Our Side of the Story A policy report on the lived experience Coalition for Health Promotion and Social Development and opinions of Ugandan health workers HEPS-Uganda, The Coalition for Health Promotion and Social Development
Established in 2000, HEPS-Uganda, the Coalition for Health Promotion and Social Development, is a health rights organisation that advocates for increased access to affordable essential medicines for poor and vulnerable people in Uganda. HEPS promotes pro-people health policies and carries out campaigns at local, national and regional levels. It also initiates and conducts research necessary for health and human rights advocacy. Since 2007, HEPS-Uganda has actively promoted health rights within seven local government districts, addressing maternal health and equitable access to healthcare. Working in some of the most disadvantaged rural areas of Uganda, HEPS has trained community representatives to spread the word about health rights and how to exercise them. It also promotes the responsible use of healthcare resources and effective ways of communicating with health workers. For more details, visit: www.heps.or.ug
VSO Uganda
VSO Uganda volunteers are currently working in the central, western and northern regions of the country, in the fields of participation and governance, disability, health, education and livelihoods. Poor and disadvantaged people in Uganda are badly affected by preventable diseases. Health service provision and access is low, and staff retention is a challenge. VSO is supporting the Ugandan Government in implementing the Health Sector Strategic Plan (HSSP) to improve health systems in the context of a decentralised health delivery system at district level. HSSP focuses on working with communities and the implementation of primary and preventive healthcare services, as well as good-quality, accessible clinical services as stipulated in the minimum healthcare package. It has a particular emphasis on reaching the majority of the population, over 80% of whom live in rural areas, where the people tend to be poorer than in urban settings. For more details, visit: www.vsointernational.org/where-we-work/uganda.asp
VSO International
VSO is different from most organisations that fight poverty. Instead of sending money or food, we bring people together to share skills and knowledge. In doing so, we create lasting change.
Our volunteers work in whatever fields are necessary to fight the forces that keep people in poverty – from education and health through to helping people learn the skills to make a living. We have health programmes in 11 countries, with plans to open further health programmes in the coming years.
From extensive experience supporting health and HIV programmes in developing countries, VSO believes that in order for health systems to improve, more health workers must be recruited and retained. They must be of good quality, in the right places, well trained and with access to the basic equipment and drugs needed. They also need to be well supported – placed in the right location, treated fairly and managed well.
Through our Valuing Health Workers research and advocacy project, VSO identifies the issues that affect health workers’ ability to deliver quality healthcare. These findings will support partners to carry out further research and make a significant contribution to improvements in the quality of health worker recruitment, training and management. For more details visit: www.vsointernational.org/what-we-do/advocacy Our Side of the Story: The lived experience and opinions of Ugandan health workers
Acknowledgements
The Valuing Health Workers research and advocacy project is the initiative of VSO International. This report is based on research in Uganda in partnership with HEPS-Uganda, the Coalition for Health Promotion and Social Development, and with support from VSO Uganda. Thanks are due to Rosette Mutambi, executive director of HEPS-Uganda, Sarah Kyobe, VSO Uganda health programme manager, and Stephen Nock, VSO International policy and advocacy adviser, for their practical support and encouragement. Stacey-Anne Penny brought to the project her drive to explore and understand the lived experience of Ugandan nurses and her invaluable contribution as co-researcher up to August 2010. HEPS-Uganda colleagues provided a supportive and friendly working environment. The following HEPS staff played practical roles in managing consultative workshops, facilitating access to fieldwork sites and co-convening and transcribing focus group discussions: Prima Kazoora, Phiona Kulabako, Aaron Muhinda and Kenneth Mwehonge. This report would not have been possible without the willing participation of 122 health workers across Uganda. Thank you to them for voicing the rewards and challenges of their daily lives. Thank you to local managers for making staff available, and to patients for their forbearance while their health workers gave time to the research. Not least, thanks are due to the representatives of organisations concerned with health worker and health consumer interests, for their participation in workshops and interviews. Patricia Thornton
Text: Patricia Thornton Field research: Patricia Thornton, Stacey-Anne Penny, Prima Kazoora, Phiona Kulabako, Aaron Muhinda and Kenneth Mwehonge Editing: Stephen Nock, Diane Milan, Stephanie Debere and Emily Wooster. Layout: www.revangeldesigns.co.uk Photography: Cover photo © Matthew Oldfield/Science Photo Library
©VSO 2012 Unless indicated otherwise, any part of this publication may be reproduced without permission for non-profit and educational purposes on the condition that VSO is acknowledged. Please send VSO a copy of any materials in which VSO material has been used. For any reproduction with commercial ends, permission must first be obtained from VSO. The views expressed in this report belong to individuals who participated in the research and may not necessarily reflect the views of HEPS-Uganda, VSO Uganda or VSO International.
ISBN: 978 1903697 337
3 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Contents
Summary 6
1. Introduction 12 1.1 The VSO Valuing Health Workers initiative 12 1.2 The Valuing Health Workers research in Uganda 12 1.3 The research approach and participants 14 1.4 Structure of the report 14
2. Healthcare in Uganda: challenges and provision 15 2.1 Ugandan healthcare challenges 16 2.2 Formal healthcare provision 19 2.3 The Ugandan health workforce 21
3. Research design and methods 25 3.1 The research stages 25 3.2 Qualitative research methodology and the purposive sampling design 25 3.3 Data collection 26 3.4 Data analysis 26 3.5 The health worker participants 26
4. The rewards 28 4.1 Benefiting others 28 4.2 Job satisfaction 28 4.3 Being recognised, appreciated and valued 29 4.4 Appreciative and supportive management and colleagues 29
5. Reasons for becoming a health worker: the “right heart” and the “wrong heart” 30 5.1 A passion for the patients 30 5.2 “They join for the wrong reasons” 31 5.3 Recommendations 31
6. Workload 33 6.1 The context 33 6.2 The health worker experience 33 Unmanageable workloads 34 Too many tasks and responsibilities 34 Working day and night 34 Over-long shifts and too little time off 34 Impacts on health 34 Restricted professional development 34 Failing the patients 35 6.3 Factors contributing to understaffing and work overload 36 6.4 Recommendations 37
4 Our Side of the Story: The lived experience and opinions of Ugandan health workers
7. The facility infrastructure 38 7.1 The context 38 7.2 The health worker experience 39 Low job satisfaction 39 Risks to health workers 39 Risks to patients 39 7.3 Recommendations 40
8. Equipment and medical supplies 41 8.1 The context 41 8.2 The health worker experience 41 8.3 Recommendations 43
9. Medicine supplies 44 9.1 The context 44 9.2 The health worker experience 44 9.3 Recommendations 47
10. Pay 48 10.1 The context 48 10.2 The health worker experience 48 Money worries 49 Failing to meet social expectations 49 Disrespect 49 Thwarted professional ambitions 49 Unfair pay 49 10.3 Poor pay, turnover and loss to Uganda 51 10.4 Recommendations 52
11. The way forward 53 11.1 Raising the voices of health workers 53 11.2 Changing public perceptions of health workers 55 11.3 Bridging patient communities and healthcare facilities and staff 55 11.4 Summary of participants’ recommendations 57
Appendix A: Sample details 59
Appendix B: Local government structures in Uganda 61
References 63
Annex: Health worker topic guide 66
5 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Summary
The Valuing Health Workers research regions of Uganda and in the capital city, Kampala, covering government, not-for-profit and private ownership organisations. and advocacy initiative Health worker participants contributed their perspectives in small group discussions or individual interviews. In addition, The Valuing Health Workers research and advocacy project 24 stakeholders from civil society organisations, trades unions, is an initiative of VSO International. It recognises that health professional associations and regulatory councils participated workers’ voices must be heard and acted on to improve in workshops or interviews. access to healthcare and so help to achieve the Millennium Development Goals. VSO International started participatory research in four countries in Africa and Asia in partnership Ugandan healthcare challenges with in-country non-governmental organisations. VSO carried and provision out research in Uganda from February 2010 to February 2011 in partnership with HEPS-Uganda, the Coalition for Health Uganda has the third-highest rate of population growth in the Promotion and Social Development. VSO will support local world, with most people living in rural areas with extremely partners to use the research findings to advocate for health poor access to electricity and low access to improved water workers in their countries, and will gather the research supplies. Maternal, infant and under-five death rates show evidence to advocate on a global level. only small improvements. Malaria is the main sickness and a major cause of childhood deaths. Uganda has only one doctor per 10,000 people, and only 14 health workers (doctors, nurses The research in Uganda and midwives) per 10,000 people, significantly below the 23 health workers per 10,000 recommended by the World Health In Uganda, negative images of health workers are presented Organisation (WHO). Medical doctors and the most highly in the media, political speeches, healthcare user research qualified nurses and midwives are concentrated in and around and health consumer advocacy projects. It is said that health the capital city. The Government of Uganda is committed under workers absent themselves from work, are rude, neglectful the Abuja Declaration to apportion 15% of its budget to health, and abusive to patients, extort money from patients and steal but it has not exceeded 10% in the last 10 years. medicines. Yet policy documents acknowledge that many health workers live and work in impoverished conditions. Healthcare in the formal system is delivered in a hierarchy of The Valuing Health Workers research set out to explore with health centres and hospitals. Patients should be referred from frontline health workers and their managers how working a lower- to a higher-level facility for the services they need. conditions affect attitudes, behaviour and practices. It also The government runs 60% of hospitals and health centres; sought the positive side of the health worker experience. around 20% are run by not-for-profit organisations (mostly faith-based) and around 20% by private organisations. Fewer This report documents the experiences and views of 122 nursing than four in 10 Ugandans turn to health centres or hospitals assistants, nurses, midwives, clinical officers and medical doctors, when they fall sick. Pregnant women and children are the including facility managers and local government district health largest groups of patients. officers. The facility-based participants worked at 18 hospitals and health centres in seven local government districts in all
6 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Reasons for becoming a health worker The impact of working conditions and rewards of the work Workload, workplace infrastructure, medical equipment and supplies, the availability of essential medicines and the level of The urge to help, prevent suffering and save lives stood out remuneration affected health workers’ well-being, the quality among the reasons people gave for becoming a health worker. of care they could provide and relations with patient communities. It had been common in rural areas to see people suffer in pain It is apparent from health workers’ experiences that working and die with no proper medical care. Their training would conditions are the root cause of the attitudes, behaviours and bring to the community knowledge to help prevent illnesses, practices for which health workers have been criticised. discourage harmful traditional healing practices and save lives. Participants who had been impressed by caring nurses and Workload the skills of medical staff wanted to give something in return. Interest was stimulated by the example of family members who Ministry of Health sources reveal almost half of approved worked in healthcare. Experiencing poor service also prompted posts at health centres and hospitals are vacant – a shortfall a desire to raise healthcare standards. of 25,506 staff. There are gross disparities across local government districts, with four districts having less than A desire for money was not a driving force. Clinical officers and 30% of posts filled, while 10 districts filled more than 70%. medical doctors told of expectations on them as the brightest school students to enter one of the prestigious professions. Unmanageable workloads overwhelmed nurses and made It was widely believed that new entrants to nursing came with them physically and mentally ill. Too many tasks and “the wrong heart”, resulting in unhappy, disinterested and responsibilities led to burn-out. Lack of more qualified staff self-serving recruits, who resorted to bad habits and forgot meant taking on stressful roles beyond the scope of duty. their accountability to patients. Participants told of working round the clock, foregoing meals and compromising their health. Overlong shifts and limited The benefits to the community, to individual patients and to time off allowed little personal or family time. Feeling they their own families were the biggest sources of satisfaction. Job were failing the patients added to health workers’ distress. satisfaction came from making a difference to patients, doing their duty the best they could, using their skills and learning Hospital nurses torn apart by calls for attention and too through work. Health workers valued being appreciated, many tasks recognised they could lose their temper. Midwife respected and trusted by patients. Tangible demonstrations of behaviour changed as a result of working alone day and night. appreciation by managers were a huge positive, as were good Long, tiring shifts, when overwhelmed by the workload, led teamwork and supportive managers who created opportunities to nurses being short with patients, not interacting with them for health workers to raise their concerns. and conveying disinterest through attitude and expression.
7 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Managers and frontline doctors had seen how hunger made Equipment and medical supplies nursing staff bad-tempered and rude to patients. It was said that long shifts, together with poor pay, led nurses to not turn up The Ministry of Health acknowledges a shortage of basic for duty and leave work early. Managers observed that lack of equipment in health facilities and that only 40% of equipment opportunity to fulfil their proper professional role demotivated in place is in good condition. An independent survey reveals nurses, who then ran out of compassion and skip out from a gross lack of equipment for the diagnosis and treatment work. Work overload and staff shortages had impacted on of malaria, and that six in 10 facilities surveyed were not community relations, and participants told of aggressive equipped to measure haemoglobin. outpatients and wrongful accusations of neglect of duty. Health workers praised well-equipped facilities and imaginative Managers explained that financial allocations for salaries stood management that solved temporary supply problems by in the way of recruiting more staff and that vacancies persisted borrowing from other facilities. Elsewhere, working with due to bureaucratic procedures. Paradoxically, scarcity of inadequate equipment was a huge challenge. There was staff was a barrier to holding public sector health workers to widespread frustration at not being able to work effectively. account, as disciplinary procedures might lead to transfer and Failing their patients greatly distressed nurses and doctors, an even worse workload for remaining staff. who saw patients die because of lack of supplies and missing or poorly maintained diagnostic equipment. In the government Infrastructure sector, doctors and nurses told of interruptions in supplies of oxygen and blood; missing needles giving sets and sutures, According to official sources, most facilities are in a state of and minimal urine testing kits and family planning supplies. disrepair. Many health centres have non-functional operating Rural midwives in government facilities told of struggling with theatres. Only one in four facilities has electricity or a back-up no delivery kit, cord clamp, sucker, gauze or cotton wool and generator and only 31% have a year-round water supply. just one pair of scissors. The regulatory prohibition on asking Over half facilities lack transport for patient referral in maternal patients to buy medical supplies was a huge frustration which emergencies and only 6% have technology to communicate. challenged their ethical duty to do their best for their patients.
Government sector workers in rural facilities bore the brunt Managers recognised that doctors lose morale when unable to of infrastructure failures. When theatres were unusable, operate, and that being unable to apply knowledge was very underemployed doctors lost interest and left. Lack of electricity demotivating. It was said that nurses forgot what they had compromised staff and patient safety. At night, patient notes been taught and as a result some did not work, so projecting a could be not read to ascertain HIV status and deliveries bad image to the community, which in turn made nurses feel were carried out by the light of a mobile phone or a candle. not respected and prompted them to leave. Health workers felt Maternity workers said patients construed their behaviour as blamed for the lack of supplies. They noted patients’ attitudes rude or neglectful because they shied away from risk. Lack of change if asked to buy their own, with some carers becoming generator fuel meant operations were completed by torchlight. angry and violent. Nurses feared assault working in unlit wards or crossing dark compounds, a risk made worse by lockless doors, breaches in Availability of essential medicines compound fences and inadequately equipped or absent guards. A lack of water to flush toilets forced staff to return home, The proportion of health facilities registering ‘stock-outs’ in fuelling patients’ beliefs they were not at work. Infection essential medicines has consistently been over 60% for the control was near impossible when nursing staff had to beg last 10 years. Not one of 40 essential medicines was available the little water spared by patients’ family attendants to wash in every government facility in a sample survey in the second their hands. It was deeply upsetting to know that poor patients quarter of 2010. Only eight were found in each not-for-profit would die because the facility had no means of transporting sector facility surveyed. them to a hospital that could give the treatment they needed. Making transport available to bring patients to the facility, Participants working outside the government sector mostly supported by easy mobile phone access to staff, was said to considered medicine supplies adequate. In the government benefit community relations. sector there was sharp contrast between praise for the better stocked facilities and disgruntlement that essential drugs were
8 Our Side of the Story: The lived experience and opinions of Ugandan health workers
used up in a matter of weeks or even days. Complaints centred they had put in, and going unrewarded for doing the same on undersupply for population demand; shortfalls in supply work as higher grade staff was thought bitterly unfair. Doctors where deliveries did not match orders; erratic deliveries (such as being paid less than secretaries and drivers in some statutory oversupply of condoms but no anti-malaria drugs) and irregular agencies underscored the little value attached to the medical deliveries which did not conform to promised quarterly schedules. profession in Uganda. Salaries were doubly unfair because they did not reflect the long hours many health workers put in. Unable to give their patients the drugs they needed, health workers became demoralised by the futility of their roles, Participants acknowledged that poverty led to bad practices – and their self-esteem suffered when patients lost confidence minimal effort, late arrival at work, venting of frustrations on in them. Health workers grieved for their patients’ suffering patients, small-scale pilfering of drugs and accepting money from the lack of medicines, such as antiretroviral drugs, which offered by patients. It was widely believed that urban health should be taken on a lifelong basis. Helplessness was hard to workers were forced to work in two or even three jobs to make bear when they felt forced to tell poor patients to buy their ends meet, leading to exhaustion and behaviour which patients medication in the private market. Health workers struggled perceived as rude. with disappointed patients and their limited understanding of reasons for shortfalls in supplies. They also told of angry, bitter Better pay was not an overriding consideration for working patients who cursed them and refused to listen. They said that outside Uganda. Nurses explained they were looking for an communities served by government facilities assumed health environment where their work would be respected and workers took the drugs. where they could learn about different medical conditions, use equipment they were trained to use, update their skills There was widespread indignation at accusations of stealing and have the chance to advance professionally. Doctors spoke non-existent medications. Health workers resented negative about the attraction of a better income from work abroad, but stories in the media and felt that local leaders and politicians opportunities to use proper equipment and enjoy the work made matters worse when they failed to present the true also were important. picture to complaining patients, and even accused health workers in front of patients. There was hurt and indignation about top public figures spoiling the professions’ reputations Conclusions and participants’ by stating publicly that health workers are thieves. recommendations Pay Health workers’ accounts show that working conditions were the root causes of bad practices and unethical behaviour, and Ugandan nurses’ and doctors’ salaries are the lowest in East that health workers bore the brunt of the blame for system Africa. Monthly starting salaries in public service in 2009-10 failures. The research revealed a vicious circle: impoverished were 353,887 UGX (Ugandan Shillings) ($US 191) for a registered working environments and low pay affected the quality of nurse and 657,490 UGX (($US 354) for a medical officer. High patient care; patients blamed the health workers; the wider court judges received 6.8 million UGX (($US 3,664) per month.1 community then distrusted health workers and so health workers’ distress increased. The situation was made worse by Nursing staff spoke heatedly about their struggles to survive negative media stories and political leaders’ vocal criticism of on low pay and support their dependents, see their children health workers, which fuelled public distrust, damaged the through education, pay for a roof over their heads, settle standing of the profession, added to health workers’ distress essential bills, afford transport to work and save towards and raised the barriers to access to healthcare. the costs of further training. Financial worries added to the stresses caused by impoverished workplaces. Doctors felt The view of civil society organisations and of some managers was socially embarrassed when they could not contribute large that frontline health workers are not empowered to speak up. sums of money at functions held to raise funds for weddings or The concept of ‘voice’ was unfamiliar to many frontline health funerals, or meet expectations to help with school fees. It was workers in the research, and the idea that they might speak out said that patients look down on nurses when they know how and gain support to improve poor working conditions and quality little they are paid. Participants voiced strong opinions that of care was new to them. The research identified barriers to the pay was unfair and undervalued health workers. Nurses individual health workers voicing their concerns, and health complained that their salaries did not reflect the years of study workers’ preferences for advocacy by representative organisations.
1. US dollar = 1,856 Ugandan Shillings at 31 March 2010 9 Our Side of the Story: The lived experience and opinions of Ugandan health workers
The findings identified two priorities for action: Recruitment blockages 1. to value health workers for their contributions to the health • Manage health worker recruitment and deployment of Ugandans centrally, to address the problem of unfilled posts and 2. to expose the poor working conditions that prevent health uneven distribution of health workers. workers from providing good quality healthcare. Decent staff accommodation Four enabling strategies emerged from health workers’ • The Government should follow through on its strategy to accounts and stakeholder advice: provide decent and safe accommodation for health workers 1. to improve the quality and relevance of training at health facilities, especially in remote areas. Civil society 2. to raise the voices of health workers through representation organisations should continue to monitor implementation 3. to change public perceptions through the media of this strategy and press for concrete targets. 4. to build bridges with patient communities. Facility infrastructure • Ensure regular meetings between management and Priorities department heads, at which facility-related problems 1. Value health workers for their contributions can be raised and decisions taken on actions needed. • Invest in good theatre facilities and their staffing in a small to the health of Ugandans number of level IV health centres, and showcase them as good practice before embarking on further investment. Health worker terms and conditions of service • Review salary scales to determine whether increases in Equipment, medical and medicine supplies basic salaries are possible. Reform government salary • Give much more attention to the maintenance and quick scales to recognise first and postgraduate degrees, in order repair of medical equipment, including systems for monitoring to attract degree nurses to public sector jobs and ensure equipment maintenance and adequate stocks of spare parts. their education is used to support patient care directly. • Hold regular formal consultations with frontline workers • Consider the establishment of a minimum wage and to enable them to participate in decision-making about the feasibility of imposing the same salary structure equipment and supplies, and to improve transparency in all sectors (government, not-for-profit and private). in equipment procurement processes. • Encourage international donors to provide large items Overtime and responsibility payments of equipment directly. • Explore a system for remunerating health workers for overtime. • Consider implementing a responsibility allowance paid when a nurse has sole charge of a ward. Enabling strategies 1. Improve the quality and relevance Small financial motivations • Incentivise staff through small items of personal support, such of health worker training as food for the household, snacks at work, and Christmas and Easter gifts. Contributions towards family burials, medical Career guidance and early contact operations and provision of cloth for uniforms are well received. • Ensure well-motivated trainees, for example through • Review current allowances for risk, hardship, housing, more talks at schools and work experience placements. transport, responsibility and study, to ensure consistency and fairness across all facilities. Training schools’ admission procedures • Use the income from local government hospitals’ private • Reject applicants who seem to be applying for the “wrong wings to benefit staff, by supplementing salaries or allowances. reasons”, including those allocated to a university course which is not their first or second choice. 2. Ensure working conditions enable health workers to provide good-quality healthcare Developing and sustaining “the right heart” in training schools • Return oversight of training to the Ministry of Health from Health worker/patient ratios the Ministry of Education and Sports. • Introduce standards for patient/nurse and patient/doctor • Reduce nursing and midwifery class-sizes and improve ratios, so that health worker overload is transparent and tutor capacity, to ensure the right attitudes and practical quantifiable, and managers have information to help reduce understanding of the ethical code are encouraged pressure on overloaded staff. throughout pre-qualification training.
