1. Our Side of the Story
Ugandan health workers speak upCoalition for Health Promotion
and Social Development
2. 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
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
4. Our Side of the Story: Ugandan health workers speak up
4
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.
VSO recognises that health workers’ voices must be heard and acted on to improve
access to healthcare and to help achieve the Millennium Development Goals.
It therefore started participatory research in four countries in Africa and Asia,
in partnership with in-country non-governmental organisations (NGOs). In Uganda,
research was carried out in partnership with HEPS-Uganda, the Coalition for Health
Promotion and Social Development, from February 2010 to February 2011. VSO will
support local partners to use the research findings to advocate for health workers,
and will gather the research evidence to advocate on a global level.
In Uganda, negative images of health workers are projected in the media, political
speeches, policy documents, healthcare user research and health consumer advocacy
projects. 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, 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.
This short report documents the experiences and views of 122 health workers –
medical doctors, clinical officers, nurses, midwives and nursing assistants. They include
frontline workers, facility managers and local government district health officers.
Through small group discussions and individual interviews in the workplace,
the researchers encouraged health workers to speak freely in response to open
questions, having been promised that identities would not be revealed.
The facility-based participants worked at 18 hospitals and health centres across 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, trade unions, professional
associations and regulatory councils contributed their perspectives through workshops
and individual interviews.
A full report gives further details of the research approach. It includes a comprehensive
overview of the Ugandan healthcare context, along with extensive references. It can be
accessed at: http://www.vsointernational.org/what-we-do/health.asp
5. Our Side of the Story: Ugandan health workers speak up
5
Contents
Healthcare in Uganda: challenges and provision 6
Challenging working conditions 7
The rewards 8
Benefiting others 8
Job satisfaction 8
Being recognised, appreciated and valued 9
Appreciative and supportive management and colleagues 9
Reasons for becoming a health worker: the “right heart” and the “wrong heart” 10
A passion for the patients 10
“They join for the wrong reasons” 11
Workload 12
The impact on health workers 12
The impact on attitudes, behaviour and practices 13
The impact on community relations 14
Factors contributing to understaffing and work overload 14
Facility infrastructure 16
The impact on health workers 16
The impact on attitudes, behaviour and practices 17
The impact on community relations 17
Equipment and medical supplies 18
The impact on health workers 18
The impact on attitudes, behaviour and practices 19
The impact on community relations 19
Medicine supplies 20
The drug supply situation 20
The impact on health workers and the quality of care 20
The impact on community relations 22
Pay 24
The impact on health workers 24
The impact on attitudes, behaviour and practices 26
Poor pay, turnover and loss to Uganda 27
The way forward 28
Raising the voices of health workers 28
Speaking through professional associations, unions and regulatory councils 28
Changing public perceptions of health workers 30
Bridging communities and healthcare facilities and staff 31
Summary of participants’ recommendations 32
References 34
6. Our Side of the Story: Ugandan health workers speak up
6
A major challenge for the Ugandan healthcare system is posed
by a rapidly growing population, with the third-highest growth
rate in the world, a strikingly high birth rate (especially among
teenage women) and a very young profile. A further challenge
is to serve 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 recommended by the World Health Organization
(WHO). Only four other countries have poorer provision of
hospital beds than Uganda. Only 16 countries worldwide spend
smaller proportions of their gross domestic product on health.
Although the Government is committed under the Abuja
Declaration to apportion 15% of its budget to health, its health
spending 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 level IV health centre, 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 just one. The situation is likely to have
worsened as districts go on being created, reaching a total of
112 in mid-2010. One in four facilities is classified as a health
centre III and should provide maternity, inpatient and laboratory
services. Two-thirds of health facilities are classed as health
centre II, intended for preventive services and outpatient
curative care. Three in ten of these 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 use health
centres more than urban dwellers, while the urban population
use 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 25% of Ugandans live
more than 5km from their nearest health facility. Nine in ten
walk or cycle to their government health centre.
The available data on the make-up of the Ugandan health
workforce show extreme shortfalls in the most highly qualified
occupational groups and maldistribution across the country.
Although the aim is to phase them out, Uganda has relied
heavily on nursing assistants, especially in rural areas. Medical
doctors and the most highly qualified midwives and nurses are
concentrated in urban areas, especially in and around Kampala.
An estimated 40% of the facility-based workforce are in the
government sector, 30% in the not-for-profit sector 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.
Healthcare in Uganda: challenges and provision
A queue of people waiting to see a doctor. A doctor in Uganda serves an
average of 10,000 people.
