Our Side of the Story

Coalition for Health Promotion and Social Development

A policy report on the lived experience and opinions of Ugandan health workers

HEPS-Uganda, The Coalition for Health Promotion and Social Development
Established in 2000, HEPS-Uganda, the Coalition for Health Promotion and Social Development, is a health rights organisation that advocates for increased access to affordable essential medicines for poor and vulnerable people in Uganda. HEPS promotes pro-people health policies and carries out campaigns at local, national and regional levels. It also initiates and conducts research necessary for health and human rights advocacy. Since 2007, HEPS-Uganda has actively promoted health rights within seven local government districts, addressing maternal health and equitable access to healthcare. Working in some of the most disadvantaged rural areas of Uganda, HEPS has trained community representatives to spread the word about health rights and how to exercise them. It also promotes the responsible use of healthcare resources and effective ways of communicating with health workers. For more details, visit: www.heps.or.ug

VSO Uganda
VSO Uganda volunteers are currently working in the central, western and northern regions of the country, in the fields of participation and governance, disability, health, education and livelihoods. Poor and disadvantaged people in Uganda are badly affected by preventable diseases. Health service provision and access is low, and staff retention is a challenge. VSO is supporting the Ugandan Government in implementing the Health Sector Strategic Plan (HSSP) to improve health systems in the context of a decentralised health delivery system at district level. HSSP focuses on working with communities and the implementation of primary and preventive healthcare services, as well as good-quality, accessible clinical services as stipulated in the minimum healthcare package. It has a particular emphasis on reaching the majority of the population, over 80% of whom live in rural areas, where the people tend to be poorer than in urban settings. For more details, visit: www.vsointernational.org/where-we-work/uganda.asp

VSO International
VSO is different from most organisations that fight poverty. Instead of sending money or food, we bring people together to share skills and knowledge. In doing so, we create lasting change. Our volunteers work in whatever fields are necessary to fight the forces that keep people in poverty – from education and health through to helping people learn the skills to make a living. We have health programmes in 11 countries, with plans to open further health programmes in the coming years. From extensive experience supporting health and HIV programmes in developing countries, VSO believes that in order for health systems to improve, more health workers must be recruited and retained. They must be of good quality, in the right places, well trained and with access to the basic equipment and drugs needed. They also need to be well supported – placed in the right location, treated fairly and managed well. Through our Valuing Health Workers research and advocacy project, VSO identifies the issues that affect health workers’ ability to deliver quality healthcare. These findings will support partners to carry out further research and make a significant contribution to improvements in the quality of health worker recruitment, training and management. For more details visit: www.vsointernational.org/what-we-do/advocacy

Our Side of the Story: The lived experience and opinions of Ugandan health workers

Acknowledgements
The Valuing Health Workers research and advocacy project is the initiative of VSO International. This report is based on research in Uganda in partnership with HEPS-Uganda, the Coalition for Health Promotion and Social Development, and with support from VSO Uganda. Thanks are due to Rosette Mutambi, executive director of HEPS-Uganda, Sarah Kyobe, VSO Uganda health programme manager, and Stephen Nock, VSO International policy and advocacy adviser, for their practical support and encouragement. Stacey-Anne Penny brought to the project her drive to explore and understand the lived experience of Ugandan nurses and her invaluable contribution as co-researcher up to August 2010. HEPS-Uganda colleagues provided a supportive and friendly working environment. The following HEPS staff played practical roles in managing consultative workshops, facilitating access to fieldwork sites and co-convening and transcribing focus group discussions: Prima Kazoora, Phiona Kulabako, Aaron Muhinda and Kenneth Mwehonge. This report would not have been possible without the willing participation of 122 health workers across Uganda. Thank you to them for voicing the rewards and challenges of their daily lives. Thank you to local managers for making staff available, and to patients for their forbearance while their health workers gave time to the research. Not least, thanks are due to the representatives of organisations concerned with health worker and health consumer interests, for their participation in workshops and interviews.

Patricia Thornton

Text: Patricia Thornton Field research: Patricia Thornton, Stacey-Anne Penny, Prima Kazoora, Phiona Kulabako, Aaron Muhinda and Kenneth Mwehonge Editing: Stephen Nock, Diane Milan, Stephanie Debere and Emily Wooster. Layout: www.revangeldesigns.co.uk Photography: Cover photo © Matthew Oldfield/Science Photo Library
©VSO 2012 Unless indicated otherwise, any part of this publication may be reproduced without permission for non-profit and educational purposes on the condition that VSO is acknowledged. Please send VSO a copy of any materials in which VSO material has been used. For any reproduction with commercial ends, permission must first be obtained from VSO. The views expressed in this report belong to individuals who participated in the research and may not necessarily reflect the views of HEPS-Uganda, VSO Uganda or VSO International.

ISBN: 978 1903697 337

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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

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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

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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.

Ugandan healthcare challenges and provision
Uganda has the third-highest rate of population growth in the world, with most people living in rural areas with extremely poor access to electricity and low access to improved water supplies. Maternal, infant and under-five death rates show only small improvements. Malaria is the main sickness and a major cause of childhood deaths. Uganda has only one doctor per 10,000 people, and only 14 health workers (doctors, nurses and midwives) per 10,000 people, significantly below the 23 health workers per 10,000 recommended by the World Health Organisation (WHO). Medical doctors and the most highly qualified nurses and midwives are concentrated in and around the capital city. The Government of Uganda is committed under the Abuja Declaration to apportion 15% of its budget to health, but it has not exceeded 10% in the last 10 years. Healthcare in the formal system is delivered in a hierarchy of health centres and hospitals. Patients should be referred from a lower- to a higher-level facility for the services they need. The government runs 60% of hospitals and health centres; around 20% are run by not-for-profit organisations (mostly faith-based) and around 20% by private organisations. Fewer than four in 10 Ugandans turn to health centres or hospitals when they fall sick. Pregnant women and children are the largest groups of patients.

The research in Uganda
In Uganda, negative images of health workers are presented in the media, political speeches, healthcare user research and health consumer advocacy projects. It is said that health workers absent themselves from work, are rude, neglectful and abusive to patients, extort money from patients and steal medicines. Yet policy documents acknowledge that many health workers live and work in impoverished conditions. The Valuing Health Workers research set out to explore with frontline health workers and their managers how working conditions affect attitudes, behaviour and practices. It also sought the positive side of the health worker experience. This report documents the experiences and views of 122 nursing assistants, nurses, midwives, clinical officers and medical doctors, including facility managers and local government district health officers. The facility-based participants worked at 18 hospitals and health centres in seven local government districts in all

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Our Side of the Story: The lived experience and opinions of Ugandan health workers

Reasons for becoming a health worker and rewards of the work
The urge to help, prevent suffering and save lives stood out among the reasons people gave for becoming a health worker. It had been common in rural areas to see people suffer in pain and die with no proper medical care. Their training would bring to the community knowledge to help prevent illnesses, discourage harmful traditional healing practices and save lives. Participants who had been impressed by caring nurses and the skills of medical staff wanted to give something in return. Interest was stimulated by the example of family members who worked in healthcare. Experiencing poor service also prompted a desire to raise healthcare standards. A desire for money was not a driving force. Clinical officers and medical doctors told of expectations on them as the brightest school students to enter one of the prestigious professions. It was widely believed that new entrants to nursing came with “the wrong heart”, resulting in unhappy, disinterested and self-serving recruits, who resorted to bad habits and forgot their accountability to patients. The benefits to the community, to individual patients and to their own families were the biggest sources of satisfaction. Job satisfaction came from making a difference to patients, doing their duty the best they could, using their skills and learning through work. Health workers valued being appreciated, respected and trusted by patients. Tangible demonstrations of appreciation by managers were a huge positive, as were good teamwork and supportive managers who created opportunities for health workers to raise their concerns.

The impact of working conditions
Workload, workplace infrastructure, medical equipment and supplies, the availability of essential medicines and the level of remuneration affected health workers’ well-being, the quality of care they could provide and relations with patient communities. It is apparent from health workers’ experiences that working conditions are the root cause of the attitudes, behaviours and practices for which health workers have been criticised.

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.

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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.

Equipment and medical supplies
The Ministry of Health acknowledges a shortage of basic equipment in health facilities and that only 40% of equipment in place is in good condition. An independent survey reveals a gross lack of equipment for the diagnosis and treatment of malaria, and that six in 10 facilities surveyed were not equipped to measure haemoglobin. Health workers praised well-equipped facilities and imaginative management that solved temporary supply problems by borrowing from other facilities. Elsewhere, working with inadequate equipment was a huge challenge. There was widespread frustration at not being able to work effectively. Failing their patients greatly distressed nurses and doctors, who saw patients die because of lack of supplies and missing or poorly maintained diagnostic equipment. In the government sector, doctors and nurses told of interruptions in supplies of oxygen and blood; missing needles giving sets and sutures, and minimal urine testing kits and family planning supplies. Rural midwives in government facilities told of struggling with no delivery kit, cord clamp, sucker, gauze or cotton wool and just one pair of scissors. The regulatory prohibition on asking patients to buy medical supplies was a huge frustration which challenged their ethical duty to do their best for their patients. Managers recognised that doctors lose morale when unable to operate, and that being unable to apply knowledge was very demotivating. It was said that nurses forgot what they had been taught and as a result some did not work, so projecting a bad image to the community, which in turn made nurses feel not respected and prompted them to leave. Health workers felt blamed for the lack of supplies. They noted patients’ attitudes change if asked to buy their own, with some carers becoming angry and violent.

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.

Availability of essential medicines
The proportion of health facilities registering ‘stock-outs’ in essential medicines has consistently been over 60% for the last 10 years. Not one of 40 essential medicines was available in every government facility in a sample survey in the second quarter of 2010. Only eight were found in each not-for-profit sector facility surveyed. Participants working outside the government sector mostly considered medicine supplies adequate. In the government sector there was sharp contrast between praise for the better stocked facilities and disgruntlement that essential drugs were

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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.

Conclusions and participants’ recommendations
Health workers’ accounts show that working conditions were the root causes of bad practices and unethical behaviour, and that health workers bore the brunt of the blame for system failures. The research revealed a vicious circle: impoverished working environments and low pay affected the quality of patient care; patients blamed the health workers; the wider community then distrusted health workers and so health workers’ distress increased. The situation was made worse by negative media stories and political leaders’ vocal criticism of health workers, which fuelled public distrust, damaged the standing of the profession, added to health workers’ distress and raised the barriers to access to healthcare. The view of civil society organisations and of some managers was that frontline health workers are not empowered to speak up. The concept of ‘voice’ was unfamiliar to many frontline health workers in the research, and the idea that they might speak out and gain support to improve poor working conditions and quality of care was new to them. The research identified barriers to individual health workers voicing their concerns, and health workers’ preferences for advocacy by representative organisations.

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.

US dollar = 1,856 Ugandan Shillings at 31 March 2010

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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.

2. 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.

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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 patient’s 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.

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.

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.

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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? VSO’s 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.

1.2 The Valuing Health Workers research in Uganda
In Uganda negative images of health workers are projected in the media, political speeches, policy documents, healthcare user research and health consumer advocacy work. The overriding message is that health workers’ attitudes, behaviour and practices present barriers to accessing healthcare. The Valuing Health Workers research in Uganda set out to explore with frontline health workers and their managers the conditions underlying accusations of unethical behaviour and service inadequacies. The overall objective was to give opinion formers and healthcare service users a realistic picture of what life is like as a health worker in Uganda, so as to increase understanding and modify expectations. Ugandan civil society organisations will use the findings to help build mutual understanding and promote harmonious relationships between healthcare users and workers, as well as to advocate for improved conditions for health workers in Uganda. It has been well-documented through research and health rights projects that healthcare users in Uganda experience from health workers bad attitudes, rudeness, inhumane treatment, neglect, discrimination and extortion of illegal fees for services. They also face staff absences and the unavailability of medicines and other treatment supplies.2 Research has reported patient community perceptions that drugs are stolen.3 The press and radio media have fuelled negative perceptions of health workers’ behaviour, branding them as shirkers and thieves.4 Indeed, the media have reported leaders in government accusing health workers of stealing medicines.

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-wagging’15, 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; O’Neil 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 Björkman 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

1.3 The research approach and participants
VSO carried out the research in Uganda from February 2010 to February 2011 in partnership with HEPS-Uganda, the Coalition for Health Promotion and Social Development. Using qualitative research methods, the researchers encouraged health workers to speak freely in response to open questions, promising that identities would not be revealed. In all, 122 health workers – medical doctors, clinical officers, nurses, midwives and nursing assistants (including frontline workers, facility managers and local government district health officers) – participated in small group discussions and individual interviews at their workplaces. The facility-based participants were working at 18 hospitals and health centres in seven local government districts in all regions of Uganda and in the capital city, Kampala. The selection of facilities took account of region, the extent to which the district was easy or hard to serve, the level of hospital and health centre, location (urban or rural) and ownership (government, not-for-profit or private sector). Many participants drew on their prior experiences from training or working in different sectors and levels of healthcare facility. In addition, 24 stakeholders from civil society organisations, trades unions, professional associations and regulatory councils contributed their perspectives on the issues facing health workers in Uganda, through workshops and individual interviews.

