Our Side of the Story - VSO

Coalition for Health Promotionand Social DevelopmentOur Side of the StoryA policy report on the lived experienceand opinions of Ugandan health workers

HEPS-Uganda, The Coalition for Health Promotion and Social DevelopmentEstablished 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 medicinesfor poor and vulnerable people in Uganda. HEPS promotes pro-people health policies and carriesout campaigns at local, national and regional levels. It also initiates and conducts research necessaryfor health and human rights advocacy. Since 2007, HEPS-Uganda has actively promoted healthrights within seven local government districts, addressing maternal health and equitable access tohealthcare. Working in some of the most disadvantaged rural areas of Uganda, HEPS has trainedcommunity 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 communicatingwith health workers. For more details, visit: www.heps.or.ugVSO UgandaVSO Uganda volunteers are currently working in the central, western and northern regions of thecountry, in the fields of participation and governance, disability, health, education and livelihoods.Poor and disadvantaged people in Uganda are badly affected by preventable diseases. Healthservice provision and access is low, and staff retention is a challenge. VSO is supporting theUgandan Government in implementing the Health Sector Strategic Plan (HSSP) to improve healthsystems in the context of a decentralised health delivery system at district level. HSSP focuses onworking with communities and the implementation of primary and preventive healthcare services,as well as good-quality, accessible clinical services as stipulated in the minimum healthcarepackage. It has a particular emphasis on reaching the majority of the population, over 80% ofwhom live in rural areas, where the people tend to be poorer than in urban settings. For moredetails, visit: www.vsointernational.org/where-we-work/uganda.aspVSO InternationalVSO 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 inpoverty – 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 inthe 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 recruitedand retained. They must be of good quality, in the right places, well trained and with access tothe basic equipment and drugs needed. They also need to be well supported – placed in theright location, treated fairly and managed well.Through our Valuing Health Workers research and advocacy project, VSO identifies the issuesthat affect health workers’ ability to deliver quality healthcare. These findings will supportpartners to carry out further research and make a significant contribution to improvementsin 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 workersAcknowledgementsThe Valuing Health Workers research and advocacy project is the initiative ofVSO International. This report is based on research in Uganda in partnership withHEPS-Uganda, the Coalition for Health Promotion and Social Development, andwith support from VSO Uganda. Thanks are due to Rosette Mutambi, executivedirector of HEPS-Uganda, Sarah Kyobe, VSO Uganda health programme manager,and Stephen Nock, VSO International policy and advocacy adviser, for theirpractical support and encouragement.Stacey-Anne Penny brought to the project her drive to explore and understandthe lived experience of Ugandan nurses and her invaluable contribution asco-researcher up to August 2010. HEPS-Uganda colleagues provided a supportiveand friendly working environment. The following HEPS staff played practical rolesin managing consultative workshops, facilitating access to fieldwork sites andco-convening and transcribing focus group discussions: Prima Kazoora, PhionaKulabako, Aaron Muhinda and Kenneth Mwehonge.This report would not have been possible without the willing participation of122 health workers across Uganda. Thank you to them for voicing the rewardsand challenges of their daily lives. Thank you to local managers for makingstaff available, and to patients for their forbearance while their health workersgave time to the research. Not least, thanks are due to the representatives oforganisations concerned with health worker and health consumer interests,for their participation in workshops and interviews.Patricia ThorntonText: Patricia ThorntonField research: Patricia Thornton, Stacey-Anne Penny, Prima Kazoora,Phiona Kulabako, Aaron Muhinda and Kenneth MwehongeEditing: Stephen Nock, Diane Milan, Stephanie Debere and Emily Wooster.Layout: www.revangeldesigns.co.ukPhotography: Cover photo © Matthew Oldfield/Science Photo Library©VSO 2012 Unless indicated otherwise, any part of this publication may be reproduced withoutpermission 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 reproductionwith commercial ends, permission must first be obtained from VSO.The views expressed in this report belong to individuals who participated in the research and maynot necessarily reflect the views of HEPS-Uganda, VSO Uganda or VSO International.ISBN: 978 1903697 3373

Our Side of the Story: The lived experience and opinions of Ugandan health workersContentsSummary 61. Introduction 121.1 The VSO Valuing Health Workers initiative 121.2 The Valuing Health Workers research in Uganda 121.3 The research approach and participants 141.4 Structure of the report 142. Healthcare in Uganda: challenges and provision 152.1 Ugandan healthcare challenges 162.2 Formal healthcare provision 192.3 The Ugandan health workforce 213. Research design and methods 253.1 The research stages 253.2 Qualitative research methodology and the purposive sampling design 253.3 Data collection 263.4 Data analysis 263.5 The health worker participants 264. The rewards 284.1 Benefiting others 284.2 Job satisfaction 284.3 Being recognised, appreciated and valued 294.4 Appreciative and supportive management and colleagues 295. Reasons for becoming a health worker: the “right heart” and the “wrong heart” 305.1 A passion for the patients 305.2 “They join for the wrong reasons” 315.3 Recommendations 316. Workload 336.1 The context 336.2 The health worker experience 33Unmanageable workloads 34Too many tasks and responsibilities 34Working day and night 34Over-long shifts and too little time off 34Impacts on health 34Restricted professional development 34Failing the patients 356.3 Factors contributing to understaffing and work overload 366.4 Recommendations 374

Our Side of the Story: The lived experience and opinions of Ugandan health workers7. The facility infrastructure 387.1 The context 387.2 The health worker experience 39Low job satisfaction 39Risks to health workers 39Risks to patients 397.3 Recommendations 408. Equipment and medical supplies 418.1 The context 418.2 The health worker experience 418.3 Recommendations 439. Medicine supplies 449.1 The context 449.2 The health worker experience 449.3 Recommendations 4710. Pay 4810.1 The context 4810.2 The health worker experience 48Money worries 49Failing to meet social expectations 49Disrespect 49Thwarted professional ambitions 49Unfair pay 4910.3 Poor pay, turnover and loss to Uganda 5110.4 Recommendations 5211. The way forward 5311.1 Raising the voices of health workers 5311.2 Changing public perceptions of health workers 5511.3 Bridging patient communities and healthcare facilities and staff 5511.4 Summary of participants’ recommendations 57Appendix A: Sample details 59Appendix B: Local government structures in Uganda 61References 63Annex: Health worker topic guide 665

Our Side of the Story: The lived experience and opinions of Ugandan health workersReasons for becoming a health workerand rewards of the workThe urge to help, prevent suffering and save lives stood outamong the reasons people gave for becoming a health worker.It had been common in rural areas to see people suffer in painand die with no proper medical care. Their training wouldbring to the community knowledge to help prevent illnesses,discourage harmful traditional healing practices and save lives.Participants who had been impressed by caring nurses andthe skills of medical staff wanted to give something in return.Interest was stimulated by the example of family members whoworked in healthcare. Experiencing poor service also prompteda desire to raise healthcare standards.A desire for money was not a driving force. Clinical officers andmedical doctors told of expectations on them as the brightestschool 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 andself-serving recruits, who resorted to bad habits and forgottheir accountability to patients.The benefits to the community, to individual patients and totheir own families were the biggest sources of satisfaction. Jobsatisfaction came from making a difference to patients, doingtheir duty the best they could, using their skills and learningthrough work. Health workers valued being appreciated,respected and trusted by patients. Tangible demonstrations ofappreciation by managers were a huge positive, as were goodteamwork and supportive managers who created opportunitiesfor health workers to raise their concerns.The impact of working conditionsWorkload, workplace infrastructure, medical equipment andsupplies, the availability of essential medicines and the level ofremuneration affected health workers’ well-being, the qualityof care they could provide and relations with patient communities.It is apparent from health workers’ experiences that workingconditions are the root cause of the attitudes, behaviours andpractices for which health workers have been criticised.WorkloadMinistry of Health sources reveal almost half of approvedposts at health centres and hospitals are vacant – a shortfallof 25,506 staff. There are gross disparities across localgovernment districts, with four districts having less than30% of posts filled, while 10 districts filled more than 70%.Unmanageable workloads overwhelmed nurses and madethem physically and mentally ill. Too many tasks andresponsibilities led to burn-out. Lack of more qualified staffmeant taking on stressful roles beyond the scope of duty.Participants told of working round the clock, foregoing mealsand compromising their health. Overlong shifts and limitedtime off allowed little personal or family time. Feeling theywere failing the patients added to health workers’ distress.Hospital nurses torn apart by calls for attention and toomany tasks recognised they could lose their temper. Midwifebehaviour changed as a result of working alone day and night.Long, tiring shifts, when overwhelmed by the workload, ledto nurses being short with patients, not interacting with themand conveying disinterest through attitude and expression.7

Our Side of the Story: The lived experience and opinions of Ugandan health workersManagers and frontline doctors had seen how hunger madenursing staff bad-tempered and rude to patients. It was saidthat long shifts, together with poor pay, led nurses to not turn upfor duty and leave work early. Managers observed that lack ofopportunity to fulfil their proper professional role demotivatednurses, who then ran out of compassion and skip out fromwork. Work overload and staff shortages had impacted oncommunity relations, and participants told of aggressiveoutpatients and wrongful accusations of neglect of duty.Managers explained that financial allocations for salaries stoodin the way of recruiting more staff and that vacancies persisteddue to bureaucratic procedures. Paradoxically, scarcity ofstaff was a barrier to holding public sector health workers toaccount, as disciplinary procedures might lead to transfer andan even worse workload for remaining staff.InfrastructureAccording to official sources, most facilities are in a state ofdisrepair. Many health centres have non-functional operatingtheatres. Only one in four facilities has electricity or a back-upgenerator and only 31% have a year-round water supply.Over half facilities lack transport for patient referral in maternalemergencies and only 6% have technology to communicate.Government sector workers in rural facilities bore the bruntof infrastructure failures. When theatres were unusable,underemployed doctors lost interest and left. Lack of electricitycompromised staff and patient safety. At night, patient notescould be not read to ascertain HIV status and deliverieswere carried out by the light of a mobile phone or a candle.Maternity workers said patients construed their behaviour asrude or neglectful because they shied away from risk. Lack ofgenerator fuel meant operations were completed by torchlight.Nurses feared assault working in unlit wards or crossing darkcompounds, a risk made worse by lockless doors, breaches incompound 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. Infectioncontrol was near impossible when nursing staff had to begthe little water spared by patients’ family attendants to washtheir hands. It was deeply upsetting to know that poor patientswould die because the facility had no means of transportingthem 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 tobenefit community relations.Equipment and medical suppliesThe Ministry of Health acknowledges a shortage of basicequipment in health facilities and that only 40% of equipmentin place is in good condition. An independent survey revealsa gross lack of equipment for the diagnosis and treatmentof malaria, and that six in 10 facilities surveyed were notequipped to measure haemoglobin.Health workers praised well-equipped facilities and imaginativemanagement that solved temporary supply problems byborrowing from other facilities. Elsewhere, working withinadequate equipment was a huge challenge. There waswidespread 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 missingor poorly maintained diagnostic equipment. In the governmentsector, doctors and nurses told of interruptions in supplies ofoxygen 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 withno delivery kit, cord clamp, sucker, gauze or cotton wool andjust one pair of scissors. The regulatory prohibition on askingpatients to buy medical supplies was a huge frustration whichchallenged their ethical duty to do their best for their patients.Managers recognised that doctors lose morale when unable tooperate, and that being unable to apply knowledge was verydemotivating. It was said that nurses forgot what they hadbeen taught and as a result some did not work, so projecting abad image to the community, which in turn made nurses feelnot respected and prompted them to leave. Health workers feltblamed for the lack of supplies. They noted patients’ attitudeschange if asked to buy their own, with some carers becomingangry and violent.Availability of essential medicinesThe proportion of health facilities registering ‘stock-outs’ inessential medicines has consistently been over 60% for thelast 10 years. Not one of 40 essential medicines was availablein every government facility in a sample survey in the secondquarter of 2010. Only eight were found in each not-for-profitsector facility surveyed.Participants working outside the government sector mostlyconsidered medicine supplies adequate. In the governmentsector there was sharp contrast between praise for the betterstocked facilities and disgruntlement that essential drugs were8

Our Side of the Story: The lived experience and opinions of Ugandan health workersused up in a matter of weeks or even days. Complaints centredon undersupply for population demand; shortfalls in supplywhere deliveries did not match orders; erratic deliveries (such asoversupply of condoms but no anti-malaria drugs) and irregulardeliveries which did not conform to promised quarterly schedules.Unable to give their patients the drugs they needed, healthworkers became demoralised by the futility of their roles,and their self-esteem suffered when patients lost confidencein them. Health workers grieved for their patients’ sufferingfrom the lack of medicines, such as antiretroviral drugs, whichshould be taken on a lifelong basis. Helplessness was hard tobear when they felt forced to tell poor patients to buy theirmedication in the private market. Health workers struggledwith disappointed patients and their limited understanding ofreasons for shortfalls in supplies. They also told of angry, bitterpatients who cursed them and refused to listen. They said thatcommunities served by government facilities assumed healthworkers took the drugs.There was widespread indignation at accusations of stealingnon-existent medications. Health workers resented negativestories in the media and felt that local leaders and politiciansmade matters worse when they failed to present the truepicture to complaining patients, and even accused healthworkers in front of patients. There was hurt and indignationabout top public figures spoiling the professions’ reputationsby stating publicly that health workers are thieves.PayUgandan nurses’ and doctors’ salaries are the lowest in EastAfrica. Monthly starting salaries in public service in 2009-10were 353,887 UGX (Ugandan Shillings) ($US 191) for a registerednurse and 657,490 UGX (($US 354) for a medical officer. Highcourt judges received 6.8 million UGX (($US 3,664) per month. 1Nursing staff spoke heatedly about their struggles to surviveon low pay and support their dependents, see their childrenthrough education, pay for a roof over their heads, settleessential bills, afford transport to work and save towardsthe costs of further training. Financial worries added to thestresses caused by impoverished workplaces. Doctors feltsocially embarrassed when they could not contribute largesums of money at functions held to raise funds for weddings orfunerals, or meet expectations to help with school fees. It wassaid that patients look down on nurses when they know howlittle they are paid. Participants voiced strong opinions thatthe pay was unfair and undervalued health workers. Nursescomplained that their salaries did not reflect the years of studythey had put in, and going unrewarded for doing the samework as higher grade staff was thought bitterly unfair. Doctorsbeing paid less than secretaries and drivers in some statutoryagencies underscored the little value attached to the medicalprofession in Uganda. Salaries were doubly unfair because theydid 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 onpatients, small-scale pilfering of drugs and accepting moneyoffered by patients. It was widely believed that urban healthworkers were forced to work in two or even three jobs to makeends meet, leading to exhaustion and behaviour which patientsperceived as rude.Better pay was not an overriding consideration for workingoutside Uganda. Nurses explained they were looking for anenvironment where their work would be respected andwhere they could learn about different medical conditions,use equipment they were trained to use, update their skillsand have the chance to advance professionally. Doctors spokeabout the attraction of a better income from work abroad, butopportunities to use proper equipment and enjoy the workalso were important.Conclusions and participants’recommendationsHealth workers’ accounts show that working conditions werethe root causes of bad practices and unethical behaviour, andthat health workers bore the brunt of the blame for systemfailures. The research revealed a vicious circle: impoverishedworking environments and low pay affected the quality ofpatient care; patients blamed the health workers; the widercommunity then distrusted health workers and so healthworkers’ distress increased. The situation was made worse bynegative media stories and political leaders’ vocal criticism ofhealth workers, which fuelled public distrust, damaged thestanding of the profession, added to health workers’ distressand raised the barriers to access to healthcare.The view of civil society organisations and of some managers wasthat frontline health workers are not empowered to speak up.The concept of ‘voice’ was unfamiliar to many frontline healthworkers in the research, and the idea that they might speak outand gain support to improve poor working conditions and qualityof care was new to them. The research identified barriers toindividual health workers voicing their concerns, and healthworkers’ preferences for advocacy by representative organisations.1. US dollar = 1,856 Ugandan Shillings at 31 March 20109

Our Side of the Story: The lived experience and opinions of Ugandan health workersThe findings identified two priorities for action:1. to value health workers for their contributions to the healthof Ugandans2. to expose the poor working conditions that prevent healthworkers from providing good quality healthcare.Four enabling strategies emerged from health workers’accounts and stakeholder advice:1. to improve the quality and relevance of training2. to raise the voices of health workers through representation3. to change public perceptions through the media4. to build bridges with patient communities.Priorities1. Value health workers for their contributionsto the health of UgandansHealth worker terms and conditions of service• Review salary scales to determine whether increases inbasic salaries are possible. Reform government salaryscales to recognise first and postgraduate degrees, in orderto attract degree nurses to public sector jobs and ensuretheir education is used to support patient care directly.• Consider the establishment of a minimum wage andthe feasibility of imposing the same salary structurein 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 whena nurse has sole charge of a ward.Small financial motivations• Incentivise staff through small items of personal support, suchas food for the household, snacks at work, and Christmas andEaster gifts. Contributions towards family burials, medicaloperations and provision of cloth for uniforms are well received.• Review current allowances for risk, hardship, housing,transport, responsibility and study, to ensure consistencyand fairness across all facilities.• Use the income from local government hospitals’ privatewings to benefit staff, by supplementing salaries or allowances.2. Ensure working conditions enable healthworkers to provide good-quality healthcareHealth worker/patient ratios• Introduce standards for patient/nurse and patient/doctorratios, so that health worker overload is transparent andquantifiable, and managers have information to help reducepressure on overloaded staff.Recruitment blockages• Manage health worker recruitment and deploymentcentrally, to address the problem of unfilled posts anduneven distribution of health workers.Decent staff accommodation• The Government should follow through on its strategy toprovide decent and safe accommodation for health workersat health facilities, especially in remote areas. Civil societyorganisations should continue to monitor implementationof this strategy and press for concrete targets.Facility infrastructure• Ensure regular meetings between management anddepartment heads, at which facility-related problemscan be raised and decisions taken on actions needed.• Invest in good theatre facilities and their staffing in a smallnumber of level IV health centres, and showcase them asgood practice before embarking on further investment.Equipment, medical and medicine supplies• Give much more attention to the maintenance and quickrepair of medical equipment, including systems for monitoringequipment maintenance and adequate stocks of spare parts.• Hold regular formal consultations with frontline workersto enable them to participate in decision-making aboutequipment and supplies, and to improve transparencyin equipment procurement processes.• Encourage international donors to provide large itemsof equipment directly.Enabling strategies1. Improve the quality and relevanceof health worker trainingCareer guidance and early contact• Ensure well-motivated trainees, for example throughmore talks at schools and work experience placements.Training schools’ admission procedures• Reject applicants who seem to be applying for the “wrongreasons”, including those allocated to a university coursewhich 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 fromthe Ministry of Education and Sports.• Reduce nursing and midwifery class-sizes and improvetutor capacity, to ensure the right attitudes and practicalunderstanding of the ethical code are encouragedthroughout pre-qualification training.10

Our Side of the Story: The lived experience and opinions of Ugandan health workersHealth and human rights training• Expand existing partnerships between training institutionsand health consumer advocacy organisations. Improvenursing course content to make sure that students takeon board the role of the nurse as a patient’s advocate.De-urbanise health worker training• Increase the number of training schools and residencyprogrammes in rural areas to produce staff already adaptedto rural environments and connected to the local community.• Improve the community service element in medical curriculaand increase the exposure of urban health students to ruralsettings with increased fieldwork.Nurses and Midwives Council registration interviews• The Nurses and Midwives Council should weigh up theadvantages of screening interviews held as a prerequisitefor registration post-qualification against detrimentaleffects on nurse morale.2. Raise the voices of health workersSharing of experience and common approaches• Encourage staff to meet with people from other healthcarefacilities to discuss solutions to common problems andcommunicate them to sub-district level managers. Thesemanagers could also be encouraged to instigate similar forums.Speaking through professional associations, unions andregulatory councils• Channel health worker concerns to the Ministry of Health,Government or Parliament through bodies that speak forthem, such as professional organisations and trade unions.• Professional associations and unions should do more to bringmembers together, for instance at local general meetings,and make greater efforts to visit facilities and talk with healthworkers so that the “right voices” can be taken to the top.They should compile strong collective arguments to improveconditions in the workplace, as well as addressing individualgrievances and traditional welfare issues.• The Health Workforce Advocacy Forum – Uganda (a coalitionof health professional associations, unions and health rightsorganisations) should expand its membership and continue itscampaign for a positive practice environment for health workers.3. Change public perceptions by influencing the media• Inform journalists about the obstacles to health workerrecruitment and discourage them from writing sensationalistor negative stories in the media. Put complaints on locallanguage radio call-in shows into a wider context. Encouragethe running of positive human interest features, such asprofiles of individual health workers and the work they do.Work with the Uganda Health Communication Alliance.• Improve the capacity of civil society and health workerorganisations to write press releases, hold press conferencesand build relationships with individual reporters and mediahouses, so the key campaign messages hit home.4. Build bridges between patient communities,healthcare facilities and staffTransparency on drug availability• Use well-managed public opening of medicine deliveries tohelp 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. Supportwith paperwork to show what has been ordered and delivered.• Ensure that local leaders are fully informed through regularmeetings about the demand for and supply of drugs and thatthey use this information responsibly.Connecting communities and facilities• Use opportunities to talk with people on their own groundand explain the problems health workers face, for instancethrough Village Health Teams, facility-based health workersproviding outreach immunisation services, and talks towomen awaiting prenatal checks.• Promote ‘community dialogue’ meetings bringing togetherservice users, local leaders and health unit managementteams. Increase funds to cover these activities.• Invite top local politicians to spend time in facilities alongsidestaff to see what the work is really like.• Civil society organisations should continue their work tocreate common cause between health workers and patients.11