7. Our Side of the Story: Ugandan health workers speak up
7
Challenging working conditions
Staffing shortfalls
• Almost half (48%) of approved posts at health centres and
hospitals are vacant, a shortfall of 25,506 staff. The situation
is worst in the lower-level health centres, yet health centre
IVs and general hospitals respectively lack 45% and 38% of
their approved staff complements. (Matsiko, 2010)
• Hospitals at regional level are missing 30% of the staff
they should have. There are gross disparities across local
government districts. In four districts, less than 30% of posts
are filled, while only ten districts filled more than 70% of
posts. (Oketcho et al, 2009)
• Health centre IVs have an acute shortage of medical doctors:
64% of these posts were vacant across the two-thirds of health
centre IVs that provided data. Across the 42 general hospitals
reporting, four in ten medical doctor posts and four in ten
nursing positions were not filled. (Ministry of Health, 2010)
Dilapidated infrastructure
• Most facilities are in a state of disrepair.
(Ministry of Health, 2010)
• Many health centre IVs lack crucial infrastructure to make
them fully functional: half those reporting to the Ministry
of Health have an incomplete or non-functional operating
theatre or no theatre at all. (Republic of Uganda, 2010)
• Only one in four health facilities has electricity or a backup
generator with fuel routinely available during service hours.
Only 31% have year-round water supplied in the facility by
tap or available within 500m. (Ministry of Finance, Planning
and Economic Development, 2010)
• Less than half of all facilities can transport a patient to a
referral site in maternal emergencies. (Ministry of Finance,
Planning and Economic Development, 2010)
• Only 6% of health facilities have information and
communication technology – mobile phone, radio,
TV or computer. (Ministry of Health, 2010)
Deficits in 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. (Ministry of Health, 2010)
• An independent survey reveals a gross lack of equipment
for the diagnosis and treatment of malaria: half of health
centre IIIs and a fifth of health centre IVs and hospitals in the
survey lack a functional microscope, 86% of health centre IIs
and IIIs had no rapid diagnostic tests, and 60% of all facilities
surveyed were not equipped to measure haemoglobin.
(Achan et al, 2011)
• Other evidence suggests that only one in 20 facilities has
a vacuum extractor (used for assisted vaginal delivery)
and only one in ten a dilation and curettage kit (needed to
remove a retained placenta). (Ministry of Finance, Planning
and Economic Development, 2010)
Non-availability of essential medicines
• The percentage of health facilities registering ‘stock-outs’ in
essential medicines has consistently been over 60% for the
last ten years. (Ministry of Finance, Planning and Economic
Development, 2010)
• Not one of 40 essential medicines was available in every
government facility in a sample survey in the second quarter
of 2010, and only eight of the 40 essential medicines were
found in all the not-for-profit facilities surveyed. (Uganda
Country Working Group, 2010)
• Essential medicines were on average out of stock for
73 days of the year in government facilities and seven days
in not-for-profit facilities, according to a 2008 sample survey.
(Ministry of Health, 2008a)
• Only one in three respondents surveyed in 2008 agreed
that their nearest government facility usually had all the
medicines the household needed. (Ministry of Health, 2008b)
Low pay
• Monthly starting salaries in public service in 2009–10 were:
–– 353,887 UGX (Uganda shillings) for a registered nurse
(US$191)
–– 657,490 UGX for a medical officer (US$354)
–– 840,749 UGX for a senior medical officer (US$453)1
(Matsiko, 2010).
• In contrast, high court judges received 6.8 million UGX
per month (US$3,664)
• Ugandan nurses’ and doctors’ salaries are the lowest in
East Africa.
1. 1,856 Uganda shillings = 1 US dollar at 31 March 2010
Uganda has only one doctor per
10,000 people, and only 14 health
workers (doctors, nurses and
midwives) per 10,000 people
8. Our Side of the Story: Ugandan health workers speak up
8
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. Strikingly, the benefits to the community, to
individual patients and to families were the chief sources
of satisfaction, even in the harshest working environments.
Benefiting the wider community
Health workers liked sharing their knowledge and skills with
communities in order 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 they were
involved in new programmes and could see their impacts,
such as a nutrition clinic, a mental health unit or the prevention
of mother-to-child HIV transmission. Satisfaction came from
being part of a health facility that put 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 inpatients, 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 of the joy and pride they felt when
a patient who arrived sick, even on the verge 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 – “live mother and a live baby” – and achieving
something positive with neither mother nor 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, encouraged 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 mentioned 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 of referral to a health centre or hospital. It was
said in some facilities that staff and their family members
received free medication.
