Professional Documents
Culture Documents
A policy report on the lived experience and opinions of Ugandan health workers
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.
Our Side of the Story: The lived experience and opinions of Ugandan health workers
Contents
Summary 1. Introduction 1.1 The VSO Valuing Health Workers initiative 1.2 The Valuing Health Workers research in Uganda 1.3 The research approach and participants 1.4 Structure of the report 2. Healthcare in Uganda: challenges and provision 2.1 Ugandan healthcare challenges 2.2 Formal healthcare provision 2.3 The Ugandan health workforce 3. Research design and methods 3.1 The research stages 3.2 Qualitative research methodology and the purposive sampling design 3.3 Data collection 3.4 Data analysis 3.5 The health worker participants 4. The rewards 4.1 Benefiting others 4.2 Job satisfaction 4.3 Being recognised, appreciated and valued 4.4 Appreciative and supportive management and colleagues 5. Reasons for becoming a health worker: the right heart and the wrong heart 5.1 A passion for the patients 5.2 They join for the wrong reasons 5.3 Recommendations 6. Workload 6.1 The context 6.2 The health worker experience Unmanageable workloads Too many tasks and responsibilities Working day and night Over-long shifts and too little time off Impacts on health Restricted professional development Failing the patients 6.3 Factors contributing to understaffing and work overload 6.4 Recommendations 6 12 12 12 14 14 15 16 19 21 25 25 25 26 26 26 28 28 28 29 29 30 30 31 31 33 33 33 34 34 34 34 34 34 35 36 37
Our Side of the Story: The lived experience and opinions of Ugandan health workers
7. The facility infrastructure 7.1 The context 7.2 The health worker experience Low job satisfaction Risks to health workers Risks to patients 7.3 Recommendations 8. Equipment and medical supplies 8.1 The context 8.2 The health worker experience 8.3 Recommendations 9. Medicine supplies 9.1 The context 9.2 The health worker experience 9.3 Recommendations 10. Pay 10.1 The context 10.2 The health worker experience Money worries Failing to meet social expectations Disrespect Thwarted professional ambitions Unfair pay 10.3 Poor pay, turnover and loss to Uganda 10.4 Recommendations 11. The way forward 11.1 Raising the voices of health workers 11.2 Changing public perceptions of health workers 11.3 Bridging patient communities and healthcare facilities and staff 11.4 Summary of participants recommendations Appendix A: Sample details Appendix B: Local government structures in Uganda References Annex: Health worker topic guide
38 38 39 39 39 39 40 41 41 41 43 44 44 44 47 48 48 48 49 49 49 49 49 51 52 53 53 55 55 57 59 61 63 66
Our Side of the Story: The lived experience and opinions of Ugandan health workers
Summary
The Valuing Health Workers research and advocacy initiative
The Valuing Health Workers research and advocacy project is an initiative of VSO International. It recognises that health workers voices must be heard and acted on to improve 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 with in-country non-governmental organisations. VSO carried out research in Uganda from February 2010 to February 2011 in partnership with HEPS-Uganda, the Coalition for Health Promotion and Social Development. 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. regions of Uganda and in the capital city, Kampala, covering government, not-for-profit and private ownership organisations. Health worker participants contributed their perspectives in small group discussions or individual interviews. In addition, 24 stakeholders from civil society organisations, trades unions, professional associations and regulatory councils participated in workshops or interviews.
Our Side of the Story: The lived experience and opinions of Ugandan health workers
Workload
Ministry of Health sources reveal almost half of approved posts at health centres and hospitals are vacant a shortfall of 25,506 staff. There are gross disparities across local government districts, with four districts having less than 30% of posts filled, while 10 districts filled more than 70%. Unmanageable workloads overwhelmed nurses and made them physically and mentally ill. Too many tasks and responsibilities led to burn-out. Lack of more qualified staff meant taking on stressful roles beyond the scope of duty. Participants told of working round the clock, foregoing meals and compromising their health. Overlong shifts and limited time off allowed little personal or family time. Feeling they were failing the patients added to health workers distress. Hospital nurses torn apart by calls for attention and too many tasks recognised they could lose their temper. Midwife behaviour changed as a result of working alone day and night. Long, tiring shifts, when overwhelmed by the workload, led to nurses being short with patients, not interacting with them and conveying disinterest through attitude and expression.
Our Side of the Story: The lived experience and opinions of Ugandan health workers
Managers and frontline doctors had seen how hunger made nursing staff bad-tempered and rude to patients. It was said that long shifts, together with poor pay, led nurses to not turn up for duty and leave work early. Managers observed that lack of opportunity to fulfil their proper professional role demotivated nurses, who then ran out of compassion and skip out from work. Work overload and staff shortages had impacted on community relations, and participants told of aggressive outpatients and wrongful accusations of neglect of duty. Managers explained that financial allocations for salaries stood in the way of recruiting more staff and that vacancies persisted due to bureaucratic procedures. Paradoxically, scarcity of staff was a barrier to holding public sector health workers to account, as disciplinary procedures might lead to transfer and an even worse workload for remaining staff.
Infrastructure
According to official sources, most facilities are in a state of disrepair. Many health centres have non-functional operating theatres. Only one in four facilities has electricity or a back-up generator and only 31% have a year-round water supply. Over half facilities lack transport for patient referral in maternal emergencies and only 6% have technology to communicate. Government sector workers in rural facilities bore the brunt of infrastructure failures. When theatres were unusable, underemployed doctors lost interest and left. Lack of electricity compromised staff and patient safety. At night, patient notes could be not read to ascertain HIV status and deliveries were carried out by the light of a mobile phone or a candle. Maternity workers said patients construed their behaviour as rude or neglectful because they shied away from risk. Lack of generator fuel meant operations were completed by torchlight. Nurses feared assault working in unlit wards or crossing dark compounds, a risk made worse by lockless doors, breaches in compound fences and inadequately equipped or absent guards. A lack of water to flush toilets forced staff to return home, fuelling patients beliefs they were not at work. Infection control was near impossible when nursing staff had to beg the little water spared by patients family attendants to wash their hands. It was deeply upsetting to know that poor patients would die because the facility had no means of transporting them to a hospital that could give the treatment they needed. Making transport available to bring patients to the facility, supported by easy mobile phone access to staff, was said to benefit community relations.
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 on undersupply for population demand; shortfalls in supply where deliveries did not match orders; erratic deliveries (such as oversupply of condoms but no anti-malaria drugs) and irregular deliveries which did not conform to promised quarterly schedules. Unable to give their patients the drugs they needed, health workers became demoralised by the futility of their roles, and their self-esteem suffered when patients lost confidence in them. Health workers grieved for their patients suffering from the lack of medicines, such as antiretroviral drugs, which should be taken on a lifelong basis. Helplessness was hard to bear when they felt forced to tell poor patients to buy their medication in the private market. Health workers struggled with disappointed patients and their limited understanding of reasons for shortfalls in supplies. They also told of angry, bitter patients who cursed them and refused to listen. They said that communities served by government facilities assumed health workers took the drugs. There was widespread indignation at accusations of stealing non-existent medications. Health workers resented negative stories in the media and felt that local leaders and politicians made matters worse when they failed to present the true 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 by stating publicly that health workers are thieves.
they had put in, and going unrewarded for doing the same work as higher grade staff was thought bitterly unfair. Doctors being paid less than secretaries and drivers in some statutory agencies underscored the little value attached to the medical profession in Uganda. Salaries were doubly unfair because they did not reflect the long hours many health workers put in. Participants acknowledged that poverty led to bad practices minimal effort, late arrival at work, venting of frustrations on patients, small-scale pilfering of drugs and accepting money offered by patients. It was widely believed that urban health workers were forced to work in two or even three jobs to make ends meet, leading to exhaustion and behaviour which patients perceived as rude. Better pay was not an overriding consideration for working outside Uganda. Nurses explained they were looking for an environment where their work would be respected and where they could learn about different medical conditions, use equipment they were trained to use, update their skills and have the chance to advance professionally. Doctors spoke about the attraction of a better income from work abroad, but opportunities to use proper equipment and enjoy the work also were important.
Pay
Ugandan nurses and doctors salaries are the lowest in East Africa. Monthly starting salaries in public service in 2009-10 were 353,887 UGX (Ugandan Shillings) ($US 191) for a registered nurse and 657,490 UGX (($US 354) for a medical officer. High court judges received 6.8 million UGX (($US 3,664) per month.1 Nursing staff spoke heatedly about their struggles to survive on low pay and support their dependents, see their children through education, pay for a roof over their heads, settle essential bills, afford transport to work and save towards the costs of further training. Financial worries added to the stresses caused by impoverished workplaces. Doctors felt socially embarrassed when they could not contribute large sums of money at functions held to raise funds for weddings or funerals, or meet expectations to help with school fees. It was said that patients look down on nurses when they know how little they are paid. Participants voiced strong opinions that the pay was unfair and undervalued health workers. Nurses complained that their salaries did not reflect the years of study
1.
Our Side of the Story: The lived experience and opinions of Ugandan health workers
The findings identified two priorities for action: 1. to value health workers for their contributions to the health of Ugandans 2. to 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. to improve the quality and relevance of training 2. to raise the voices of health workers through representation 3. to change public perceptions through the media 4. to build bridges with patient communities.
Recruitment blockages Manage health worker recruitment and deployment centrally, to address the problem of unfilled posts and uneven distribution of health workers. Decent staff accommodation The Government should follow through on its strategy to provide decent and safe accommodation for health workers at health facilities, especially in remote areas. Civil society organisations should continue to monitor implementation of this strategy and press for concrete targets. Facility infrastructure Ensure regular meetings between management and department heads, at which facility-related problems can be raised and decisions taken on actions needed. Invest in good theatre facilities and their staffing in a small number of level IV health centres, and showcase them as good practice before embarking on further investment. 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.
