health workforce developments: challenges and...

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12Health Workforce Developments: Challenges and Opportunities to Secure Universal Health Coverage in Uganda

Freddie Ssengooba, Suzanne N Kiwanuka

Key Messages

• Thegovernmenthasamyriadofhealthworkforceproblemstofixinordertoachieveadequateservicecoveragewithwell-constitutedworkteamsatalllevelsofhealthcare.

• Merely framing the problem of the workforce in Uganda asabsenteeismisunlikelytogeneratethecorrectsolutiontopervasiveworkforceshortageandinadequateskillmix,poormotivationandlabourmarketdynamics.

• Thedriversoftheworkforceshortage–inparticulartheconstraintsonthewagebillandrestrictivemacro-economicrationales–needtoberelaxedtoeffectivelysolvetheworkforcechallengesinproduction,deploymentandretention.

• Trainingpoliciesandinstitutionsneedtobeenhancedtosustainablygenerate adequate, appropriately skilled, fit-for-purpose and well-distributedhealthworkers.

• The governance ofmultiple agencies that espouse conflicting andadverseobjectiveswithregardtotheworkforcedevelopmentsneedtobe realignedwith theoverallaimof improvingUganda’shealthsystemperformanceandresilience.

Citation: F. Ssengooba, SN Kiwanuka, E. Rutebemberwa, E. Ekirapa-Kiracho (2017), Universal Health Coverage in Uganda: Looking Back and Forward to Speed up the Progress. Makerere University, Kampala Uganda.

246 Universal Health Coverage in Uganda - Part IV

• Themajorleverforthealleviationofworkforceshortageiswagebillincrease,whichwouldstimulateproductionandguaranteeattractiveremunerationforhealthprofessionalsenteringemployment,coupledwithimprovedprovisionsforworkforceperformancetoimproveandsustainservicecoverage.

Introduction

AsUganda seeks to improve the coverage andqualityof services, the roleplayedbyanadequatelyskilledandwelldistributedhealthworkforcebecomesacentralconcern.AdvancingUniversalHealthCoverage(UHC)isessentiallya functionofworkforcedensity– i.e. thenumbersofhealthworkers inagivenpopulationtobeserved.TheJointLearningInitiatives(JLI)Reportof2006andtheWorldHealthReportof2006providedthebenchmarksfortheworkforcedensitynecessary to improvenational coverageof interventionslikechildsurvivalandmaternalmortality.Thereportstates that“a10percent increase in the sizeof theworkforceper1,000population leads to a2 to 5 per cent decrease in themortality rate (1).This decrease is higherformaternalmortalityandchildmortalitythanforinfantmortality”(page154).Likewise,thisreportprovidedbenchmarksfortheworkforcedensitiesrequiredtoimprovehealthservicecoverage.Forinstance,toimproveskilledbirthattendanceto80percent,countriesneededtohavebetween2.02and2.54healthworkersper1,000population.Althoughbasedon2002data,Uganda’sworkforcedensityof0.14per1,000populationatthetime(Figure12.1)ofthisanalysiswasamongtheworstontheglobalmap–indicatingtheexistenceofasevereshortfallinthedensityandcoverage.EstimatesbytheseanalysesshowedthatUgandaneededtoincreaseitsworkforcethreefoldinorder tomeet thisminimumstandardof2.5healthworkersper1,000population(2).

Inthelast15years,since2000,thenationalhealthsystemhasattemptedseveralsolutions,albeitwithsignificantimplementationinsufficiency,majorshiftsindirectionand,mostimportantly,withdysfunctionalcoordinationandgovernanceoftheworkforcesub-sector.ThejourneytoimproveworkforcedensityforessentialhealthprogrammesinUgandaischaracterisedbymajorsuccesses aswell as challenges.This chapterhighlights themajor issues inworkforcedevelopmentthatarevitalinadvancingthehealthcoverageagendainUgandaandsimilarcountries.

247Chapter 12: Health Workforce Developments

Figure 12.1: Workforce density and countries with high medium and low mortality rates(2)

Source: Chen et al. 2004 (2)

Toaidtheanalysisaframework(Figure12.2)belowisemployedtoorganisethemajorworkforceissuesinfourmaindomainsofconcern,asreflectedinthe labourmarket and the technocraticdiscourses forworkforceplanningand management. The concerns regarding the workforce have mainlyfocusedon theperformance, production and labourmarket issues aswellasgovernanceofthesub-sector.Addressinghealthworkforceissuesrequiresthatkeenattentionispaidtotheproductionofhealthworkers,theireffectivedeployment and, ultimately, their management for service outputs. Atproductionlevel,issuesofadequateenrolment,trainingstandards,curriculathatarefit forpurposeand learningexperiencesarekeyareasof focus. Intermsofachievingcoverageandquality,equitabledeployment,stabilityandmobility,andadequatewagesneedtobeassured.Forworkforcemanagementitisimportanttohaveadequatenumbersinwellconstitutedteamsthataremotivated and resourced to effectively execute their roles.These issues arereflectedintheframeworkbelow.