Job satisfaction
Linked to the happiness of seeing someone recover is the
satisfaction of knowing your own contribution, especially among
medical doctors and clinical officers: “I feel happy when I give
treatment to my patients and they get well. I feel so proud, I
feel very fine,” and “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.”
Maternity workers spoke of their joy when they safely delivered
a healthy baby, “when everyone is smiling”, and the satisfaction
of seeing that baby grow.
The rewards
Ugandan health workers rarely get the chance to speak about the positives
of what they do – the rewards and satisfactions – and participants welcomed
the opportunity the research gave them. The most satisfying aspects of their
work were helping others, doing a good job and being valued for what they did.
Positive practice environments were by no means commonplace, however some
participants were so discouraged by working conditions that they struggled to find
anything 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.
“I love it when someone comes
in ill and goes back happy”
9. Our Side of the Story: Ugandan health workers speak up
9
Having done good nursing work treating a very ill patient who
improved and was discharged gave “a kind of job satisfaction
and encourages me to care for patients a little more”. For nurses,
it was good to have done something, no matter how little, to
help save a life. Achieving successes is not easy in Uganda, and
an occasional “victory”, such as when a sick child recovers, was
something to “live for” that “makes you do what you do”.
Participants took satisfaction in doing a good job when there
was enough equipment, other medical supplies and medicines
to enable proper care: “Most of what you need for a patient
is available, so your job is not much interfered with,” and
“You cannot forget your skills.” Elsewhere health workers
commented on the satisfaction of just being able to play their
part and do their duty the best they could, despite many
shortcomings in supplies and equipment and staffing shortfalls.
Some spoke of pride in working efficiently to treat patients or
caring tenderly where they could.
Particularly for younger participants, opportunities to learn
through work and to experience managing different kinds of
medical condition were highly valued. While not commonly
reported, opportunities to learn new skills, such as counselling,
were valued for their benefits to patients. In the few instances
where workplace-based education programmes were in place,
participants spoke enthusiastically about how they shared their
learning with other staff and developed new communication skills.
Being recognised, appreciated and valued
Community recognition
Some nurses in rural settings liked being acknowledged and
known in the community: “When you go out you are respected,”
or “You are famous.” Being a nurse meant being seen as an
educated person; it was gratifying to be called a “small doctor”.
Nurses sometimes felt their training set them apart from other
people, conferring a certain prestige, especially when they
could use their knowledge to help outside their formal work.
Nursing was also valued as a way to meet different types of
people, get to know many people and make friends.
Patients’ appreciation, trust and respect
Health workers valued being liked, appreciated, praised,
respected and trusted by patients.
It was noted that expressing thanks was not the norm in some
parts of Uganda, and health workers spoke enthusiastically
about the boost a ‘thank you’ from a patient gave them:
“You feel very happy after your work when they say thank you.
So you keep on, because you are enjoying it.” For some, the
pleasure of helping was enough, whether praised or not: “I feel
it inside my heart.” As well as appreciation, recognition of their
expertise was important to nurses: “Their confidence in you
boosts your own confidence.”
Midwives are delighted when a baby is given their name.
Nursing staff and medical doctors emphasised how recognised
and appreciated they felt when a past patient greeted and
thanked them warmly or showed off “your baby”. Being
remembered by patients was seen as a mark of trust and
boosted the nurse’s own confidence. For some nurses, respect
and trust on the part of patients or caregivers opened up
disclosure of confidences and opportunities for further help.
Appreciative and supportive
management and colleagues
Appreciation on the part of managers was a huge positive,
although not widely reported: “When you are recognised
that you are doing good work, I think that is important, it
motivates.” Simply being told ‘thank you’ was not necessarily
very satisfying in difficult working conditions. Health workers
valued the provision of more tangible tokens of appreciation,
such as open internet access, Christmas and Easter presents
and staff parties. Rare, and especially valued, was facility
sponsorship of further training, with a job to return to.
Uniquely in the study, participants in a local government hospital
praised management who “appreciate us so much”. Certificates
of appreciation, staff parties, presents, financial contributions
to costs of burials and operations, help with costs of further
study, days off to recover from illness, interest in their work
and responsiveness to problems staff identified were cited as
proof of this appreciation.
Health workers felt valued by good, supportive managers
who created opportunities for them to raise their concerns,
were always willing to discuss a problem, and sought and
implemented solutions.
