Our Side of the Story- A policy report on the lived experience and opinions of Ugandan health workers

Our Side of the Story
A policy report on the lived experience
and opinions of Ugandan health workersCoalition for Health Promotion
and Social Development

HEPS-Uganda, The Coalition for Health Promotion and Social Development
Established 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 medicines
for poor and vulnerable people in Uganda. HEPS promotes pro-people health policies and carries
out campaigns at local, national and regional levels. It also initiates and conducts research necessary
for health and human rights advocacy. Since 2007, HEPS-Uganda has actively promoted health
rights within seven local government districts, addressing maternal health and equitable access to
healthcare. Working in some of the most disadvantaged rural areas of Uganda, HEPS has trained
community 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 communicating
with health workers. For more details, visit: www.heps.or.ug
VSO Uganda
VSO Uganda volunteers are currently working in the central, western and northern regions of the
country, in the fields of participation and governance, disability, health, education and livelihoods.
Poor and disadvantaged people in Uganda are badly affected by preventable diseases. Health
service provision and access is low, and staff retention is a challenge. VSO is supporting the
Ugandan Government in implementing the Health Sector Strategic Plan (HSSP) to improve health
systems in the context of a decentralised health delivery system at district level. HSSP focuses on
working with communities and the implementation of primary and preventive healthcare services,
as well as good-quality, accessible clinical services as stipulated in the minimum healthcare
package. It has a particular emphasis on reaching the majority of the population, over 80% of
whom live in rural areas, where the people tend to be poorer than in urban settings. For more
details, visit: www.vsointernational.org/where-we-work/uganda.asp
VSO International
VSO 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 in
poverty – 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 in
the 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 recruited
and retained. They must be of good quality, in the right places, well trained and with access to
the basic equipment and drugs needed. They also need to be well supported – placed in the
right location, treated fairly and managed well.
Through our Valuing Health Workers research and advocacy project, VSO identifies the issues
that affect health workers’ ability to deliver quality healthcare. These findings will support
partners to carry out further research and make a significant contribution to improvements
in 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 workers
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Acknowledgements
The Valuing Health Workers research and advocacy project is the initiative of
VSO International. This report is based on research in Uganda in partnership with
HEPS-Uganda, the Coalition for Health Promotion and Social Development, and
with support from VSO Uganda. Thanks are due to Rosette Mutambi, executive
director of HEPS-Uganda, Sarah Kyobe, VSO Uganda health programme manager,
and Stephen Nock, VSO International policy and advocacy adviser, for their
practical support and encouragement.
Stacey-Anne Penny brought to the project her drive to explore and understand
the lived experience of Ugandan nurses and her invaluable contribution as
co-researcher up to August 2010. HEPS-Uganda colleagues provided a supportive
and friendly working environment. The following HEPS staff played practical roles
in managing consultative workshops, facilitating access to fieldwork sites and
co-convening and transcribing focus group discussions: Prima Kazoora, Phiona
Kulabako, Aaron Muhinda and Kenneth Mwehonge.
This report would not have been possible without the willing participation of
122 health workers across Uganda. Thank you to them for voicing the rewards
and challenges of their daily lives. Thank you to local managers for making
staff available, and to patients for their forbearance while their health workers
gave time to the research. Not least, thanks are due to the representatives of
organisations concerned with health worker and health consumer interests,
for their participation in workshops and interviews.
Patricia Thornton
Text: Patricia Thornton
Field research: Patricia Thornton, Stacey-Anne Penny, Prima Kazoora,
Phiona Kulabako, Aaron Muhinda and Kenneth Mwehonge
Editing: Stephen Nock, Diane Milan, Stephanie Debere and Emily Wooster.
Layout: www.revangeldesigns.co.uk
Photography: Cover photo © Matthew Oldfield/Science Photo Library
©VSO 2012 Unless indicated otherwise, any part of this publication may be reproduced without
permission 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 reproduction
with commercial ends, permission must first be obtained from VSO.
The views expressed in this report belong to individuals who participated in the research and may
not necessarily reflect the views of HEPS-Uganda, VSO Uganda or VSO International.
ISBN: 978 1903697 337

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Contents
Summary 6
1. Introduction 12
1.1 The VSO Valuing Health Workers initiative 12
1.2 The Valuing Health Workers research in Uganda 12
1.3 The research approach and participants 14
1.4 Structure of the report 14
2. Healthcare in Uganda: challenges and provision 15
2.1 Ugandan healthcare challenges 16
2.2 Formal healthcare provision 19
2.3 The Ugandan health workforce 21
3. Research design and methods 25
3.1 The research stages 25
3.2 Qualitative research methodology and the purposive sampling design 25
3.3 Data collection 26
3.4 Data analysis 26
3.5 The health worker participants 26
4. The rewards 28
4.1 Benefiting others 28
4.2 Job satisfaction 28
4.3 Being recognised, appreciated and valued 29
4.4 Appreciative and supportive management and colleagues 29
5. Reasons for becoming a health worker: the “right heart” and the “wrong heart” 30
5.1 A passion for the patients 30
5.2 “They join for the wrong reasons” 31
5.3 Recommendations 31
6. Workload 33
6.1 The context 33
6.2 The health worker experience 33
Unmanageable workloads 34
Too many tasks and responsibilities 34
Working day and night 34
Over-long shifts and too little time off 34
Impacts on health 34
Restricted professional development 34
Failing the patients 35
6.3 Factors contributing to understaffing and work overload 36

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7. The facility infrastructure 38
7.1 The context 38
Low job satisfaction 39
Risks to health workers 39
Risks to patients 39
8. Equipment and medical supplies 41
8.1 The context 41
9. Medicine supplies 44
9.1 The context 44
10. Pay 48
10.1 The context 48
Money worries 49
Failing to meet social expectations 49
Disrespect 49
Thwarted professional ambitions 49
Unfair pay 49
10.3 Poor pay, turnover and loss to Uganda 51
11. The way forward 53
11.1 Raising the voices of health workers 53
11.2 Changing public perceptions of health workers 55
11.3 Bridging patient communities and healthcare facilities and staff 55
11.4 Summary of participants’ recommendations 57
Appendix A: Sample details 59
Appendix B: Local government structures in Uganda 61
References 63
Annex: Health worker topic guide 66

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The Valuing Health Workers research
and advocacy initiative
The Valuing Health Workers research and advocacy project
is an initiative of VSO International. It recognises that health
workers’ voices must be heard and acted on to improve
access to healthcare and so help to achieve the Millennium
Development Goals. VSO International started participatory
research in four countries in Africa and Asia in partnership
with in-country non-governmental organisations. VSO carried
out research in Uganda from February 2010 to February 2011
in partnership with HEPS-Uganda, the Coalition for Health
Promotion and Social Development. VSO will support local
partners to use the research findings to advocate for health
workers in their countries, and will gather the research
evidence to advocate on a global level.
The research in Uganda
In Uganda, negative images of health workers are presented
in the media, political speeches, healthcare user research
and health consumer advocacy projects. It is said that health
workers absent themselves from work, are rude, neglectful
and abusive to patients, extort money from patients and steal
medicines. Yet policy documents acknowledge that many
health workers live and work in impoverished conditions.
The Valuing Health Workers research set out to explore with
frontline health workers and their managers how working
conditions affect attitudes, behaviour and practices. It also
sought the positive side of the health worker experience.
This report documents the experiences and views of 122 nursing
assistants, nurses, midwives, clinical officers and medical doctors,
including facility managers and local government district health
officers. The facility-based participants worked at 18 hospitals
and health centres in seven local government districts in all
regions of Uganda and in the capital city, Kampala, covering
government, not-for-profit and private ownership organisations.
Health worker participants contributed their perspectives in
small group discussions or individual interviews. In addition,
24 stakeholders from civil society organisations, trades unions,
professional associations and regulatory councils participated
in workshops or interviews.
Ugandan healthcare challenges
and provision
Uganda has the third-highest rate of population growth in the
world, with most people living in rural areas with extremely
poor access to electricity and low access to improved water
supplies. Maternal, infant and under-five death rates show
only small improvements. Malaria is the main sickness and a
major cause of childhood deaths. Uganda has only one doctor
per 10,000 people, and only 14 health workers (doctors, nurses
and midwives) per 10,000 people, significantly below the
23 health workers per 10,000 recommended by the World Health
Organisation (WHO). Medical doctors and the most highly
qualified nurses and midwives are concentrated in and around
the capital city. The Government of Uganda is committed under
the Abuja Declaration to apportion 15% of its budget to health,
but it has not exceeded 10% in the last 10 years.
Healthcare in the formal system is delivered in a hierarchy of
health centres and hospitals. Patients should be referred from
a lower- to a higher-level facility for the services they need.
The government runs 60% of hospitals and health centres;
around 20% are run by not-for-profit organisations (mostly
faith-based) and around 20% by private organisations. Fewer
than four in 10 Ugandans turn to health centres or hospitals
when they fall sick. Pregnant women and children are the
largest groups of patients.
Summary