Priorities
1. Value health workers for their contributions to the health of Ugandans
Health worker terms and conditions of service Review salary scales to determine whether increases in basic salaries are possible. Reform government salary scales to recognise first and postgraduate degrees, in order to attract degree nurses to public sector jobs and ensure their education is used to support patient care directly. Consider the establishment of a minimum wage and the feasibility of imposing the same salary structure in all sectors (government, not-for-profit and private). Overtime and responsibility payments Explore a system for remunerating health workers for overtime. Consider implementing a responsibility allowance paid when a nurse has sole charge of a ward. Small financial motivations Incentivise staff through small items of personal support, such as food for the household, snacks at work, and Christmas and Easter gifts. Contributions towards family burials, medical operations and provision of cloth for uniforms are well received. Review current allowances for risk, hardship, housing, transport, responsibility and study, to ensure consistency and fairness across all facilities. Use the income from local government hospitals private wings to benefit staff, by supplementing salaries or allowances.
Enabling strategies
1. Improve the quality and relevance of health worker training
Career guidance and early contact Ensure well-motivated trainees, for example through more talks at schools and work experience placements. Training schools admission procedures Reject applicants who seem to be applying for the wrong reasons, including those allocated to a university course which is not their first or second choice. Developing and sustaining the right heart in training schools Return oversight of training to the Ministry of Health from the Ministry of Education and Sports. Reduce nursing and midwifery class-sizes and improve tutor capacity, to ensure the right attitudes and practical understanding of the ethical code are encouraged throughout pre-qualification training.
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Health and human rights training Expand existing partnerships between training institutions and health consumer advocacy organisations. Improve nursing course content to make sure that students take on board the role of the nurse as a patients advocate. De-urbanise health worker training Increase the number of training schools and residency programmes in rural areas to produce staff already adapted to rural environments and connected to the local community. Improve the community service element in medical curricula and increase the exposure of urban health students to rural settings with increased fieldwork. Nurses and Midwives Council registration interviews The Nurses and Midwives Council should weigh up the advantages of screening interviews held as a prerequisite for registration post-qualification against detrimental effects on nurse morale.
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1. Introduction
1.1 The VSO Valuing Health Workers initiative
What is life like working in healthcare in a low-income country? What prompts nurses, midwives and doctors to take up their professions and what are the rewards? What do health workers say about the barriers they face in providing access to healthcare? What in their view needs to change? And how can their voices be heard? VSOs Valuing Health Workers initiative is listening to the experiences of health workers and gathering evidence to advocate for change.
The lived experience and opinions of health workers are rarely recorded in the many explorations of solutions to the health worker crisis affecting the developing world. Health workers are commonly seen as human resources, as a part of a healthcare delivery mechanism to which levers may be applied, and not as human beings whose individual actions are influenced by the societies and conditions in which they live and work. Rather, performance management techniques and incentives to attract and retain staff dominate research and policy. VSO International set out to redress this imbalance through its Valuing Health Workers research and advocacy initiative. Recognising that health workers voices must be heard and acted on to improve 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 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. 3. 4.
See Kiwanuka et al 2008 for a systematic research review Kiguli et al 2009 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 negatively on health workers low productivity, high absence rates, poor attitudes and lack of accountability to client communities. Organisations promoting health rights have seen distrust and hostility among communities and some defensive reactions among health facility staff. Health workers in Uganda face harsh working conditions. The Ugandan Ministry of Health acknowledges staff shortages, inadequate pay, poor worksites, risk and insecurity in the workplace, limited and poor-quality staff accommodation, and harassment; it also recognises that staff endure poor supervision and leadership and a lack of promotion, training opportunities and career progression.5 Facilities and equipment in states of disrepair, and shortages and wastage of medicines, have been pervasive problems.6 Yet little attention has been paid to the impacts of working conditions on the lives of healthcare staff, and so on the quality of services they can provide. Research on or with Ugandan health workers has focussed on workforce retention questions, such as migration, intent to migrate and turnover.7 It has measured job satisfaction and quantified work factors related to intent to stay or leave.8 A second area of research has measured health workers informal income generation practices, such as spending working hours engaged in agriculture and operating private clinics, and has quantified absenteeism.9 10 Certainly, some research reports include the voiced experiences of health workers.11 But only exceptionally has research started from the viewpoint of health staff as workers and members of families and communities, as opposed to the viewpoint of the system.12 Only one study has focussed on the distress and emotional toll of working with insufficient resources for acceptable levels of care.13
The starting assumption of the Valuing Health Workers research in Uganda was that health workers are unfairly blamed for attitudes and behaviour caused by the system in which they work. Health workers are human beings men and women with their own worries, working in very challenging circumstances and they develop ways of coping with difficulties, frustrations and being under-valued. The research does not condone unethical or unprofessional behaviour and dereliction of duty, but it does not brand as quiet corruption absences from the workplace and external income-generating activities.14 Such moralising finger-wagging15, which addresses issues in terms of lack of motivation, corruption and betrayal of professional codes of conduct, diverts attention from structural conditions and social and cultural environments.16 The research set out to challenge the overwhelmingly negative commentary on Ugandan health workers. It wanted to hear the positive side from health workers themselves: their passion for their professions, commitment to patients and communities, determination to give their best and the satisfaction gained from contributing what they can. The research was especially concerned to find ways of bridging the seemingly widening gap between communities and healthcare facility staff. Projects on the ground in Uganda have tended to focus on promoting the rights of healthcare users and increasing the community role in monitoring health workers.17 While less attention has been given to the health worker side, community-based projects have latterly fostered mutually respectful relationships.18 Research in Uganda and five other African countries recommended improved understanding of the roles of health workers and encouragement of mutual respect through better communication and interaction.19
5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
Ministry of Health 2006 Ministry of Health 2010a; 2010b Awases et al 2004; Dambisya 2004; Nguyen et al 2008; Onzubo 2007; ONeil and Paydos 2008 Ministry of Health 2009a; Hagopian et al 2009 McPake et al 1999; McPake et al 2000 Chaudhury et al 2006; UNHCO 2010 Ministry of Health 2009a; UNFPA Uganda Country Office 2009 Kyaddondo and Whyte 2003 Harrowing and Mill 2010; Harrowing 2011 World Bank 2010 Van Lerberghe et al 2000 p3 Schwalbach et al 2000 Bjrkman and Svensson 2007 Muhinda et al 2008 Awases et al 2004
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
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
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
1 14 4 94 42
Disease in Uganda
Sickness is normal rather than exceptional. Over 4 in 10 household members surveyed (43%) said they had fallen sick in the previous 30 days; malaria or fever is by far the most prevalent illness, reported by over half, followed by respiratory illnesses which affected 15%.28 Seventy per cent of child deaths are due to disease or malnutrition, with malaria accounting for one third of these deaths.29 HIV prevalence fell to 7% in 2007-08 from 27% in 2000-01.30 Yet the number of people living with HIV in 2010, around 1.2 million, was higher than at the peak of the epidemic in the 1990s.31 The WHO ranked Uganda 16th of the 22 countries with a high tuberculosis burden in 2010. Uganda has the second highest accident burden.32
World Health Organisation 2010 Ministry of Finance, Planning and Economic Development 2010 Baryahirwa 2010 Ministry of Health 2010a Ibid. Ministry of Finance, Planning and Economic Development 2010 Ministry of Health 2010b
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Table 5 Health financing and expenditure 2000-01 to 2009-1036 (in billion Uganda shillings)
Year 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10* Government of Uganda funding 124.23 169.79 195.96 207.80 219.56 229.86 242.63 277.36 375.46 435.80 Donor Projects and Global Health Initiatives 114.77 144.07 141.96 175.27 146.74 268.38 139.23 141.12 253.00 301.80 Total 239.00 313.86 337.92 383.07 366.30 498.24 381.86 418.48 628.46 737.60 Government health expenditure as % of total government expenditure 7.5 8.9 9.4 9.6 9.7 8.9 9.3 9.0 8.3 9.6
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
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Ministry of Health 2010b Nabudere et al 2010 Republic of Uganda 2010 Ministry of Health 2009c p3 Konde-Lule et al 2007 Retrieved at www.unfpa.org/sowmy/resources/en/library.htm Includes 134 facilities under construction or otherwise not functioning Ministry of Health 2010b Ministry of Health 2010b Table 5.3
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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 a health centre IV should refer patients it cannot serve. The Ministry of Healths inventory shows that 15 out of 80 districts had no hospital. The problem of providing a district-level hospital has become more acute since the number of districts reached 112 in mid-2010. A general hospital is expected to refer patients to the nearest of the 13 government-sector regional referral hospitals for services not available at general hospitals. Current policy does not allow not-for-profit or private hospitals to be designated as regional referral hospitals, although in practice some not-for-profit general hospitals fulfil that role. The main national referral hospital stands at the top of the pyramid and provides specialist services.45 Patients may, and often do, by-pass lower levels and go direct a referral hospital. The central government oversees the semi-autonomous national and regional referral hospitals. Since decentralisation in 2006, district health offices oversee general hospitals and health centres. Health sub-districts are expected to plan, conduct in-service training, coordinate service delivery and supervise their lower-level health units. They are normally headed by a medical doctor at a general hospital or an upgraded health centre IV. All local government health centres and hospitals must have a Health Unit Management Committee (HUMC) which should oversee the running of the facility. Committee members can be selected by the District Council, locally elected or appointed because they hold other positions. They have been recommended as vehicles for community participation, but have been reported as not functioning as expected.46 47 HUMCs had a chequered reputation in the past, believed to 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. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59.