Nurses spoke of the satisfaction of working cooperatively
with other staff, having someone to consult if needed, sharing
ideas and reaching solutions. Teamwork also meant helping
each other out, such as an off-duty nurse caring for another
nurse’s sick child and willingness to extend hours to cover for a
nurse’s delayed arrival at work. Where working conditions were
especially challenging, nurses valued being part of a support
network where everyone understood the difficulties.
10. Our Side of the Story: Ugandan health workers speak up
10
A passion for the patients
For many health workers, the strong need to give to others was
born of childhood experience. It had been common in rural
areas to see close family and members of the local community
suffer and die in pain, with no proper medical care. Participants
recounted how siblings and parents had died of mysterious
illnesses that, they later realised, were due to preventable
epidemics or treatable with modern medicine. Training as a
nurse, clinician or medical doctor would bring to the community
essential knowledge to help prevent illnesses, discourage
harmful traditional healing practices and save lives: “They were
really suffering, people were dying, there were no doctors, no
nurses, nobody to give them an idea about their health. I wanted
to help my people.” Others spoke of atrocities in conflict
areas and the need for medical skills to rebuild communities.
Health workers spoke warmly of positive experiences undergone
when they or family members were in hospital. The gentle and
caring touch and the healing words of nursing staff left a lasting
impression. They wanted to be that person, to give in that
caring way, to stop others’ pain. Growing up, they learnt how
the skills of the medical staff had saved the life of someone
close to them, or even their own life, and they wanted to give
something in return. Some were encouraged by a parent who,
gratefully remembering a midwife, urged that their child
become a midwife too.
Not all impressions were good. Negative experiences of
healthcare services fuelled a desire to raise the standard of
medicine in Uganda. Young men and women said they felt
compelled to join their professions because they believed
that professional neglect had contributed to the deaths of a
parent, siblings or a newborn baby, or because they perceived
the limitations of Ugandan medical expertise in the face of a
life-threatening condition. Unsympathetic handling prompted
a wish to improve the quality of nursing, and the shouts of
women abandoned in labour evoked a desire to help.
Women spoke of only ever wanting to be a nurse from as early
as primary school stage. They saw themselves as naturally kind,
a helping sort of person, with an urge to relieve suffering: “I
just had it in me,” or “I had that heart.” Some women found
they “developed the heart” as young adults when they had
to nurse a family member. Not-for-profit sector participants
especially cited a desire “to love and serve the patients” or
“to care for the needy”, spoke of coming “closer to God” or
explained they had “a call” or were “chosen by God”.
Health workers emphasised giving, and spoke less about what
they had expected to gain from their profession, though the
prospect of knowledge to care for and treat one’s family and
oneself was important, especially among lesser-qualified
women in rural areas. Nurses’ happiness when a patient
recovered was mentioned, as was the respect people gave
to a local nurse. The nurse had status as a life saver, a person
of importance to call on in an emergency.
Young girls who went on to be nurses had been greatly attracted
by the dress and deportment of nurses, their smart, clean
uniforms, shoes and gloves and the way they walked, which
set them apart from other people. Among would-be medical
doctors there was some admiration of smart white coats and
acknowledgement of the prestige attached to being a doctor.
Financial gain was not a driving force, though earning in a steady
job was certainly a better option than ‘digging’ in vegetable
gardens and relying on uncertain harvests. In the most remote
rural area, the health facility was the only source of training
and employment locally, and so a magnet for school-leavers.
Reasons for becoming a health worker:
the “right heart” and the “wrong heart”
Participants explained what prompted them to become healthcare professionals.
The urge to help, prevent suffering and save lives stood out. The overriding
impression emerged of a heartfelt desire to ‘make a difference’ as a nurse, midwife,
clinical officer or medical doctor, rather than merely to earn a living. It is a mark
of their professional commitment that almost all participants said they would still
choose to become a health worker.
Participants observed that some people joined the health professions, notably
nursing, for the “wrong” reasons. This, in their view, was one explanation for poor
attitudes and unethical behaviour, and they put forward suggestions for improving
the calibre of recruits. The recommendations also include other stakeholders’ views.
11. Our Side of the Story: Ugandan health workers speak up
11
For most participants, the decision to become a health professional
was positive and informed. Time spent at hospitals or health
centres – as a patient, relative of a patient or just as a curious
child allowed to sit with nurses – had shown how nurses worked
with patients, and helped stimulate an interest. Empathy for
patients sometimes developed when ‘touched’ by their condition.
Having a father, mother, sister, brother or aunt in a nursing or
medical field gave some insight into the work, through visiting
their place of work, living in staff quarters or listening to their
accounts of day-to-day happenings. A close relative’s positive
attitude, humility or empathy for patients attracted young
women to nursing. For many of these participants, the example
of their relative was the main reason for entering a nursing or
medical profession. With little career guidance at school, it was
natural to do what members of the family were doing.