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Reasons for becoming a health worker
and rewards of the work
The urge to help, prevent suffering and save lives stood out
among the reasons people gave for becoming a health worker.
It had been common in rural areas to see people suffer in pain
and die with no proper medical care. Their training would
bring to the community knowledge to help prevent illnesses,
discourage harmful traditional healing practices and save lives.
Participants who had been impressed by caring nurses and
the skills of medical staff wanted to give something in return.
Interest was stimulated by the example of family members who
worked in healthcare. Experiencing poor service also prompted
a desire to raise healthcare standards.
A desire for money was not a driving force. Clinical officers and
medical doctors told of expectations on them as the brightest
school 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 and
self-serving recruits, who resorted to bad habits and forgot
their accountability to patients.
The benefits to the community, to individual patients and to
their own families were the biggest sources of satisfaction. Job
satisfaction came from making a difference to patients, doing
their duty the best they could, using their skills and learning
through work. Health workers valued being appreciated,
respected and trusted by patients. Tangible demonstrations of
appreciation by managers were a huge positive, as were good
teamwork and supportive managers who created opportunities
for health workers to raise their concerns.
The impact of working conditions
Workload, workplace infrastructure, medical equipment and
supplies, the availability of essential medicines and the level of
remuneration affected health workers’ well-being, the quality
of care they could provide and relations with patient communities.
It is apparent from health workers’ experiences that working
conditions are the root cause of the attitudes, behaviours and
practices for which health workers have been criticised.
Workload
Ministry of Health sources reveal almost half of approved
posts at health centres and hospitals are vacant – a shortfall
of 25,506 staff. There are gross disparities across local
government districts, with four districts having less than
30% of posts filled, while 10 districts filled more than 70%.
Unmanageable workloads overwhelmed nurses and made
them physically and mentally ill. Too many tasks and
responsibilities led to burn-out. Lack of more qualified staff
meant taking on stressful roles beyond the scope of duty.
Participants told of working round the clock, foregoing meals
and compromising their health. Overlong shifts and limited
time off allowed little personal or family time. Feeling they
were failing the patients added to health workers’ distress.
Hospital nurses torn apart by calls for attention and too
many tasks recognised they could lose their temper. Midwife
behaviour changed as a result of working alone day and night.
Long, tiring shifts, when overwhelmed by the workload, led
to nurses being short with patients, not interacting with them
and conveying disinterest through attitude and expression.

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Managers and frontline doctors had seen how hunger made
nursing staff bad-tempered and rude to patients. It was said
that long shifts, together with poor pay, led nurses to not turn up
for duty and leave work early. Managers observed that lack of
opportunity to fulfil their proper professional role demotivated
nurses, who then ran out of compassion and skip out from
work. Work overload and staff shortages had impacted on
community relations, and participants told of aggressive
outpatients and wrongful accusations of neglect of duty.
Managers explained that financial allocations for salaries stood
in the way of recruiting more staff and that vacancies persisted
due to bureaucratic procedures. Paradoxically, scarcity of
staff was a barrier to holding public sector health workers to
account, as disciplinary procedures might lead to transfer and
an even worse workload for remaining staff.
Infrastructure
According to official sources, most facilities are in a state of
disrepair. Many health centres have non-functional operating
theatres. Only one in four facilities has electricity or a back-up
generator and only 31% have a year-round water supply.
Over half facilities lack transport for patient referral in maternal
emergencies and only 6% have technology to communicate.
Government sector workers in rural facilities bore the brunt
of infrastructure failures. When theatres were unusable,
underemployed doctors lost interest and left. Lack of electricity
compromised staff and patient safety. At night, patient notes
could be not read to ascertain HIV status and deliveries
were carried out by the light of a mobile phone or a candle.
Maternity workers said patients construed their behaviour as
rude or neglectful because they shied away from risk. Lack of
generator fuel meant operations were completed by torchlight.
Nurses feared assault working in unlit wards or crossing dark
compounds, a risk made worse by lockless doors, breaches in
compound 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. Infection
control was near impossible when nursing staff had to beg
the little water spared by patients’ family attendants to wash
their hands. It was deeply upsetting to know that poor patients
would die because the facility had no means of transporting
them 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 to
benefit community relations.
Equipment and medical supplies
The Ministry of Health acknowledges a shortage of basic
equipment in health facilities and that only 40% of equipment
in place is in good condition. An independent survey reveals
a gross lack of equipment for the diagnosis and treatment
of malaria, and that six in 10 facilities surveyed were not
equipped to measure haemoglobin.
Health workers praised well-equipped facilities and imaginative
management that solved temporary supply problems by
borrowing from other facilities. Elsewhere, working with
inadequate equipment was a huge challenge. There was
widespread 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 missing
or poorly maintained diagnostic equipment. In the government
sector, doctors and nurses told of interruptions in supplies of
oxygen 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 with
no delivery kit, cord clamp, sucker, gauze or cotton wool and
just one pair of scissors. The regulatory prohibition on asking
patients to buy medical supplies was a huge frustration which
challenged their ethical duty to do their best for their patients.
Managers recognised that doctors lose morale when unable to
operate, and that being unable to apply knowledge was very
demotivating. It was said that nurses forgot what they had
been taught and as a result some did not work, so projecting a
bad image to the community, which in turn made nurses feel
not respected and prompted them to leave. Health workers felt
blamed for the lack of supplies. They noted patients’ attitudes
change if asked to buy their own, with some carers becoming
angry and violent.
Availability of essential medicines
The proportion of health facilities registering ‘stock-outs’ in
essential medicines has consistently been over 60% for the
last 10 years. Not one of 40 essential medicines was available
in every government facility in a sample survey in the second
quarter of 2010. Only eight were found in each not-for-profit
sector facility surveyed.
Participants working outside the government sector mostly
considered medicine supplies adequate. In the government
sector there was sharp contrast between praise for the better
stocked facilities and disgruntlement that essential drugs were

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used up in a matter of weeks or even days. Complaints centred
on undersupply for population demand; shortfalls in supply
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 promised quarterly schedules.
Unable to give their patients the drugs they needed, health
workers became demoralised by the futility of their roles,
and their self-esteem suffered when patients lost confidence
in them. Health workers grieved for their patients’ suffering
from the lack of medicines, such as antiretroviral drugs, which
should be taken on a lifelong basis. Helplessness was hard to
bear when they felt forced to tell poor patients to buy their
medication in the private market. Health workers struggled
with disappointed patients and their limited understanding of
reasons for shortfalls in supplies. They also told of angry, bitter
patients who cursed them and refused to listen. They said that
communities served by government facilities assumed health
workers took the drugs.
There was widespread indignation at accusations of stealing
non-existent medications. Health workers resented negative
stories in the media and felt that local leaders and politicians
made matters worse when they failed to present the true
picture to complaining patients, and even accused health
workers in front of patients. There was hurt and indignation
about top public figures spoiling the professions’ reputations
by stating publicly that health workers are thieves.
Pay
Ugandan nurses’ and doctors’ salaries are the lowest in East
Africa. Monthly starting salaries in public service in 2009-10
were 353,887 UGX (Ugandan Shillings) ($US 191) for a registered
nurse and 657,490 UGX (($US 354) for a medical officer. High
court judges received 6.8 million UGX (($US 3,664) per month.1
Nursing staff spoke heatedly about their struggles to survive
on low pay and support their dependents, see their children
through education, pay for a roof over their heads, settle
essential bills, afford transport to work and save towards
the costs of further training. Financial worries added to the
stresses caused by impoverished workplaces. Doctors felt
socially embarrassed when they could not contribute large
sums of money at functions held to raise funds for weddings or
funerals, or meet expectations to help with school fees. It was
said that patients look down on nurses when they know how
little they are paid. Participants voiced strong opinions that
the pay was unfair and undervalued health workers. Nurses
complained that their salaries did not reflect the years of study
they had put in, and going unrewarded for doing the same
work as higher grade staff was thought bitterly unfair. Doctors
being paid less than secretaries and drivers in some statutory
agencies underscored the little value attached to the medical
profession in Uganda. Salaries were doubly unfair because they
did 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 on
patients, small-scale pilfering of drugs and accepting money
offered by patients. It was widely believed that urban health
workers were forced to work in two or even three jobs to make
ends meet, leading to exhaustion and behaviour which patients
perceived as rude.
Better pay was not an overriding consideration for working
outside Uganda. Nurses explained they were looking for an
environment where their work would be respected and
where they could learn about different medical conditions,
use equipment they were trained to use, update their skills
and have the chance to advance professionally. Doctors spoke
about the attraction of a better income from work abroad, but
opportunities to use proper equipment and enjoy the work
also were important.
Conclusions and participants’
recommendations
Health workers’ accounts show that working conditions were
the root causes of bad practices and unethical behaviour, and
that health workers bore the brunt of the blame for system
failures. The research revealed a vicious circle: impoverished
working environments and low pay affected the quality of
patient care; patients blamed the health workers; the wider
community then distrusted health workers and so health
workers’ distress increased. The situation was made worse by
negative media stories and political leaders’ vocal criticism of
health workers, which fuelled public distrust, damaged the
standing of the profession, added to health workers’ distress
and raised the barriers to access to healthcare.
The view of civil society organisations and of some managers was
that frontline health workers are not empowered to speak up.
The concept of ‘voice’ was unfamiliar to many frontline health
workers in the research, and the idea that they might speak out
and gain support to improve poor working conditions and quality
of care was new to them. The research identified barriers to
individual health workers voicing their concerns, and health
workers’ preferences for advocacy by representative organisations.
1. US dollar = 1,856 Ugandan Shillings at 31 March 2010