1. Introduction1.1 The VSO Valuing HealthWorkers initiativeWhat is life like working in healthcare ina low-income country? What promptsnurses, midwives and doctors to takeup their professions and what are therewards? What do health workers sayabout the barriers they face in providingaccess to healthcare? What in their viewneeds to change? And how can their voicesbe heard? VSO’s Valuing Health Workersinitiative is listening to the experiences ofhealth workers and gathering evidence toadvocate for change.The lived experience and opinions of health workersare rarely recorded in the many explorations ofsolutions to the health worker crisis affecting thedeveloping world. Health workers are commonlyseen as ‘human resources’, as a part of a healthcaredelivery mechanism to which ‘levers’ may be applied,and not as human beings whose individual actions areinfluenced by the societies and conditions in whichthey live and work. Rather, performance managementtechniques and incentives to attract and retain staffdominate research and policy.VSO International set out to redress this imbalancethrough its Valuing Health Workers research andadvocacy initiative. Recognising that health workers’voices must be heard and acted on to improve accessto healthcare, and so help to achieve the MillenniumDevelopment Goals, VSO International startedparticipatory research in four countries in Africa andAsia, in partnership with in-country non-governmentalorganisations. VSO will support local partners to usethe research findings to advocate for health workers intheir countries, and will gather the research evidenceto advocate on a global level.1.2 The Valuing Health Workersresearch in UgandaIn Uganda negative images of health workers areprojected in the media, political speeches, policydocuments, healthcare user research and healthconsumer advocacy work. The overriding messageis that health workers’ attitudes, behaviour andpractices present barriers to accessing healthcare.The Valuing Health Workers research in Ugandaset out to explore with frontline health workersand their managers the conditions underlyingaccusations of unethical behaviour and serviceinadequacies. The overall objective was to giveopinion formers and healthcare service usersa realistic picture of what life is like as a healthworker in Uganda, so as to increase understandingand modify expectations. Ugandan civil societyorganisations will use the findings to help buildmutual understanding and promote harmoniousrelationships between healthcare users andworkers, as well as to advocate for improvedconditions for health workers in Uganda.It has been well-documented through researchand health rights projects that healthcareusers in Uganda experience from health workersbad attitudes, rudeness, inhumane treatment,neglect, discrimination and extortion of illegalfees for services. They also face staff absencesand the unavailability of medicines and othertreatment supplies. 2 Research has reportedpatient community perceptions that drugs arestolen. 3 The press and radio media have fuellednegative perceptions of health workers’ behaviour,branding them as shirkers and thieves. 4 Indeed,the media have reported leaders in governmentaccusing health workers of stealing medicines.2. See Kiwanuka et al 2008 for a systematic research review3. Kiguli et al 20094. Medicines and Health Service Delivery Monitoring Unit2010 lists 43 press articles in under one year, almost allreporting negatively on health worker behaviour

Our Side of the Story: The lived experience and opinions of Ugandan health workersEven Ugandan health policy documents have commentednegatively on health workers’ low productivity, high absencerates, poor attitudes and lack of accountability to clientcommunities. Organisations promoting health rights have seendistrust and hostility among communities and some defensivereactions 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 theworkplace, limited and poor-quality staff accommodation,and harassment; it also recognises that staff endure poorsupervision and leadership and a lack of promotion, trainingopportunities and career progression. 5 Facilities and equipmentin states of disrepair, and shortages and wastage of medicines,have been pervasive problems. 6Yet little attention has been paid to the impacts of workingconditions on the lives of healthcare staff, and so on the qualityof services they can provide. Research on or with Ugandanhealth workers has focussed on workforce retention questions,such as migration, intent to migrate and turnover. 7 It hasmeasured job satisfaction and quantified work factors related tointent to stay or leave. 8 A second area of research has measuredhealth workers’ informal income generation practices, such asspending working hours engaged in agriculture and operatingprivate clinics, and has quantified absenteeism. 9 10 Certainly,some research reports include the voiced experiences of healthworkers. 11 But only exceptionally has research started from theviewpoint of health staff as workers and members of familiesand communities, as opposed to the viewpoint of the system. 12Only one study has focussed on the distress and emotional toll ofworking with insufficient resources for acceptable levels of care. 13The starting assumption of the Valuing Health Workers researchin Uganda was that health workers are unfairly blamed forattitudes and behaviour caused by the system in which they work.Health workers are human beings – men and women with theirown worries, working in very challenging circumstances – andthey develop ways of coping with difficulties, frustrations andbeing under-valued. The research does not condone unethicalor unprofessional behaviour and dereliction of duty, but it doesnot brand as ‘quiet corruption’ absences from the workplaceand external income-generating activities. 14 Such ‘moralisingfinger-wagging’ 15 , which addresses issues in terms of lack ofmotivation, corruption and betrayal of professional codes ofconduct, diverts attention from structural conditions and socialand cultural environments. 16The research set out to challenge the overwhelmingly negativecommentary on Ugandan health workers. It wanted to hear thepositive side from health workers themselves: their passion fortheir professions, commitment to patients and communities,determination to give their best and the satisfaction gainedfrom contributing what they can.The research was especially concerned to find ways ofbridging the seemingly widening gap between communitiesand healthcare facility staff. Projects on the ground in Ugandahave tended to focus on promoting the rights of healthcareusers and increasing the community role in monitoring healthworkers. 17 While less attention has been given to the healthworker side, community-based projects have latterly fosteredmutually respectful relationships. 18 Research in Uganda and fiveother African countries recommended improved understandingof the roles of health workers and encouragement of mutualrespect through better communication and interaction. 195. Ministry of Health 20066. Ministry of Health 2010a; 2010b7. Awases et al 2004; Dambisya 2004; Nguyen et al 2008; Onzubo 2007; O’Neil and Paydos 20088. Ministry of Health 2009a; Hagopian et al 20099. McPake et al 1999; McPake et al 200010. Chaudhury et al 2006; UNHCO 201011. Ministry of Health 2009a; UNFPA Uganda Country Office 200912. Kyaddondo and Whyte 200313. Harrowing and Mill 2010; Harrowing 201114. World Bank 201015. Van Lerberghe et al 2000 p316. Schwalbach et al 200017. Björkman and Svensson 200718. Muhinda et al 200819. Awases et al 200413

Our Side of the Story: The lived experience and opinions of Ugandan health workers1.3 The research approachand participantsVSO carried out the research in Uganda from February 2010 toFebruary 2011 in partnership with HEPS-Uganda, the Coalitionfor Health Promotion and Social Development.Using qualitative research methods, the researchersencouraged health workers to speak freely in response to openquestions, promising that identities would not be revealed.In all, 122 health workers – medical doctors, clinical officers,nurses, midwives and nursing assistants (including frontlineworkers, facility managers and local government district healthofficers) – participated in small group discussions and individualinterviews at their workplaces. The facility-based participantswere working at 18 hospitals and health centres in seven localgovernment districts in all regions of Uganda and in the capitalcity, Kampala. The selection of facilities took account of region,the extent to which the district was easy or hard to serve, thelevel of hospital and health centre, location (urban or rural) andownership (government, not-for-profit or private sector). Manyparticipants drew on their prior experiences from training orworking in different sectors and levels of healthcare facility.1.4 Structure of the reportChapter 2 introduces the main challenges to healthcareprovision in Uganda, outlines healthcare provision andpatterns of use, and describes the health workforce.The research approach is described in Chapter 3, along with anoverview of the participants (with further details in Appendix A).Chapter 4 presents what participants said about the rewardsof being a health worker. Chapter 5 looks at why they becamehealth workers.The chapters that follow address elements of the main themesthat emerged from the participatory research – the impactsof workload (Chapter 6); the infrastructure of the healthcarefacilities (Chapter 7); the availability of medical equipment andsupplies (Chapter 8); supplies of medicines (Chapter 9); andlevels of remuneration (Chapter 10).Each element is followed by the relevant recommendationsfor change drawn from health workers’ and stakeholders’contributions. Chapter 11 lists all recommendations underpotential strategies for change.In addition, 24 stakeholders from civil society organisations,trades unions, professional associations and regulatory councilscontributed their perspectives on the issues facing healthworkers in Uganda, through workshops and individual interviews.14

Our Side of the Story: The lived experience and opinions of Ugandan health workers2. Healthcare in Uganda:challenges and provisionSummaryA major challenge for the Ugandan healthcare system is therapidly growing population, with the third-highest growth ratein the world and a strikingly high birth rate (especially amongteenage women) and a very young profile. A further challengeis serving the exceptionally high proportion of the populationresiding in rural areas, who have extremely poor access toelectricity and low access to improved water supplies. Althoughdeclining somewhat, maternal, infant and under-five deathrates are still not under control. Malaria is the main sicknessand a major cause of childhood deaths.Uganda has only one doctor per 10,000 people, and only14 health workers (doctors, nurses and midwives) per 10,000people. This is significantly below the level of 23 healthworkers per 10,000 people recommended by the World HealthOrganisation (WHO). Only four other countries have poorerprovision of hospital beds. Only 16 countries worldwide spendsmaller proportions of their Gross Domestic Product on healththan Uganda. Although the Government of Uganda is committedunder the Ajuba declaration to apportion 15% of its budget tohealth, its expenditure on health has never exceeded 10% oftotal public expenditure.Most healthcare in the formal system is delivered at healthcentres and at hospitals at national, regional and district levels.One in five local government districts had no hospital whenan official inventory of the (then) 80 districts was drawn up in2010. Each sub-district should have a health centre IV, headedby a medical doctor and providing emergency surgery: five ofthe 80 districts in the inventory had no health centre IV at alland a further 23 had one only. The situation is likely to haveworsened with the continuing creation of districts, to total 112in mid-2010. One in four facilities is classified as a health centreIII and should provide maternity, in-patient and laboratoryservices. Two-thirds of health facilities are classed as healthcentre II, intended for preventive services and outpatientcurative 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 under20%. Private for-profit organisations run just over 20% of theofficially-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 orhospitals when they fall sick. The rural population uses healthcentres more than urban dwellers, while the urban populationuses hospitals more than people in rural areas. The poorer youare in Uganda, the more likely you are to go to a governmenthealth centre. Children and pregnant women are the largestgroups of health facility patients. Over one in four Ugandanslives 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 healthworkforce shows extreme shortfalls of the most highly qualifiedoccupational groups, and mal-distribution across the country.Although the aim is to phase nursing assistants out, Ugandahas relied heavily on them , especially in rural areas. Medicaldoctors and the most highly qualified midwives and nursesare concentrated in urban areas, especially in and aroundthe capital city. An estimated four in 10 of the facility-basedworkforce are in the government sector, 30% in the not-forprofitand 30% in the private sector. Medical doctors areconcentrated in the private sector although there are high ratesof dual employment, with medical doctors working in bothprivate and government sectors. Half the medical doctors andfour in ten nurses employed in government facilities work inthe regional and national referral hospitals.15

Our Side of the Story: The lived experience and opinions of Ugandan health workers2.1 Ugandan healthcare challengesUganda is one of the 48 least-developed countries of the world. 20It stands at 143 out of the 169 countries in the United NationsHuman Development Index, and is classed as a low humandevelopment country. The United Nations DevelopmentProgramme (UNDP) publishes statistics for the indicatorsused in the Human Development Index. 21 These allowcomparisons between Uganda and other least-developedcountries, Sub-Saharan Africa and the world overall. 22Table 1Estimated population 2010 23Total population: 30.7 millionAged 0-14 years 50.8%Aged 14-64 years 46.1%Aged 65+ years 3.1%Table 2Population growth and birth ratesUganda’s rate of population growth (3.2 %) is the third-highestin the world. It is a very young population with an average ageof 15.6 years, the second-lowest in the world. The averagewoman will give birth to 5.9 children if she lives to the ageof 50; only three countries have a higher fertility rate thanUganda. The birth rate among women aged 15 to 19 is alsostriking: 150 per 1000 women, which is considerably higherthan in Sub-Saharan Africa overall and is surpassed in onlytwo countries in the world. The contraceptive prevalence rate(23.6%) is on a par with that of Sub-Saharan Africa.Infant, under-five and maternal mortalityIn Uganda, 85 of every thousand babies born alive are likelyto die before their first birthday (the infant mortality rate) and135 of every thousand are likely to die before they are five (theunder-five mortality rate). These rates are somewhat higherthan for least-developed countries overall and somewhat lowerthan for Sub-Saharan Africa, yet they are close to twice globalrates. Maternal deaths (the death of women while pregnant orwithin 42 days of the end of pregnancy) are estimated by UNDPto be 550 for every 100,000 live births, a considerably betterratio than across Sub-Saharan Africa, but twice the global ratio. 24At 54.1 years, life expectancy stands above that of Sub-SaharanAfrica but falls far short of the 69.3 years in the world overall.Population growth and mortality indicators in international context 25UgandaSub-SaharanAfricaLeast-DevelopedCountriesWorldAverage annual population growth (2010-15) (%) 3.2 2.4 2.2 1.1Median age (2010) 15.6 18.6 19.9 29.1Total fertility rate (2010-15) 5.9 3.6 4.1 2.3Number of births per 1000 women age 15-19 150.0 122.3 104.5 53.7Contraceptive prevalence rate, any method(% of married women ages 15-49)23.7 23.6 29.5 -Infant mortality per 1000 live births (2008) 85 86 82 44Under-five mortality per 1000 live births (2008) 135 144 126 63Maternal mortality ratio per 100,000 live births 550 881 786 273Life expectancy at birth (2010) 54.1 52.7 57.7 69.320. Countries with less than 75 million population, gross national income per capita of under $905, high economic vulnerability and combined poor indicatorsof under-five mortality, undernourishment, secondary school enrolment and adult literacy.21. United Nations Human Development Programme 2010, Statistical Annex22. 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 201024. 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 Annex16

Our Side of the Story: The lived experience and opinions of Ugandan health workersRural population, access to electricityand to improved waterOnly 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 ofinhabitants with no access to electricity, 91.1%. A third ofits population has no access to improved water; 25 countrieshave worse access than Uganda. Over half of the population(52%) has no access to improved sanitation, a better ratethan most low human development countries.Availability of formal healthcareUganda has one doctor for every 10,000 people. With only14 doctors, nurses and midwives for every 10,000 peopleUganda is one of 44 low-income countries that do not meetthe WHO minimum threshold of 23 doctors, nurses andmidwives per 10,000 population necessary to deliveressential maternal and child health services. 26Uganda has four hospital beds per 10,000 people; in only fourother countries is the ratio lower. The proportion of womenmaking at least one antenatal visit is high, at 94%, but theproportion of births attended by skilled health personnel dropsto 42%. The Uganda Millennium Development Goals reportfor 2010 gives the following information. 27 An expectantmother’s first antenatal visit is late in the pregnancy, a medianof 5.5 months. Among the poorest fifth of the population, theshare of births attended by skilled health personnel was29% in 2005-06 compared to 77% among the wealthiest fifth.There are also large urban-rural inequalities: 80% of deliveriesin urban areas were attended by a doctor, nurse or midwifebut only 37% in rural areas.Table 3Availability of formal healthcareMedical doctor per 10,000 people* 1Doctors, nurses and midwives per 10,000** 14Hospital beds per 10,000 people* 4Antenatal coverage of at least one visit (%)* 94Births attended by skilled health personnel (%)* 42*UNDP 2010; **WHO 2010Disease in UgandaSickness is normal rather than exceptional. Over 4 in 10household members surveyed (43%) said they had fallen sickin the previous 30 days; malaria or fever is by far the mostprevalent illness, reported by over half, followed by respiratoryillnesses which affected 15%. 28 Seventy per cent of child deathsare due to disease or malnutrition, with malaria accounting forone third of these deaths. 29HIV prevalence fell to 7% in 2007-08 from 27% in 2000-01. 30Yet the number of people living with HIV in 2010, around1.2 million, was higher than at the peak of the epidemic inthe 1990s. 31 The WHO ranked Uganda 16th of the 22 countrieswith a high tuberculosis burden in 2010. Uganda has thesecond highest accident burden. 3226. World Health Organisation 201027. Ministry of Finance, Planning and Economic Development 201028. Baryahirwa 201029. Ministry of Health 2010a30. Ibid.31. Ministry of Finance, Planning and Economic Development 201032. Ministry of Health 2010b17

Our Side of the Story: The lived experience and opinions of Ugandan health workersPublic expenditure on healthUganda’s public expenditure on health stands at 1.6% ofGross National Product (GDP) (in 2008). Only 16 countriesspend smaller proportions of GDP on health than Uganda.At 2.3% of GDP, Ugandan military expenditure is almost50% more than its health expenditure; only 10 other lowhuman development countries devote higher proportionsof GDP to military than to health.Government of Uganda health expenditure as a percentageof total government expenditure in 2009-10 was estimatedat 9.6%. The proportion is 2.1 points above that of 2000-01and just under that of the peak year of 2004-05, and continuesto stand well below the Ajuba target 34 and the Government’sown target of 15% by 2014-15. From Table 5 it may bededuced that the Government funded almost 60% of healthexpenditure in 2009-10, while donor projects accounted for40%. It should be noted that several development partnerschannel development assistance through off-budget support:government estimates indicate that 77% of health projectsupport in 2009-10 was off-budget. 35Table 4Ugandan public expenditure 33Education (% of GDP) 3.8%Military (% of GDP) 2.3%Health (% of GDP) 1.6%Debt service (% of GDP) 0.5%Expenditure on health per capita (PPP$) 74Table 5Health financing and expenditure 2000-01 to 2009-10 36 (in billion Uganda shillings)YearGovernment ofUganda fundingDonor Projectsand GlobalHealth InitiativesTotalGovernment healthexpenditure as % of totalgovernment expenditure2000/01 124.23 114.77 239.00 7.52001/02 169.79 144.07 313.86 8.92002/03 195.96 141.96 337.92 9.42003/04 207.80 175.27 383.07 9.62004/05 219.56 146.74 366.30 9.72005/06 229.86 268.38 498.24 8.92006/07 242.63 139.23 381.86 9.32007/08 277.36 141.12 418.48 9.02008/09 375.46 253.00 628.46 8.32009/10* 435.80 301.80 737.60 9.6*Provisional Budget outturn 2009-1033. United Nations Human Development Programme 2010, Statistical Annex34. 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 2.236. Ministry of Health 2010b table 2.318

Our Side of the Story: The lived experience and opinions of Ugandan health workers2.2 Formal healthcare provisionIn Ugandan policy, the healthcare system comprises servicesaccessed at health units (hospitals, health centres, clinics and‘drug shops’ selling medicines) and community services whichrange from home-based care (typically provided by organisationsfunded through overseas aid) to traditional and complementarymedicine practitioners. Approximately 60% of Uganda’spopulation seeks care from traditional and complementarymedicine practitioners (herbalists, bone-setters, birth attendants,hydro-therapists, spiritualists and dentists) before and aftervisiting the formal sector. 37 It is reported that birth attendantsconstitute 12.3% of traditional healers and have organised aregistered association with about 60,000 members. 38Within the formal system, healthcare is provided primarilyin hospitals and health centres run by the government,not-for-profit organisations and private profit-makingorganisations. Not-for-profit providers, three-quarters of whichare under the umbrellas of the Protestant, Catholic, Muslim andOrthodox Medical Bureaux, are well integrated into the publichealth system. The government oversees not-for-profit facilitieswithin its devolved district management system and subsidisesthem at around 16% in 2008-09, down from 22% in 2007-08. 39The expansion of private health providers has been describedby the Ministry of Health itself as “largely unregulated andchaotic”. 40 There are innumerable unregistered private sectorunits, including drug shops. A count in 2005 in three districtsfound government and not-for-profit units together made up aslittle as 4% of all health units. 41The Ministry of Health’s recent inventory of facilities, drawn upin 2010, lists 4,441 facilities officially registered as a hospital orhealth 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 hospitalsHealth centres and hospitals are structured in tiers in line withthe local government structure (see Appendix B). The originallowest level of health centre (health centre I), equivalent toan aid post, has been phased out. Now the Ministry of Healthis promoting Village Health Teams. Unpaid local people aretrained to increase health awareness, as well as to treat minorillnesses, and are expected to link communities with healthcentres. In late November 2009, teams had been establishedin three-quarters of districts, but only a third of districts hadtrained teams in all villages. 43The size of population served and the services that shouldbe offered by health centres increase from the bottomlevel upwards. A health centre II should provide preventive,promotive and outpatient curative health services. TheMinistry of Health’s inventory shows over a quarter of healthcentre II facilities located in the capital, Kampala, with 98.5%of those in private hands. Some 95% of private health centre IIswere found in four districts, including Kampala. A health centreIII 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 bloodtransfusion in addition to the types of services a health centreIII should offer, and should be headed by a medical doctor. In2009-10, less than 25% of the 119 health centre IVs reportingto the Ministry of Health provided at least 10 of 12 key servicesexpected of a health centre IV, and only 57% of those had amedical officer. 44 Five of the 80 districts in the inventory hadno health centre IV at all and a further 23 had one only.Table 6Health facilities by level and ownershipHospital Health Centre IV Health Centre III Health Centre II TotalNo. % No. % No. % No. % No. %Government 65 49.6 165 92.7 847 76.0 1572 52.1 2649 59.7Not-for-profit 57 43.5 12 6.7 241 21.7 486 16.1 796 17.9Private 9 6.9 1 0.6 26 2.3 960 31.8 996 22.4Total 131 100 178 100 1114 100 3018 100 4441 10037. Ministry of Health 2010b38. Nabudere et al 201039. Republic of Uganda 201040. Ministry of Health 2009c p341. Konde-Lule et al 200742. Retrieved at www.unfpa.org/sowmy/resources/en/library.htm Includes 134 facilities under construction or otherwise not functioning43. Ministry of Health 2010b44. Ministry of Health 2010b Table 5.319