1.4 Structure of the report
Chapter 2 introduces the main challenges to healthcare provision in Uganda, outlines healthcare provision and patterns of use, and describes the health workforce. The research approach is described in Chapter 3, along with an overview of the participants (with further details in Appendix A). Chapter 4 presents what participants said about the rewards of being a health worker. Chapter 5 looks at why they became health workers. The chapters that follow address elements of the main themes that emerged from the participatory research – the impacts of workload (Chapter 6); the infrastructure of the healthcare facilities (Chapter 7); the availability of medical equipment and supplies (Chapter 8); supplies of medicines (Chapter 9); and levels of remuneration (Chapter 10). Each element is followed by the relevant recommendations for change drawn from health workers’ and stakeholders’ contributions. Chapter 11 lists all recommendations under potential strategies for change.

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Our Side of the Story: The lived experience and opinions of Ugandan health workers

2. Healthcare in Uganda: challenges and provision
Summary
A major challenge for the Ugandan healthcare system is the rapidly growing population, with the third-highest growth rate in the world and a strikingly high birth rate (especially among teenage women) and a very young profile. A further challenge is serving the exceptionally high proportion of the population residing in rural areas, who have extremely poor access to electricity and low access to improved water supplies. Although declining somewhat, maternal, infant and under-five death rates are still not under control. Malaria is the main sickness and a major cause of childhood deaths. Uganda has only one doctor per 10,000 people, and only 14 health workers (doctors, nurses and midwives) per 10,000 people. This is significantly below the level of 23 health workers per 10,000 people recommended by the World Health Organisation (WHO). Only four other countries have poorer provision of hospital beds. Only 16 countries worldwide spend smaller proportions of their Gross Domestic Product on health than Uganda. Although the Government of Uganda is committed under the Ajuba declaration to apportion 15% of its budget to health, its expenditure on health has never exceeded 10% of total public expenditure. Most healthcare in the formal system is delivered at health centres and at hospitals at national, regional and district levels. One in five local government districts had no hospital when an official inventory of the (then) 80 districts was drawn up in 2010. Each sub-district should have a health centre IV, headed by a medical doctor and providing emergency surgery: five of the 80 districts in the inventory had no health centre IV at all and a further 23 had one only. The situation is likely to have worsened with the continuing creation of districts, to total 112 in mid-2010. One in four facilities is classified as a health centre III and should provide maternity, in-patient and laboratory services. Two-thirds of health facilities are classed as health centre II, intended for preventive services and outpatient curative care; three in 10 of those are in the capital city. The Government runs 60% of the hospitals and health centres. Not-for-profit organisations, mostly faith-based, run just under 20%. Private for-profit organisations run just over 20% of the officially-classified healthcare facilities, mainly in urban areas. There are also innumerable unrecognised small private units. Fewer than four in ten Ugandans turn to health centres or hospitals when they fall sick. The rural population uses health centres more than urban dwellers, while the urban population uses hospitals more than people in rural areas. The poorer you are in Uganda, the more likely you are to go to a government health centre. Children and pregnant women are the largest groups of health facility patients. Over one in four Ugandans lives more than five kilometres from their nearest health facility. Nine in 10 walk or cycle to their government health centre. The available data on the make-up of the Ugandan health workforce shows extreme shortfalls of the most highly qualified occupational groups, and mal-distribution across the country. Although the aim is to phase nursing assistants out, Uganda has relied heavily on them , especially in rural areas. Medical doctors and the most highly qualified midwives and nurses are concentrated in urban areas, especially in and around the capital city. An estimated four in 10 of the facility-based workforce are in the government sector, 30% in the not-forprofit and 30% in the private sector. Medical doctors are concentrated in the private sector although there are high rates of dual employment, with medical doctors working in both private and government sectors. Half the medical doctors and four in ten nurses employed in government facilities work in the regional and national referral hospitals.

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Our Side of the Story: The lived experience and opinions of Ugandan health workers

2.1 Ugandan healthcare challenges
Uganda is one of the 48 least-developed countries of the world.20 It stands at 143 out of the 169 countries in the United Nations Human Development Index, and is classed as a low human development country. The United Nations Development Programme (UNDP) publishes statistics for the indicators used in the Human Development Index.21 These allow comparisons between Uganda and other least-developed countries, Sub-Saharan Africa and the world overall.22

Population growth and birth rates
Uganda’s rate of population growth (3.2 %) is the third-highest in the world. It is a very young population with an average age of 15.6 years, the second-lowest in the world. The average woman will give birth to 5.9 children if she lives to the age of 50; only three countries have a higher fertility rate than Uganda. The birth rate among women aged 15 to 19 is also striking: 150 per 1000 women, which is considerably higher than in Sub-Saharan Africa overall and is surpassed in only two countries in the world. The contraceptive prevalence rate (23.6%) is on a par with that of Sub-Saharan Africa.

Table 1 Estimated population 201023
Total population: 30.7 million Aged 0-14 years Aged 14-64 years Aged 65+ years 50.8% 46.1% 3.1%

Infant, under-five and maternal mortality
In Uganda, 85 of every thousand babies born alive are likely to die before their first birthday (the infant mortality rate) and 135 of every thousand are likely to die before they are five (the under-five mortality rate). These rates are somewhat higher than for least-developed countries overall and somewhat lower than for Sub-Saharan Africa, yet they are close to twice global rates. Maternal deaths (the death of women while pregnant or within 42 days of the end of pregnancy) are estimated by UNDP to be 550 for every 100,000 live births, a considerably better ratio than across Sub-Saharan Africa, but twice the global ratio.24 At 54.1 years, life expectancy stands above that of Sub-Saharan Africa but falls far short of the 69.3 years in the world overall.

Table 2 Population growth and mortality indicators in international context25
Uganda Average annual population growth (2010-15) (%) Median age (2010) Total fertility rate (2010-15) Number of births per 1000 women age 15-19 Contraceptive prevalence rate, any method (% of married women ages 15-49) Infant mortality per 1000 live births (2008) Under-five mortality per 1000 live births (2008) Maternal mortality ratio per 100,000 live births Life expectancy at birth (2010) 3.2 15.6 5.9 150.0 23.7 85 135 550 54.1 Sub-Saharan Africa 2.4 18.6 3.6 122.3 23.6 86 144 881 52.7 Least-Developed Countries 2.2 19.9 4.1 104.5 29.5 82 126 786 57.7 44 63 273 69.3 World 1.1 29.1 2.3 53.7 -

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

Rural population, access to electricity and to improved water
Only 13.3% of Uganda’s population lives in an urban area; only one country has a lower proportion of urban dwellers. This is in striking contrast to Sub-Saharan Africa (37%), least-developed countries (29.1%) and the world overall (50.5%). Globally, Uganda has the highest proportion of inhabitants with no access to electricity, 91.1%. A third of its population has no access to improved water; 25 countries have worse access than Uganda. Over half of the population (52%) has no access to improved sanitation, a better rate than most low human development countries.

Table 3 Availability of formal healthcare
Medical doctor per 10,000 people* Doctors, nurses and midwives per 10,000** Hospital beds per 10,000 people* Antenatal coverage of at least one visit (%)* Births attended by skilled health personnel (%)*
*UNDP 2010; **WHO 2010

1 14 4 94 42

Availability of formal healthcare
Uganda has one doctor for every 10,000 people. With only 14 doctors, nurses and midwives for every 10,000 people Uganda is one of 44 low-income countries that do not meet the WHO minimum threshold of 23 doctors, nurses and midwives per 10,000 population necessary to deliver essential maternal and child health services.26 Uganda has four hospital beds per 10,000 people; in only four other countries is the ratio lower. The proportion of women making at least one antenatal visit is high, at 94%, but the proportion of births attended by skilled health personnel drops to 42%. The Uganda Millennium Development Goals report for 2010 gives the following information.27 An expectant mother’s first antenatal visit is late in the pregnancy, a median of 5.5 months. Among the poorest fifth of the population, the share of births attended by skilled health personnel was 29% in 2005-06 compared to 77% among the wealthiest fifth. There are also large urban-rural inequalities: 80% of deliveries in urban areas were attended by a doctor, nurse or midwife but only 37% in rural areas.

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

26. 27. 28. 29. 30. 31. 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

Public expenditure on health
Uganda’s public expenditure on health stands at 1.6% of Gross National Product (GDP) (in 2008). Only 16 countries spend smaller proportions of GDP on health than Uganda. At 2.3% of GDP, Ugandan military expenditure is almost 50% more than its health expenditure; only 10 other low human development countries devote higher proportions of GDP to military than to health. Government of Uganda health expenditure as a percentage of total government expenditure in 2009-10 was estimated at 9.6%. The proportion is 2.1 points above that of 2000-01 and just under that of the peak year of 2004-05, and continues to stand well below the Ajuba target34 and the Government’s own target of 15% by 2014-15. From Table 5 it may be deduced that the Government funded almost 60% of health expenditure in 2009-10, while donor projects accounted for 40%. It should be noted that several development partners channel development assistance through off-budget support: government estimates indicate that 77% of health project support in 2009-10 was off-budget.35

Table 4 Ugandan public expenditure33
Education (% of GDP) Military (% of GDP) Health (% of GDP) Debt service (% of GDP) Expenditure on health per capita (PPP$) 3.8% 2.3% 1.6% 0.5% 74

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

*Provisional Budget outturn 2009-10

33. United Nations Human Development Programme 2010, Statistical Annex 34. In 2001, African Heads of State made a commitment to allocate 15% of their annual domestic budgets to health during the special summit on AIDS, TB and Malaria held in Abuja, Nigeria. The Abuja commitment was to exclude donor support. 35. Ministry of Health 2010b table 2.2 36. Ministry of Health 2010b table 2.3

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Our Side of the Story: The lived experience and opinions of Ugandan health workers

2.2 Formal healthcare provision
In Ugandan policy, the healthcare system comprises services accessed at health units (hospitals, health centres, clinics and ‘drug shops’ selling medicines) and community services which range from home-based care (typically provided by organisations funded through overseas aid) to traditional and complementary medicine practitioners. Approximately 60% of Uganda’s population seeks care from traditional and complementary medicine practitioners (herbalists, bone-setters, birth attendants, hydro-therapists, spiritualists and dentists) before and after visiting the formal sector.37 It is reported that birth attendants constitute 12.3% of traditional healers and have organised a registered association with about 60,000 members.38 Within the formal system, healthcare is provided primarily in hospitals and health centres run by the government, not-for-profit organisations and private profit-making organisations. Not-for-profit providers, three-quarters of which are under the umbrellas of the Protestant, Catholic, Muslim and Orthodox Medical Bureaux, are well integrated into the public health system. The government oversees not-for-profit facilities within its devolved district management system and subsidises them at around 16% in 2008-09, down from 22% in 2007-08.39 The expansion of private health providers has been described by the Ministry of Health itself as “largely unregulated and chaotic”.40 There are innumerable unregistered private sector units, including drug shops. A count in 2005 in three districts found government and not-for-profit units together made up as little as 4% of all health units.41 The Ministry of Health’s recent inventory of facilities, drawn up in 2010, lists 4,441 facilities officially registered as a hospital or health centre.42 Table 6 shows 60% in the government sector, 18% in the not-for-profit sector and 22% in the private sector.

The health facility hierarchy: health centres and hospitals
Health centres and hospitals are structured in tiers in line with the local government structure (see Appendix B). The original lowest level of health centre (health centre I), equivalent to an aid post, has been phased out. Now the Ministry of Health is promoting Village Health Teams. Unpaid local people are trained to increase health awareness, as well as to treat minor illnesses, and are expected to link communities with health centres. In late November 2009, teams had been established in three-quarters of districts, but only a third of districts had trained teams in all villages.43 The size of population served and the services that should be offered by health centres increase from the bottom level upwards. A health centre II should provide preventive, promotive and outpatient curative health services. The Ministry of Health’s inventory shows over a quarter of health centre II facilities located in the capital, Kampala, with 98.5% of those in private hands. Some 95% of private health centre IIs were found in four districts, including Kampala. A health centre III should provide maternity, in-patient and laboratory services, in addition to health centre II-type services. A health centre IV should provide emergency surgery and blood transfusion in addition to the types of services a health centre III should offer, and should be headed by a medical doctor. In 2009-10, less than 25% of the 119 health centre IVs reporting to the Ministry of Health provided at least 10 of 12 key services expected of a health centre IV, and only 57% of those had a medical officer.44 Five of the 80 districts in the inventory had no health centre IV at all and a further 23 had one only.