Figure 12.2: Framework for health workforce assessment at national level

carrying

learningTraining

Source: Authors’ framework

1. Production of Human Resources for Health

Theproductionoftheworkforceisanintricateprocessthatstartswiththeprocess of ensuring that enough good quality candidates are available forrecruitmentintothehealth-traininginstitutions.AccordingtothescorecardbytheUgandaScienceEducationProgramme(2012),Uganda’s long-terminsufficient investment in teaching sciences in secondary schools has ledtoaneducationalsystemwhereonly30percentoflearnerspursuesciencecareersoutofthe47percentneeded(Figure12.3).Thecountryhasinitiatedpoliciestotrytoboosttraininginsciencesacrossthecountry,amongwhicharethescienceprioritisationpolicyandVision2040toimprovethequalityof the teaching and learning of sciences(3). Nonetheless, gaps remain inthecapacitytoproduceapoolofscience-readygraduatestofeedthehealthprofessionaltrainingpipeline.


Figure 12.3: The status of teaching sciences in Uganda (3)

Source: USEP, 2017 (3)

Beyond thepreparatory schooling systems (primaryand secondary levels),the problem shifts to the carrying capacity of health-training institutions.Although some expansion has been made – thanks to donor grants –shortagesremainintheinfrastructureandlearningresourcessuchastutors.Theprocess of updating the training curricula has started, although theseremainmostly rooted in themedicalmodel,with lessorientation towardshealthpromotiondemandedbytheUHCagenda(4).TheUgandaHealthSystemsAssessment(2010)foundmajorgapsinthetrainingprocesses,withinsufficient tutors, tools and stock-outs for essential elements needed fortheeffectivetrainingofnursesandclinicians(5).Thesegapscreatelessthanoptimaltrainingexperiencesandcompetencies.Forinstance,someschoolstrainingmidwivesanddentistshavebeenthreatenedwithclosureowingtothe existence of quality gaps (6).Managerial roles become prominent forhealthprofessionalsyetthisisnotwellarticulatedinthetrainingcurricula(4).Clearly,therearevitalissuesthatneedtobeaddressedintheproductionprocessesofhealthworkersinUganda.


Theframingofworkforceproductionconcerns inUgandahas shiftedover time.Aswe embarkon theUHCagenda, the concernshavemostlydweltontheprivatisationoftheproductionfunctionoftheworkforce(7)andhowmajorinnovationsinthetrainingofnursesandmidwiveshavebeenintegratedintoservicedeliverytoimprovequalityandworkforcesize.Thestructural adjustment programmes of the 1990s provide a vital historicalcontextofgovernmentactionsforworkforceproductionandtheevolutionofworkforcemanagementinthebroaderpublicservicesandthehealthsectorinparticular.Thesestructuralreforms,triggeredbytheeconomicshockofthe1970s,resultedinpolicyactionsthatsloweddownthepubliclyfundedproduction of health workers, led to privatised production processes andreduced theoverall stockofhealthworkers in thehealth system for threedecades(8).Thesearebrieflydiscussedbelow.

Privatisation of training programmes

Although symbolic financial provisions exist in the public financing ofhealth-training institutions, these have experienced diminishing financialcontributionsovertheyearsasthegovernmentprioritisedfreeprimaryandsecondary education. During the 1980s and late 2000s, the governmentdivesteditselfoftheroletotrainprofessionalcadreslikemidwivesandnursesbyadoptingagovernment-wide–albeit informal–policyofprivatisationofhealth-training institutions.Although it takesabout$12,000 to trainamedical doctor inUganda, government contributions have averaged onlyabout $4,000 to this cost (9). Since the implementation of structuraladjustmentsprogrammes,thefinancingofhighereducationgenerallyand,inparticular, thefinancingofhealth-training institutionshas shifted frombeingpredominantlygovernmentfundedtoincreasinglyprivatefunded(7).Evidenceshowsthatmostoftheproductionofhealthworkers–especiallythevitalhealthsystemcadressuchasnursesandmidwives–iscarriedoutinprivateinstitutionswheretuitionandtrainingcostsaremostlycateredforfromout-of-pocketcontributionsbythecommunityandhouseholds.Faith-basedsub-sectorshaveattemptedtobridgethegapleftbythegovernment’swithdrawalfromhealthworkforcetrainingfunctions.Estimatesinthemid-2000sshowthatover60percentofthenursesandmidwives–thelynchpinofservicedeliveryinUganda–weretrainedinfaith-basedschoolsandwithprivate financing (10). Private health-training institutions have increasedexponentially in the2010s to take advantageof thehighdemand for the


trainingofhealthworkersinUgandaandglobally.AccordingtotheAlliedHealthProfessionalCouncilinUganda(40),43outof52recognisedtraininginstitutions are private (AHPCU, 2017). For the nursing and midwiferycourse,outofthe84recognisedinstitutions,only15aregovernment-owned,with50percentofallschoolsbeingprivatelyowned(41).Although this transfer of financing for healthworker education from thegovernment to the individual citizens can be perceived as a success insaving public resources, the implications it has had for the governance oftheworkforcehavebeenlesswellarticulated.Forinstance,overtimethegovernmenthaslostthelegitimacytodeploytheworkforcetoachievefaircoverage–partlybecausehealthworkersgraduatingfromprivatelyfundedtrainingprogrammeshaveadiminishedobligationtoservepublicinterests.The privatemotivation to recoup private investment (tuition etc.) duringtrainingpartlyexplainswhytheUgandangovernmenthasweakertools todeploy healthworkers in hard-to-reach areas and retain them to improveservicequalityandcoverage.Italsoexplainswhymanyhealthworkersprefertoundertakeprivatepracticeordualpracticeinurbancentres–wheretheywork in public services alongside their private enterprises to earn moreincome(11).