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The findings identified two priorities for action:
to value health workers for their contributions to the health1.
of Ugandans
to expose the poor working conditions that prevent health2.
workers from providing good quality healthcare.
Four enabling strategies emerged from health workers’
accounts and stakeholder advice:
to improve the quality and relevance of training1.
to raise the voices of health workers through representation2.
to change public perceptions through the media3.
to build bridges with patient communities.4.
Priorities
1. Value health workers for their contributions
to the health of Ugandans
Health worker terms and conditions of service
Review salary scales to determine whether increases in•
basic salaries are possible. Reform government salary
scales to recognise first and postgraduate degrees, in order
to attract degree nurses to public sector jobs and ensure
their education is used to support patient care directly.
Consider the establishment of a minimum wage and•
the feasibility of imposing the same salary structure
in 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 when•
a nurse has sole charge of a ward.
Small financial motivations
Incentivise staff through small items of personal support, such•
as food for the household, snacks at work, and Christmas and
Easter gifts. Contributions towards family burials, medical
operations and provision of cloth for uniforms are well received.
Review current allowances for risk, hardship, housing,•
transport, responsibility and study, to ensure consistency
and fairness across all facilities.
Use the income from local government hospitals’ private•
wings to benefit staff, by supplementing salaries or allowances.
2. Ensure working conditions enable health
workers to provide good-quality healthcare
Health worker/patient ratios
Introduce standards for patient/nurse and patient/doctor•
ratios, so that health worker overload is transparent and
quantifiable, and managers have information to help reduce
pressure on overloaded staff.
Recruitment blockages
Manage health worker recruitment and deployment•
centrally, to address the problem of unfilled posts and
uneven distribution of health workers.
Decent staff accommodation
The Government should follow through on its strategy to•
provide decent and safe accommodation for health workers
at health facilities, especially in remote areas. Civil society
organisations should continue to monitor implementation
of this strategy and press for concrete targets.
Facility infrastructure
Ensure regular meetings between management and•
department heads, at which facility-related problems
can be raised and decisions taken on actions needed.
Invest in good theatre facilities and their staffing in a small•
number of level IV health centres, and showcase them as
good practice before embarking on further investment.
Equipment, medical and medicine supplies
Give much more attention to the maintenance and quick•
repair of medical equipment, including systems for monitoring
equipment maintenance and adequate stocks of spare parts.
Hold regular formal consultations with frontline workers•
to enable them to participate in decision-making about
equipment and supplies, and to improve transparency
in equipment procurement processes.
Encourage international donors to provide large items•
of equipment directly.
Enabling strategies
1. Improve the quality and relevance
of health worker training
Career guidance and early contact
Ensure well-motivated trainees, for example through•
more talks at schools and work experience placements.
Training schools’ admission procedures
Reject applicants who seem to be applying for the “wrong•
reasons”, including those allocated to a university course
which 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 from•
the Ministry of Education and Sports.
Reduce nursing and midwifery class-sizes and improve•
tutor capacity, to ensure the right attitudes and practical
understanding of the ethical code are encouraged
throughout pre-qualification training.

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Health and human rights training
Expand existing partnerships between training institutions•
and health consumer advocacy organisations. Improve
nursing course content to make sure that students take
on board the role of the nurse as a patient’s advocate.
De-urbanise health worker training
Increase the number of training schools and residency•
programmes in rural areas to produce staff already adapted
to rural environments and connected to the local community.
Improve the community service element in medical curricula•
and increase the exposure of urban health students to rural
settings with increased fieldwork.
Nurses and Midwives Council registration interviews
The Nurses and Midwives Council should weigh up the•
advantages of screening interviews held as a prerequisite
for registration post-qualification against detrimental
effects on nurse morale.
2. Raise the voices of health workers
Sharing of experience and common approaches
Encourage staff to meet with people from other healthcare•
facilities to discuss solutions to common problems and
communicate them to sub-district level managers. These
managers could also be encouraged to instigate similar forums.
Speaking through professional associations, unions and
regulatory councils
Channel health worker concerns to the Ministry of Health,•
Government or Parliament through bodies that speak for
them, such as professional organisations and trade unions.
Professional associations and unions should do more to bring•
members together, for instance at local general meetings,
and make greater efforts to visit facilities and talk with health
workers so that the “right voices” can be taken to the top.
They should compile strong collective arguments to improve
conditions in the workplace, as well as addressing individual
grievances and traditional welfare issues.
The Health Workforce Advocacy Forum – Uganda (a coalition•
of health professional associations, unions and health rights
organisations) should expand its membership and continue its
campaign for a positive practice environment for health workers.
3. Change public perceptions by influencing the media
Inform journalists about the obstacles to health worker•
recruitment and discourage them from writing sensationalist
or negative stories in the media. Put complaints on local
language radio call-in shows into a wider context. Encourage
the running of positive human interest features, such as
profiles of individual health workers and the work they do.
Work with the Uganda Health Communication Alliance.
Improve the capacity of civil society and health worker•
organisations to write press releases, hold press conferences
and build relationships with individual reporters and media
houses, so the key campaign messages hit home.
4. Build bridges between patient communities,
healthcare facilities and staff
Transparency on drug availability
Use well-managed public opening of medicine deliveries to•
help 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. Support
with paperwork to show what has been ordered and delivered.
Ensure that local leaders are fully informed through regular•
meetings about the demand for and supply of drugs and that
they use this information responsibly.
Connecting communities and facilities
Use opportunities to talk with people on their own ground•
and explain the problems health workers face, for instance
through Village Health Teams, facility-based health workers
providing outreach immunisation services, and talks to
women awaiting prenatal checks.
Promote ‘community dialogue’ meetings bringing together•
service users, local leaders and health unit management
teams. Increase funds to cover these activities.
Invite top local politicians to spend time in facilities alongside•
staff to see what the work is really like.
Civil society organisations should continue their work to•
create common cause between health workers and patients.

1.2 The Valuing Health Workers
research in Uganda
In Uganda negative images of health workers are
projected in the media, political speeches, policy
documents, healthcare user research and health
consumer advocacy work. The overriding message
is that health workers’ attitudes, behaviour and
practices present barriers to accessing healthcare.
The Valuing Health Workers research in Uganda
set out to explore with frontline health workers
and their managers the conditions underlying
accusations of unethical behaviour and service
inadequacies. The overall objective was to give
opinion formers and healthcare service users
a realistic picture of what life is like as a health
worker in Uganda, so as to increase understanding
and modify expectations. Ugandan civil society
organisations will use the findings to help build
mutual understanding and promote harmonious
relationships between healthcare users and
workers, as well as to advocate for improved
conditions for health workers in Uganda.
It has been well-documented through research
and health rights projects that healthcare
users in Uganda experience from health workers
bad attitudes, rudeness, inhumane treatment,
neglect, discrimination and extortion of illegal
fees for services. They also face staff absences
and the unavailability of medicines and other
treatment supplies.2
Research has reported
patient community perceptions that drugs are
stolen.3
The press and radio media have fuelled
negative perceptions of health workers’ behaviour,
branding them as shirkers and thieves.4
Indeed,
the media have reported leaders in government
accusing health workers of stealing medicines.
1. Introduction
2. See Kiwanuka et al 2008 for a systematic research review
3. Kiguli et al 2009
4. Medicines and Health Service Delivery Monitoring Unit
2010 lists 43 press articles in under one year, almost all
reporting negatively on health worker behaviour
1.1 The VSO Valuing Health
Workers initiative
What is life like working in healthcare in
a low-income country? What prompts
nurses, midwives and doctors to take
up their professions and what are the
rewards? What do health workers say
about the barriers they face in providing
access to healthcare? What in their view
needs to change? And how can their voices
be heard? VSO’s Valuing Health Workers
initiative is listening to the experiences of
health workers and gathering evidence to
advocate for change.
The lived experience and opinions of health workers
are rarely recorded in the many explorations of
solutions to the health worker crisis affecting the
developing world. Health workers are commonly
seen as ‘human resources’, as a part of a healthcare
delivery mechanism to which ‘levers’ may be applied,
and not as human beings whose individual actions are
influenced by the societies and conditions in which
they live and work. Rather, performance management
techniques and incentives to attract and retain staff
dominate research and policy.
VSO International set out to redress this imbalance
through its Valuing Health Workers research and
advocacy initiative. Recognising that health workers’
voices must be heard and acted on to improve access
to healthcare, and so help to achieve the Millennium
Development Goals, VSO International started
participatory research in four countries in Africa and
Asia, in partnership with in-country non-governmental
organisations. VSO will support local partners to use
the research findings to advocate for health workers in
their countries, and will gather the research evidence
to advocate on a global level.