Table 6 Health facilities by level and ownership
Hospital No. Government Not-for-profit Private Total 65 57 9 131 % 49.6 43.5 6.9 100 Health Centre IV No. 165 12 1 178 % 92.7 6.7 0.6 100 Health Centre III No. 847 241 26 1114 % 76.0 21.7 2.3 100 Health Centre II No. 1572 486 960 3018 % 52.1 16.1 31.8 100 No. 2649 796 996 4441 Total % 59.7 17.9 22.4 100

37. 38. 39. 40. 41. 42. 43. 44.

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 Health’s 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

Patterns of use of health facilities
The vast majority of Ugandans, 93%, seek treatment for sickness.51 Ugandans turn to private clinics and drug shops for walk-in healthcare and medication, and favour health centres and hospitals for more serious conditions and in-patient care.52 Well over half (58%) go to drug shops and private clinics, 28% to health centres and nine% to hospitals; considerably higher proportions of rural than urban dwellers use health centres, while higher proportions of urban dwellers use hospitals.53 The poorer you are in Uganda, the more likely you are to go to a government health centre. Almost half of the poorest tenth of the population use a government health centre, compared with only 12% of the richest tenth. Moreover, the poorest tenth almost doubled their use over a five-year period, while the richest 10% increased use only marginally.54 In 2010, over one in four Ugandans (28%) lived more than five kilometres from the nearest health facility.55 The government has invested in improving physical access to healthcare by building more health units. By 2009-10 the average distance to a government health centre was 4.6 kilometres, which the majority of people walk (75%) or cycle (14%).56 Children and pregnant women are the largest groups of health facility patients: 38% are children aged 0-14, with the majority (97%) seeking immunisation services; and 38% are women seeking antenatal and delivery care services.57 The proportion of deliveries in government and not-for-profit facilities in 2009-10 was 33%.58 In contrast, traditional birth attendants assisted 23% of deliveries, and relatives or other unskilled helpers 25% in 2005-06.59

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

2.3 The Ugandan health workforce
There are no available up-to-date data on the constitution of the Ugandan health workforce. The prime source is the 2002 Population and Housing Census.60 The census recorded people who had worked paid or unpaid in a health occupation in the previous seven days. Most commentary relies on the census data.61 In addition, WHO has produced estimates for 2004 and 2005.62 These cover people working full-time in paid activities in organisations whose primary intent is to improve health, as well as those whose personal actions are primarily intended to improve health but who work for other types of organisation.

Occupations: numbers and density
This chapter focuses on the main occupational groups (Box 1).

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

Percentage 6.9 9.0 48.0 36.1 100

Per 10,000 population 1.2 1.6 8.3 6.3 19.1

2,919 3,785 20,186 15,228 42,118

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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Employment status and attrition
Official documents have complained of “rampant dualism”.73 In 2002, 30% of all medical doctors, dentists, medical specialists and consultants were privately employed and only one quarter of those worked full-time.74 A survey in 2005 confirmed that dual employment is common among medical doctors: 54% of medical doctors employed in private healthcare facilities also worked in the government sector.75 While the census found 29% of nurses privately employed, almost all (95%) were employed full-time. 14% of medical doctors and of nurses and midwives were self-employed.76 While there are no data on health worker unemployment, there are indications that some nurses and midwives disappear from view after qualifying. All practising health workers in the country are required to register with the relevant professional regulatory council and obtain a licence to practise in Uganda.77 A new human resource information system supported by the United States Agency for International Development (USAID) allowed the Uganda Nurses and Midwives Council to see how many nurses and midwives failed to register. The first published analysis showed that 12% of the 17,297 nurses and midwives passing final examinations from 1980 to 2004 did not register with the council.78 When the period of analysis was extended to cover 1970 to 2005, the proportion increased slightly to 13%.79 Some qualified students went into employment without registration to avoid paying the registration fees.80 The human resource information system revealed that 55% of registered midwives (4,075 midwives) did not obtain a licence to practise from the Nurses and Midwives Council.81

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

The facility-based workforce
Of particular interest to this research are health workers employed in facilities. The Ministry of Health has a new human resource information system, but the publicly available comparative data relate to 2004 and 2005. Table 9 shows that 45% of facility-based health workers were in government facilities (excluding district health office staff) and 23% in not-for-profit facilities in 2004; and that in 2005, the number in private for-profit facilities was estimated at 12,775, representing a 32% share of the total 39,663 employees. It should not be assumed that almost 40,000 different people worked in facilities in 2004 and 2005. The data for the for-profit sector include an estimated 3,228 people employed simultaneously in other sectors.87 It is possible that government data include personnel working also in the not-for-profit sector (it is not permitted to be employed in more than one government facility).

Table 9 Facility-based staff 200488 and 200589
Health occupations Government (2004) Not-for-profit (2004) Private for-profit (2005) Total 15,124 6,102 12,775* Other staff 2,619 3,052 Per cent 45 23 32 Total 17,743 9,145 12,775 39,663

*Non-health occupations not recorded separately; includes 3,228 employed simultaneously in other sectors

73. 74. 75. 76. 77. 78. 79. 80. 81.

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

82. 83. 84. 85. 86. 87. 88. 89.

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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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

90. 91. 92. 93.

Republic of Uganda 2010 Matsiko 2010 Ministry of Health and The Capacity Project 2008 Medicines and Health Service Delivery Monitoring Unit 2010

94. 95. 96. 97.

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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3. Research design and methods
This chapter first describes the three-stage approach to the research. Outlines of the qualitative research methodology and sampling design, data collection and data analysis follow. The chapter concludes with an overview of the health worker participants. Further details are in Appendix A.

3.1 The research stages
The research was conducted in three main stages: consultation with local stakeholders on the draft protocol to be submitted for ethical approval98; focus groups and individual interviews with health facility staff and managers; and stakeholder feedback on draft findings. In June 2010, VSO Uganda and HEPS-Uganda held a research workshop with support from VSO International. Fourteen representatives of organisations concerned with health worker issues in Uganda attended, including healthcare provider organisations, professional associations, regulatory councils and consumer and health worker advocacy organisations. Participants explored practical challenges in gathering and disseminating the views of health workers. The workshop started to build an alliance of interested stakeholders to take forward the research findings. Main-stage fieldwork was carried out from late June 2010 to February 2011. From June to August 2010, the Valuing Health Workers researcher, a VSO volunteer, joined forces with a second VSO volunteer who had in February 2010 begun similar research with nurses as an independent initiative. The two topic guides were combined, and a small number of interviews and focus groups already conducted in the nursing research project were amalgamated with the Valuing Health Workers data. VSO produced a report of interim findings to coincide with the Global Health Workers Forum in Bangkok in January 2011.99 A roundtable discussion at a VSO-led side meeting at the Forum followed a presentation of selected findings from the Valuing Health Workers research in Uganda. Ugandan and other participants shared their perspectives on the issues presented and put forward promising solutions. In January and February 2011, interim findings were shared with stakeholders in Uganda through one-to-one meetings and a stakeholder workshop organised by HEPS-Uganda. The workshop brought together 16 representatives of organisations including professional associations and unions, regulatory councils and health and human rights organisations. The workshop served both to validate the findings and to elicit suggestions for coverage of additional aspects in the final report.

3.2 Qualitative research methodology and the purposive sampling design
Qualitative research aims to provide an in-depth understanding of the social world of research participants through learning about their social and material circumstances, experiences, perspectives and histories.100 Qualitative research is not based on statistically representative samples and so does not produce statistically significant findings. Participants are selected in a non-random way, according to characteristics of most interest to the particular study. This is known as purposive sampling. The criteria used to select participants are more important than the number of people taking part. Indeed, qualitative research is often based on a small number of cases. In reporting, qualitative research does not use numbers; any experience or perspective has value, regardless of how often or seldom it appears. The research sampled facility-based health workers whose prime role is treating or caring for patients, and facility-based managers: nursing assistants, nurses, midwives, clinical officers and medical doctors. The study design thus excluded other professional groups. In achieving the health worker sample it was first necessary to ensure that all regions were included, as although not an administrative grouping, region has social and political importance in Uganda. The strategy was to select one local government district in each of the Central, West, South West, North, North East and East regions, and also to include the capital city. It was felt important to include a range of districts in terms of how far they were deemed easy or hard to serve. Within each district in the sample, one hospital (where one existed) and at least one health centre were to be selected, covering urban and rural facilities. Among the selected facilities, the aim was for a spread of level of hospital and health centre, and inclusion of not-for-profit and private facilities as well as government facilities.

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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3.3 Data collection
Seven districts in six regions and the capital city, Kampala, were selected, so the selected facilities were distributed across all regions (Table A.1). The districts ranged from very hard to serve to not hard to serve, according to the Ministry of Health criteria (Table A.3). The 18 facilities in the sample comprised three referral hospitals, six general hospitals, four health centre IVs and five health centre IIIs. Eleven were government-run, five were run by not-for-profit organisations and two by private organisations (Table A.2). Permission to carry out the research was obtained from district health officers in the five districts where government facilities were included in the sample. District health offices assisted in linking the researchers to district-level government facilities. Referral hospitals and not-for-profit and private sector facilities were approached directly. At each facility the staff member in charge was asked to arrange for staff to meet with the researcher in small groups of peers: enrolled nurses or midwives, registered nurses or midwives, nursing assistants and those in charge of wards. In smaller facilities, mixed groups and individual interviews were necessary because of the limited numbers of available staff. Medical doctors, clinical officers and facility managers were interviewed individually, apart from one joint interview with two managers. Sixteen small group discussions with a total of 71 participants and 46 one-to-one interviews took place at the 18 facilities. One health worker declined to take part because of a lack of staff to cover her absence. The five district health officers were also interviewed. Group discussions and interviews were carried out in English. Informed consent was gained from all participants. Participants were encouraged to talk freely in response to a set of open questions. They were assured that they and their facility would not be identifiable in the research reports. The topics discussed covered reasons for becoming a health worker; understanding of the professional role; rewards; challenges, their impact and coping strategies; reasons for negative attitudes towards health workers; areas for change, and ways of increasing the voice of health workers. The full topic guide is included in the Appendix. Facility managers and district health officers were asked additionally about management issues they faced, although frontline workers were not asked directly about their management. Participants also completed a short biographical proforma.

3.4 Data analysis
Discussion groups and interviews were audio-recorded and transcribed with participants’ permission. The analytical process started with repeated readings of the transcripts to identify a thematic framework. The textual data were then structured in matrices with a row for each group or individual and a column for each thematic area. Mapping and interpretation followed from this charting process, to define concepts, find associations and provide explanations. As already noted, early findings were validated by non-governmental stakeholders through individual interviews and workshops.

3.5 The health worker participants
A general hospital was the most common workplace for participants (53 out of 122); 40 participants worked in health centres (Figure 1). Government employees numbered 75, not-for-profit 36 and private sector 11.

Figure 1 Workplace of participants
5 20 53 20 24
General hospital Referral hospital Health centre IV Health centre III District health office

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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).

There was a broad spectrum of ages among participants (Figure 4).

Figure 2 Participants’ professional status
2 6 15 44 1
Registered nurse and/or midwife Enrolled nurse and/or midwife Nursing assistant Medical doctor

Figure 4 Age groups of participants
1
20-29

16 41 24 40

30-39 40-49 50-59 60-69

24 30

Clinical officer None Other

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).

Figure 5 Sex of professional groups

Figure 3 Participants’ roles
Nurse Midwife Nursing assistant 70 60 Male

63

Female

6 11

4 3 3 44

50 40 30 20 10 0

Administration only Medical doctor

19 11
Nurses & midwives

26 25

Medical doctor in charge Clinical officer in charge Clinical officer

14 6 0
Doctors Clinical officers

5
Nursing assistants

1

2

1

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.

4.1 Benefiting others
Participants told of feeling happy carrying out their vocation, helping their people, giving something back, delivering care and comfort, helping those unable to help themselves and saving lives. Very strikingly, the benefits to the community, to individual patients and to families were the biggest sources of satisfaction even in the harshest working environments.

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 the wider community
Health workers emphasised the rewards of sharing their knowledge and skills with communities to counter harmful traditional beliefs and practices, educate people about ways of preventing disease and encourage take-up of health services. Seeing more women delivering babies in health units, diseases controlled through immunisation programmes, or reduced reliance on harmful traditional remedies brought great satisfaction. Health workers were especially pleased when involved in new programmes and able to see their impacts, such as a nutrition clinic, a mental health unit or prevention of mother-to-child HIV transmission. Satisfaction came from being part of a health facility that put the patients first. Especially in rural areas, health workers were happy to use their knowledge to help informally outside working hours and around their homes. For an off-duty nurse, it was good to socialise with in-patients, hear their family problems and have the chance to give some health education.