Our Side of the Story: The lived experience and opinions of Ugandan health workersThe next tier up is the general hospital at district level, to whicha health centre IV should refer patients it cannot serve. TheMinistry of Health’s inventory shows that 15 out of 80 districtshad no hospital. The problem of providing a district-levelhospital has become more acute since the number of districtsreached 112 in mid-2010. A general hospital is expected torefer patients to the nearest of the 13 government-sectorregional referral hospitals for services not available at generalhospitals. Current policy does not allow not-for-profit orprivate hospitals to be designated as regional referral hospitals,although in practice some not-for-profit general hospitals fulfilthat role. The main national referral hospital stands at the top ofthe pyramid and provides specialist services. 45 Patients may, andoften do, by-pass lower levels and go direct a referral hospital.The central government oversees the semi-autonomousnational and regional referral hospitals. Since decentralisationin 2006, district health offices oversee general hospitals andhealth centres. Health sub-districts are expected to plan,conduct in-service training, coordinate service delivery andsupervise their lower-level health units. They are normallyheaded by a medical doctor at a general hospital or anupgraded health centre IV.All local government health centres and hospitals must havea Health Unit Management Committee (HUMC) which shouldoversee the running of the facility. Committee memberscan be selected by the District Council, locally elected orappointed because they hold other positions. They havebeen recommended as vehicles for community participation,46 47but have been reported as not functioning as expected.HUMCs had a chequered reputation in the past, believed tobe implicated in disappearance of medicines and distrustedby local communities. 48 They rarely met after the abolition ofuser 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 inboth government and not-for-profit facilities. 50Patterns of use of health facilitiesThe vast majority of Ugandans, 93%, seek treatment forsickness. 51 Ugandans turn to private clinics and drug shops forwalk-in healthcare and medication, and favour health centresand hospitals for more serious conditions and in-patient care. 52Well over half (58%) go to drug shops and private clinics, 28%to health centres and nine% to hospitals; considerably higherproportions of rural than urban dwellers use health centres,while higher proportions of urban dwellers use hospitals. 53The poorer you are in Uganda, the more likely you are to go toa government health centre. Almost half of the poorest tenthof the population use a government health centre, comparedwith only 12% of the richest tenth. Moreover, the pooresttenth almost doubled their use over a five-year period, whilethe richest 10% increased use only marginally. 54 In 2010, overone in four Ugandans (28%) lived more than five kilometresfrom the nearest health facility. 55 The government has investedin improving physical access to healthcare by building morehealth units. By 2009-10 the average distance to a governmenthealth centre was 4.6 kilometres, which the majority of peoplewalk (75%) or cycle (14%). 56Children and pregnant women are the largest groups of healthfacility patients: 38% are children aged 0-14, with the majority(97%) seeking immunisation services; and 38% are womenseeking antenatal and delivery care services. 57 The proportionof deliveries in government and not-for-profit facilities in2009-10 was 33%. 58 In contrast, traditional birth attendantsassisted 23% of deliveries, and relatives or other unskilledhelpers 25% in 2005-06. 5945. The other national referral hospital is a psychiatric hospital.46. Kapiriri et al 200347. Rutebemberawa et al 200948. Azfar et al n.d49. Burnham et al 200450. Kidder 201051. Uganda Bureau of Statistics 200852. Konde-Lule et al 200753. Baryahirwa 201054. Ministry of Finance, Planning and Economic Development 201055. Ministry of Health 2010b56. Baguma 201057. Uganda Bureau of Statistics 200858. Republic of Uganda 201059. Uganda Bureau of Statistics 200620

Our Side of the Story: The lived experience and opinions of Ugandan health workers2.3 The Ugandan health workforceThere are no available up-to-date data on the constitution ofthe Ugandan health workforce. The prime source is the 2002Population and Housing Census. 60 The census recorded peoplewho had worked paid or unpaid in a health occupation in theprevious seven days. Most commentary relies on the censusdata. 61 In addition, WHO has produced estimates for 2004 and2005. 62 These cover people working full-time in paid activitiesin organisations whose primary intent is to improve health, aswell as those whose personal actions are primarily intended toimprove health but who work for other types of organisation.Occupations: numbers and densityThis chapter focuses on the main occupational groups (Box 1).Box 1The 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 consultantdepends on the availability of posts. 63The clinical officer is a distinct cadre in Uganda, termed medical assistant prior to 1996. Clinical officers undergothree years’ training in specialist schools. Their clinical work has expanded from diagnosis and treatment, includingprescribing, 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 healthcentre IV lacks a medical doctor, the clinical officer provides both outpatient and inpatient services, except for major64 65surgery. Clinical officers are often responsible for administration as the person ‘in charge’ of a health centre.Nurses and midwives fall into three groups within the Ugandan health system: registered nurses, registered midwivesor those doubly registered as nurse and midwife (that is, with a diploma or degree in nursing); enrolled nurses, enrolledmidwives or those enrolled as both (that is, having completed a certificate programme); and comprehensive nurses, eitherregistered 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 generalnursing, midwifery, public health, psychiatry, paediatrics and management, and able to provide basic health services inprimary healthcare. Enrolled comprehensive nurse training programmes have replaced the traditional enrolled nursing andenrolled midwifery training programmes in all government-owned health training institutions, and have been introducedinto many not-for-profit training institutes. The future of comprehensive nurse training is under review. 66Nursing 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 nursingaides as a temporary solution until more qualified staff were trained and made available. 67 The current policy is to graduallyphase out the nursing assistant/aide position and ban recruitment and formal training, though new training institutionshave continued to emerge. 68 Regulation of nursing assistants has been difficult, as the Nurses and Midwifery Council doesnot recognise the cadre. 6960. Uganda Bureau of Statistics 200261. 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 201062. World Health Organisation Global Atlas of the Health Workforce63. East, Central, and Southern African Health Community 201064. Banerjee et al 200565. East, Central, and Southern African Health Community 201066. UNFPA 201067. Ministry of Health 200468. Republic of Uganda 201069. East, Central, and Southern African Health Community 201021

Our Side of the Story: The lived experience and opinions of Ugandan health workersTable 7 shows the proportions of these occupational groupsin the 2002 census. Nurses and midwives made up almosthalf, nursing assistants/aides over one third, and allied healthprofessionals (including clinical officers) 70 and medical doctorsless than 10% each. The census found 1.2 doctors and 14.5nurses, midwives and nursing assistants per 10,000 people.WHO data for 2005 give a similar picture of 1.2 doctors and13.1 nursing and midwifery personnel per 10,000 of thepopulation. While there are no comprehensive up-to-datedata, it is known that numbers have increased – as has thepopulation of Uganda. For example, it was reported in 2011that Uganda has 9,701 midwives; however this numberequates to only seven midwives per 1000 live births. 71Geographical distributionUrban/rural imbalance in the distribution of health workers isa key problem in the delivery of healthcare. WHO 2004 data inTable 8 show that the majority of medical doctors (61%) wereurban-based, while the great majority of nurses, midwives andespecially medical assistants (clinical officers) were rural-based.Moreover, data from the 2002 census show that the mosthighly qualified professionals were concentrated in theregion which includes the capital, Kampala (Central region).It contained only 27% of the population but had 64% of thenursing and midwifery professionals (degree holders andspecialist registered nurses) and 71% of medical doctors. 72Table 7Number, distribution and density of five main occupational groups(2002 Census data)NumberPercentagePer 10,000populationMedical doctors 2,919 6.9 1.2Allied health professionals 3,785 9.0 1.6Nursing & midwifery occupations 20,186 48.0 8.3Nursing aides / assistants 15,228 36.1 6.3Total 42,118 100 19.1Population 2002 = 24.4 millionTable 8Urban / rural distribution of four main cadres (WHO 2004 data)UrbanRuralTotal No % No %Medical doctors 2,209 1,345 60.9 864 39.1Medical assistants 2,472 247 10.0 2,225 90.0Nurses 14,805 2,613 17.6 12,192 82.4Midwives 4,164 1,047 25.1 3117 74.9Totals 23,650 5,252 22.2 18,398 78.870. 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 201172. Ministry of Health 200622

Our Side of the Story: The lived experience and opinions of Ugandan health workersEmployment status and attritionOfficial documents have complained of “rampant dualism”. 73In 2002, 30% of all medical doctors, dentists, medical specialistsand consultants were privately employed and only one quarterof those worked full-time. 74 A survey in 2005 confirmed thatdual employment is common among medical doctors: 54% ofmedical doctors employed in private healthcare facilities alsoworked in the government sector. 75 While the census found29% of nurses privately employed, almost all (95%) wereemployed full-time. 14% of medical doctors and of nurses andmidwives were self-employed. 76While there are no data on health worker unemployment,there are indications that some nurses and midwives disappearfrom view after qualifying. All practising health workers in thecountry are required to register with the relevant professionalregulatory council and obtain a licence to practise in Uganda. 77A new human resource information system supported by theUnited States Agency for International Development (USAID)allowed the Uganda Nurses and Midwives Council to see howmany nurses and midwives failed to register. The first publishedanalysis showed that 12% of the 17,297 nurses and midwivespassing final examinations from 1980 to 2004 did not registerwith the council. 78 When the period of analysis was extendedto cover 1970 to 2005, the proportion increased slightly to13%. 79 Some qualified students went into employment withoutregistration to avoid paying the registration fees. 80 The humanresource information system revealed that 55% of registeredmidwives (4,075 midwives) did not obtain a licence to practisefrom the Nurses and Midwives Council. 81Table 9Facility-based staff 2004 88 and 2005 89It is widely held that medical doctors and nurses leave Ugandafor employment in other countries, but comprehensivesupportive data are not available. 82 The Uganda Nurses andMidwives Council verified that 808 nurses left Uganda in2009-10, nearly half for the UK. 83 The destinations of qualifiedstaff leaving six hospitals in a remote region between 1999and 2004 did not include work in other countries. 84 Follow-upof a cohort of graduates of one medical school found deaths,most presumed to be AIDS-related, “a bigger brain-drainthan emigration” in the 20 years after graduation in 1984. 85Premature death is emerging as one of the most importantcauses of exit from the workforce in Sub-Saharan Africa, causingUganda to lose an estimated 2% or so of its medical, nursingand midwifery workforce each year. Annually an estimated 26physicians in every 1,000 and 22 nurses and midwives in every1,000 die before the age of 60 in Uganda, among the highestrates in the 12 African countries for which data are available. 86The facility-based workforceOf particular interest to this research are health workersemployed in facilities. The Ministry of Health has a newhuman resource information system, but the publicly availablecomparative data relate to 2004 and 2005. Table 9 showsthat 45% of facility-based health workers were in governmentfacilities (excluding district health office staff) and 23% innot-for-profit facilities in 2004; and that in 2005, the number inprivate for-profit facilities was estimated at 12,775, representinga 32% share of the total 39,663 employees. It should not beassumed that almost 40,000 different people worked in facilitiesin 2004 and 2005. The data for the for-profit sector includean estimated 3,228 people employed simultaneously in othersectors. 87 It is possible that government data include personnelworking also in the not-for-profit sector (it is not permitted tobe employed in more than one government facility).HealthoccupationsOther staff Per cent TotalGovernment (2004) 15,124 2,619 45 17,743Not-for-profit (2004) 6,102 3,052 23 9,145Private for-profit (2005) 12,775* 32 12,775Total 39,663*Non-health occupations not recorded separately; includes 3,228 employed simultaneously in other sectors73. Ministry of Health 2009c, p674. Ministry of Health 200675. Mandelli et al 200576. Ministry of Health 200677. Africa Health Workforce Observatory 200978. Dal Poz et al 2009 Table 5.379. Spero et al 201180. De Vries 200981. Spero and McQuide 201182. Africa Health Workforce Observatory 200983. Senkabirwa 201084. Onzubo 200785. Dambisya 2004 p60186. Dal Poz et al 200987. Mandelli et al 200588. Ministry of Health HSSP II Table 189. Mandelli et al 200523

Our Side of the Story: The lived experience and opinions of Ugandan health workersMore recent sources state that members of three faith-basedmedical bureaux (Catholic, Protestant and Muslim) together in2009-10 had slightly over 11,600 health workers, around 30%of the combined government and not-for-profit workforce, 90and that government facility staff numbers had reached 23,452in 2009. 91 Despite efforts to clean the government payroll andupdate rosters, there are still problems in determining howmany staff in each cadre are on the payroll and where they areassigned. 92 In 2010, ‘ghost workers’ were exposed in a numberof districts and notably at a national referral hospital, andtransferred staff were found to be still receiving salaries at theiroriginal place of work. 93The most recently available data on occupational breakdownacross sectors are for 2004 and 2005, as shown in Table 10. Ashealth workers, especially medical doctors, have jobs in morethan one sector, the numbers include double-counting. It isreported that “more recent tables show that there has beentremendous improvement in health worker staffing levels inUganda since 2004” and that the total number of medicaldoctors in health facilities is 3,917 (presumably in governmentand not-for-profit facilities). 94In 2004, almost half the medical doctors and over four in 10nurse employees in government facilities worked in the twonational referral hospitals and the 11 regional referral hospitals,while the great majority of nursing assistants, clinical officersand midwives worked in district level facilities (Table 11).Overall, there are severe shortages of facility-based health workersin the formal sector. Chapter 6 details the shortfalls and theconsequent impact on health workers and access to healthcare.Table 10Occupational groups in government and not-for-profit facilities(August 2004) 95 and private facilities (estimated 2005) 96Occupation Government Not-for-profit PrivateMedical doctor 598 305 1,511Clinical officer 1,585 436 190Midwife 2,129 914 1,377Nurse 4,500 1,915 3,557Nursing assistant/aide 4,463 2,005 1,146Table 11Occupational groups in local government district facilities and nationaland regional referral hospitals, August 2004 97OccupationDistrict facilitiesNational & regionalreferral hospitalsNumber % of total Number % of totalTotalMedical doctor 308 51.5 290 48.5 598Clinical officer 1,319 83.2 266 16.8 1,585Midwife 1,635 76.8 494 23.2 2,129Nurse 2,542 56.5 1,958 43.5 4,500Nursing assistant 4,165 93.3 298 6.7 4,46390. Republic of Uganda 201091. Matsiko 201092. Ministry of Health and The Capacity Project 200893. Medicines and Health Service Delivery Monitoring Unit 201094. Matsiko 2010 p2495. Adapted from Matsiko 2010 Table 3.196. Mandelli et al 2005 Table 997. Adapted from Matsiko 2010 Table 3.124

Our Side of the Story: The lived experience and opinions of Ugandan health workers3. Research design and methodsThis chapter first describes the three-stage approach to the research.Outlines of the qualitative research methodology and sampling design, datacollection and data analysis follow. The chapter concludes with an overviewof the health worker participants. Further details are in Appendix A.3.1 The research stagesThe research was conducted in three main stages: consultationwith local stakeholders on the draft protocol to be submittedfor ethical approval 98 ; focus groups and individual interviewswith health facility staff and managers; and stakeholderfeedback on draft findings.In June 2010, VSO Uganda and HEPS-Uganda held a researchworkshop with support from VSO International. Fourteenrepresentatives of organisations concerned with health workerissues in Uganda attended, including healthcare providerorganisations, professional associations, regulatory councilsand consumer and health worker advocacy organisations.Participants explored practical challenges in gathering anddisseminating the views of health workers. The workshopstarted to build an alliance of interested stakeholders to takeforward the research findings.Main-stage fieldwork was carried out from late June 2010 toFebruary 2011. From June to August 2010, the Valuing HealthWorkers researcher, a VSO volunteer, joined forces with asecond VSO volunteer who had in February 2010 begun similarresearch with nurses as an independent initiative. The two topicguides were combined, and a small number of interviews andfocus groups already conducted in the nursing research projectwere amalgamated with the Valuing Health Workers data.VSO produced a report of interim findings to coincide with theGlobal Health Workers Forum in Bangkok in January 2011. 99A roundtable discussion at a VSO-led side meeting at theForum followed a presentation of selected findings from theValuing Health Workers research in Uganda. Ugandan andother participants shared their perspectives on the issuespresented and put forward promising solutions. In January andFebruary 2011, interim findings were shared with stakeholdersin Uganda through one-to-one meetings and a stakeholderworkshop organised by HEPS-Uganda. The workshop broughttogether 16 representatives of organisations includingprofessional associations and unions, regulatory councils andhealth and human rights organisations. The workshop servedboth to validate the findings and to elicit suggestions forcoverage of additional aspects in the final report.3.2 Qualitative research methodologyand the purposive sampling designQualitative research aims to provide an in-depth understandingof the social world of research participants through learningabout their social and material circumstances, experiences,perspectives and histories. 100 Qualitative research is not basedon statistically representative samples and so does not producestatistically significant findings. Participants are selectedin a non-random way, according to characteristics of mostinterest to the particular study. This is known as purposivesampling. The criteria used to select participants are moreimportant 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; anyexperience or perspective has value, regardless of how often orseldom it appears.The research sampled facility-based health workers whoseprime role is treating or caring for patients, and facility-basedmanagers: nursing assistants, nurses, midwives, clinical officersand medical doctors. The study design thus excluded otherprofessional groups.In achieving the health worker sample it was first necessaryto ensure that all regions were included, as although notan administrative grouping, region has social and politicalimportance in Uganda. The strategy was to select one localgovernment district in each of the Central, West, SouthWest, North, North East and East regions, and also to includethe capital city. It was felt important to include a range ofdistricts in terms of how far they were deemed easy or hardto serve. Within each district in the sample, one hospital(where one existed) and at least one health centre were tobe selected, covering urban and rural facilities. Among theselected facilities, the aim was for a spread of level of hospitaland health centre, and inclusion of not-for-profit and privatefacilities 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 UgandaNational Council for Science and Technology.99. VSO 2011100. Ritchie and Lewis 200325

Our Side of the Story: The lived experience and opinions of Ugandan health workers3.3 Data collectionSeven districts in six regions and the capital city, Kampala, wereselected, so the selected facilities were distributed acrossall regions (Table A.1). The districts ranged from very hard toserve to not hard to serve, according to the Ministry of Healthcriteria (Table A.3). The 18 facilities in the sample comprisedthree referral hospitals, six general hospitals, four health centreIVs and five health centre IIIs. Eleven were government-run,five were run by not-for-profit organisations and two by privateorganisations (Table A.2).Permission to carry out the research was obtained from districthealth officers in the five districts where government facilitieswere included in the sample. District health offices assisted inlinking the researchers to district-level government facilities.Referral hospitals and not-for-profit and private sector facilitieswere approached directly.At each facility the staff member in charge was asked toarrange for staff to meet with the researcher in small groupsof peers: enrolled nurses or midwives, registered nurses ormidwives, nursing assistants and those in charge of wards. Insmaller facilities, mixed groups and individual interviews werenecessary because of the limited numbers of available staff.Medical doctors, clinical officers and facility managers wereinterviewed individually, apart from one joint interview withtwo managers. Sixteen small group discussions with a total of71 participants and 46 one-to-one interviews took place at the18 facilities. One health worker declined to take part becauseof a lack of staff to cover her absence. The five district healthofficers were also interviewed.Group discussions and interviews were carried out in English.Informed consent was gained from all participants. Participantswere encouraged to talk freely in response to a set of openquestions. They were assured that they and their facilitywould not be identifiable in the research reports. The topicsdiscussed covered reasons for becoming a health worker;understanding of the professional role; rewards; challenges,their impact and coping strategies; reasons for negativeattitudes towards health workers; areas for change, and waysof increasing the voice of health workers. The full topic guide isincluded in the Appendix. Facility managers and district healthofficers were asked additionally about management issuesthey faced, although frontline workers were not asked directlyabout their management. Participants also completed a shortbiographical proforma.3.4 Data analysisDiscussion groups and interviews were audio-recorded andtranscribed with participants’ permission. The analytical processstarted with repeated readings of the transcripts to identify athematic framework. The textual data were then structured inmatrices with a row for each group or individual and a columnfor each thematic area. Mapping and interpretation followedfrom this charting process, to define concepts, find associationsand provide explanations. As already noted, early findings werevalidated by non-governmental stakeholders through individualinterviews and workshops.3.5 The health worker participantsA general hospital was the most common workplace forparticipants (53 out of 122); 40 participants worked in healthcentres (Figure 1). Government employees numbered 75,not-for-profit 36 and private sector 11.Figure 1Workplace of participants202052453General hospitalReferral hospitalHealth centre IVHealth centre IIIDistrict health office26