Others were expected by their family to take up a profession
and saw health work as a more appealing option than teaching,
secretarial or business occupations, even rebelling against fathers
who insisted on a teaching course. Some older participants had
been encouraged by adults at school or family friends, such
as priests and nuns, to apply for a medical or nursing course.
Others from that generation had been recruited to nursing by
agents of the Ministry of Health, or had followed family wishes
or suggestions in complete ignorance of what nursing involved.
Clinical officers and medical doctors told of expectations on
them as the brightest school students to enter one of the
prestigious professions. Engineering and medicine were the
prime alternatives if they excelled in science subjects. So the
path towards medicine could be set in early years when top
students were pushed towards sciences.
Faced with a choice of career direction, financial security was
something younger men had taken into account, in the context
of many qualified professionals chasing too few jobs: “At least
you can always find a job.” But nobody said they joined the
nursing or medical profession purely for that reason. Among
doctors, the choice of medical training over another science-
based profession was in some cases influenced by the prospect
of professional advancement and mobility, self-employment
and private practice.
Not all those who had decided on a career in the medical field
entered via the course of their choice. Lacking financial backing
from their families, uncertain about getting the grades, or
failing to gain entry, would-be medical doctors had to settle
for clinical officer training or a nursing course, and aspiring
clinical officers became nurses. It was sometimes hard at first
to accept a substitute course, especially when other people
said nursing is for “failures”.
“They join for the wrong reasons”
There were widespread beliefs among nursing and midwifery
professionals that poor attitudes and unethical behaviours
are linked to joining nursing for “the wrong reasons”. It was
thought that more recent recruits joined because they had
no other option, because nursing was a last resort when they
failed to qualify for more prestigious professions or because
parents pushed them into it. Pursuing pay, looking only at the
job market and even aspiring to leave the country were other
presumed reasons for joining nursing.
Older nurse managers had noted “very few nurses come with
a sense of vocation now.” There was a widespread view that
people enter nursing with “the wrong heart”. It was believed
that as a result, unhappy, disinterested and self-serving recruits
resort to bad habits, become rude and forget their ethics and
accountability to patients. There were also some comments
by managers about medical doctors’ questionable attitudes to
work when they seemed to lack that “inner drive”.
Yet more than one nurse, and also a medical doctor, said they
came to love their profession only when in practice. A story
was told of how a lecturer inspired an enthusiasm for nursing
in a student whose sole ambition had been to train as a doctor.
Indeed, some of those most critical of motives for joining were
staff who had developed an interest in their profession after
they started work.
Participants’ recommendations include:
• career guidance for school students and arrangements
between schools and health facilities for work experience
• tighter admission procedures for nurse training, to probe
reasons for applying
• improvements to standards of nurse training schools,
including more and better-quality tutors, smaller class
sizes and more attention to the practical application of
professional ethics
• integration of health and human rights training into
the curricula
• improvements to the community-based education
component of pre-qualification training
• the establishment of more training schools in rural areas, to
produce health workers adapted to rural lifestyles and bind
health workers to the community
• a review of the value of the Nurses and Midwives Council
registration interviews.
12. Our Side of the Story: Ugandan health workers speak up
12
The impact on health workers
Unmanageable workloads
‘Overwhelmed’ was a word widely used by nurses speaking
about unmanageable workloads in many government hospitals
and a not-for-profit hospital: “How can you manage? It does
something to you.” Nurses spoke of being affected mentally and
“destroyed” to the extent of becoming ill: “One nurse running
a full ward, with patients sleeping on the floor as well, the
overwhelming number can affect the nurse psychologically.” With
a nurse off sick, the workload became even harder to manage.
Too many tasks and responsibilities
In government health centres, midwifery and nursing staff said
they were stretched to the limit by too many tasks: “You have to
run the antenatal clinic, conduct deliveries, carry out post-natal,
do the ward round, one person. Then you have to run most of
the young child clinic.” Burnout resulted: “You have to do the
counselling, take blood, see the patients, prescribe for them
and do everything. When you leave at the end of the day, you
are burnt down completely.”
Among nurses in government hospitals there were complaints
about having to take on doctors’ duties: “I don’t know when a
ward round was last done. We review patients, even prescribe.”
The non-availability of a doctor caused dilemmas for midwives,
who feared blame if they undertook a medical procedure beyond
their scope of duty. Health centre nurses believed they did the
work of a clinical officer. Government hospital nursing assistants
complained about doing work which should be done by nurses.