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.

4.2 Job satisfaction
Linked to the happiness of seeing someone recover is the satisfaction of knowing your own contribution, among medical doctors and clinical officers especially: “I feel happy when I give treatment to my patients and they get well, I feel so proud, I feel very fine” or “I can see the difference I have made, that’s very important.” Introducing new treatments and bringing about change in a challenging environment was hugely satisfying: “What others thought was so difficult, I have been able to do.”

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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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 nurse’s 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.

4.4 Appreciative and supportive management and colleagues
Appreciation on the part of managers was a huge positive, although not widely reported: “When you are recognised that you are doing good work, I think that is important, it motivates”. Simply being told “thank you” was not necessarily very satisfying in difficult working conditions. Health workers valued more tangible demonstrations of appreciation, such as open internet access, Christmas and Easter presents and staff parties. Rare, and especially valued, was facility sponsorship of further training with a job to return to. Uniquely in the study, participants in a local government hospital praised management who “appreciate us so much.” They told of certificates of appreciation, staff parties, presents, financial contributions to costs of burials and operations, help with costs of further study, days off to recover from illness, interest in staff’s work and responsiveness to problems staff identified. Health workers felt valued by good, supportive managers who created opportunities for them to raise their concerns, were always willing to discuss a problem, and sought and implemented solutions. Nurses spoke of the satisfaction of working cooperatively with other staff, having someone to consult if needed, sharing ideas and reaching solutions. Teamwork also meant helping each other out, such as an off-duty nurse caring for another nurse’s sick child, and willingness to extend hours to cover for a nurse’s delayed arrival at work. Where working conditions were especially challenging, nurses valued being part of a support network where everyone understood the difficulties.

4.3 Being recognised, appreciated and valued
Community recognition
Some nurses in rural settings liked being acknowledged and known in the community: “When you go out you are respected” or “You are famous.” Being a nurse meant being seen as an educated person; it was gratifying to be called a “small doctor.” Nurses sometimes felt their training set them apart from other people, conferring a certain prestige, especially when they could use their knowledge to help outside their formal work. Nursing was also valued as a way to meet different types of people, get to know many people and make friends.

Patients’ appreciation, trust and respect
Health workers valued being liked, appreciated, praised, respected and trusted by patients.

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5. Reasons for becoming a health worker: the “right heart” and the “wrong heart”
Participants explained what prompted them to become healthcare professionals. The urge to help, prevent suffering and save lives stood out. The overriding impression from their words was of a heartfelt desire to “make a difference” as a nurse, midwife, clinical officer or medical doctor, rather than merely to earn a living. It is a mark of their professional commitment that almost all participants said they would still choose to be health worker. Participants commented on people joining health professions, notably nursing, for the “wrong” reasons. This, in their view, was one explanation for poor attitudes and unethical behaviour, and they put forward suggestions for improving the calibre of recruits. The recommendations also include views of other stakeholders.

5.1 A passion for the patients
For many health workers, the strong need to give to others was born from childhood experiences. It had been common in rural areas to see close family and members of the local community suffer in pain and die, with no proper medical care. Participants recounted how siblings and parents had died from mysterious illnesses that, they later realised, were caused by preventable epidemics or treatable with modern medicine. Training as a nurse, clinician or medical doctor would bring to the community essential knowledge to help prevent illnesses, discourage harmful traditional healing practices and save lives. “They were really suffering, people were dying, there were no doctors, no nurses, nobody to give them an idea about their health. I wanted to help my people.” Others spoke of atrocities in conflict areas and the need for medical skills to rebuild communities. Health workers spoke warmly of positive experiences when they or family members were in hospital. The gentle and caring touch and the healing words of nursing staff left a lasting impression. They wanted to be that person, to give in that caring way. They saw how nurses stopped pain and wanted to stop others’ pain. Growing up, they learnt how the skills of the medical staff had saved the life of someone close to them, or even their own life, and they wanted to give something in return. Some were encouraged by a grateful parent who remembered midwives urging that the baby become a midwife too. Not all impressions were good. Negative experiences of healthcare services lay behind a desire to raise the standard of medicine in Uganda. Young men and women said they felt compelled to join their professions because they believed that professional neglect had contributed to the deaths of a parent, siblings and a newborn baby, or because they had perceived the limitations of Ugandan medical expertise for a

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 one’s 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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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 relative’s 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”.

5.2 “They join for the wrong reasons”
There were widespread beliefs among nursing and midwifery professionals that poor attitudes and unethical behaviour are linked to people joining nursing for “the wrong reasons”. It was thought that more recent recruits joined because they had no other option, because nursing was a last resort when they failed to qualify for more prestigious professions or because parents pushed them into it. Pursuing pay, looking only at the job market and even as a route to leaving the country were other presumed reasons for joining nursing. Older nurse managers had noted “very few nurses come with a sense of vocation now”. There was a widespread view that people enter nursing with “the wrong heart”. It was believed that as a result, unhappy, disinterested and self-serving recruits resort to bad habits, become rude and forget their ethics and accountability to patients. There were also some comments by managers about medical doctors’ questionable attitudes to work when they seemed to lack that “inner drive”. Yet more than one nurse and a medical doctor told how they came to love their profession only when in practice, and a story was told of how a lecturer inspired an enthusiasm for nursing in a student whose sole ambition had been to train as a doctor. Indeed, some of the loudest voices criticising motives for joining belonged to staff who had developed an interest in their profession after they started work.

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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Training schools’ admission procedures
There were calls for nurse training schools to apply tighter admission procedures, to make sure applicants have not been forced into nursing and to probe attitude, so as to screen out those with no “heart” and the “wrong elements” that spoil the name of “genuine” nurses. Admission interviewers should “study the psychology of the person”, investigate thoroughly and reject applicants who seem not to be driven by the “right reasons”. There were also calls for reform of the points-based system through which university applicants can be allocated to a nursing course when nursing is not their first or even second choice.

Health and human rights training
Stakeholders advocated for the integration of health and human rights training into curricula, through expansion of existing partnerships between training institutions and health consumer advocacy organisations.102 Civil society organisations have also advocated for health and human rights training for in-service health workers.103

Improve the community service element of pre-qualification training
Stakeholders stated that community service curricula in most medical professional education is not of sufficient quantity or quality to prepare students for the conditions they face in the field, and should be improved. Community-based education programmes, which typically run for between four and eight weeks in each year of training, have been found to create some awareness of healthcare communities but implementation concerns and strategies to improve the curricula need to be addressed.104

Developing and sustaining “the right heart” in training schools
It was generally thought that the person with the “wrong heart” cannot be reformed: “Some personalities are naturally rude, she can’t change”. On the other hand, there were some beliefs that the “right heart” can be developed and sustained through training. With training now falling under the remit of the Ministry of Education and Sports, it was commented that nursing schools had become indistinguishable from other higher education institutions, and had been allowed to multiply regardless of standards, notably in the private sector. It was said that as a consequence of too many nursing schools with ill-qualified tutors, students come out lacking respect for patients and patient’s confidentiality. Some participants added their voice to calls for oversight of training to revert to the Ministry of Health “because they were producing competent people and now standards have dropped”; “new nurses are not so interested in the work.” The prospects of inculcating the right attitudes through pre-qualification training would be improved if nursing and midwifery class-sizes were reduced and tutor capacity improved: “Two hundred students in a class when you are supposed to have 60!” and “If you are a serious tutor, how do you teach and how do you supervise and follow up 200 students in one class?” Nurse participants and stakeholders recommended that training schools do more to ensure that nurses not only know the theory of the code of ethical conduct, but also understand how it should be applied in the workplace.101 Nursing course content could be improved to make sure that students take on board the role of the nurse as the patient’s advocate.

Nurses and Midwives Council registration interviews
Nurses and midwives had mixed opinions on the interviews the Nurses and Midwives Council held as a prerequisite for registration. Some found them an unnecessary, timeconsuming and expensive imposition, given that they had already graduated from nurse training schools and that attending interviews took them away from caring for patients. It was explained that when nurses and midwives were not accepted for registration, they were posted to certain hospitals for supervised practice and mentoring, and among nurse managers there were views that this in itself contributed to poor attitudes, as nurses became tired and fed up with their hard life. For other managers, the interviews were a valid way of filtering out those with gaps. A mark of the commitment of health workers in the study is the belief that the desire to care, help and make a difference stays with a person. On the other hand, managers who had observed the working environments and cultures of differing workplaces believed that good intentions can dissipate. Chapters 6 to 10 look at how aspects of the working environment undermine motivations for being a health worker.

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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6. Workload
6.1 The context
Public health facilities are required to adhere to a job structure, set centrally, that limits the number and cadres of staff that can be employed at a facility; this defined establishment of employment posts is commonly referred to as the ‘norm’.

Staffing shortfalls: key facts
Nationally, 48% of posts are vacant, representing a shortfall of 25,506 staff; the lower the level of facility, the greater the shortfall (December 2009).105 Percentage of Staffing posts vacant shortfall Health centre II Health centre III Health centre IV General hospital Regional referral hospital Main national referral hospital 64% 54% 45% 38% 30% 10% 7,245 8,051 3,396 2,750 1,082 222 Across local government districts, 47% of approved positions are filled; in only 10 of the 80 districts are more than 70% of positions filled. 106 Percentage of approved posts filled 21-30 31-40 41-50 51-60 61-70 71-80 81-90 90-100 In 2009-10: • 41% of medical doctor positions in 42 general hospitals were not filled – a shortfall of 180 doctors • 41% of nursing positions in 42 general hospitals were not filled – a shortfall of 3,380 nurses • 64% of medical doctor positions at 117 health centre IVs were not filled, a shortfall of 154.107 Number of districts 4 25 15 11 15 7 2 1

6.2 The health worker experience
Concerns about understaffing and workload were most marked among health workers and managers in government facilities at all levels. At some not-for-profit and private facilities the concern barely surfaced, while at others it was a key issue for participants. Overload was reported even in well-staffed hospitals within the not-for-profit sector.

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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The impact on health workers
Unmanageable workloads “Overwhelmed” was a word widely used by nurses speaking about unmanageable workloads in many government hospitals and a not-for-profit hospital: “How can you manage? It does something to you.” Nurses spoke of being affected mentally and “destroyed” to the extent of becoming ill: “One nurse running a full ward, with patients sleeping on the floor as well, the overwhelming number can affect the nurse psychologically.” With a nurse off sick, the workload became even harder to manage. Too many tasks and responsibilities In government health centres, midwifery and nursing staff said they were stretched to the limit by too many tasks: “You have to run the ante-natal clinic, conduct deliveries, carry out postnatal, do the ward round, one person. Then you have to run most of the young child clinic.” Burn-out resulted: “You have to do the counselling, take blood, see the patients, prescribe for them and do everything. When you leave at the end of the day, you are burnt down completely.” Among nurses in government hospitals, there were complaints about having to take on doctors’ duties: “I don’t know when a ward round was last done. We review patients, even prescribe.” Non-availability of a doctor caused dilemmas for midwives, who feared blame if they undertook a medical procedure beyond their scope of duty. Health centre nurses believed they did the work of a clinical officer. Government hospital nursing assistants complained about undertaking work which should be done by nurses. Working in a team had been one of the attractions of nursing as a career choice. It was frustrating and disheartening when cooperation was lacking, such as when a relief worker failed to turn up: “No teamwork at all, and when it is an emergency and they delay, you really feel bad. You know what the outcome will be but you can’t help.” Working day and night Health workers in government health centres told of working day and night, often alone, due to understaffing and staff absences. It was pointed out that clinical officers, midwives, nurses and nursing assistants had stayed on duty round the clock or even longer, contrary to government rules and codes of conduct. They said they kept on in the face of fatigue because of their commitment to helping others: “If God were not calling, you could not do this work 24 hours.”

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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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 person’s suffering: “If I’m 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”.