Our Side of the Story: The lived experience and opinions of Ugandan health workersThe largest professional group was registered nurseand/or midwife, followed by enrolled nurse and/ormidwife and nursing assistant (Figure 2).There was a broad spectrum of ages among participants(Figure 4).Figure 2Participants’ professional statusFigure 4Age groups of participants26152430144Registered nurseand/or midwifeEnrolled nurseand/or midwifeNursing assistantMedical doctorClinical officerNone24164014120-2930-3940-4950-5960-69OtherEleven participants worked solely in administration: fivequalified nurses, five medical doctors and one with anothermedical-related qualification. A further seven participantscombined a role being in-charge of a facility with frontlinecare. The remainder were frontline employees, mostworking in nursing or midwifery roles (Figure 3).Figure 3Participants’ roles113 3 46262544NurseMidwifeNursing assistantAdministration onlyMedical doctorMedical doctor in chargeClinical officer in chargeClinical officerOf the 122 participants, 38 were men. Men were in alloccupational groups except clinical officer (Figure 5).Figure 5Sex of professional groups70605040302010063MaleFemale1911145 6 01 2 1Nurses & Nursing Clinical Doctors Other/nonemidwives assistants officers27

Our Side of the Story: The lived experience and opinions of Ugandan health workers4. The RewardsUgandan health workers rarely get the chance to speak about the positives ofbeing a healthcare worker – the rewards and satisfactions – and participantswelcomed the opportunity the research gave them. The main areas of satisfactionwere helping others, doing a good job and being valued for what they did. Positivepractice environments were by no means commonplace. Some participants wereso discouraged by working conditions that they struggled to find anything else goodto say about being a health worker. For a few the only positives were the materialbenefits of a regular salary and a free house. Later chapters will show how workingenvironments damaged chances for fulfilment and satisfaction at work.4.1 Benefiting othersParticipants told of feeling happy carrying out their vocation,helping their people, giving something back, delivering careand comfort, helping those unable to help themselves andsaving lives. Very strikingly, the benefits to the community, toindividual patients and to families were the biggest sources ofsatisfaction even in the harshest working environments.Benefiting the wider communityHealth workers emphasised the rewards of sharing theirknowledge and skills with communities to counter harmfultraditional beliefs and practices, educate people about ways ofpreventing disease and encourage take-up of health services.Seeing more women delivering babies in health units, diseasescontrolled through immunisation programmes, or reducedreliance on harmful traditional remedies brought greatsatisfaction. Health workers were especially pleased wheninvolved in new programmes and able to see their impacts,such as a nutrition clinic, a mental health unit or preventionof mother-to-child HIV transmission. Satisfaction came frombeing part of a health facility that put the patients first.Especially in rural areas, health workers were happy to usetheir knowledge to help informally outside working hoursand around their homes. For an off-duty nurse, it was good tosocialise with in-patients, hear their family problems and havethe chance to give some health education.Benefiting patientsParticipants highlighted the visible results of care and treatment.They expressed their delight at the benefits to patients. Nursesand medical doctors spoke about how happy and proud theyfelt when a patient who arrived sick, even on the edge ofdeath, went home recovered: “I love it when someone comesin ill and goes back happy.” Seeing life enhanced was alsohugely 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 oftwo people, “a live mother and a live baby” – and achievingsomething positive with no mother or baby lost.Benefiting families“The nurse is the most important person in the family.”Especially for nurses in rural settings or from rural families it washugely rewarding to be able to deal with family health problems.Knowing how to prevent and treat illness in your immediatefamily, as well as how to protect yourself, was a significantfactor encouraging a commitment to nursing which would lastup to and beyond retirement: “You will be a nurse until you die.”Nurses at some rural health centres pointed to the advantagesto their family and themselves of quick access to free treatment.The nurse could use his or her knowledge to treat a relativeand save the costs associated with referral to a health centre orhospital. It was said in some facilities that staff and their familymembers were given free medication.4.2 Job satisfactionLinked to the happiness of seeing someone recover is thesatisfaction of knowing your own contribution, among medicaldoctors and clinical officers especially: “I feel happy when I givetreatment to my patients and they get well, I feel so proud, Ifeel very fine” or “I can see the difference I have made, that’svery important.” Introducing new treatments and bringing aboutchange in a challenging environment was hugely satisfying:“What others thought was so difficult, I have been able to do.”28

Our Side of the Story: The lived experience and opinions of Ugandan health workersMaternity workers spoke of their joy when they safelydelivered 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 whoimproved and was discharged gave “a kind of job satisfactionand encourages me to care for patients a little more.” For nurses,it was good to have done something, no matter how little, tohelp save a life. Achieving successes is not easy in Uganda andan occasional “victory”, such as when a sick child recovers, wassomething to “live for”, that “makes you do what you do”.Participants spoke of the satisfaction of doing a good job whenthere was enough equipment, other medical supplies andmedicines to enable proper care: “Most of what you need fora patient is available, so your job is not much interfered with”or “You cannot forget your skills”. Elsewhere health workerscommented on the satisfaction of just being able to playtheir part and do their duty the best they could despite manyshortcomings in supplies and equipment and staffing shortfalls.Some spoke of pride in working efficiently to treat patients orcaring tenderly where they could.Particularly for younger participants, opportunities to learnthrough work and to experience managing different kinds ofmedical condition were highly valued. While not commonlyreported, opportunities to learn new skills, such as counselling,were valued for their benefits to patients. In the few instanceswhere workplace-based education programmes were in place,participants spoke enthusiastically about how they shared theirlearning with other staff and developed new communication skills.4.3 Being recognised, appreciatedand valuedCommunity recognitionSome nurses in rural settings liked being acknowledged andknown in the community: “When you go out you are respected”or “You are famous.” Being a nurse meant being seen as aneducated person; it was gratifying to be called a “small doctor.”Nurses sometimes felt their training set them apart from otherpeople, conferring a certain prestige, especially when theycould use their knowledge to help outside their formal work.Nursing was also valued as a way to meet different types ofpeople, get to know many people and make friends.Patients’ appreciation, trust and respectHealth workers valued being liked, appreciated, praised,respected and trusted by patients.It was noted that expressing thanks was not the norm in someparts of Uganda, and health workers spoke enthusiasticallyabout the boost a “thank you” from a patient gave them: “Youfeel very happy after your work when they say thank you.So you keep on, because you are enjoying it.” For some, thepleasure of helping was enough whether praised or not: “I feelit inside my heart.” As well as appreciation, recognition of theirexpertise was important to nurses: “Their confidence in youboosts your own confidence.”Midwives expressed their delight when a baby was giventheir name. Nursing staff and medical doctors emphasisedhow recognised and appreciated they felt when a past patientgreeted and thanked them warmly or showed off “your baby”.Being remembered by patients was seen as a mark of trustand a boost to the nurse’s own confidence. For some nurses,respect and trust on the part of patients or caregivers openedup disclosure of confidences and opportunities for further help.4.4 Appreciative and supportivemanagement and colleaguesAppreciation on the part of managers was a huge positive,although not widely reported: “When you are recognisedthat you are doing good work, I think that is important, itmotivates”. Simply being told “thank you” was not necessarilyvery satisfying in difficult working conditions. Health workersvalued more tangible demonstrations of appreciation, such asopen internet access, Christmas and Easter presents and staffparties. Rare, and especially valued, was facility sponsorship offurther training with a job to return to.Uniquely in the study, participants in a local government hospitalpraised management who “appreciate us so much.” They toldof certificates of appreciation, staff parties, presents, financialcontributions to costs of burials and operations, help with costsof further study, days off to recover from illness, interest instaff’s work and responsiveness to problems staff identified.Health workers felt valued by good, supportive managerswho created opportunities for them to raise their concerns,were always willing to discuss a problem, and sought andimplemented solutions.Nurses spoke of the satisfaction of working cooperativelywith other staff, having someone to consult if needed, sharingideas and reaching solutions. Teamwork also meant helpingeach other out, such as an off-duty nurse caring for anothernurse’s sick child, and willingness to extend hours to cover for anurse’s delayed arrival at work. Where working conditions wereespecially challenging, nurses valued being part of a supportnetwork where everyone understood the difficulties.29

Our Side of the Story: The lived experience and opinions of Ugandan health workers5. Reasons for becoming a health worker:the “right heart” and the “wrong heart”Participants explained what prompted them to become healthcare professionals. The urgeto help, prevent suffering and save lives stood out. The overriding impression from theirwords was of a heartfelt desire to “make a difference” as a nurse, midwife, clinical officeror medical doctor, rather than merely to earn a living. It is a mark of their professionalcommitment that almost all participants said they would still choose to be health worker.Participants commented on people joining health professions, notably nursing, forthe “wrong” reasons. This, in their view, was one explanation for poor attitudes andunethical behaviour, and they put forward suggestions for improving the calibre ofrecruits. The recommendations also include views of other stakeholders.5.1 A passion for the patientsFor many health workers, the strong need to give to others wasborn from childhood experiences. It had been common in ruralareas to see close family and members of the local communitysuffer in pain and die, with no proper medical care. Participantsrecounted how siblings and parents had died from mysteriousillnesses that, they later realised, were caused by preventableepidemics or treatable with modern medicine. Training as anurse, clinician or medical doctor would bring to the communityessential knowledge to help prevent illnesses, discourage harmfultraditional healing practices and save lives. “They were reallysuffering, people were dying, there were no doctors, no nurses,nobody to give them an idea about their health. I wanted tohelp my people.” Others spoke of atrocities in conflict areasand the need for medical skills to rebuild communities.Health workers spoke warmly of positive experiences when theyor family members were in hospital. The gentle and caring touchand the healing words of nursing staff left a lasting impression.They wanted to be that person, to give in that caring way. Theysaw how nurses stopped pain and wanted to stop others’ pain.Growing up, they learnt how the skills of the medical staff hadsaved the life of someone close to them, or even their ownlife, and they wanted to give something in return. Some wereencouraged by a grateful parent who remembered midwivesurging that the baby become a midwife too.Not all impressions were good. Negative experiences ofhealthcare services lay behind a desire to raise the standardof medicine in Uganda. Young men and women said they feltcompelled to join their professions because they believedthat professional neglect had contributed to the deaths ofa parent, siblings and a newborn baby, or because they hadperceived the limitations of Ugandan medical expertise for alife-threatening condition. Unsympathetic handling prompteda wish to improve the quality of nursing, and the shouts ofwomen abandoned in labour evoked an urge to help.Women spoke of wanting to be a nurse from as early as primaryschool stage, never considering any alternative. They sawthemselves as naturally kind, a helping sort of person, with anurge to relieve suffering: “I just had it in me” or “I had that heart.”Some women found they “developed the heart” as young adultswhen they had to nurse a family member. Not-for-profit sectorparticipants especially cited a desire “to love and serve thepatients” or “to care for the needy”, spoke of coming “closer toGod” or explained they had “a call” or were “chosen by God”.Health workers emphasised giving and spoke less about whatthey had expected to gain from their profession, though theprospect of knowledge to care for and treat one’s family andoneself was important, especially among lesser qualified womenin rural areas. Nurses’ happiness when a patient recovered wasmentioned, as was the respect people gave to a local nurse.The nurse had status as a life-saver, a person of importance tocall on in an emergency. Young girls who went on to be nurseshad been greatly attracted by the dress and deportment ofnurses, admiring their smart, clean uniforms, shoes and gloves,and the way they walked, which distinguished them from otherpeople. Among would-be medical doctors there was someadmiration of smart white coats and acknowledgement of theprestige attached to doctors.A desire for money was not a driving force, though earning in asteady job was certainly a better option than “digging” in vegetablegardens and relying on uncertain harvests. In the most remoterural area, the health facility was the only source of trainingand employment locally, and so a magnet for school-leavers.30

Our Side of the Story: The lived experience and opinions of Ugandan health workersFor most participants, the decision to become a healthprofessional was positive and informed. Time spent at hospitalsor health centres – as a patient, relative of a patient or just asa curious child allowed to sit with nurses – had shown hownurses 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 ormedical field gave some insight into the work, through visitingtheir place of work, living in staff quarters or listening to theiraccounts of day-to-day happenings. A close relative’s positiveattitude, humility or empathy for patients attracted youngwomen to nursing. For many of those participants, the exampleof their relative was the main reason for entering a nursing ormedical profession. With little career guidance at school, it wasnatural to do what members of the family were doing.Others felt family expectations to take up some kind of professionand saw health work as more appealing than the teaching,secretarial or business occupations suggested – even rebellingagainst fathers who insisted on a teaching course. Some olderparticipants spoke of encouragement from adults at school orfamily friends, such as priests and nuns, to apply for a medicalor nursing course. There were a few instances of people fromthat generation recruited to apply for nursing by agents ofthe Ministry of Health, and also of following family wishes orsuggestions in complete ignorance of what nursing involved.Clinical officers and medical doctors told of expectations onthem as the brightest school students to enter one of theprestigious professions. If they excelled in science subjects,engineering and medicine were the prime alternatives. Thepath towards medicine could be set in early years when topstudents were pushed towards sciences.Where faced with a choice of career direction, financial securitywas something younger men had considered, in the context ofmany qualified professionals chasing too few jobs: “At least youcan always find a job.” But nobody said they joined the nursingor medical profession purely for that reason. Among doctors,the choice of medical training against another science-basedprofession was in some cases influenced by the prospect ofprofessional advancement and mobility, self-employment andprivate practice.Not all those who had decided on a career in the medical fieldentered via the course of their choice. Lacking financial backingfrom their families, uncertain about getting the grades orfailing to gain entry, would-be medical doctors had to settle forclinical officer training or a nursing course, and aspiring clinicalofficers became nurses. It was sometimes hard at first to accepta substitute course, especially when other people said nursingis for “failures”.5.2 “They join for the wrong reasons”There were widespread beliefs among nursing and midwiferyprofessionals that poor attitudes and unethical behaviour arelinked to people joining nursing for “the wrong reasons”. It wasthought that more recent recruits joined because they hadno other option, because nursing was a last resort when theyfailed to qualify for more prestigious professions or becauseparents pushed them into it. Pursuing pay, looking only at thejob market and even as a route to leaving the country wereother presumed reasons for joining nursing.Older nurse managers had noted “very few nurses come witha sense of vocation now”. There was a widespread view thatpeople enter nursing with “the wrong heart”. It was believedthat as a result, unhappy, disinterested and self-serving recruitsresort to bad habits, become rude and forget their ethics andaccountability to patients. There were also some commentsby managers about medical doctors’ questionable attitudes towork when they seemed to lack that “inner drive”.Yet more than one nurse and a medical doctor told how theycame to love their profession only when in practice, and astory was told of how a lecturer inspired an enthusiasm fornursing in a student whose sole ambition had been to train asa doctor. Indeed, some of the loudest voices criticising motivesfor joining belonged to staff who had developed an interest intheir profession after they started work.5.3 RecommendationsCareer guidance and early contactThere were suggestions from frontline health workers andmanagers on how the decision to join nursing and medicinemight be better informed and professionalism thus improved.A strenuous profession like nursing was said to need emotionalpreparedness, with career guidance at an early stage “to knowwhat it takes”. It was suggested that more talks at schoolsshould set out to “give the real picture”.What emerged strongly from participants’ accounts was theimpact of contact with nurses, midwives and medical workersduring formative years. It was told how staff at a boardingschool regularly took pupils to visit a local hospital, and howinterest in nursing grew out of voluntary employment initiallyundertaken reluctantly. Experiences such as these suggestvalue in schools arranging contact between students andhealth facilities, and work experience placements.31

Our Side of the Story: The lived experience and opinions of Ugandan health workersTraining schools’ admission proceduresThere were calls for nurse training schools to apply tighteradmission procedures, to make sure applicants have not beenforced into nursing and to probe attitude, so as to screen outthose with no “heart” and the “wrong elements” that spoil thename of “genuine” nurses. Admission interviewers should “studythe psychology of the person”, investigate thoroughly and rejectapplicants who seem not to be driven by the “right reasons”.There were also calls for reform of the points-based systemthrough which university applicants can be allocated to a nursingcourse when nursing is not their first or even second choice.Developing and sustaining “the right heart”in training schoolsIt was generally thought that the person with the “wrongheart” cannot be reformed: “Some personalities are naturallyrude, she can’t change”. On the other hand, there were somebeliefs that the “right heart” can be developed and sustainedthrough training.With training now falling under the remit of the Ministry ofEducation and Sports, it was commented that nursing schoolshad become indistinguishable from other higher educationinstitutions, and had been allowed to multiply regardless ofstandards, notably in the private sector. It was said that as aconsequence of too many nursing schools with ill-qualifiedtutors, students come out lacking respect for patients andpatient’s confidentiality. Some participants added their voiceto calls for oversight of training to revert to the Ministry ofHealth “because they were producing competent peopleand now standards have dropped”; “new nurses are not sointerested in the work.”The prospects of inculcating the right attitudes throughpre-qualification training would be improved if nursingand midwifery class-sizes were reduced and tutor capacityimproved: “Two hundred students in a class when you aresupposed to have 60!” and “If you are a serious tutor, howdo you teach and how do you supervise and follow up 200students in one class?”Nurse participants and stakeholders recommended thattraining schools do more to ensure that nurses not only knowthe theory of the code of ethical conduct, but also understandhow it should be applied in the workplace. 101 Nursing coursecontent could be improved to make sure that students take onboard the role of the nurse as the patient’s advocate.Health and human rights trainingStakeholders advocated for the integration of health andhuman rights training into curricula, through expansion ofexisting partnerships between training institutions and healthconsumer advocacy organisations. 102 Civil society organisationshave also advocated for health and human rights training forin-service health workers. 103Improve the community service elementof pre-qualification trainingStakeholders stated that community service curricula in mostmedical professional education is not of sufficient quantityor quality to prepare students for the conditions they facein the field, and should be improved. Community-basededucation programmes, which typically run for between fourand eight weeks in each year of training, have been foundto create some awareness of healthcare communities butimplementation concerns and strategies to improve thecurricula need to be addressed. 104Nurses and Midwives Council registration interviewsNurses and midwives had mixed opinions on the interviewsthe Nurses and Midwives Council held as a prerequisitefor registration. Some found them an unnecessary, timeconsumingand expensive imposition, given that they hadalready graduated from nurse training schools and thatattending interviews took them away from caring for patients.It was explained that when nurses and midwives were notaccepted for registration, they were posted to certain hospitalsfor supervised practice and mentoring, and among nursemanagers there were views that this in itself contributed topoor attitudes, as nurses became tired and fed up with theirhard life. For other managers, the interviews were a valid wayof filtering out those with gaps.A mark of the commitment of health workers in the study is thebelief that the desire to care, help and make a difference stayswith a person. On the other hand, managers who had observedthe working environments and cultures of differing workplacesbelieved that good intentions can dissipate. Chapters 6 to 10look at how aspects of the working environment underminemotivations 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 theinterest 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 2010103. Action Group for Health, Human Rights, and HIV/AIDS 2010104. Kaye et al 201132

Our Side of the Story: The lived experience and opinions of Ugandan health workers6. Workload6.1 The contextPublic health facilities are required to adhere to a job structure,set centrally, that limits the number and cadres of staff thatcan be employed at a facility; this defined establishment ofemployment posts is commonly referred to as the ‘norm’.Staffing shortfalls: key factsNationally, 48% of posts are vacant, representing a shortfallof 25,506 staff; the lower the level of facility, the greaterthe shortfall (December 2009). 105Across local government districts, 47% of approvedpositions are filled; in only 10 of the 80 districts aremore than 70% of positions filled. 106Percentage ofposts vacantStaffingshortfallPercentage ofapproved posts filledNumber ofdistrictsHealth centre II 64% 7,245Health centre III 54% 8,051Health centre IV 45% 3,396General hospital 38% 2,750Regional referral hospital 30% 1,082Main national referral hospital 10% 22221-30 431-40 2541-50 1551-60 1161-70 1571-80 781-90 290-100 1In 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 nurses107• 64% of medical doctor positions at 117 health centre IVs were not filled, a shortfall of 154.6.2 The health worker experienceConcerns about understaffing and workload were most markedamong health workers and managers in government facilitiesat all levels. At some not-for-profit and private facilities theconcern barely surfaced, while at others it was a key issuefor participants. Overload was reported even in well-staffedhospitals within the not-for-profit sector.Not surprisingly, health workers told of the personalrepercussions of understaffing and heavy workloads.But also they spoke passionately about the damaging effectson patients and on community perceptions of health workers.105. Matsiko 2010 Table 3.2106. Adapted from Oketcho et al 2009 Slide 6107. Ministry of Health 2010b Tables 3.35 and 5.433