The other national referral hospital is a psychiatric hospital. Kapiriri et al 2003 Rutebemberawa et al 2009 Azfar et al n.d Burnham et al 2004 Kidder 2010 Uganda Bureau of Statistics 2008 Konde-Lule et al 2007 Baryahirwa 2010 Ministry of Finance, Planning and Economic Development 2010 Ministry of Health 2010b Baguma 2010 Uganda Bureau of Statistics 2008 Republic of Uganda 2010 Uganda Bureau of Statistics 2006
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
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
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Table 7 shows the proportions of these occupational groups in the 2002 census. Nurses and midwives made up almost half, nursing assistants/aides over one third, and allied health professionals (including clinical officers)70 and medical doctors less than 10% each. The census found 1.2 doctors and 14.5 nurses, midwives and nursing assistants per 10,000 people. WHO data for 2005 give a similar picture of 1.2 doctors and 13.1 nursing and midwifery personnel per 10,000 of the population. While there are no comprehensive up-to-date data, it is known that numbers have increased as has the population of Uganda. For example, it was reported in 2011 that Uganda has 9,701 midwives; however this number equates to only seven midwives per 1000 live births.71
Geographical distribution
Urban/rural imbalance in the distribution of health workers is a key problem in the delivery of healthcare. WHO 2004 data in Table 8 show that the majority of medical doctors (61%) were urban-based, while the great majority of nurses, midwives and especially medical assistants (clinical officers) were rural-based. Moreover, data from the 2002 census show that the most highly qualified professionals were concentrated in the region which includes the capital, Kampala (Central region). It contained only 27% of the population but had 64% of the 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)
Number Medical doctors Allied health professionals Nursing & midwifery occupations Nursing aides / assistants Total
Population 2002 = 24.4 million
Table 8 Urban / rural distribution of four main cadres (WHO 2004 data)
Urban Total Medical doctors Medical assistants Nurses Midwives Totals 2,209 2,472 14,805 4,164 23,650 No 1,345 247 2,613 1,047 5,252 % 60.9 10.0 17.6 25.1 22.2 No 864 2,225 12,192 3117 18,398 Rural % 39.1 90.0 82.4 74.9 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
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
It is widely held that medical doctors and nurses leave Uganda for employment in other countries, but comprehensive supportive data are not available.82 The Uganda Nurses and Midwives Council verified that 808 nurses left Uganda in 2009-10, nearly half for the UK.83 The destinations of qualified staff leaving six hospitals in a remote region between 1999 and 2004 did not include work in other countries.84 Follow-up of a cohort of graduates of one medical school found deaths, most presumed to be AIDS-related, a bigger brain-drain than emigration in the 20 years after graduation in 1984.85 Premature death is emerging as one of the most important causes of exit from the workforce in Sub-Saharan Africa, causing Uganda to lose an estimated 2% or so of its medical, nursing and midwifery workforce each year. Annually an estimated 26 physicians in every 1,000 and 22 nurses and midwives in every 1,000 die before the age of 60 in Uganda, among the highest rates in the 12 African countries for which data are available.86
*Non-health occupations not recorded separately; includes 3,228 employed simultaneously in other sectors
Ministry of Health 2009c, p6 Ministry of Health 2006 Mandelli et al 2005 Ministry of Health 2006 Africa Health Workforce Observatory 2009 Dal Poz et al 2009 Table 5.3 Spero et al 2011 De Vries 2009 Spero and McQuide 2011
Africa Health Workforce Observatory 2009 Senkabirwa 2010 Onzubo 2007 Dambisya 2004 p601 Dal Poz et al 2009 Mandelli et al 2005 Ministry of Health HSSP II Table 1 Mandelli et al 2005
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
More recent sources state that members of three faith-based medical bureaux (Catholic, Protestant and Muslim) together in 2009-10 had slightly over 11,600 health workers, around 30% of the combined government and not-for-profit workforce,90 and that government facility staff numbers had reached 23,452 in 2009.91 Despite efforts to clean the government payroll and update rosters, there are still problems in determining how many staff in each cadre are on the payroll and where they are assigned.92 In 2010, ghost workers were exposed in a number of districts and notably at a national referral hospital, and transferred staff were found to be still receiving salaries at their original place of work.93 The most recently available data on occupational breakdown across sectors are for 2004 and 2005, as shown in Table 10. As health workers, especially medical doctors, have jobs in more
than one sector, the numbers include double-counting. It is reported that more recent tables show that there has been tremendous improvement in health worker staffing levels in Uganda since 2004 and that the total number of medical doctors in health facilities is 3,917 (presumably in government and not-for-profit facilities).94 In 2004, almost half the medical doctors and over four in 10 nurse employees in government facilities worked in the two national referral hospitals and the 11 regional referral hospitals, while the great majority of nursing assistants, clinical officers and midwives worked in district level facilities (Table 11). Overall, there are severe shortages of facility-based health workers in the formal sector. Chapter 6 details the shortfalls and the 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 Medical doctor Clinical officer Midwife Nurse Nursing assistant/aide Government 598 1,585 2,129 4,500 4,463 Not-for-profit 305 436 914 1,915 2,005 Private 1,511 190 1,377 3,557 1,146
Table 11 Occupational groups in local government district facilities and national and regional referral hospitals, August 200497
Occupation District facilities Number Medical doctor Clinical officer Midwife Nurse Nursing assistant 308 1,319 1,635 2,542 4,165 % of total 51.5 83.2 76.8 56.5 93.3 National & regional referral hospitals Number 290 266 494 1,958 298 % of total 48.5 16.8 23.2 43.5 6.7 598 1,585 2,129 4,500 4,463 Total
Republic of Uganda 2010 Matsiko 2010 Ministry of Health and The Capacity Project 2008 Medicines and Health Service Delivery Monitoring Unit 2010
Matsiko 2010 p24 Adapted from Matsiko 2010 Table 3.1 Mandelli et al 2005 Table 9 Adapted from Matsiko 2010 Table 3.1
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
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
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
The largest professional group was registered nurse and/or midwife, followed by enrolled nurse and/or midwife and nursing assistant (Figure 2).
16 41 24 40
24 30
Eleven participants worked solely in administration: five qualified nurses, five medical doctors and one with another 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).
Of the 122 participants, 38 were men. Men were in all occupational groups except clinical officer (Figure 5).
63
Female
6 11
4 3 3 44
50 40 30 20 10 0
19 11
Nurses & midwives
26 25
14 6 0
Doctors Clinical officers
5
Nursing assistants
Other/none
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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.
in ill and goes back happy. Seeing life enhanced was also hugely rewarding: Making people happy makes me happy. Just seeing some improvement in a patient was cheering. Midwives spoke of the rewards of working for the welfare of two people, a live mother and a live baby and achieving something positive with no mother or baby lost.
Benefiting families
The nurse is the most important person in the family. Especially for nurses in rural settings or from rural families it was hugely rewarding to be able to deal with family health problems. Knowing how to prevent and treat illness in your immediate family, as well as how to protect yourself, was a significant factor encouraging a commitment to nursing which would last up to and beyond retirement: You will be a nurse until you die. Nurses at some rural health centres pointed to the advantages to their family and themselves of quick access to free treatment. The nurse could use his or her knowledge to treat a relative and save the costs associated with referral to a health centre or hospital. It was said in some facilities that staff and their family members were given free medication.
Benefiting patients
Participants highlighted the visible results of care and treatment. They expressed their delight at the benefits to patients. Nurses and medical doctors spoke about how happy and proud they felt when a patient who arrived sick, even on the edge of death, went home recovered: I love it when someone comes
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Maternity workers spoke of their joy when they safely delivered a healthy baby, when everyone is smiling, and the satisfaction of seeing that baby grow. Having done good nursing work treating a badly-off patient who improved and was discharged gave a kind of job satisfaction and encourages me to care for patients a little more. For nurses, it was good to have done something, no matter how little, to help save a life. Achieving successes is not easy in Uganda and an occasional victory, such as when a sick child recovers, was something to live for, that makes you do what you do. Participants spoke of the satisfaction of doing a good job when there was enough equipment, other medical supplies and medicines to enable proper care: Most of what you need for a patient is available, so your job is not much interfered with or You cannot forget your skills. Elsewhere health workers commented on the satisfaction of just being able to play 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 caring tenderly where they could. Particularly for younger participants, opportunities to learn through work and to experience managing different kinds of medical condition were highly valued. While not commonly reported, opportunities to learn new skills, such as counselling, were valued for their benefits to patients. In the few instances where workplace-based education programmes were in place, participants spoke enthusiastically about how they shared their learning with other staff and developed new communication skills.
It was noted that expressing thanks was not the norm in some parts of Uganda, and health workers spoke enthusiastically about the boost a thank you from a patient gave them: You feel very happy after your work when they say thank you. So you keep on, because you are enjoying it. For some, the pleasure of helping was enough whether praised or not: I feel it inside my heart. As well as appreciation, recognition of their expertise was important to nurses: Their confidence in you boosts your own confidence. Midwives expressed their delight when a baby was given their name. Nursing staff and medical doctors emphasised how recognised and appreciated they felt when a past patient greeted and thanked them warmly or showed off your baby. Being remembered by patients was seen as a mark of trust and a boost to the nurses own confidence. For some nurses, respect and trust on the part of patients or caregivers opened up disclosure of confidences and opportunities for further help.
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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.
life-threatening condition. Unsympathetic handling prompted a wish to improve the quality of nursing, and the shouts of women abandoned in labour evoked an urge to help. Women spoke of wanting to be a nurse from as early as primary school stage, never considering any alternative. They saw themselves as naturally kind, a helping sort of person, with an urge to relieve suffering: I just had it in me or I had that heart. Some women found they developed the heart as young adults when they had to nurse a family member. Not-for-profit sector participants especially cited a desire to love and serve the patients or to care for the needy, spoke of coming closer to God or explained they had a call or were chosen by God. Health workers emphasised giving and spoke less about what they had expected to gain from their profession, though the prospect of knowledge to care for and treat ones family and oneself was important, especially among lesser qualified women in rural areas. Nurses happiness when a patient recovered was mentioned, as was the respect people gave to a local nurse. The nurse had status as a life-saver, a person of importance to call on in an emergency. Young girls who went on to be nurses had been greatly attracted by the dress and deportment of nurses, admiring their smart, clean uniforms, shoes and gloves, and the way they walked, which distinguished them from other people. Among would-be medical doctors there was some admiration of smart white coats and acknowledgement of the prestige attached to doctors. A desire for money was not a driving force, though earning in a steady job was certainly a better option than digging in vegetable gardens and relying on uncertain harvests. In the most remote rural area, the health facility was the only source of training and employment locally, and so a magnet for school-leavers.