The impact on attitudes, behaviour and practices
Hospital nurses acknowledged that overload damaged quality of work: “At the end you are very tired and no quality of work is done.” Participants employed outside the government sector were especially outspoken about the impact on the quality of nursing in a large government hospital where they had seen performance drop and patients’ needs neglected. Personal distress made things worse, they felt: “Understaffed in a ward full of patients, on top of family worries, they find they can’t perform, miss things and cannot provide all the services patients need.” The nursing role should be much more than taking routine observations and giving treatment, but it was impossible for an overworked nurse to find time to talk with patients, uncover their problems and deal with the whole picture. Consequently task-oriented nursing was unavoidable and even routine tasks were hard to complete: “With two nurses for 50 patients, you are reduced to trouble-shooting, it’s not nursing.” Hospital nurses “torn apart” by patients calling for attention found it hard to make patients understand that they had to wait their turn. They recognised they could lose their temper in such stressful situations and forget their basic good intentions: “You become different.” Medical staff had seen the effects of tiredness: “The tone of voice changes” and “The nurses end up losing it, when they are already frustrated by poor pay.” Managers were generally understanding: “As a human being you can get irritated and lose your temper because of fatigue” and “What do you expect with only half the nurses you should have? They become rude.” Participants working in well-staffed private and not-for-profit hospitals had seen the consequences of work overload in the government sector. Managers observed that a lack of opportunity to fulfil their proper professional role “demotivates” nurses, who then adapt to a culture of poor standards of care in their work environment. A “don’t care” attitude resulted: “By the time she is 30 she is used up. Already tired due to understaffing,

The impact on community relations
Aggressive or demanding outpatients were a particular concern for medical doctors and clinical officers. With so many patients waiting for attention, it was important to prioritise their treatment. But patients either did not understand the triage system or believed they deserved priority. Such challenges to professional judgement were especially hard to handle when aggrieved patients called on local leaders to intervene on their behalf. Among midwives working round the clock, huge distress was caused by patients accusing them of not working when they had found a little time to rest. This misperception was said to fuel community hostility towards health workers.

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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.

Local management factors
In the local government sector the problems of overwork and too little time off stemmed in part from limited management capacity to draw up fair duty rosters. It was noted that poorly planned rosters scheduled nurses to work back-to-back day and night shifts. The view among nurses was that properly organised time off would motivate them to work. Concerned health centre managers said they recognised the need to manage staff hours fairly, but with so few staff that was almost impossible. Government sector managers explained how unexpected absences worsened the load on nursing staff. When staff did not turn up for work, and especially when they did not communicate their intent, managers struggled to find workers to fill the gaps and patients were left waiting. While there was sympathy among managers for the personal and family problems that kept staff from work, there were also feelings that the reasons offered were not always genuine. In Ugandan culture, it was hard to question whether family sickness or burials had actually occurred and hard to enforce a requirement to produce sick notes. Sometimes managers suspected, or even knew, that absent staff were “moonlighting” or pursuing a “side income”, “doing other things to survive”. Managers and frontline workers commented that staff who lived on site were rarely absent, unless they were sick or a relative had a problem, as they would be ashamed when patients came looking for them at home. Participants working in government health centres explained how their hours and workload increased at short notice when senior colleagues were called away to workshops and meetings. They rarely questioned why these activities took

6.3 Factors contributing to understaffing and work overload
It is important to understand the structural causes of inadequate staff numbers in government health facilities. It is not necessarily the case that there is a shortage of health workers available in the labour force; some government sector managers were aware of huge numbers of applicants for advertised vacancies, while others said they had failed to recruit. Among managers at district level, views were expressed that decentralisation of the health system was to blame for the uneven distribution of health workers in local government.

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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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 don’t 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 won’t 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.

Decent staff accommodation
Participants spoke enthusiastically about the benefits of good quality staff accommodation, equipped with electric lighting and a clean water supply, suitable for families. A decent place to live attracted health workers to remote and rural facilities and made for a more contented workforce. On-site accommodation was said to reduce absenteeism. Civil society organisations advocating for health workers should hold to their objective of monitoring the government’s intention to “provide decent and safe accommodation for health workers at health facilities, especially in hard-to-reach areas”112 and press for concrete targets.

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.

De-urbanise health worker training
It was suggested that more training schools located in rural areas would produce nurses and midwives already adapted to rural environments. Managers saw value in attaching nurse training to remote hospitals, both to generate a local workforce and to bind health workers to the community. Civil society organisations recommend targeting admission policies to enrol students with rural backgrounds, exposing students to greater rural field work and building schools and residency programmes outside major urban areas.113

Health worker/patient ratios
There were views that the norm was out-dated and failed to recognise the changing nature of services, such as HIV and AIDS treatment clinics, new cadres coming out of training schools and local population growth. It was recommended
108. 109. 110. 111. 112. 113. Mwita et al 2009 East, Central, and Southern African Health Community (ECSA-HC) 2010 See Ministry of Health and The Capacity Project 2008. Matsiko 2010 Ministry of Health 2010b p102 Action Group for Health, Human Rights, and HIV/AIDS 2010

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7. The facility infrastructure
Government sector workers in rural hospitals and health centres bore the brunt of dilapidated conditions: non-functioning operating theatres, erratic or non-existent electric power, unreliable access to clean water, blocked sewers, broken-down transport and no communication technology. They told of damaging effects on job satisfaction, risks to themselves and deeply felt harm to patients.

7.1 The context
Official reports paint a gloomy picture of the physical state of health facilities. While new health centres have been built and some health centres upgraded with newly constructed theatres, outpatient departments and maternity wards, the government acknowledges that most facilities are in disrepair and that inadequate allocation of funds hampers maintenance and rehabilitation. The government also recognises failures in electricity and water supplies, transport and communications technology.

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

Failing infrastructure: key facts
Most facilities are in a state of disrepair. Rehabilitation of buildings is not carried out regularly.114 Many health centre IVs still lack crucial infrastructure to make them fully functional: 49% [of the 117 health centre IVs providing information] either have no operating theatre or have an incomplete or non-functional theatre.115 Only about 24% of health facilities have electricity or a backup generator with fuel routinely available during service hours. Only 31% have year-round water supplied in the facility by tap or available within 500 metres.116 Only 47% of all facilities can transport a patient to a referral site in maternal emergencies.117 An independent evaluation of the ambulance service in 13 districts of northern Uganda found only 8% of mothers reported using an ambulance to reach the health facility during their last delivery.118 Only 6% of health facilities have information and communication technology, mostly comprising mobile phone, radio, TV and, to a smaller extent, computers.119

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

114. 115. 116. 117.

Ministry of Health 2010b Republic of Uganda 2010 Ministry of Finance, Planning and Economic Development 2010 Ministry of Finance, Planning and Economic Development 2010

118. 119. 120. 121.

Womakuyu 2010 Ministry of Health 2010b HEPS-Uganda 2010, Annex IX Schmid et al 2008, Chapter 6

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7.2 The health worker experience
The state of facilities
Among government facility managers and district health officers there were questions about why more health centres were being constructed when existing facilities could not work as they should. Facility managers in the government sector told of struggling with inadequate budgets to repair or replace decades-old infrastructure: “The only borehole, you pump for 30 minutes and then it stops for two hours”. Pumping water only every second day and encouraging rainwater collection in jerry cans and drums was a partial solution. Elsewhere, the best that could be hoped for was being earmarked for rehabilitation – “at least we are in a programme” – or “a good Samaritan” to help connect to a distant water source. On the other hand, external funding coupled with well-managed in-house technical services allowed a not-for-profit hospital manager to speak with pride of rainwater conservation and solar power systems. There was a marked contrast between a hospital where wards were cleaned three times a day and one which had no piped water supply “for years”.

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 patient’s case notes at night, midwives could not tell if she had HIV and so reduce the risk to the baby. Only a donor’s 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.

The impact on health workers
“The condition of the working environment is one of the biggest challenges. So that people can work with a smile, wake up in the morning and be happy going to work. You enjoy your work and your profession.” Low job satisfaction A key concern was the state of operating theatres at health centre IVs. Government sector managers spoke of theatres that could not function because of poor design or shoddy construction. They said that when a theatre was unusable, or lacked proper equipment or anaesthetists, underemployed medical doctors lost interest and left. Frontline doctors commented that the lack of opportunity to practise surgery explained the unwillingness to take up a medical doctor post at a health centre IV. For nurses working with only one paraffin lamp and limited fuel, proper care of night-time emergency admissions was impossible: “How can you manage to put in the intravenous line with a dim light?” Sharing one paraffin lamp across three wards was very hard, yet: “We just have to bear with it for the betterment of our community.” Nurses working with no good light felt they were failing their duty to patients in need of scheduled treatments during night hours. Hospital communication systems do not work without power, and midwives can be left to bear the brunt when a doctor cannot be called.

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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 women’s 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.

The building and rehabilitation programme
A suggestion was to 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.

Responsiveness to problems identified by staff
Government sector frontline workers noted facility and district managers who had been slow to respond to requests for improved lighting. Another source tells that a similar request was not acted on although a large stock of lamps was held in the district store.123 Good practices identified in the not-forprofit sector included regular meetings between management and department heads at which faults were raised for action.

Health worker ‘ownership’ of the facility
It appears beneficial to get facility staff involved in tackling infrastructure problems. For example, staff at a government hospital organised rainwater collection.

The impact on attitudes, behaviour and practices
Health workers spoke of their distress over how a lack of electric power, water and transport affected the quality of service. They wanted to do their best for patients but had to protect themselves too. They explained how patient perceptions of rudeness arose from the lack of power and water. The fear of infection influenced their approach to patients: “Sometimes we come in with a scared heart” and “Sometimes you shy away from risk and the patient thinks you are rude, but it is the working conditions.”122 They also acknowledged that the frustrations of working in the dark caused impatience and delays that patients construed as neglect.

The impact on community relations
It was said that patients refused to be admitted for treatment when the toilets did not work and they were not able to bathe, thus damaging the reputation of the facility. A lack of water to flush toilets forced staff to return home, fuelling patients’ beliefs they were not at work and running the risk of their being blamed by local political leaders for leaving the workplace while on duty.

122. Similar findings reported by Dieleman et al 2007 123. Medicines and Health Service Delivery Monitoring Unit 2010

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8. Equipment and medical supplies
This chapter looks at the impacts of deficits in equipment and associated medical supplies, and the following chapter reports the impacts of shortages of medicines in healthcare facilities.

8.1 The context
Equipment failures: key facts
There is a shortage of basic equipment in health facilities. Only 40% of available equipment was in good condition and about 17% needed replacement [in 2008-09].124 A survey in 11 districts showed the extent to which health facilities lacked equipment to diagnose and treat malaria in mid-2009. Of the 105 facilities surveyed, 83% were in the government sector. The survey found: • No functional microscope in about 50% of the 35 health centre IIIs and 20% of the 10 hospitals and 12 health centre IVs • No malaria rapid diagnostic tests in 86% of the 83 health centre IIs and IIIs • No haemoglobin measurement equipment in 61% of all facilities During the three months prior to the survey, none of the hospitals and health centre IVs had all seven components of a basic care package for the management of severe malaria consistently available. The most common ‘stock-out’ was blood for transfusion, available in only one facility. Blood transfusion sets were lacking in around two thirds of facilities and over half had no giving sets.125 Evidence suggests that only 5% of facilities have a vacuum extractor (used for assisted vaginal delivery) and only 10% have a dilation and curettage kit (needed to remove a retained placenta).126

8.2 The health worker experience
Health workers praised facilities with good diagnostic equipment, such as x-ray and ultrasound, and with a commitment to a well-equipped establishment: “It’s a good place, that’s why I have stayed so long.” Elsewhere, working with inadequate equipment was a huge challenge, damaging workers’ professional fulfilment, the quality of services and community relationships. The difficulties were acute in the government sector, but also present in parts of the not-for-profit sector.

The impact on health workers
Government sector medical doctors and nurses told of interruptions to the supplies of oxygen and blood; missing canulas, needles, giving sets and sutures; minimal availability of urine testing kits and family planning supplies; insufficient dressing packs, and absent or faulty diagnostic equipment. Rural midwives in the government sector told how they struggled to provide a service with no delivery kit, cord clamp, sucker, gauze or cotton wool and just one pair of scissors.

124. Ministry of Health 2010b 125. Achan et al 2011 126. Ministry of Finance, Planning and Economic Development 2010

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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 can’t 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 patient’s 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 don’t 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 don’t 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.

The impact on attitudes, behaviour and practices
Participants working in the private and not-for-profit sectors spoke frankly about effects of shortages they had seen during their time in government facilities. They told of nurses forgetting what they had been taught in training schools and some not working as a result, so projecting a bad image to the community which in turn made nurses feel not respected and prompted them to leave. Participants in the government sector did not identify these effects. However, there was a suggestion that nurses were reluctant to come to work and face patients and their relatives knowing that essential supplies were lacking: “Staff don’t want to come in and look at a mother with a dying child and no canula to give intravenous fluids.”

The impact on community relations
Health workers felt blamed for the lack of supplies and resented accusations of theft. The patient’s attitude changed when asked to buy supplies: “You feel bad when somebody is not appreciating what you are doing.” Patients’ carers were sometimes angry and violent, such as a husband who hit a midwife when asked to buy gloves. There were fears of personal repercussions if the rule was disregarded and the patient was asked to buy supplies: “The Government is going to see you as a bad person.” Staff in one facility were stressed by the arrest of a health worker who asked a patient to buy essential supplies. The view there was that local political candidates had set the arrest in motion to discredit the incumbent leader.

127. User charges were abolished in 2001 in all government facilities except private wings in hospitals.

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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.