10 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Health and human rights training 3. Change public perceptions by influencing the media • Expand existing partnerships between training institutions and health consumer advocacy organisations. Improve • Inform journalists about the obstacles to health worker nursing course content to make sure that students take recruitment and discourage them from writing sensationalist on board the role of the nurse as a patient’s advocate. or negative stories in the media. Put complaints on local language radio call-in shows into a wider context. Encourage De-urbanise health worker training the running of positive human interest features, such as • Increase the number of training schools and residency profiles of individual health workers and the work they do. programmes in rural areas to produce staff already adapted Work with the Uganda Health Communication Alliance. to rural environments and connected to the local community. • Improve the capacity of civil society and health worker • Improve the community service element in medical curricula organisations to write press releases, hold press conferences and increase the exposure of urban health students to rural and build relationships with individual reporters and media settings with increased fieldwork. houses, so the key campaign messages hit home.
Nurses and Midwives Council registration interviews 4. Build bridges between patient communities, • The Nurses and Midwives Council should weigh up the healthcare facilities and staff advantages of screening interviews held as a prerequisite for registration post-qualification against detrimental Transparency on drug availability effects on nurse morale. • Use well-managed public opening of medicine deliveries to help convince communities that medicines are not in stock, 2. Raise the voices of health workers and to counter accusations of theft. Call on local notables, police or patients to witness the opening of boxes. Support Sharing of experience and common approaches with paperwork to show what has been ordered and delivered. • Encourage staff to meet with people from other healthcare • Ensure that local leaders are fully informed through regular facilities to discuss solutions to common problems and meetings about the demand for and supply of drugs and that communicate them to sub-district level managers. These they use this information responsibly. managers could also be encouraged to instigate similar forums. Connecting communities and facilities Speaking through professional associations, unions and • Use opportunities to talk with people on their own ground regulatory councils and explain the problems health workers face, for instance • Channel health worker concerns to the Ministry of Health, through Village Health Teams, facility-based health workers Government or Parliament through bodies that speak for providing outreach immunisation services, and talks to them, such as professional organisations and trade unions. women awaiting prenatal checks. • Professional associations and unions should do more to bring • Promote ‘community dialogue’ meetings bringing together members together, for instance at local general meetings, service users, local leaders and health unit management and make greater efforts to visit facilities and talk with health teams. Increase funds to cover these activities. workers so that the “right voices” can be taken to the top. • Invite top local politicians to spend time in facilities alongside They should compile strong collective arguments to improve staff to see what the work is really like. conditions in the workplace, as well as addressing individual • Civil society organisations should continue their work to grievances and traditional welfare issues. create common cause between health workers and patients. • The Health Workforce Advocacy Forum – Uganda (a coalition of health professional associations, unions and health rights organisations) should expand its membership and continue its campaign for a positive practice environment for health workers.
11 1. Introduction
1.1 The VSO Valuing Health 1.2 The Valuing Health Workers Workers initiative research in Uganda
What is life like working in healthcare in In Uganda negative images of health workers are a low-income country? What prompts projected in the media, political speeches, policy nurses, midwives and doctors to take documents, healthcare user research and health consumer advocacy work. The overriding message up their professions and what are the is that health workers’ attitudes, behaviour and rewards? What do health workers say practices present barriers to accessing healthcare. about the barriers they face in providing The Valuing Health Workers research in Uganda set out to explore with frontline health workers access to healthcare? What in their view and their managers the conditions underlying needs to change? And how can their voices accusations of unethical behaviour and service be heard? VSO’s Valuing Health Workers inadequacies. The overall objective was to give opinion formers and healthcare service users initiative is listening to the experiences of a realistic picture of what life is like as a health health workers and gathering evidence to worker in Uganda, so as to increase understanding advocate for change. and modify expectations. Ugandan civil society organisations will use the findings to help build mutual understanding and promote harmonious The lived experience and opinions of health workers relationships between healthcare users and are rarely recorded in the many explorations of workers, as well as to advocate for improved solutions to the health worker crisis affecting the conditions for health workers in Uganda. developing world. Health workers are commonly seen as ‘human resources’, as a part of a healthcare It has been well-documented through research delivery mechanism to which ‘levers’ may be applied, and health rights projects that healthcare and not as human beings whose individual actions are users in Uganda experience from health workers influenced by the societies and conditions in which bad attitudes, rudeness, inhumane treatment, they live and work. Rather, performance management neglect, discrimination and extortion of illegal techniques and incentives to attract and retain staff fees for services. They also face staff absences dominate research and policy. and the unavailability of medicines and other treatment supplies.2 Research has reported VSO International set out to redress this imbalance patient community perceptions that drugs are through its Valuing Health Workers research and stolen.3 The press and radio media have fuelled advocacy initiative. Recognising that health workers’ negative perceptions of health workers’ behaviour, voices must be heard and acted on to improve access branding them as shirkers and thieves.4 Indeed, to healthcare, and so help to achieve the Millennium the media have reported leaders in government Development Goals, VSO International started accusing health workers of stealing medicines. participatory research in four countries in Africa and Asia, in partnership with in-country non-governmental organisations. VSO will support local partners to use the research findings to advocate for health workers in their countries, and will gather the research evidence to advocate on a global level.
2. See Kiwanuka et al 2008 for a systematic research review 3. Kiguli et al 2009 4. Medicines and Health Service Delivery Monitoring Unit 2010 lists 43 press articles in under one year, almost all reporting negatively on health worker behaviour Our Side of the Story: The lived experience and opinions of Ugandan health workers
Even Ugandan health policy documents have commented The starting assumption of the Valuing Health Workers research negatively on health workers’ low productivity, high absence in Uganda was that health workers are unfairly blamed for rates, poor attitudes and lack of accountability to client attitudes and behaviour caused by the system in which they work. communities. Organisations promoting health rights have seen Health workers are human beings – men and women with their distrust and hostility among communities and some defensive own worries, working in very challenging circumstances – and reactions among health facility staff. they develop ways of coping with difficulties, frustrations and being under-valued. The research does not condone unethical Health workers in Uganda face harsh working conditions. or unprofessional behaviour and dereliction of duty, but it does The Ugandan Ministry of Health acknowledges staff shortages, not brand as ‘quiet corruption’ absences from the workplace inadequate pay, poor worksites, risk and insecurity in the and external income-generating activities.14 Such ‘moralising workplace, limited and poor-quality staff accommodation, finger-wagging’15, which addresses issues in terms of lack of and harassment; it also recognises that staff endure poor motivation, corruption and betrayal of professional codes of supervision and leadership and a lack of promotion, training conduct, diverts attention from structural conditions and social opportunities and career progression.5 Facilities and equipment and cultural environments.16 in states of disrepair, and shortages and wastage of medicines, have been pervasive problems.6 The research set out to challenge the overwhelmingly negative commentary on Ugandan health workers. It wanted to hear the Yet little attention has been paid to the impacts of working positive side from health workers themselves: their passion for conditions on the lives of healthcare staff, and so on the quality their professions, commitment to patients and communities, of services they can provide. Research on or with Ugandan determination to give their best and the satisfaction gained health workers has focussed on workforce retention questions, from contributing what they can. such as migration, intent to migrate and turnover.7 It has measured job satisfaction and quantified work factors related to The research was especially concerned to find ways of intent to stay or leave.8 A second area of research has measured bridging the seemingly widening gap between communities health workers’ informal income generation practices, such as and healthcare facility staff. Projects on the ground in Uganda spending working hours engaged in agriculture and operating have tended to focus on promoting the rights of healthcare private clinics, and has quantified absenteeism.9 10 Certainly, users and increasing the community role in monitoring health some research reports include the voiced experiences of health workers.17 While less attention has been given to the health workers.11 But only exceptionally has research started from the worker side, community-based projects have latterly fostered viewpoint of health staff as workers and members of families mutually respectful relationships.18 Research in Uganda and five and communities, as opposed to the viewpoint of the system.12 other African countries recommended improved understanding Only one study has focussed on the distress and emotional toll of of the roles of health workers and encouragement of mutual working with insufficient resources for acceptable levels of care.13 respect through better communication and interaction.19
5. Ministry of Health 2006 6. Ministry of Health 2010a; 2010b 7. Awases et al 2004; Dambisya 2004; Nguyen et al 2008; Onzubo 2007; O’Neil and Paydos 2008 8. Ministry of Health 2009a; Hagopian et al 2009 9. McPake et al 1999; McPake et al 2000 10. Chaudhury et al 2006; UNHCO 2010 11. Ministry of Health 2009a; UNFPA Uganda Country Office 2009 12. Kyaddondo and Whyte 2003 13. Harrowing and Mill 2010; Harrowing 2011 14. World Bank 2010 15. Van Lerberghe et al 2000 p3 16. Schwalbach et al 2000 17. Björkman and Svensson 2007 18. Muhinda et al 2008 19. Awases et al 2004 13 Our Side of the Story: The lived experience and opinions of Ugandan health workers
1.3 The research approach 1.4 Structure of the report and participants Chapter 2 introduces the main challenges to healthcare provision in Uganda, outlines healthcare provision and VSO carried out the research in Uganda from February 2010 to patterns of use, and describes the health workforce. February 2011 in partnership with HEPS-Uganda, the Coalition for Health Promotion and Social Development. The research approach is described in Chapter 3, along with an overview of the participants (with further details in Appendix A). Using qualitative research methods, the researchers encouraged health workers to speak freely in response to open Chapter 4 presents what participants said about the rewards questions, promising that identities would not be revealed. of being a health worker. Chapter 5 looks at why they became In all, 122 health workers – medical doctors, clinical officers, health workers. nurses, midwives and nursing assistants (including frontline workers, facility managers and local government district health The chapters that follow address elements of the main themes officers) – participated in small group discussions and individual that emerged from the participatory research – the impacts interviews at their workplaces. The facility-based participants of workload (Chapter 6); the infrastructure of the healthcare were working at 18 hospitals and health centres in seven local facilities (Chapter 7); the availability of medical equipment and government districts in all regions of Uganda and in the capital supplies (Chapter 8); supplies of medicines (Chapter 9); and city, Kampala. The selection of facilities took account of region, levels of remuneration (Chapter 10). the extent to which the district was easy or hard to serve, the level of hospital and health centre, location (urban or rural) and Each element is followed by the relevant recommendations ownership (government, not-for-profit or private sector). Many for change drawn from health workers’ and stakeholders’ participants drew on their prior experiences from training or contributions. Chapter 11 lists all recommendations under working in different sectors and levels of healthcare facility. potential strategies for change.
In addition, 24 stakeholders from civil society organisations, trades unions, professional associations and regulatory councils contributed their perspectives on the issues facing health workers in Uganda, through workshops and individual interviews.
14 Our Side of the Story: The lived experience and opinions of Ugandan health workers
2. Healthcare in Uganda: challenges and provision
Summary The Government runs 60% of the hospitals and health centres. Not-for-profit organisations, mostly faith-based, run just under A major challenge for the Ugandan healthcare system is the 20%. Private for-profit organisations run just over 20% of the rapidly growing population, with the third-highest growth rate officially-classified healthcare facilities, mainly in urban areas. in the world and a strikingly high birth rate (especially among There are also innumerable unrecognised small private units. teenage women) and a very young profile. A further challenge is serving the exceptionally high proportion of the population Fewer than four in ten Ugandans turn to health centres or residing in rural areas, who have extremely poor access to hospitals when they fall sick. The rural population uses health electricity and low access to improved water supplies. Although centres more than urban dwellers, while the urban population declining somewhat, maternal, infant and under-five death uses hospitals more than people in rural areas. The poorer you rates are still not under control. Malaria is the main sickness are in Uganda, the more likely you are to go to a government and a major cause of childhood deaths. health centre. Children and pregnant women are the largest groups of health facility patients. Over one in four Ugandans Uganda has only one doctor per 10,000 people, and only lives more than five kilometres from their nearest health facility. 14 health workers (doctors, nurses and midwives) per 10,000 Nine in 10 walk or cycle to their government health centre. people. This is significantly below the level of 23 health workers per 10,000 people recommended by the World Health The available data on the make-up of the Ugandan health Organisation (WHO). Only four other countries have poorer workforce shows extreme shortfalls of the most highly qualified provision of hospital beds. Only 16 countries worldwide spend occupational groups, and mal-distribution across the country. smaller proportions of their Gross Domestic Product on health Although the aim is to phase nursing assistants out, Uganda than Uganda. Although the Government of Uganda is committed has relied heavily on them , especially in rural areas. Medical under the Ajuba declaration to apportion 15% of its budget to doctors and the most highly qualified midwives and nurses health, its expenditure on health has never exceeded 10% of are concentrated in urban areas, especially in and around total public expenditure. the capital city. An estimated four in 10 of the facility-based workforce are in the government sector, 30% in the not-for- Most healthcare in the formal system is delivered at health profit and 30% in the private sector. Medical doctors are centres and at hospitals at national, regional and district levels. concentrated in the private sector although there are high rates One in five local government districts had no hospital when of dual employment, with medical doctors working in both an official inventory of the (then) 80 districts was drawn up in private and government sectors. Half the medical doctors and 2010. Each sub-district should have a health centre IV, headed four in ten nurses employed in government facilities work in by a medical doctor and providing emergency surgery: five of the regional and national referral hospitals. the 80 districts in the inventory had no health centre IV at all and a further 23 had one only. The situation is likely to have worsened with the continuing creation of districts, to total 112 in mid-2010. One in four facilities is classified as a health centre III and should provide maternity, in-patient and laboratory services. Two-thirds of health facilities are classed as health centre II, intended for preventive services and outpatient curative care; three in 10 of those are in the capital city.
15 Our Side of the Story: The lived experience and opinions of Ugandan health workers
2.1 Ugandan healthcare challenges Population growth and birth rates Uganda is one of the 48 least-developed countries of the world.20 Uganda’s rate of population growth (3.2 %) is the third-highest It stands at 143 out of the 169 countries in the United Nations in the world. It is a very young population with an average age Human Development Index, and is classed as a low human of 15.6 years, the second-lowest in the world. The average development country. The United Nations Development woman will give birth to 5.9 children if she lives to the age Programme (UNDP) publishes statistics for the indicators of 50; only three countries have a higher fertility rate than used in the Human Development Index.21 These allow Uganda. The birth rate among women aged 15 to 19 is also comparisons between Uganda and other least-developed striking: 150 per 1000 women, which is considerably higher countries, Sub-Saharan Africa and the world overall.22 than in Sub-Saharan Africa overall and is surpassed in only two countries in the world. The contraceptive prevalence rate (23.6%) is on a par with that of Sub-Saharan Africa.
Infant, under-five and maternal mortality Table 1 In Uganda, 85 of every thousand babies born alive are likely Estimated population 201023 to die before their first birthday (the infant mortality rate) and 135 of every thousand are likely to die before they are five (the Total population: 30.7 million under-five mortality rate). These rates are somewhat higher than for least-developed countries overall and somewhat lower Aged 0-14 years 50.8% than for Sub-Saharan Africa, yet they are close to twice global rates. Maternal deaths (the death of women while pregnant or Aged 14-64 years 46.1% within 42 days of the end of pregnancy) are estimated by UNDP Aged 65+ years 3.1% to be 550 for every 100,000 live births, a considerably better ratio than across Sub-Saharan Africa, but twice the global ratio.24 At 54.1 years, life expectancy stands above that of Sub-Saharan Africa but falls far short of the 69.3 years in the world overall. Table 2 Population growth and mortality indicators in international context25
Sub-Saharan Least-Developed Uganda World Africa Countries Average annual population growth (2010-15) (%) 3.2 2.4 2.2 1.1 Median age (2010) 15.6 18.6 19.9 29.1 Total fertility rate (2010-15) 5.9 3.6 4.1 2.3 Number of births per 1000 women age 15-19 150.0 122.3 104.5 53.7 Contraceptive prevalence rate, any method 23.7 23.6 29.5 - (% of married women ages 15-49) Infant mortality per 1000 live births (2008) 85 86 82 44 Under-five mortality per 1000 live births (2008) 135 144 126 63 Maternal mortality ratio per 100,000 live births 550 881 786 273 Life expectancy at birth (2010) 54.1 52.7 57.7 69.3
20. Countries with less than 75 million population, gross national income per capita of under $905, high economic vulnerability and combined poor indicators of under-five mortality, undernourishment, secondary school enrolment and adult literacy. 21. United Nations Human Development Programme 2010, Statistical Annex 22. As the UNDP has to make sure its data are from comparable time periods, the statistics in the 2010 Report are not necessarily the most up-to-date. The UNDP and national estimates sometimes differ. 23. Baryahirwa 2010 24. According to data collected in the Uganda Demographic Health Surveys, the maternal mortality ratio declined to 435 in 2005-06 from 505 in 2000-01, but the change is not statistically significant (Ministry of Finance, Planning and Economic Development 2010). 25. United Nations Human Development Programme 2010, Statistical Annex
16 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Rural population, access to electricity Table 3 and to improved water Availability of formal healthcare Only 13.3% of Uganda’s population lives in an urban area; only one country has a lower proportion of urban dwellers. Medical doctor per 10,000 people* 1 This is in striking contrast to Sub-Saharan Africa (37%), least-developed countries (29.1%) and the world overall Doctors, nurses and midwives per 10,000** 14 (50.5%). Globally, Uganda has the highest proportion of inhabitants with no access to electricity, 91.1%. A third of Hospital beds per 10,000 people* 4 its population has no access to improved water; 25 countries have worse access than Uganda. Over half of the population Antenatal coverage of at least one visit (%)* 94 (52%) has no access to improved sanitation, a better rate than most low human development countries. Births attended by skilled health personnel (%)* 42
Availability of formal healthcare *UNDP 2010; **WHO 2010 Uganda has one doctor for every 10,000 people. With only 14 doctors, nurses and midwives for every 10,000 people Uganda is one of 44 low-income countries that do not meet the WHO minimum threshold of 23 doctors, nurses and Disease in Uganda midwives per 10,000 population necessary to deliver essential maternal and child health services.26 Sickness is normal rather than exceptional. Over 4 in 10 household members surveyed (43%) said they had fallen sick Uganda has four hospital beds per 10,000 people; in only four in the previous 30 days; malaria or fever is by far the most other countries is the ratio lower. The proportion of women prevalent illness, reported by over half, followed by respiratory making at least one antenatal visit is high, at 94%, but the illnesses which affected 15%.28 Seventy per cent of child deaths proportion of births attended by skilled health personnel drops are due to disease or malnutrition, with malaria accounting for to 42%. The Uganda Millennium Development Goals report one third of these deaths.29 for 2010 gives the following information.27 An expectant mother’s first antenatal visit is late in the pregnancy, a median HIV prevalence fell to 7% in 2007-08 from 27% in 2000-01.30 of 5.5 months. Among the poorest fifth of the population, the Yet the number of people living with HIV in 2010, around share of births attended by skilled health personnel was 1.2 million, was higher than at the peak of the epidemic in 29% in 2005-06 compared to 77% among the wealthiest fifth. the 1990s.31 The WHO ranked Uganda 16th of the 22 countries There are also large urban-rural inequalities: 80% of deliveries with a high tuberculosis burden in 2010. Uganda has the in urban areas were attended by a doctor, nurse or midwife second highest accident burden.32 but only 37% in rural areas.
26. World Health Organisation 2010 27. Ministry of Finance, Planning and Economic Development 2010 28. Baryahirwa 2010 29. Ministry of Health 2010a 30. Ibid. 31. Ministry of Finance, Planning and Economic Development 2010 32. Ministry of Health 2010b
17 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Public expenditure on health Table 4 33 Uganda’s public expenditure on health stands at 1.6% of Ugandan public expenditure Gross National Product (GDP) (in 2008). Only 16 countries spend smaller proportions of GDP on health than Uganda. Education (% of GDP) 3.8% At 2.3% of GDP, Ugandan military expenditure is almost 50% more than its health expenditure; only 10 other low Military (% of GDP) 2.3% human development countries devote higher proportions of GDP to military than to health. Health (% of GDP) 1.6%
Government of Uganda health expenditure as a percentage Debt service (% of GDP) 0.5% of total government expenditure in 2009-10 was estimated at 9.6%. The proportion is 2.1 points above that of 2000-01 Expenditure on health per capita (PPP$) 74 and just under that of the peak year of 2004-05, and continues to stand well below the Ajuba target34 and the Government’s own target of 15% by 2014-15. From Table 5 it may be deduced that the Government funded almost 60% of health expenditure in 2009-10, while donor projects accounted for 40%. It should be noted that several development partners channel development assistance through off-budget support: government estimates indicate that 77% of health project support in 2009-10 was off-budget.35
Table 5 Health financing and expenditure 2000-01 to 2009-1036 (in billion Uganda shillings)
Donor Projects Government health Government of Year and Global Total expenditure as % of total Uganda funding Health Initiatives government expenditure
2000/01 124.23 114.77 239.00 7.5 2001/02 169.79 144.07 313.86 8.9 2002/03 195.96 141.96 337.92 9.4 2003/04 207.80 175.27 383.07 9.6 2004/05 219.56 146.74 366.30 9.7 2005/06 229.86 268.38 498.24 8.9 2006/07 242.63 139.23 381.86 9.3 2007/08 277.36 141.12 418.48 9.0 2008/09 375.46 253.00 628.46 8.3 2009/10* 435.80 301.80 737.60 9.6
*Provisional Budget outturn 2009-10
33. United Nations Human Development Programme 2010, Statistical Annex 34. In 2001, African Heads of State made a commitment to allocate 15% of their annual domestic budgets to health during the special summit on AIDS, TB and Malaria held in Abuja, Nigeria. The Abuja commitment was to exclude donor support. 35. Ministry of Health 2010b table 2.2 36. Ministry of Health 2010b table 2.3 18 Our Side of the Story: The lived experience and opinions of Ugandan health workers
2.2 Formal healthcare provision The health facility hierarchy: health centres and hospitals In Ugandan policy, the healthcare system comprises services accessed at health units (hospitals, health centres, clinics and Health centres and hospitals are structured in tiers in line with ‘drug shops’ selling medicines) and community services which the local government structure (see Appendix B). The original range from home-based care (typically provided by organisations lowest level of health centre (health centre I), equivalent to funded through overseas aid) to traditional and complementary an aid post, has been phased out. Now the Ministry of Health medicine practitioners. Approximately 60% of Uganda’s is promoting Village Health Teams. Unpaid local people are population seeks care from traditional and complementary trained to increase health awareness, as well as to treat minor medicine practitioners (herbalists, bone-setters, birth attendants, illnesses, and are expected to link communities with health hydro-therapists, spiritualists and dentists) before and after centres. In late November 2009, teams had been established visiting the formal sector.37 It is reported that birth attendants in three-quarters of districts, but only a third of districts had constitute 12.3% of traditional healers and have organised a trained teams in all villages.43 registered association with about 60,000 members.38 The size of population served and the services that should Within the formal system, healthcare is provided primarily be offered by health centres increase from the bottom in hospitals and health centres run by the government, level upwards. A health centre II should provide preventive, not-for-profit organisations and private profit-making promotive and outpatient curative health services. The organisations. Not-for-profit providers, three-quarters of which Ministry of Health’s inventory shows over a quarter of health are under the umbrellas of the Protestant, Catholic, Muslim and centre II facilities located in the capital, Kampala, with 98.5% Orthodox Medical Bureaux, are well integrated into the public of those in private hands. Some 95% of private health centre IIs health system. The government oversees not-for-profit facilities were found in four districts, including Kampala. A health centre within its devolved district management system and subsidises III should provide maternity, in-patient and laboratory services, them at around 16% in 2008-09, down from 22% in 2007-08.39 in addition to health centre II-type services. The expansion of private health providers has been described by the Ministry of Health itself as “largely unregulated and A health centre IV should provide emergency surgery and blood chaotic”.40 There are innumerable unregistered private sector transfusion in addition to the types of services a health centre units, including drug shops. A count in 2005 in three districts III should offer, and should be headed by a medical doctor. In found government and not-for-profit units together made up as 2009-10, less than 25% of the 119 health centre IVs reporting little as 4% of all health units.41 to the Ministry of Health provided at least 10 of 12 key services expected of a health centre IV, and only 57% of those had a The Ministry of Health’s recent inventory of facilities, drawn up medical officer.44 Five of the 80 districts in the inventory had in 2010, lists 4,441 facilities officially registered as a hospital or no health centre IV at all and a further 23 had one only. health centre.42 Table 6 shows 60% in the government sector, 18% in the not-for-profit sector and 22% in the private sector.