Working in a team had been one of the attractions of nursing
as a career choice. It was frustrating and disheartening when
cooperation was lacking, such as when a relief worker failed to
turn up: “No teamwork at all, and when it is an emergency and
they delay, you really feel bad. You know what the outcome will
be, but you can’t help.”
Working day and night
Health workers in government health centres told of working
day and night, often alone, due to understaffing and staff
absences. It was pointed out that clinical officers, midwives,
nurses and nursing assistants had stayed on duty round the
clock or even longer, contrary to government rules and codes
of conduct. They said they kept on in the face of fatigue
because of their commitment to helping others: “If God
were not calling, you could not do this work 24 hours.”
Health centre midwives suffered especially. Midwives in rural
health centres told of working alone day and night, sleeping
with their children in disused wards, always on call to deal
with expectant mothers often arriving in late stages of labour.
A manager acknowledged that a midwife had worked alone
and on call for five months.
In a private sector health centre, scheduled time off had to be
forgone for the sake of the patients: “If a doctor prescribes care
for 24 hours, we have to stay and then work again next day.”
Over-long shifts and too little time off
Among not-for-profit hospital nurses there were complaints
about being forced into working 12-hour shifts. Taking up the
option of working shorter hours would reduce days off from
two to one, a hard choice for nurses with children and homes
to look after. Days off duty are important times to “do your own
things” and should be an entitlement. Yet it seemed taken for
granted that nurses and nursing assistants living on site in staff
accommodation would turn out in their ‘off’ time to fill staffing
gaps in some health centres. Even a not-for-profit hospital with
clearly specified conditions of service was reported not to give
good time off because of understaffing.
Workload
Concerns about understaffing and workload were most marked among health
workers and managers in government facilities at all levels. At some not-for-profit
and private facilities the concern barely surfaced, while at others it was a key issue
for participants. Overload was reported even in well-staffed hospitals within the
not-for-profit sector.
Not surprisingly, health workers dwelt on the consequences for them of
understaffing and heavy workloads. But also they spoke passionately about the
damaging effects on patients and on community perceptions of health workers.
“When you leave at the end of the
day you are burnt down completely”
13. Our Side of the Story: Ugandan health workers speak up
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Impacts on health
Among nursing staff in government health centres and general
hospitals there were concerns about the effects on health
of forgoing or delaying meals because of work pressure. Not
eating on schedule was a key concern when suffering from
diabetes, and eating well was important to maintain immunity
against infection from patients. Even taking a drink was not
easy because “how would it look when they are in pain?”
It was even hard to make a quick toilet visit without being
reprimanded by hospital managers.
Restricted professional development
Managers’ concerns included the impact on clinical officers’
development when they lacked the opportunity to work
under the guidance of a medical doctor, and the professionally
isolating consequences for staff with no supporting teamwork:
“Nobody to consult when you are stuck, nobody to delegate
to when you are unable.”
A nursing assistant had been put in a role that took her away
from direct patient care, to fill gaps in the professional staff
complement: “I want to learn more from the patients, but
I have no choice.”
There were views that opportunities for further study were
blocked because the facility would not be able to recruit a
replacement if the nurse left.
Failing the patients
Among health centre IV workers, the lack of a medical doctor
was one of the biggest concerns, more important to them
than frustrations about individual workload and personal
consequences: “I can get demoralised seeing someone dying
in my hands because we are missing a doctor,” and “It really
hurts a lot when a patient is dying and you know what should
be done. You even go home depressed.”
Health workers who expressed these feelings were adamant
that they kept on turning up for work to stop the next person’s
suffering: “If I’m depressed because someone has died and I
say I am not going to work the next day, then we are going to
lose more.”
The impact on attitudes,
behaviour and practices
Hospital nurses acknowledged that overload damaged the
quality of work: “At the end, you are very tired and no quality of
work is done.” Participants employed outside the government
sector were especially outspoken about the impact on the
quality of nursing in a large government hospital where they
had seen performance drop and patients’ needs neglected.
Personal distress made things worse, they felt: “Understaffed in
a ward full of patients, on top of family worries, they find they
can’t perform, miss things and cannot provide all the services
patients need.” The nursing role should be much more than
taking routine observations and giving treatment, but it was
impossible for an overworked nurse to find time to talk with
patients, uncover their problems and deal with the whole picture.
Consequently task-oriented nursing was unavoidable and even
routine tasks were hard to complete: “With two nurses for 50
patients, you are reduced to troubleshooting, it’s not nursing.”