13
Even Ugandan health policy documents have commented
negatively on health workers’ low productivity, high absence
rates, poor attitudes and lack of accountability to client
communities. Organisations promoting health rights have seen
distrust and hostility among communities and some defensive
reactions 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 the
workplace, limited and poor-quality staff accommodation,
and harassment; it also recognises that staff endure poor
supervision and leadership and a lack of promotion, training
opportunities and career progression.5
Facilities and equipment
in states of disrepair, and shortages and wastage of medicines,
have been pervasive problems.6
Yet little attention has been paid to the impacts of working
conditions on the lives of healthcare staff, and so on the quality
of services they can provide. Research on or with Ugandan
health workers has focussed on workforce retention questions,
such as migration, intent to migrate and turnover.7
It has
measured job satisfaction and quantified work factors related to
intent to stay or leave.8
A second area of research has measured
health workers’ informal income generation practices, such as
spending working hours engaged in agriculture and operating
private clinics, and has quantified absenteeism.9 10
Certainly,
some research reports include the voiced experiences of health
workers.11
But only exceptionally has research started from the
viewpoint of health staff as workers and members of families
and communities, as opposed to the viewpoint of the system.12
Only one study has focussed on the distress and emotional toll of
working with insufficient resources for acceptable levels of care.13
The starting assumption of the Valuing Health Workers research
in Uganda was that health workers are unfairly blamed for
attitudes and behaviour caused by the system in which they work.
Health workers are human beings – men and women with their
own worries, working in very challenging circumstances – and
they develop ways of coping with difficulties, frustrations and
being under-valued. The research does not condone unethical
or unprofessional behaviour and dereliction of duty, but it does
not brand as ‘quiet corruption’ absences from the workplace
and external income-generating activities.14
Such ‘moralising
finger-wagging’15
, which addresses issues in terms of lack of
motivation, corruption and betrayal of professional codes of
conduct, diverts attention from structural conditions and social
and cultural environments.16
The research set out to challenge the overwhelmingly negative
commentary on Ugandan health workers. It wanted to hear the
positive side from health workers themselves: their passion for
their professions, commitment to patients and communities,
determination to give their best and the satisfaction gained
from contributing what they can.
The research was especially concerned to find ways of
bridging the seemingly widening gap between communities
and healthcare facility staff. Projects on the ground in Uganda
have tended to focus on promoting the rights of healthcare
users and increasing the community role in monitoring health
workers.17
While less attention has been given to the health
worker side, community-based projects have latterly fostered
mutually respectful relationships.18
Research in Uganda and five
other African countries recommended improved understanding
of the roles of health workers and encouragement of mutual
respect through better communication and interaction.19
5. Ministry of Health 2006
6. Ministry of Health 2010a; 2010b
7. Awases et al 2004; Dambisya 2004; Nguyen et al 2008; Onzubo 2007; O’Neil and Paydos 2008
8. Ministry of Health 2009a; Hagopian et al 2009
9. McPake et al 1999; McPake et al 2000
10. Chaudhury et al 2006; UNHCO 2010
11. Ministry of Health 2009a; UNFPA Uganda Country Office 2009
12. Kyaddondo and Whyte 2003
13. Harrowing and Mill 2010; Harrowing 2011
14. World Bank 2010
15. Van Lerberghe et al 2000 p3
16. Schwalbach et al 2000
17. Björkman and Svensson 2007
18. Muhinda et al 2008
19. Awases et al 2004

14
1.3 The research approach
and participants
VSO carried out the research in Uganda from February 2010 to
February 2011 in partnership with HEPS-Uganda, the Coalition
for Health Promotion and Social Development.
Using qualitative research methods, the researchers
encouraged health workers to speak freely in response to open
questions, promising that identities would not be revealed.
In all, 122 health workers – medical doctors, clinical officers,
nurses, midwives and nursing assistants (including frontline
workers, facility managers and local government district health
officers) – participated in small group discussions and individual
interviews at their workplaces. The facility-based participants
were working at 18 hospitals and health centres in seven local
government districts in all regions of Uganda and in the capital
city, Kampala. The selection of facilities took account of region,
the extent to which the district was easy or hard to serve, the
level of hospital and health centre, location (urban or rural) and
ownership (government, not-for-profit or private sector). Many
participants drew on their prior experiences from training or
working in different sectors and levels of healthcare facility.
In addition, 24 stakeholders from civil society organisations,
trades unions, professional associations and regulatory councils
contributed their perspectives on the issues facing health
workers in Uganda, through workshops and individual interviews.
1.4 Structure of the report
Chapter 2 introduces the main challenges to healthcare
provision in Uganda, outlines healthcare provision and
patterns of use, and describes the health workforce.
The research approach is described in Chapter 3, along with an
overview of the participants (with further details in Appendix A).
Chapter 4 presents what participants said about the rewards
of being a health worker. Chapter 5 looks at why they became
health workers.
The chapters that follow address elements of the main themes
that emerged from the participatory research – the impacts
of workload (Chapter 6); the infrastructure of the healthcare
facilities (Chapter 7); the availability of medical equipment and
supplies (Chapter 8); supplies of medicines (Chapter 9); and
levels of remuneration (Chapter 10).
Each element is followed by the relevant recommendations
for change drawn from health workers’ and stakeholders’
contributions. Chapter 11 lists all recommendations under
potential strategies for change.

15
2. Healthcare in Uganda:
challenges and provision
Summary
A major challenge for the Ugandan healthcare system is the
rapidly growing population, with the third-highest growth rate
in the world and a strikingly high birth rate (especially among
teenage women) and a very young profile. A further challenge
is serving the exceptionally high proportion of the population
residing in rural areas, who have extremely poor access to
electricity and low access to improved water supplies. Although
declining somewhat, maternal, infant and under-five death
rates are still not under control. Malaria is the main sickness
and a major cause of childhood deaths.
Uganda has only one doctor per 10,000 people, and only
14 health workers (doctors, nurses and midwives) per 10,000
people. This is significantly below the level of 23 health
workers per 10,000 people recommended by the World Health
Organisation (WHO). Only four other countries have poorer
provision of hospital beds. Only 16 countries worldwide spend
smaller proportions of their Gross Domestic Product on health
than Uganda. Although the Government of Uganda is committed
under the Ajuba declaration to apportion 15% of its budget to
health, its expenditure on health has never exceeded 10% of
total public expenditure.
Most healthcare in the formal system is delivered at health
centres and at hospitals at national, regional and district levels.
One in five local government districts had no hospital when
an official inventory of the (then) 80 districts was drawn up in
2010. Each sub-district should have a health centre IV, headed
by a medical doctor and providing emergency surgery: five of
the 80 districts in the inventory had no health centre IV at all
and a further 23 had one only. The situation is likely to have
worsened with the continuing creation of districts, to total 112
in mid-2010. One in four facilities is classified as a health centre
III and should provide maternity, in-patient and laboratory
services. Two-thirds of health facilities are classed as health
centre II, intended for preventive services and outpatient
curative 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 under
20%. Private for-profit organisations run just over 20% of the
officially-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 or
hospitals when they fall sick. The rural population uses health
centres more than urban dwellers, while the urban population
uses hospitals more than people in rural areas. The poorer you
are in Uganda, the more likely you are to go to a government
health centre. Children and pregnant women are the largest
groups of health facility patients. Over one in four Ugandans
lives 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 health
workforce shows extreme shortfalls of the most highly qualified
occupational groups, and mal-distribution across the country.
Although the aim is to phase nursing assistants out, Uganda
has relied heavily on them , especially in rural areas. Medical
doctors and the most highly qualified midwives and nurses
are concentrated in urban areas, especially in and around
the capital city. An estimated four in 10 of the facility-based
workforce are in the government sector, 30% in the not-for-
profit and 30% in the private sector. Medical doctors are
concentrated in the private sector although there are high rates
of dual employment, with medical doctors working in both
private and government sectors. Half the medical doctors and
four in ten nurses employed in government facilities work in
the regional and national referral hospitals.