Table 6 Health facilities by level and ownership
Hospital Health Centre IV Health Centre III Health Centre II Total No. % No. % No. % No. % No. % Government 65 49.6 165 92.7 847 76.0 1572 52.1 2649 59.7 Not-for-profit 57 43.5 12 6.7 241 21.7 486 16.1 796 17.9 Private 9 6.9 1 0.6 26 2.3 960 31.8 996 22.4 Total 131 100 178 100 1114 100 3018 100 4441 100
37. Ministry of Health 2010b 38. Nabudere et al 2010 39. Republic of Uganda 2010 40. Ministry of Health 2009c p3 41. Konde-Lule et al 2007 42. Retrieved at www.unfpa.org/sowmy/resources/en/library.htm Includes 134 facilities under construction or otherwise not functioning 43. Ministry of Health 2010b 44. Ministry of Health 2010b Table 5.3 19 Our Side of the Story: The lived experience and opinions of Ugandan health workers
The next tier up is the general hospital at district level, to which Patterns of use of health facilities a health centre IV should refer patients it cannot serve. The Ministry of Health’s inventory shows that 15 out of 80 districts The vast majority of Ugandans, 93%, seek treatment for had no hospital. The problem of providing a district-level sickness.51 Ugandans turn to private clinics and drug shops for hospital has become more acute since the number of districts walk-in healthcare and medication, and favour health centres reached 112 in mid-2010. A general hospital is expected to and hospitals for more serious conditions and in-patient care.52 refer patients to the nearest of the 13 government-sector Well over half (58%) go to drug shops and private clinics, 28% regional referral hospitals for services not available at general to health centres and nine% to hospitals; considerably higher hospitals. Current policy does not allow not-for-profit or proportions of rural than urban dwellers use health centres, private hospitals to be designated as regional referral hospitals, while higher proportions of urban dwellers use hospitals.53 although in practice some not-for-profit general hospitals fulfil that role. The main national referral hospital stands at the top of The poorer you are in Uganda, the more likely you are to go to the pyramid and provides specialist services.45 Patients may, and a government health centre. Almost half of the poorest tenth often do, by-pass lower levels and go direct a referral hospital. of the population use a government health centre, compared with only 12% of the richest tenth. Moreover, the poorest The central government oversees the semi-autonomous tenth almost doubled their use over a five-year period, while national and regional referral hospitals. Since decentralisation the richest 10% increased use only marginally.54 In 2010, over in 2006, district health offices oversee general hospitals and one in four Ugandans (28%) lived more than five kilometres health centres. Health sub-districts are expected to plan, from the nearest health facility.55 The government has invested conduct in-service training, coordinate service delivery and in improving physical access to healthcare by building more supervise their lower-level health units. They are normally health units. By 2009-10 the average distance to a government headed by a medical doctor at a general hospital or an health centre was 4.6 kilometres, which the majority of people upgraded health centre IV. walk (75%) or cycle (14%).56
All local government health centres and hospitals must have Children and pregnant women are the largest groups of health a Health Unit Management Committee (HUMC) which should facility patients: 38% are children aged 0-14, with the majority oversee the running of the facility. Committee members (97%) seeking immunisation services; and 38% are women can be selected by the District Council, locally elected or seeking antenatal and delivery care services.57 The proportion appointed because they hold other positions. They have of deliveries in government and not-for-profit facilities in been recommended as vehicles for community participation, 2009-10 was 33%.58 In contrast, traditional birth attendants but have been reported as not functioning as expected.46 47 assisted 23% of deliveries, and relatives or other unskilled HUMCs had a chequered reputation in the past, believed to helpers 25% in 2005-06.59 be implicated in disappearance of medicines and distrusted by local communities.48 They rarely met after the abolition of user fees in government facilities.49 The Ministry of Health, with support from the USAID-supported Capacity Programme, has embarked on a training programme for HUMC members in both government and not-for-profit facilities.50
45. The other national referral hospital is a psychiatric hospital. 46. Kapiriri et al 2003 47. Rutebemberawa et al 2009 48. Azfar et al n.d 49. Burnham et al 2004 50. Kidder 2010 51. Uganda Bureau of Statistics 2008 52. Konde-Lule et al 2007 53. Baryahirwa 2010 54. Ministry of Finance, Planning and Economic Development 2010 55. Ministry of Health 2010b 56. Baguma 2010 57. Uganda Bureau of Statistics 2008 58. Republic of Uganda 2010 59. Uganda Bureau of Statistics 2006
20 Our Side of the Story: The lived experience and opinions of Ugandan health workers
2.3 The Ugandan health workforce Occupations: numbers and density There are no available up-to-date data on the constitution of This chapter focuses on the main occupational groups (Box 1). the Ugandan health workforce. The prime source is the 2002 Population and Housing Census.60 The census recorded people who had worked paid or unpaid in a health occupation in the previous seven days. Most commentary relies on the census data.61 In addition, WHO has produced estimates for 2004 and 2005.62 These cover people working full-time in paid activities in organisations whose primary intent is to improve health, as well as those whose personal actions are primarily intended to improve health but who work for other types of organisation.
Box 1 The medical doctor hierarchy includes intern (junior house officer), medical officer, medical officer special grade (specialist with a few years’ experience), consultant (specialist with at least five years’ post-specialisation experience) and senior consultant (consultant with many years experience). Appointment as consultant and senior consultant depends on the availability of posts.63 The clinical officer is a distinct cadre in Uganda, termed medical assistant prior to 1996. Clinical officers undergo three years’ training in specialist schools. Their clinical work has expanded from diagnosis and treatment, including prescribing, in primary healthcare to cover outpatient treatment and admission in district and regional hospitals. At the better-equipped health centres and at district hospitals, they carry out minor surgical procedures. When a health centre IV lacks a medical doctor, the clinical officer provides both outpatient and inpatient services, except for major surgery. Clinical officers are often responsible for administration as the person ‘in charge’ of a health centre.64 65
Nurses and midwives fall into three groups within the Ugandan health system: registered nurses, registered midwives or those doubly registered as nurse and midwife (that is, with a diploma or degree in nursing); enrolled nurses, enrolled midwives or those enrolled as both (that is, having completed a certificate programme); and comprehensive nurses, either registered or enrolled. The registered comprehensive nurse and the enrolled comprehensive nurse training programmes, started in 1994 and 2003 respectively, were intended to create a multi-purpose nurse with competencies in general nursing, midwifery, public health, psychiatry, paediatrics and management, and able to provide basic health services in primary healthcare. Enrolled comprehensive nurse training programmes have replaced the traditional enrolled nursing and enrolled midwifery training programmes in all government-owned health training institutions, and have been introduced into many not-for-profit training institutes. The future of comprehensive nurse training is under review.66 Nursing aides, who have no formal training, have over time upgraded into nursing assistants through short formal courses, though the workforce still contains significant numbers of untrained nursing aides. The initial strategy was to train nursing aides as a temporary solution until more qualified staff were trained and made available.67 The current policy is to gradually phase out the nursing assistant/aide position and ban recruitment and formal training, though new training institutions have continued to emerge.68 Regulation of nursing assistants has been difficult, as the Nurses and Midwifery Council does not recognise the cadre.69
60. Uganda Bureau of Statistics 2002 61. Eg Ministry of Health 2006; Uganda Ministry of Health and The Capacity Project 2008; Africa Health Workforce Observatory 2009; Ministry of Health 2010b; Nabudere et al 2010 62. World Health Organisation Global Atlas of the Health Workforce 63. East, Central, and Southern African Health Community 2010 64. Banerjee et al 2005 65. East, Central, and Southern African Health Community 2010 66. UNFPA 2010 67. Ministry of Health 2004 68. Republic of Uganda 2010 69. East, Central, and Southern African Health Community 2010
21 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Table 7 shows the proportions of these occupational groups Geographical distribution in the 2002 census. Nurses and midwives made up almost half, nursing assistants/aides over one third, and allied health Urban/rural imbalance in the distribution of health workers is professionals (including clinical officers)70 and medical doctors a key problem in the delivery of healthcare. WHO 2004 data in less than 10% each. The census found 1.2 doctors and 14.5 Table 8 show that the majority of medical doctors (61%) were nurses, midwives and nursing assistants per 10,000 people. urban-based, while the great majority of nurses, midwives and WHO data for 2005 give a similar picture of 1.2 doctors and especially medical assistants (clinical officers) were rural-based. 13.1 nursing and midwifery personnel per 10,000 of the population. While there are no comprehensive up-to-date Moreover, data from the 2002 census show that the most data, it is known that numbers have increased – as has the highly qualified professionals were concentrated in the population of Uganda. For example, it was reported in 2011 region which includes the capital, Kampala (Central region). that Uganda has 9,701 midwives; however this number It contained only 27% of the population but had 64% of the equates to only seven midwives per 1000 live births.71 nursing and midwifery professionals (degree holders and specialist registered nurses) and 71% of medical doctors.72
Table 7 Number, distribution and density of five main occupational groups (2002 Census data)
Per 10,000 Number Percentage population
Medical doctors 2,919 6.9 1.2 Allied health professionals 3,785 9.0 1.6 Nursing & midwifery occupations 20,186 48.0 8.3 Nursing aides / assistants 15,228 36.1 6.3 Total 42,118 100 19.1
Population 2002 = 24.4 million
Table 8 Urban / rural distribution of four main cadres (WHO 2004 data)
Urban Rural
Total No % No % Medical doctors 2,209 1,345 60.9 864 39.1 Medical assistants 2,472 247 10.0 2,225 90.0 Nurses 14,805 2,613 17.6 12,192 82.4 Midwives 4,164 1,047 25.1 3117 74.9 Totals 23,650 5,252 22.2 18,398 78.8
70. Under The Allied Health Professionals Act, allied health professionals comprise clinical officers (medical, anaesthetic, ophthalmic, psychiatric, orthopaedic); public health dental officers and dental technologists; laboratory technologists and technicians; dispensers; orthopaedic technicians; physiotherapists; occupational therapists; radiographers; health inspectors; health associates; and assistant field officers for entomology. 71. UNFPA 2011 72. Ministry of Health 2006 22 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Employment status and attrition It is widely held that medical doctors and nurses leave Uganda for employment in other countries, but comprehensive Official documents have complained of “rampant dualism”.73 supportive data are not available.82 The Uganda Nurses and In 2002, 30% of all medical doctors, dentists, medical specialists Midwives Council verified that 808 nurses left Uganda in and consultants were privately employed and only one quarter 2009-10, nearly half for the UK.83 The destinations of qualified of those worked full-time.74 A survey in 2005 confirmed that staff leaving six hospitals in a remote region between 1999 dual employment is common among medical doctors: 54% of and 2004 did not include work in other countries.84 Follow-up medical doctors employed in private healthcare facilities also of a cohort of graduates of one medical school found deaths, worked in the government sector.75 While the census found most presumed to be AIDS-related, “a bigger brain-drain 29% of nurses privately employed, almost all (95%) were than emigration” in the 20 years after graduation in 1984.85 employed full-time. 14% of medical doctors and of nurses and Premature death is emerging as one of the most important midwives were self-employed.76 causes of exit from the workforce in Sub-Saharan Africa, causing Uganda to lose an estimated 2% or so of its medical, nursing While there are no data on health worker unemployment, and midwifery workforce each year. Annually an estimated 26 there are indications that some nurses and midwives disappear physicians in every 1,000 and 22 nurses and midwives in every from view after qualifying. All practising health workers in the 1,000 die before the age of 60 in Uganda, among the highest country are required to register with the relevant professional rates in the 12 African countries for which data are available.86 regulatory council and obtain a licence to practise in Uganda.77 A new human resource information system supported by the The facility-based workforce United States Agency for International Development (USAID) allowed the Uganda Nurses and Midwives Council to see how Of particular interest to this research are health workers many nurses and midwives failed to register. The first published employed in facilities. The Ministry of Health has a new analysis showed that 12% of the 17,297 nurses and midwives human resource information system, but the publicly available passing final examinations from 1980 to 2004 did not register comparative data relate to 2004 and 2005. Table 9 shows with the council.78 When the period of analysis was extended that 45% of facility-based health workers were in government to cover 1970 to 2005, the proportion increased slightly to facilities (excluding district health office staff) and 23% in 13%.79 Some qualified students went into employment without not-for-profit facilities in 2004; and that in 2005, the number in registration to avoid paying the registration fees.80 The human private for-profit facilities was estimated at 12,775, representing resource information system revealed that 55% of registered a 32% share of the total 39,663 employees. It should not be midwives (4,075 midwives) did not obtain a licence to practise assumed that almost 40,000 different people worked in facilities from the Nurses and Midwives Council.81 in 2004 and 2005. The data for the for-profit sector include an estimated 3,228 people employed simultaneously in other sectors.87 It is possible that government data include personnel working also in the not-for-profit sector (it is not permitted to be employed in more than one government facility). Table 9 Facility-based staff 200488 and 200589
Health Other staff Per cent Total occupations Government (2004) 15,124 2,619 45 17,743 Not-for-profit (2004) 6,102 3,052 23 9,145 Private for-profit (2005) 12,775* 32 12,775 Total 39,663
*Non-health occupations not recorded separately; includes 3,228 employed simultaneously in other sectors
73. Ministry of Health 2009c, p6 82. Africa Health Workforce Observatory 2009 74. Ministry of Health 2006 83. Senkabirwa 2010 75. Mandelli et al 2005 84. Onzubo 2007 76. Ministry of Health 2006 85. Dambisya 2004 p601 77. Africa Health Workforce Observatory 2009 86. Dal Poz et al 2009 78. Dal Poz et al 2009 Table 5.3 87. Mandelli et al 2005 79. Spero et al 2011 88. Ministry of Health HSSP II Table 1 80. De Vries 2009 89. Mandelli et al 2005 81. Spero and McQuide 2011 23 Our Side of the Story: The lived experience and opinions of Ugandan health workers
More recent sources state that members of three faith-based than one sector, the numbers include double-counting. It is medical bureaux (Catholic, Protestant and Muslim) together in reported that “more recent tables show that there has been 2009-10 had slightly over 11,600 health workers, around 30% tremendous improvement in health worker staffing levels in of the combined government and not-for-profit workforce,90 Uganda since 2004” and that the total number of medical and that government facility staff numbers had reached 23,452 doctors in health facilities is 3,917 (presumably in government in 2009.91 Despite efforts to clean the government payroll and and not-for-profit facilities).94 update rosters, there are still problems in determining how many staff in each cadre are on the payroll and where they are In 2004, almost half the medical doctors and over four in 10 assigned.92 In 2010, ‘ghost workers’ were exposed in a number nurse employees in government facilities worked in the two of districts and notably at a national referral hospital, and national referral hospitals and the 11 regional referral hospitals, transferred staff were found to be still receiving salaries at their while the great majority of nursing assistants, clinical officers original place of work.93 and midwives worked in district level facilities (Table 11).
The most recently available data on occupational breakdown Overall, there are severe shortages of facility-based health workers across sectors are for 2004 and 2005, as shown in Table 10. As in the formal sector. Chapter 6 details the shortfalls and the health workers, especially medical doctors, have jobs in more consequent impact on health workers and access to healthcare.
Table 10 Occupational groups in government and not-for-profit facilities (August 2004)95 and private facilities (estimated 2005)96
Occupation Government Not-for-profit Private
Medical doctor 598 305 1,511 Clinical officer 1,585 436 190 Midwife 2,129 914 1,377 Nurse 4,500 1,915 3,557 Nursing assistant/aide 4,463 2,005 1,146
Table 11 Occupational groups in local government district facilities and national and regional referral hospitals, August 200497
National & regional Occupation District facilities referral hospitals Total Number % of total Number % of total Medical doctor 308 51.5 290 48.5 598 Clinical officer 1,319 83.2 266 16.8 1,585 Midwife 1,635 76.8 494 23.2 2,129 Nurse 2,542 56.5 1,958 43.5 4,500 Nursing assistant 4,165 93.3 298 6.7 4,463
90. Republic of Uganda 2010 94. Matsiko 2010 p24 91. Matsiko 2010 95. Adapted from Matsiko 2010 Table 3.1 92. Ministry of Health and The Capacity Project 2008 96. Mandelli et al 2005 Table 9 93. Medicines and Health Service Delivery Monitoring Unit 2010 97. Adapted from Matsiko 2010 Table 3.1 24 Our Side of the Story: The lived experience and opinions of Ugandan health workers
3. Research design and methods
This chapter first describes the three-stage approach to the research. Outlines of the qualitative research methodology and sampling design, data collection and data analysis follow. The chapter concludes with an overview of the health worker participants. Further details are in Appendix A.
3.1 The research stages 3.2 Qualitative research methodology The research was conducted in three main stages: consultation and the purposive sampling design with local stakeholders on the draft protocol to be submitted for ethical approval98; focus groups and individual interviews Qualitative research aims to provide an in-depth understanding with health facility staff and managers; and stakeholder of the social world of research participants through learning feedback on draft findings. about their social and material circumstances, experiences, perspectives and histories.100 Qualitative research is not based In June 2010, VSO Uganda and HEPS-Uganda held a research on statistically representative samples and so does not produce workshop with support from VSO International. Fourteen statistically significant findings. Participants are selected representatives of organisations concerned with health worker in a non-random way, according to characteristics of most issues in Uganda attended, including healthcare provider interest to the particular study. This is known as purposive organisations, professional associations, regulatory councils sampling. The criteria used to select participants are more and consumer and health worker advocacy organisations. important than the number of people taking part. Indeed, Participants explored practical challenges in gathering and qualitative research is often based on a small number of cases. disseminating the views of health workers. The workshop In reporting, qualitative research does not use numbers; any started to build an alliance of interested stakeholders to take experience or perspective has value, regardless of how often or forward the research findings. seldom it appears.
Main-stage fieldwork was carried out from late June 2010 to The research sampled facility-based health workers whose February 2011. From June to August 2010, the Valuing Health prime role is treating or caring for patients, and facility-based Workers researcher, a VSO volunteer, joined forces with a managers: nursing assistants, nurses, midwives, clinical officers second VSO volunteer who had in February 2010 begun similar and medical doctors. The study design thus excluded other research with nurses as an independent initiative. The two topic professional groups. guides were combined, and a small number of interviews and focus groups already conducted in the nursing research project In achieving the health worker sample it was first necessary were amalgamated with the Valuing Health Workers data. to ensure that all regions were included, as although not an administrative grouping, region has social and political VSO produced a report of interim findings to coincide with the importance in Uganda. The strategy was to select one local Global Health Workers Forum in Bangkok in January 2011.99 government district in each of the Central, West, South A roundtable discussion at a VSO-led side meeting at the West, North, North East and East regions, and also to include Forum followed a presentation of selected findings from the the capital city. It was felt important to include a range of Valuing Health Workers research in Uganda. Ugandan and districts in terms of how far they were deemed easy or hard other participants shared their perspectives on the issues to serve. Within each district in the sample, one hospital presented and put forward promising solutions. In January and (where one existed) and at least one health centre were to February 2011, interim findings were shared with stakeholders be selected, covering urban and rural facilities. Among the in Uganda through one-to-one meetings and a stakeholder selected facilities, the aim was for a spread of level of hospital workshop organised by HEPS-Uganda. The workshop brought and health centre, and inclusion of not-for-profit and private together 16 representatives of organisations including facilities as well as government facilities. professional associations and unions, regulatory councils and health and human rights organisations. The workshop served both to validate the findings and to elicit suggestions for coverage of additional aspects in the final report.