Hospital nurses “torn apart” by patients calling for attention
found it hard to make patients understand that they had to
wait their turn. They recognised they could lose their temper in
such stressful situations and forget their basic good intentions:
“You become different.” Medical staff had seen the effects of
tiredness: “The tone of voice changes,” and “The nurses end
up losing it, when they are already frustrated by poor pay.”
Managers were generally understanding: “As a human being
you can get irritated and lose your temper because of fatigue,”
or “What do you expect with only half the nurses you should
have? They become rude.”
Participants working in well-staffed private and not-for-profit
hospitals had seen the consequences of work overload in the
government sector. Managers observed that lack of opportunity
to fulfil their proper professional role “demotivates” nurses, who
then adapt to a culture of poor standards of care in their work
environment. A “don’t care” attitude resulted: “By the time
she is 30 she is used up. Already tired due to understaffing,
she has run out of compassion and the patients say she is not
caring.” They said that overwhelmed nurses skip out from
work, ask to be transferred and “run away” to the private
sector where patients do not complain they are neglected.
“I can get demoralised seeing
someone dying in my hands
because we are missing a doctor”
“As a human being you can get
irritated and lose your temper
because of fatigue”
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Midwife behaviour towards patients changed as a result of
working alone all day and all night, especially with “no peace
of mind” due to personal and family worries: “So you become
tough with the mother so that she understands and you get a
live baby and a live mother.”
Managers were well aware of the unacceptably long hours
midwives put in and spoke openly about the effects they had
seen: “As time goes by, because of the fatigue and perpetual
calling, somehow as a human being you tend to deteriorate.”
Midwives no longer in the government sector understood how
over-tired midwives were forced to “escape” from 24-hour
work in health centres, to make contact with their families.
For midwives, perpetual responsibility for the lives of mothers
and babies was “a burden” and it was hard to stay patient with
the mothers.
Nurses discussed the knock-on effects on their patients of their
having to do too many things at once: “You find you are stressed
and are rude to patients unknowingly.” There were some strong
views that the workload in some large hospitals was increased
by senior staff “malingering” or not pulling their weight. A view
from the private sector was that frustrated junior nurses in the
government sector “took it out on the patients”.
Long, tiring shifts led to overworked nurses being short with
patients, not interacting with them and conveying disinterest
through attitude and expression. 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, made nurses look for ways of “escaping”– not turning up
for duty and leaving work early. It was also said that even after
12-hour shifts, some nurses went on to other nursing jobs just
to survive financially, and so developed “bad habits”.
The impact on community relations
Aggressive or demanding outpatients were a particular concern
for medical doctors and clinical officers. With so many patients
waiting for attention it was important to prioritise their treatment.
But patients either did not understand the triage system or
believed they deserved priority. Such challenges to professional
judgment were especially hard to handle when aggrieved
patients called on local leaders to intervene on their behalf.
Midwives working round the clock were distressed by patients
accusing them of not working when they had found a little time
to rest. This misperception was said to fuel community hostility
towards health workers.
Health centre workers realised that no respite in long shifts led
to community complaints about harsh language: “We work the
whole day without resting, and in the late afternoon we get
tired and then we change face.”
Staff working set hours had met some hostility from local people
who assumed the health centre was closed to outpatients
when they saw health workers socialising together towards
the end of the working day. The staff there pointed out that
they worked hard to serve outpatients quickly and so deserved
some rest-time after patients had stopped arriving. It was also
hard to make waiting patients understand that health workers
were not resting when they sat completing paperwork.
Health workers in sole charge of patients faced a dilemma:
go hungry or leave the patients alone? Doing the latter was
reported to have brought unfortunate consequences for staff
who were arrested for neglect of duty. The arrests were said
to be motivated by local political candidates seeking to gain
electoral favour by discrediting ruling politicians with oversight
of the facility. Clinical officers can be left alone to cover an
entire health centre, running from one department to another.
So, it was deeply upsetting when a patient arrived, assumed
no staff were available, and called on a local leader who then
complained to higher authorities.
The lack of a medical doctor rebounded on other staff: “When
the patient dies, the community look on you as a bad person
who refused to treat the patient.”
Lack of a midwife or qualified nurse meant that nursing
assistants carried out deliveries. They found it hard to
convince patients to put their trust in them, especially as they
themselves recognised they lacked the full range of knowledge
to save pregnant women in difficulty.