16
2.1 Ugandan healthcare challenges
Uganda is one of the 48 least-developed countries of the world.20
It stands at 143 out of the 169 countries in the United Nations
Human Development Index, and is classed as a low human
development country. The United Nations Development
Programme (UNDP) publishes statistics for the indicators
used in the Human Development Index.21
These allow
comparisons between Uganda and other least-developed
countries, Sub-Saharan Africa and the world overall.22
20. Countries with less than 75 million population, gross national income per capita of under $905, high economic vulnerability and combined poor indicators
of under-five mortality, undernourishment, secondary school enrolment and adult literacy.
21. United Nations Human Development Programme 2010, Statistical Annex
22. 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 2010
24. 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).
Population growth and mortality indicators in international context25
Total population: 30.7 million
Aged 0-14 years 50.8%
Aged 14-64 years 46.1%
Aged 65+ years 3.1%
Estimated population 201023
Table 1
Table 2
Uganda
Sub-Saharan
Africa
Least-Developed
Countries
World
Average annual population growth (2010-15) (%) 3.2 2.4 2.2 1.1
Median age (2010) 15.6 18.6 19.9 29.1
Total fertility rate (2010-15) 5.9 3.6 4.1 2.3
Number of births per 1000 women age 15-19 150.0 122.3 104.5 53.7
Contraceptive 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 44
Under-five mortality per 1000 live births (2008) 135 144 126 63
Maternal mortality ratio per 100,000 live births 550 881 786 273
Life expectancy at birth (2010) 54.1 52.7 57.7 69.3
Population growth and birth rates
Uganda’s rate of population growth (3.2 %) is the third-highest
in the world. It is a very young population with an average age
of 15.6 years, the second-lowest in the world. The average
woman will give birth to 5.9 children if she lives to the age
of 50; only three countries have a higher fertility rate than
Uganda. The birth rate among women aged 15 to 19 is also
striking: 150 per 1000 women, which is considerably higher
than in Sub-Saharan Africa overall and is surpassed in only
two 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 mortality
In Uganda, 85 of every thousand babies born alive are likely
to die before their first birthday (the infant mortality rate) and
135 of every thousand are likely to die before they are five (the
under-five mortality rate). These rates are somewhat higher
than for least-developed countries overall and somewhat lower
than for Sub-Saharan Africa, yet they are close to twice global
rates. Maternal deaths (the death of women while pregnant or
within 42 days of the end of pregnancy) are estimated by UNDP
to be 550 for every 100,000 live births, a considerably better
ratio than across Sub-Saharan Africa, but twice the global ratio.24
At 54.1 years, life expectancy stands above that of Sub-Saharan
Africa but falls far short of the 69.3 years in the world overall.

17
26. World Health Organisation 2010
27. Ministry of Finance, Planning and Economic Development 2010
28. Baryahirwa 2010
29. Ministry of Health 2010a
30. Ibid.
32. Ministry of Health 2010b
Rural population, access to electricity
and to improved water
Only 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 of
inhabitants with no access to electricity, 91.1%. A third of
its population has no access to improved water; 25 countries
have worse access than Uganda. Over half of the population
(52%) has no access to improved sanitation, a better rate
than most low human development countries.
Availability of formal healthcare
Uganda has one doctor for every 10,000 people. With only
14 doctors, nurses and midwives for every 10,000 people
Uganda is one of 44 low-income countries that do not meet
the WHO minimum threshold of 23 doctors, nurses and
midwives per 10,000 population necessary to deliver
essential maternal and child health services.26
Uganda has four hospital beds per 10,000 people; in only four
other countries is the ratio lower. The proportion of women
making at least one antenatal visit is high, at 94%, but the
proportion of births attended by skilled health personnel drops
to 42%. The Uganda Millennium Development Goals report
for 2010 gives the following information.27
An expectant
mother’s first antenatal visit is late in the pregnancy, a median
of 5.5 months. Among the poorest fifth of the population, the
share of births attended by skilled health personnel was
29% in 2005-06 compared to 77% among the wealthiest fifth.
There are also large urban-rural inequalities: 80% of deliveries
in urban areas were attended by a doctor, nurse or midwife
but only 37% in rural areas.
Medical doctor per 10,000 people* 1
Doctors, nurses and midwives per 10,000** 14
Hospital beds per 10,000 people* 4
Antenatal coverage of at least one visit (%)* 94
Births attended by skilled health personnel (%)* 42
*UNDP 2010; **WHO 2010
Availability of formal healthcare
Table 3
Disease in Uganda
Sickness is normal rather than exceptional. Over 4 in 10
household members surveyed (43%) said they had fallen sick
in the previous 30 days; malaria or fever is by far the most
prevalent illness, reported by over half, followed by respiratory
illnesses which affected 15%.28
Seventy per cent of child deaths
are due to disease or malnutrition, with malaria accounting for
one third of these deaths.29
HIV prevalence fell to 7% in 2007-08 from 27% in 2000-01.30
Yet the number of people living with HIV in 2010, around
1.2 million, was higher than at the peak of the epidemic in
the 1990s.31
The WHO ranked Uganda 16th of the 22 countries
with a high tuberculosis burden in 2010. Uganda has the
second highest accident burden.32

18
Education (% 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$) 74
Ugandan public expenditure33
Table 4Public expenditure on health
Uganda’s public expenditure on health stands at 1.6% of
Gross National Product (GDP) (in 2008). Only 16 countries
spend smaller proportions of GDP on health than Uganda.
At 2.3% of GDP, Ugandan military expenditure is almost
50% more than its health expenditure; only 10 other low
human development countries devote higher proportions
of GDP to military than to health.
Government of Uganda health expenditure as a percentage
of total government expenditure in 2009-10 was estimated
at 9.6%. The proportion is 2.1 points above that of 2000-01
and just under that of the peak year of 2004-05, and continues
to stand well below the Ajuba target34
and the Government’s
own target of 15% by 2014-15. From Table 5 it may be
deduced that the Government funded almost 60% of health
expenditure in 2009-10, while donor projects accounted for
40%. It should be noted that several development partners
channel development assistance through off-budget support:
government estimates indicate that 77% of health project
support in 2009-10 was off-budget.35
Health financing and expenditure 2000-01 to 2009-1036
(in billion Uganda shillings)
Table 5
Year
Government of
Uganda funding
Donor Projects
and Global
Health Initiatives
Total
Government health
expenditure as % of total
government expenditure
2000/01 124.23 114.77 239.00 7.5
2001/02 169.79 144.07 313.86 8.9
2002/03 195.96 141.96 337.92 9.4
2003/04 207.80 175.27 383.07 9.6
2004/05 219.56 146.74 366.30 9.7
2005/06 229.86 268.38 498.24 8.9
2006/07 242.63 139.23 381.86 9.3
2007/08 277.36 141.12 418.48 9.0
2008/09 375.46 253.00 628.46 8.3
2009/10* 435.80 301.80 737.60 9.6
*Provisional Budget outturn 2009-10
34. 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 2.2
36. Ministry of Health 2010b table 2.3