98. The study protocol was approved by Makerere University School of Public Health Higher Degrees, Research and Ethics Committee and by the Uganda National Council for Science and Technology. 99. VSO 2011 100. Ritchie and Lewis 2003 25 Our Side of the Story: The lived experience and opinions of Ugandan health workers
3.3 Data collection 3.4 Data analysis Seven districts in six regions and the capital city, Kampala, were Discussion groups and interviews were audio-recorded and selected, so the selected facilities were distributed across transcribed with participants’ permission. The analytical process all regions (Table A.1). The districts ranged from very hard to started with repeated readings of the transcripts to identify a serve to not hard to serve, according to the Ministry of Health thematic framework. The textual data were then structured in criteria (Table A.3). The 18 facilities in the sample comprised matrices with a row for each group or individual and a column three referral hospitals, six general hospitals, four health centre for each thematic area. Mapping and interpretation followed IVs and five health centre IIIs. Eleven were government-run, from this charting process, to define concepts, find associations five were run by not-for-profit organisations and two by private and provide explanations. As already noted, early findings were organisations (Table A.2). validated by non-governmental stakeholders through individual interviews and workshops. Permission to carry out the research was obtained from district health officers in the five districts where government facilities were included in the sample. District health offices assisted in 3.5 The health worker participants linking the researchers to district-level government facilities. Referral hospitals and not-for-profit and private sector facilities A general hospital was the most common workplace for were approached directly. participants (53 out of 122); 40 participants worked in health centres (Figure 1). Government employees numbered 75, At each facility the staff member in charge was asked to not-for-profit 36 and private sector 11. arrange for staff to meet with the researcher in small groups of peers: enrolled nurses or midwives, registered nurses or midwives, nursing assistants and those in charge of wards. In smaller facilities, mixed groups and individual interviews were necessary because of the limited numbers of available staff. Figure 1 Medical doctors, clinical officers and facility managers were interviewed individually, apart from one joint interview with Workplace of participants two managers. Sixteen small group discussions with a total of 71 participants and 46 one-to-one interviews took place at the 5 18 facilities. One health worker declined to take part because General hospital of a lack of staff to cover her absence. The five district health 20 officers were also interviewed. Referral hospital 53 Group discussions and interviews were carried out in English. Health centre IV Informed consent was gained from all participants. Participants 20 were encouraged to talk freely in response to a set of open Health centre III questions. They were assured that they and their facility 24 District health office would not be identifiable in the research reports. The topics discussed covered reasons for becoming a health worker; understanding of the professional role; rewards; challenges, their impact and coping strategies; reasons for negative attitudes towards health workers; areas for change, and ways of increasing the voice of health workers. The full topic guide is included in the Appendix. Facility managers and district health officers were asked additionally about management issues they faced, although frontline workers were not asked directly about their management. Participants also completed a short biographical proforma.
26 Our Side of the Story: The lived experience and opinions of Ugandan health workers
The largest professional group was registered nurse There was a broad spectrum of ages among participants and/or midwife, followed by enrolled nurse and/or (Figure 4). midwife and nursing assistant (Figure 2).
Figure 2 Figure 4 Participants’ professional status Age groups of participants
1 2 1 Registered nurse and/or midwife 20-29 16 6 Enrolled nurse 30-39 and/or midwife 15 41 40-49 44 Nursing assistant 24 50-59 Medical doctor 24 Clinical officer 40 60-69 30 None
Other
Eleven participants worked solely in administration: five Of the 122 participants, 38 were men. Men were in all qualified nurses, five medical doctors and one with another occupational groups except clinical officer (Figure 5). medical-related qualification. A further seven participants combined a role being in-charge of a facility with frontline care. The remainder were frontline employees, most working in nursing or midwifery roles (Figure 3). Figure 5 Sex of professional groups Figure 3
Participants’ roles 70 Male
60 63 Female Nurse 50 3 4 3 Midwife 6 40 Nursing assistant 30 11 44 Administration only 20 Medical doctor 19 26 10 14 11 1 2 1 Medical doctor in charge 5 6 0 25 0 Clinical officer in charge Nurses & Nursing Clinical Doctors Other/none midwives assistants officers Clinical officer
27 Our Side of the Story: The lived experience and opinions of Ugandan health workers
4. The Rewards
Ugandan health workers rarely get the chance to speak about the positives of being a healthcare worker – the rewards and satisfactions – and participants welcomed the opportunity the research gave them. The main areas of satisfaction were helping others, doing a good job and being valued for what they did. Positive practice environments were by no means commonplace. Some participants were so discouraged by working conditions that they struggled to find anything else good to say about being a health worker. For a few the only positives were the material benefits of a regular salary and a free house. Later chapters will show how working environments damaged chances for fulfilment and satisfaction at work.
4.1 Benefiting others in ill and goes back happy.” Seeing life enhanced was also hugely rewarding: “Making people happy makes me happy.” Participants told of feeling happy carrying out their vocation, Just seeing some improvement in a patient was cheering. helping their people, giving something back, delivering care and comfort, helping those unable to help themselves and Midwives spoke of the rewards of working for the welfare of saving lives. Very strikingly, the benefits to the community, to two people, “a live mother and a live baby” – and achieving individual patients and to families were the biggest sources of something positive with no mother or baby lost. satisfaction even in the harshest working environments. Benefiting families Benefiting the wider community “The nurse is the most important person in the family.” Health workers emphasised the rewards of sharing their Especially for nurses in rural settings or from rural families it was knowledge and skills with communities to counter harmful hugely rewarding to be able to deal with family health problems. traditional beliefs and practices, educate people about ways of Knowing how to prevent and treat illness in your immediate preventing disease and encourage take-up of health services. family, as well as how to protect yourself, was a significant Seeing more women delivering babies in health units, diseases factor encouraging a commitment to nursing which would last controlled through immunisation programmes, or reduced up to and beyond retirement: “You will be a nurse until you die.” reliance on harmful traditional remedies brought great satisfaction. Health workers were especially pleased when Nurses at some rural health centres pointed to the advantages involved in new programmes and able to see their impacts, to their family and themselves of quick access to free treatment. such as a nutrition clinic, a mental health unit or prevention The nurse could use his or her knowledge to treat a relative of mother-to-child HIV transmission. Satisfaction came from and save the costs associated with referral to a health centre or being part of a health facility that put the patients first. hospital. It was said in some facilities that staff and their family members were given free medication. Especially in rural areas, health workers were happy to use their knowledge to help informally outside working hours and around their homes. For an off-duty nurse, it was good to 4.2 Job satisfaction socialise with in-patients, hear their family problems and have the chance to give some health education. Linked to the happiness of seeing someone recover is the satisfaction of knowing your own contribution, among medical Benefiting patients doctors and clinical officers especially: “I feel happy when I give treatment to my patients and they get well, I feel so proud, I Participants highlighted the visible results of care and treatment. feel very fine” or “I can see the difference I have made, that’s They expressed their delight at the benefits to patients. Nurses very important.” Introducing new treatments and bringing about and medical doctors spoke about how happy and proud they change in a challenging environment was hugely satisfying: felt when a patient who arrived sick, even on the edge of “What others thought was so difficult, I have been able to do.” death, went home recovered: “I love it when someone comes
28 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Maternity workers spoke of their joy when they safely It was noted that expressing thanks was not the norm in some delivered a healthy baby, “when everyone is smiling”, parts of Uganda, and health workers spoke enthusiastically and the satisfaction of seeing that baby grow. about the boost a “thank you” from a patient gave them: “You feel very happy after your work when they say thank you. Having done good nursing work treating a badly-off patient who So you keep on, because you are enjoying it.” For some, the improved and was discharged gave “a kind of job satisfaction pleasure of helping was enough whether praised or not: “I feel and encourages me to care for patients a little more.” For nurses, it inside my heart.” As well as appreciation, recognition of their it was good to have done something, no matter how little, to expertise was important to nurses: “Their confidence in you help save a life. Achieving successes is not easy in Uganda and boosts your own confidence.” an occasional “victory”, such as when a sick child recovers, was something to “live for”, that “makes you do what you do”. Midwives expressed their delight when a baby was given their name. Nursing staff and medical doctors emphasised Participants spoke of the satisfaction of doing a good job when how recognised and appreciated they felt when a past patient there was enough equipment, other medical supplies and greeted and thanked them warmly or showed off “your baby”. medicines to enable proper care: “Most of what you need for Being remembered by patients was seen as a mark of trust a patient is available, so your job is not much interfered with” and a boost to the nurse’s own confidence. For some nurses, or “You cannot forget your skills”. Elsewhere health workers respect and trust on the part of patients or caregivers opened commented on the satisfaction of just being able to play up disclosure of confidences and opportunities for further help. their part and do their duty the best they could despite many shortcomings in supplies and equipment and staffing shortfalls. Some spoke of pride in working efficiently to treat patients or 4.4 Appreciative and supportive caring tenderly where they could. management and colleagues Particularly for younger participants, opportunities to learn Appreciation on the part of managers was a huge positive, through work and to experience managing different kinds of although not widely reported: “When you are recognised medical condition were highly valued. While not commonly that you are doing good work, I think that is important, it reported, opportunities to learn new skills, such as counselling, motivates”. Simply being told “thank you” was not necessarily were valued for their benefits to patients. In the few instances very satisfying in difficult working conditions. Health workers where workplace-based education programmes were in place, valued more tangible demonstrations of appreciation, such as participants spoke enthusiastically about how they shared their open internet access, Christmas and Easter presents and staff learning with other staff and developed new communication skills. parties. Rare, and especially valued, was facility sponsorship of further training with a job to return to.
4.3 Being recognised, appreciated Uniquely in the study, participants in a local government hospital and valued praised management who “appreciate us so much.” They told of certificates of appreciation, staff parties, presents, financial Community recognition contributions to costs of burials and operations, help with costs of further study, days off to recover from illness, interest in Some nurses in rural settings liked being acknowledged and staff’s work and responsiveness to problems staff identified. known in the community: “When you go out you are respected” or “You are famous.” Being a nurse meant being seen as an Health workers felt valued by good, supportive managers educated person; it was gratifying to be called a “small doctor.” who created opportunities for them to raise their concerns, Nurses sometimes felt their training set them apart from other were always willing to discuss a problem, and sought and people, conferring a certain prestige, especially when they implemented solutions. could use their knowledge to help outside their formal work. Nursing was also valued as a way to meet different types of Nurses spoke of the satisfaction of working cooperatively people, get to know many people and make friends. with other staff, having someone to consult if needed, sharing ideas and reaching solutions. Teamwork also meant helping Patients’ appreciation, trust and respect each other out, such as an off-duty nurse caring for another nurse’s sick child, and willingness to extend hours to cover for a Health workers valued being liked, appreciated, praised, nurse’s delayed arrival at work. Where working conditions were respected and trusted by patients. especially challenging, nurses valued being part of a support network where everyone understood the difficulties.
29 Our Side of the Story: The lived experience and opinions of Ugandan health workers
5. Reasons for becoming a health worker: the “right heart” and the “wrong heart”
Participants explained what prompted them to become healthcare professionals. The urge to help, prevent suffering and save lives stood out. The overriding impression from their words was of a heartfelt desire to “make a difference” as a nurse, midwife, clinical officer or medical doctor, rather than merely to earn a living. It is a mark of their professional commitment that almost all participants said they would still choose to be health worker. Participants commented on people joining health professions, notably nursing, for the “wrong” reasons. This, in their view, was one explanation for poor attitudes and unethical behaviour, and they put forward suggestions for improving the calibre of recruits. The recommendations also include views of other stakeholders.
5.1 A passion for the patients life-threatening condition. Unsympathetic handling prompted a wish to improve the quality of nursing, and the shouts of For many health workers, the strong need to give to others was women abandoned in labour evoked an urge to help. born from childhood experiences. It had been common in rural areas to see close family and members of the local community Women spoke of wanting to be a nurse from as early as primary suffer in pain and die, with no proper medical care. Participants school stage, never considering any alternative. They saw recounted how siblings and parents had died from mysterious themselves as naturally kind, a helping sort of person, with an illnesses that, they later realised, were caused by preventable urge to relieve suffering: “I just had it in me” or “I had that heart.” epidemics or treatable with modern medicine. Training as a Some women found they “developed the heart” as young adults nurse, clinician or medical doctor would bring to the community when they had to nurse a family member. Not-for-profit sector essential knowledge to help prevent illnesses, discourage harmful participants especially cited a desire “to love and serve the traditional healing practices and save lives. “They were really patients” or “to care for the needy”, spoke of coming “closer to suffering, people were dying, there were no doctors, no nurses, God” or explained they had “a call” or were “chosen by God”. nobody to give them an idea about their health. I wanted to help my people.” Others spoke of atrocities in conflict areas Health workers emphasised giving and spoke less about what and the need for medical skills to rebuild communities. they had expected to gain from their profession, though the prospect of knowledge to care for and treat one’s family and Health workers spoke warmly of positive experiences when they oneself was important, especially among lesser qualified women or family members were in hospital. The gentle and caring touch in rural areas. Nurses’ happiness when a patient recovered was and the healing words of nursing staff left a lasting impression. mentioned, as was the respect people gave to a local nurse. They wanted to be that person, to give in that caring way. They The nurse had status as a life-saver, a person of importance to saw how nurses stopped pain and wanted to stop others’ pain. call on in an emergency. Young girls who went on to be nurses Growing up, they learnt how the skills of the medical staff had had been greatly attracted by the dress and deportment of saved the life of someone close to them, or even their own nurses, admiring their smart, clean uniforms, shoes and gloves, life, and they wanted to give something in return. Some were and the way they walked, which distinguished them from other encouraged by a grateful parent who remembered midwives people. Among would-be medical doctors there was some urging that the baby become a midwife too. admiration of smart white coats and acknowledgement of the prestige attached to doctors. Not all impressions were good. Negative experiences of healthcare services lay behind a desire to raise the standard A desire for money was not a driving force, though earning in a of medicine in Uganda. Young men and women said they felt steady job was certainly a better option than “digging” in vegetable compelled to join their professions because they believed gardens and relying on uncertain harvests. In the most remote that professional neglect had contributed to the deaths of rural area, the health facility was the only source of training a parent, siblings and a newborn baby, or because they had and employment locally, and so a magnet for school-leavers. perceived the limitations of Ugandan medical expertise for a
30 Our Side of the Story: The lived experience and opinions of Ugandan health workers
For most participants, the decision to become a health 5.2 “They join for the wrong reasons” professional was positive and informed. Time spent at hospitals or health centres – as a patient, relative of a patient or just as There were widespread beliefs among nursing and midwifery a curious child allowed to sit with nurses – had shown how professionals that poor attitudes and unethical behaviour are nurses worked with patients and helped stimulate an interest. linked to people joining nursing for “the wrong reasons”. It was Empathy for patients sometimes developed when “touched” thought that more recent recruits joined because they had by their condition. no other option, because nursing was a last resort when they failed to qualify for more prestigious professions or because Having a father, mother, sister, brother or aunt in a nursing or parents pushed them into it. Pursuing pay, looking only at the medical field gave some insight into the work, through visiting job market and even as a route to leaving the country were their place of work, living in staff quarters or listening to their other presumed reasons for joining nursing. accounts of day-to-day happenings. A close relative’s positive attitude, humility or empathy for patients attracted young Older nurse managers had noted “very few nurses come with women to nursing. For many of those participants, the example a sense of vocation now”. There was a widespread view that of their relative was the main reason for entering a nursing or people enter nursing with “the wrong heart”. It was believed medical profession. With little career guidance at school, it was that as a result, unhappy, disinterested and self-serving recruits natural to do what members of the family were doing. resort to bad habits, become rude and forget their ethics and accountability to patients. There were also some comments Others felt family expectations to take up some kind of profession by managers about medical doctors’ questionable attitudes to and saw health work as more appealing than the teaching, work when they seemed to lack that “inner drive”. secretarial or business occupations suggested – even rebelling against fathers who insisted on a teaching course. Some older Yet more than one nurse and a medical doctor told how they participants spoke of encouragement from adults at school or came to love their profession only when in practice, and a family friends, such as priests and nuns, to apply for a medical story was told of how a lecturer inspired an enthusiasm for or nursing course. There were a few instances of people from nursing in a student whose sole ambition had been to train as that generation recruited to apply for nursing by agents of a doctor. Indeed, some of the loudest voices criticising motives the Ministry of Health, and also of following family wishes or for joining belonged to staff who had developed an interest in suggestions in complete ignorance of what nursing involved. their profession after they started work.
Clinical officers and medical doctors told of expectations on them as the brightest school students to enter one of the 5.3 Recommendations prestigious professions. If they excelled in science subjects, engineering and medicine were the prime alternatives. The Career guidance and early contact path towards medicine could be set in early years when top students were pushed towards sciences. There were suggestions from frontline health workers and managers on how the decision to join nursing and medicine Where faced with a choice of career direction, financial security might be better informed and professionalism thus improved. was something younger men had considered, in the context of A strenuous profession like nursing was said to need emotional many qualified professionals chasing too few jobs: “At least you preparedness, with career guidance at an early stage “to know can always find a job.” But nobody said they joined the nursing what it takes”. It was suggested that more talks at schools or medical profession purely for that reason. Among doctors, should set out to “give the real picture”. the choice of medical training against another science-based profession was in some cases influenced by the prospect of What emerged strongly from participants’ accounts was the professional advancement and mobility, self-employment and impact of contact with nurses, midwives and medical workers private practice. during formative years. It was told how staff at a boarding school regularly took pupils to visit a local hospital, and how Not all those who had decided on a career in the medical field interest in nursing grew out of voluntary employment initially entered via the course of their choice. Lacking financial backing undertaken reluctantly. Experiences such as these suggest from their families, uncertain about getting the grades or value in schools arranging contact between students and failing to gain entry, would-be medical doctors had to settle for health facilities, and work experience placements. clinical officer training or a nursing course, and aspiring clinical officers became nurses. It was sometimes hard at first to accept a substitute course, especially when other people said nursing is for “failures”.
31 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Training schools’ admission procedures Health and human rights training
There were calls for nurse training schools to apply tighter Stakeholders advocated for the integration of health and admission procedures, to make sure applicants have not been human rights training into curricula, through expansion of forced into nursing and to probe attitude, so as to screen out existing partnerships between training institutions and health those with no “heart” and the “wrong elements” that spoil the consumer advocacy organisations.102 Civil society organisations name of “genuine” nurses. Admission interviewers should “study have also advocated for health and human rights training for the psychology of the person”, investigate thoroughly and reject in-service health workers.103 applicants who seem not to be driven by the “right reasons”. There were also calls for reform of the points-based system Improve the community service element through which university applicants can be allocated to a nursing of pre-qualification training course when nursing is not their first or even second choice. Stakeholders stated that community service curricula in most Developing and sustaining “the right heart” medical professional education is not of sufficient quantity in training schools or quality to prepare students for the conditions they face in the field, and should be improved. Community-based It was generally thought that the person with the “wrong education programmes, which typically run for between four heart” cannot be reformed: “Some personalities are naturally and eight weeks in each year of training, have been found rude, she can’t change”. On the other hand, there were some to create some awareness of healthcare communities but beliefs that the “right heart” can be developed and sustained implementation concerns and strategies to improve the through training. curricula need to be addressed.104
With training now falling under the remit of the Ministry of Nurses and Midwives Council registration interviews Education and Sports, it was commented that nursing schools had become indistinguishable from other higher education Nurses and midwives had mixed opinions on the interviews institutions, and had been allowed to multiply regardless of the Nurses and Midwives Council held as a prerequisite standards, notably in the private sector. It was said that as a for registration. Some found them an unnecessary, time- consequence of too many nursing schools with ill-qualified consuming and expensive imposition, given that they had tutors, students come out lacking respect for patients and already graduated from nurse training schools and that patient’s confidentiality. Some participants added their voice attending interviews took them away from caring for patients. to calls for oversight of training to revert to the Ministry of It was explained that when nurses and midwives were not Health “because they were producing competent people accepted for registration, they were posted to certain hospitals and now standards have dropped”; “new nurses are not so for supervised practice and mentoring, and among nurse interested in the work.” managers there were views that this in itself contributed to poor attitudes, as nurses became tired and fed up with their The prospects of inculcating the right attitudes through hard life. For other managers, the interviews were a valid way pre-qualification training would be improved if nursing of filtering out those with gaps. and midwifery class-sizes were reduced and tutor capacity improved: “Two hundred students in a class when you are A mark of the commitment of health workers in the study is the supposed to have 60!” and “If you are a serious tutor, how belief that the desire to care, help and make a difference stays do you teach and how do you supervise and follow up 200 with a person. On the other hand, managers who had observed students in one class?” the working environments and cultures of differing workplaces believed that good intentions can dissipate. Chapters 6 to 10 Nurse participants and stakeholders recommended that look at how aspects of the working environment undermine training schools do more to ensure that nurses not only know motivations for being a health worker. the theory of the code of ethical conduct, but also understand how it should be applied in the workplace.101 Nursing course content could be improved to make sure that students take on board the role of the nurse as the patient’s advocate.
101. Codes of conduct and ethics require health professionals to act in a manner that safeguards and promotes the interest of individual patients; serves the interest of society; justifies public trust and confidence; and upholds and enhances the good standing and reputation of the professions (HWAF-U 2010). 102. See Open Society Initiative for East Africa 2010 103. Action Group for Health, Human Rights, and HIV/AIDS 2010 104. Kaye et al 2011 32 Our Side of the Story: The lived experience and opinions of Ugandan health workers
6. Workload
6.1 The context Public health facilities are required to adhere to a job structure, set centrally, that limits the number and cadres of staff that can be employed at a facility; this defined establishment of employment posts is commonly referred to as the ‘norm’.
Staffing shortfalls: key facts
Nationally, 48% of posts are vacant, representing a shortfall Across local government districts, 47% of approved of 25,506 staff; the lower the level of facility, the greater positions are filled; in only 10 of the 80 districts are the shortfall (December 2009).105 more than 70% of positions filled. 106
Percentage of Staffing Percentage of Number of posts vacant shortfall approved posts filled districts
Health centre II 64% 7,245 21-30 4
Health centre III 54% 8,051 31-40 25 41-50 15 Health centre IV 45% 3,396 51-60 11 General hospital 38% 2,750 61-70 15 Regional referral hospital 30% 1,082 71-80 7 Main national referral hospital 10% 222 81-90 2 90-100 1 In 2009-10: • 41% of medical doctor positions in 42 general hospitals were not filled – a shortfall of 180 doctors • 41% of nursing positions in 42 general hospitals were not filled – a shortfall of 3,380 nurses • 64% of medical doctor positions at 117 health centre IVs were not filled, a shortfall of 154.107
6.2 The health worker experience Not surprisingly, health workers told of the personal repercussions of understaffing and heavy workloads. Concerns about understaffing and workload were most marked But also they spoke passionately about the damaging effects among health workers and managers in government facilities on patients and on community perceptions of health workers. at all levels. At some not-for-profit and private facilities the concern barely surfaced, while at others it was a key issue for participants. Overload was reported even in well-staffed hospitals within the not-for-profit sector.