Health workforce policy: Prioritising shortages

The2006MinistryofHealth’sHumanResourcesforHealth(HRH)PolicyandtheHRHPlan(2005-2020)missedtheopportunitytosettargetsthatcorrect the problem of workforce shortage. The projection scenario forworkforcesizeadoptedbytheMinistryofHealth(MoH)fortheHRHPolicyandStrategicPlan(2005–2020)waswaybelowthe2.5healthworkersfor1,000population–abenchmarkadvisedbytheWHO.ItwasalsobelowtheworkforcesizeestimatedbasedontheworkloadinUganda’shealthsystematdifferentlevels(12,13).The15yearscoveredbytheHRHPlanindicateamarginalincreaseintheworkforce(Figure12.4)butdoesnotcorrectthesevereshortagethathasbeencreatedbymanyyearsofdivestinginworkforceproduction,recruitmentanddeploymentduetothestructuraladjustmentpoliciesofthe1980sand1990s(14).

Figure12.4belowshowsthegapbetweentheestimatesoftheworkforceasadoptedinthepolicycomparedtotheexpectedsizecalculatedonthebasisofthepopulationgrowthandservicerequirements.AccordingtotheHRHpolicyprovisions,theworkforcegapisexpectedtowidenovertime–moving


fromadeficitof42,000by2005toabove58,000by2020.Thisisdespiteamarkedincreaseinthedemandforhealthservices.Forexample,estimatesby theUgandaDemographic andHealth Survey (UDHS) show that thenumberofchildbirthsinhealthfacilitiesforthefiveyearspriortothesurveyincreasedfrom1.5millionin1995to4.2millionin2011(15).

Figure 12.4: Gap between the WHO standard for workforce requirements and estimated workforce in Uganda

Source: Author analysis and MoH, 2007 (15)

Despite a nearly threefold (300 per cent) increase in the workload, thenumber of midwives in the country has only increased by about 20 percentduringthisperiod.ThisperiodhasalsobeenassociatedwithatwofoldexpansionofthescopeofworkformidwivesasmoretasksforHIVscreening,counselling including the whole programming of prevention of mother-to-child transmission (PMTCT), which was introduced in maternal careservices(16).

IntheearlyphaseoftheHRHPlan,theMoHinsteadprioritisedshort-termremedies. The involvementofcommunity-levelhealthworkers suchasTraditional Birth Attendants (TBAs),VillageHealthWorkers (VHTs),on-the-jobtrainedNursesAssistantsconstitutedinterventionsthatattractedheavyinvestmentsaimedatfixingtheworkforceproblemwithcheaplabouroptions.Unfortunately,eventhesecommunity-levelhealthworkersareoftenfocused on curative care (e.g. drug distribution) rather than emphasisinghealth promotion to mitigate the cost and burden on the professional


workforce. The policy to decentralise the recruitment of health workersalsoweakenedthecapacityofthegovernmenttoensurefairdistributionordeployment of theworkforce.Experience shows that resource-constrainedand remote districts are less competitive in attracting healthworkers andexperiencemoreproblemsofstaffattritionandturnover(17).

Over the years, major gaps have emerged in the cadre mix in theworkforce.Only a few schoolshave invested in trainingdiagnostic cadressuchaslaboratorytechnicians,radiographersandsimilarprofessionals.Whenthehealthsystemsinthe2010sstartedtodemandmorediagnosticcadrestoexpandHIV-relatedtreatmentprogrammes,privateandpublic trainingschools rushed to revamp the training of diagnostic cadres to address thecriticalshortagescreatedoverthelasttwodecades.

Moreover,mostcurriculainthesetrainingschoolshavenotevolvedintandemwith emerging diseases, conditions and technology advances. Forexample,thetrainingofcareproviderswithspecialattentiontoinjuriesandnon-communicablediseaseshasbeengrosslyneglected, even though thesearetheservicesmostincreasinglysoughtafterwithinthesector.Withregardto technology,asmoreequipmentandtreatmentprotocolsare introducedwithin thehealthcarefield,healthworkers requireorientation training intheformofcontinuousmedicaleducation,anaspectwhichremainslargelyunstructuredtomeetthedemandsofthesectorandtheworkforce.

Failed innovation: Production of comprehensive nurses

Amidsttheseproductiondilemmas,Ugandasuccessfullyintegratedthetrainingofnursesandmidwifery–astrategythatwasaimedatboostingtheskillmixandefficiencyinworkforceperformanceandcoverage.By2005,insidersintheMinistryofHealthwereconcernedabouttheimplementation.AsobservedbyAmanduaet(2005).