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
For most participants, the decision to become a health professional was positive and informed. Time spent at hospitals or health centres as a patient, relative of a patient or just as a curious child allowed to sit with nurses had shown how nurses worked with patients and helped stimulate an interest. Empathy for patients sometimes developed when touched by their condition. Having a father, mother, sister, brother or aunt in a nursing or medical field gave some insight into the work, through visiting their place of work, living in staff quarters or listening to their accounts of day-to-day happenings. A close relatives positive attitude, humility or empathy for patients attracted young women to nursing. For many of those participants, the example of their relative was the main reason for entering a nursing or medical profession. With little career guidance at school, it was natural to do what members of the family were doing. Others felt family expectations to take up some kind of profession and saw health work as more appealing than the teaching, secretarial or business occupations suggested even rebelling against fathers who insisted on a teaching course. Some older participants spoke of encouragement from adults at school or family friends, such as priests and nuns, to apply for a medical or nursing course. There were a few instances of people from that generation recruited to apply for nursing by agents of the Ministry of Health, and also of following family wishes or suggestions in complete ignorance of what nursing involved. Clinical officers and medical doctors told of expectations on them as the brightest school students to enter one of the prestigious professions. If they excelled in science subjects, engineering and medicine were the prime alternatives. The path towards medicine could be set in early years when top students were pushed towards sciences. Where faced with a choice of career direction, financial security was something younger men had considered, in the context of many qualified professionals chasing too few jobs: At least you can always find a job. But nobody said they joined the nursing or medical profession purely for that reason. Among doctors, the choice of medical training against another science-based profession was in some cases influenced by the prospect of professional advancement and mobility, self-employment and private practice. Not all those who had decided on a career in the medical field entered via the course of their choice. Lacking financial backing from their families, uncertain about getting the grades or failing to gain entry, would-be medical doctors had to settle for 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.
5.3 Recommendations
Career guidance and early contact
There were suggestions from frontline health workers and managers on how the decision to join nursing and medicine might be better informed and professionalism thus improved. A strenuous profession like nursing was said to need emotional preparedness, with career guidance at an early stage to know what it takes. It was suggested that more talks at schools should set out to give the real picture. What emerged strongly from participants accounts was the impact of contact with nurses, midwives and medical workers during formative years. It was told how staff at a boarding school regularly took pupils to visit a local hospital, and how interest in nursing grew out of voluntary employment initially undertaken reluctantly. Experiences such as these suggest value in schools arranging contact between students and health facilities, and work experience placements.
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
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
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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.
Not surprisingly, health workers told of the personal repercussions of understaffing and heavy workloads. But also they spoke passionately about the damaging effects on patients and on community perceptions of health workers.
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
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Health centre midwives suffered especially. Midwives in rural health centres told of working alone day and night, sleeping with their children in disused wards, always on call to deal with expectant mothers often arriving in late stages of labour. A manager acknowledged that a midwife had worked alone and on call for five months. In a private sector health centre scheduled time off had to be foregone for the sake the patients: If a doctor prescribes care for 24 hours we have to stay, and then work again next day. Over-long shifts and too little time off Among not-for-profit hospital nurses there were complaints about being forced into working 12-hour shifts. Taking up the option of working shorter hours would reduce days off from two to one, a hard choice for nurses with children and homes to look after. Days off duty are important times to do your own things and should be an entitlement. Yet it seemed taken for granted that nurses and nursing assistants living on site in staff accommodation would turn out in their off time to fill staffing gaps in some health centres. Even a not-forprofit hospital with clearly specified conditions of service was reported not to give good time off because of understaffing. Impacts on health Among nursing staff in government health centres and general hospitals there were concerns about the effects on health of foregoing or delaying meals because of work pressure. Not eating on schedule was a key concern when suffering from diabetes, and eating well was important to maintain immunity against infection from patients. Even taking a drink was not easy because how would it look when they are in pain? It was even hard to make a quick toilet visit without being reprimanded by hospital managers. Restricted professional development Managers concerns included the impact on clinical officers development when they lacked the opportunity to work under the guidance of a medical doctor, and the professionally isolating consequences for staff with no supporting teamwork: Nobody to consult when you are stuck, nobody to delegate to when you are unable. A nursing assistant had been put in a role that took her away from direct patient care, to fill gaps in the professional staff complement: I want to learn more from the patients but I have no choice. 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.
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Failing the patients Among health centre IV workers the lack of a medical doctor was one of the biggest concerns, more important to them than frustrations about individual workload and personal consequences: I can get demoralised seeing someone dying in my hands because we are missing a doctor and It really hurts a lot when a patient is dying and you know what should be done. You even go home depressed. Health workers who expressed these feelings were adamant that they kept on turning up for work to stop the next persons suffering: If Im depressed because someone has died and I say I am not going to work the next day, then we are going to lose more.
she has run out of compassion and the patients say she is not caring. They said that overwhelmed nurses skip out from work, ask to be transferred and run away to the private sector, where patients do not complain they are neglected. Midwife behaviour towards patients changed as a result of working alone all day and all night, especially with no peace of mind due to personal and family worries: So you become tough with the mother so that she understands and you get a live baby and a live mother. Managers were well aware of the unacceptably long hours midwives put in and spoke openly about the effects they had seen: As time goes by, because of the fatigue and perpetual calling, somehow as a human being you tend to deteriorate. Midwives no longer in the government sector understood how overtired midwives were forced to escape from 24-hour work in health centres to make contact with their families. Among midwives, perpetual responsibility for the lives of mothers and babies was a burden and it was hard to stay patient with the mothers. Nurses spoke about the knock-on effects on their patients of their having to do too many things at once: You find you are stressed and are rude to patients unknowingly. There were some strong views that workload in some large hospitals was made worse by senior staff malingering or not pulling their weight. A view from the private sector was that frustrated junior nurses in the government sector took it out on the patients. Long tiring, shifts led to nurses overwhelmed by the workload being short with patients, not interacting with them and conveying disinterest through attitude and expression. Managers and frontline doctors had seen how hunger made nursing staff bad-tempered and rude to patients. It was said that long shifts, together with poor pay, made nurses look for ways of escaping: not turning up for duty and leaving work early. Yet it was also said that even after 12-hour shifts, some nurses went on to other nursing jobs, just to survive financially, and so developed bad habits.
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Health centre workers realised that no respite in long shifts led to community complaints about harsh language: We work the whole day without resting, and in the late afternoon we get tired and then we change face. Staff working set hours had met some hostility from local people who assumed the health centre was closed to outpatients when they saw health workers socialising together towards the end of the working day. The staff there pointed out that they worked hard to serve outpatients quickly and so deserved some rest-time after patients had stopped arriving. It was also hard to make waiting patients understand that health workers were not resting when they sat completing paperwork. Health workers in sole charge of patients faced a dilemma: go hungry or leave the patients alone? Doing the latter was reported to have brought unfortunate consequences for staff who were arrested for neglect of duty. It was said that the arrests were motivated by local political candidates seeking to gain electoral favour through discrediting ruling politicians with oversight of the facility. Clinical officers can be left alone to cover an entire health centre, running from one department to another. So it was deeply upsetting when a patient arrived, assumed no staff were available, and called on a local leader who then complained to higher authorities. The lack of a medical doctor rebounded on other staff: When the patient dies, the community look on you as a bad person who refused to treat the patient. Lack of a midwife or qualified nurse meant that nursing assistants carried out deliveries. They found it hard to convince patients to put their trust in them, especially as they themselves recognised they lacked the full range of knowledge to save pregnant women in difficulty.
Managers explained why remote and rural facilities found it hard to recruit and retain medical doctors, nurses and midwives. They sympathised with new recruits who turned round and left for want of something to do in a village: They post someone out there in the wilderness and they expect them to work! With no electricity for TV and internet, people were not connected to the world. Poor roads and no public transport at night left staff stuck. Free staff accommodation was widely believed to make it easier for nurses and medical doctors to leave behind the amenities of town life. Poor-quality staff quarters, on the other hand, were a deterrent to taking up and staying in posts. An example was cited of rented accommodation of so poor a standard that it was not safe to raise a child there, leading to a nurse leaving her post. Health workers living in towns spoke along similar lines, adding that the cost of food was high in remote areas and educational standards poor. It was remarked that medical doctors dislike working in villages because of the lack of opportunity for learning and career advancement. It was also said that medical doctors avoid jobs at district level because local politicians misuse health service resources and interfere in treatment decisions.
Recruitment barriers
Government sector managers explained that financial allocations for salaries stood in the way of recruiting more staff: there was simply no money in the pot to pay more health workers. Even if funds were made available to fill authorised posts, vacancies remained due to bureaucratic procedures and the absence of a District Service Commission tasked with recruiting health personnel to the district.
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
priority over clinical and management duties at the facility, though the attraction of attendance allowances was alluded to. Paradoxically, staff scarcity was a barrier to holding public sector health workers to account for their absences. Turning a blind eye was preferable to starting disciplinary procedures which would likely lead to a transfer. It would be suicide to lose someone, as the remaining few would be more overburdened and blame the manager. Managers noted wryly that they had little leeway to dictate to medical doctors and midwives in understaffed facilities: They hold you at ransom, they know they have power because they can just go and get work somewhere else. A frontline doctor echoed the point: You work in a relaxed environment, they dont want to pressure you too much and push you away. It is reported elsewhere that Ugandan facility managers have no authority to discipline staff.108 Scarcity was similarly a barrier to redistribution of staff within a district. While in theory a district health manager could move a nurse or midwife from a better-served health centre to ease understaffing at another centre in the district, in practice the manager met resistance: They wont go because they know they are marketable.
that standards for patient/nurse and patient/doctor ratios be introduced so that health worker overload is transparent and quantifiable. Pressures would reduce if ratios were adhered to: The nurse can manage if a limit is put on the number of patients per nurse.