Encourage international donors to provide large items of equipment directly
There was a view that mismanagement and corruption dissipated development partners’ support to the Ugandan health budget and that donors should provide large items of equipment directly. It was felt that it would be counter-productive if donors were to donate smaller, more easily removable items.

Equipment maintenance
The view was expressed that more attention needed to be given to the maintenance of existing medical equipment. It was frustrating to have equipment on site that could not be used because of broken or missing small parts. The expense of the parts was a minor issue. Rather, the problem was said to stem from inertia and poor organisation among facility management.

Improve frontline health worker voice and participation
Frontline health workers showed limited knowledge of how the ordering and delivery system is supposed to work and how financial allocations and priorities are set. Workers in the government sector told of putting requests to facility management, but did not understand why their needs were not met. Workers in district-level facilities commonly blamed the Ministry of Health for deficits. Participants at a government hospital identified as good practice formal consultations by management to find out what equipment frontline workers needed, and enabling them to participate in decision-making about equipment and supplies. Health workers were free to identify not only equipment essential for patient treatment but also items that made their work easier and more comfortable, such as fans and radios. Transparent decision-making on priorities and implementation allowed workers to have a voice and see that their views had been listened to.

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9. Medicine supplies
Medicine shortages and ‘stock-outs’ emerged as one of the biggest challenges for government health workers. Unable to give their patients the drugs they needed, health workers grieved for their patients’ suffering and became demoralised by the futility of their roles. They struggled with disappointed or angry patients and their limited understanding of the reasons for shortfalls in supplies. They were deeply hurt by accusations of stealing drugs, the lack of trust the public had in health facility staff, a seemingly hostile press and by what they saw as politically motivated moves to discredit them.

9.1 The context
Drug availability failures: key facts
“The percentage of health facilities registering stock-outs in essential medicines has consistently been over 60% for the last 10 years.”128 The availability of 40 essential medicines in the period April-June 2010 was recorded in a sample of 28 government and 18 not-for-profit facilities across Uganda. None of the 40 medicines was available in every government facility when surveyed, while eight of the 40 were found in all of the not-for-profit facilities. Average availability of the 40 medicines was 59% in the government facilities, compared with 78% in the non-for-profit facilities.129 An assessment of the pharmaceutical situation in 36 government and 36 not-for-profit health facilities with pharmacies or dispensaries in six districts was carried out in 2008. For the listed essential medicines, the average ‘stock-out’ days per year were 72.9 in government facilities and 7.6 in not-for-profit ones.130 Only one in three respondents surveyed in 2008 agreed that their nearest government facility usually had all the medicines the household needed.131

9.2 The health worker experience
The drug supply situation
Outside the government sector, medicine supplies were generally thought adequate to treat most conditions. A sufficient supply brought health workers the satisfaction of working effectively, as well as pride in an efficient facility that logged all movements of medicines. The not-for-profit sector was not immune to shortages, however; in one facility, shortages were said to be due to loss of revenue because it gave impoverished patients drugs on credit.

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.”

128. 129. 130. 131.

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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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 person’s 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.

The impact on community relations
“It puts a lot of strain on community relations.” Health workers said it was hard to make patients and other community members understand why drugs were not available at all times. They acknowledged that among people sick and in pain there was little appetite for words of explanation, and that the complexities of the supply system were beyond the understanding of some people without education. But they also told of angry, bitter patients who cursed them and refused to listen. In the past, Ugandan healthcare users maintained a belief that government health facilities lacked medicines even when receipts increased.133 According to health worker participants, there now appears to be a prevailing belief that health facilities are well supplied with medicines: “People say why don’t you give us drugs?” A particular problem arose when a health facility changed ownership from not-for-profit to government and the previously superior supply of medicines could not be maintained. Health workers said that communities served by government facilities assumed health workers took the drugs: “Patients think you steal” and “Patients call us thieves.” They said that patients believed that health workers took government supplies to stock their own clinics and drug shops, to which patients were then sent to buy medicines. It was acknowledged that such abuses had occurred. Indeed, good supplies in one hospital were attributed to the fact that few of its nurses ran private clinics and drug shops. Health workers expressed sorrow about the lack of trust put in them and the effect on community attitudes: “When drugs are not there, they tend to hate nurses.” In contrast, it had been observed that patients’ attitudes towards health workers improved when given supplies of drugs to last several days. It was especially upsetting to be directly accused of theft when a patient demanded a drug that the clinician knew was not appropriate for the patient’s condition.

The impact on health workers and the quality of care
Health workers said they felt “disappointed” and that the lack of drugs “demoralises” them. Job satisfaction suffered when they were unable to give patients the drugs they needed. Their presence in the workplace sometimes seemed futile: “You are here and there is nothing to give the patients. You are just sitting waiting for them, then tell them to go back as there is no drug.” Helplessness was especially hard to bear when forced to tell poor patients to buy their medication in the private market: “I hate the situation of being helpless before the patient when they can’t afford to buy drugs” and “You feel you have not done much for the patient when they have to buy.” It seemed like fobbing off the patient: “You tell them to buy, but the patient is expecting answers.” It was hard to be seen as letting down patients keen to have family planning supplies who could barely afford the transport to the facility: “You feel so bad, it seems as if you are deceiving them and they lose confidence in you.” Self-esteem suffered when drugs were not available: “They look at you and think the health workers are bad, and yet it is the government, not us” or “Their eye looks at the nurse and that doesn’t make me able to be the nurse I want to be.” The biggest source of distress for health workers was the impact on the patients, and they spoke emotionally about how they felt for their patients when no medicines were available for them. In the case of antiretroviral drugs against HIV, which should

132. Some 51.5% of Ugandans live on less than $1.50 a day (UNDP 2010 Statistical Annex) 133. Nabyonga-Orem et al 2008

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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 that’s 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 can’t 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 President’s 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.

“Museveni warns medical workers
Quoting a proverb that says ‘a dog which steals pays with its back’, Mr Museveni told a rally […] that the same would be done to health workers who steal drugs from now on.”135

“Politicians stop playing games on the right to health
A story is often told of a politician who delivered a truck laden with ‘medicines’ to a health centre in his constituency. The truck was reportedly containing all the medicines that this health centre needed at the time. In a country where getting medicines in public facilities is intermittent and health workers are reviled for ‘stealing’ medicines, this politician was an angel straight from heaven. Now, long after the speeches and pleasantries had ended, and the MP had gone, it was time to open the boxes. But alas, the boxes were full of saline solution. […] There was no way medics at the facility would tell people the next day that there was no medicine. To the politician he had scored a political goal. But in the process, the health workers had been put in a tight position.”136

134. The Unit’s first annual report exposed malpractices and “vices” identified through its staff visits to 145 facilities in 45 districts, with an average of three follow-up visits in each district. Initially visits were impromptu, in response to “emergency calls” from the public about the state of healthcare and alleged drug thefts, and routine monitoring visits were introduced later in the year. 135. Emojong 2010 136. Kirunda 2011

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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.

Educate community members
Some health workers said they had tried hard to help patients to understand the ordering and delivery system. Others had wearied of such attempts or had barely tried: “They only want drugs, not your words.” Some simply wrote off local people as uneducated, illiterate and incapable of understanding – a point of view contested by health consumer organisations in the study. It was pointed out that patients were not receptive to explanations when in pain or angry when asked to buy medicines, though it was acknowledged that opportunities for facility-based information sharing do exist, such as with groups of women waiting for pre-natal checks. The most promising solution was to talk with community members during outreach visits, such as child immunisation days, though some health workers had limited confidence that they could succeed in changing entrenched suspicions. Others pointed to a lack of funding for outreach allowances. There were also views that Village Health Teams might have a bigger role in sensitising the community to the real situation.

Drug movements within the facility
Participants within the not-for-profit and private sectors recommended recording drug inflows and outflows, although it was also said that such time-consuming steps were not necessary when staff were trusted by management and the community. Management staff in a not-for-profit sector health centre welcomed scrutiny by the higher level body to which it was accountable.

137. HEPS-Uganda 2010

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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.

10.1 The context
Salaries: key facts
Starting salaries per month in government service in 2009-10140,141 Senior medical officer Medical officer Registered nurse Nursing assistant UGX 840,749 (USD 453)142 UGX 657,490 (USD 354) UGX 353,887 (USD 191) UGX 113,306 (USD 61)

10.2 The health worker experience
The frontline workers and managers participating in the research said they did not join their professions just for the money. They wanted to use their training to help others, prevent and cure illness and save lives: “I became a nurse not so much because I am interested in money, though money is also important. I feel it really was a vocation.” In any case, salaries were simply not attractive enough: “With so little money, nurses must want to care and help patients, just to keep going.” Money was never an overriding factor for job satisfaction, though among frontline doctors there were expectations of earning enough to “help build yourself up” and feel good about helping people at the same time. Yet there were some strongly held views among participants that some of the recent generation of health workers entered the profession with no natural interest for it and became disaffected because salaries were so low. Staff in rural health facilities said that despite long working hours with little chance to rest, they worked over weekends and on public holidays for the sake of the patients. They even volunteered their help unpaid on top of their regular work, out of commitment to patients’ welfare, for instance in HIV clinics. Low salaries were of course a huge and widespread concern, and there were many calls for better financial compensation. But it is very striking that when asked about what had to change to make things better for them, health workers emphasised improvements in the infrastructure that would result in better care and treatment for patients. Frustration with equipment and supplies outstripped frustration over salaries, as found in other studies.146

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

138. 139. 140. 141. 142. 143. 144. 145. 146.

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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The impact on health workers
Money worries Health workers said salaries were not enough for the costs of ordinary daily living, to allow them to pursue a career or to meet social expectations. They said that money worries got in the way of doing their best work and even contributed to bad practices. Managers said inadequate pay was one of the biggest challenges to healthcare delivery. 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 and afford transport to work. Financial worries added to the stresses of long hours and little rest, the burden of too many patients, the frustrations of not enough medical supplies or the lack of appreciation in the workplace: “If better paid, a nurse will work with patients with love and happiness knowing that rent and bills are paid.” In areas where demand for housing had pushed up rents, health workers found housing costs hard to meet or were forced to pay high transport costs to reach more affordable accommodation. Paying US $1.50 or more a day for transport was very hard to afford on a nursing assistant’s salary. In Uganda income is important not just to meet daily living costs. There are extended families to support: participants had up to 15 children depending on them. One of the satisfactions of earning is being in a position to support the study costs of a family member. As educated people, health professionals naturally want a good education for their children. Public primary and secondary education is free, but schools often impose fees for lunch, uniforms and building development, and many Ugandans favour the private schools that comprise over a quarter of the secondary education sector.147 Worry about school fees pervaded health workers’ lives. A participant spoke heatedly about the impossibility of affording university fees of US $900 a semester with three children and a monthly salary of US $330. Failing to meet social expectations As a health professional there are also social expectations to meet. Families, friends and social associates assume you are well off, and it was shaming to reveal how little the salary actually was. Medical doctors especially felt socially embarrassed when they could not afford to contribute large sums of money at functions held to raise funds for wedding or funeral expenses. They also spoke of how they were expected to help with school fees or medical costs: “Society expects so much from you. It’s impossible to convince people that you don’t have money when you are a doctor.” The pressure came from the community expecting a nurse or doctor to

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: “It’s 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.

147. Uganda Bureau of Statistics 2008

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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 government’s 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. That’s 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.

Impact on attitudes, behaviour and practices
Health workers and managers were encouraged to say what in their view explained behaviour regularly criticised in the Ugandan media, including being rude to patients, stealing medicines and supplies, not turning up or coming late to work, and taking money from patients. Health workers acknowledged that these bad practices did happen in some places: “It’s poverty. You get a salary of US $200, you pay school fees of around US $150, you get stuck. You don’t have transport to take you to work, you don’t have food in the house, you don’t have anything, children are crying, your parents need you to

148. Ferrinho et al 2004 149. Hospital health workers in Tanzania frequently commented in focus groups that unofficial payments were more commonly initiated by users than by workers (Stringhini et al 2009)

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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 don’t 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.”

