Transcript HRH Issues and Challenges In Uganda What Is The Evidence?

HEALTH WORKER
SHORTFALL: IMPACT IN
UGANDA
Right to Health: Challenges in funding, health
systems and universal access in development
polities
Madrid, June 01 2010
Sandra Kiapi,
Action Group for Health, Human Rights and HIV/AIDS (AGHA)
Uganda (www.aghauganda.org)
Presentation Outline
HRH Staffing Levels and Distribution;
HRH Production Capacity
Staff Attrition and Turnover;
HRH Management and Regulatory
Systems;
Health Worker Concerns;
Key Conclusions and Recommended
actions
About AGHA

AGHA’s Mission is to raise the awareness
of all health care providers and the
communities they serve in Uganda about
the human rights aspects in health….
1. HRH Staffing Levels and Distribution
Uganda among the 57 countries with critical
shortage of HRH
 Staffing levels low by all standards:
◦ WHO - Staff Ratio of 1: 1818 vs. 1: 439
2,919 Physicians working in the country which is
equivalent to1: 8,373) people if spread
throughout the country;
20, 165 nurses and midwives= 1: 1,212
◦ MoH, AHSPR 2008/2010 – average of 56%
approved positions filled by qualified health
workers.

Staffing Levels, cont’d
Significant shortage of certain categories of staff;Medical Officers (MOs), and specialized cadrespsychiatrists
 Gross Mal-distribution:
◦ 70% of MOs, 80% of Pharmacists and 40% on
Nurses/Midwives are based in urban areas with
12% of the Pop;
◦ Significant variation in district staffing levels (30%
to 90%);
◦ Majority of staff are located in Central Region
(over 60% of MOs)

Regional Distribution of Medical and
Clinical Officers
Fig. 2 Regional distribution of Medical Doctors and Clinical Officers
Compared
2500
2000
Number
1500
1000
500
0
Central
Eastern
Northern Western
Region
Medical Doctors
Allied H. clinical
Doctors/MOs in 2002
◦ 1,349 in Kampala
◦ 505 in Wakiso
)
◦ 99 in Jinja
◦ ….
◦ Total 2,919 (60% in central region
where about 12% of the population
lives
Case Study: Kaabong in NE Uganda



Kaabong district
approved Posts filled
average of 39.4% in
2007/08
8 Midwifes (6 in the
district hospital) for
257,174 in 9 subcounties
Watchmen stepping in to
prescribe! (ACSD
exercise 2008)
Case Study: Kotido 2007/2008






Out of the 118 health jobs advertised
only 41 responded all of whom were
interviewed and offered the jobs.
Of these only 36 accepted and took up the
posts.
Only 29 of these were new people
of which only 6 were professional health
workers; the rest were support and
administrative staffs.
All these a midst a promise of 30% incentive of
6 months in a lump
Kotido Recruitment 2007/08 selected positions
position
advertised
Interview’d
Offered/a
ppointed
Reported
for duty
SMO
1
1
1
0
0
0
0
0
0
0
0
0
Anesthetic
Officer
4
1
0
0
0
0
0
0
Enrolled
Nurse
9
0
0
0
Enrolled
Midwife
13
0
0
0
Health
Assistant
13
4
4
3
New
Staff
Porters
27
21
21
20
New
Staff
MO
Public
Health
nurse
Lab. Asst
comments
2. HRH Production Capacity
Uganda has potential to produce
adequate numbers of health workers –
GoU, PNFPs and Private;
 Mismatch between training and health
needs;
 Production not keeping pace with
growing demands – much worse for
certain cadres;
 Competence and Skills of Graduates

Health Sector Actual (2008) and Projected
(2020) Health Worker to Population Ratios
and Numbers by Option
Options and investment
period
Actual 2008
BU Scenario 2020
LGN Scenario 2020
WHO-norm Scenario
2020
(Doctors + Nurses +
Uganda’s
Midwives)/population Population
(millions)
29.6M
1:1818
48.8M
1:1818
48.8M
1:666
48.8M
1:439
Doctors, Nurses,
Midwives
(Total)
16,280
26,840
73,200
111,264
All
HRH
(Total)
45,598
97,454
265,282
403,229
3. Staff Attrition and Turnover