Recruitment blockages
Sensationalist media headlines about shortages contribute to negative images of health professions. Health reporters should be informed about obstacles to recruitment. The district level recruitment process is cumbersome and lengthy, entailing a number of steps as responsibility and paperwork pass from one authority to another. The District Service Commission has a role at several stages, but meets infrequently because of the costs of convening members and advertising vacancies.110 Many remote districts have no functional District Service Commission and no personnel officers to declare the vacant posts for recruitment.111 It was suggested that the problem of unfilled posts and mal-distribution of health workers across local government districts would reduce if health worker recruitment and deployment were managed centrally. Health workers explained that the current system de-motivates potential applicants who have to seek out and apply for positions.
Task-shifting
It is clear from workers accounts that work overload, stress and poor community relations result from doing work for which they were not qualified or trained. Such task-shifting has been found in government healthcare facilities elsewhere in Uganda.109 Managers and frontline workers expressed concerns about staff working beyond their scope of practice, when a nursing assistant acted as a nurse, a nurse as a midwife and a midwife as a medical doctor. This is necessitated by shortages and absences of suitably qualified staff. However, it seems that task-shifting was also a deliberate strategy to save money by employing less-qualified staff.
6.4 Recommendations
Staff shortages and work overload damage health workers, the quality of care and community relations. Attitudes and behaviour for which health workers have been criticised stem from physical and mental exhaustion, moral distress and burn-out.
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
What official documents do not show is the extent of broken or non-functioning power, water, transport and communications, revealed in an independent survey of a sample of 41 out of 64 government health centres in two districts.120 (Box 2) Data from a survey of not-for-profit sector facilities indicate a better picture, but the survey was biased towards urban facilities. Electricity was most often reported to be sometimes available, although in a few cases it was never available. Access to water 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
Box 2: Basic conditions in a random sample of government health centres in two districts
(November-December 2009) 25% no power source 10% functioning electric power 30% functioning solar panel 25% non-functional solar panel 1 of 5 generator sets functional 10% functioning piped water supply 10% non-functional piped supply 40% functioning rainwater supply 10% functioning ambulance 12% non-functional ambulance 50% functioning motorcycle 20% non-functioning motorcycle 0% a landline, functioning official cell phone or email 10% functioning radio call 20% non-functioning radio call
Power
Water
Transport
Communication
Ministry of Health 2010b Republic of Uganda 2010 Ministry of Finance, Planning and Economic Development 2010 Ministry of Finance, Planning and Economic Development 2010
Womakuyu 2010 Ministry of Health 2010b HEPS-Uganda 2010, Annex IX Schmid et al 2008, Chapter 6
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Risks to health workers Working with no power or water, health workers naturally were worried about the huge risks to themselves: We are risking our lives. Maternity workers emphasised the risk of contamination from infected blood when working in the dark. Nurses expressed fear of assault working often alone in unlit wards or crossing dark compounds, a risk increased by lockless doors, breaches in compound fences and inadequately equipped or absent guards: We fear to answer the door when somebody knocks for help. No functioning flush toilet at the workplace forced a dangerous walk home through a snake-infested compound. Risks to patients Midwives and maternity nurses emphasised the risks to women giving birth at night. Assisting deliveries by the light of a mobile phone or a candle begged from a patient, they were forced to delay repairing episiotomies until daylight. Unable to read the patients case notes at night, midwives could not tell if she had HIV and so reduce the risk to the baby. Only a donors gift of lamps relieved months of suffering delivering in the dark. Infection control was near impossible when nursing staff had to beg the little water spared by patients attendants to wash their hands, and so try to prevent carrying infections to the patients. Participants told how expensive fuel for electricity generators ran out at crucial moments: Just yesterday we were doing an operation and we had to complete stitching by torchlight. Sterilisation was a huge challenge. As generator power must be conserved, it could not be used routinely for precious equipment, such as an ultrasound machine which mostly stood idle despite having a trained operator. Limited generator power did not allow refrigerated blood storage and patients could rarely afford the costs of travel to the referral hospital, to the distress of health workers: I feel so sympathetic and sorry. Transport is essential if the referral system is to work as intended, and is crucial when a facility cannot provide the intended services because of lack of infrastructure, power, equipment, supplies or qualified staff. Health workers showed pride in their facility when it had a functioning ambulance to transport referred patients or could rely on an ambulance sent on request from a higher tier facility. On the other hand, working in a facility with no patient transport was deeply upsetting because many patients just could not afford to pay their own transport costs: They say they will go to the hospital but they go home and later you find out that they died. Health workers 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.
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Commonly, budgets did not stretch to fuel the vehicle for referrals. It was widely acknowledged that patients were asked to pay towards fuel but that was often beyond the reach of people in poor communities. The negative impact on nurses and midwives cannot be exaggerated. They came into nursing to save lives, to use their knowledge to benefit their communities. For them it was very hard and frustrating to stand by unhappy and helpless, knowing that a mother and baby would die because the vehicle lacked fuel. Nor was it a good experience to see patients return to the facility in a terrible condition and very weak or with complications because of the lack of fuel for referral. Health workers also spoke of their frustrations when mechanical problems were left unattended. A managerial concern in the government sector was that effective referral systems need a means of communication from lower- to higher-level facilities. Health workers seemed resigned to using their personal mobile phones and paying for calls from their own pockets to contact referral hospitals. Because of the constraints on providing transport, it was unusual to hear of a vehicle being used to bring patients to a health facility. Staff in a government sector hospital were proud that it provided an ambulance service to bring in emergency patients, and noted how relations with the community benefitted as a result. There was also praise and gratitude expressed for a project that supported pregnant womens transport costs, resulting in more facility-based deliveries.
7.3 Recommendations
Frontline staff seemed resigned to working in poor conditions and struggled to identify ways of improving them, short of wholesale rehabilitation that would need unrealistic amounts of public expenditure. Recommendations are mostly from managers.
122. Similar findings reported by Dieleman et al 2007 123. Medicines and Health Service Delivery Monitoring Unit 2010
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
124. Ministry of Health 2010b 125. Achan et al 2011 126. Ministry of Finance, Planning and Economic Development 2010
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Working without protective wear gloves, aprons, gumboots, shoes, masks was a huge risk, especially for midwives working in the dark: You are bathed in blood. Lacking gloves, midwives even used their own clothes and plastic bags to grasp the baby during delivery. Workers in some rural facilities in the government sector provided their own work clothes as, it was said, the Ministry of Health no longer supplied uniforms. In the government sector there was widespread frustration at not being able to work effectively: What really hinders my work is lack of some equipment and The equipment does not allow you to do what you are supposed to do. Nurses spoke about thwarted professional fulfilment. Willing to work and capable of offering a full service, they felt handicapped and disappointed. 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 and You cant really be happy in such conditions, but would be happier with equipment to do your best. Frontline medical doctors spoke of struggling with the minimum and of feeling deflated by poorly maintained equipment such as x-ray machines with blown bulbs or no chemical to print the film: You wake up and have the same problem, you go home, you come back and it has not changed. Doctors wanting the satisfaction of doing their best for their patients spoke of frustrations such as a lack of diagnostic equipment or facility for blood counts. Managers recognised that medical doctors eventually lose morale when they are unable to operate on a patient because oxygen or sutures are missing, and that being unable to apply knowledge was very demotivating. Failing their patients greatly distressed nurses and doctors. Patients died because of the lack of essential supplies: We would have saved that life if we had oxygen. It stresses you. A lack of diagnostic equipment lost lives too: The patient probably would have survived if you were able to investigate. Government sector workers faced a dilemma when the facility ran out of supplies. User charges were abolished in the government sector127 and health workers told of prohibitions on asking patients to go and buy missing items: It is very annoying, you go home dissatisfied. The medical doctor has a duty towards the patients health: What do you do? Ask the patient to buy or see them get worse? The other option was to be kind and refer the patient to a higher-level facility.
Participants spoke against the policy: I dont feel it wrong to ask a patient to buy needles in order to help them, and it was clear that patients in some facilities were being asked to buy supplies. It was hard to ask a patient to buy items that should have been provided free of charge: I dont want to be the one to say go and look for a canula. Participants in facilities with relatively good supplies welcomed relief from the stresses of telling patients to buy their own. They also spoke of pride in a facility that did not force patients to spend their little money on intravenous fluids, canulas, gloves, dressings and the like. There was praise for imaginative management that solved temporary supply problems by borrowing from other facilities.
127. User charges were abolished in 2001 in all government facilities except private wings in hospitals.
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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.
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.
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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.
In parts of the government sector there was some acknowledgement that government efforts to improve the delivery system of the central medical store had brought improvements in supplies of essential medicines. It was also noted also that drug supply increased after a government stamp on packets was introduced. There was enthusiasm about how better supplies now benefited patients: Now we have enough drugs, I would not say all drugs, and inpatients get the drugs the doctors prescribe.
Ministry of Finance, Planning and Economic Development 2010 Uganda Country Working Group 2010 Ministry of Health 2008a Ministry of Health 2008b
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
There was sharp contrast between praise for medicine supplies in better-stocked facilities and disgruntlement among workers elsewhere. Health workers told of some essential drugs used up in a matter of weeks, or even days: They bring one tin of quinine tabs for a whole unit and Just five tins of panadol which the department can use up in one day. Complaints centred on undersupply for population demand; shortfalls in supply where deliveries did not match orders; erratic deliveries, such as oversupply of condoms but no anti-malaria drugs, and irregular deliveries which did not conform to promised quarterly schedules. It was suggested that shortages were made worse by patients taking unfair advantage of brief periods of plenty but with no testing equipment it was hard to refuse drugs to patients who claimed the common complaint of malaria. And it had been noted that patients turned up with a different patient record book every day of the week in order to stock up with drugs at home. Government facilities typically could not stretch their budgets to purchase drugs in the private market, and were forced to sit and wait for the next delivery from the central medical store. However, one hospital dedicated a quarter of its private-wing income to medicines.
be taken for the rest of a persons life, it was very hard to see patients go for up to six months without treatment. Health workers cared passionately about the consequences for poor patients: Few can afford even 2,000 shillings [$1], so day after day they walk here and wait. Walk 15, 20 km despite the pain.132 They felt the pain too when patients became more sick while waiting for their families to raise money to purchase medication. Hospital doctors spoke of how they were forced to refer admitted patients who could not afford to buy medicines, or just keep them in a bed without medication. The quality of care also suffered when the patient could afford only cheaper, inferior drugs which then failed to improve their condition, resulting in referral, an option many patients could not afford.