10.3 Poor pay, turnover and loss to Uganda
The research participants were, of course, “stayers” in their profession. Career histories showed a fair amount of mobility from one health facility to another, but only very exceptionally did a participant speak of leaving their profession, and that was to earn more. The consensus was that the biggest turnover was among medical doctors. There were firm beliefs that Ugandan-trained doctors left the government sector to work for NGOs, prestigious not-for-profit hospitals or the private sector. Private sector work was tempting, in order to get more money and avoid the “frustrations” of government hospitals. Managers and practising doctors told how young doctors “run away” from hard-to-fill rural posts because of poor salaries. As well as low pay, reasons were believed to include limited opportunity to use professional skills in poorly equipped facilities, disinclination to live far from modern amenities and a lack of earning potential from private practice. Yet practising doctors explained that for many young doctors, a year or two gaining experience in a rural setting, even in deprived circumstances, was a step towards acceptance for specialist training. Staying longer meant passing the age limit for scholarships. Specialism was then the gateway to private practice and considerably higher earnings. In any case, district level facilities rarely could support the costs of a specialist if they wished to return after training. Participants were asked if they had thought about working abroad and why. For some nurses the possibility was remote: family responsibilities came first, the barriers to getting a nursing job abroad were just too high, or they had not even realised it was allowed. For others, nursing abroad was a real aspiration, and there were one or two stories about disappointments. Nurses’ reasons for considering working outside Uganda counter the widely-held perception that the lure of money pulls nurses to lucrative jobs in other countries. Better pay was not an overriding consideration. Nurses explained they were looking for an environment where “there’s respect for what you do” 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. Individual advancement was not the sole driving factor: “I would bring my skills back to share with Ugandan nurses” and “I would bring back the knowledge to my people.”

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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 don’t 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 facility’s 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.

Overtime and responsibility payments
While staff often willingly worked over-long hours for the sake the patients, there were views that their extra hours should not go unrewarded. No health worker told of overtime payments. Staff told of the stresses of working alone and bearing sole responsibility. A good practice cited from the not-for-profit sector is a responsibility allowance paid when a nurse has sole charge of a ward.

150. Some health workers reported receiving allowances for risk and transport. There seemed little awareness that a proportion of government sector salaries constitutes a housing allowance.

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11. The way forward
Work overload, poor infrastructure and the lack of medical equipment, supplies and medicines frustrated and distressed health workers. They felt unrewarded for the work they do and undervalued. Their accounts show that working conditions were the root causes of bad practices and unethical behaviour, and that health workers bore the brunt of the blame for system failures. The research revealed a vicious circle: impoverished working environments, along with low pay, affected the quality of patient care; patients blamed the health workers; the wider community then distrusted health workers, and so health workers’ distress increased. The situation was made worse by negative media stories and political leaders’ vocal criticism of health workers, which fuelled public distrust, damaged the standing of the health profession, added to workers’ distress and, most importantly, raised the barriers to access to healthcare.

11.1 Raising the voices of health workers
The view of civil society organisations, and of some managers, was that frontline health workers are not empowered to speak up. Indeed the concept of ‘voice’ was unfamiliar, and the idea that they might speak out and gain support to improve poor working conditions and the quality of care was new to many frontline health workers. The research identified barriers to individual health workers voicing their concerns, and their preferences for advocacy by representative organisations.

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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Speaking through professional associations, unions and regulatory councils
Health worker participants favoured channelling concerns to the Ministry of Health, Government or Parliament through bodies that spoke for them as, unlike individual health workers, such bodies “know the way”. Awareness of professional organisations and trades unions was not widespread and there was some confusion over their names, how their status differed and which body did what. Some health workers felt unions were doing a good job, evidenced by salary increases and the successful legal defence of individual workers. Health workers saw advantages in the protection of a union and the pursuit of individual complaints. A union had the advantage over an association of registration with the Ministry of Labour and permission to negotiate with the government. Male frontline workers spoke most enthusiastically about the potential of unions as a collective voice, and saw a need for local organisation and meetings at district level. They also identified a role for unions to strengthen advocacy within health facilities and talk to management on behalf of the workers: “They need to bring in people from above and help us at a lower level to improve things.” Women too saw the potential strength of the nurses’ union if all nurses joined collectively, paid subscriptions and attended meetings. There was some confidence that more involvement in unions would get nurses listened to at national level. Supporters of the nurses’ union acknowledged that nurses were not currently well-informed about it. It was suggested that professional associations might do more to bring members together, such as convening annual meetings to discuss challenges facing the profession. Opportunities to attend professional association conferences were few but highly valued, and there were calls for them to be held locally. However, there were also doubts about the value of the unions and professional associations.151 It was pointed out that bodies did not do enough to inform their memberships about their activities or call them to meetings. A lack of feedback, no tangible benefits and no evidence of proper financial

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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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.

11.3 Bridging patient communities and healthcare facilities and staff
Connecting communities and facilities
There seemed, from health workers’ accounts, places where relationships between patient communities and facilities worked well. These were places which ignored status “so they don’t feel you are greater than them” and welcomed patients “on the same level”; where off-duty nurses mixed socially with patients; where Village Health Team workers visited the facility and had direct phone contact with the facility head and other staff; where people called for an ambulance and it came; where local people volunteered to clean the facility and look after the compound; where facility management listened to what the local community wanted from it, and where the community saw the facility as their own. At district level, managers told of ongoing efforts to build or repair bridges with communities. There was a role for members of Village Health Teams (where they were functional) as go-betweens to explain to people in their own homes the problems health workers faced. ‘Outreach’, where facility-based health workers took services such as immunisation to the community, was thought a good opportunity to talk with people on their own ground, though limited by a lack of transport. There were hopes that “empowered” health unit management committees would “tell the community the truth”. The aim was for committee members to explain how facilities work, for example, how supplies are ordered and staff disciplined, as well as to encourage people to use their services. But funds were short to cover the expenses of village health workers, outreach and health unit management committee members.

11.2 Changing public perceptions of health workers
Participants were hugely affected by the persistently negative portrayal of health workers in Uganda: “I feel like I am a professional being abused.” Members of civil society and professional organisations identified priority actions to reverse that image through targeting the media. Strong views were expressed by health workers that the public must hear their story: “We haven’t gone to the radio to tell people the problem is not us. We should be talking about our side of the story.” The public must be told the real causes: “Papers always blame the person, saying nurses are rude. etc, but there’s a need to dig and find what really causes it.” People must see the contributions health workers make: “We never show why we should be valued.” Participants said that reporters working for the national media are inadequately informed about the health worker situation and are overly reliant on official briefings for their information. It is important to increase 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 that the key campaign messages hit home. It is similarly important to engage with local reporters and try to moderate the tendency to create sensational stories from isolated incidents. The Uganda Health Communication Alliance is an important ally.

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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 don’t respect the nurses’ needs, we don’t respect each other.” Interfering and demanding politicians seemed an intractable problem, but health workers reported favourable effects when a top local politician’s 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

Mutual respect and understanding
Health workers understood what life is like for patients, they felt the pain that patients feel, and they wanted better conditions to improve things for patients. It was exceptional to hear that patients empathised with health workers: “Patients also feel badly when they see us with no way to help them. They don’t blame us. When you explain they understand.” More commonly, health workers said that patients did not understand what life is like for health workers: “They don’t understand what we go through, that sometimes nurses are rude due to the working conditions.” Patients seemed not to realise that health workers, like any other people, get tired, need to eat and fall sick. Health workers said they tried “to get them to understand we are human beings.”

153. Eg TARSC and HEPS 2011

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11.4 Summary of participants’ recommendations
The findings identified two priorities for action • Value health workers for their contributions to the health of Ugandans. • Expose the poor working conditions that prevent health workers from providing good-quality healthcare. Four enabling strategies emerged from health workers’ accounts and stakeholder advice 1. Improve the quality and relevance of training. 2. Raise the voices of health workers through representation. 3. Change public perceptions through the media. 4. Build bridges with patient communities.

Priorities
Value health workers for their contributions 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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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 patient’s 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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Appendix A: Sample details
Table A.1 Number of facilities and participants by region
Kampala Facilities Participants 3 17 Central 1 6 West 5 31 South West 1 4 North 4 27 North East 1 17 East 3 20

Table A.2 Level of facility by provider type
Referral Hospital Govt 3
*NFP: Not-for-profit

General Hospital Govt 2

Health Centre IV NFP* Private -

Health Centre III Govt 2 NFP* Private 2 1

Total

NFP* Private Govt 3 1 4

18

Table A.3 Distribution of districts according to Ministry of Health hard-to-serve scores
Very hard- to-serve (score 55-100) Ministry Sample 13 2 Hard-to-serve (score 35-54) 13 2 Medium hard-toserve (score 20-34) 14 2 Somewhat hard-toserve (score 1-19) 13 1 Not hard-toserve (score 0) 3 1 Total Districts 56 8

The sampling design aimed at a spread of districts in terms of how the Ministry of Health ranked them as hard-to-serve. The Ministry’s 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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Figure 6
Enrolled and registered nurse/midwife participants (n=74)
25

Comprehensive Nurse

20

21

Midwife Nurse / midwife

15

14
10

9
5

10 8 5 2

5

0

Enrolled

Registered

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Appendix B: Local government structures in Uganda
Local government is organised in five tiers from the village to the district, as outlined below.157 A village is the lowest political administrative unit. A village usually consists of between 50 and 70 households and 250 to 1,000 people. The 2002 Census found 44,000 villages.158 Each village is run by a local council I (LCI) and is governed by a LCI chairman and nine other executive committee members. The parish, the next level up from the village, is made up of a number of villages. Each parish has a local council II (LCII) committee, made up of all the chairmen of the village LCIs in the parish. Each LCII elects, from among its members, an executive committee. LCIIs are largely involved in settling land distributions and mobilising the community for various activities. The parish is largely run by a parish chief, a government employee who provides technical leadership to the LCII. The sub-county is the next level up and is made up of a number of parishes. The sub-county is run by the sub-county chief on the technical side and by an elected local council III (LCIII) chairman and his or her executive committee. The sub-county also has an LCIII council, a kind of parliament at that level, complete with a speaker and a deputy speaker. The council consists of elected councillors representing the parishes, other government officials involved in health, development and education, and NGO officials in the sub-county. In towns, a sub-county is called a division. A county is made up of several sub-counties. Each county is represented in the national parliament by an elected member (an MP). In major towns, the equivalent of a county is a municipality (which is a set of divisions). LCIII executive committee members of all the sub-counties constitute the local council IV (LCIV). They then elect an LCIV executive committee from among themselves. These committees have limited powers, except in municipalities, which they run. A district is led by an elected local council V (LCV) chairman and his executive. There is also an elected LCV council, with representatives from the sub-counties and technical staff in the district. There are also district councillors representing special interest groups such as women, youth and disabled people. The council debates budgets, decisions and bylaws. On the technical side, the district is led by a chief administrative officer, appointed by central government. The district also has heads of various departments such as health, education, environment and planning, which are responsible for relevant matters across the whole district. Uganda has an exceptionally high number of districts, the total having risen from 17 at independence in 1962 to 112 in July 2010. In 2008, when its districts had grown to 79, Uganda stood fourth in the world in number of highest level sub-national administrative units (ie districts).159 Since the current president, Yoweri Museveni, came to power in 1986, 78 districts have been created. It has been noted that bursts in district creation occurred around the times of presidential elections in 1996, 2000 and 2006;160 that pattern continued with further districts created around the 2010 election.

157. 158. 159. 160.

Drawing on Kavuma 2009 Africa Health Workforce Observatory 2009 Green 2008 Green 2008