Despitetherelevanceofastudyprogrammeandtheintendedgraduates,apoorlyconceptualisedandplannedimplementationprocesscanresultinthefailureofanotherwisegoodtrainingprogrammeinachievingitsintendedgoals.Itwasevidentthatinthecaseoftheenrolledandcertificatecomprehensiveprogramme,stakeholderinvolvementattheonset of the programme was minimal, yet for effective programmeoutcomes,theirinvolvementiscriticalateverystageoftheprogrammeplanningandimplementationprocesspage(18,page673)


Between2001and2010,theComprehensiveNursesProgramme(CNP)was rolled out in all major nurse/midwifery training Institutions. Donorprogrammes came in to aid government in the strengthening of healthsystemsandespeciallytheworkforcedevelopments.AmongthedonorsweretheEuropeanUnion,IrishAID,DANIDAandtheUSGovernment(19).These aid programmes aimed at expanding the infrastructure for trainingschools,modernizingthecurricularandskillingtutorsandmanagersaswellas providing scholarships especially for trainees from remote and under-servedcommunities.By2015,over30,000comprehensivenurseshadbeenproduced.Theparadoxisthatthegovernmentdidnotabsorbordeploythesegraduatesfortheirintendedpurpose.ManygraduatesfromCNPhavefoundtheirwayintotheprivatesector.

ClaimsemergedfromUNFPAandtheInternationalMidwiferyAssociationthat CNP graduates had inadequate midwifery competences compared tothosetrainedinatraditionalcurriculumtobecomemidwifes.Astheglobalagendatoreducematernaldeathbyexpandingskilledbirthattendantsgainedmomentum, the definition of a skilled-attendant at birth became morecontrolledbyexternalforces(IMAandUNFPA)–Uganda’sregulatorycouncil– excludedCNPgraduates from thebracket of skilled attendants (21, 22).Asnoted in theNurseandMidwiferyPolicydocumentofMoH, themainchallengeswere:“Nursesandmidwiveswithbachelor’sdegreeandpostgraduatetrainingarenotrecognizedintheexistingemploymentsystemofhealthcare(and)graduatesofthecomprehensivenursingprogrammemehavenotbeenaccepted by public service and other stakeholders nor positions created forthemintheschemeofservices.(page10)(22)

By implication, Uganda’s policy to produce comprehensive nurseshas generated 30,000 graduates who were not deployed to contribute toimproving health coverage. This strategy constituted a major waste ofthe health system resources and especially of private investments whichenabledthetrainingofthesecadres,aswellasthedonoraidthatproppedupthisworkforceproductionprocess.Thisdisconnectbetweenpolicyandimplementationprovidesanexampleofmissedopportunitiesforthehealthsystemtoimprovetheworkforcedensityandscale-upofhealthprogrammes.

Overall,theinadequateworkforcehasleftservicegapsthataremostlyperceived as “unfilled posts” or “vacancies” by technical actors and as“absenteeism” by those who are concerned with service quality from thecommunityperspectives.Innovationslikecommunityreporting,attendanceregistersandtechnologyforclocking-inandclocking-outattheworkplace


arebeing expanded in the currentHealthSectorDevelopmentPlan (22).Unfortunately,thesearenotabletoovercomethefundamentalshortfallinthestockoftheworkforcethatisrootedindeliberatechoicesinHRHpolicyandtheHRHPlanofMoH.Re-definingtheproblemandreframingofthemainworkforce challenge as “inadequate stock andunbalanced skillmix”will help to re-direct policy interventions and investments to address theworkforceproductionanddiversificationoftheskill/cadremix.

Regulation of workforce production

Thenew and urgent challenge is regulating healthworkforce production.Thisproblememergesfromtheprivatehealth-traininginstitutionsthathavemushroomedtotakeadvantageofthedemandfortraininghealthworkers.Reportsshowthatthegovernmentisnowconcernedaboutaddressingtheregulatoryweaknessestoensurethattheseenterprisesadheretostandardsoftrainingandproducecompetenthealthworkers.Traininginstitutions,bothprivateandgovernment-owned,havemajorqualitygaps.AsKitanda(2008)observed:

Criticaltutorunderstaffingandthefewpresenttutorsworkingundergreatpressuretocovertheworkloadwasadirectthreattothequalityofthetrainingintheschoolsandtothesubsequentqualityofcare.(6)

Understaffingismostlyduetonon-appointmentoftutors,compoundedbyunderfunding from the government and private entrepreneurs.Disruptedmandates and institutional loyalties of tutors and health training schoolsfromtheirparentMoHtodifferentagenciessuchastheNationalCouncilforHigherEducation(NCHE)andtheMinistryofEducationandSports(MoES)(23)havealsogeneratedloopholesintheregulatoryfunction(24).In her statement to the health sector annual review meeting (2015), thedirector of the Medicines and Health Service Delivery Monitoring Unit(MHSDMU)wasquotedassaying:

Howcanprivateschoolsproduce300doctorsayearwithoutfacilitieslikehospitals?Whyhaven’t theregulatorybodiesbeenable tocheckthisproblem?Unleashingill-traineddoctorstothepublicisaproblemthat should be addressed. (Director MHSDMU at Annual HealthSectorReviewMeeting,2015)


TheestablishmentoftheUgandaNursesandMidwivesExaminationBoard(UNMEB)in2005providedapositivedevelopmentintheregulationoftheproductionof theworkforce.Theexaminationboardemerged inresponseto the problemof the emergence ofmany private training schoolswhosetrainingprogrammeswere lesswell controlled forquality assurance.Since2013,priortobeingregisteredforpractice,allnursesandmidwiveshavetopass theUNMEBexaminations.These examinations also serve toprovidevital information about the number and type of nursing and midwiferycadresenteringtheprofession(seethefigurebelow).