132. Some 51.5% of Ugandans live on less than $1.50 a day (UNDP 2010 Statistical Annex) 133. Nabyonga-Orem et al 2008
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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 stealing? or What kinds of drugs can we steal? Paracetamol? Because thats the only drug in the hospital! and How can they take things that are not there! Health workers felt that local leaders and politicians made matters worse when they 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. Health workers resented negative stories in the print media, TV and radio, believing that journalists blew up single incidents unfairly to give an exaggerated picture of the extent to which frontline health workers were guilty of pilfering drugs. A stakeholder concurred: We cant brand all health workers as thieves just because someone has stolen a tin of aspirin. Stakeholders noted that press stories about health workers stealing drugs had increased with the work of the Medicines and Health Supplies Delivery Monitoring Unit, an autonomous unit set up in October 2009 within the Presidents Office.134 While there was support for its efforts to expose poor working conditions as well as abuses, the view was expressed that it was unhelpful to create a media story around every wrongdoing the unit uncovered: They tried to create publicity instead of dealing with the real issue of what is causing the stock-outs. There was hurt and indignation too about top public figures spoiling the professions reputations when they stated publicly that health workers are thieves: How can any patient value a doctor, value a nurse, when they say such things about us! There were beliefs that government conspired to make out 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 Units 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
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9.3 Recommendations
Transparency at the point of delivery
They see the boxes coming and if next day you say there are no drugs, they feel like beating you up. Public opening of deliveries was one step that government sector health centres had taken, with varying degrees of success, to try to convince communities that medicines were not in stock. For example, to counter the community assumption that a lorry had delivered drugs, it was important to show that boxes offloaded contained condoms or saline solution. When essential medicines were delivered, their quantities were verified openly. Health workers told how variously the chairperson of the health unit management committee, the elected chair of the local community, the government internal security officer, police and patients witnessed the opening of boxes. This step must be supported by paperwork to show what has been ordered and delivered; government health centre recording of orders, deliveries and purchases has been described as appalling.137
Local leaders
The local government structure produces a large number of committee or council members and leaders at village, parish and sub-county level (see Appendix B). These people, often termed local politicians or local leaders, can have considerable influence over their local communities. Health centre workers told of dissatisfied patients who called on local leaders to support their demands for drugs. It is therefore essential that local leaders are fully informed and use information responsibly. Staff at one facility reported that trouble from local politicians had reduced after a meeting with them.
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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.
Average monthly salary for a senior nurse/midwife in government service143 Uganda Tanzania Kenya USD 341 USD 630 USD 1,384
As local government districts have discretion to top up salaries, these vary among staff of the same level. The Ministry of Health introduced salary top-ups in the most hard-to-serve areas, to attract and retain staff. It is reported that top-ups of up to 30% for six months attracted professionals to these areas.144 Facilities in the not-for-profit and private sectors set their own pay levels. It is known that not-for-profit sector salaries are lower than in the public sector.145
Matsiko 2010 Ladu 2010 Matsiko 2010 Ministry of Public Service http://www.publicservice.go.ug/public/Traditinal%20Salary%20Structure%202010%20-%202011.pdf 1 US Dollar = 1,856 Ugandan Shillings at 31 March 2010 Ministry of Health 2010b p37 Matsiko 2010 Schmid et al 2008 Fonn et al 2001
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be at a certain level and seeing them as not responsive to community problems. It was also hard for doctors to face the disbelief of patients begging them to pay for life-saving treatment that should have been freely available: You look in their eyes and see the hurt and the disappointment. Medical doctors and senior nurses spoke of unaffordable lifestyle aspirations such as a house that befits their status. Doctors wanted to be in a position to afford a decent house rather than put up with low-standard government sector accommodation on site. Disrespect In Uganda respect comes with how much you earn. It was said that patients look down on nurses when they know how little they are paid. Rural nursing assistants who were especially poorly paid said this would be a barrier to enlisting the local community to advocate for higher salaries: Its our secret. Thwarted professional ambitions A widespread and serious concern was unaffordable further training: I have to sponsor my own study yet I am serving the nation! Health workers spoke, often passionately, about thwarted ambitions to improve on skills and knowledge. Nursing assistants wanted to train as enrolled nurses or midwives, and enrolled nurses and midwives to train as registered nurses and midwives. Moreover, registered nurses wished to add midwifery to their qualifications or go to degree level. Doctors wished to bring their knowledge up to date and train as specialists. Unfair pay Participants regularly voiced strong opinions that the pay was unfair and undervalued health workers. Nurses complained that their salaries did not reflect the years of study they had put in. They pointed to other medical jobs that required the same length of training yet were more highly paid: Nursing is one of the lowest paid medical professions. Doctors pointed to the much higher salaries of other professionals: We send our children to the same schools, buy our food at the same markets. It was dispiriting to see their university contemporaries earning so much more yet working less hard. The fact that medical doctors are paid less than secretaries and drivers in some statutory agencies underscored the little value attached to the medical profession in Uganda. There were some strong feelings, notably among managers and practising doctors, that low pay reflected a lack of political will at ministerial and presidential level to invest in healthcare. There was some anger about public spending on political campaigns, the military and a presidential jet, and about wastage through corruption, while healthcare was grossly underfunded.
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Salaries were doubly unfair because they did not reflect the long hours many health workers put in: You can give your family neither time nor money. Nor did salary levels take account of the risks of infection health workers faced. Not being rewarded for doing the same work as higher-grade staff was thought bitterly unfair. It sometimes seemed to hospital nurses that doctors did little while they did all the work. Nurses complained that after paying for additional training to upgrade their skills, they lingered for years on their previous salary until promotion was granted. A further area of perceived unfairness was the disparity in salaries offered by the government, not-for-profit and private sectors. Not-for-profit sector workers pointed to their longer hours, and it was commented that unlike some government health workers, they worked the hours they were paid for. It was pointed out that not-for-profit and private facilities were free to decide their own salary levels and acknowledge seniority in their own way, resulting in lower pay than in government settings. A particular grievance was the absence of a senior clinical officer grade in a not-for-profit facility. A further concern was that the governments salary enhancement for employment in hard-to-reach areas seemed not to have been adopted systematically in the not-for-profit sector. Rarely was it said outright that health workers are exploited, although there were views that unfair advantage is taken of their professional ethics and dedication to patients: Nurses are trained to love and serve, and no matter how little we are paid we have to have that love. Indeed, among managers there was some intolerance of frontline workers complaints about low salaries, and an attitude that commitment to the work regardless of the pay was praiseworthy: Patients have to get a service, poorly paid or not. Yet managers were among the most vocal critics of salary levels: The salary is deplorable! Overall, participants appeared more resigned than militant about unfair pay, though there was some anger that the government cited the Hippocratic Oath to prevent doctors from protesting.
keep them. Thats what drives people to do those things. But they also argued that the media exaggerated the scale of such practices by unfairly generalising a single instance to all health workers: It spoils the reputation of all nurses, it pains and discourages us so much. One of the hottest topics in the Ugandan media is the apparent disappearance of essential medicines and medical supplies between the central store and patients in government health facilities. Theft on the part of health workers is only one explanation for shortfalls in supplies (see Chapter 9). Participants acknowledged that theft did occur within some health facilities. In their view, the explanation lay with low pay and money worries: They are not stealing medicines because they are evil their income does not satisfy their needs. Delays in salary payment were implicated too: They steal for survival. In no way was stealing condoned. Some participants expressed sorrow that patients were deprived of already scarce supplies. Others were bewildered that health workers could put their own interests before those of the patients. Only rarely did participants believe that greed led health workers to steal. Some health workers thought that pilfering of medicines happened only on a small scale, and that drugs were taken for personal or family needs and not to sell. But there were also views that helping yourself had become a habit, with reports of staff openly justifying selling supplies on the grounds that the facility did not reward them well enough. Participants with experience of closely managed facilities spoke of tighter administrative practices that helped to safeguard medicines. Workplace cultures which accepted stealing were also noted. The suggested solutions were tighter management to reduce opportunities for abuse, and holding staff to their codes of employment. As found in research elsewhere, peer influence to change behaviour was seldom proposed.148 Taking money from patients is a sensitive topic which some health workers were understandably reluctant to discuss. Soliciting bribes from patients was thought to be rare and was unacceptable because it would add to patients poverty. If it did occur, it was attributable to low pay: If paid a satisfactory salary, I think they would not get money from the patients. There was also a view that worries about surviving on retirement pensions drove health workers to ask for bribes. It was observed that in some settings, patients expected to give staff some inducement to attend to them.149 Such mistrust was hurtful and offensive, and it was suggested that the distance between workers and patients widened as a result. Participants told of scams whereby patients were robbed of their little money by conmen masquerading as health workers, and of angry patients subsequently attacking legitimate staff.
