HEALTH WORKER SHORTFALL: IMPACT IN UGANDA

1. 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)

2. 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

3. 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….

4. 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.

5. Staffing Levels, cont’d • Significant shortage of certain categories of staff;- Medical Officers (MOs), and specialized cadres-psychiatrists • 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)

6. Regional Distribution of Medical and Clinical Officers

7. 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 • )

8. 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 sub-counties • Watchmen stepping in to prescribe! (ACSD exercise 2008)

9. 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

10. Kotido Recruitment 2007/08 selected positions

11. 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

12. Health Sector Actual (2008) and Projected (2020) Health Worker to Population Ratios and Numbers by Option

13. 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.

14. Characteristics of health workers who died/ left - Jan 2002- July 2008 (%)

15. Attrition rate of doctors, nurses/midwives and clinical officers in public sector for the years 2002 to 2007. Mulago Hospital excluded

16. Average annual attrition rate of health workers from 2002 to 2007 in 12 districts: Mulago hospital excluded

17. Attrition rate for Doctors, Nurses/Midwives, clinical officers at Mulago Hospital

18. Average Annual Attrition Rate of Health Workers by Cadre between 2002 to 2007 in PNFP Facilities

19. Job Stability: Intent to Leave/Stay • 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.

20. Intent to Leave by Cadre • Intent To Leave By Cadre

21. 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.

22. 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.

23. Absenteeism

24. 5. Health Worker Concerns • Job Satisfaction: • 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: • Consider salary package unfair (86%); • Considered Family Health Care (87%), Salary (85%) and Allowance (80%) important; • Low Job Security: • Public (58%), UMMB (53%), UCMB (44%) and UPMB (37%)

25. 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%)

26. Access to Drugs, Supplies and Equipment (%)

27. Health workers concerns in the Media

28. 6. Conclusions and Recommendations • The main problems regarding HRH stem from gaps in management which have led to: • Low staffing and maldistribution • 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 2005-2020) • CSOs advocacy HRH issues.

29. Acknowledgments/Bibliography • 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.