Figure 12.5: Production and licensing of nurses and midwives 2006-2016

Discipline 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 TOTALDCN 110 90 237 54 910 314 277 229 268 161 39 2689DPHN 16 16DN 268 65 985 349 304 401 467 669 145 3654DM 212 21 788 239 258 268 429 329 124 2668DMHN 5 76 40 39 47 58 72 4 341DPN 1 19 14 1 6 4 3 - 48RN 355 536 143 290 745 - - 2049RM 298 296 69 88 575 - - 1326RPN 9 6 7 2 20 - - 44RMHN 46 26 72 36 165 - - 345CCN 184 536 964 2478 1971 2966 1072 2076 2315 1809 1004 17375CN 550 294 191 775 546 271 393 763 1433 1678 1326 8220CM 324 111 158 585 290 228 229 546 1214 1498 1007 6190CMN 49 53 100 167 207 123 124 109 92 91 95 1210TOTAL 1925 1948 2421 4567 7297 4544 2891 4445 6196 5810 3744 45788

Source: UNMC, 2016 (41)

2. Managing Health Workforce Performance

Overtheyears,theperformanceoftheworkforcehasemergedasahighlyvisible but contentious issue among technocrats and the politicians alike.While absenteeism is a common way to frame the issue of workforceperformanceamongthepoliticiansandcommunities,thetechnicalleadersinthehealthsectorhavemostlyframedtheperformanceproblemintermsofinsufficientworkforcestock(shortage),unbalancedskillmixandinadequatesuppliesforservicedelivery.Directvoicesfromtheworkforceitselfindicateawidersetofissuesthatareresponsibleforinadequateworkforceperformance.Althoughlargelyignored,thevoicesofhealthworkersconsistentlyidentify


inadequacies in the support systems (inadequate work environment,insufficienttoolsandmedicinesandlackofcomplementaryskill)toenablethem to do their job property as the main problem, closely followed byinadequatewagesandremuneration(25).Amongthemanyissuesraisedbyhealthworkers, absenteeism and the implications of its criminalisation ofabsenteeismarehighlightedbelow.

Absenteeism: Solving the wrong problem?

Fromthecommunityperspective,healthworkforceshortagesmanifestasafewstaffavailabletoattendtotheclients,long-waitingtimesandinabilityto provide adequate staff coverage (26, 27). Coverage expectation fromthecommunityisfora24-7service,i.e.24hoursforeverydayinaweek,all year round.These are the standard expectationsofhealth caredeliveryinternationally(28).Acloselookattheworkforcestandards(establishment)withinthehealthfacilitiesfallsshortofprovidingtheexpected24-7servicecoverage.According to thepopulation size tobe served,Ugandaneeds tohave a workforce stock of about 81,000 (nurses, midwives and doctors),according to the MoH standards, to achieve the expected coverage. TheMoHHRHaudit report in2015 showed that the totalworkforce (acrossallcadres)was54,864–ashortfallof32percent.Ifthisgapistranslatedintoacoveragegaporworkforceabsenteeism,theimplicationisthathealthfacilitiesareexpectedtobe“closed”fortwodayseachweekorsevenhourseachday! Unfortunately,powerfulgroups innationalpolitical circlesandglobalhealthpolicydiscourseshavepropagatedtheworkforce“absenteeism”andothertoxicrhetoric(25,29)thatblametheworkforceforpooroutcomesarisingfromdeliberatelyineffectivepolicychoices(30).

Absenteeismhas,however,degeneratedintoanegativespiralofpolicyand public discourse that has resulted in the toxic branding of healthworkers. Ill-conceived studies have portrayed absenteeism as fully due towilfulandillegalabsencefromwork.Althoughillegalabsenteeismexiststoasmallextent,abigpartofthisiscontributedtobyworkforceshortageandlegalprescriptionsoflabourlawsgoverningallcivilservants,includingthehealthworkersinUganda.Universallabourlawsandtherightsofemployees– includinghealthworkers–specifyeighthoursadayofworkandrightstovacation,publicholidaysandsickleave.Thishascometobeignoredbyboth technocratic and political leaders inUganda. Just like communities,the“landmark”studiesexaminingabsenteeismunreasonablyexpect24-hourpresenceatthehealthfacilityfromthefewavailablehealthworkerswithnotimeoff-dutynorvacation.


Methodologiesforcomputingabsenteeismhavetakenaradicalbutnaïveview of absolute “presenteeism” – many going beyond the commonsenseunderstandingof labour lawsandall legitimate spaces for servicedelivery.For example, the main methods of inferring absenteeism in studies (26,27,31)–bothfundedbytheWorldBankResearchGroup–haverevolvedaround“on-spotinspection”and“unannouncedvisits”toinspecttheworkerspresentonthatday(usuallymorninghours)whenthestudyteamarrivesatthehealthfacility.Thismethodologyignoresoff-sitefunctionssuchasstaffworkingonoutreachandadministrativetasksthatrequirehealthworkerstofunctionaway fromtheir facilities.Using the“factoryfloor”model as themethodforevaluatingabsenteeismispartoftheproblem.Itleadsdecision-makers toprescribesolutions to thewrongproblem.More fundamentally,themethodologyignorestherequirementforthethreeworkteamsrequiredto cover the three 8-hour shifts in a 24-hour day and the right of healthworkerstobeoff-dutyonweekendsandpublicholidays,andtotakeannualand sick leave. To cater for these extra workdays, the estimation of therequiredworkforce should take into account three-work teamsperday tocaterforservicecoverageatalltimes.Theseproblemsrequiredirectactionstomitigatetheworkforceshortageandtherelatedconstraintsonfinancing,andtooptimiseworkforceproduction,recruitment,retentionandprovisionsforperformance.