105. Matsiko 2010 Table 3.2 106. Adapted from Oketcho et al 2009 Slide 6 107. Ministry of Health 2010b Tables 3.35 and 5.4 33 Our Side of the Story: The lived experience and opinions of Ugandan health workers
The impact on health workers Health centre midwives suffered especially. Midwives in rural health centres told of working alone day and night, sleeping Unmanageable workloads with their children in disused wards, always on call to deal with expectant mothers often arriving in late stages of labour. A “Overwhelmed” was a word widely used by nurses speaking manager acknowledged that a midwife had worked alone and about unmanageable workloads in many government hospitals on call for five months. and a not-for-profit hospital: “How can you manage? It does something to you.” Nurses spoke of being affected mentally and In a private sector health centre scheduled time off had to be “destroyed” to the extent of becoming ill: “One nurse running foregone for the sake the patients: “If a doctor prescribes care a full ward, with patients sleeping on the floor as well, the for 24 hours we have to stay, and then work again next day.” overwhelming number can affect the nurse psychologically.” With a nurse off sick, the workload became even harder to manage. Over-long shifts and too little time off
Too many tasks and responsibilities Among not-for-profit hospital nurses there were complaints about being forced into working 12-hour shifts. Taking up the In government health centres, midwifery and nursing staff said option of working shorter hours would reduce days off from they were stretched to the limit by too many tasks: “You have two to one, a hard choice for nurses with children and homes to run the ante-natal clinic, conduct deliveries, carry out post- to look after. Days off duty are important times “to do your natal, do the ward round, one person. Then you have to run own things” and should be an entitlement. Yet it seemed most of the young child clinic.” Burn-out resulted: “You have to taken for granted that nurses and nursing assistants living on do the counselling, take blood, see the patients, prescribe for site in staff accommodation would turn out in their “off” time them and do everything. When you leave at the end of the day, to fill staffing gaps in some health centres. Even a not-for- you are burnt down completely.” profit hospital with clearly specified conditions of service was reported not to give good time off because of understaffing. Among nurses in government hospitals, there were complaints about having to take on doctors’ duties: “I don’t know when a Impacts on health ward round was last done. We review patients, even prescribe.” Non-availability of a doctor caused dilemmas for midwives, Among nursing staff in government health centres and general who feared blame if they undertook a medical procedure hospitals there were concerns about the effects on health of beyond their scope of duty. Health centre nurses believed they foregoing or delaying meals because of work pressure. Not did the work of a clinical officer. Government hospital nursing eating on schedule was a key concern when suffering from assistants complained about undertaking work which should be diabetes, and eating well was important to maintain immunity done by nurses. against infection from patients. Even taking a drink was not easy “because how would it look when they are in pain?” Working in a team had been one of the attractions of nursing It was even hard to make a quick toilet visit without being as a career choice. It was frustrating and disheartening when reprimanded by hospital managers. cooperation was lacking, such as when a relief worker failed to turn up: “No teamwork at all, and when it is an emergency and Restricted professional development they delay, you really feel bad. You know what the outcome will be but you can’t help.” Managers’ concerns included the impact on clinical officers’ development when they lacked the opportunity to work Working day and night under the guidance of a medical doctor, and the professionally isolating consequences for staff with no supporting teamwork: Health workers in government health centres told of working “Nobody to consult when you are stuck, nobody to delegate to day and night, often alone, due to understaffing and staff when you are unable.” absences. It was pointed out that clinical officers, midwives, nurses and nursing assistants had stayed on duty round the A nursing assistant had been put in a role that took her away clock or even longer, contrary to government rules and codes from direct patient care, to fill gaps in the professional staff of conduct. They said they kept on in the face of fatigue complement: “I want to learn more from the patients but I because of their commitment to helping others: “If God were have no choice.” not calling, you could not do this work 24 hours.” There were views that opportunities for further study were blocked because the facility would not be able to recruit a replacement if the nurse left.
34 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Failing the patients she has run out of compassion and the patients say she is not caring.” They said that overwhelmed nurses skip out from Among health centre IV workers the lack of a medical doctor work, ask to be transferred and “run away” to the private was one of the biggest concerns, more important to them sector, where patients do not complain they are neglected. than frustrations about individual workload and personal consequences: “I can get demoralised seeing someone dying Midwife behaviour towards patients changed as a result of in my hands because we are missing a doctor” and “It really working alone all day and all night, especially with “no peace of hurts a lot when a patient is dying and you know what should mind” due to personal and family worries: “So you become tough be done. You even go home depressed.” with the mother so that she understands and you get a live baby and a live mother.” Managers were well aware of the unacceptably Health workers who expressed these feelings were adamant long hours midwives put in and spoke openly about the effects that they kept on turning up for work to stop the next person’s they had seen: “As time goes by, because of the fatigue and suffering: “If I’m depressed because someone has died and perpetual calling, somehow as a human being you tend to I say I am not going to work the next day, then we are going deteriorate.” Midwives no longer in the government sector to lose more.” understood how overtired midwives were forced to “escape” from 24-hour work in health centres to make contact with their families. The impact on attitudes,behaviour and practices Among midwives, perpetual responsibility for the lives of Hospital nurses acknowledged that overload damaged quality mothers and babies was “a burden” and it was hard to stay of work: “At the end you are very tired and no quality of work patient with the mothers. is done.” Participants employed outside the government sector were especially outspoken about the impact on the quality of Nurses spoke about the knock-on effects on their patients of nursing in a large government hospital where they had seen their having to do too many things at once: “You find you are performance drop and patients’ needs neglected. Personal stressed and are rude to patients unknowingly.” There were distress made things worse, they felt: “Understaffed in a ward some strong views that workload in some large hospitals was full of patients, on top of family worries, they find they can’t made worse by senior staff “malingering” or not pulling their perform, miss things and cannot provide all the services patients weight. A view from the private sector was that frustrated junior need.” The nursing role should be much more than taking routine nurses in the government sector “took it out on the patients”. observations and giving treatment, but it was impossible for an overworked nurse to find time to talk with patients, uncover Long tiring, shifts led to nurses overwhelmed by the workload their problems and deal with the whole picture. Consequently being short with patients, not interacting with them and task-oriented nursing was unavoidable and even routine tasks conveying disinterest through attitude and expression. were hard to complete: “With two nurses for 50 patients, you Managers and frontline doctors had seen how hunger made are reduced to trouble-shooting, it’s not nursing.” nursing staff bad-tempered and rude to patients. It was said that long shifts, together with poor pay, made nurses look for Hospital nurses “torn apart” by patients calling for attention ways of “escaping”: not turning up for duty and leaving work found it hard to make patients understand that they had to early. Yet it was also said that even after 12-hour shifts, some wait their turn. They recognised they could lose their temper in nurses went on to other nursing jobs, just to survive financially, such stressful situations and forget their basic good intentions: and so developed “bad habits”. “You become different.” Medical staff had seen the effects of tiredness: “The tone of voice changes” and “The nurses end The impact on community relations up losing it, when they are already frustrated by poor pay.” Managers were generally understanding: “As a human being Aggressive or demanding outpatients were a particular concern you can get irritated and lose your temper because of fatigue” for medical doctors and clinical officers. With so many patients and “What do you expect with only half the nurses you should waiting for attention, it was important to prioritise their treatment. have? They become rude.” But patients either did not understand the triage system or believed they deserved priority. Such challenges to professional Participants working in well-staffed private and not-for-profit judgement were especially hard to handle when aggrieved hospitals had seen the consequences of work overload in the patients called on local leaders to intervene on their behalf. government sector. Managers observed that a lack of opportunity to fulfil their proper professional role “demotivates” nurses, Among midwives working round the clock, huge distress was who then adapt to a culture of poor standards of care in their caused by patients accusing them of not working when they work environment. A “don’t care” attitude resulted: “By the had found a little time to rest. This misperception was said to time she is 30 she is used up. Already tired due to understaffing, fuel community hostility towards health workers.
35 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Health centre workers realised that no respite in long shifts Managers explained why remote and rural facilities found it led to community complaints about harsh language: “We work hard to recruit and retain medical doctors, nurses and midwives. the whole day without resting, and in the late afternoon we They sympathised with new recruits who turned round and left get tired and then we change face.” Staff working set hours for want of something to do in a village: “They post someone had met some hostility from local people who assumed the out there in the wilderness and they expect them to work!” With health centre was closed to outpatients when they saw health no electricity for TV and internet, people were “not connected workers socialising together towards the end of the working to the world”. Poor roads and no public transport at night left day. The staff there pointed out that they worked hard to serve staff “stuck”. Free staff accommodation was widely believed to outpatients quickly and so deserved some rest-time after make it easier for nurses and medical doctors to leave behind patients had stopped arriving. It was also hard to make waiting the amenities of town life. Poor-quality staff quarters, on the patients understand that health workers were not resting when other hand, were a deterrent to taking up and staying in posts. they sat completing paperwork. An example was cited of rented accommodation of so poor a standard that it was not safe to raise a child there, leading to Health workers in sole charge of patients faced a dilemma: a nurse leaving her post. Health workers living in towns spoke go hungry or leave the patients alone? Doing the latter was along similar lines, adding that the cost of food was high in reported to have brought unfortunate consequences for staff remote areas and educational standards poor. who were arrested for neglect of duty. It was said that the arrests were motivated by local political candidates seeking It was remarked that medical doctors dislike working in villages to gain electoral favour through discrediting ruling politicians because of the lack of opportunity for learning and career with oversight of the facility. Clinical officers can be left alone advancement. It was also said that medical doctors avoid jobs to cover an entire health centre, running from one department at district level because local politicians misuse health service to another. So it was deeply upsetting when a patient arrived, resources and interfere in treatment decisions. assumed no staff were available, and called on a local leader who then complained to higher authorities. Local management factors The lack of a medical doctor rebounded on other staff: “When In the local government sector the problems of overwork and the patient dies, the community look on you as a bad person too little time off stemmed in part from limited management who refused to treat the patient.” Lack of a midwife or qualified capacity to draw up fair duty rosters. It was noted that poorly nurse meant that nursing assistants carried out deliveries. They planned rosters scheduled nurses to work back-to-back day and found it hard to convince patients to put their trust in them, night shifts. The view among nurses was that properly organised especially as they themselves recognised they lacked the full time off would motivate them to work. Concerned health range of knowledge to save pregnant women in difficulty. centre managers said they recognised the need to manage staff hours fairly, but with so few staff that was almost impossible.
6.3 Factors contributing to understaffing Government sector managers explained how unexpected and work overload absences worsened the load on nursing staff. When staff did not turn up for work, and especially when they did It is important to understand the structural causes of not communicate their intent, managers struggled to find inadequate staff numbers in government health facilities. It workers to fill the gaps and patients were left waiting. While is not necessarily the case that there is a shortage of health there was sympathy among managers for the personal and workers available in the labour force; some government family problems that kept staff from work, there were also sector managers were aware of huge numbers of applicants feelings that the reasons offered were not always genuine. for advertised vacancies, while others said they had failed to In Ugandan culture, it was hard to question whether family recruit. Among managers at district level, views were expressed sickness or burials had actually occurred and hard to enforce that decentralisation of the health system was to blame for the a requirement to produce sick notes. Sometimes managers uneven distribution of health workers in local government. suspected, or even knew, that absent staff were “moonlighting” or pursuing a “side income”, “doing other things to survive”. Recruitment barriers Managers and frontline workers commented that staff who lived on site were rarely absent, unless they were sick or a Government sector managers explained that financial allocations relative had a problem, as they would be ashamed when for salaries stood in the way of recruiting more staff: there was patients came looking for them at home. simply no money in the pot to pay more health workers. Even if funds were made available to fill authorised posts, vacancies Participants working in government health centres explained remained due to bureaucratic procedures and the absence of how their hours and workload increased at short notice a District Service Commission tasked with recruiting health when senior colleagues were called away to workshops and personnel to the district. meetings. They rarely questioned why these activities took
36 Our Side of the Story: The lived experience and opinions of Ugandan health workers
priority over clinical and management duties at the facility, that standards for patient/nurse and patient/doctor ratios be though the attraction of attendance allowances was alluded to. introduced so that health worker overload is transparent and quantifiable. Pressures would reduce if ratios were adhered Paradoxically, staff scarcity was a barrier to holding public to: “The nurse can manage if a limit is put on the number of sector health workers to account for their absences. “Turning patients per nurse.” a blind eye” was preferable to starting disciplinary procedures which would likely lead to a transfer. It would be “suicide” to lose Recruitment blockages someone, as the remaining few would be more overburdened and blame the manager. Managers noted wryly that they had Sensationalist media headlines about ‘shortages’ contribute to little leeway to dictate to medical doctors and midwives in negative images of health professions. Health reporters should understaffed facilities: “They hold you at ransom, they know be informed about obstacles to recruitment. The district level they have power because they can just go and get work recruitment process is cumbersome and lengthy, entailing a somewhere else.” A frontline doctor echoed the point: “You number of steps as responsibility and paperwork pass from one work in a relaxed environment, they don’t want to pressure you authority to another. The District Service Commission has a role too much and push you away.” It is reported elsewhere that at several stages, but meets infrequently because of the costs of Ugandan facility managers have no authority to discipline staff.108 convening members and advertising vacancies.110 Many remote districts have no functional District Service Commission and no Scarcity was similarly a barrier to redistribution of staff within personnel officers to declare the vacant posts for recruitment.111 a district. While in theory a district health manager could move a nurse or midwife from a better-served health centre to ease It was suggested that the problem of unfilled posts and understaffing at another centre in the district, in practice the mal-distribution of health workers across local government manager met resistance: “They won’t go because they know districts would reduce if health worker recruitment and they are marketable.” deployment were managed centrally. Health workers explained that the current system de-motivates potential applicants who Task-shifting have to seek out and apply for positions. It is clear from workers’ accounts that work overload, stress Decent staff accommodation and poor community relations result from doing work for which they were not qualified or trained. Such task-shifting has Participants spoke enthusiastically about the benefits of good been found in government healthcare facilities elsewhere in quality staff accommodation, equipped with electric lighting Uganda.109 Managers and frontline workers expressed concerns and a clean water supply, suitable for families. A decent place to about staff working beyond their scope of practice, when a live attracted health workers to remote and rural facilities and nursing assistant acted as a nurse, a nurse as a midwife and a made for a more contented workforce. On-site accommodation midwife as a medical doctor. This is necessitated by shortages was said to reduce absenteeism. Civil society organisations and absences of suitably qualified staff. However, it seems that advocating for health workers should hold to their objective of task-shifting was also a deliberate strategy to save money by monitoring the government’s intention to “provide decent and employing less-qualified staff. safe accommodation for health workers at health facilities, especially in hard-to-reach areas”112 and press for concrete targets.
6.4 Recommendations De-urbanise health worker training Staff shortages and work overload damage health workers, the It was suggested that more training schools located in rural quality of care and community relations. Attitudes and behaviour areas would produce nurses and midwives already adapted for which health workers have been criticised stem from to rural environments. Managers saw value in attaching physical and mental exhaustion, moral distress and burn-out. nurse training to remote hospitals, both to generate a local workforce and to bind health workers to the community. Civil Health worker/patient ratios society organisations recommend targeting admission policies to enrol students with rural backgrounds, exposing students There were views that the norm was out-dated and failed to to greater rural field work and building schools and residency recognise the changing nature of services, such as HIV and programmes outside major urban areas.113 AIDS treatment clinics, new cadres coming out of training schools and local population growth. It was recommended
108. Mwita et al 2009 109. East, Central, and Southern African Health Community (ECSA-HC) 2010 110. See Ministry of Health and The Capacity Project 2008. 111. Matsiko 2010 112. Ministry of Health 2010b p102 113. Action Group for Health, Human Rights, and HIV/AIDS 2010
37 Our Side of the Story: The lived experience and opinions of Ugandan health workers
7. The facility infrastructure
Government sector workers in rural hospitals and health centres bore the brunt of dilapidated conditions: non-functioning operating theatres, erratic or non-existent electric power, unreliable access to clean water, blocked sewers, broken-down transport and no communication technology. They told of damaging effects on job satisfaction, risks to themselves and deeply felt harm to patients.
7.1 The context What official documents do not show is the extent of broken or non-functioning power, water, transport and communications, Official reports paint a gloomy picture of the physical state of revealed in an independent survey of a sample of 41 out of 64 health facilities. While new health centres have been built and government health centres in two districts.120 (Box 2) some health centres upgraded with newly constructed theatres, outpatient departments and maternity wards, the government Data from a survey of not-for-profit sector facilities indicate a acknowledges that most facilities are in disrepair and that better picture, but the survey was biased towards urban facilities. inadequate allocation of funds hampers maintenance and Electricity was most often reported to be “sometimes available”, rehabilitation. The government also recognises failures in electricity although in a few cases it was “never available”. Access to water and water supplies, transport and communications technology. was most commonly described as being generally reliable. About two-thirds of facilities reported always having access to telephones. Half the sites had reliable email access. In a quarter of the sites, ambulance or transport services were not available.121
Failing infrastructure: key facts
Most facilities are in a state of disrepair. Rehabilitation Box 2: Basic conditions in a random sample of buildings is not carried out regularly.114 of government health centres in two districts (November-December 2009) Many health centre IVs still lack crucial infrastructure to make them fully functional: 49% [of the 117 health centre IVs providing information] either have no 25% no power source operating theatre or have an incomplete or 10% functioning electric power non-functional theatre.115 Power 30% functioning solar panel 25% non-functional solar panel Only about 24% of health facilities have electricity or a 1 of 5 generator sets functional backup generator with fuel routinely available during service hours. Only 31% have year-round water supplied 10% functioning piped water supply in the facility by tap or available within 500 metres.116 Water 10% non-functional piped supply 40% functioning rainwater supply Only 47% of all facilities can transport a patient to a 10% functioning ambulance referral site in maternal emergencies.117 An independent 12% non-functional ambulance evaluation of the ambulance service in 13 districts of Transport 50% functioning motorcycle northern Uganda found only 8% of mothers reported 20% non-functioning motorcycle using an ambulance to reach the health facility during their last delivery.118 0% a landline, functioning official cell phone or email Communication Only 6% of health facilities have information and 10% functioning radio call communication technology, mostly comprising mobile 20% non-functioning radio call phone, radio, TV and, to a smaller extent, computers.119
114. Ministry of Health 2010b 118. Womakuyu 2010 115. Republic of Uganda 2010 119. Ministry of Health 2010b 116. Ministry of Finance, Planning and Economic Development 2010 120. HEPS-Uganda 2010, Annex IX 117. Ministry of Finance, Planning and Economic Development 2010 121. Schmid et al 2008, Chapter 6 38 Our Side of the Story: The lived experience and opinions of Ugandan health workers
7.2 The health worker experience Risks to health workers The state of facilities Working with no power or water, health workers naturally were worried about the huge risks to themselves: “We are Among government facility managers and district health risking our lives.” Maternity workers emphasised the risk of officers there were questions about why more health centres contamination from infected blood when working in the dark. were being constructed when existing facilities could not work as they should. Facility managers in the government sector Nurses expressed fear of assault working often alone in unlit told of struggling with inadequate budgets to repair or replace wards or crossing dark compounds, a risk increased by lockless decades-old infrastructure: “The only borehole, you pump for doors, breaches in compound fences and inadequately equipped 30 minutes and then it stops for two hours”. Pumping water or absent guards: “We fear to answer the door when somebody only every second day and encouraging rainwater collection knocks for help.” No functioning flush toilet at the workplace in jerry cans and drums was a partial solution. Elsewhere, forced a dangerous walk home through a snake-infested compound. the best that could be hoped for was being earmarked for rehabilitation – “at least we are in a programme” – or “a good Risks to patients Samaritan” to help connect to a distant water source. On the other hand, external funding coupled with well-managed Midwives and maternity nurses emphasised the risks to women in-house technical services allowed a not-for-profit hospital giving birth at night. Assisting deliveries by the light of a mobile manager to speak with pride of rainwater conservation and phone or a candle begged from a patient, they were forced to solar power systems. There was a marked contrast between a delay repairing episiotomies until daylight. Unable to read the hospital where wards were cleaned three times a day and one patient’s case notes at night, midwives could not tell if she had which had no piped water supply “for years”. HIV and so reduce the risk to the baby. Only a donor’s gift of lamps relieved months of “suffering” delivering in the dark. The impact on health workers Infection control was near impossible when nursing staff had to “The condition of the working environment is one of the biggest beg the little water spared by patients’ attendants to wash their challenges. So that people can work with a smile, wake up in hands, and so try to prevent carrying infections to the patients. the morning and be happy going to work. You enjoy your work and your profession.” Participants told how expensive fuel for electricity generators ran out at crucial moments: “Just yesterday we were doing Low job satisfaction an operation and we had to complete stitching by torchlight.” Sterilisation was “a huge challenge”. As generator power must A key concern was the state of operating theatres at health be conserved, it could not be used routinely for precious centre IVs. Government sector managers spoke of theatres that equipment, such as an ultrasound machine which mostly stood could not function because of poor design or shoddy construction. idle despite having a trained operator. Limited generator power They said that when a theatre was unusable, or lacked proper did not allow refrigerated blood storage and patients could equipment or anaesthetists, underemployed medical doctors rarely afford the costs of travel to the referral hospital, to the lost interest and left. Frontline doctors commented that the lack distress of health workers: “I feel so sympathetic and sorry.” of opportunity to practise surgery explained the unwillingness to take up a medical doctor post at a health centre IV. Transport is essential if the referral system is to work as intended, and is crucial when a facility cannot provide the intended For nurses working with only one paraffin lamp and limited fuel, services because of lack of infrastructure, power, equipment, proper care of night-time emergency admissions was impossible: supplies or qualified staff. Health workers showed pride in “How can you manage to put in the intravenous line with a dim their facility when it had a functioning ambulance to transport light?” Sharing one paraffin lamp across three wards was very referred patients or could rely on an ambulance sent on hard, yet: “We just have to bear with it for the betterment of request from a higher tier facility. On the other hand, working our community.” Nurses working with no good light felt they in a facility with no patient transport was deeply upsetting were failing their duty to patients in need of scheduled treatments because many patients just could not afford to pay their own during night hours. Hospital communication systems do not transport costs: “They say they will go to the hospital but they work without power, and midwives can be left to bear the go home and later you find out that they died.” Health workers’ brunt when a doctor cannot be called. distress was acute when a health centre patient was referred direct to a distant regional referral hospital. They knew that patients were deterred not only by the travel costs but also by the prospect of a strange hospital and an alien language.