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)
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Health workers distinguished accepting appreciation from demanding money, and some acknowledged a temptation to accept unsolicited money from patients as compensation for ill-paid, exhausting work. It was suggested that some see health workers accepting appreciation and wrongly conclude that a bribe has passed hands. It was widely believed that urban health workers were forced to work in two or even three jobs to make ends meet, with government sector employees working also in private clinics or private hospitals. One unfortunate consequence, it was said, was to reinforce patients suspicions that health workers steal drugs from their workplace to sell in private clinics. Moonlighting was often known, or suspected, to explain absences: Most people, when they dont turn up for work you find they are running a clinic somewhere. It was said that absenteeism was not a problem in areas where private treatment or drugs were unaffordable. Exhaustion from doing too many jobs was thought to cause behaviour patients saw as rude. Rural areas were said to offer many fewer opportunities for side-employment, but there it seemed that health workers were sometimes forced to take time out to tend crops to feed their families. It was noted that before decentralisation, rural workers regularly saw to their vegetable gardens before leaving for work, when salaries arrived late or not at all. It was suggested that this habit continued. There were beliefs that absence from the workplace was encouraged by lump sums given notionally to cover transport and attendance at workshops, and there were grievances about perceived unfair selection of participants: They only want the big people. The more junior staff valued the learning and professional contacts that workshops offered. Effort at work was affected by low pay, managers felt. Views were expressed that nurses put in minimal effort because they feel they are not getting what they are worth. It was observed that because nurses are paid so little, they take out their frustrations on patients, arrive late, fail to monitor patients and are unkind to them. It was noted how hard it was to get people to work when they lacked the basic minimum, and that with no incentive of a decent wage, it was impossible to retain skilled and interested workers. Occasionally, in managers eyes, low morale was related to low pay. Low pay was argued to contribute to doctors questionable attitude to work. Things would change with better pay: When you are paid highly you are more motivated and If the pay was more, the nurses would respect their work more and respect the job that pays them.
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Among participants with medical qualifications there were beliefs that medical doctors left country in large numbers for greener pastures, as well as claims that few of their graduation contemporaries were still in Uganda, though the lack of hard facts on the extent of emigration was also acknowledged. The prevailing assumption was that doctors moved in pursuit of money. When questioned about their own intent, doctors spoke about the attraction of a better income. Yet opportunities to work with proper equipment and love what you do also were important not simply a good salary. Doctors spoke about the possibilities of working in highly regarded, well-resourced hospitals in other East African countries or in Southern Africa. African countries were attractive because they are close to home, but the USA and Europe were not ruled out. Not all doctors wanted to leave for better working conditions, and there were also keen ambitions to take their skills to countries even more in need of medical doctors than Uganda, such as Sudan or Somaliland.
Financial motivators
We are not motivated, they should give us some motivation, some appreciation. In Uganda motivation often means extra money or payments in kind. Being given something signifies appreciation. Non-financial rewards were no substitute for money: Lovely words of thank you dont feed a family! Free accommodation of a good standard, with electricity and water paid for, was hugely appreciated and said to be a factor in attracting and retaining staff. Even free housing of lower standard was valued and its absence a cause for resentment, especially among nursing assistants. Free food for the household, tea and snacks provided at work and Christmas and Easter gifts were identified as especially appropriate ways to value and motivate Ugandan health workers. Staff of a government facility spoke enthusiastically about the help it gave towards costs of family burials and medical operations, as well as the provision of cloth to make their own uniforms. Generally in Uganda, allowances on top of basic salary are common and can contribute quite significantly to the overall pay. Small allowances for outreach visits, such as to provide immunisation services, were much appreciated. There were calls for allowances for risk, housing, transport, responsibility and study.150 Hardship allowances were suggested to compensate for living and working in remote locations where it is difficult to access facilities and goods, and where the standard of accommodation is very poor and lacking in essential utilities. A private sector facilitys monthly award for nurses who met high standards of dress and customer care had a multiple effect in pushing up standards, boosting income and valuing individual staff. It was pointed out that local government hospitals are allowed to run private wings and that some use the income to benefit staff. One hospital allocated over half of that income to enhance the monthly salaries of all its staff: health workers feel owned and happy. It was recommended that local government hospital administrations inform staff about their private wing income and how it is spent.
10.4 Recommendations
Ugandan health workers feel undervalued because salary levels do not match their needs and social expectations. The pay is felt to be unfair and failing to signify an appropriate return for what they put in. Not surprisingly, there were very many calls for increases in basic salaries. There were concerns about exploitation in private clinics and a suggestion that a minimum wage be introduced. Ideally, the same salary structure should apply in all sectors. Government salary scales should recognise first and post-graduate degrees. There was considerable frustration that this issue was not being resolved and calls for reform in order to attract degree nurses to public sector jobs and ensure their education is used to directly support patient care. A common demand was to address blockages to promotion. There were also practical recommendations to reward effort and improve motivation.
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.
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Constraints on speaking up
There were views among frontline workers that responsibility for improvements lies with facility managers, district management or the Ministry of Health. Stakeholders noted that where decisions are made with no staff involvement the staff are afraid for their jobs, they fear to speak up. Anxiety about repercussions was a barrier to speaking out in public. It was explained that in Uganda, there is a lot of fear of being pin-pointed if you talk out about your problems. The researchers observed some apprehension over signing their consent form, although health workers were willing to take part in the research and seemed satisfied with the researchers assurances of confidentiality and the safe-keeping of data. The unspoken fear, it seems, was that their participation might 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.
Lack of respect from management undermined nurses. Those with experience in large urban hospitals told of senior nurse managers and administrators who sat on, barked at and belittled them in front of patients. They also spoke of doctors who publicly ignored and disparaged their knowledge and contributions as mere nurses: I have quite often heard doctors tell a nurse she is stupid. Such behaviour coloured patients respect for nursing staff and damaged their reputation in the wider community: They think a nurse barked at is nothing. They said management blamed nurses unfairly, failed to investigate problems and made their lives miserable. Suppressed and voiceless in the workplace, it is not surprising that nurses had little appetite for championing their profession. This report has shown that rural workers in government facilities have faced disappointed, distrustful and sometimes angry patients, interfering and bullying local politicians and politically engineered attacks on health workers credibility. Hostile environments and impoverished workplaces drained any will they had to do more than meet patients needs the best they could. Moreover, health workers had few chances to meet with people from other healthcare facilities to exchange experiences and build solidarity. Nurses spoke enthusiastically about a forum organised by a health sub-district which discussed solutions to common problems.
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management, alongside rumours of power struggles, were deterrents to workers spending part of their little salary on subscriptions to remote associations and unions. There were also suspicions that those at the top of the organisations had different agendas from workers on the frontline. The effectiveness of representative bodies was also questioned, given a history of government suppression. There were conflicting interpretations and some misunderstandings of the remit of the regulatory councils.152 Some health workers saw their council as equivalent to a union, with a role to advocate for their constituency. Others saw a punishing attitude, and complained that the Nurses and Midwives Council was down on nurses and investigated only serious, high-profile cases of irregular behaviour. Concerns were voiced that the council did little to defend nurses accused of stealing medicines and that no action had been taken against politicians who beat up nurses. The nurses council was seen as remote from nurses on the ground, preoccupied with meetings, disinclined to inform members of what they discussed and not independent enough of government. It was suggested that it would be better if representatives of professional associations, unions and regulatory councils were less remote from workers on the ground. In particular, there were calls for people up there to visit health facilities, talk with health workers and learn about their difficulties first hand, so that the right voices were taken to the top. Recommendations among managers were that representative organisations compare reports from different places and compile strong collective arguments to improve conditions in the workplace, rather than simply address individual grievances and traditional welfare issues. Representatives of associations and unions acknowledged shortcomings and weaknesses. They were understaffed and severely under-resourced, with poor office facilities. The consensus among stakeholders was that individual associations and unions were not yet strong voices for health workers and that working in an alliance would be more effective. It was recognised that much would have to be done to align the efforts of multiple and sometimes competing professional 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).
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
An advocacy alliance
In Uganda, countless small civil society organisations work to promote health rights. Dependent on financial support from a patchwork of sources (mainly development partners), they gain strength through loose, generally informal coalitions based on common aims. They are broadly aligned to consumers interests. Health workers interests fall mainly to the professional organisations. Coalitions rarely bridge the two sets of interest. The Health Workforce Advocacy Forum-Uganda is a coalition of health professional associations, unions and health rights organisations. A membership organisation largely made up of health workers, it has recently campaigned for a positive practice environment for health workers. The Valuing Health Workers research found consensus that a way forward would be for all civil society organisations concerned about limits on access to healthcare to join with the Health Workforce Advocacy Forum-Uganda, to support and strengthen its advocacy on behalf of health workers.
While it was widely understood that the media look for bad news, there was scope for positive human interest features, such as profiles of individual health workers and the work they do. It will be important to avoid suspicions of favouritism in selection of the health workers featured. Local language radio is highly popular in Uganda and is a vehicle often used by civil society advocacy organisations. Radio call-in shows attract health users voicing complaints about local services: You hear them on the radio, it makes us uncomfortable. While health workers are restricted in what they can say publicly, civil society organisations have the opportunity to put complaints in the wider context and speak up for health workers.
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Community dialogue meetings were recommended to bring together service users, local leaders and those involved in providing services: If there can be community dialogue meetings in each village, then we can discuss with them their problems. We tell them what we do, they express their problems, how we go wrong, I also tell them where they go wrong. Community dialogues also meant that district managers learnt community views about individual health workers. There were places where the distance between communities and facilities appeared hard to bridge. Patients arrived expecting staff not to help, and health workers came to work fearing that patients would complain. They dont respect the nurses needs, we dont respect each other. Interfering and demanding politicians seemed an intractable problem, but health workers reported favourable effects when a top local politicians family used maternity services at a local government facility. Seeing the challenges encouraged the 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.