Figure 12.6: Proportion and reasons provided for absenteeism – MoH study, 2016

Source: MoH Joint Review presentation, 2017


Accordingtothesestatistics,(seeFigure12.6)ahealthworkerwhoisinthecommunityprovidingoutreachservices iscategorisedasabsentfromduty.Legalabsence fromworkdue toannual leaveand legaloff-dutyhoursareadded to the computationof absenteeism to inflate themagnitudeof theproblem.Thisiscontrarytothe8-hourlyshiftsthatallowthedeploymentof the availableworkers to covermorning, eveningandnightdutyhours.Unfortunately, thesestudieshavebeenwidelycited inpolicycircles–andin many cases used by decision-makers to arrive at wrong decisions orsolvethewrongproblem.Forexample,inWakisodistrict,healthworkerswerepubliclyparadedbythepresidentatapublicrally,withthepresidentproceeding to then direct that they be “dischargedwith disgrace” for notbeingavailableallthetimetoservethecommunity(32).Similarstudieshaveerroneously estimated that eliminating health workers’ absenteeism couldsavegovernmentclosetoUSh.30billion(33,34).Thesestudieshaveaddedto themisguidance of decision-makers. Instead of advising that the rootcauseoftheproblem–theinadequatestockoftheworkforce–beaddressed,these studies frame the problem of shortage of the workforce as illegalabsenteeismthatonlyneedsmanagerialenforcementof“presenteeism”.Itisironicalthatthesameactorsthatwereresponsiblefordecadesofdivestmentintheworkforcearetheleadersoftheenterprisetoreframetheworkforceshortageasabsenteeism.Ifpolicyisdevelopedonthebasisoftheproblemframed as “absenteeism” of health workers, the solution space for policyinterventions will focus on pressuring the current workforce to optimise“presenteeism”.Facility-basedassessmentofworkforce“presenteeism”runscountertothelegitimateactivitiesthatrequirehealthworkerstoservethecommunitiesthroughoutreachplatforms.Healthpromotionanduniversalhealthcoveragegoalswillbeunder-servedifthecurrentpreoccupationwithfacility-based“presenteeism”isenforcedinanaïvemanner.Themanagementof illegitimateabsenteeismshouldbegroundedinhealthsystemsthinkingalongsideeconomicmodelsfromindustrieslikeairlinesthatareconcernedwithpublic safetyand risks/errors thatmayarise fromworkoverloadandprolongedhoursatwork.

Workload pressure

The government has incrementally increased the workforce size in thepublicsectorthroughsporadicinitiativestoboosttherecruitmentofhealthworkersinthepublicservice.TheMoHworkforceaudit2009-2016shows


improvementinthepercentageofstaffingovertheyears(Figure12.7)–from53percentto71percentoftheapprovednumberofhealthworkersinthegovernmenthealthfacilities.Asdiscussedbelow,recruitmenthasnotbeensuccessfulinsolvingtheproblemofaninadequateworkforce.

Figure 12.7: Percentage of positions filled in the government health facilities

Source: MoH annual sector report, 2009-2016

Despitetheincreasesinthetrendsofavailablehealthworkers,thereferencestandardsofthestaffingnormsaremuchlowercomparedtotheworkloadburdenatthehealthfacilities(13).Thiscallsforworkforceredistributioninaccordancewithobjectivemeanssuchasworkloadandtheexpansionofthestaffingnorms to copewith the expandingburden forhealth servicesduetoarapidlygrowingpopulationandemergingdiseasesandconditions.Forinstance,Namagandaetal.(2015)notedthathealthcentreshadashortageofnursesandmidwives,rangingfrom42percentto70percent(13).Thestudy recommends increasing the investments to expand the stock of thehealthworkers.Itnotes:

“The results highlighting discrepancies between Uganda’ s actualstaffingnorms and theworkloadbased requirements.When staffinglevels are far below the minimum required to provide services ofreasonablequality,thegovernmentanddevelopmentpartnersshouldfocusonincreasinginvestmentsinhealthworkerrecruitmenttoreachthestaffingstandards.(Namagandaetal.,2015:10)”


Unbalanced skill sets

The distinctive characteristics of clinical care are teamwork and teamproduction.Forinstance,anoutpatientclientwithmalariainahealthcentreideallyneedstomakecontactwithatleastfivepersonswithdifferentskillstoenableeffectivediagnosticsandtreatment.Thesemightinclude:

1. Areceptionist to register, screen/triageanddirect theclient to therightplaceforclinicalevaluation/consultation;

2. Aclinicalexpert(clinicalofficer,nurseordoctor)forclinicalassess-mentandprescription;

3. A laboratory technician if laboratory tests,e.g.malaria testing,arerequired;

4. Adispenser,whowillberequiredtoprovidethemedicinesandex-plaintheiruse;and

5. Aninjectionroomnurse,whoisrequiredifaninjectionisprescribed.

Ifoneormoreoftheaboveskillsaremissing–forexampleifthelaboratorypersonortheinjection-roomnurseisnotavailable–thetreatmentprocesswouldbe ineffective.Thiswould causedelays in the treatmentprocess orover-prescriptionofmalariaorantibioticmedicines.Studieshaveshownthatintheabsenceoflaboratorytests,cliniciansblindlyprescribemoreantibioticsorantimalarialmedication–asituationthatcreatesunnecessarycostsofthemedicinesinthehealthsystemandmakescoverageobjectivescostlytoattain(35).