39 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Commonly, budgets did not stretch to fuel the vehicle for 7.3 Recommendations referrals. It was widely acknowledged that patients were asked to pay towards fuel but that was often beyond the reach of Frontline staff seemed resigned to working in poor conditions people in poor communities. The negative impact on nurses and struggled to identify ways of improving them, short and midwives cannot be exaggerated. They came into nursing to of wholesale rehabilitation that would need unrealistic save lives, to use their knowledge to benefit their communities. amounts of public expenditure. Recommendations are For them it was very hard and frustrating to stand by unhappy mostly from managers. and helpless, knowing that a mother and baby would die because the vehicle lacked fuel. Nor was it a good experience The building and rehabilitation programme to see patients return to the facility “in a terrible condition and very weak” or with complications because of the lack of fuel for A suggestion was to invest in good theatre facilities and their referral. Health workers also spoke of their frustrations when staffing in a small number of health centre IVs and showcase mechanical problems were left unattended. them as good practice before embarking on further work.
A managerial concern in the government sector was that Responsiveness to problems identified by staff effective referral systems need a means of communication from lower- to higher-level facilities. Health workers seemed Government sector frontline workers noted facility and district resigned to using their personal mobile phones and paying for managers who had been slow to respond to requests for calls from their own pockets to contact referral hospitals. improved lighting. Another source tells that a similar request was not acted on although a large stock of lamps was held in Because of the constraints on providing transport, it was the district store.123 Good practices identified in the not-for- unusual to hear of a vehicle being used to bring patients to a profit sector included regular meetings between management health facility. Staff in a government sector hospital were proud and department heads at which faults were raised for action. that it provided an ambulance service to bring in emergency patients, and noted how relations with the community Health worker ‘ownership’ of the facility benefitted as a result. There was also praise and gratitude expressed for a project that supported pregnant women’s It appears beneficial to get facility staff involved in tackling transport costs, resulting in more facility-based deliveries. infrastructure problems. For example, staff at a government hospital organised rainwater collection. The impact on attitudes, behaviour and practices Health workers spoke of their distress over how a lack of electric power, water and transport affected the quality of service. They wanted to do their best for patients but had to protect themselves too. They explained how patient perceptions of rudeness arose from the lack of power and water. The fear of infection influenced their approach to patients: “Sometimes we come in with a scared heart” and “Sometimes you shy away from risk and the patient thinks you are rude, but it is the working conditions.”122 They also acknowledged that the frustrations of working in the dark caused impatience and delays that patients construed as neglect.
The impact on community relations It was said that patients refused to be admitted for treatment when the toilets did not work and they were not able to bathe, thus damaging the reputation of the facility. A lack of water to flush toilets forced staff to return home, fuelling patients’ beliefs they were not at work and running the risk of their being blamed by local political leaders for leaving the workplace while on duty.
122. Similar findings reported by Dielemanet al 2007 123. Medicines and Health Service Delivery Monitoring Unit 2010 40 Our Side of the Story: The lived experience and opinions of Ugandan health workers
8. Equipment and medical supplies
This chapter looks at the impacts of deficits in equipment and associated medical supplies, and the following chapter reports the impacts of shortages of medicines in healthcare facilities.
8.1 The context
Equipment failures: key facts
There is a shortage of basic equipment in health facilities. Only 40% of available equipment was in good condition and about 17% needed replacement [in 2008-09].124
A survey in 11 districts showed the extent to which health facilities lacked equipment to diagnose and treat malaria in mid-2009. Of the 105 facilities surveyed, 83% were in the government sector. The survey found: • No functional microscope in about 50% of the 35 health centre IIIs and 20% of the 10 hospitals and 12 health centre IVs • No malaria rapid diagnostic tests in 86% of the 83 health centre IIs and IIIs • No haemoglobin measurement equipment in 61% of all facilities During the three months prior to the survey, none of the hospitals and health centre IVs had all seven components of a basic care package for the management of severe malaria consistently available. The most common ‘stock-out’ was blood for transfusion, available in only one facility. Blood transfusion sets were lacking in around two thirds of facilities and over half had no giving sets.125 Evidence suggests that only 5% of facilities have a vacuum extractor (used for assisted vaginal delivery) and only 10% have a dilation and curettage kit (needed to remove a retained placenta).126
8.2 The health worker experience The impact on health workers Health workers praised facilities with good diagnostic equipment, Government sector medical doctors and nurses told of such as x-ray and ultrasound, and with a commitment to a interruptions to the supplies of oxygen and blood; missing well-equipped establishment: “It’s a good place, that’s why canulas, needles, giving sets and sutures; minimal availability I have stayed so long.” Elsewhere, working with inadequate of urine testing kits and family planning supplies; insufficient equipment was a huge challenge, damaging workers’ dressing packs, and absent or faulty diagnostic equipment. professional fulfilment, the quality of services and community Rural midwives in the government sector told how they relationships. The difficulties were acute in the government struggled to provide a service with no delivery kit, cord clamp, sector, but also present in parts of the not-for-profit sector. sucker, gauze or cotton wool and just one pair of scissors.
124. Ministry of Health 2010b 125. Achan et al 2011 126. Ministry of Finance, Planning and Economic Development 2010
41 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Working without protective wear – gloves, aprons, gumboots, Participants spoke against the policy: “I don’t feel it wrong to shoes, masks – was a huge risk, especially for midwives ask a patient to buy needles in order to help them,” and it was working in the dark: “You are bathed in blood.” Lacking gloves, clear that patients in some facilities were being asked to buy midwives even used their own clothes and plastic bags to grasp supplies. It was hard to ask a patient to buy items that should the baby during delivery. Workers in some rural facilities in the have been provided free of charge: “I don’t want to be the one government sector provided their own work clothes as, it was to say go and look for a canula.” said, the Ministry of Health no longer supplied uniforms. Participants in facilities with relatively good supplies welcomed In the government sector there was widespread frustration at relief from the stresses of telling patients to buy their own. not being able to work effectively: “What really hinders my work They also spoke of pride in a facility that did not force patients is lack of some equipment” and “The equipment does not allow to spend their little money on intravenous fluids, canulas, you to do what you are supposed to do.” Nurses spoke about gloves, dressings and the like. There was praise for imaginative thwarted professional fulfilment. Willing to work and capable of management that solved temporary supply problems by offering a full service, they felt “handicapped” and “disappointed”. borrowing from other facilities. As a result, work was neither enjoyable nor happy: “If I am provided with what I am supposed to use, I can enjoy the work” The impact on attitudes, behaviour and practices and “You can’t really be happy in such conditions, but would be happier with equipment to do your best.” Participants working in the private and not-for-profit sectors spoke frankly about effects of shortages they had seen Frontline medical doctors spoke of “struggling with the minimum” during their time in government facilities. They told of nurses and of feeling “deflated” by poorly maintained equipment such forgetting what they had been taught in training schools and as x-ray machines with blown bulbs or no chemical to print the some not working as a result, so projecting a bad image to the film: “You wake up and have the same problem, you go home, community which in turn made nurses feel not respected and you come back and it has not changed.” Doctors wanting the prompted them to leave. Participants in the government sector satisfaction of doing their best for their patients spoke of did not identify these effects. However, there was a suggestion frustrations such as a lack of diagnostic equipment or facility that nurses were reluctant to come to work and face patients for blood counts. Managers recognised that medical doctors and their relatives knowing that essential supplies were lacking: “eventually lose morale” when they are unable to operate on a “Staff don’t want to come in and look at a mother with a dying patient because oxygen or sutures are missing, and that being child and no canula to give intravenous fluids.” unable to apply knowledge was “very demotivating”. The impact on community relations Failing their patients greatly distressed nurses and doctors. Patients died because of the lack of essential supplies: “We Health workers felt blamed for the lack of supplies and would have saved that life if we had oxygen. It stresses you.” resented accusations of theft. The patient’s attitude changed A lack of diagnostic equipment lost lives too: “The patient when asked to buy supplies: “You feel bad when somebody probably would have survived if you were able to investigate.” is not appreciating what you are doing.” Patients’ carers were sometimes angry and violent, such as a husband who hit a Government sector workers faced a dilemma when the midwife when asked to buy gloves. facility ran out of supplies. User charges were abolished in the government sector127 and health workers told of prohibitions There were fears of personal repercussions if the rule was on asking patients to go and buy missing items: “It is very disregarded and the patient was asked to buy supplies: “The annoying, you go home dissatisfied.” The medical doctor has a Government is going to see you as a bad person.” Staff in one duty towards the patient’s health: “What do you do? Ask the facility were stressed by the arrest of a health worker who patient to buy or see them get worse?” The other option was asked a patient to buy essential supplies. The view there was “to be kind” and refer the patient to a higher-level facility. that local political candidates had set the arrest in motion to discredit the incumbent leader.
127. User charges were abolished in 2001 in all government facilities except private wings in hospitals.
42 Our Side of the Story: The lived experience and opinions of Ugandan health workers
8.3 Recommendations The limitations of equipment and medical supplies seemed an intractable problem to many participants. Frontline workers saw the supply problem as out of their hands and it was hard for them to come up with recommendations other than the obvious – increase equipment and ensure constant treatment supplies.
Encourage international donors to provide large items of equipment directly There was a view that mismanagement and corruption dissipated development partners’ support to the Ugandan health budget and that donors should provide large items of equipment directly. It was felt that it would be counter-productive if donors were to donate smaller, more easily removable items.
Equipment maintenance The view was expressed that more attention needed to be given to the maintenance of existing medical equipment. It was frustrating to have equipment on site that could not be used because of broken or missing small parts. The expense of the parts was a minor issue. Rather, the problem was said to stem from inertia and poor organisation among facility management.
Improve frontline health worker voice and participation Frontline health workers showed limited knowledge of how the ordering and delivery system is supposed to work and how financial allocations and priorities are set. Workers in the government sector told of putting requests to facility management, but did not understand why their needs were not met. Workers in district-level facilities commonly blamed the Ministry of Health for deficits. Participants at a government hospital identified as good practice formal consultations by management to find out what equipment frontline workers needed, and enabling them to participate in decision-making about equipment and supplies. Health workers were free to identify not only equipment essential for patient treatment but also items that made their work easier and more comfortable, such as fans and radios. Transparent decision-making on priorities and implementation allowed workers to have a voice and see that their views had been listened to.
43 Our Side of the Story: The lived experience and opinions of Ugandan health workers
9. Medicine supplies
Medicine shortages and ‘stock-outs’ emerged as one of the biggest challenges for government health workers. Unable to give their patients the drugs they needed, health workers grieved for their patients’ suffering and became demoralised by the futility of their roles. They struggled with disappointed or angry patients and their limited understanding of the reasons for shortfalls in supplies. They were deeply hurt by accusations of stealing drugs, the lack of trust the public had in health facility staff, a seemingly hostile press and by what they saw as politically motivated moves to discredit them.
9.1 The context
Drug availability failures: key facts
“The percentage of health facilities registering stock-outs in essential medicines has consistently been over 60% for the last 10 years.”128 The availability of 40 essential medicines in the period April-June 2010 was recorded in a sample of 28 government and 18 not-for-profit facilities across Uganda. None of the 40 medicines was available in every government facility when surveyed, while eight of the 40 were found in all of the not-for-profit facilities. Average availability of the 40 medicines was 59% in the government facilities, compared with 78% in the non-for-profit facilities.129
An assessment of the pharmaceutical situation in 36 government and 36 not-for-profit health facilities with pharmacies or dispensaries in six districts was carried out in 2008. For the listed essential medicines, the average ‘stock-out’ days per year were 72.9 in government facilities and 7.6 in not-for-profit ones.130
Only one in three respondents surveyed in 2008 agreed that their nearest government facility usually had all the medicines the household needed.131
9.2 The health worker experience In parts of the government sector there was some acknowledgement that government efforts to improve the The drug supply situation delivery system of the central medical store had brought improvements in supplies of essential medicines. It was also Outside the government sector, medicine supplies were noted also that drug supply increased after a government generally thought adequate to treat most conditions. A stamp on packets was introduced. There was enthusiasm sufficient supply brought health workers the satisfaction of about how better supplies now benefited patients: “Now working effectively, as well as pride in an efficient facility we have enough drugs, I would not say all drugs, and in- that logged all movements of medicines. The not-for-profit patients get the drugs the doctors prescribe.” sector was not immune to shortages, however; in one facility, shortages were said to be due to loss of revenue because it gave impoverished patients drugs on credit.
128. Ministry of Finance, Planning and Economic Development 2010 129. Uganda Country Working Group 2010 130. Ministry of Health 2008a 131. Ministry of Health 2008b 44 Our Side of the Story: The lived experience and opinions of Ugandan health workers
There was sharp contrast between praise for medicine supplies be taken for the rest of a person’s life, it was very hard to see in better-stocked facilities and disgruntlement among workers patients go for up to six months without treatment. Health elsewhere. Health workers told of some essential drugs used workers cared passionately about the consequences for poor up in a matter of weeks, or even days: “They bring one tin of patients: “Few can afford even 2,000 shillings [$1], so day after quinine tabs for a whole unit” and “Just five tins of panadol day they walk here and wait. Walk 15, 20 km despite the pain.”132 which the department can use up in one day.” Complaints They felt the pain too when patients became more sick while centred on undersupply for population demand; shortfalls in waiting for their families to raise money to purchase medication. supply where deliveries did not match orders; erratic deliveries, such as oversupply of condoms but no anti-malaria drugs, Hospital doctors spoke of how they were forced to refer and irregular deliveries which did not conform to promised admitted patients who could not afford to buy medicines, or quarterly schedules. It was suggested that shortages were just keep them in a bed without medication. The quality of made worse by patients taking unfair advantage of brief care also suffered when the patient could afford only cheaper, periods of plenty but with no testing equipment it was hard to inferior drugs which then failed to improve their condition, refuse drugs to patients who claimed the common complaint of resulting in referral, an option many patients could not afford. malaria. And it had been noted that patients turned up with a different patient record book every day of the week in order to The impact on community relations stock up with drugs at home. “It puts a lot of strain on community relations.” Health workers Government facilities typically could not stretch their budgets said it was hard to make patients and other community to purchase drugs in the private market, and were forced to sit members understand why drugs were not available at all times. and wait for the next delivery from the central medical store. They acknowledged that among people sick and in pain there However, one hospital dedicated a quarter of its private-wing was little appetite for words of explanation, and that the income to medicines. complexities of the supply system were beyond the understanding of some people without education. But they also told of angry, The impact on health workers and the quality of care bitter patients who cursed them and refused to listen. Health workers said they felt “disappointed” and that the lack In the past, Ugandan healthcare users maintained a belief of drugs “demoralises” them. Job satisfaction suffered when that government health facilities lacked medicines even when they were unable to give patients the drugs they needed. receipts increased.133 According to health worker participants, Their presence in the workplace sometimes seemed futile: there now appears to be a prevailing belief that health facilities “You are here and there is nothing to give the patients. You are are well supplied with medicines: “People say why don’t you just sitting waiting for them, then tell them to go back as there give us drugs?” A particular problem arose when a health facility is no drug.” Helplessness was especially hard to bear when changed ownership from not-for-profit to government and the forced to tell poor patients to buy their medication in the private previously superior supply of medicines could not be maintained. market: “I hate the situation of being helpless before the patient when they can’t afford to buy drugs” and “You feel you Health workers said that communities served by government have not done much for the patient when they have to buy.” facilities assumed health workers took the drugs: “Patients think you steal” and “Patients call us thieves.” They said that patients It seemed like fobbing off the patient: “You tell them to buy, but believed that health workers took government supplies to stock the patient is expecting answers.” It was hard to be seen as their own clinics and drug shops, to which patients were then letting down patients keen to have family planning supplies who sent to buy medicines. It was acknowledged that such abuses could barely afford the transport to the facility: “You feel so bad, had occurred. Indeed, good supplies in one hospital were it seems as if you are deceiving them and they lose confidence attributed to the fact that few of its nurses ran private clinics and in you.” Self-esteem suffered when drugs were not available: drug shops. Health workers expressed sorrow about the lack “They look at you and think the health workers are bad, and of trust put in them and the effect on community attitudes: yet it is the government, not us” or “Their eye looks at the nurse “When drugs are not there, they tend to hate nurses.” and that doesn’t make me able to be the nurse I want to be.” In contrast, it had been observed that patients’ attitudes towards health workers improved when given supplies of drugs The biggest source of distress for health workers was the impact to last several days. It was especially upsetting to be directly on the patients, and they spoke emotionally about how they felt accused of theft when a patient demanded a drug that the for their patients when no medicines were available for them. clinician knew was not appropriate for the patient’s condition. In the case of antiretroviral drugs against HIV, which should
132. Some 51.5% of Ugandans live on less than $1.50 a day (UNDP 2010 Statistical Annex) 133. Nabyonga-Orem et al 2008 45 Our Side of the Story: The lived experience and opinions of Ugandan health workers
There was widespread indignation at accusations of stealing nonexistent medications: “What are they supposed to be “Museveni warns medical workers stealing?” or “What kinds of drugs can we steal? Paracetamol? Quoting a proverb that says ‘a dog which steals Because that’s the only drug in the hospital!” and “How can pays with its back’, Mr Museveni told a rally […] they take things that are not there!” Health workers felt that that the same would be done to health workers local leaders and politicians made matters worse when they who steal drugs from now on.”135 failed to present the true picture to complaining patients, and even accused health workers in front of patients: “It is making us lose morale for what we are supposed to do.” “Politicians stop playing games Health workers resented negative stories in the print media, on the right to health TV and radio, believing that journalists blew up single incidents unfairly to give an exaggerated picture of the extent to which A story is often told of a politician who frontline health workers were guilty of pilfering drugs. delivered a truck laden with ‘medicines’ to a A stakeholder concurred: “We can’t brand all health workers health centre in his constituency. The truck as thieves just because someone has stolen a tin of aspirin.” was reportedly containing all the medicines Stakeholders noted that press stories about health workers that this health centre needed at the time. In stealing drugs had increased with the work of the Medicines a country where getting medicines in public and Health Supplies Delivery Monitoring Unit, an autonomous facilities is intermittent and health workers are unit set up in October 2009 within the President’s Office.134 reviled for ‘stealing’ medicines, this politician While there was support for its efforts to expose poor working was an angel straight from heaven. conditions as well as abuses, the view was expressed that it was unhelpful to create a media story around every wrongdoing Now, long after the speeches and pleasantries the unit uncovered: “They tried to create publicity instead of had ended, and the MP had gone, it was time dealing with the real issue of what is causing the stock-outs.” to open the boxes. But alas, the boxes were full of saline solution. […] There was no way There was hurt and indignation too about top public figures medics at the facility would tell people the spoiling the professions’ reputations when they stated publicly next day that there was no medicine. To the that health workers are thieves: “How can any patient value politician he had scored a political goal. But in a doctor, value a nurse, when they say such things about us!” the process, the health workers had been put 136 There were beliefs that government conspired to make out in a tight position.” that all health workers were thieves although, in the opinion of health workers, top managers and not frontline workers were the chief culprits. Public accusations by the President were especially damaging to health workers’ self esteem.
“Patients get angry because the politicians tell them drugs are provided”. Views were expressed that politicians deliberately mislead the public: “Government makes them believe they have sent drugs” and “The public is being hoodwinked!” But for a public servant it would be “suicide” to contradict political masters.
134. The Unit’s first annual report exposed malpractices and “vices” identified through its staff visits to 145 facilities in 45 districts, with an average of three follow-up visits in each district. Initially visits were impromptu, in response to “emergency calls” from the public about the state of healthcare and alleged drug thefts, and routine monitoring visits were introduced later in the year. 135. Emojong 2010 136. Kirunda 2011
46 Our Side of the Story: The lived experience and opinions of Ugandan health workers
9.3 Recommendations Local leaders Transparency at the point of delivery The local government structure produces a large number of committee or council members and leaders at village, parish “They see the boxes coming and if next day you say there are and sub-county level (see Appendix B). These people, often no drugs, they feel like beating you up.” Public opening of termed local politicians or local leaders, can have considerable deliveries was one step that government sector health centres influence over their local communities. Health centre workers had taken, with varying degrees of success, to try to convince told of dissatisfied patients who called on local leaders to communities that medicines were not in stock. For example, to support their demands for drugs. It is therefore essential counter the community assumption that a lorry had delivered that local leaders are fully informed and use information drugs, it was important to show that boxes offloaded contained responsibly. Staff at one facility reported that “trouble from condoms or saline solution. When essential medicines were local politicians” had reduced after a meeting with them. delivered, their quantities were verified openly. Health workers told how variously the chairperson of the health Educate community members unit management committee, the elected chair of the local community, the government internal security officer, police Some health workers said they had tried hard to help patients and patients witnessed the opening of boxes. This step must to understand the ordering and delivery system. Others had be supported by paperwork to show what has been ordered wearied of such attempts or had barely tried: “They only want and delivered; government health centre recording of orders, drugs, not your words.” Some simply wrote off local people deliveries and purchases has been described as “appalling”.137 as uneducated, illiterate and incapable of understanding – a point of view contested by health consumer organisations in Drug movements within the facility the study. It was pointed out that patients were not receptive to explanations when in pain or angry when asked to buy Participants within the not-for-profit and private sectors medicines, though it was acknowledged that opportunities recommended recording drug inflows and outflows, although for facility-based information sharing do exist, such as with it was also said that such time-consuming steps were not groups of women waiting for pre-natal checks. The most necessary when staff were trusted by management and the promising solution was to talk with community members community. Management staff in a not-for-profit sector health during outreach visits, such as child immunisation days, though centre welcomed scrutiny by the higher level body to which it some health workers had limited confidence that they could was accountable. succeed in changing entrenched suspicions. Others pointed to a lack of funding for outreach allowances. There were also views that Village Health Teams might have a bigger role in sensitising the community to the real situation.