Our Side of the Story: The lived experience and opinions of Ugandan health workersThe impact on health workersUnmanageable workloads“Overwhelmed” was a word widely used by nurses speakingabout unmanageable workloads in many government hospitalsand a not-for-profit hospital: “How can you manage? It doessomething to you.” Nurses spoke of being affected mentally and“destroyed” to the extent of becoming ill: “One nurse runninga full ward, with patients sleeping on the floor as well, theoverwhelming number can affect the nurse psychologically.” Witha nurse off sick, the workload became even harder to manage.Too many tasks and responsibilitiesIn government health centres, midwifery and nursing staff saidthey were stretched to the limit by too many tasks: “You haveto run the ante-natal clinic, conduct deliveries, carry out postnatal,do the ward round, one person. Then you have to runmost of the young child clinic.” Burn-out resulted: “You have todo the counselling, take blood, see the patients, prescribe forthem and do everything. When you leave at the end of the day,you are burnt down completely.”Among nurses in government hospitals, there were complaintsabout having to take on doctors’ duties: “I don’t know when award 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 procedurebeyond their scope of duty. Health centre nurses believed theydid the work of a clinical officer. Government hospital nursingassistants complained about undertaking work which should bedone by nurses.Working in a team had been one of the attractions of nursingas a career choice. It was frustrating and disheartening whencooperation was lacking, such as when a relief worker failed toturn up: “No teamwork at all, and when it is an emergency andthey delay, you really feel bad. You know what the outcome willbe but you can’t help.”Working day and nightHealth workers in government health centres told of workingday and night, often alone, due to understaffing and staffabsences. It was pointed out that clinical officers, midwives,nurses and nursing assistants had stayed on duty round theclock or even longer, contrary to government rules and codesof conduct. They said they kept on in the face of fatiguebecause of their commitment to helping others: “If God werenot calling, you could not do this work 24 hours.”Health centre midwives suffered especially. Midwives in ruralhealth centres told of working alone day and night, sleepingwith their children in disused wards, always on call to deal withexpectant mothers often arriving in late stages of labour. Amanager acknowledged that a midwife had worked alone andon call for five months.In a private sector health centre scheduled time off had to beforegone for the sake the patients: “If a doctor prescribes carefor 24 hours we have to stay, and then work again next day.”Over-long shifts and too little time offAmong not-for-profit hospital nurses there were complaintsabout being forced into working 12-hour shifts. Taking up theoption of working shorter hours would reduce days off fromtwo to one, a hard choice for nurses with children and homesto look after. Days off duty are important times “to do yourown things” and should be an entitlement. Yet it seemedtaken for granted that nurses and nursing assistants living onsite in staff accommodation would turn out in their “off” timeto fill staffing gaps in some health centres. Even a not-forprofithospital with clearly specified conditions of service wasreported not to give good time off because of understaffing.Impacts on healthAmong nursing staff in government health centres and generalhospitals there were concerns about the effects on health offoregoing or delaying meals because of work pressure. Noteating on schedule was a key concern when suffering fromdiabetes, and eating well was important to maintain immunityagainst infection from patients. Even taking a drink was noteasy “because how would it look when they are in pain?”It was even hard to make a quick toilet visit without beingreprimanded by hospital managers.Restricted professional developmentManagers’ concerns included the impact on clinical officers’development when they lacked the opportunity to workunder the guidance of a medical doctor, and the professionallyisolating consequences for staff with no supporting teamwork:“Nobody to consult when you are stuck, nobody to delegate towhen you are unable.”A nursing assistant had been put in a role that took her awayfrom direct patient care, to fill gaps in the professional staffcomplement: “I want to learn more from the patients but Ihave no choice.”There were views that opportunities for further study wereblocked because the facility would not be able to recruit areplacement if the nurse left.34

Our Side of the Story: The lived experience and opinions of Ugandan health workersFailing the patientsAmong health centre IV workers the lack of a medical doctorwas one of the biggest concerns, more important to themthan frustrations about individual workload and personalconsequences: “I can get demoralised seeing someone dyingin my hands because we are missing a doctor” and “It reallyhurts a lot when a patient is dying and you know what shouldbe done. You even go home depressed.”Health workers who expressed these feelings were adamantthat they kept on turning up for work to stop the next person’ssuffering: “If I’m depressed because someone has died andI say I am not going to work the next day, then we are goingto lose more.”The impact on attitudes, behaviour and practicesHospital nurses acknowledged that overload damaged qualityof work: “At the end you are very tired and no quality of workis done.” Participants employed outside the government sectorwere especially outspoken about the impact on the quality ofnursing in a large government hospital where they had seenperformance drop and patients’ needs neglected. Personaldistress made things worse, they felt: “Understaffed in a wardfull of patients, on top of family worries, they find they can’tperform, miss things and cannot provide all the services patientsneed.” The nursing role should be much more than taking routineobservations and giving treatment, but it was impossible for anoverworked nurse to find time to talk with patients, uncovertheir problems and deal with the whole picture. Consequentlytask-oriented nursing was unavoidable and even routine taskswere hard to complete: “With two nurses for 50 patients, youare reduced to trouble-shooting, it’s not nursing.”Hospital nurses “torn apart” by patients calling for attentionfound it hard to make patients understand that they had towait their turn. They recognised they could lose their temper insuch stressful situations and forget their basic good intentions:“You become different.” Medical staff had seen the effects oftiredness: “The tone of voice changes” and “The nurses endup losing it, when they are already frustrated by poor pay.”Managers were generally understanding: “As a human beingyou can get irritated and lose your temper because of fatigue”and “What do you expect with only half the nurses you shouldhave? They become rude.”Participants working in well-staffed private and not-for-profithospitals had seen the consequences of work overload in thegovernment sector. Managers observed that a lack of opportunityto fulfil their proper professional role “demotivates” nurses,who then adapt to a culture of poor standards of care in theirwork environment. A “don’t care” attitude resulted: “By thetime she is 30 she is used up. Already tired due to understaffing,she has run out of compassion and the patients say she is notcaring.” They said that overwhelmed nurses skip out fromwork, ask to be transferred and “run away” to the privatesector, where patients do not complain they are neglected.Midwife behaviour towards patients changed as a result ofworking alone all day and all night, especially with “no peace ofmind” due to personal and family worries: “So you become toughwith the mother so that she understands and you get a live babyand a live mother.” Managers were well aware of the unacceptablylong hours midwives put in and spoke openly about the effectsthey had seen: “As time goes by, because of the fatigue andperpetual calling, somehow as a human being you tend todeteriorate.” Midwives no longer in the government sectorunderstood how overtired midwives were forced to “escape” from24-hour work in health centres to make contact with their families.Among midwives, perpetual responsibility for the lives ofmothers and babies was “a burden” and it was hard to staypatient with the mothers.Nurses spoke about the knock-on effects on their patients oftheir having to do too many things at once: “You find you arestressed and are rude to patients unknowingly.” There weresome strong views that workload in some large hospitals wasmade worse by senior staff “malingering” or not pulling theirweight. A view from the private sector was that frustrated juniornurses in the government sector “took it out on the patients”.Long tiring, shifts led to nurses overwhelmed by the workloadbeing short with patients, not interacting with them andconveying disinterest through attitude and expression.Managers and frontline doctors had seen how hunger madenursing staff bad-tempered and rude to patients. It was saidthat long shifts, together with poor pay, made nurses look forways of “escaping”: not turning up for duty and leaving workearly. Yet it was also said that even after 12-hour shifts, somenurses went on to other nursing jobs, just to survive financially,and so developed “bad habits”.The impact on community relationsAggressive or demanding outpatients were a particular concernfor medical doctors and clinical officers. With so many patientswaiting for attention, it was important to prioritise their treatment.But patients either did not understand the triage system orbelieved they deserved priority. Such challenges to professionaljudgement were especially hard to handle when aggrievedpatients called on local leaders to intervene on their behalf.Among midwives working round the clock, huge distress wascaused by patients accusing them of not working when theyhad found a little time to rest. This misperception was said tofuel community hostility towards health workers.35

Our Side of the Story: The lived experience and opinions of Ugandan health workersHealth centre workers realised that no respite in long shiftsled to community complaints about harsh language: “We workthe whole day without resting, and in the late afternoon weget tired and then we change face.” Staff working set hourshad met some hostility from local people who assumed thehealth centre was closed to outpatients when they saw healthworkers socialising together towards the end of the workingday. The staff there pointed out that they worked hard to serveoutpatients quickly and so deserved some rest-time afterpatients had stopped arriving. It was also hard to make waitingpatients understand that health workers were not resting whenthey sat completing paperwork.Health workers in sole charge of patients faced a dilemma:go hungry or leave the patients alone? Doing the latter wasreported to have brought unfortunate consequences for staffwho were arrested for neglect of duty. It was said that thearrests were motivated by local political candidates seekingto gain electoral favour through discrediting ruling politicianswith oversight of the facility. Clinical officers can be left aloneto cover an entire health centre, running from one departmentto another. So it was deeply upsetting when a patient arrived,assumed no staff were available, and called on a local leaderwho then complained to higher authorities.The lack of a medical doctor rebounded on other staff: “Whenthe patient dies, the community look on you as a bad personwho refused to treat the patient.” Lack of a midwife or qualifiednurse meant that nursing assistants carried out deliveries. Theyfound it hard to convince patients to put their trust in them,especially as they themselves recognised they lacked the fullrange of knowledge to save pregnant women in difficulty.6.3 Factors contributing to understaffingand work overloadIt is important to understand the structural causes ofinadequate staff numbers in government health facilities. Itis not necessarily the case that there is a shortage of healthworkers available in the labour force; some governmentsector managers were aware of huge numbers of applicantsfor advertised vacancies, while others said they had failed torecruit. Among managers at district level, views were expressedthat decentralisation of the health system was to blame for theuneven distribution of health workers in local government.Recruitment barriersGovernment sector managers explained that financial allocationsfor salaries stood in the way of recruiting more staff: there wassimply no money in the pot to pay more health workers. Evenif funds were made available to fill authorised posts, vacanciesremained due to bureaucratic procedures and the absence ofa District Service Commission tasked with recruiting healthpersonnel to the district.Managers explained why remote and rural facilities found ithard to recruit and retain medical doctors, nurses and midwives.They sympathised with new recruits who turned round and leftfor want of something to do in a village: “They post someoneout there in the wilderness and they expect them to work!” Withno electricity for TV and internet, people were “not connectedto the world”. Poor roads and no public transport at night leftstaff “stuck”. Free staff accommodation was widely believed tomake it easier for nurses and medical doctors to leave behindthe amenities of town life. Poor-quality staff quarters, on theother hand, were a deterrent to taking up and staying in posts.An example was cited of rented accommodation of so poor astandard that it was not safe to raise a child there, leading toa nurse leaving her post. Health workers living in towns spokealong similar lines, adding that the cost of food was high inremote areas and educational standards poor.It was remarked that medical doctors dislike working in villagesbecause of the lack of opportunity for learning and careeradvancement. It was also said that medical doctors avoid jobsat district level because local politicians misuse health serviceresources and interfere in treatment decisions.Local management factorsIn the local government sector the problems of overwork andtoo little time off stemmed in part from limited managementcapacity to draw up fair duty rosters. It was noted that poorlyplanned rosters scheduled nurses to work back-to-back day andnight shifts. The view among nurses was that properly organisedtime off would motivate them to work. Concerned healthcentre managers said they recognised the need to manage staffhours fairly, but with so few staff that was almost impossible.Government sector managers explained how unexpectedabsences worsened the load on nursing staff. When staffdid not turn up for work, and especially when they didnot communicate their intent, managers struggled to findworkers to fill the gaps and patients were left waiting. Whilethere was sympathy among managers for the personal andfamily problems that kept staff from work, there were alsofeelings that the reasons offered were not always genuine.In Ugandan culture, it was hard to question whether familysickness or burials had actually occurred and hard to enforcea requirement to produce sick notes. Sometimes managerssuspected, 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 wholived on site were rarely absent, unless they were sick or arelative had a problem, as they would be ashamed whenpatients came looking for them at home.Participants working in government health centres explainedhow their hours and workload increased at short noticewhen senior colleagues were called away to workshops andmeetings. They rarely questioned why these activities took36

Our Side of the Story: The lived experience and opinions of Ugandan health workerspriority 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 publicsector health workers to account for their absences. “Turninga blind eye” was preferable to starting disciplinary procedureswhich would likely lead to a transfer. It would be “suicide” to losesomeone, as the remaining few would be more overburdenedand blame the manager. Managers noted wryly that they hadlittle leeway to dictate to medical doctors and midwives inunderstaffed facilities: “They hold you at ransom, they knowthey have power because they can just go and get worksomewhere else.” A frontline doctor echoed the point: “Youwork in a relaxed environment, they don’t want to pressure youtoo much and push you away.” It is reported elsewhere thatUgandan facility managers have no authority to discipline staff. 108Scarcity was similarly a barrier to redistribution of staff withina district. While in theory a district health manager could movea nurse or midwife from a better-served health centre to easeunderstaffing at another centre in the district, in practice themanager met resistance: “They won’t go because they knowthey are marketable.”Task-shiftingIt is clear from workers’ accounts that work overload, stressand poor community relations result from doing work forwhich they were not qualified or trained. Such task-shifting hasbeen found in government healthcare facilities elsewhere inUganda. 109 Managers and frontline workers expressed concernsabout staff working beyond their scope of practice, when anursing assistant acted as a nurse, a nurse as a midwife and amidwife as a medical doctor. This is necessitated by shortagesand absences of suitably qualified staff. However, it seems thattask-shifting was also a deliberate strategy to save money byemploying less-qualified staff.6.4 RecommendationsStaff shortages and work overload damage health workers, thequality of care and community relations. Attitudes and behaviourfor which health workers have been criticised stem fromphysical and mental exhaustion, moral distress and burn-out.Health worker/patient ratiosThere were views that the norm was out-dated and failed torecognise the changing nature of services, such as HIV andAIDS treatment clinics, new cadres coming out of trainingschools and local population growth. It was recommendedthat standards for patient/nurse and patient/doctor ratios beintroduced so that health worker overload is transparent andquantifiable. Pressures would reduce if ratios were adheredto: “The nurse can manage if a limit is put on the number ofpatients per nurse.”Recruitment blockagesSensationalist media headlines about ‘shortages’ contribute tonegative images of health professions. Health reporters shouldbe informed about obstacles to recruitment. The district levelrecruitment process is cumbersome and lengthy, entailing anumber of steps as responsibility and paperwork pass from oneauthority to another. The District Service Commission has a roleat several stages, but meets infrequently because of the costs ofconvening members and advertising vacancies. 110 Many remotedistricts have no functional District Service Commission and nopersonnel officers to declare the vacant posts for recruitment. 111It was suggested that the problem of unfilled posts andmal-distribution of health workers across local governmentdistricts would reduce if health worker recruitment anddeployment were managed centrally. Health workers explainedthat the current system de-motivates potential applicants whohave to seek out and apply for positions.Decent staff accommodationParticipants spoke enthusiastically about the benefits of goodquality staff accommodation, equipped with electric lightingand a clean water supply, suitable for families. A decent place tolive attracted health workers to remote and rural facilities andmade for a more contented workforce. On-site accommodationwas said to reduce absenteeism. Civil society organisationsadvocating for health workers should hold to their objective ofmonitoring the government’s intention to “provide decent andsafe accommodation for health workers at health facilities,especially in hard-to-reach areas” 112 and press for concrete targets.De-urbanise health worker trainingIt was suggested that more training schools located in ruralareas would produce nurses and midwives already adaptedto rural environments. Managers saw value in attachingnurse training to remote hospitals, both to generate a localworkforce and to bind health workers to the community. Civilsociety organisations recommend targeting admission policiesto enrol students with rural backgrounds, exposing studentsto greater rural field work and building schools and residencyprogrammes outside major urban areas. 113108. Mwita et al 2009109. East, Central, and Southern African Health Community (ECSA-HC) 2010110. See Ministry of Health and The Capacity Project 2008.111. Matsiko 2010112. Ministry of Health 2010b p102113. Action Group for Health, Human Rights, and HIV/AIDS 201037

Our Side of the Story: The lived experience and opinions of Ugandan health workers7. The facility infrastructureGovernment sector workers in rural hospitals and health centres bore the brunt ofdilapidated conditions: non-functioning operating theatres, erratic or non-existentelectric power, unreliable access to clean water, blocked sewers, broken-downtransport and no communication technology. They told of damaging effects on jobsatisfaction, risks to themselves and deeply felt harm to patients.7.1 The contextOfficial reports paint a gloomy picture of the physical state ofhealth facilities. While new health centres have been built andsome health centres upgraded with newly constructed theatres,outpatient departments and maternity wards, the governmentacknowledges that most facilities are in disrepair and thatinadequate allocation of funds hampers maintenance andrehabilitation. The government also recognises failures in electricityand water supplies, transport and communications technology.What official documents do not show is the extent of broken ornon-functioning power, water, transport and communications,revealed in an independent survey of a sample of 41 out of 64government health centres in two districts. 120 (Box 2)Data from a survey of not-for-profit sector facilities indicate abetter 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 waterwas most commonly described as being generally reliable.About two-thirds of facilities reported always having access totelephones. Half the sites had reliable email access. In a quarterof the sites, ambulance or transport services were not available. 121Failing infrastructure: key factsMost facilities are in a state of disrepair. Rehabilitationof buildings is not carried out regularly. 114Many health centre IVs still lack crucial infrastructureto make them fully functional: 49% [of the 117 healthcentre IVs providing information] either have nooperating theatre or have an incomplete ornon-functional theatre. 115Only about 24% of health facilities have electricity or abackup generator with fuel routinely available duringservice hours. Only 31% have year-round water suppliedin the facility by tap or available within 500 metres. 116Only 47% of all facilities can transport a patient to areferral site in maternal emergencies. 117 An independentevaluation of the ambulance service in 13 districts ofnorthern Uganda found only 8% of mothers reportedusing an ambulance to reach the health facility duringtheir last delivery. 118Only 6% of health facilities have information andcommunication technology, mostly comprising mobilephone, radio, TV and, to a smaller extent, computers. 119Box 2: Basic conditions in a random sampleof government health centres in two districts(November-December 2009)PowerWaterTransportCommunication25% no power source10% functioning electric power30% functioning solar panel25% non-functional solar panel1 of 5 generator sets functional10% functioning piped water supply10% non-functional piped supply40% functioning rainwater supply10% functioning ambulance12% non-functional ambulance50% functioning motorcycle20% non-functioning motorcycle0% a landline, functioningofficial cell phone or email10% functioning radio call20% non-functioning radio call114. Ministry of Health 2010b115. Republic of Uganda 2010116. Ministry of Finance, Planning and Economic Development 2010117. Ministry of Finance, Planning and Economic Development 2010118. Womakuyu 2010119. Ministry of Health 2010b120. HEPS-Uganda 2010, Annex IX121. Schmid et al 2008, Chapter 638

Our Side of the Story: The lived experience and opinions of Ugandan health workers7.2 The health worker experienceThe state of facilitiesAmong government facility managers and district healthofficers there were questions about why more health centreswere being constructed when existing facilities could not workas they should. Facility managers in the government sectortold of struggling with inadequate budgets to repair or replacedecades-old infrastructure: “The only borehole, you pump for30 minutes and then it stops for two hours”. Pumping wateronly every second day and encouraging rainwater collectionin jerry cans and drums was a partial solution. Elsewhere,the best that could be hoped for was being earmarked forrehabilitation – “at least we are in a programme” – or “a goodSamaritan” to help connect to a distant water source. On theother hand, external funding coupled with well-managedin-house technical services allowed a not-for-profit hospitalmanager to speak with pride of rainwater conservation andsolar power systems. There was a marked contrast between ahospital where wards were cleaned three times a day and onewhich had no piped water supply “for years”.The impact on health workers“The condition of the working environment is one of the biggestchallenges. So that people can work with a smile, wake up inthe morning and be happy going to work. You enjoy your workand your profession.”Low job satisfactionA key concern was the state of operating theatres at healthcentre IVs. Government sector managers spoke of theatres thatcould not function because of poor design or shoddy construction.They said that when a theatre was unusable, or lacked properequipment or anaesthetists, underemployed medical doctorslost interest and left. Frontline doctors commented that the lackof opportunity to practise surgery explained the unwillingnessto 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 dimlight?” Sharing one paraffin lamp across three wards was veryhard, yet: “We just have to bear with it for the betterment ofour community.” Nurses working with no good light felt theywere failing their duty to patients in need of scheduled treatmentsduring night hours. Hospital communication systems do notwork without power, and midwives can be left to bear thebrunt when a doctor cannot be called.Risks to health workersWorking with no power or water, health workers naturallywere worried about the huge risks to themselves: “We arerisking our lives.” Maternity workers emphasised the risk ofcontamination from infected blood when working in the dark.Nurses expressed fear of assault working often alone in unlitwards or crossing dark compounds, a risk increased by locklessdoors, breaches in compound fences and inadequately equippedor absent guards: “We fear to answer the door when somebodyknocks for help.” No functioning flush toilet at the workplaceforced a dangerous walk home through a snake-infested compound.Risks to patientsMidwives and maternity nurses emphasised the risks to womengiving birth at night. Assisting deliveries by the light of a mobilephone or a candle begged from a patient, they were forced todelay repairing episiotomies until daylight. Unable to read thepatient’s case notes at night, midwives could not tell if she hadHIV and so reduce the risk to the baby. Only a donor’s gift oflamps relieved months of “suffering” delivering in the dark.Infection control was near impossible when nursing staff had tobeg the little water spared by patients’ attendants to wash theirhands, and so try to prevent carrying infections to the patients.Participants told how expensive fuel for electricity generatorsran out at crucial moments: “Just yesterday we were doingan operation and we had to complete stitching by torchlight.”Sterilisation was “a huge challenge”. As generator power mustbe conserved, it could not be used routinely for preciousequipment, such as an ultrasound machine which mostly stoodidle despite having a trained operator. Limited generator powerdid not allow refrigerated blood storage and patients couldrarely afford the costs of travel to the referral hospital, to thedistress 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 intendedservices because of lack of infrastructure, power, equipment,supplies or qualified staff. Health workers showed pride intheir facility when it had a functioning ambulance to transportreferred patients or could rely on an ambulance sent onrequest from a higher tier facility. On the other hand, workingin a facility with no patient transport was deeply upsettingbecause many patients just could not afford to pay their owntransport costs: “They say they will go to the hospital but theygo home and later you find out that they died.” Health workers’distress was acute when a health centre patient was referreddirect to a distant regional referral hospital. They knew thatpatients were deterred not only by the travel costs but also bythe prospect of a strange hospital and an alien language.39