Thescenariofor in-patientcare isofgreaterconcernbecausethegapsintheskillsetsaremuchwider,forexampleinthecaseofsurgicalserviceswhereamixofbothspecialisedandsupport skills is required.Amongthesmallest number of health professionals in theworkforce are anaesthetists– responsible for painmanagement during surgical operations.The 2015workforceauditbytheMoHshowsthatonly238anaesthetistsareavailablecomparedtothe878positions–avacancylevelof73percent.Relatedly,anassessmentofhospitalandhealthcentreIVfunctionality(36)foundthatsurgicalserviceswerelessavailable–mostlyduetotheinsufficientavailabilityofhealthworkerswiththeessentialsurgicalskills(doctorsandanaesthetics)atthislevel.AsillustratedinFigure12.8below,surgicalservicesforfamilyplanning, dental care andC-sections aremuch less available compared tonon-surgical services. Inadequate essential supplies for surgical services arealsopartlytoblameforthisproblem.


Figure 12.8: Service availability at health centre IV in government health facilities

Source: MoH, 2014 (36)

Policy responses to improve workforce performance should prioritise theworkforceshortage,intentionallyseektoaddresstheskillmixproblemandensureadequategeographical,populationandservicecoveragewithaviewofachievingUHC.

3. Labour Market Dynamics and Strategic Governance

Governanceinthisrespectbroadlyseekstoensurethatstrategicframeworksexisttosteertheworkforcestakeholdersandmultipleintereststhatrequirecoordination.Governancealsoseekstooptimisepublicvalueandgoalsbymanaging the interests of different stakeholders. Workforce production,performanceandlabourmarketmanagementpresentaclassicalchallengeoftoomanyinstitutionswhoseinterestsrequireactivegovernancetoalignthemwith the commonpublicpolicygoals. TheAnnualHealthSectorReport(AHSR)2009/2010observed:

Various organisations and agencies among theHealthDevelopmentPartners have taken up interest in HRH issues and are providingfinancial,technicalandinfrastructuresupporttothegovernment,and


PNFPs, (….).These include agencies such as the EuropeanUnion,DANIDA,JICA,theWorldBank,USAID,SIDA,BelgianTechnicalCo-operationandmanymore.Thishasbroughtinplentyofchallenges– equity, duplication, uneconomical use of resources, ineffectivedeliveryofservices.ThismultiplicityofactorsinHRHinterventions,requirecoordination.(MoHAHSR,2009/2010:152)

Thetablebelowillustrates thenumberof institutionsandtheiroverridingobjectives in theworkforcegovernance space. Ingeneral, there aremajorconflicts in the objectives of agencies managing the different functionsof the healthworkforce. Evenwithin government, there are interests thatruncounter tothegoalofprovidinganadequatestockofhealthworkers.Therearemanydysfunctionalobjectives, for instance toexport thehealthworkforcetogenerateinflowsoffinancialremittancesfromtheworkers intheDiaspora(37)despiteashortageofthecurrentstockoftheworkforcetoservethehealthneedsofUgandansathome.Someofthesedysfunctionalobjectivesarechampionedbyhigh-levelpoliticalleaders,whoareelectedtorepresentunder-servedcommunities.Thissituationillustratesthelackofasharedvisionamongthepoliticalelites.Assuch,theroleofgovernanceinensuring thathealthworkers are adequate,well trainedanddistributed toserveallUgandanshasmajorcontestationsandcompetingobjectives.

Working at cross-purposes is probably the major problem in thegovernance space for the workforce (see Table 12.1). The reforms inthe production sector havemade the costs of productionmove from thegovernmenttocommunities.Mosttrainingschoolsfornursesandmidwivesare in the private sector, where training costs are high, thus curbing thenumbersthatcanbeproduced.Iflefttotheirowndevices,thestakeholdersare likely to continue working at cross-purposes and fail to improve theworkforcesituationinUganda.RecenthistoryhasshownthatthereismarkedpotentialinbuildingcoherenceingovernmentactionsforhealthworkforcemanagementinUganda.


Table 12.1: Conflicted objectives: Institutions and agencies involved in workforce governance

Institution Main role Main objective(s)

MinistryofHealth

Employerandsteward

Toovercomeshortage,diversifytheskillmix,ensureequitabledistributionandboostperformance

MinistryofEducationandSports

Production ToFinanceandcoordinatealltraininginstitutionsatalllevels.