137. HEPS-Uganda 2010
47 Our Side of the Story: The lived experience and opinions of Ugandan health workers
10. Pay
Ugandan health workers’ salaries are low compared with those in other East African countries. They are also low compared to the market value of goods and services in the country.138 Especially among medical doctors, the disparity between their salaries and those of other professionals is a huge grievance. There have been calls to raise doctors’ salaries to match those of high court judges, whose income at 6.8 million shillings (US$ 3,664) was more than eight times the starting salary of a senior medical officer in 2009-10.139 Regardless of how much they themselves were paid, health workers spoke out about the damaging consequences of low pay for themselves, patients and the profession.
10.1 The context 10.2 The health worker experience The frontline workers and managers participating in the research said they did not join their professions just for the money. They Salaries: key facts wanted to use their training to help others, prevent and cure illness and save lives: “I became a nurse not so much because Starting salaries per month in government I am interested in money, though money is also important. I service in 2009-10140,141 feel it really was a vocation.” In any case, salaries were simply Senior medical officer UGX 840,749 (USD 453)142 not attractive enough: “With so little money, nurses must want to care and help patients, just to keep going.” Money was Medical officer UGX 657,490 (USD 354) never an overriding factor for job satisfaction, though among Registered nurse UGX 353,887 (USD 191) frontline doctors there were expectations of earning enough to Nursing assistant UGX 113,306 (USD 61) “help build yourself up” and feel good about helping people at the same time. Yet there were some strongly held views among Average monthly salary for a senior participants that some of the recent generation of health nurse/midwife in government service143 workers entered the profession with no natural interest for it Uganda USD 341 and became disaffected because salaries were so low. Tanzania USD 630 Staff in rural health facilities said that despite long working Kenya USD 1,384 hours with little chance to rest, they worked over weekends and on public holidays for the sake of the patients. They even volunteered their help unpaid on top of their regular work, out of commitment to patients’ welfare, for instance in HIV clinics. As local government districts have discretion to top up salaries, Low salaries were of course a huge and widespread concern, these vary among staff of the same level. The Ministry of and there were many calls for better financial compensation. Health introduced salary top-ups in the most hard-to-serve But it is very striking that when asked about what had to areas, to attract and retain staff. It is reported that top-ups change to make things better for them, health workers of up to 30% for six months attracted professionals to these emphasised improvements in the infrastructure that would areas.144 Facilities in the not-for-profit and private sectors set result in better care and treatment for patients. Frustration their own pay levels. It is known that not-for-profit sector with equipment and supplies outstripped frustration over salaries are lower than in the public sector.145 salaries, as found in other studies.146
138. Matsiko 2010 139. Ladu 2010 140. Matsiko 2010 141. Ministry of Public Service http://www.publicservice.go.ug/public/Traditinal%20Salary%20Structure%202010%20-%202011.pdf 142. 1 US Dollar = 1,856 Ugandan Shillings at 31 March 2010 143. Ministry of Health 2010b p37 144. Matsiko 2010 145. Schmid et al 2008 146. Fonn et al 2001 48 Our Side of the Story: The lived experience and opinions of Ugandan health workers
The impact on health workers be “at a certain level” and seeing them as not responsive to community problems. It was also hard for doctors to face Money worries the disbelief of patients begging them to pay for life-saving treatment that should have been freely available: “You look in Health workers said salaries were not enough for the costs of their eyes and see the hurt and the disappointment.” ordinary daily living, to allow them to pursue a career or to meet social expectations. They said that money worries got Medical doctors and senior nurses spoke of unaffordable in the way of doing their best work and even contributed to lifestyle aspirations such as a house that befits their status. bad practices. Managers said inadequate pay was one of the Doctors wanted to be in a position to afford a decent house biggest challenges to healthcare delivery. rather than put up with low-standard government sector accommodation on site. Nursing staff spoke heatedly about their struggles to survive on low pay and support their dependents, see their children Disrespect through education, pay for a roof over their heads, settle essential bills and afford transport to work. Financial worries “In Uganda respect comes with how much you earn.” It was added to the stresses of long hours and little rest, the burden said that patients “look down on nurses” when they know how of too many patients, the frustrations of not enough medical little they are paid. Rural nursing assistants who were especially supplies or the lack of appreciation in the workplace: “If better poorly paid said this would be a barrier to enlisting the local paid, a nurse will work with patients with love and happiness community to advocate for higher salaries: “It’s our secret.” knowing that rent and bills are paid.” Thwarted professional ambitions In areas where demand for housing had pushed up rents, health workers found housing costs hard to meet or were A widespread and serious concern was unaffordable further forced to pay high transport costs to reach more affordable training: “I have to sponsor my own study yet I am serving accommodation. Paying US $1.50 or more a day for transport the nation!” Health workers spoke, often passionately, about was very hard to afford on a nursing assistant’s salary. thwarted ambitions to improve on skills and knowledge. Nursing assistants wanted to train as enrolled nurses or In Uganda income is important not just to meet daily living midwives, and enrolled nurses and midwives to train as costs. There are extended families to support: participants registered nurses and midwives. Moreover, registered had up to 15 children depending on them. One of the nurses wished to add midwifery to their qualifications or satisfactions of earning is being in a position to support the go to degree level. Doctors wished to bring their knowledge study costs of a family member. As educated people, health up to date and train as specialists. professionals naturally want a good education for their children. Public primary and secondary education is free, but Unfair pay schools often impose fees for lunch, uniforms and building development, and many Ugandans favour the private schools Participants regularly voiced strong opinions that the pay was that comprise over a quarter of the secondary education unfair and undervalued health workers. Nurses complained sector.147 Worry about school fees pervaded health workers’ that their salaries did not reflect the years of study they had lives. A participant spoke heatedly about the impossibility of put in. They pointed to other medical jobs that required the affording university fees of US $900 a semester with three same length of training yet were more highly paid: “Nursing children and a monthly salary of US $330. is one of the lowest paid medical professions.” Doctors pointed to the much higher salaries of other professionals: Failing to meet social expectations “We send our children to the same schools, buy our food at the same markets.” It was dispiriting to see their university As a health professional there are also social expectations contemporaries earning so much more yet working less hard. to meet. Families, friends and social associates assume you are well off, and it was shaming to reveal how little the The fact that medical doctors are paid less than secretaries and salary actually was. Medical doctors especially felt socially drivers in some statutory agencies underscored the little value embarrassed when they could not afford to contribute large attached to the medical profession in Uganda. There were sums of money at functions held to raise funds for wedding or some strong feelings, notably among managers and practising funeral expenses. They also spoke of how they were expected doctors, that low pay reflected a lack of political will at to help with school fees or medical costs: “Society expects so ministerial and presidential level to invest in healthcare. There much from you. It’s impossible to convince people that you was some anger about public spending on political campaigns, don’t have money when you are a doctor.” The pressure the military and a presidential jet, and about wastage through came from the community expecting a nurse or doctor to corruption, while healthcare was grossly underfunded.
147. Uganda Bureau of Statistics 2008
49 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Salaries were doubly unfair because they did not reflect the keep them. That’s what drives people to do those things.” But long hours many health workers put in: “You can give your they also argued that the media exaggerated the scale of such family neither time nor money.” Nor did salary levels take practices by unfairly generalising a single instance to all health account of the risks of infection health workers faced. Not workers: “It spoils the reputation of all nurses, it pains and being rewarded for doing the same work as higher-grade staff discourages us so much.” was thought bitterly unfair. It sometimes seemed to hospital nurses that doctors did little while they did all the work. One of the hottest topics in the Ugandan media is the apparent disappearance of essential medicines and medical supplies Nurses complained that after paying for additional training to between the central store and patients in government health upgrade their skills, they lingered for years on their previous facilities. Theft on the part of health workers is only one salary until promotion was granted. explanation for shortfalls in supplies (see Chapter 9). Participants acknowledged that theft did occur within some health facilities. A further area of perceived unfairness was the disparity in In their view, the explanation lay with low pay and money salaries offered by the government, not-for-profit and private worries: “They are not stealing medicines because they are evil sectors. Not-for-profit sector workers pointed to their longer – their income does not satisfy their needs.” Delays in salary hours, and it was commented that unlike some government payment were implicated too: “They steal for survival.” health workers, they worked the hours they were paid for. It was pointed out that not-for-profit and private facilities In no way was stealing condoned. Some participants expressed were free to decide their own salary levels and acknowledge sorrow that patients were deprived of already scarce supplies. seniority in their own way, resulting in lower pay than in Others were bewildered that health workers could put their government settings. A particular grievance was the absence of own interests before those of the patients. Only rarely did a senior clinical officer grade in a not-for-profit facility. A further participants believe that greed led health workers to steal. concern was that the government’s salary enhancement for Some health workers thought that pilfering of medicines employment in hard-to-reach areas seemed not to have been happened only on a small scale, and that drugs were taken for adopted systematically in the not-for-profit sector. personal or family needs and not to sell. But there were also views that helping yourself had become a habit, with reports Rarely was it said outright that health workers are exploited, of staff openly justifying selling supplies on the grounds that although there were views that unfair advantage is taken of the facility did not reward them well enough. Participants their professional ethics and dedication to patients: “Nurses with experience of closely managed facilities spoke of tighter are trained to love and serve, and no matter how little we are administrative practices that helped to safeguard medicines. paid we have to have that love.” Indeed, among managers there Workplace cultures which accepted stealing were also noted. was some intolerance of frontline workers’ complaints about The suggested solutions were tighter management to reduce low salaries, and an attitude that commitment to the work opportunities for abuse, and holding staff to their codes of regardless of the pay was praiseworthy: “Patients have to get a employment. As found in research elsewhere, peer influence to service, poorly paid or not.” Yet managers were among the most change behaviour was seldom proposed.148 vocal critics of salary levels: “The salary is deplorable!” Overall, participants appeared more resigned than militant about unfair Taking money from patients is a sensitive topic which some pay, though there was some anger that the government cited health workers were understandably reluctant to discuss. the Hippocratic Oath to prevent doctors from protesting. Soliciting bribes from patients was thought to be rare and was unacceptable because it would add to patients’ poverty. If it Impact on attitudes, behaviour and practices did occur, it was attributable to low pay: “If paid a satisfactory salary, I think they would not get money from the patients.” Health workers and managers were encouraged to say what There was also a view that worries about surviving on in their view explained behaviour regularly criticised in the retirement pensions drove health workers to ask for bribes. It Ugandan media, including being rude to patients, stealing was observed that in some settings, patients expected to give medicines and supplies, not turning up or coming late to work, staff some inducement to attend to them.149 Such mistrust was and taking money from patients. Health workers acknowledged hurtful and offensive, and it was suggested that the distance that these bad practices did happen in some places: “It’s between workers and patients widened as a result. Participants poverty. You get a salary of US $200, you pay school fees of told of scams whereby patients were robbed of their little around US $150, you get stuck. You don’t have transport to money by conmen masquerading as health workers, and of take you to work, you don’t have food in the house, you don’t angry patients subsequently attacking legitimate staff. have anything, children are crying, your parents need you to
148. Ferrinho et al 2004 149. Hospital health workers in Tanzania frequently commented in focus groups that unofficial payments were more commonly initiated by users than by workers (Stringhini et al 2009) 50 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Health workers distinguished accepting “appreciation” from 10.3 Poor pay, turnover demanding money, and some acknowledged a temptation to accept unsolicited money from patients as compensation for and loss to Uganda ill-paid, exhausting work. It was suggested that some see health workers accepting appreciation and wrongly conclude The research participants were, of course, “stayers” in their that a bribe has passed hands. profession. Career histories showed a fair amount of mobility from one health facility to another, but only very exceptionally It was widely believed that urban health workers were forced did a participant speak of leaving their profession, and that to work in two or even three jobs to make ends meet, with was to earn more. government sector employees working also in private clinics or private hospitals. One unfortunate consequence, it was said, The consensus was that the biggest turnover was among medical was to reinforce patients’ suspicions that health workers steal doctors. There were firm beliefs that Ugandan-trained doctors drugs from their workplace to sell in private clinics. Moonlighting left the government sector to work for NGOs, prestigious was often known, or suspected, to explain absences: “Most not-for-profit hospitals or the private sector. Private sector people, when they don’t turn up for work you find they are work was tempting, in order to get more money and avoid running a clinic somewhere.” It was said that absenteeism the “frustrations” of government hospitals. Managers and was not a problem in areas where private treatment or drugs practising doctors told how young doctors “run away” from were unaffordable. Exhaustion from doing too many jobs was hard-to-fill rural posts because of poor salaries. As well as low thought to cause behaviour patients saw as rude. pay, reasons were believed to include limited opportunity to use professional skills in poorly equipped facilities, disinclination to Rural areas were said to offer many fewer opportunities for live far from modern amenities and a lack of earning potential side-employment, but there it seemed that health workers from private practice. Yet practising doctors explained that for were sometimes forced to take time out to tend crops to many young doctors, a year or two gaining experience in a rural feed their families. It was noted that before decentralisation, setting, even in deprived circumstances, was a step towards rural workers regularly saw to their vegetable gardens before acceptance for specialist training. Staying longer meant passing leaving for work, when salaries arrived late or not at all. It was the age limit for scholarships. Specialism was then the gateway suggested that this habit continued. to private practice and considerably higher earnings. In any case, district level facilities rarely could support the costs of a There were beliefs that absence from the workplace was specialist if they wished to return after training. encouraged by lump sums given notionally to cover transport and attendance at workshops, and there were grievances Participants were asked if they had thought about working about perceived unfair selection of participants: “They only abroad and why. For some nurses the possibility was remote: want the big people.” The more junior staff valued the learning family responsibilities came first, the barriers to getting a and professional contacts that workshops offered. nursing job abroad were just too high, or they had not even realised it was allowed. For others, nursing abroad was a Effort at work was affected by low pay, managers felt. Views real aspiration, and there were one or two stories about were expressed that nurses put in minimal effort “because they disappointments. Nurses’ reasons for considering working feel they are not getting what they are worth.” It was observed outside Uganda counter the widely-held perception that the that because nurses are paid so little, “they take out their lure of money pulls nurses to lucrative jobs in other countries. frustrations on patients’, arrive late, fail to monitor patients and Better pay was not an overriding consideration. Nurses are unkind to them. It was noted how hard it was to get people explained they were looking for an environment where “there’s to work when they lacked the basic minimum, and that with respect for what you do” and where they could learn about no “incentive” of a decent wage, it was impossible to retain different medical conditions, use equipment they were trained skilled and interested workers. Occasionally, in managers’ eyes, to use, update their skills and have the chance to advance “low morale” was related to low pay. Low pay was argued to professionally. Individual advancement was not the sole driving contribute to doctors’ “questionable attitude to work”. Things factor: “I would bring my skills back to share with Ugandan would change with better pay: “When you are paid highly you nurses” and “I would bring back the knowledge to my people.” are more motivated” and “If the pay was more, the nurses would respect their work more and respect the job that pays them.”
51 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Among participants with medical qualifications there were Financial motivators beliefs that medical doctors left country in large numbers for “greener pastures”, as well as claims that few of their “We are not motivated, they should give us some motivation, graduation contemporaries were still in Uganda, though some appreciation.” In Uganda “motivation” often means extra the lack of hard facts on the extent of emigration was also money or payments in kind. Being given something signifies acknowledged. The prevailing assumption was that doctors appreciation. Non-financial rewards were no substitute for moved in pursuit of money. When questioned about their money: “Lovely words of thank you don’t feed a family!” own intent, doctors spoke about the attraction of a better income. Yet opportunities to work with proper equipment Free accommodation of a good standard, with electricity and and “love what you do” also were important – not simply a water paid for, was hugely appreciated and said to be a factor good salary. Doctors spoke about the possibilities of working in attracting and retaining staff. Even free housing of lower in highly regarded, well-resourced hospitals in other East standard was valued and its absence a cause for resentment, African countries or in Southern Africa. African countries were especially among nursing assistants. attractive because they are close to home, but the USA and Europe were not ruled out. Not all doctors wanted to leave for Free food for the household, tea and snacks provided at work better working conditions, and there were also keen ambitions and Christmas and Easter gifts were identified as especially to take their skills to countries even more in need of medical appropriate ways to value and motivate Ugandan health workers. doctors than Uganda, such as Sudan or Somaliland. Staff of a government facility spoke enthusiastically about the help it gave towards costs of family burials and medical operations, 10.4 Recommendations as well as the provision of cloth to make their own uniforms.
Ugandan health workers feel undervalued because salary levels Generally in Uganda, allowances on top of basic salary are do not match their needs and social expectations. The pay is common and can contribute quite significantly to the overall felt to be unfair and failing to signify an appropriate return for pay. Small allowances for outreach visits, such as to provide what they put in. immunisation services, were much appreciated. There were calls for allowances for risk, housing, transport, responsibility and Not surprisingly, there were very many calls for increases study.150 Hardship allowances were suggested to compensate in basic salaries. There were concerns about exploitation for living and working in remote locations where it is difficult in private clinics and a suggestion that a minimum wage be to access facilities and goods, and where the standard of introduced. Ideally, the same salary structure should apply in accommodation is very poor and lacking in essential utilities. all sectors. Government salary scales should recognise first and post-graduate degrees. There was considerable frustration that A private sector facility’s monthly award for nurses who met this issue was not being resolved and calls for reform in order high standards of dress and customer care had a multiple to attract degree nurses to public sector jobs and ensure their effect in pushing up standards, boosting income and valuing education is used to directly support patient care. A common individual staff. demand was to address blockages to promotion. It was pointed out that local government hospitals are allowed There were also practical recommendations to reward effort to run private wings and that some use the income to benefit and improve motivation. staff. One hospital allocated over half of that income to enhance the monthly salaries of all its staff: “health workers Overtime and responsibility payments feel owned and happy.” It was recommended that local government hospital administrations inform staff about their While staff often willingly worked over-long hours for the sake private wing income and how it is spent. the patients, there were views that their extra hours should not go unrewarded. No health worker told of overtime payments.
Staff told of the stresses of working alone and bearing sole responsibility. A good practice cited from the not-for-profit sector is a responsibility allowance paid when a nurse has sole charge of a ward.
150. Some health workers reported receiving allowances for risk and transport. There seemed little awareness that a proportion of government sector salaries constitutes a housing allowance. 52 Our Side of the Story: The lived experience and opinions of Ugandan health workers
11. The way forward
Work overload, poor infrastructure and the lack of medical equipment, supplies and medicines frustrated and distressed health workers. They felt unrewarded for the work they do and undervalued. Their accounts show that working conditions were the root causes of bad practices and unethical behaviour, and that health workers bore the brunt of the blame for system failures. The research revealed a vicious circle: impoverished working environments, along with low pay, affected the quality of patient care; patients blamed the health workers; the wider community then distrusted health workers, and so health workers’ distress increased. The situation was made worse by negative media stories and political leaders’ vocal criticism of health workers, which fuelled public distrust, damaged the standing of the health profession, added to workers’ distress and, most importantly, raised the barriers to access to healthcare.
11.1 Raising the voices of health workers Lack of respect from management undermined nurses. Those with experience in large urban hospitals told of senior nurse The view of civil society organisations, and of some managers, managers and administrators who “sat on”, “barked at” was that frontline health workers are not empowered to speak and “belittled” them in front of patients. They also spoke of up. Indeed the concept of ‘voice’ was unfamiliar, and the idea doctors who publicly ignored and disparaged their knowledge that they might speak out and gain support to improve poor and contributions as “mere nurses”: “I have quite often working conditions and the quality of care was new to many heard doctors tell a nurse she is stupid.” Such behaviour frontline health workers. The research identified barriers to coloured patients’ respect for nursing staff and damaged their individual health workers voicing their concerns, and their reputation in the wider community: “They think a nurse barked preferences for advocacy by representative organisations. at is nothing.” They said management blamed nurses unfairly, failed to investigate problems and made their lives “miserable”. Constraints on speaking up Suppressed and voiceless in the workplace, it is not surprising that nurses had little appetite for championing their profession. There were views among frontline workers that responsibility for improvements lies with facility managers, district This report has shown that rural workers in government management or the Ministry of Health. Stakeholders noted facilities have faced disappointed, distrustful and sometimes that where decisions are made with no staff involvement “the angry patients, interfering and bullying local politicians and staff are afraid for their jobs, they fear to speak up.” politically engineered attacks on health workers’ credibility. Hostile environments and impoverished workplaces drained Anxiety about repercussions was a barrier to speaking out in any will they had to do more than meet patients’ needs the public. It was explained that “in Uganda, there is a lot of fear best they could. of being pin-pointed if you talk out about your problems.” The researchers observed some apprehension over signing their Moreover, health workers had few chances to meet with consent form, although health workers were willing to take people from other healthcare facilities to exchange experiences part in the research and seemed satisfied with the researchers’ and build solidarity. Nurses spoke enthusiastically about a assurances of confidentiality and the safe-keeping of data. The forum organised by a health sub-district which discussed unspoken fear, it seems, was that their participation might solutions to common problems. rebound on them.
The low esteem accorded to health workers was a further barrier. It was said that nurses do not speak out because of stigma attached to the profession: “The moment you stand up and say you are a nurse, people see you as a person who kills patients, they assume you are a bad nurse, a failure.”