Our Side of the Story: The lived experience and opinions of Ugandan health workersCommonly, budgets did not stretch to fuel the vehicle forreferrals. It was widely acknowledged that patients were askedto pay towards fuel but that was often beyond the reach ofpeople in poor communities. The negative impact on nursesand midwives cannot be exaggerated. They came into nursing tosave lives, to use their knowledge to benefit their communities.For them it was very hard and frustrating to stand by unhappyand helpless, knowing that a mother and baby would diebecause the vehicle lacked fuel. Nor was it a good experienceto see patients return to the facility “in a terrible condition andvery weak” or with complications because of the lack of fuel forreferral. Health workers also spoke of their frustrations whenmechanical problems were left unattended.A managerial concern in the government sector was thateffective referral systems need a means of communicationfrom lower- to higher-level facilities. Health workers seemedresigned to using their personal mobile phones and paying forcalls from their own pockets to contact referral hospitals.Because of the constraints on providing transport, it wasunusual to hear of a vehicle being used to bring patients to ahealth facility. Staff in a government sector hospital were proudthat it provided an ambulance service to bring in emergencypatients, and noted how relations with the communitybenefitted as a result. There was also praise and gratitudeexpressed for a project that supported pregnant women’stransport costs, resulting in more facility-based deliveries.The impact on attitudes, behaviour and practicesHealth workers spoke of their distress over how a lack ofelectric power, water and transport affected the quality ofservice. They wanted to do their best for patients but hadto protect themselves too. They explained how patientperceptions 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 “Sometimesyou shy away from risk and the patient thinks you are rude, butit is the working conditions.” 122 They also acknowledged thatthe frustrations of working in the dark caused impatience anddelays that patients construed as neglect.7.3 RecommendationsFrontline staff seemed resigned to working in poor conditionsand struggled to identify ways of improving them, shortof wholesale rehabilitation that would need unrealisticamounts of public expenditure. Recommendations aremostly from managers.The building and rehabilitation programmeA suggestion was to invest in good theatre facilities and theirstaffing in a small number of health centre IVs and showcasethem as good practice before embarking on further work.Responsiveness to problems identified by staffGovernment sector frontline workers noted facility and districtmanagers who had been slow to respond to requests forimproved lighting. Another source tells that a similar requestwas not acted on although a large stock of lamps was held inthe district store. 123 Good practices identified in the not-forprofitsector included regular meetings between managementand department heads at which faults were raised for action.Health worker ‘ownership’ of the facilityIt appears beneficial to get facility staff involved in tacklinginfrastructure problems. For example, staff at a governmenthospital organised rainwater collection.The impact on community relationsIt was said that patients refused to be admitted for treatmentwhen the toilets did not work and they were not able tobathe, thus damaging the reputation of the facility. A lackof water to flush toilets forced staff to return home, fuellingpatients’ beliefs they were not at work and running the riskof their being blamed by local political leaders for leaving theworkplace while on duty.122. Similar findings reported by Dieleman et al 2007123. Medicines and Health Service Delivery Monitoring Unit 201040

Our Side of the Story: The lived experience and opinions of Ugandan health workers8. Equipment and medical suppliesThis chapter looks at the impacts of deficits in equipment andassociated medical supplies, and the following chapter reportsthe impacts of shortages of medicines in healthcare facilities.8.1 The contextEquipment failures: key factsThere is a shortage of basic equipment in health facilities. Only 40% of availableequipment was in good condition and about 17% needed replacement [in 2008-09]. 124A survey in 11 districts showed the extent to which health facilities lacked equipmentto diagnose and treat malaria in mid-2009. Of the 105 facilities surveyed, 83% were inthe government sector. The survey found:• No functional microscope in about 50% of the 35 health centre IIIs and 20% of the10 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 facilitiesDuring the three months prior to the survey, none of the hospitals and healthcentre IVs had all seven components of a basic care package for the management ofsevere malaria consistently available. The most common ‘stock-out’ was blood fortransfusion, available in only one facility. Blood transfusion sets were lacking in aroundtwo thirds of facilities and over half had no giving sets. 125Evidence suggests that only 5% of facilities have a vacuum extractor (used for assistedvaginal delivery) and only 10% have a dilation and curettage kit (needed to remove aretained placenta). 1268.2 The health worker experienceHealth workers praised facilities with good diagnostic equipment,such as x-ray and ultrasound, and with a commitment to awell-equipped establishment: “It’s a good place, that’s whyI have stayed so long.” Elsewhere, working with inadequateequipment was a huge challenge, damaging workers’professional fulfilment, the quality of services and communityrelationships. The difficulties were acute in the governmentsector, but also present in parts of the not-for-profit sector.The impact on health workersGovernment sector medical doctors and nurses told ofinterruptions to the supplies of oxygen and blood; missingcanulas, needles, giving sets and sutures; minimal availabilityof urine testing kits and family planning supplies; insufficientdressing packs, and absent or faulty diagnostic equipment.Rural midwives in the government sector told how theystruggled 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 2010b125. Achan et al 2011126. Ministry of Finance, Planning and Economic Development 201041

Our Side of the Story: The lived experience and opinions of Ugandan health workersWorking without protective wear – gloves, aprons, gumboots,shoes, masks – was a huge risk, especially for midwivesworking in the dark: “You are bathed in blood.” Lacking gloves,midwives even used their own clothes and plastic bags to graspthe baby during delivery. Workers in some rural facilities in thegovernment sector provided their own work clothes as, it wassaid, the Ministry of Health no longer supplied uniforms.In the government sector there was widespread frustration atnot being able to work effectively: “What really hinders my workis lack of some equipment” and “The equipment does not allowyou to do what you are supposed to do.” Nurses spoke aboutthwarted professional fulfilment. Willing to work and capable ofoffering a full service, they felt “handicapped” and “disappointed”.As a result, work was neither enjoyable nor happy: “If I amprovided with what I am supposed to use, I can enjoy the work”and “You can’t really be happy in such conditions, but would behappier with equipment to do your best.”Frontline medical doctors spoke of “struggling with the minimum”and of feeling “deflated” by poorly maintained equipment suchas x-ray machines with blown bulbs or no chemical to print thefilm: “You wake up and have the same problem, you go home,you come back and it has not changed.” Doctors wanting thesatisfaction of doing their best for their patients spoke offrustrations such as a lack of diagnostic equipment or facilityfor blood counts. Managers recognised that medical doctors“eventually lose morale” when they are unable to operate on apatient because oxygen or sutures are missing, and that beingunable to apply knowledge was “very demotivating”.Failing their patients greatly distressed nurses and doctors.Patients died because of the lack of essential supplies: “Wewould have saved that life if we had oxygen. It stresses you.”A lack of diagnostic equipment lost lives too: “The patientprobably would have survived if you were able to investigate.”Government sector workers faced a dilemma when thefacility ran out of supplies. User charges were abolished in thegovernment sector 127 and health workers told of prohibitionson asking patients to go and buy missing items: “It is veryannoying, you go home dissatisfied.” The medical doctor has aduty towards the patient’s health: “What do you do? Ask thepatient 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 toask a patient to buy needles in order to help them,” and it wasclear that patients in some facilities were being asked to buysupplies. It was hard to ask a patient to buy items that shouldhave been provided free of charge: “I don’t want to be the oneto say go and look for a canula.”Participants in facilities with relatively good supplies welcomedrelief from the stresses of telling patients to buy their own.They also spoke of pride in a facility that did not force patientsto spend their little money on intravenous fluids, canulas,gloves, dressings and the like. There was praise for imaginativemanagement that solved temporary supply problems byborrowing from other facilities.The impact on attitudes, behaviour and practicesParticipants working in the private and not-for-profit sectorsspoke frankly about effects of shortages they had seenduring their time in government facilities. They told of nursesforgetting what they had been taught in training schools andsome not working as a result, so projecting a bad image to thecommunity which in turn made nurses feel not respected andprompted them to leave. Participants in the government sectordid not identify these effects. However, there was a suggestionthat nurses were reluctant to come to work and face patientsand their relatives knowing that essential supplies were lacking:“Staff don’t want to come in and look at a mother with a dyingchild and no canula to give intravenous fluids.”The impact on community relationsHealth workers felt blamed for the lack of supplies andresented accusations of theft. The patient’s attitude changedwhen asked to buy supplies: “You feel bad when somebodyis not appreciating what you are doing.” Patients’ carers weresometimes angry and violent, such as a husband who hit amidwife when asked to buy gloves.There were fears of personal repercussions if the rule wasdisregarded and the patient was asked to buy supplies: “TheGovernment is going to see you as a bad person.” Staff in onefacility were stressed by the arrest of a health worker whoasked a patient to buy essential supplies. The view there wasthat local political candidates had set the arrest in motion todiscredit the incumbent leader.127. User charges were abolished in 2001 in all government facilities except private wings in hospitals.42

Our Side of the Story: The lived experience and opinions of Ugandan health workers8.3 RecommendationsThe limitations of equipment and medical supplies seemed anintractable problem to many participants. Frontline workers sawthe supply problem as out of their hands and it was hard forthem to come up with recommendations other than the obvious– increase equipment and ensure constant treatment supplies.Encourage international donors to provide largeitems of equipment directlyThere was a view that mismanagement and corruption dissipateddevelopment partners’ support to the Ugandan health budgetand that donors should provide large items of equipmentdirectly. It was felt that it would be counter-productive ifdonors were to donate smaller, more easily removable items.Equipment maintenanceThe view was expressed that more attention needed to begiven to the maintenance of existing medical equipment. It wasfrustrating to have equipment on site that could not be usedbecause of broken or missing small parts. The expense of theparts was a minor issue. Rather, the problem was said to stemfrom inertia and poor organisation among facility management.Improve frontline health worker voiceand participationFrontline health workers showed limited knowledge of howthe ordering and delivery system is supposed to work andhow financial allocations and priorities are set. Workers inthe government sector told of putting requests to facilitymanagement, but did not understand why their needs werenot met. Workers in district-level facilities commonly blamedthe Ministry of Health for deficits. Participants at a governmenthospital identified as good practice formal consultations bymanagement to find out what equipment frontline workersneeded, and enabling them to participate in decision-makingabout equipment and supplies. Health workers were free toidentify not only equipment essential for patient treatment butalso items that made their work easier and more comfortable,such as fans and radios. Transparent decision-making onpriorities and implementation allowed workers to have a voiceand see that their views had been listened to.43

Our Side of the Story: The lived experience and opinions of Ugandan health workers9. Medicine suppliesMedicine shortages and ‘stock-outs’ emerged as one of the biggest challengesfor government health workers. Unable to give their patients the drugs theyneeded, health workers grieved for their patients’ suffering and becamedemoralised by the futility of their roles. They struggled with disappointed orangry patients and their limited understanding of the reasons for shortfallsin supplies. They were deeply hurt by accusations of stealing drugs, the lackof trust the public had in health facility staff, a seemingly hostile press and bywhat they saw as politically motivated moves to discredit them.9.1 The contextDrug availability failures: key facts“The percentage of health facilities registering stock-outs in essential medicines hasconsistently been over 60% for the last 10 years.” 128The availability of 40 essential medicines in the period April-June 2010 was recorded in asample of 28 government and 18 not-for-profit facilities across Uganda. None of the 40medicines was available in every government facility when surveyed, while eight of the40 were found in all of the not-for-profit facilities. Average availability of the 40 medicineswas 59% in the government facilities, compared with 78% in the non-for-profit facilities. 129An assessment of the pharmaceutical situation in 36 government and 36 not-for-profithealth 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 ingovernment facilities and 7.6 in not-for-profit ones. 130Only one in three respondents surveyed in 2008 agreed that their nearest governmentfacility usually had all the medicines the household needed. 1319.2 The health worker experienceThe drug supply situationOutside the government sector, medicine supplies weregenerally thought adequate to treat most conditions. Asufficient supply brought health workers the satisfaction ofworking effectively, as well as pride in an efficient facilitythat logged all movements of medicines. The not-for-profitsector was not immune to shortages, however; in one facility,shortages were said to be due to loss of revenue because itgave impoverished patients drugs on credit.In parts of the government sector there was someacknowledgement that government efforts to improve thedelivery system of the central medical store had broughtimprovements in supplies of essential medicines. It was alsonoted also that drug supply increased after a governmentstamp on packets was introduced. There was enthusiasmabout how better supplies now benefited patients: “Nowwe have enough drugs, I would not say all drugs, and inpatientsget the drugs the doctors prescribe.”128. Ministry of Finance, Planning and Economic Development 2010129. Uganda Country Working Group 2010130. Ministry of Health 2008a131. Ministry of Health 2008b44

Our Side of the Story: The lived experience and opinions of Ugandan health workersThere was sharp contrast between praise for medicine suppliesin better-stocked facilities and disgruntlement among workerselsewhere. Health workers told of some essential drugs usedup in a matter of weeks, or even days: “They bring one tin ofquinine tabs for a whole unit” and “Just five tins of panadolwhich the department can use up in one day.” Complaintscentred on undersupply for population demand; shortfalls insupply 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 promisedquarterly schedules. It was suggested that shortages weremade worse by patients taking unfair advantage of briefperiods of plenty but with no testing equipment it was hard torefuse drugs to patients who claimed the common complaint ofmalaria. And it had been noted that patients turned up with adifferent patient record book every day of the week in order tostock up with drugs at home.Government facilities typically could not stretch their budgetsto purchase drugs in the private market, and were forced to sitand wait for the next delivery from the central medical store.However, one hospital dedicated a quarter of its private-wingincome to medicines.The impact on health workers and the quality of careHealth workers said they felt “disappointed” and that the lackof drugs “demoralises” them. Job satisfaction suffered whenthey 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 arejust sitting waiting for them, then tell them to go back as thereis no drug.” Helplessness was especially hard to bear whenforced to tell poor patients to buy their medication in the privatemarket: “I hate the situation of being helpless before thepatient when they can’t afford to buy drugs” and “You feel youhave not done much for the patient when they have to buy.”It seemed like fobbing off the patient: “You tell them to buy, butthe patient is expecting answers.” It was hard to be seen asletting down patients keen to have family planning supplies whocould barely afford the transport to the facility: “You feel so bad,it seems as if you are deceiving them and they lose confidencein you.” Self-esteem suffered when drugs were not available:“They look at you and think the health workers are bad, andyet it is the government, not us” or “Their eye looks at the nurseand that doesn’t make me able to be the nurse I want to be.”The biggest source of distress for health workers was the impacton the patients, and they spoke emotionally about how they feltfor their patients when no medicines were available for them.In the case of antiretroviral drugs against HIV, which shouldbe taken for the rest of a person’s life, it was very hard to seepatients go for up to six months without treatment. Healthworkers cared passionately about the consequences for poorpatients: “Few can afford even 2,000 shillings [$1], so day afterday they walk here and wait. Walk 15, 20 km despite the pain.” 132They felt the pain too when patients became more sick whilewaiting for their families to raise money to purchase medication.Hospital doctors spoke of how they were forced to referadmitted patients who could not afford to buy medicines, orjust keep them in a bed without medication. The quality ofcare 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 workerssaid it was hard to make patients and other communitymembers understand why drugs were not available at all times.They acknowledged that among people sick and in pain therewas little appetite for words of explanation, and that thecomplexities of the supply system were beyond the understandingof 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 beliefthat government health facilities lacked medicines even whenreceipts increased. 133 According to health worker participants,there now appears to be a prevailing belief that health facilitiesare well supplied with medicines: “People say why don’t yougive us drugs?” A particular problem arose when a health facilitychanged ownership from not-for-profit to government and thepreviously superior supply of medicines could not be maintained.Health workers said that communities served by governmentfacilities assumed health workers took the drugs: “Patients thinkyou steal” and “Patients call us thieves.” They said that patientsbelieved that health workers took government supplies to stocktheir own clinics and drug shops, to which patients were thensent to buy medicines. It was acknowledged that such abuseshad occurred. Indeed, good supplies in one hospital wereattributed to the fact that few of its nurses ran private clinics anddrug shops. Health workers expressed sorrow about the lackof 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’ attitudestowards health workers improved when given supplies of drugsto last several days. It was especially upsetting to be directlyaccused of theft when a patient demanded a drug that theclinician knew was not appropriate for the patient’s condition.132. Some 51.5% of Ugandans live on less than $1.50 a day (UNDP 2010 Statistical Annex)133. Nabyonga-Orem et al 200845

Our Side of the Story: The lived experience and opinions of Ugandan health workersThere was widespread indignation at accusations of stealingnonexistent medications: “What are they supposed to bestealing?” or “What kinds of drugs can we steal? Paracetamol?Because that’s the only drug in the hospital!” and “How canthey take things that are not there!” Health workers felt thatlocal leaders and politicians made matters worse when theyfailed to present the true picture to complaining patients, andeven accused health workers in front of patients: “It is makingus 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 incidentsunfairly to give an exaggerated picture of the extent to whichfrontline health workers were guilty of pilfering drugs.A stakeholder concurred: “We can’t brand all health workersas thieves just because someone has stolen a tin of aspirin.”Stakeholders noted that press stories about health workersstealing drugs had increased with the work of the Medicinesand Health Supplies Delivery Monitoring Unit, an autonomousunit set up in October 2009 within the President’s Office. 134While there was support for its efforts to expose poor workingconditions as well as abuses, the view was expressed that it wasunhelpful to create a media story around every wrongdoingthe unit uncovered: “They tried to create publicity instead ofdealing with the real issue of what is causing the stock-outs.”There was hurt and indignation too about top public figuresspoiling the professions’ reputations when they stated publiclythat health workers are thieves: “How can any patient valuea doctor, value a nurse, when they say such things about us!”There were beliefs that government conspired to make outthat all health workers were thieves although, in the opinion ofhealth workers, top managers and not frontline workers werethe chief culprits. Public accusations by the President wereespecially damaging to health workers’ self esteem.“Museveni warns medical workersQuoting a proverb that says ‘a dog which stealspays with its back’, Mr Museveni told a rally […]that the same would be done to health workerswho steal drugs from now on.” 135“Politicians stop playing gameson the right to healthA story is often told of a politician whodelivered a truck laden with ‘medicines’ to ahealth centre in his constituency. The truckwas reportedly containing all the medicinesthat this health centre needed at the time. Ina country where getting medicines in publicfacilities is intermittent and health workers arereviled for ‘stealing’ medicines, this politicianwas an angel straight from heaven.Now, long after the speeches and pleasantrieshad ended, and the MP had gone, it was timeto open the boxes. But alas, the boxes werefull of saline solution. […] There was no waymedics at the facility would tell people thenext day that there was no medicine. To thepolitician he had scored a political goal. But inthe process, the health workers had been putin a tight position.” 136“Patients get angry because the politicians tell them drugs areprovided”. Views were expressed that politicians deliberatelymislead the public: “Government makes them believe they havesent drugs” and “The public is being hoodwinked!” But for apublic servant it would be “suicide” to contradict political masters.134. The Unit’s first annual report exposed malpractices and “vices” identified through its staff visits to 145 facilities in 45 districts, with an average of threefollow-up visits in each district. Initially visits were impromptu, in response to “emergency calls” from the public about the state of healthcare and allegeddrug thefts, and routine monitoring visits were introduced later in the year.135. Emojong 2010136. Kirunda 201146

Our Side of the Story: The lived experience and opinions of Ugandan health workers9.3 RecommendationsTransparency at the point of delivery“They see the boxes coming and if next day you say there areno drugs, they feel like beating you up.” Public opening ofdeliveries was one step that government sector health centreshad taken, with varying degrees of success, to try to convincecommunities that medicines were not in stock. For example, tocounter the community assumption that a lorry had delivereddrugs, it was important to show that boxes offloaded containedcondoms or saline solution. When essential medicines weredelivered, their quantities were verified openly. Healthworkers told how variously the chairperson of the healthunit management committee, the elected chair of the localcommunity, the government internal security officer, policeand patients witnessed the opening of boxes. This step mustbe supported by paperwork to show what has been orderedand delivered; government health centre recording of orders,deliveries and purchases has been described as “appalling”. 137Drug movements within the facilityParticipants within the not-for-profit and private sectorsrecommended recording drug inflows and outflows, althoughit was also said that such time-consuming steps were notnecessary when staff were trusted by management and thecommunity. Management staff in a not-for-profit sector healthcentre welcomed scrutiny by the higher level body to which itwas accountable.Local leadersThe local government structure produces a large number ofcommittee or council members and leaders at village, parishand sub-county level (see Appendix B). These people, oftentermed local politicians or local leaders, can have considerableinfluence over their local communities. Health centre workerstold of dissatisfied patients who called on local leaders tosupport their demands for drugs. It is therefore essentialthat local leaders are fully informed and use informationresponsibly. Staff at one facility reported that “trouble fromlocal politicians” had reduced after a meeting with them.Educate community membersSome health workers said they had tried hard to help patientsto understand the ordering and delivery system. Others hadwearied of such attempts or had barely tried: “They only wantdrugs, not your words.” Some simply wrote off local peopleas uneducated, illiterate and incapable of understanding – apoint of view contested by health consumer organisations inthe study. It was pointed out that patients were not receptiveto explanations when in pain or angry when asked to buymedicines, though it was acknowledged that opportunitiesfor facility-based information sharing do exist, such as withgroups of women waiting for pre-natal checks. The mostpromising solution was to talk with community membersduring outreach visits, such as child immunisation days, thoughsome health workers had limited confidence that they couldsucceed in changing entrenched suspicions. Others pointedto a lack of funding for outreach allowances. There were alsoviews that Village Health Teams might have a bigger role insensitising the community to the real situation.137. HEPS-Uganda 201047