19
2.2 Formal healthcare provision
In Ugandan policy, the healthcare system comprises services
accessed at health units (hospitals, health centres, clinics and
‘drug shops’ selling medicines) and community services which
range from home-based care (typically provided by organisations
funded through overseas aid) to traditional and complementary
medicine practitioners. Approximately 60% of Uganda’s
population seeks care from traditional and complementary
medicine practitioners (herbalists, bone-setters, birth attendants,
hydro-therapists, spiritualists and dentists) before and after
visiting the formal sector.37
It is reported that birth attendants
constitute 12.3% of traditional healers and have organised a
registered association with about 60,000 members.38
Within the formal system, healthcare is provided primarily
in hospitals and health centres run by the government,
not-for-profit organisations and private profit-making
organisations. Not-for-profit providers, three-quarters of which
are under the umbrellas of the Protestant, Catholic, Muslim and
Orthodox Medical Bureaux, are well integrated into the public
health system. The government oversees not-for-profit facilities
within its devolved district management system and subsidises
them at around 16% in 2008-09, down from 22% in 2007-08.39
The expansion of private health providers has been described
by the Ministry of Health itself as “largely unregulated and
chaotic”.40
There are innumerable unregistered private sector
units, including drug shops. A count in 2005 in three districts
found government and not-for-profit units together made up as
little as 4% of all health units.41
The Ministry of Health’s recent inventory of facilities, drawn up
in 2010, lists 4,441 facilities officially registered as a hospital or
health 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 hospitals
Health centres and hospitals are structured in tiers in line with
the local government structure (see Appendix B). The original
lowest level of health centre (health centre I), equivalent to
an aid post, has been phased out. Now the Ministry of Health
is promoting Village Health Teams. Unpaid local people are
trained to increase health awareness, as well as to treat minor
illnesses, and are expected to link communities with health
centres. In late November 2009, teams had been established
in three-quarters of districts, but only a third of districts had
trained teams in all villages.43
The size of population served and the services that should
be offered by health centres increase from the bottom
level upwards. A health centre II should provide preventive,
promotive and outpatient curative health services. The
Ministry of Health’s inventory shows over a quarter of health
centre II facilities located in the capital, Kampala, with 98.5%
of those in private hands. Some 95% of private health centre IIs
were found in four districts, including Kampala. A health centre
III 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 blood
transfusion in addition to the types of services a health centre
III should offer, and should be headed by a medical doctor. In
2009-10, less than 25% of the 119 health centre IVs reporting
to the Ministry of Health provided at least 10 of 12 key services
expected of a health centre IV, and only 57% of those had a
medical officer.44
Five of the 80 districts in the inventory had
no health centre IV at all and a further 23 had one only.
Health facilities by level and ownership
Table 6
38. Nabudere et al 2010
39. Republic of Uganda 2010
40. Ministry of Health 2009c p3
41. Konde-Lule et al 2007
42. Retrieved at www.unfpa.org/sowmy/resources/en/library.htm Includes 134 facilities under construction or otherwise not functioning
44. Ministry of Health 2010b Table 5.3
Hospital Health Centre IV Health Centre III Health Centre II Total
No. % No. % No. % No. % No. %
Government 65 49.6 165 92.7 847 76.0 1572 52.1 2649 59.7
Not-for-profit 57 43.5 12 6.7 241 21.7 486 16.1 796 17.9
Private 9 6.9 1 0.6 26 2.3 960 31.8 996 22.4
Total 131 100 178 100 1114 100 3018 100 4441 100

20
The next tier up is the general hospital at district level, to which
a health centre IV should refer patients it cannot serve. The
Ministry of Health’s inventory shows that 15 out of 80 districts
had no hospital. The problem of providing a district-level
hospital has become more acute since the number of districts
reached 112 in mid-2010. A general hospital is expected to
refer patients to the nearest of the 13 government-sector
regional referral hospitals for services not available at general
hospitals. Current policy does not allow not-for-profit or
private hospitals to be designated as regional referral hospitals,
although in practice some not-for-profit general hospitals fulfil
that role. The main national referral hospital stands at the top of
the pyramid and provides specialist services.45
Patients may, and
often do, by-pass lower levels and go direct a referral hospital.
The central government oversees the semi-autonomous
national and regional referral hospitals. Since decentralisation
in 2006, district health offices oversee general hospitals and
health centres. Health sub-districts are expected to plan,
conduct in-service training, coordinate service delivery and
supervise their lower-level health units. They are normally
headed by a medical doctor at a general hospital or an
upgraded health centre IV.
All local government health centres and hospitals must have
a Health Unit Management Committee (HUMC) which should
oversee the running of the facility. Committee members
can be selected by the District Council, locally elected or
appointed because they hold other positions. They have
been recommended as vehicles for community participation,
but have been reported as not functioning as expected.46 47
HUMCs had a chequered reputation in the past, believed to
be implicated in disappearance of medicines and distrusted
by local communities.48
They rarely met after the abolition of
user 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 in
both government and not-for-profit facilities.50
Patterns of use of health facilities
The vast majority of Ugandans, 93%, seek treatment for
sickness.51
Ugandans turn to private clinics and drug shops for
walk-in healthcare and medication, and favour health centres
and hospitals for more serious conditions and in-patient care.52
Well over half (58%) go to drug shops and private clinics, 28%
to health centres and nine% to hospitals; considerably higher
proportions of rural than urban dwellers use health centres,
while higher proportions of urban dwellers use hospitals.53
The poorer you are in Uganda, the more likely you are to go to
a government health centre. Almost half of the poorest tenth
of the population use a government health centre, compared
with only 12% of the richest tenth. Moreover, the poorest
tenth almost doubled their use over a five-year period, while
the richest 10% increased use only marginally.54
In 2010, over
one in four Ugandans (28%) lived more than five kilometres
from the nearest health facility.55
The government has invested
in improving physical access to healthcare by building more
health units. By 2009-10 the average distance to a government
health centre was 4.6 kilometres, which the majority of people
walk (75%) or cycle (14%).56
Children and pregnant women are the largest groups of health
facility patients: 38% are children aged 0-14, with the majority
(97%) seeking immunisation services; and 38% are women
seeking antenatal and delivery care services.57
The proportion
of deliveries in government and not-for-profit facilities in
2009-10 was 33%.58
In contrast, traditional birth attendants
assisted 23% of deliveries, and relatives or other unskilled
helpers 25% in 2005-06.59
45. The other national referral hospital is a psychiatric hospital.
46. Kapiriri et al 2003
47. Rutebemberawa et al 2009
48. Azfar et al n.d
49. Burnham et al 2004
50. Kidder 2010
51. Uganda Bureau of Statistics 2008
52. Konde-Lule et al 2007
53. Baryahirwa 2010
56. Baguma 2010

21
61. 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 2010
62. World Health Organisation Global Atlas of the Health Workforce
63. East, Central, and Southern African Health Community 2010
64. Banerjee et al 2005
66. UNFPA 2010
2.3 The Ugandan health workforce
There are no available up-to-date data on the constitution of
the Ugandan health workforce. The prime source is the 2002
Population and Housing Census.60
The census recorded people
who had worked paid or unpaid in a health occupation in the
previous seven days. Most commentary relies on the census
data.61
In addition, WHO has produced estimates for 2004 and
2005.62
These cover people working full-time in paid activities
in organisations whose primary intent is to improve health, as
well as those whose personal actions are primarily intended to
improve health but who work for other types of organisation.
Occupations: numbers and density
This chapter focuses on the main occupational groups (Box 1).
Box 1
The 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 consultant
depends on the availability of posts.63
The clinical officer is a distinct cadre in Uganda, termed medical assistant prior to 1996. Clinical officers undergo
three years’ training in specialist schools. Their clinical work has expanded from diagnosis and treatment, including
prescribing, 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 health
centre IV lacks a medical doctor, the clinical officer provides both outpatient and inpatient services, except for major
surgery. Clinical officers are often responsible for administration as the person ‘in charge’ of a health centre.64 65
Nurses and midwives fall into three groups within the Ugandan health system: registered nurses, registered midwives
or those doubly registered as nurse and midwife (that is, with a diploma or degree in nursing); enrolled nurses, enrolled
midwives or those enrolled as both (that is, having completed a certificate programme); and comprehensive nurses, either
registered 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 general
nursing, midwifery, public health, psychiatry, paediatrics and management, and able to provide basic health services in
primary healthcare. Enrolled comprehensive nurse training programmes have replaced the traditional enrolled nursing and
enrolled midwifery training programmes in all government-owned health training institutions, and have been introduced
into many not-for-profit training institutes. The future of comprehensive nurse training is under review.66
Nursing 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 nursing
aides as a temporary solution until more qualified staff were trained and made available.67
The current policy is to gradually
phase out the nursing assistant/aide position and ban recruitment and formal training, though new training institutions
have continued to emerge.68
Regulation of nursing assistants has been difficult, as the Nurses and Midwifery Council does
not recognise the cadre.69

22
70. 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 2011
Table 7 shows the proportions of these occupational groups
in the 2002 census. Nurses and midwives made up almost
half, nursing assistants/aides over one third, and allied health
professionals (including clinical officers)70
and medical doctors
less than 10% each. The census found 1.2 doctors and 14.5
nurses, midwives and nursing assistants per 10,000 people.
WHO data for 2005 give a similar picture of 1.2 doctors and
13.1 nursing and midwifery personnel per 10,000 of the
population. While there are no comprehensive up-to-date
data, it is known that numbers have increased – as has the
population of Uganda. For example, it was reported in 2011
that Uganda has 9,701 midwives; however this number
equates to only seven midwives per 1000 live births.71
Geographical distribution
Urban/rural imbalance in the distribution of health workers is
a key problem in the delivery of healthcare. WHO 2004 data in
Table 8 show that the majority of medical doctors (61%) were
urban-based, while the great majority of nurses, midwives and
especially medical assistants (clinical officers) were rural-based.
Moreover, data from the 2002 census show that the most
highly qualified professionals were concentrated in the
region which includes the capital, Kampala (Central region).
It contained only 27% of the population but had 64% of the
nursing and midwifery professionals (degree holders and
specialist registered nurses) and 71% of medical doctors.72
Number Percentage
Per 10,000
population
Medical doctors 2,919 6.9 1.2
Allied health professionals 3,785 9.0 1.6
Nursing & midwifery occupations 20,186 48.0 8.3
Nursing aides / assistants 15,228 36.1 6.3
Total 42,118 100 19.1
Population 2002 = 24.4 million
Urban Rural
Total No % No %
Medical doctors 2,209 1,345 60.9 864 39.1
Medical assistants 2,472 247 10.0 2,225 90.0
Nurses 14,805 2,613 17.6 12,192 82.4
Midwives 4,164 1,047 25.1 3117 74.9
Totals 23,650 5,252 22.2 18,398 78.8
Number, distribution and density of five main occupational groups
(2002 Census data)
Urban / rural distribution of four main cadres (WHO 2004 data)
Table 7
Table 8