53 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Speaking through professional associations, management, alongside rumours of power struggles, were unions and regulatory councils deterrents to workers spending part of their little salary on subscriptions to remote associations and unions. There were Health worker participants favoured channelling concerns also suspicions that those at the top of the organisations to the Ministry of Health, Government or Parliament through had different agendas from workers on the frontline. The bodies that spoke for them as, unlike individual health workers, effectiveness of representative bodies was also questioned, such bodies “know the way”. Awareness of professional given a history of government suppression. organisations and trades unions was not widespread and there was some confusion over their names, how their There were conflicting interpretations and some status differed and which body did what. misunderstandings of the remit of the regulatory councils.152 Some health workers saw their council as equivalent to a Some health workers felt unions were doing a good job, union, with a role to advocate for their constituency. Others evidenced by salary increases and the successful legal defence saw a “punishing attitude”, and complained that the Nurses of individual workers. Health workers saw advantages in the and Midwives Council was “down on nurses” and investigated protection of a union and the pursuit of individual complaints. only serious, high-profile cases of irregular behaviour. Concerns A union had the advantage over an association of registration were voiced that the council did little to defend nurses accused with the Ministry of Labour and permission to negotiate with of stealing medicines and that no action had been taken the government. against politicians who “beat up” nurses. The nurses’ council was seen as remote from nurses on the ground, preoccupied Male frontline workers spoke most enthusiastically about the with meetings, disinclined to inform members of what they potential of unions as a collective voice, and saw a need for discussed and not independent enough of government. local organisation and meetings at district level. They also identified a role for unions to strengthen advocacy within It was suggested that it would be better if representatives of health facilities and talk to management on behalf of the professional associations, unions and regulatory councils were workers: “They need to bring in people from above and help less remote from workers on the ground. In particular, there us at a lower level to improve things.” Women too saw the were calls for people “up there” to visit health facilities, talk potential strength of the nurses’ union if all nurses joined with health workers and learn about their difficulties first hand, collectively, paid subscriptions and attended meetings. There so that the “right voices” were taken to the top. was some confidence that more involvement in unions would get nurses listened to at national level. Supporters of the Recommendations among managers were that representative nurses’ union acknowledged that nurses were not currently organisations compare reports from different places and well-informed about it. compile strong collective arguments to improve conditions in the workplace, rather than simply address individual grievances It was suggested that professional associations might do more and traditional welfare issues. to bring members together, such as convening annual meetings to discuss challenges facing the profession. Opportunities to Representatives of associations and unions acknowledged attend professional association conferences were few but shortcomings and weaknesses. They were understaffed and highly valued, and there were calls for them to be held locally. severely under-resourced, with poor office facilities. The consensus among stakeholders was that individual associations However, there were also doubts about the value of the and unions were not yet strong voices for health workers and unions and professional associations.151 It was pointed out that that working in an alliance would be more effective. It was bodies did not do enough to inform their memberships about recognised that much would have to be done to align the their activities or call them to meetings. A lack of feedback, efforts of multiple and sometimes competing professional no tangible benefits and no evidence of proper financial unions and associations.
151. A survey for the Ugandan Association of Nurses and Midwives found only one third of members completing a questionnaire rated it as very effective in promoting nursing (Zuyderduin et al 2009) 152. The legal functions of the Nurses and Midwives Council are to regulate standards and conduct; exercise disciplinary control; approve courses of study; supervise and regulate training; grant diplomas or certificates; supervise registration and enrolment; advise and make recommendations to the Government on matters relating to the nursing and midwifery professions; and exercise general supervision and control over the two professions (according to the Nurses and Midwives Act 1996). 54 Our Side of the Story: The lived experience and opinions of Ugandan health workers
An advocacy alliance While it was widely understood that the media look for bad news, there was scope for positive human interest features, In Uganda, countless small civil society organisations work to such as profiles of individual health workers and the work they promote health rights. Dependent on financial support from do. It will be important to avoid suspicions of favouritism in a patchwork of sources (mainly development partners), they selection of the health workers featured. gain strength through loose, generally informal coalitions based on common aims. They are broadly aligned to consumers’ Local language radio is highly popular in Uganda and is a interests. Health workers’ interests fall mainly to the vehicle often used by civil society advocacy organisations. professional organisations. Coalitions rarely bridge the two sets Radio call-in shows attract health users voicing complaints of interest. The Health Workforce Advocacy Forum-Uganda is a about local services: “You hear them on the radio, it makes coalition of health professional associations, unions and health us uncomfortable.” While health workers are restricted in rights organisations. A membership organisation largely made what they can say publicly, civil society organisations have the up of health workers, it has recently campaigned for a positive opportunity to put complaints in the wider context and speak practice environment for health workers. up for health workers.
The Valuing Health Workers research found consensus that a way forward would be for all civil society organisations 11.3 Bridging patient communities and concerned about limits on access to healthcare to join with the healthcare facilities and staff Health Workforce Advocacy Forum-Uganda, to support and strengthen its advocacy on behalf of health workers. Connecting communities and facilities There seemed, from health workers’ accounts, places where 11.2 Changing public perceptions relationships between patient communities and facilities of health workers worked well. These were places which ignored status “so they don’t feel you are greater than them” and welcomed patients Participants were hugely affected by the persistently negative “on the same level”; where off-duty nurses mixed socially portrayal of health workers in Uganda: “I feel like I am a with patients; where Village Health Team workers visited the professional being abused.” Members of civil society and facility and had direct phone contact with the facility head professional organisations identified priority actions to reverse and other staff; where people called for an ambulance and it that image through targeting the media. Strong views were came; where local people volunteered to clean the facility and expressed by health workers that the public must hear their look after the compound; where facility management listened story: “We haven’t gone to the radio to tell people the problem to what the local community wanted from it, and where the is not us. We should be talking about our side of the story.” community saw the facility as their own. The public must be told the real causes: “Papers always blame the person, saying nurses are rude. etc, but there’s a need At district level, managers told of ongoing efforts to build to dig and find what really causes it.” People must see the or repair bridges with communities. There was a role for contributions health workers make: “We never show why we members of Village Health Teams (where they were functional) should be valued.” as go-betweens to explain to people in their own homes the problems health workers faced. ‘Outreach’, where facility-based Participants said that reporters working for the national media health workers took services such as immunisation to the are inadequately informed about the health worker situation community, was thought a good opportunity to talk with people and are overly reliant on official briefings for their information. on their own ground, though limited by a lack of transport. It is important to increase the capacity of civil society and There were hopes that “empowered” health unit management health worker organisations to write press releases, hold press committees would “tell the community the truth”. The aim conferences and build relationships with individual reporters was for committee members to explain how facilities work, for and media houses, so that the key campaign messages hit example, how supplies are ordered and staff disciplined, as well home. It is similarly important to engage with local reporters as to encourage people to use their services. But funds were and try to moderate the tendency to create sensational stories short to cover the expenses of village health workers, outreach from isolated incidents. The Uganda Health Communication and health unit management committee members. Alliance is an important ally.
55 Our Side of the Story: The lived experience and opinions of Ugandan health workers
‘Community dialogue’ meetings were recommended to bring Civil society organisations have been working to create together service users, local leaders and those involved in common cause between health workers and patients. Early providing services: “If there can be community dialogue meetings projects learnt that empowering community members to in each village, then we can discuss with them their problems. exercise their health rights must go hand in hand with valuing We tell them what we do, they express their problems, how we health workers. Otherwise there is a real risk of adversarial go wrong, I also tell them where they go wrong”. Community relationships between healthcare workers and users. Indeed, dialogues also meant that district managers learnt community early experiences were that community members, fired up views about individual health workers. with new knowledge about violations of their health rights, reprimanded workers they perceived to be rude, while health There were places where the distance between communities workers complained of harassment and threatened to resign. and facilities appeared hard to bridge. Patients arrived expecting staff not to help, and health workers came to work Subsequently, community-based training has enabled health fearing that patients would complain. “They don’t respect workers to talk out about the structural problems, with service the nurses’ needs, we don’t respect each other.” Interfering users coming to appreciate the reasons behind health worker and demanding politicians seemed an intractable problem, behaviour they object to. Now the focus of community-based but health workers reported favourable effects when a top training has moved towards fostering mutual understanding local politician’s family used maternity services at a local and communication through participatory methods involving government facility. Seeing the challenges encouraged the health workers and community members together.153 politician to understand their root causes. A more general recommendation was to invite politicians to spend time in facilities alongside staff to see what the work is really like.
Mutual respect and understanding Health workers understood what life is like for patients, they felt the pain that patients feel, and they wanted better conditions to improve things for patients. It was exceptional to hear that patients empathised with health workers: “Patients also feel badly when they see us with no way to help them. They don’t blame us. When you explain they understand.” More commonly, health workers said that patients did not understand what life is like for health workers: “They don’t understand what we go through, that sometimes nurses are rude due to the working conditions.” Patients seemed not to realise that health workers, like any other people, get tired, need to eat and fall sick. Health workers said they tried “to get them to understand we are human beings.”
153. Eg TARSC and HEPS 2011
56 Our Side of the Story: The lived experience and opinions of Ugandan health workers
11.4 Summary of participants’ recommendations The findings identified two priorities for action • Value health workers for their contributions to the health of Ugandans. • Expose the poor working conditions that prevent health workers from providing good-quality healthcare.
Four enabling strategies emerged from health workers’ accounts and stakeholder advice 1. Improve the quality and relevance of training. 2. Raise the voices of health workers through representation. 3. Change public perceptions through the media. 4. Build bridges with patient communities.
Priorities Value health workers for their contributions Ensure working conditions enable health workers to provide to the health of Ugandans good-quality healthcare
Health worker terms and conditions of service Health worker/patient ratios • Review salary scales to determine whether increases in • Introduce standards for patient/nurse and patient/doctor basic salaries are possible. Reform government salary ratios, so that health worker overload is transparent and scales to recognise first and postgraduate degrees, in order quantifiable, and managers have information to help reduce to attract degree nurses to public sector jobs and ensure pressure on overloaded staff. their education is used to support patient care directly. • Consider the establishment of a minimum wage and Recruitment blockages the feasibility of imposing the same salary structure • Manage health worker recruitment and deployment in all sectors (government, not-for-profit and private). centrally, to address the problem of unfilled posts and uneven distribution of health workers. Overtime and responsibility payments • Explore a system for remunerating health workers for overtime. Decent staff accommodation • Consider implementing a responsibility allowance paid when • The Government should follow through on its strategy to a nurse has sole charge of a ward. provide decent and safe accommodation for health workers at health facilities, especially in remote areas. Civil society Small financial motivations organisations should continue to monitor implementation • Incentivise staff through small items of personal support, such of this strategy and press for concrete targets. as food for the household, snacks at work, and Christmas and Easter gifts. Contributions towards family burials, medical Facility infrastructure operations and provision of cloth for uniforms are well received. • Ensure regular meetings between management and • Review current allowances for risk, hardship, housing, department heads, at which facility-related problems transport, responsibility and study, to ensure consistency can be raised and decisions taken on actions needed. and fairness across all facilities. • Invest in good theatre facilities and their staffing in a small • Use the income from local government hospitals’ private number of health centre IVs, and showcase them as good wings to benefit staff, by supplementing salaries or allowances. practice before embarking on further work.
Equipment, medical and medicine supplies • Give much more attention to the maintenance and quick repair of medical equipment, including systems for monitoring equipment maintenance and adequate stocks of spare parts. • Hold regular formal consultations with frontline workers to enable them to participate in decision-making about equipment and supplies, and to improve transparency in equipment procurement processes. • Encourage international donors to provide large items of equipment directly.
57 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Enabling strategies • Professional associations and unions should do more to bring members together, for instance at local general 1. Improve the quality and relevance of health worker training meetings, and make greater efforts to visit facilities and talk with health workers so that the “right voices” can be taken Career guidance and early contact to the top. They should compile strong collective arguments • Ensure well-motivated trainees, for example through to improve conditions in the workplace, as well as addressing more talks at schools and work experience placements. individual grievances and traditional welfare issues. Training schools’ admission procedures • The Health Workforce Advocacy Forum – Uganda (a coalition • Reject applicants who seem to be applying for the “wrong of health professional associations, unions and health rights reasons”, including those allocated to a university course organisations) should expand its membership and continue its which is not their first or second choice. campaign for a positive practice environment for health workers.
Developing and sustaining “the right heart” in training schools 3. Change public perceptions by influencing the media • Return oversight of training to the Ministry of Health from the Ministry of Education and Sports. • Inform journalists about the obstacles to health worker • Reduce nursing and midwifery class-sizes and improve recruitment and discourage them from writing sensationalist tutor capacity, to ensure the right attitudes and practical or negative stories in the media. Put complaints on local understanding of the ethical code are encouraged language radio call-in shows into a wider context. Encourage throughout pre-qualification training. the running of positive human interest features, such as profiles of individual health workers and the work they do. Health and human rights training Work with the Uganda Health Communication Alliance. • Expand existing partnerships between training institutions • Improve the capacity of civil society and health worker and health consumer advocacy organisations. Improve organisations to write press releases, hold press conferences nursing course content to make sure that students take and build relationships with individual reporters and media on board the role of the nurse as a patient’s advocate. houses, so the key campaign messages hit home.
De-urbanise health worker training 4. Build bridges between patient communities, healthcare • Increase the number of training schools and residency facilities and staff programmes in rural areas to produce staff already adapted to rural environments and connected to the local community. Transparency on drug availability • Improve the community service element in medical curricula • Use well-managed public opening of medicine deliveries to and increase the exposure of urban health students to rural help convince communities that medicines are not in stock, settings with increased fieldwork. and to counter accusations of theft. Call on local notables, police or patients to witness the opening of boxes. Support Nurses and Midwives Council registration interviews with paperwork to show what has been ordered and delivered. • The Nurses and Midwives Council should weigh up the • Ensure that local leaders are fully informed through regular advantages of screening interviews held as a prerequisite meetings about the demand for and supply of drugs and for registration post-qualification against detrimental that they use this information responsibly. effects on nurse morale. Connecting communities and facilities 2. Raise the voices of health workers • Use opportunities to talk with people on their own ground and explain the problems health workers face, for instance Sharing of experience and common approaches through Village Health Teams, facility-based health workers • Encourage staff to meet with people from other healthcare providing outreach immunisation services, and talks to facilities to discuss solutions to common problems and women awaiting prenatal checks. communicate them to sub-district level managers. These • Promote community dialogue meetings bringing together managers could also be encouraged to instigate similar forums. service users, local leaders and health unit management teams. Increase funds to cover these activities. Speaking through professional associations, unions and • Invite top local politicians to spend time in facilities regulatory councils alongside staff to see what the work is really like. • Channel health worker concerns to the Ministry of Health, • Civil society organisations should continue their work to Government or Parliament through bodies that speak for create common cause between health workers and patients. them, such as professional organisations and trade unions.
58 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Appendix A: Sample details
Table A.1 Number of facilities and participants by region
Kampala Central West South West North North East East
Facilities 3 1 5 1 4 1 3 Participants 17 6 31 4 27 17 20
Table A.2 Level of facility by provider type
Referral Hospital General Hospital Health Centre IV Health Centre III Total
Govt Govt NFP* Private Govt NFP* Private Govt NFP* Private 3 2 3 1 4 - - 2 2 1 18
*NFP: Not-for-profit
Table A.3 Distribution of districts according to Ministry of Health hard-to-serve scores
Very hard- to-serve Hard-to-serve Medium hard-to- Somewhat hard-to- Not hard-to- Total (score 55-100) (score 35-54) serve (score 20-34) serve (score 1-19) serve (score 0) Districts
Ministry 13 13 14 13 3 56 Sample 2 2 2 1 1 8
The sampling design aimed at a spread of districts in terms of approved staff positions appropriately filled with health of how the Ministry of Health ranked them as hard-to-serve. workers (30%).154 The formula was designed some years ago The Ministry’s scoring formula took into account degree of when Uganda had only 56 districts and when insecurity was insecurity, measured by the proportion of the population greater than at the time of this study. Researchers have noted in internally displaced persons camps (50% of total score); some anomalies in the scoring.155 The scores were therefore distance from the capital, Kampala (10%); presence of social only a guide to sampling decisions. Table A.3 shows that the amenities and utilities (bank, grid electricity, tarmac road and sample under-represents districts that scored 1 to 19.156 a tertiary education institution) (10%), and the proportion
154. Africa Health Workforce Observatory 2009 155. Ministry of Health 2009a 156. Based on Africa Health Workforce Observatory 2009, Annex 2
59 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Figure 6 Enrolled and registered nurse/midwife participants (n=74)
25 Comprehensive
Nurse 20 21 Midwife
Nurse / midwife 15 14 10 10 9 8 5 5 5 2 0 Enrolled Registered
60 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Appendix B: Local government structures in Uganda
Local government is organised in five tiers from the village to the district, as outlined below.157
A village is the lowest political administrative unit. A village usually consists of between 50 and 70 households and 250 to 1,000 people. The 2002 Census found 44,000 villages.158 Each village is run by a local council I (LCI) and is governed by a LCI chairman and nine other executive committee members.
The parish, the next level up from the village, is made up of a number of villages. Each parish has a local council II (LCII) committee, made up of all the chairmen of the village LCIs in the parish. Each LCII elects, from among its members, an executive committee. LCIIs are largely involved in settling land distributions and mobilising the community for various activities. The parish is largely run by a parish chief, a government employee who provides technical leadership to the LCII.
The sub-county is the next level up and is made up of a number of parishes. The sub-county is run by the sub-county chief on the technical side and by an elected local council III (LCIII) chairman and his or her executive committee. The sub-county also has an LCIII council, a kind of parliament at that level, complete with a speaker and a deputy speaker. The council consists of elected councillors representing the parishes, other government officials involved in health, development and education, and NGO officials in the sub-county. In towns, a sub-county is called a division.
A county is made up of several sub-counties. Each county is represented in the national parliament by an elected member (an MP). In major towns, the equivalent of a county is a municipality (which is a set of divisions). LCIII executive committee members of all the sub-counties constitute the local council IV (LCIV). They then elect an LCIV executive committee from among themselves. These committees have limited powers, except in municipalities, which they run.
A district is led by an elected local council V (LCV) chairman and his executive. There is also an elected LCV council, with representatives from the sub-counties and technical staff in the district. There are also district councillors representing special interest groups such as women, youth and disabled people. The council debates budgets, decisions and bylaws. On the technical side, the district is led by a chief administrative officer, appointed by central government. The district also has heads of various departments such as health, education, environment and planning, which are responsible for relevant matters across the whole district.
Uganda has an exceptionally high number of districts, the total having risen from 17 at independence in 1962 to 112 in July 2010. In 2008, when its districts had grown to 79, Uganda stood fourth in the world in number of highest level sub-national administrative units (ie districts).159 Since the current president, Yoweri Museveni, came to power in 1986, 78 districts have been created. It has been noted that bursts in district creation occurred around the times of presidential elections in 1996, 2000 and 2006;160 that pattern continued with further districts created around the 2010 election.
157. Drawing on Kavuma 2009 158. Africa Health Workforce Observatory 2009 159. Green 2008 160. Green 2008 61 Our Side of the Story: The lived experience and opinions of Ugandan health workers
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65 Our Side of the Story: The lived experience and opinions of Ugandan health workers
Annex: Health worker topic guide
1. Tell me why you decided to become a [----] Probe • Influences • Attraction of the profession • Ambitions • Alternatives considered • Doubts
2. What do you believe the [----] role is supposed to be? Prompt: Why do you think that? Probe • Influence of training, text books • Role models • Peers
3. What words would you use to describe a good [----]?
4. How does what you do in your work fit with your ideas of what the [----] role should be? Probe • Fit with work of nurses / doctors / clinical officers / nursing aides • Patients’ care needs • Constraints – staffing, equipment, drugs, work environment • Other people’s attitudes
5. What is good about being a [----] (in Uganda)? Probe • Material aspects – pay, housing, transport, etc • Uniform • Training, career prospects • Caring • Other people’s opinion of you
6. What helps make [----] feel good about themselves? Probe • Praise • Gratitude • Respect • Achievement • Recognition • Status
7. What is not so good about being a [----]? What are the challenges and difficulties? Probe • Pay • Hours of work, multiple jobs • Transport • Accommodation, facilities for self and family • Training, career prospects • Constraints – staffing, equipment, drugs, work environment • Pressure of work • Harassment, threats • Lack of respect – from colleagues, patients, public
66 Our Side of the Story: The lived experience and opinions of Ugandan health workers
8. How does [specified difficulty] make [----] feel about their work? About themselves? What words come up when they talk about how they feel? What do they mean? Probe • Not respected • Not valued • Pressured / stressed • Demoralised / demotivated • Blamed
9. We are interested in how health workers get by – how they survive – in difficult conditions. Prompt • Managing to get enough money to survive on • Coping with family responsibilities • Dealing with frustrations • Coping with bad feelings
10. What do you say to stories that criticise health workers? Prompt • Not turning up for work • Leaving the workplace to do other things • Taking away drugs or equipment • Taking money from patients • Talking harshly to patients
11. If you had your time over again, would you still decide to become a [----]? Prompt • Are reasons for becoming a [----] still valid • Ever considered working as a [----] outside Uganda • Would consider working as a [----] outside Uganda in future
12. What would you like to change about working as a [----]? And how might the change come about? Prompt • Things that realistically might be achieved
13. What if anything might be done so that health workers have more of a say and are listened to? Prompt • Council • Association • Union • Other advocacy organisations
14. Is there anything else that you would like to share with us about being a health worker?
67 ISBN 978-1-903697-33-7
9 781903 697337
Valuing Health Workers is VSO’s research and advocacy If you would like to volunteer with VSO please visit: initiative, which supports the achievement of the vsointernational.org/volunteer health-related Millennium Development Goals. Valuing Health Workers research is currently underway In addition to this publication, the following research in four countries. Following on from the research, and publications may also be of interest: advocacy strategies will be created, which will include the development of volunteer placements in civil society • Participatory Advocacy: a Toolkit for Staff, Volunteers coalitions, professional associations and health ministries. and Partners – this manual is an easily accessible guide to lobbying and campaigning, and can be used by health VSO works with the Health Workforce Advocacy Initiative activists and other campaigners for social justice. (HWAI). HWAI is the civil-society led network of the Global Health Workforce Alliance (GHWA) and engages • Ugandan Health Workers Speak: The Rewards and in evidence-based advocacy with the goal of enabling the Realities – a report of initial findings of the everyone to access skilled, motivated and supported health Valuing Health Workers research in Uganda. workers who are part of well-functioning health systems. • Valuing Health Workers in Cambodia – a short briefing www.healthworkforce.info/HWAI/Welcome.html on the research approach in Cambodia.
VSO works with Action for Global Health – a cross-European • Valuing Health Workers: Implementing Sustainable network of health development organisations. The network Interventions to Improve Health Worker Motivation (Malawi) calls on European Governments and the European – a report drawing together existing research in Malawi, Commission to act now to support developing countries to and identifying recommendations to tackle the HRH crises. achieve the health-related Millennium Development Goals. • Local Volunteering Responses to Health Care: Challenges www.actionforglobalhealth.eu and Lessons from Malawi, Mongolia and the Philippines – this report looks at how community volunteers can be For more information please contact: involved in delivering health services. [email protected] • Brain Gain: Making Health Worker Migration Work for Rich and Poor Countries. VSO Briefing: the perspective from Africa.
• The IMF, the Global Crisis and Human Resources for Health – this 2010 report, written with the Stop Aids Campaign and Action for Global Health, shows how the IMF is constraining the fiscal space for developing countries and impeding the recruitment of much-needed new health workers.
• Our Side of the Story: Ugandan health workers speak up – a report on the rewards, challenges and recommendations for the future, from the perspective of Ugandan health workers.
To access any of these publications, please visit: www.vsointernational.org/health
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Published July 2012