Contrary to common perceptions, overall attrition rate
is not high in the public sector;
1.2% in public and 13% in the PNFP sectors;
Varied by districts;
Attrition quite low for national referral Hospital
Mulago;
Absconding and retirement are the major cause of loss
of staff;
Attrition is highest for medical officers and Dispensers;
Noted increase from 2005.
Characteristics of health workers who
died/ left - Jan 2002- July 2008 (%)
Reason
Public PNFP
Died
19.1
Absconded
37.8
Resigned
10.1
Went for further studies & 7.1
never came back
Retired
23.5
Dismissed
0.0
Unknown
2.4
Total
1.0
57.4
28.7
8.9
15.2
42.0
14.0
7.5
2.9
1.0
0.0
19.2
0.2
1.9
Attrition rate of doctors, nurses/midwives and clinical officers in
public sector for the years 2002 to 2007. Mulago Hospital
excluded
10.0
9.0
Attrition rate (%)
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
2002
2003
2004
2005
2006
2007
Year
Doctors
Clinical officers
Enrolled Nurses/Midwives
Registered Nurses/Midwive
15
Average annual attrition rate of health workers from
2002 to 2007 in 12 districts: Mulago hospital excluded
5.0
4.3
4.5
4.0
3.5
3.2
2.8
3.0
2.5
2.0
2.0
1.5
1.2
1.0
0.6
0.5
0.0
D octo
rs
ives
ives
midw
M idw
/
/
e
e
s
s
r
r
u
u
Enr .N
Reg.N
nsers
D isp e
al o ff
Clin ic
16
icer s
fes
ll.Pr o
A
r
e
Oth
s
Attrition rate for Doctors, Nurses/Midwives,
clinical officers at Mulago Hospital
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
2002
2003
2004
2005
2006
2007
Doctors
Enrolled Nurses/midwives
Registered Nurses/Midwives
Clinical officers
17
Average Annual Attrition Rate of Health Workers
by Cadre between 2002 to 2007 in PNFP Facilities
2002
% (n/N)
Doctors
0.0
(0/1)
Enrolled
0.0
Nurses/Midwives (0/22)
Registered
0.0
Nurses/Midwives (0/8)
Pharmacists
--
2003
% (n/N)
-9.5
(2/21)
0.0
(0/9)
--
Year
2004
2005
% (n/N)
% (n/N)
-0.0
(0/2)
4.8
0.0
(1/21)
(0/23)
0.0
0.0
(0/8)
(0/8)
---
Dispensers
0.0
(0/1)
33.3
(1/3)
0.0
(0/3)
0.0
(0/1)
0.0
(0/2)
0.0
(0/2)
Profession
Clinical
Officers
Other allied
professional
0.0
(0/1)
0.0
(0/2)
0.0
(0/2)
0.0
(0/1)
0.0
(0/4)
0.0
(0/5)
Average
2006
% (n/N)
0.0
(0/2)
21.4
(6/28)
16.7
(2/12)
-100.0
(1/1)
50.0
(3/6)
0.0
(0/7)
2007
% (n/N)
0.0
(0/3)
52.0
(13/28)
12.5
(1/8)
0.0
(0/1)
0
(0/1)
14.3
(1/7)
33.3
(3/9)
0.0
15.7
5.7
0.0
(0/1)
14.3
20.8
10.7
Job Stability: Intent to Leave/Stay
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Greater job stability in the public sector (53%) compared to PNFPs
(21%)- over 10 years;
Physicians intent to leave current jobs in two years (43%) and
country (31%);
Nurses least likely to leave - intent to stay over 3 years (83%);
Residents in the North expressed least desire to leave;
60% Public and 47% PNFP workers intent to stay indefinitely;
Only 8% intended to leave ‘as soon as possible;
UCMB had highest number (33%) intent on leave within 2 years;
Salary, involvement in the facility, manageable workload, flexibility
and opportunity for promotion reduced odds to leave.
Intent to Leave by Cadre