Our Side of the Story: The lived experience and opinions of Ugandan health workers10. PayUgandan health workers’ salaries are low compared with those in other EastAfrican countries. They are also low compared to the market value of goodsand services in the country. 138 Especially among medical doctors, the disparitybetween their salaries and those of other professionals is a huge grievance.There have been calls to raise doctors’ salaries to match those of high courtjudges, whose income at 6.8 million shillings (US$ 3,664) was more than eighttimes the starting salary of a senior medical officer in 2009-10. 139 Regardlessof how much they themselves were paid, health workers spoke out about thedamaging consequences of low pay for themselves, patients and the profession.10.1 The contextSalaries: key factsStarting salaries per month in governmentservice in 2009-10 140,141Senior medical officer UGX 840,749 (USD 453) 142Medical officer UGX 657,490 (USD 354)Registered nurse UGX 353,887 (USD 191)Nursing assistant UGX 113,306 (USD 61)Average monthly salary for a seniornurse/midwife in government service 143Uganda USD 341Tanzania USD 630Kenya USD 1,384As local government districts have discretion to top up salaries,these vary among staff of the same level. The Ministry ofHealth introduced salary top-ups in the most hard-to-serveareas, to attract and retain staff. It is reported that top-upsof up to 30% for six months attracted professionals to theseareas. 144 Facilities in the not-for-profit and private sectors settheir own pay levels. It is known that not-for-profit sectorsalaries are lower than in the public sector. 14510.2 The health worker experienceThe frontline workers and managers participating in the researchsaid they did not join their professions just for the money. Theywanted to use their training to help others, prevent and cureillness and save lives: “I became a nurse not so much becauseI am interested in money, though money is also important. Ifeel it really was a vocation.” In any case, salaries were simplynot attractive enough: “With so little money, nurses must wantto care and help patients, just to keep going.” Money wasnever an overriding factor for job satisfaction, though amongfrontline doctors there were expectations of earning enough to“help build yourself up” and feel good about helping people atthe same time. Yet there were some strongly held views amongparticipants that some of the recent generation of healthworkers entered the profession with no natural interest for itand became disaffected because salaries were so low.Staff in rural health facilities said that despite long workinghours with little chance to rest, they worked over weekendsand on public holidays for the sake of the patients. They evenvolunteered their help unpaid on top of their regular work, outof 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 tochange to make things better for them, health workersemphasised improvements in the infrastructure that wouldresult in better care and treatment for patients. Frustrationwith equipment and supplies outstripped frustration oversalaries, as found in other studies. 146138. Matsiko 2010139. Ladu 2010140. Matsiko 2010141. Ministry of Public Service http://www.publicservice.go.ug/public/Traditinal%20Salary%20Structure%202010%20-%202011.pdf142. 1 US Dollar = 1,856 Ugandan Shillings at 31 March 2010143. Ministry of Health 2010b p37144. Matsiko 2010145. Schmid et al 2008146. Fonn et al 200148

Our Side of the Story: The lived experience and opinions of Ugandan health workersThe impact on health workersMoney worriesHealth workers said salaries were not enough for the costs ofordinary daily living, to allow them to pursue a career or tomeet social expectations. They said that money worries gotin the way of doing their best work and even contributed tobad practices. Managers said inadequate pay was one of thebiggest challenges to healthcare delivery.Nursing staff spoke heatedly about their struggles to surviveon low pay and support their dependents, see their childrenthrough education, pay for a roof over their heads, settleessential bills and afford transport to work. Financial worriesadded to the stresses of long hours and little rest, the burdenof too many patients, the frustrations of not enough medicalsupplies or the lack of appreciation in the workplace: “If betterpaid, a nurse will work with patients with love and happinessknowing 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 wereforced to pay high transport costs to reach more affordableaccommodation. Paying US $1.50 or more a day for transportwas very hard to afford on a nursing assistant’s salary.In Uganda income is important not just to meet daily livingcosts. There are extended families to support: participantshad up to 15 children depending on them. One of thesatisfactions of earning is being in a position to support thestudy costs of a family member. As educated people, healthprofessionals naturally want a good education for theirchildren. Public primary and secondary education is free, butschools often impose fees for lunch, uniforms and buildingdevelopment, and many Ugandans favour the private schoolsthat comprise over a quarter of the secondary educationsector. 147 Worry about school fees pervaded health workers’lives. A participant spoke heatedly about the impossibility ofaffording university fees of US $900 a semester with threechildren and a monthly salary of US $330.Failing to meet social expectationsAs a health professional there are also social expectationsto meet. Families, friends and social associates assumeyou are well off, and it was shaming to reveal how little thesalary actually was. Medical doctors especially felt sociallyembarrassed when they could not afford to contribute largesums of money at functions held to raise funds for wedding orfuneral expenses. They also spoke of how they were expectedto help with school fees or medical costs: “Society expects somuch from you. It’s impossible to convince people that youdon’t have money when you are a doctor.” The pressurecame from the community expecting a nurse or doctor tobe “at a certain level” and seeing them as not responsive tocommunity problems. It was also hard for doctors to facethe disbelief of patients begging them to pay for life-savingtreatment that should have been freely available: “You look intheir eyes and see the hurt and the disappointment.”Medical doctors and senior nurses spoke of unaffordablelifestyle aspirations such as a house that befits their status.Doctors wanted to be in a position to afford a decent houserather than put up with low-standard government sectoraccommodation on site.Disrespect“In Uganda respect comes with how much you earn.” It wassaid that patients “look down on nurses” when they know howlittle they are paid. Rural nursing assistants who were especiallypoorly paid said this would be a barrier to enlisting the localcommunity to advocate for higher salaries: “It’s our secret.”Thwarted professional ambitionsA widespread and serious concern was unaffordable furthertraining: “I have to sponsor my own study yet I am servingthe nation!” Health workers spoke, often passionately, aboutthwarted ambitions to improve on skills and knowledge.Nursing assistants wanted to train as enrolled nurses ormidwives, and enrolled nurses and midwives to train asregistered nurses and midwives. Moreover, registerednurses wished to add midwifery to their qualifications orgo to degree level. Doctors wished to bring their knowledgeup to date and train as specialists.Unfair payParticipants regularly voiced strong opinions that the pay wasunfair and undervalued health workers. Nurses complainedthat their salaries did not reflect the years of study they hadput in. They pointed to other medical jobs that required thesame length of training yet were more highly paid: “Nursingis one of the lowest paid medical professions.” Doctorspointed to the much higher salaries of other professionals:“We send our children to the same schools, buy our food atthe same markets.” It was dispiriting to see their universitycontemporaries earning so much more yet working less hard.The fact that medical doctors are paid less than secretaries anddrivers in some statutory agencies underscored the little valueattached to the medical profession in Uganda. There weresome strong feelings, notably among managers and practisingdoctors, that low pay reflected a lack of political will atministerial and presidential level to invest in healthcare. Therewas some anger about public spending on political campaigns,the military and a presidential jet, and about wastage throughcorruption, while healthcare was grossly underfunded.147. Uganda Bureau of Statistics 200849

Our Side of the Story: The lived experience and opinions of Ugandan health workersSalaries were doubly unfair because they did not reflect thelong hours many health workers put in: “You can give yourfamily neither time nor money.” Nor did salary levels takeaccount of the risks of infection health workers faced. Notbeing rewarded for doing the same work as higher-grade staffwas thought bitterly unfair. It sometimes seemed to hospitalnurses that doctors did little while they did all the work.Nurses complained that after paying for additional training toupgrade their skills, they lingered for years on their previoussalary until promotion was granted.A further area of perceived unfairness was the disparity insalaries offered by the government, not-for-profit and privatesectors. Not-for-profit sector workers pointed to their longerhours, and it was commented that unlike some governmenthealth workers, they worked the hours they were paid for.It was pointed out that not-for-profit and private facilitieswere free to decide their own salary levels and acknowledgeseniority in their own way, resulting in lower pay than ingovernment settings. A particular grievance was the absence ofa senior clinical officer grade in a not-for-profit facility. A furtherconcern was that the government’s salary enhancement foremployment in hard-to-reach areas seemed not to have beenadopted 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 oftheir professional ethics and dedication to patients: “Nursesare trained to love and serve, and no matter how little we arepaid we have to have that love.” Indeed, among managers therewas some intolerance of frontline workers’ complaints aboutlow salaries, and an attitude that commitment to the workregardless of the pay was praiseworthy: “Patients have to get aservice, poorly paid or not.” Yet managers were among the mostvocal critics of salary levels: “The salary is deplorable!” Overall,participants appeared more resigned than militant about unfairpay, though there was some anger that the government citedthe Hippocratic Oath to prevent doctors from protesting.Impact on attitudes, behaviour and practicesHealth workers and managers were encouraged to say whatin their view explained behaviour regularly criticised in theUgandan media, including being rude to patients, stealingmedicines and supplies, not turning up or coming late to work,and taking money from patients. Health workers acknowledgedthat these bad practices did happen in some places: “It’spoverty. You get a salary of US $200, you pay school fees ofaround US $150, you get stuck. You don’t have transport totake you to work, you don’t have food in the house, you don’thave anything, children are crying, your parents need you tokeep them. That’s what drives people to do those things.” Butthey also argued that the media exaggerated the scale of suchpractices by unfairly generalising a single instance to all healthworkers: “It spoils the reputation of all nurses, it pains anddiscourages us so much.”One of the hottest topics in the Ugandan media is the apparentdisappearance of essential medicines and medical suppliesbetween the central store and patients in government healthfacilities. Theft on the part of health workers is only oneexplanation for shortfalls in supplies (see Chapter 9). Participantsacknowledged that theft did occur within some health facilities.In their view, the explanation lay with low pay and moneyworries: “They are not stealing medicines because they are evil– their income does not satisfy their needs.” Delays in salarypayment were implicated too: “They steal for survival.”In no way was stealing condoned. Some participants expressedsorrow that patients were deprived of already scarce supplies.Others were bewildered that health workers could put theirown interests before those of the patients. Only rarely didparticipants believe that greed led health workers to steal.Some health workers thought that pilfering of medicineshappened only on a small scale, and that drugs were taken forpersonal or family needs and not to sell. But there were alsoviews that helping yourself had become a habit, with reportsof staff openly justifying selling supplies on the grounds thatthe facility did not reward them well enough. Participantswith experience of closely managed facilities spoke of tighteradministrative practices that helped to safeguard medicines.Workplace cultures which accepted stealing were also noted.The suggested solutions were tighter management to reduceopportunities for abuse, and holding staff to their codes ofemployment. As found in research elsewhere, peer influence tochange behaviour was seldom proposed. 148Taking money from patients is a sensitive topic which somehealth workers were understandably reluctant to discuss.Soliciting bribes from patients was thought to be rare and wasunacceptable because it would add to patients’ poverty. If itdid occur, it was attributable to low pay: “If paid a satisfactorysalary, I think they would not get money from the patients.”There was also a view that worries about surviving onretirement pensions drove health workers to ask for bribes. Itwas observed that in some settings, patients expected to givestaff some inducement to attend to them. 149 Such mistrust washurtful and offensive, and it was suggested that the distancebetween workers and patients widened as a result. Participantstold of scams whereby patients were robbed of their littlemoney by conmen masquerading as health workers, and ofangry patients subsequently attacking legitimate staff.148. Ferrinho et al 2004149. Hospital health workers in Tanzania frequently commented in focus groups that unofficial payments were more commonly initiated by users than by workers(Stringhini et al 2009)50

Our Side of the Story: The lived experience and opinions of Ugandan health workersHealth workers distinguished accepting “appreciation” fromdemanding money, and some acknowledged a temptation toaccept unsolicited money from patients as compensation forill-paid, exhausting work. It was suggested that some seehealth workers accepting appreciation and wrongly concludethat a bribe has passed hands.It was widely believed that urban health workers were forcedto work in two or even three jobs to make ends meet, withgovernment sector employees working also in private clinics orprivate hospitals. One unfortunate consequence, it was said,was to reinforce patients’ suspicions that health workers stealdrugs from their workplace to sell in private clinics. Moonlightingwas often known, or suspected, to explain absences: “Mostpeople, when they don’t turn up for work you find they arerunning a clinic somewhere.” It was said that absenteeismwas not a problem in areas where private treatment or drugswere unaffordable. Exhaustion from doing too many jobs wasthought to cause behaviour patients saw as rude.Rural areas were said to offer many fewer opportunities forside-employment, but there it seemed that health workerswere sometimes forced to take time out to tend crops tofeed their families. It was noted that before decentralisation,rural workers regularly saw to their vegetable gardens beforeleaving for work, when salaries arrived late or not at all. It wassuggested that this habit continued.There were beliefs that absence from the workplace wasencouraged by lump sums given notionally to cover transportand attendance at workshops, and there were grievancesabout perceived unfair selection of participants: “They onlywant the big people.” The more junior staff valued the learningand professional contacts that workshops offered.Effort at work was affected by low pay, managers felt. Viewswere expressed that nurses put in minimal effort “because theyfeel they are not getting what they are worth.” It was observedthat because nurses are paid so little, “they take out theirfrustrations on patients’, arrive late, fail to monitor patients andare unkind to them. It was noted how hard it was to get peopleto work when they lacked the basic minimum, and that withno “incentive” of a decent wage, it was impossible to retainskilled and interested workers. Occasionally, in managers’ eyes,“low morale” was related to low pay. Low pay was argued tocontribute to doctors’ “questionable attitude to work”. Thingswould change with better pay: “When you are paid highly youare more motivated” and “If the pay was more, the nurses wouldrespect their work more and respect the job that pays them.”10.3 Poor pay, turnoverand loss to UgandaThe research participants were, of course, “stayers” in theirprofession. Career histories showed a fair amount of mobilityfrom one health facility to another, but only very exceptionallydid a participant speak of leaving their profession, and thatwas to earn more.The consensus was that the biggest turnover was among medicaldoctors. There were firm beliefs that Ugandan-trained doctorsleft the government sector to work for NGOs, prestigiousnot-for-profit hospitals or the private sector. Private sectorwork was tempting, in order to get more money and avoidthe “frustrations” of government hospitals. Managers andpractising doctors told how young doctors “run away” fromhard-to-fill rural posts because of poor salaries. As well as lowpay, reasons were believed to include limited opportunity to useprofessional skills in poorly equipped facilities, disinclination tolive far from modern amenities and a lack of earning potentialfrom private practice. Yet practising doctors explained that formany young doctors, a year or two gaining experience in a ruralsetting, even in deprived circumstances, was a step towardsacceptance for specialist training. Staying longer meant passingthe age limit for scholarships. Specialism was then the gatewayto private practice and considerably higher earnings. In anycase, district level facilities rarely could support the costs of aspecialist if they wished to return after training.Participants were asked if they had thought about workingabroad and why. For some nurses the possibility was remote:family responsibilities came first, the barriers to getting anursing job abroad were just too high, or they had not evenrealised it was allowed. For others, nursing abroad was areal aspiration, and there were one or two stories aboutdisappointments. Nurses’ reasons for considering workingoutside Uganda counter the widely-held perception that thelure of money pulls nurses to lucrative jobs in other countries.Better pay was not an overriding consideration. Nursesexplained they were looking for an environment where “there’srespect for what you do” and where they could learn aboutdifferent medical conditions, use equipment they were trainedto use, update their skills and have the chance to advanceprofessionally. Individual advancement was not the sole drivingfactor: “I would bring my skills back to share with Ugandannurses” and “I would bring back the knowledge to my people.”51

Our Side of the Story: The lived experience and opinions of Ugandan health workersAmong participants with medical qualifications there werebeliefs that medical doctors left country in large numbersfor “greener pastures”, as well as claims that few of theirgraduation contemporaries were still in Uganda, thoughthe lack of hard facts on the extent of emigration was alsoacknowledged. The prevailing assumption was that doctorsmoved in pursuit of money. When questioned about theirown intent, doctors spoke about the attraction of a betterincome. Yet opportunities to work with proper equipmentand “love what you do” also were important – not simply agood salary. Doctors spoke about the possibilities of workingin highly regarded, well-resourced hospitals in other EastAfrican countries or in Southern Africa. African countries wereattractive because they are close to home, but the USA andEurope were not ruled out. Not all doctors wanted to leave forbetter working conditions, and there were also keen ambitionsto take their skills to countries even more in need of medicaldoctors than Uganda, such as Sudan or Somaliland.10.4 RecommendationsUgandan health workers feel undervalued because salary levelsdo not match their needs and social expectations. The pay isfelt to be unfair and failing to signify an appropriate return forwhat they put in.Not surprisingly, there were very many calls for increasesin basic salaries. There were concerns about exploitationin private clinics and a suggestion that a minimum wage beintroduced. Ideally, the same salary structure should apply inall sectors. Government salary scales should recognise first andpost-graduate degrees. There was considerable frustration thatthis issue was not being resolved and calls for reform in orderto attract degree nurses to public sector jobs and ensure theireducation is used to directly support patient care. A commondemand was to address blockages to promotion.There were also practical recommendations to reward effortand improve motivation.Overtime and responsibility paymentsWhile staff often willingly worked over-long hours for the sakethe patients, there were views that their extra hours should notgo unrewarded. No health worker told of overtime payments.Financial motivators“We are not motivated, they should give us some motivation,some appreciation.” In Uganda “motivation” often means extramoney or payments in kind. Being given something signifiesappreciation. Non-financial rewards were no substitute formoney: “Lovely words of thank you don’t feed a family!”Free accommodation of a good standard, with electricity andwater paid for, was hugely appreciated and said to be a factorin attracting and retaining staff. Even free housing of lowerstandard was valued and its absence a cause for resentment,especially among nursing assistants.Free food for the household, tea and snacks provided at workand Christmas and Easter gifts were identified as especiallyappropriate ways to value and motivate Ugandan health workers.Staff of a government facility spoke enthusiastically about thehelp 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 arecommon and can contribute quite significantly to the overallpay. Small allowances for outreach visits, such as to provideimmunisation services, were much appreciated. There were callsfor allowances for risk, housing, transport, responsibility andstudy. 150 Hardship allowances were suggested to compensatefor living and working in remote locations where it is difficultto access facilities and goods, and where the standard ofaccommodation is very poor and lacking in essential utilities.A private sector facility’s monthly award for nurses who methigh standards of dress and customer care had a multipleeffect in pushing up standards, boosting income and valuingindividual staff.It was pointed out that local government hospitals are allowedto run private wings and that some use the income to benefitstaff. One hospital allocated over half of that income toenhance the monthly salaries of all its staff: “health workersfeel owned and happy.” It was recommended that localgovernment hospital administrations inform staff about theirprivate wing income and how it is spent.Staff told of the stresses of working alone and bearing soleresponsibility. A good practice cited from the not-for-profitsector is a responsibility allowance paid when a nurse hassole 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 salariesconstitutes a housing allowance.52

Our Side of the Story: The lived experience and opinions of Ugandan health workers11. The way forwardWork overload, poor infrastructure and the lack of medical equipment, suppliesand medicines frustrated and distressed health workers. They felt unrewardedfor the work they do and undervalued. Their accounts show that workingconditions were the root causes of bad practices and unethical behaviour, andthat health workers bore the brunt of the blame for system failures. The researchrevealed a vicious circle: impoverished working environments, along with lowpay, affected the quality of patient care; patients blamed the health workers; thewider community then distrusted health workers, and so health workers’ distressincreased. The situation was made worse by negative media stories and politicalleaders’ vocal criticism of health workers, which fuelled public distrust, damagedthe standing of the health profession, added to workers’ distress and, mostimportantly, raised the barriers to access to healthcare.11.1 Raising the voices of health workersThe view of civil society organisations, and of some managers,was that frontline health workers are not empowered to speakup. Indeed the concept of ‘voice’ was unfamiliar, and the ideathat they might speak out and gain support to improve poorworking conditions and the quality of care was new to manyfrontline health workers. The research identified barriers toindividual health workers voicing their concerns, and theirpreferences for advocacy by representative organisations.Constraints on speaking upThere were views among frontline workers that responsibilityfor improvements lies with facility managers, districtmanagement or the Ministry of Health. Stakeholders notedthat where decisions are made with no staff involvement “thestaff are afraid for their jobs, they fear to speak up.”Anxiety about repercussions was a barrier to speaking out inpublic. It was explained that “in Uganda, there is a lot of fearof being pin-pointed if you talk out about your problems.” Theresearchers observed some apprehension over signing theirconsent form, although health workers were willing to takepart in the research and seemed satisfied with the researchers’assurances of confidentiality and the safe-keeping of data. Theunspoken fear, it seems, was that their participation mightrebound on them.Lack of respect from management undermined nurses. Thosewith experience in large urban hospitals told of senior nursemanagers and administrators who “sat on”, “barked at”and “belittled” them in front of patients. They also spoke ofdoctors who publicly ignored and disparaged their knowledgeand contributions as “mere nurses”: “I have quite oftenheard doctors tell a nurse she is stupid.” Such behaviourcoloured patients’ respect for nursing staff and damaged theirreputation in the wider community: “They think a nurse barkedat 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 surprisingthat nurses had little appetite for championing their profession.This report has shown that rural workers in governmentfacilities have faced disappointed, distrustful and sometimesangry patients, interfering and bullying local politicians andpolitically engineered attacks on health workers’ credibility.Hostile environments and impoverished workplaces drainedany will they had to do more than meet patients’ needs thebest they could.Moreover, health workers had few chances to meet withpeople from other healthcare facilities to exchange experiencesand build solidarity. Nurses spoke enthusiastically about aforum organised by a health sub-district which discussedsolutions to common problems.The low esteem accorded to health workers was a furtherbarrier. It was said that nurses do not speak out because ofstigma attached to the profession: “The moment you stand upand say you are a nurse, people see you as a person who killspatients, they assume you are a bad nurse, a failure.”53