23
73. Ministry of Health 2009c, p6
75. Mandelli et al 2005
77. Africa Health Workforce Observatory 2009
78. Dal Poz et al 2009 Table 5.3
79. Spero et al 2011
80. De Vries 2009
81. Spero and McQuide 2011
82. Africa Health Workforce Observatory 2009
83. Senkabirwa 2010
84. Onzubo 2007
85. Dambisya 2004 p601
86. Dal Poz et al 2009
88. Ministry of Health HSSP II Table 1
Employment status and attrition
Official documents have complained of “rampant dualism”.73
In 2002, 30% of all medical doctors, dentists, medical specialists
and consultants were privately employed and only one quarter
of those worked full-time.74
A survey in 2005 confirmed that
dual employment is common among medical doctors: 54% of
medical doctors employed in private healthcare facilities also
worked in the government sector.75
While the census found
29% of nurses privately employed, almost all (95%) were
employed full-time. 14% of medical doctors and of nurses and
midwives were self-employed.76
While there are no data on health worker unemployment,
there are indications that some nurses and midwives disappear
from view after qualifying. All practising health workers in the
country are required to register with the relevant professional
regulatory council and obtain a licence to practise in Uganda.77
A new human resource information system supported by the
United States Agency for International Development (USAID)
allowed the Uganda Nurses and Midwives Council to see how
many nurses and midwives failed to register. The first published
analysis showed that 12% of the 17,297 nurses and midwives
passing final examinations from 1980 to 2004 did not register
with the council.78
When the period of analysis was extended
to cover 1970 to 2005, the proportion increased slightly to
13%.79
Some qualified students went into employment without
registration to avoid paying the registration fees.80
The human
resource information system revealed that 55% of registered
midwives (4,075 midwives) did not obtain a licence to practise
from the Nurses and Midwives Council.81
It is widely held that medical doctors and nurses leave Uganda
for employment in other countries, but comprehensive
supportive data are not available.82
The Uganda Nurses and
Midwives Council verified that 808 nurses left Uganda in
2009-10, nearly half for the UK.83
The destinations of qualified
staff leaving six hospitals in a remote region between 1999
and 2004 did not include work in other countries.84
Follow-up
of a cohort of graduates of one medical school found deaths,
most presumed to be AIDS-related, “a bigger brain-drain
than emigration” in the 20 years after graduation in 1984.85
Premature death is emerging as one of the most important
causes of exit from the workforce in Sub-Saharan Africa, causing
Uganda to lose an estimated 2% or so of its medical, nursing
and midwifery workforce each year. Annually an estimated 26
physicians in every 1,000 and 22 nurses and midwives in every
1,000 die before the age of 60 in Uganda, among the highest
rates in the 12 African countries for which data are available.86
The facility-based workforce
Of particular interest to this research are health workers
employed in facilities. The Ministry of Health has a new
human resource information system, but the publicly available
comparative data relate to 2004 and 2005. Table 9 shows
that 45% of facility-based health workers were in government
facilities (excluding district health office staff) and 23% in
not-for-profit facilities in 2004; and that in 2005, the number in
private for-profit facilities was estimated at 12,775, representing
a 32% share of the total 39,663 employees. It should not be
assumed that almost 40,000 different people worked in facilities
in 2004 and 2005. The data for the for-profit sector include
an estimated 3,228 people employed simultaneously in other
sectors.87
It is possible that government data include personnel
working also in the not-for-profit sector (it is not permitted to
be employed in more than one government facility).
Facility-based staff 200488
and 200589
Table 9
Health
occupations
Other staff Per cent Total
Government (2004) 15,124 2,619 45 17,743
Not-for-profit (2004) 6,102 3,052 23 9,145
Private for-profit (2005) 12,775* 32 12,775
Total 39,663
*Non-health occupations not recorded separately; includes 3,228 employed simultaneously in other sectors

24
More recent sources state that members of three faith-based
medical bureaux (Catholic, Protestant and Muslim) together in
2009-10 had slightly over 11,600 health workers, around 30%
of the combined government and not-for-profit workforce,90
and that government facility staff numbers had reached 23,452
in 2009.91
Despite efforts to clean the government payroll and
update rosters, there are still problems in determining how
many staff in each cadre are on the payroll and where they are
assigned.92
In 2010, ‘ghost workers’ were exposed in a number
of districts and notably at a national referral hospital, and
transferred staff were found to be still receiving salaries at their
original place of work.93
The most recently available data on occupational breakdown
across sectors are for 2004 and 2005, as shown in Table 10. As
health workers, especially medical doctors, have jobs in more
than one sector, the numbers include double-counting. It is
reported that “more recent tables show that there has been
tremendous improvement in health worker staffing levels in
Uganda since 2004” and that the total number of medical
doctors in health facilities is 3,917 (presumably in government
and not-for-profit facilities).94
In 2004, almost half the medical doctors and over four in 10
nurse employees in government facilities worked in the two
national referral hospitals and the 11 regional referral hospitals,
while the great majority of nursing assistants, clinical officers
and midwives worked in district level facilities (Table 11).
Overall, there are severe shortages of facility-based health workers
in the formal sector. Chapter 6 details the shortfalls and the
consequent impact on health workers and access to healthcare.
91. Matsiko 2010
92. Ministry of Health and The Capacity Project 2008
93. Medicines and Health Service Delivery Monitoring Unit 2010
94. Matsiko 2010 p24
95. Adapted from Matsiko 2010 Table 3.1
96. Mandelli et al 2005 Table 9
97. Adapted from Matsiko 2010 Table 3.1
Occupational groups in government and not-for-profit facilities
(August 2004)95
and private facilities (estimated 2005)96
Occupational groups in local government district facilities and national
and regional referral hospitals, August 200497
Table 10
Table 11
Occupation Government Not-for-profit Private
Medical doctor 598 305 1,511
Clinical officer 1,585 436 190
Midwife 2,129 914 1,377
Nurse 4,500 1,915 3,557
Nursing assistant/aide 4,463 2,005 1,146
Occupation District facilities
National & regional
referral hospitals Total
Number % of total Number % of total
Medical doctor 308 51.5 290 48.5 598
Clinical officer 1,319 83.2 266 16.8 1,585
Midwife 1,635 76.8 494 23.2 2,129
Nurse 2,542 56.5 1,958 43.5 4,500
Nursing assistant 4,165 93.3 298 6.7 4,463

