in Yei Civil Hospital?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

115

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................


............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

.........................................................................................

14. What shows that they are achieved in Yei Civil Hospital?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

.......................................................................................................................

PART 1: Data for Marta Primary Health Care Centre (Private health facility)

1. What types of services are offered in Martha Primary Care Centre?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

116

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

2. How do you know that the services have taken place Martha Primary Care Centre?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

3. As a local government what are your role in Martha Primary Care Centre?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

4. What have you achieved working with the NGOs supporting Martha Primary Care

Centre?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

117

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

5. What do you do together with the NGOs to achieve results?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

6. What are the challenges in working with the NGOs, providers and profit organizations

delivery health services?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

7. What are the best ways to address these challenges in order to improve health services in

Martha Primary Care Centre?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

118

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

8. Which organizations support the health sector and what type of do they give in Martha

Primary Care Centre?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

9. What in your Opinion is a good example of the collaboration with the NGOs in the

delivery of the basic health services in Martha primary health care?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

10. Who are they supporting in the health sector?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

119

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

11. How are they supporting Martha Primary Care Centre?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

12. What are the achievements of the health sector Martha Primary Care Centre?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................

13. What shows that they are achieved?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

120

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

...........................................................................................................


............................................................................................................................................................

................................................................................................................................................

Thank You

121

Interview Guide for the Beneficiaries

Total number of respondents ..................Male...................Female................

1. In your own opinion. How has the Yei Civil Hospital and Martha Primary Heath Centre

the performed in Delivery of health service?

2. Is the health sector properly managed by the NGOs

3. Which years do you think the health sector was well functioning and why

4. In what way are Yei Civil hospital and Martha primary health Centre helped the

community

5. Have you and your community ever experienced any problem from the health sector in

Yei what are those problems and why more details?

6. Have you ever faced any problem from the health sector in Yei civil hospital and Martha

Primary health care Centre?

7. If yes, what are they?

8. In your own opinion, how can your community solve the above mentioned problems?

9. 6. In your own opinion, how can the NGO and local government work together to solve

the above mentioned problems?

10. Why do you choose the health Centre?

11. What are the good things in the hospital and the health Centre?

12. Do you think it is necessary to continue the delivery of the health services?

Thank you.

122

Interview Guide for, Health and Local Government Officials

1. Who funds the health sector?

2. Which NGOs Run the heath sector

3. From which year to which year

4. What made the NGO to leave delivery of the health service?

5. To whom are the NGO accountable to?

6. Do the local governments Monitor the NGOs and cooperate with them while delivery the

health services?

If yes, how often do you do it?

7. When did the partnership started between the NGOs and the Local government and what

kind of partnership?

8. Are there any problem/ challenges related to the partnership between NGOs and Local

government? If Yes List the problem/ challenges

9. Are there measures taken by the health sector to solve the problems/ challenges?

10. Are partnership with local government and the NGOs delivery the health services

important why do you think so?

Thank you.

Observation guide at the hospital and the primary health care to asses important

1. Are there adequate structures at the premises of the hospital and the primary health care?

2. Are they well maintained?

3. If not why are they not maintain?

4. Are patients receiving services?

5. What is the patient handling like (bed capacity, doctor/nurse attention, diagnostic

equipment, and payment structure)?

6. Is there free food or payment is being made?

7. About how many can be seen?

8. Do patients exist with drugs?

9. Do they look/express satisfaction?

Thank you

123

Introductory letter

124

Work Plan

the contribution of non-governmental organizations … boboya... · the data from the field was...

Documents