Our Side of the Story - VSO

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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
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Our Side of the Story - VSO

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