Our Side of the Story: The lived experience and opinions of Ugandan health workersSpeaking through professional associations,unions and regulatory councilsHealth worker participants favoured channelling concernsto the Ministry of Health, Government or Parliament throughbodies that spoke for them as, unlike individual health workers,such bodies “know the way”. Awareness of professionalorganisations and trades unions was not widespread andthere was some confusion over their names, how theirstatus differed and which body did what.Some health workers felt unions were doing a good job,evidenced by salary increases and the successful legal defenceof individual workers. Health workers saw advantages in theprotection of a union and the pursuit of individual complaints.A union had the advantage over an association of registrationwith the Ministry of Labour and permission to negotiate withthe government.Male frontline workers spoke most enthusiastically about thepotential of unions as a collective voice, and saw a need forlocal organisation and meetings at district level. They alsoidentified a role for unions to strengthen advocacy withinhealth facilities and talk to management on behalf of theworkers: “They need to bring in people from above and helpus at a lower level to improve things.” Women too saw thepotential strength of the nurses’ union if all nurses joinedcollectively, paid subscriptions and attended meetings. Therewas some confidence that more involvement in unions wouldget nurses listened to at national level. Supporters of thenurses’ union acknowledged that nurses were not currentlywell-informed about it.It was suggested that professional associations might do moreto bring members together, such as convening annual meetingsto discuss challenges facing the profession. Opportunities toattend professional association conferences were few buthighly valued, and there were calls for them to be held locally.However, there were also doubts about the value of theunions and professional associations. 151 It was pointed out thatbodies did not do enough to inform their memberships abouttheir activities or call them to meetings. A lack of feedback,no tangible benefits and no evidence of proper financialmanagement, alongside rumours of power struggles, weredeterrents to workers spending part of their little salary onsubscriptions to remote associations and unions. There werealso suspicions that those at the top of the organisationshad different agendas from workers on the frontline. Theeffectiveness of representative bodies was also questioned,given a history of government suppression.There were conflicting interpretations and somemisunderstandings of the remit of the regulatory councils. 152Some health workers saw their council as equivalent to aunion, with a role to advocate for their constituency. Otherssaw a “punishing attitude”, and complained that the Nursesand Midwives Council was “down on nurses” and investigatedonly serious, high-profile cases of irregular behaviour. Concernswere voiced that the council did little to defend nurses accusedof stealing medicines and that no action had been takenagainst politicians who “beat up” nurses. The nurses’ councilwas seen as remote from nurses on the ground, preoccupiedwith meetings, disinclined to inform members of what theydiscussed and not independent enough of government.It was suggested that it would be better if representatives ofprofessional associations, unions and regulatory councils wereless remote from workers on the ground. In particular, therewere calls for people “up there” to visit health facilities, talkwith health workers and learn about their difficulties first hand,so that the “right voices” were taken to the top.Recommendations among managers were that representativeorganisations compare reports from different places andcompile strong collective arguments to improve conditions inthe workplace, rather than simply address individual grievancesand traditional welfare issues.Representatives of associations and unions acknowledgedshortcomings and weaknesses. They were understaffed andseverely under-resourced, with poor office facilities. Theconsensus among stakeholders was that individual associationsand unions were not yet strong voices for health workers andthat working in an alliance would be more effective. It wasrecognised that much would have to be done to align theefforts of multiple and sometimes competing professionalunions 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 inpromoting 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 Governmenton matters relating to the nursing and midwifery professions; and exercise general supervision and control over the two professions (according to the Nursesand Midwives Act 1996).54

Our Side of the Story: The lived experience and opinions of Ugandan health workersAn advocacy allianceIn Uganda, countless small civil society organisations work topromote health rights. Dependent on financial support froma patchwork of sources (mainly development partners), theygain strength through loose, generally informal coalitions basedon common aims. They are broadly aligned to consumers’interests. Health workers’ interests fall mainly to theprofessional organisations. Coalitions rarely bridge the two setsof interest. The Health Workforce Advocacy Forum-Uganda is acoalition of health professional associations, unions and healthrights organisations. A membership organisation largely madeup of health workers, it has recently campaigned for a positivepractice environment for health workers.The Valuing Health Workers research found consensus thata way forward would be for all civil society organisationsconcerned about limits on access to healthcare to join with theHealth Workforce Advocacy Forum-Uganda, to support andstrengthen its advocacy on behalf of health workers.11.2 Changing public perceptionsof health workersParticipants were hugely affected by the persistently negativeportrayal of health workers in Uganda: “I feel like I am aprofessional being abused.” Members of civil society andprofessional organisations identified priority actions to reversethat image through targeting the media. Strong views wereexpressed by health workers that the public must hear theirstory: “We haven’t gone to the radio to tell people the problemis not us. We should be talking about our side of the story.”The public must be told the real causes: “Papers always blamethe person, saying nurses are rude. etc, but there’s a needto dig and find what really causes it.” People must see thecontributions health workers make: “We never show why weshould be valued.”Participants said that reporters working for the national mediaare inadequately informed about the health worker situationand are overly reliant on official briefings for their information.It is important to increase the capacity of civil society andhealth worker organisations to write press releases, hold pressconferences and build relationships with individual reportersand media houses, so that the key campaign messages hithome. It is similarly important to engage with local reportersand try to moderate the tendency to create sensational storiesfrom isolated incidents. The Uganda Health CommunicationAlliance is an important ally.While it was widely understood that the media look for badnews, there was scope for positive human interest features,such as profiles of individual health workers and the work theydo. It will be important to avoid suspicions of favouritism inselection of the health workers featured.Local language radio is highly popular in Uganda and is avehicle often used by civil society advocacy organisations.Radio call-in shows attract health users voicing complaintsabout local services: “You hear them on the radio, it makesus uncomfortable.” While health workers are restricted inwhat they can say publicly, civil society organisations have theopportunity to put complaints in the wider context and speakup for health workers.11.3 Bridging patient communities andhealthcare facilities and staffConnecting communities and facilitiesThere seemed, from health workers’ accounts, places whererelationships between patient communities and facilitiesworked well. These were places which ignored status “so theydon’t feel you are greater than them” and welcomed patients“on the same level”; where off-duty nurses mixed sociallywith patients; where Village Health Team workers visited thefacility and had direct phone contact with the facility headand other staff; where people called for an ambulance and itcame; where local people volunteered to clean the facility andlook after the compound; where facility management listenedto what the local community wanted from it, and where thecommunity saw the facility as their own.At district level, managers told of ongoing efforts to buildor repair bridges with communities. There was a role formembers of Village Health Teams (where they were functional)as go-betweens to explain to people in their own homes theproblems health workers faced. ‘Outreach’, where facility-basedhealth workers took services such as immunisation to thecommunity, was thought a good opportunity to talk with peopleon their own ground, though limited by a lack of transport.There were hopes that “empowered” health unit managementcommittees would “tell the community the truth”. The aimwas for committee members to explain how facilities work, forexample, how supplies are ordered and staff disciplined, as wellas to encourage people to use their services. But funds wereshort to cover the expenses of village health workers, outreachand health unit management committee members.55

Our Side of the Story: The lived experience and opinions of Ugandan health workers‘Community dialogue’ meetings were recommended to bringtogether service users, local leaders and those involved inproviding services: “If there can be community dialogue meetingsin each village, then we can discuss with them their problems.We tell them what we do, they express their problems, how wego wrong, I also tell them where they go wrong”. Communitydialogues also meant that district managers learnt communityviews about individual health workers.There were places where the distance between communitiesand facilities appeared hard to bridge. Patients arrivedexpecting staff not to help, and health workers came to workfearing that patients would complain. “They don’t respectthe nurses’ needs, we don’t respect each other.” Interferingand demanding politicians seemed an intractable problem,but health workers reported favourable effects when a toplocal politician’s family used maternity services at a localgovernment facility. Seeing the challenges encouraged thepolitician to understand their root causes. A more generalrecommendation was to invite politicians to spend time infacilities alongside staff to see what the work is really like.Civil society organisations have been working to createcommon cause between health workers and patients. Earlyprojects learnt that empowering community members toexercise their health rights must go hand in hand with valuinghealth workers. Otherwise there is a real risk of adversarialrelationships between healthcare workers and users. Indeed,early experiences were that community members, fired upwith new knowledge about violations of their health rights,reprimanded workers they perceived to be rude, while healthworkers complained of harassment and threatened to resign.Subsequently, community-based training has enabled healthworkers to talk out about the structural problems, with serviceusers coming to appreciate the reasons behind health workerbehaviour they object to. Now the focus of community-basedtraining has moved towards fostering mutual understandingand communication through participatory methods involvinghealth workers and community members together. 153Mutual respect and understandingHealth workers understood what life is like for patients,they felt the pain that patients feel, and they wanted betterconditions to improve things for patients. It was exceptional tohear that patients empathised with health workers: “Patientsalso 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 notunderstand what life is like for health workers: “They don’tunderstand what we go through, that sometimes nurses arerude due to the working conditions.” Patients seemed not torealise that health workers, like any other people, get tired,need to eat and fall sick. Health workers said they tried “to getthem to understand we are human beings.”153. Eg TARSC and HEPS 201156

Our Side of the Story: The lived experience and opinions of Ugandan health workers11.4 Summary of participants’ recommendationsThe 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 advice1.2.3.4.Improve the quality and relevance of training.Raise the voices of health workers through representation.Change public perceptions through the media.Build bridges with patient communities.PrioritiesValue health workers for their contributionsto the health of UgandansHealth worker terms and conditions of service• Review salary scales to determine whether increases inbasic salaries are possible. Reform government salaryscales to recognise first and postgraduate degrees, in orderto attract degree nurses to public sector jobs and ensuretheir education is used to support patient care directly.• Consider the establishment of a minimum wage andthe feasibility of imposing the same salary structurein 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 whena nurse has sole charge of a ward.Small financial motivations• Incentivise staff through small items of personal support, suchas food for the household, snacks at work, and Christmas andEaster gifts. Contributions towards family burials, medicaloperations and provision of cloth for uniforms are well received.• Review current allowances for risk, hardship, housing,transport, responsibility and study, to ensure consistencyand fairness across all facilities.• Use the income from local government hospitals’ privatewings to benefit staff, by supplementing salaries or allowances.Ensure working conditions enable health workers to providegood-quality healthcareHealth worker/patient ratios• Introduce standards for patient/nurse and patient/doctorratios, so that health worker overload is transparent andquantifiable, and managers have information to help reducepressure on overloaded staff.Recruitment blockages• Manage health worker recruitment and deploymentcentrally, to address the problem of unfilled posts anduneven distribution of health workers.Decent staff accommodation• The Government should follow through on its strategy toprovide decent and safe accommodation for health workersat health facilities, especially in remote areas. Civil societyorganisations should continue to monitor implementationof this strategy and press for concrete targets.Facility infrastructure• Ensure regular meetings between management anddepartment heads, at which facility-related problemscan be raised and decisions taken on actions needed.• Invest in good theatre facilities and their staffing in a smallnumber of health centre IVs, and showcase them as goodpractice before embarking on further work.Equipment, medical and medicine supplies• Give much more attention to the maintenance and quickrepair of medical equipment, including systems for monitoringequipment maintenance and adequate stocks of spare parts.• Hold regular formal consultations with frontline workersto enable them to participate in decision-making aboutequipment and supplies, and to improve transparencyin equipment procurement processes.• Encourage international donors to provide large itemsof equipment directly.57

Our Side of the Story: The lived experience and opinions of Ugandan health workersEnabling strategies1. Improve the quality and relevance of health worker trainingCareer guidance and early contact• Ensure well-motivated trainees, for example throughmore talks at schools and work experience placements.Training schools’ admission procedures• Reject applicants who seem to be applying for the “wrongreasons”, including those allocated to a university coursewhich 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 fromthe Ministry of Education and Sports.• Reduce nursing and midwifery class-sizes and improvetutor capacity, to ensure the right attitudes and practicalunderstanding of the ethical code are encouragedthroughout pre-qualification training.Health and human rights training• Expand existing partnerships between training institutionsand health consumer advocacy organisations. Improvenursing course content to make sure that students takeon board the role of the nurse as a patient’s advocate.De-urbanise health worker training• Increase the number of training schools and residencyprogrammes in rural areas to produce staff already adaptedto rural environments and connected to the local community.• Improve the community service element in medical curriculaand increase the exposure of urban health students to ruralsettings with increased fieldwork.Nurses and Midwives Council registration interviews• The Nurses and Midwives Council should weigh up theadvantages of screening interviews held as a prerequisitefor registration post-qualification against detrimentaleffects on nurse morale.2. Raise the voices of health workersSharing of experience and common approaches• Encourage staff to meet with people from other healthcarefacilities to discuss solutions to common problems andcommunicate them to sub-district level managers. Thesemanagers could also be encouraged to instigate similar forums.Speaking through professional associations, unions andregulatory councils• Channel health worker concerns to the Ministry of Health,Government or Parliament through bodies that speak forthem, such as professional organisations and trade unions.• Professional associations and unions should do more tobring members together, for instance at local generalmeetings, and make greater efforts to visit facilities and talkwith health workers so that the “right voices” can be takento the top. They should compile strong collective argumentsto improve conditions in the workplace, as well as addressingindividual grievances and traditional welfare issues.• The Health Workforce Advocacy Forum – Uganda (a coalitionof health professional associations, unions and health rightsorganisations) should expand its membership and continue itscampaign for a positive practice environment for health workers.3. Change public perceptions by influencing the media• Inform journalists about the obstacles to health workerrecruitment and discourage them from writing sensationalistor negative stories in the media. Put complaints on locallanguage radio call-in shows into a wider context. Encouragethe running of positive human interest features, such asprofiles of individual health workers and the work they do.Work with the Uganda Health Communication Alliance.• Improve the capacity of civil society and health workerorganisations to write press releases, hold press conferencesand build relationships with individual reporters and mediahouses, so the key campaign messages hit home.4. Build bridges between patient communities, healthcarefacilities and staffTransparency on drug availability• Use well-managed public opening of medicine deliveries tohelp 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. Supportwith paperwork to show what has been ordered and delivered.• Ensure that local leaders are fully informed through regularmeetings about the demand for and supply of drugs andthat they use this information responsibly.Connecting communities and facilities• Use opportunities to talk with people on their own groundand explain the problems health workers face, for instancethrough Village Health Teams, facility-based health workersproviding outreach immunisation services, and talks towomen awaiting prenatal checks.• Promote community dialogue meetings bringing togetherservice users, local leaders and health unit managementteams. Increase funds to cover these activities.• Invite top local politicians to spend time in facilitiesalongside staff to see what the work is really like.• Civil society organisations should continue their work tocreate common cause between health workers and patients.58

Our Side of the Story: The lived experience and opinions of Ugandan health workersAppendix A: Sample detailsTable A.1Number of facilities and participants by regionKampala Central West South West North North East EastFacilities 3 1 5 1 4 1 3Participants 17 6 31 4 27 17 20Table A.2Level of facility by provider typeReferral Hospital General Hospital Health Centre IV Health Centre III TotalGovt Govt NFP* Private Govt NFP* Private Govt NFP* Private3 2 3 1 4 - - 2 2 118*NFP: Not-for-profitTable A.3Distribution of districts according to Ministry of Health hard-to-serve scoresVery hard- to-serve(score 55-100)Hard-to-serve(score 35-54)Medium hard-toserve(score 20-34)Somewhat hard-toserve(score 1-19)Not hard-toserve(score 0)TotalDistrictsMinistry 13 13 14 13 3 56Sample 2 2 2 1 1 8The sampling design aimed at a spread of districts in termsof how the Ministry of Health ranked them as hard-to-serve.The Ministry’s scoring formula took into account degree ofinsecurity, measured by the proportion of the populationin internally displaced persons camps (50% of total score);distance from the capital, Kampala (10%); presence of socialamenities and utilities (bank, grid electricity, tarmac road anda tertiary education institution) (10%), and the proportionof approved staff positions appropriately filled with healthworkers (30%). 154 The formula was designed some years agowhen Uganda had only 56 districts and when insecurity wasgreater than at the time of this study. Researchers have notedsome anomalies in the scoring. 155 The scores were thereforeonly a guide to sampling decisions. Table A.3 shows that thesample under-represents districts that scored 1 to 19. 156154. Africa Health Workforce Observatory 2009155. Ministry of Health 2009a156. Based on Africa Health Workforce Observatory 2009, Annex 259

Our Side of the Story: The lived experience and opinions of Ugandan health workersFigure 6Enrolled and registered nurse/midwife participants (n=74)25Comprehensive2021NurseMidwife15Nurse / midwife1410595 51080Enrolled2Registered60

Our Side of the Story: The lived experience and opinions of Ugandan health workersAppendix B:Local government structures in UgandaLocal government is organised in five tiers from the village to the district, as outlined below. 157A village is the lowest political administrative unit. A village usually consists of between 50 and 70 householdsand 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, anexecutive committee. LCIIs are largely involved in settling land distributions and mobilising the community for variousactivities. 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-countychief on the technical side and by an elected local council III (LCIII) chairman and his or her executive committee. Thesub-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 electedmember (an MP). In major towns, the equivalent of a county is a municipality (which is a set of divisions). LCIII executivecommittee members of all the sub-counties constitute the local council IV (LCIV). They then elect an LCIV executivecommittee 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, withrepresentatives from the sub-counties and technical staff in the district. There are also district councillors representingspecial 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 districtalso has heads of various departments such as health, education, environment and planning, which are responsible forrelevant matters across the whole district.Uganda has an exceptionally high number of districts, the total having risen from 17 at independence in 1962 to 112in July 2010. In 2008, when its districts had grown to 79, Uganda stood fourth in the world in number of highest levelsub-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 presidentialelections in 1996, 2000 and 2006; 160 that pattern continued with further districts created around the 2010 election.157. Drawing on Kavuma 2009158. Africa Health Workforce Observatory 2009159. Green 2008160. Green 200861

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Our Side of the Story: The lived experience and opinions of Ugandan health workersAnnex: Health worker topic guide1. Tell me why you decided to become a [----]Probe • Influences• Attraction of the profession• Ambitions• Alternatives considered• Doubts2. What do you believe the [----] role is supposed to be?Prompt: Why do you think that?Probe • Influence of training, text books• Role models• Peers3. What words would you use to describe a good [----]?4. How does what you do in your work fit with your ideas of what the [----] role should be?Probe • Fit with work of nurses / doctors / clinical officers / nursing aides• Patients’ care needs• Constraints – staffing, equipment, drugs, work environment• Other people’s attitudes5. 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 you6. What helps make [----] feel good about themselves?Probe • Praise• Gratitude• Respect• Achievement• Recognition• Status7. 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, public66

Our Side of the Story: The lived experience and opinions of Ugandan health workers8. 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• Blamed9. 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 feelings10. 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 patients11. 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 future12. What would you like to change about working as a [----]? And how might the change come about?Prompt • Things that realistically might be achieved13. 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 organisations14. Is there anything else that you would like to share with us about being a health worker?67

ISBN 978-1-903697-33-79 781903 697337Valuing Health Workers is VSO’s research and advocacyinitiative, which supports the achievement of thehealth-related Millennium Development Goals.Valuing Health Workers research is currently underwayin four countries. Following on from the research,advocacy strategies will be created, which will includethe development of volunteer placements in civil societycoalitions, professional associations and health ministries.VSO works with the Health Workforce Advocacy Initiative(HWAI). HWAI is the civil-society led network of theGlobal Health Workforce Alliance (GHWA) and engagesin evidence-based advocacy with the goal of enablingeveryone to access skilled, motivated and supported healthworkers who are part of well-functioning health systems.www.healthworkforce.info/HWAI/Welcome.htmlVSO works with Action for Global Health – a cross-Europeannetwork of health development organisations. The networkcalls on European Governments and the EuropeanCommission to act now to support developing countries toachieve the health-related Millennium Development Goals.www.actionforglobalhealth.euFor more information please contact:advocacy@vso.org.ukIf you would like to volunteer with VSO please visit:vsointernational.org/volunteerIn addition to this publication, the following researchand publications may also be of interest:• Participatory Advocacy: a Toolkit for Staff, Volunteersand Partners – this manual is an easily accessible guideto lobbying and campaigning, and can be used by healthactivists and other campaigners for social justice.• Ugandan Health Workers Speak: The Rewards andthe Realities – a report of initial findings of theValuing Health Workers research in Uganda.• Valuing Health Workers in Cambodia – a short briefingon the research approach in Cambodia.• Valuing Health Workers: Implementing SustainableInterventions 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: Challengesand Lessons from Malawi, Mongolia and the Philippines– this report looks at how community volunteers can beinvolved in delivering health services.• Brain Gain: Making Health Worker Migration Work for Richand 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 andAction for Global Health, shows how the IMF is constrainingthe fiscal space for developing countries and impeding therecruitment of much-needed new health workers.• Our Side of the Story: Ugandan health workers speak up – areport on the rewards, challenges and recommendations forthe future, from the perspective of Ugandan health workers.To access any of these publications, please visit:www.vsointernational.org/healthCarlton House, 27a Carlton DrivePutney, London, SW15 2BS, UK+44 (0) 20 8780 7500www.vsointernational.orgVSO is a registered charity inEngland and in Wales (313757)and in Scotland (SC039117).Published July 2012VSO Bahaginanwww.vsobahaginan.org.phVSO Irelandwww.vso.ieVSO Jitoleewww.vsojitolee.orgVSO Netherlandswww.vso.nlVSO UKwww.vso.org.uk