Civil society organisations have been working to create common cause between health workers and patients. Early projects learnt that empowering community members to exercise their health rights must go hand in hand with valuing health workers. Otherwise there is a real risk of adversarial relationships between healthcare workers and users. Indeed, early experiences were that community members, fired up with new knowledge about violations of their health rights, reprimanded workers they perceived to be rude, while health workers complained of harassment and threatened to resign. Subsequently, community-based training has enabled health workers to talk out about the structural problems, with service users coming to appreciate the reasons behind health worker behaviour they object to. Now the focus of community-based training has moved towards fostering mutual understanding and communication through participatory methods involving health workers and community members together.153
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Priorities
Value health workers for their contributions to the health of Ugandans Health worker terms and conditions of service Review salary scales to determine whether increases in basic salaries are possible. Reform government salary scales to recognise first and postgraduate degrees, in order to attract degree nurses to public sector jobs and ensure their education is used to support patient care directly. Consider the establishment of a minimum wage and the feasibility of imposing the same salary structure in all sectors (government, not-for-profit and private). Overtime and responsibility payments Explore a system for remunerating health workers for overtime. Consider implementing a responsibility allowance paid when a nurse has sole charge of a ward. Small financial motivations Incentivise staff through small items of personal support, such as food for the household, snacks at work, and Christmas and Easter gifts. Contributions towards family burials, medical operations and provision of cloth for uniforms are well received. Review current allowances for risk, hardship, housing, transport, responsibility and study, to ensure consistency and fairness across all facilities. Use the income from local government hospitals private wings to benefit staff, by supplementing salaries or allowances. Ensure working conditions enable health workers to provide good-quality healthcare Health worker/patient ratios Introduce standards for patient/nurse and patient/doctor ratios, so that health worker overload is transparent and quantifiable, and managers have information to help reduce pressure on overloaded staff. Recruitment blockages Manage health worker recruitment and deployment centrally, to address the problem of unfilled posts and uneven distribution of health workers. Decent staff accommodation The Government should follow through on its strategy to provide decent and safe accommodation for health workers at health facilities, especially in remote areas. Civil society organisations should continue to monitor implementation of this strategy and press for concrete targets. Facility infrastructure Ensure regular meetings between management and department heads, at which facility-related problems can be raised and decisions taken on actions needed. Invest in good theatre facilities and their staffing in a small number of health centre IVs, and showcase them as good 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.
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Enabling strategies
1. Improve the quality and relevance of health worker training Career guidance and early contact Ensure well-motivated trainees, for example through more talks at schools and work experience placements. Training schools admission procedures Reject applicants who seem to be applying for the wrong reasons, including those allocated to a university course which is not their first or second choice. Developing and sustaining the right heart in training schools Return oversight of training to the Ministry of Health from the Ministry of Education and Sports. Reduce nursing and midwifery class-sizes and improve tutor capacity, to ensure the right attitudes and practical understanding of the ethical code are encouraged throughout pre-qualification training. Health and human rights training Expand existing partnerships between training institutions and health consumer advocacy organisations. Improve nursing course content to make sure that students take on board the role of the nurse as a patients advocate. De-urbanise health worker training Increase the number of training schools and residency programmes in rural areas to produce staff already adapted to rural environments and connected to the local community. Improve the community service element in medical curricula and increase the exposure of urban health students to rural settings with increased fieldwork. Nurses and Midwives Council registration interviews The Nurses and Midwives Council should weigh up the advantages of screening interviews held as a prerequisite for registration post-qualification against detrimental effects on nurse morale. 2. Raise the voices of health workers Sharing of experience and common approaches Encourage staff to meet with people from other healthcare facilities to discuss solutions to common problems and communicate them to sub-district level managers. These managers could also be encouraged to instigate similar forums. Speaking through professional associations, unions and regulatory councils Channel health worker concerns to the Ministry of Health, Government or Parliament through bodies that speak for them, such as professional organisations and trade unions.
Professional associations and unions should do more to bring members together, for instance at local general meetings, and make greater efforts to visit facilities and talk with health workers so that the right voices can be taken to the top. They should compile strong collective arguments to improve conditions in the workplace, as well as addressing individual grievances and traditional welfare issues. 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. 3. Change public perceptions by influencing the media Inform journalists about the obstacles to health worker recruitment and discourage them from writing sensationalist or negative stories in the media. Put complaints on local language radio call-in shows into a wider context. Encourage the running of positive human interest features, such as profiles of individual health workers and the work they do. Work with the Uganda Health Communication Alliance. Improve the capacity of civil society and health worker organisations to write press releases, hold press conferences and build relationships with individual reporters and media houses, so the key campaign messages hit home. 4. Build bridges between patient communities, healthcare facilities and staff Transparency on drug availability Use well-managed public opening of medicine deliveries to help convince communities that medicines are not in stock, and to counter accusations of theft. Call on local notables, police or patients to witness the opening of boxes. Support with paperwork to show what has been ordered and delivered. Ensure that local leaders are fully informed through regular meetings about the demand for and supply of drugs and that they use this information responsibly. Connecting communities and facilities Use opportunities to talk with people on their own ground and explain the problems health workers face, for instance through Village Health Teams, facility-based health workers providing outreach immunisation services, and talks to women awaiting prenatal checks. Promote community dialogue meetings bringing together service users, local leaders and health unit management teams. Increase funds to cover these activities. Invite top local politicians to spend time in facilities alongside staff to see what the work is really like. Civil society organisations should continue their work to create common cause between health workers and patients.
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Total
18
The sampling design aimed at a spread of districts in terms of how the Ministry of Health ranked them as hard-to-serve. The Ministrys scoring formula took into account degree of insecurity, measured by the proportion of the population in internally displaced persons camps (50% of total score); distance from the capital, Kampala (10%); presence of social amenities and utilities (bank, grid electricity, tarmac road and a tertiary education institution) (10%), and the proportion
of approved staff positions appropriately filled with health workers (30%).154 The formula was designed some years ago when Uganda had only 56 districts and when insecurity was greater than at the time of this study. Researchers have noted some anomalies in the scoring.155 The scores were therefore only a guide to sampling decisions. Table A.3 shows that the sample under-represents districts that scored 1 to 19.156
154. Africa Health Workforce Observatory 2009 155. Ministry of Health 2009a 156. Based on Africa Health Workforce Observatory 2009, Annex 2
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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
15
14
10
9
5
10 8 5 2
Enrolled
Registered
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
Drawing on Kavuma 2009 Africa Health Workforce Observatory 2009 Green 2008 Green 2008
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Our Side of the Story: The lived experience and opinions of Ugandan health workers
References
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UNFPA (2010) Evaluation of the Registered and Enrolled Comprehensive Nurse Training Programs in Uganda: Terms of Reference, August, UNFPA. UNFPA (2011) The State of the Worlds Midwifery 2011, UNFPA. United Nations Human Development Programme (2010) The Real Wealth of Nations: Pathways to Human Development, Human Development Report 2010, Basingstoke/New York: Palgrave Macmillan. Van Lerberghe W, Luck M, De Brouwere V, Kegels G and Ferrinho P (2000) Performance, working conditions and coping strategies: an introduction, 1-5 in P Ferrinho and W Van Lerberghe (eds) Providing Health Care under Adverse Conditions: Health Personnel Performance and Individual Coping Strategies, Studies in Health Services Organisation and Policy 16, Antwerp: ITG Press. VSO (2011) Ugandan Health Workers Speak: The Rewards and the Realities, London: VSO. Womakuyu F (2010) Ambulance shortage in rural areas costing Ugandan lives report, New Vision, 16 December. World Bank (2010) Silent and Lethal: How quiet corruption undermines Africas development efforts, An essay drawn from the Africa Development Indicators, World Bank. World Health Organisation (n.d) Global Atlas of the Health Workforce, Geneva: World Health Organisation www.who.int/ globalatlas/autologin/hrh_login.asp. World Health Organisation (2006) The World Health Report 2006: Working Together for Health, Geneva: World Health Organisation. World Health Organisation (2010) Achieving the health-related MDGs: It takes a workforce! http://www.who.int/hrh/workforce _mdgs/en/index.html Zuyderduin A, Obuni JD and Mcquide PA (2010) Strengthening the Uganda nurses and midwives association for a motivated workforce, International Nursing Review 57, 4, 419-425.
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2.
3. 4.
5.
6.
7.
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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?
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ISBN 978-1-903697-33-7
9 781903 697337
Valuing Health Workers is VSOs research and advocacy initiative, which supports the achievement of the health-related Millennium Development Goals. Valuing Health Workers research is currently underway in four countries. Following on from the research, advocacy strategies will be created, which will include the development of volunteer placements in civil society coalitions, professional associations and health ministries. VSO works with the Health Workforce Advocacy Initiative (HWAI). HWAI is the civil-society led network of the Global Health Workforce Alliance (GHWA) and engages in evidence-based advocacy with the goal of enabling everyone to access skilled, motivated and supported health workers who are part of well-functioning health systems. www.healthworkforce.info/HWAI/Welcome.html VSO works with Action for Global Health a cross-European network of health development organisations. The network calls on European Governments and the European Commission to act now to support developing countries to achieve the health-related Millennium Development Goals. www.actionforglobalhealth.eu For more information please contact: advocacy@vso.org.uk
If you would like to volunteer with VSO please visit: vsointernational.org/volunteer In addition to this publication, the following research and publications may also be of interest: Participatory Advocacy: a Toolkit for Staff, Volunteers and Partners this manual is an easily accessible guide to lobbying and campaigning, and can be used by health activists and other campaigners for social justice. Ugandan Health Workers Speak: The Rewards and the Realities a report of initial findings of the Valuing Health Workers research in Uganda. Valuing Health Workers in Cambodia a short briefing on the research approach in Cambodia. Valuing Health Workers: Implementing Sustainable Interventions to Improve Health Worker Motivation (Malawi) a report drawing together existing research in Malawi, and identifying recommendations to tackle the HRH crises. Local Volunteering Responses to Health Care: Challenges and Lessons from Malawi, Mongolia and the Philippines this report looks at how community volunteers can be involved in delivering health services. 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
Carlton House, 27a Carlton Drive Putney, London, SW15 2BS, UK +44 (0) 20 8780 7500 www.vsointernational.org VSO is a registered charity in England and in Wales (313757) and in Scotland (SC039117).
Published July 2012