25
3.1 The research stages
The research was conducted in three main stages: consultation
with local stakeholders on the draft protocol to be submitted
for ethical approval98
; focus groups and individual interviews
with health facility staff and managers; and stakeholder
feedback on draft findings.
In June 2010, VSO Uganda and HEPS-Uganda held a research
workshop with support from VSO International. Fourteen
representatives of organisations concerned with health worker
issues in Uganda attended, including healthcare provider
organisations, professional associations, regulatory councils
and consumer and health worker advocacy organisations.
Participants explored practical challenges in gathering and
disseminating the views of health workers. The workshop
started to build an alliance of interested stakeholders to take
forward the research findings.
Main-stage fieldwork was carried out from late June 2010 to
February 2011. From June to August 2010, the Valuing Health
Workers researcher, a VSO volunteer,joined forces with a
second VSO volunteer who had in February 2010 begun similar
research with nurses as an independent initiative. The two topic
guides were combined, and a small number of interviews and
focus groups already conducted in the nursing research project
were amalgamated with the Valuing Health Workers data.
VSO produced a report of interim findings to coincide with the
Global Health Workers Forum in Bangkok in January 2011.99
A roundtable discussion at a VSO-led side meeting at the
Forum followed a presentation of selected findings from the
Valuing Health Workers research in Uganda. Ugandan and
other participants shared their perspectives on the issues
presented and put forward promising solutions. In January and
February 2011, interim findings were shared with stakeholders
in Uganda through one-to-one meetings and a stakeholder
workshop organised by HEPS-Uganda. The workshop brought
together 16 representatives of organisations including
professional associations and unions, regulatory councils and
health and human rights organisations. The workshop served
both to validate the findings and to elicit suggestions for
coverage of additional aspects in the final report.
3.2 Qualitative research methodology
and the purposive sampling design
Qualitative research aims to provide an in-depth understanding
of the social world of research participants through learning
about their social and material circumstances, experiences,
perspectives and histories.100
Qualitative research is not based
on statistically representative samples and so does not produce
statistically significant findings. Participants are selected
in a non-random way, according to characteristics of most
interest to the particular study. This is known as purposive
sampling. The criteria used to select participants are more
important 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; any
experience or perspective has value, regardless of how often or
seldom it appears.
The research sampled facility-based health workers whose
prime role is treating or caring for patients, and facility-based
managers: nursing assistants, nurses, midwives, clinical officers
and medical doctors. The study design thus excluded other
professional groups.
In achieving the health worker sample it was first necessary
to ensure that all regions were included, as although not
an administrative grouping, region has social and political
importance in Uganda. The strategy was to select one local
government district in each of the Central, West, South
West, North, North East and East regions, and also to include
the capital city. It was felt important to include a range of
districts in terms of how far they were deemed easy or hard
to serve. Within each district in the sample, one hospital
(where one existed) and at least one health centre were to
be selected, covering urban and rural facilities. Among the
selected facilities, the aim was for a spread of level of hospital
and health centre, and inclusion of not-for-profit and private
facilities 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 Uganda
National Council for Science and Technology.
99. VSO 2011
100. Ritchie and Lewis 2003
3. Research design and methods
This chapter first describes the three-stage approach to the research.
Outlines of the qualitative research methodology and sampling design, data
collection and data analysis follow. The chapter concludes with an overview
of the health worker participants. Further details are in Appendix A.

26
3.3 Data collection
Seven districts in six regions and the capital city, Kampala, were
selected, so the selected facilities were distributed across
all regions (Table A.1). The districts ranged from very hard to
serve to not hard to serve, according to the Ministry of Health
criteria (Table A.3). The 18 facilities in the sample comprised
three referral hospitals, six general hospitals, four health centre
IVs and five health centre IIIs. Eleven were government-run,
five were run by not-for-profit organisations and two by private
organisations (Table A.2).
Permission to carry out the research was obtained from district
health officers in the five districts where government facilities
were included in the sample. District health offices assisted in
linking the researchers to district-level government facilities.
Referral hospitals and not-for-profit and private sector facilities
were approached directly.
At each facility the staff member in charge was asked to
arrange for staff to meet with the researcher in small groups
of peers: enrolled nurses or midwives, registered nurses or
midwives, nursing assistants and those in charge of wards. In
smaller facilities, mixed groups and individual interviews were
necessary because of the limited numbers of available staff.
Medical doctors, clinical officers and facility managers were
interviewed individually, apart from one joint interview with
two managers. Sixteen small group discussions with a total of
71 participants and 46 one-to-one interviews took place at the
18 facilities. One health worker declined to take part because
of a lack of staff to cover her absence. The five district health
officers were also interviewed.
Group discussions and interviews were carried out in English.
Informed consent was gained from all participants. Participants
were encouraged to talk freely in response to a set of open
questions. They were assured that they and their facility
would not be identifiable in the research reports. The topics
discussed covered reasons for becoming a health worker;
understanding of the professional role; rewards; challenges,
their impact and coping strategies; reasons for negative
attitudes towards health workers; areas for change, and ways
of increasing the voice of health workers. The full topic guide is
included in the Appendix. Facility managers and district health
officers were asked additionally about management issues
they faced, although frontline workers were not asked directly
about their management. Participants also completed a short
biographical proforma.
3.4 Data analysis
Discussion groups and interviews were audio-recorded and
transcribed with participants’ permission. The analytical process
started with repeated readings of the transcripts to identify a
thematic framework. The textual data were then structured in
matrices with a row for each group or individual and a column
for each thematic area. Mapping and interpretation followed
from this charting process, to define concepts, find associations
and provide explanations. As already noted, early findings were
validated by non-governmental stakeholders through individual
interviews and workshops.
3.5 The health worker participants
A general hospital was the most common workplace for
participants (53 out of 122); 40 participants worked in health
centres (Figure 1). Government employees numbered 75,
not-for-profit 36 and private sector 11.
General hospital
Referral hospital
Health centre IV
Health centre III
District health office
Workplace of participants
Figure 1
53
24
20
20
5

27
The largest professional group was registered nurse
and/or midwife, followed by enrolled nurse and/or
midwife and nursing assistant (Figure 2).
There was a broad spectrum of ages among participants
(Figure 4).
Of the 122 participants, 38 were men. Men were in all
occupational groups except clinical officer (Figure 5).
Eleven participants worked solely in administration: five
qualified nurses, five medical doctors and one with another
medical-related qualification. A further seven participants
combined a role being in-charge of a facility with frontline
care. The remainder were frontline employees, most
working in nursing or midwifery roles (Figure 3).
Registered nurse
and/or midwife
Enrolled nurse
and/or midwife
Nursing assistant
Medical doctor
Clinical officer
None
Other
Nurse
Midwife
Nursing assistant
Administration only
Medical doctor
Medical doctor in charge
Clinical officer in charge
Clinical officer
Male
Female
20-29
30-39
40-49
50-59
60-69
Participants’ professional status
Sex of professional groups
Participants’ roles
Age groups of participants
Figure 2
Figure 5
Figure 3
Figure 4
44
41
40
24
16
44
25
26
11
6
3 3 4
30
24
15
6
1
1
2
70
60
50
40
30
20
10
0
Nurses & Nursing Clinical Doctors Other/none
midwives assistants officers
11
63
19
14
6 0
1 2 1
5

28
4.1 Benefiting others
Participants told of feeling happy carrying out their vocation,
helping their people, giving something back, delivering care
and comfort, helping those unable to help themselves and
saving lives. Very strikingly, the benefits to the community, to
individual patients and to families were the biggest sources of
satisfaction even in the harshest working environments.
Benefiting the wider community
Health workers emphasised the rewards of sharing their
knowledge and skills with communities to counter harmful
traditional beliefs and practices, educate people about ways of
preventing disease and encourage take-up of health services.
Seeing more women delivering babies in health units, diseases
controlled through immunisation programmes, or reduced
reliance on harmful traditional remedies brought great
satisfaction. Health workers were especially pleased when
involved in new programmes and able to see their impacts,
such as a nutrition clinic, a mental health unit or prevention
of mother-to-child HIV transmission. Satisfaction came from
being part of a health facility that put the patients first.
Especially in rural areas, health workers were happy to use
their knowledge to help informally outside working hours
and around their homes. For an off-duty nurse, it was good to
socialise with in-patients, hear their family problems and have
the chance to give some health education.
Benefiting patients
Participants highlighted the visible results of care and treatment.
They expressed their delight at the benefits to patients. Nurses
and medical doctors spoke about how happy and proud they
felt when a patient who arrived sick, even on the edge of
death, went home recovered: “I love it when someone comes
in ill and goes back happy.” Seeing life enhanced was also
hugely 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 of
two people, “a live mother and a live baby” – and achieving
something 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 was
hugely rewarding to be able to deal with family health problems.
Knowing how to prevent and treat illness in your immediate
family, as well as how to protect yourself, was a significant
factor encouraging a commitment to nursing which would last
up to and beyond retirement: “You will be a nurse until you die.”
Nurses at some rural health centres pointed to the advantages
to their family and themselves of quick access to free treatment.
The nurse could use his or her knowledge to treat a relative
and save the costs associated with referral to a health centre or
hospital. It was said in some facilities that staff and their family
members were given free medication.
4.2 Job satisfaction
Linked to the happiness of seeing someone recover is the
satisfaction of knowing your own contribution, among medical
doctors and clinical officers especially: “I feel happy when I give
treatment to my patients and they get well, I feel so proud, I
feel very fine” or “I can see the difference I have made, that’s
very important.” Introducing new treatments and bringing about
change in a challenging environment was hugely satisfying:
“What others thought was so difficult, I have been able to do.”
4. The Rewards
Ugandan health workers rarely get the chance to speak about the positives of
being a healthcare worker – the rewards and satisfactions – and participants
welcomed the opportunity the research gave them. The main areas of satisfaction
were helping others, doing a good job and being valued for what they did. Positive
practice environments were by no means commonplace. Some participants were
so discouraged by working conditions that they struggled to find anything else good
to say about being a health worker. For a few the only positives were the material
benefits of a regular salary and a free house. Later chapters will show how working
environments damaged chances for fulfilment and satisfaction at work.

Our Side of the Story- A policy report on the lived experience and opinions of Ugandan health workers

Our Side of the Story- A policy report on the lived experience and opinions of Ugandan health workers

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