Intent To Leave By Cadre
4. HRH Management and Regulatory
Systems

Review of HRM based on Actionable
Governance Indicators:
◦
◦
◦
◦
◦
Complex fragmented HRM system;
Not linked to performance in service delivery;
Strong safeguards on due process;
Low in terms of effectiveness and efficiency;
Characterized by delays: recruitment, payroll,
confirmation, promotion etc.
HRH Mgt is a Serious Underlying
HRH Problem

Scores based on HRH for Health Action
Framework:
◦
◦
◦
◦
◦
◦
◦
HRH Mgt Systems:- 63
Leadership:- 56
Policy:- 48
Finance:-36
Education:- 27
Partnership:- 15
Others:- 13 – mainly issues beyond the health sector
e.g. external migration.
Absenteeism
Absenteeism: 47% mean, 50% median
Higher in larger facilities, no reduction in 5 years
In 50 government clinics surveyed, 51,465 worker-days lost due
to absenteeism is Uganda Shillings 300,000,000)
Source: Public Expenditure Review 2008, July 7 Presentation to Ministry of Finance
Budget Division by Dino Merotto, The World Bank.
Box 2:
% of Health Workers Assigned But Not Present (Median)
By Facility Level
By Cadre
Hospital
39%
Medical Officers
40%
HCIV
42%
Clinical Officers
44%
HCIII
40%
Nurses/Midwives
49%
HCII
40%
Other Clinical/Technical Staff 41%
Pharmacists
50%
Laboratory
33%
Source: Uganda Service Provision Assessment Survey 2007 (March 2008) 491
Facilities of which 373 Public; MOH, UBOS and DRC Macro
5. Health Worker Concerns
Job Satisfaction:
1.
◦
50% indicated overall satisfaction; PNFP (52%) and Public (49%);
◦
Morale at workplace better for the PNFPs (55%) compared to public
(42%);
◦
Medical Officers least satisfied (27%) compared nurses (50%);
◦
30% felt supervisors did not show care and doubted supervisor
competence.
Compensation:
2.
◦
Consider salary package unfair (86%);
◦
Considered Family Health Care (87%), Salary (85%) and Allowance
(80%) important;
Low Job Security:
3.
◦
Public (58%), UMMB (53%), UCMB (44%) and UPMB (37%)
Health Worker Concerns

Working Conditions:
◦ Manageable workload (52%);
◦ Availability of supplies (56%) - Public 36% and PNFPs (75%);
◦ Availability of Equipment (52%) - Public (27%) and PNFPs (76%);
◦ Access to electricity (55%) – Public (37%);
◦ Flexibility – Public (61%) and PNFPs (57%)
◦ Abuse (21%) – Public (24%) and PNFPs (22%)

Living Conditions:
◦ Poor transportation (72%);
◦ Poor access to good schooling (64%);
◦ Poor access to shops and entertainment (65%)
◦ Poor or unreliable electricity at home (65%)
Access to Drugs, Supplies
and Equipment (%)
Health workers concerns in the
Media
6. Conclusions
Recommendations
The main problemsand
regarding
HRH stem from gaps in

management which have led to:
(a) Low staffing and maldistribution
(b) Attrition and Brain Drain
Recommendations

There is need for improvements in HRH
Management and overall strengthening to Health
system

There is need to improve working and living
conditions particularly in Hard to Reach Areas so as
to retain;-(Retention Strategy, 2009, HRH SP 20052020)

CSOs advocacy HRH issues.
Acknowledgments/Bibliography
1.
2.
3.
4.
5.
6.
Ministry of Health (MoH), Annual Health Sector
Performance Report (AHSPR), 2008/2009, Uganda
MoH, Uganda Bureau of Statistics, (UBOS) Uganda
Service Provision Assessment Survey, (March 2008),
World Bank, Public Expenditure Review, Uganda
(2008)
Intra health Capacity project, Intent to Stay Study,
Uganda (2008)
AGHA/HWAF Research on Staffing Levels,
September, 2009
Doctors With Africa (CUAMM), Uganda, Presentation
by Dr. Peter Luchoro, to HWAF April 2009.