Administrative Decentralization and Maternal Healthcare Service Delivery In Rural Communities of Mitooma District,Uganda

Abstract

Decentralization has been promoted globally as a means to improve health service delivery by bringing decision-making closer to communities. In Uganda, the decentralization policy, introduced in 1993, implemented reforms such as the devolution of power to district councils, the delegation of administrative functions to local authorities, and the upgrading of lower-level health facilities (HCII to HCIII) to improve the accessibility of maternal health services. Despite these reforms, maternal health care outcomes remain suboptimal in rural areas, particularly in Mitooma District, where this study was conducted. An interpretivist phenomenological qualitative design was employed, using in-depth interviews and focus group discussions (FGDs) with key stakeholders, including healthcare workers (Midwives, and nurses), pregnant and lactating mothers, and local government officials. Participants were purposively selected across multiple communities served by four health facilities at the level of HC111, and HC11 within Mitooma districts. Data were transcribed, coded, and thematically analyzed using ATLAS.ti software to identify key themes and patterns. Ethical principles were observed throughout the research, including informed consent and confidentiality. Findings revealed that while decentralization has enhanced local autonomy and community engagement in some districts, significant challenges persist. These include limited financial and human resources, inadequate decision-making capacity at the local level, poor referral systems, and delays in emergency health care for expectant mothers. Participants also highlighted disparities in service availability and quality, particularly in rural and hard to reach communities like Kanyabwanga HC111. Despite these constraints, decentralized structures offered opportunities for locally tailored interventions and improved accountability when adequately supported. In conclusion, it was observed that decentralization alone is not sufficient to ensure improved maternal health outcomes. Strengthening district-level capacities, enhancing coordination mechanisms, and addressing systemic resource constraints are critical for the success of decentralization reforms. The study recommends targeted policy actions to bridge implementation gaps and promote equitable health