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References
Achan J, Tibenderana J, Kyabayinze D, Mawejje H, Mugizi R, Mpeka B, Talisuna A, D’Alessandro U (2011) Case Management of Severe Malaria – A Forgotten Practice: Experiences from Health Facilities in Uganda, PLoS ONE 6, 3. Action Group for Health, Human Rights, and HIV/AIDS (AGHA) (2010) Civil Society Organisations Perspectives and Priorities: Health Sector Performance FY 2009-2010, Kampala: AGHA. Africa Health Workforce Observatory (2009) Human Resources for Health Country Profile: Uganda, Africa Health Workforce Observatory. Awases M, Gbary A, Nyoni J and Chatora R (2004) Migration of Health Professionals in Six Countries: A Synthesis Report, Brazzaville: World Health Organisation Regional Office for Africa, World Health Organisation. Azfar O, Livingston J and Meagher P (n.d.) Decentralization in Uganda sticerd.lse.ac.uk/dps/decentralisation/Uganda.pdf Baguma, R (2010) Ugandans now richer, report says, New Vision, 26 October. Banerjee S, Faiz O, Rennie JA, Balyejjusa J and Walsh M (2005) Bridging the health gap in Uganda: the surgical role of the clinical officer, African Health Sciences, 5, 1, 86-89. Baryahirwa S (2010) The Uganda National Household Survey 2009/2010, PowerPoint presentation, 26 October. Benavides, B (2009) Implementation of Performance Support Approaches in Central America and Uganda, Chapel Hill, NC: The Capacity Project. Björkman M, and Svensson J (2007) Power to the People: Evidence from a Randomized Field Experiment of a Community-Based Monitoring Project in Uganda, World Bank Policy Research Working Paper No. 4268, Washington DC: World Bank. Burnham GM, Pariyo G, Galiwango E and Wabwire-Mangen F (2004) Discontinuation of cost sharing in Uganda, Bulletin of the World Health Organisation, 82,187-195. Chaudhury N, Hammer J, Kremer M, Muralidharan K and Rogers FH (2006) Missing in action: teacher and health worker absence in developing countries, Journal of Economic Perspectives, 20, 1, 91-116. Dal Poz M, Gupta N, Quain E and Soucat A (Eds) (2009) Handbook on Monitoring and Evaluation of Human Resources for Health with Special Applications for Low- and MiddleIncome Countries, USAID/World Bank/WHO. Dambisya YM (2004) ‘The fate and career destinations of doctors who qualified at Uganda’s Makerere Medical School in 1984: retrospective cohort study’, British Medical Journal 329, 600–601. De Vries D, Blair G and Morgan K (2009) Evaluation of the Capacity Project’s Human Resources Information Systems (HRIS) Strengthening Process in Swaziland, Uganda and Rwanda, Chapel Hill, N.C: The Capacity Project. Dieleman M, Bwete V, Maniple E, Bakker M, Namaganda G, Odaga J and van der Wilt GJ (2007) ‘I believe that the staff have reduced their closeness to patients’: an exploratory study on the impact of HIV/AIDS on staff in four rural hospitals in Uganda, BMC Health Services Research 7, 205. East, Central, and Southern African Health Community (ECSAHC)( 2010) Task Shifting in Uganda: Case Study. Washington, DC: Futures Group, Health Policy Initiative, Task Order 1. Emojong JA (2010) Museveni warns medical workers, Daily Monitor, 16 December. Ferrinho P, Omar MC, Fernandes M, Blaise P, Bugalho AM and Van Lerberghe W (2004) Pilfering for survival: how health workers use access to drugs as a coping strategy, Human Resources for Health, 2,4. Fonn S, Mtonga AS, Nkoloma HC, Bantebya Kyomuhendo G, Dasilva L, Kaziliman E, Davis S and Dia F (2001) Health providers’ opinions on provider-client relations: results of a multi-country study to test Health Workers for Change, Health Policy and Planning, 16 (Suppl. 1), 19–23. Green E (2008) District Creation and Decentralisation in Uganda, Working Paper No. 24, Development as State-Making, Crisis States Research Centre, London: LSE Development Studies Institute. Hagopian A, Zuyderduin A, Kyobutungi N and Yumkella F (2009) Job satisfaction and morale in the Ugandan health workforce, Health Affairs 28, 5, w863-w875. Harrowing J and Mill J (2010) Moral distress among Ugandan nurses providing HIV care: a critical ethnography, International Journal of Nursing Studies, 47, 6, 723-731. Harrowing J (2011) Compassion practice by Ugandan nurses who provide HIV care, OJIN: The Online Journal of Issues in Nursing, 16, 1, Man 5.

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Health Workforce Advocacy Forum-Uganda (HWAF-U) (2010) Health workers call on each other to observe code of conduct and ethics and on government to improve working conditions, Press Release 1 May, Kampala: HWAF-U. HEPS-Uganda (2010) Right to Essential Medicines: Tracking Uganda’s Health Sector in Budgeting, Financing and Delivery of Essential Medicines, Kampala: HEPS-Uganda. Kapiriri L, Norheim OF and Heggenhougen K (2003) Public participation in health planning and priority setting at the district level in Uganda, Health Policy and Planning 2003, 18, 2, 205-213. Kavuma RM (2009) Explainer: Local government structures in Uganda, The Guardian, http://www.guardian.co.uk/ katine/2009/dec/14/local-government-explainer Kaye D, Mwanika A, Burnham G, Chang LW, Mbalinda SN, Okullo I, Nabirye RC, Muhwezi W, Oria O, Kijjambu S, Atuyambe L and Aryeija W (2011) The organization and implementation of community-based education programs for health worker training institutions in Uganda, BMC International Health and Human Rights, 11(Suppl 1), S4. Kidder J (2010) Strengthening Health Unit Management Committees in Uganda http://www.intrahealth.org/page/ strengthening-health-unit-management-committees-in-uganda Kiguli J, Ekirapa-Kiracho E, Okui O, Mutebi A, MacGregor H, Pariyo GW (2009) Increasing access to quality health care for the poor: community perceptions on quality care in Uganda, Patient Preference and Adherence, 3, 77-85. Kirunda KA (2011) Politicians stop playing games on the right to health, Daily Monitor, 16 February. Kiwanuka SN, Ekirapa EK, Peterson S, Okui O, Hafizur Rahman M, Peters D and Pariyo GW (2008) Access to and utilisation of health services for the poor in Uganda: a systematic review of available evidence, Transactions of the Royal Society for Tropical Medicine and Hygiene, 102, 11, 1067-74. Konde-Lule J, Gitta S, Okuonzi, S and Matsiko C (2007) Access to health care in rural Uganda, iHEA 2007 6th World Congress: Explorations in Health Economics Paper. Ladu IM (2010) Health Service Commission wants doctors’ salaries raised, The Monitor, 1 May. Mandelli A, Kyomuhangi LB and Scribner S (2005) Survey of Private Health Facilities in Uganda. Bethesda, MD: The Partners for Health Reformplus Project, Abt Associates Inc. Matsiko C (2010) Positive Practice Environments in Uganda: Enhancing health worker and health system performance,

International Council of Nurses, International Pharmaceutical Federation, World Dental Federation, World Medical Association, International Hospital Federation and World Confederation for Physical Therapy. McPake B, Asiimwe D, Mwesigye F, Ofumbi M, Ortenblad L, Streefland P and Turinde A (1999) Informal economic activities of health workers in Uganda: implications for quality and accessibility of care, Social Science and Medicine 49, 7, 849-865. McPake B, Asiimwe D, Mwesigye F, Ofumbi M, Streefland P and Turinde A (2000) Coping strategies of health workers in Uganda, 131-155 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. Medicines and Health Service Delivery Monitoring Unit (2010) Annual Report 2010, Kampala: Medicines and Health Service Delivery Monitoring Unit. Ministry of Finance, Planning and Economic Development (2010) Millennium Development Goals Report for Uganda 2010. Special theme: Accelerating progress towards improving maternal health, Kampala: Ministry of Finance, Planning and Economic Development. Ministry of Health (2004) Health Sector Strategic Plan II 2005/06 – 2009/2010 Volume II, Kampala: Ministry of Health. Ministry of Health (2006) Human Resources for Health Policy, Kampala: Ministry of Health. Ministry of Health (2008a) Pharmaceutical Situation Assessment – Level II, Health Facilities Survey in Uganda: Report of a survey conducted July-August 2008, Kampala: Ministry of Health. Ministry of Health (2008b) Access to and Use of Medicines by Households in Uganda: Report of a survey conducted 2008, Kampala: Ministry of Health. Ministry of Health (2009a) Uganda Health Workforce: Satisfaction and Intent to Stay among Current Health Workers, Chapel Hill, NC: The Capacity Project. Ministry of Health (2009b) Heath Sector Strategic Plan III: 2010/11-2014/15 (draft) Ministry of Health (2009c) National Health Policy: Reducing poverty through promoting people’s health, May 2009 Version, draft. Ministry of Health (2010a) The Second National Health Policy: Promoting People’s Health to Enhance Socio-economic Development, Kampala: Uganda.

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Ministry of Health (2010b) Health Sector Strategic & Investment Plan: Promoting People’s Health to Enhance Socio-economic Development 2010/11 – 2014/15, Kampala: Ministry of Health. Muhinda A, Mutumba A and Mugarura J (2008) Community empowerment and participation in maternal health in Kamwenge district, Uganda, EQUINET PRA paper, Harare: EQUINET. Nabudere H, Asiimwe D and Mijumbi R (2010) Task shifting to optimise the roles of health workers to improve the delivery of maternal and child healthcare, Kampala: REACH, Uganda Task Shifting Working Group. Nabyonga-Orem J, Karamagi H, Atuyambe L, Bagenda F, Okuonzi SA and Walker O (2008) Maintaining quality of health services after abolition of user fees: A Uganda case study, BMC Health Services Research, 8,102. Nguyen L, Ropers S, Nderitu E, Zuyderduin A, Luboga S and Hagopian A (2008) Intent to migrate among nursing students in Uganda: measures of the brain drain in the next generation of health professionals, Human Resources for Health, 6, 5. Oketcho V, Namaganda G and Matsiko C (2009) Human Resources for Health Planning In Uganda: Practice and Lessons, Uganda Capacity Program, IntraHealth International, Uganda. O’Neil ML and Paydos M (2008) Improving retention and performance in civil society in Uganda, Human Resources for Health, 6, 11. Onzubo P (2007) Turnover of health professionals in the general hospitals in West Nile Region, Health Policy and Development, 5, 1, 28-34. Open Society Initiative for East Africa (2010) Health rights are human rights: empowering local communities to demand quality health services, Amplifying Voices: The Uganda Issue, 20-21. Republic of Uganda (2010) Annual Health Sector Performance Report Financial Year 2009/2010, Kampala: Ministry of Health. Ritchie J and Lewis J (2003) (eds) Qualitative Research Practice, London: Sage. Rutebemberawa E, Ekirapa-Kiracho E, Okui O, Walker D, Mutebi A and Pariyo G (2009) Lack of effective communication between communities and hospitals in Uganda: a qualitative exploration of missing links, BMC Health Services Research, 9, 146. Schmid B, Thomas E, Olivier J and Cochrane JR (2008) The Contribution of Religious Entities to Health in Sub-Saharan Africa. Study funded by the Bill & Melinda Gates Foundation. Unpublished report, ARHAP (Africa Religions for Health Assets Program).

Schwalbach J, Abdula M, Adam Y and Khan Z (2000) Good Samaritan or exploiter of illness? Coping strategies of Mozambican health care providers, 117-130 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. Senkabirwa A-M (2010) Over 800 nurses trek to work abroad, Daily Monitor, 29 September. Spero J and McQuide P (2011) Data show high level of attrition in Uganda. Prepared as a background document for The State of the World’s Midwifery 2011 http://www.unfpa.org/sowmy/ resources/docs/background_papers/60_SperoMcQuide_ UgandaAttrition.PDF Spero J, McQuide P and Matte R (2011) Tracking and monitoring the health workforce: a new human resources information system (HRIS) in Uganda, Human Resources for Health, 9, 6. Stringhini S, Thomas S, Bidwell P, Mtui T and Mwisongo A (2009) Understanding informal payments in health care: motivation of health workers in Tanzania, Human Resources for Health, 7, 53. TARSC and HEPS (2011) Strengthening Health Worker-Community Interactions through Health Literacy and Participatory Approaches, Uganda training workshop report, Harare: EQUINET. Uganda Bureau of Statistics (2002) Uganda Population and Housing Census. Main Report, Kampala: Uganda Bureau of Statistics. Uganda Bureau of Statistics (2006) Uganda National Household Survey 2005/2006: Report on the Socio-economic Module, Kampala: Uganda Bureau of Statistics. Uganda Bureau of Statistics (2008) Report of the National Service Delivery Survey 2008, Kampala: Uganda Bureau of Statistics. Uganda Country Working Group (2010) Medicine Price Monitor Uganda No 9 Apr-June 2010, Kampala: Uganda Country Working Group. Uganda Ministry of Health and The Capacity Project (2008) Mapping the Human Resources Management Processes in Uganda, Chapel Hill, NC: The Capacity Project. Uganda National Health Users’/Consumers’ Organisation (2010) Establishing Incidence of Health Provider Absenteeism in Bushenyi District, UNHCO: Kampala. UNFPA Uganda Country Office (2009) The State of Midwifery Training, Service and Practice in Uganda, Assessment Report, Kampala: UNFPA Uganda Country Office.

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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 World’s 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 Africa’s 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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Annex: Health worker topic guide
1. Tell me why you decided to become a [----] Probe • Influences • Attraction of the profession • Ambitions • Alternatives considered • Doubts What do you believe the [----] role is supposed to be? Prompt: Why do you think that? • Influence of training, text books Probe • Role models • Peers What words would you use to describe a good [----]? How does what you do in your work fit with your ideas of what the [----] role should be? Probe • Fit with work of nurses / doctors / clinical officers / nursing aides • Patients’ care needs • Constraints – staffing, equipment, drugs, work environment • Other people’s attitudes What is good about being a [----] (in Uganda)? Probe • Material aspects – pay, housing, transport, etc • Uniform • Training, career prospects • Caring • Other people’s opinion of you What helps make [----] feel good about themselves? Probe • Praise • Gratitude • Respect • Achievement • Recognition • Status What is not so good about being a [----]? What are the challenges and difficulties? Probe • Pay • Hours of work, multiple jobs • Transport • Accommodation, facilities for self and family • Training, career prospects • Constraints – staffing, equipment, drugs, work environment • Pressure of work • Harassment, threats • Lack of respect – from colleagues, patients, public

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 VSO’s 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

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Published July 2012

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