NationalCouncilforHigherEducation(NCHE)

Fundingandregulatinghealth-trainingschools

Toprovidestandardsandregulationsforhealth-traininginstitutionsandsimilarothers

Professionalcouncils

Licensing,elevatedstandards

Toelevatestandardsofentryintotrainingandincreasecosts/wagestothesystem

Localgovernments

Districtservice To lead service delivery mandates but littlecontroloverinputsandsupportsystems

Publicservice Employerandpayer

To provide fair wages across the publicservice,andtoresistselectivewageincreasesforhealthworkersandcreatejobs

MinistryofLabour

Jobcreationandexternalisation

Tolicenseandencouragetheexportoflabour,includinghealthworkers

MinistryofFinance

Financeandplanning

Tocontrolwagesand stabilise theeconomyby restricting financing for inputs used forworkforceperformance

PrivatesectoragenciesandPNFPbureaus

Employersandproducers

To provide alternative employment andwork environments, and dual practiceopportunitiesforsupplementaryearnings

Source: Author analysis


Competing labour markets

Another major issue is the growth of the private sector within Ugandaand the opportunities it provides to expand the labourmarket for healthprofessionals. For instance, the religious-based health provider networksemployabout12,000healthworkersandcontributeabout30percent tothecombinedPublic-PNFPworkforce.Ninetypercentoftheseareprivatelyemployed. The other 10 per cent comprise staff seconded by missionarycongregations, the local governments, and theMoH (38). Since both thepublicandprivatesectorscompeteforthesamelimitednumbersofhealthworkers,thesectorwhichisbetterabletopayhasmoreleverageinthemarketsharefortheavailableworkforce(17).Dualpractice–multiplejobholdingormoonlighting–hasbecome a commonly encounteredphenomenon ashealthworkers(bothspecialistsandfreshrecruits)seektosupplementtheirmeagreincomesintheprivatesectoralongsidetheiremploymentinthepublicsector.Indeed,publicsectormanagementhasatmanylevelsbeenforcedtoadoptanon-criticalstancewithregardtodualpractice.Oneargumentputforthtojustifythisstanceisthatthehealthworkersengagedindualpracticecontinuetoprovideservicesbeyondtheirnormalworkinghours,apracticewhichshouldbelaudedratherthancondemned(11,39).Still,thispracticeneedstobemonitoredforitseffectonthequalityofcareacrossbothsectors,especiallyconsideringthatdualpracticecontinuestostretchthefewhealthworkersavailable.

Internationallabourmarkets,too,havethecapacitytopoachthehealthworkforceinUgandaifnotcontrolled.RecruitmentagenciesfromTrinidadandTobagoaswellasfromLibyahaveallexcitedtheUgandanhealthworkersbyprovidingthemwiththeopportunitytoearnadecentwageabroadthattheUgandangovernmenthasfailedtoofferathome.Thefamouspolicyofgovernment–i.e.“market-leddevelopments”and“externalisationoflabour”(37) – should be re-examined in the light of the scarcity of the currentworkforceandtheinsatiabledemandforprofessionalhealthworkersintheinternationallabourmarkets.

Conclusion

ThehealthworkforceinUgandahaswitnessedmajorpolicyandprogrammaticchallenges. Despite some increases in the public and non-public sectorworkforcestockinthelast10-15years,thedeficitgap–betweentheminimum


standards for quality services and the currentHRH policy provisions forstaffing–iswidening.Theoutstandingproblemisshortageofthestockandskillmixoftheworkforce.However,thesolutiontothisproblemhasbeenconfusedbyunhelpfulframingoftheshortageoftheworkforceasaproblemofabsenteeism.

Aneffectivebalancemustbestruckbetweentheapparentvigilanceforthe“presenteeism”ofhealthworkersathealthfacilitiesandtheoverallgoalofkeepingUgandansinastateofgoodhealthandwell-being.Communityoutreachprogrammestopromotehealthandwell-beingwillrequirehealthworkerstospendmoretimeinthecommunity–asituationthatneedstobeencouragedbutnotcriminalisedasabsenteeism.Ultimately,goodworkforcegovernance with aligned policies and well-coordinated stakeholder effortsshouldbeexploredandinvestedintoadvanceuniversalhealthcoveragegoals.

Clearly, theUgandan government has the problem of an inadequatestockofworkforce tofix inaddition to theneed toundertakemanagerialinterventionstoaddressadequateservicecoveragewithwell-constitutedworkteamswith therequiredskill setsandseniority for theexpectedqualityofservices.Stillabsenteeism,asavalidleverofworkforceperformance,needstobeunderstoodfromasystemsthinkingperspectivegroundedinlegitimatelabourlawsandthediverseplatformsavailableforprovidinghealthservices.

Theexpansionofthepopulationsizetobeservedandthe integrationofmorehealthinterventionswithheavyadditionaltaskssuchasHIVandNCD care are all indicators of an escalating workload. Strategic trainingoftheworkforcewithdueconcernforemergingdiseasesandrequiredskillsetsiscritical.Performancemanagementstrategiesneedtoaddresstheworkenvironmentbesidesincreasingthestockandskillmixoftheworkforce.AsopportunitiesexpandforUganda’sworkforcetomoveoutandworkabroad,the government needs to invest in purposeful governancemechanisms tosafeguardtheinterestofUgandansbymakingthelabourmarketattractiveforprofessionalhealthworkerstochoosetoserveUgandansandexpandtheservicecoverageandqualityobjectivesof thehealthsystemathome. Themajorleversforthealleviationofworkforceshortagearewagebillincreasesto stimulate the production of professional cadres and to ensure thatgreater numbers of professional cadres enter employment when attractiveremunerationandsupportiveperformancesystemsareavailable.


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