Factors contributing to understaffing
and work overload
It is not necessarily the case that there is a shortage of health
workers available in the labour force. Some government
sector managers were aware of huge numbers of applicants
for advertised vacancies, while others said they had failed to
recruit. Among managers at district level, views were expressed
that decentralisation of the health system was to blame for the
uneven distribution of health workers in local government.
Recruitment barriers
Government sector managers explained that financial
allocations for salaries stood in the way of recruiting more
staff: there was simply no money in the pot to pay more health
workers. Even if funds were made available to fill authorised
posts, vacancies remained due to bureaucratic procedures
and the absence of a District Service Commission tasked with
recruiting health personnel to the district.
“When the patient dies, the community
look on you as a bad person who
refused to treat the patient”
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15
Managers explained why remote and rural facilities found it
hard to recruit and retain medical doctors, nurses and midwives.
They sympathised with new recruits who turned round and left
for want of something to do in a village: “They post someone out
there in the wilderness and they expect them to work!” With
no electricity for TV and internet, people were “not connected
to the world”. Poor roads and no public transport at night left
staff “stuck”. Free staff accommodation was widely believed to
make it easier for nurses and medical doctors to leave behind
the amenities of town life. Poor-quality staff quarters, on the
other hand, were a deterrent to taking up and staying in posts.
An example was cited of rented accommodation of so poor a
standard that it was “not safe to raise a child there”, leading to
a nurse leaving her post. Health workers living in towns spoke
along similar lines, adding that food was expensive in remote
areas and educational standards poor.
It was remarked that medical doctors dislike working in villages
because of the lack of opportunity for learning and career
advancement. It was also said that medical doctors avoid jobs
at district level because local politicians misuse health service
resources and interfere in treatment decisions.
Local management factors
In the local government sector, the problems of overwork and
too little time off stemmed in part from limited management
capacity to draw up fair duty rosters. Poorly planned rosters
scheduled nurses to work back-to-back day and night shifts.
The view among nurses was that properly organised time
off would motivate them to work. Concerned health centre
managers said they recognised the need to manage staff hours
fairly, but with so few staff that was almost impossible.
Government sector managers explained how unexpected
absences increased the load on nursing staff. When staff
failed to turn up for work, and especially when they did not
communicate their intent, managers struggled to find workers
to fill the gaps and patients were left waiting.
While there was sympathy for the personal and family problems
that kept staff from work, managers felt that the reasons
offered were not always genuine. In the Ugandan culture it was
hard to question whether family sickness or burials had actually
occurred, and hard to enforce a requirement to produce sick
notes. Sometimes managers suspected, or even knew, that
absent staff were “moonlighting” or pursuing a “side income”,
“doing other things to survive”. Managers and frontline workers
commented that staff who lived on site were rarely absent,
unless they were sick or a relative had a problem, as they would
be ashamed when patients came looking for them at home.
Participants working in government health centres explained
how their hours and workload increased at short notice when
senior colleagues were called away to workshops and meetings.
They rarely questioned why these activities took priority over
clinical and management duties at the facility, though the
attraction of attendance allowances was alluded to.
Paradoxically, staff scarcity was a barrier to holding public
sector health workers to account for their absences. ‘Turning
a blind eye’ was preferable to starting disciplinary procedures
which would likely lead to a transfer. It would be “suicide”
to lose someone, as the remaining few staff would be more
overburdened and blame the manager.
Managers noted wryly that they had little leeway to dictate to
medical doctors and midwives in understaffed facilities: “They
hold you to ransom, they know they have power because they
can just go and get work somewhere else.” A frontline doctor
echoed the point: “You work in a relaxed environment. They
don’t want to pressure you too much and push you away.”
It is reported elsewhere that Ugandan facility managers have
no authority to discipline staff.
Scarcity was similarly a barrier to the redistribution of staff
within a district. While in theory a district health manager
could move a nurse or midwife from a better-served health
centre to ease understaffing at another centre in the district,
in practice the manager met resistance: “They won’t go
because they know they are marketable”.
Task-shifting
It is clear from workers’ accounts that work overload, stress
and poor community relations result from doing work for
which they are not qualified or trained. Such task-shifting has
been found in government healthcare facilities elsewhere in
Uganda. Managers and frontline workers expressed concerns
about staff working beyond their scope of practice, when a
nursing assistant acted as a nurse, a nurse as a midwife and a
midwife as a medical doctor. This is necessitated by shortages
and absences of suitably qualified staff. However, it seems that
task-shifting was also a deliberate strategy to save money by
employing less-qualified staff.
Participants’ recommendations to reduce the impact of staff
shortages include:
• the introduction of standards for patient/nurse and patient/
doctor ratios, so that health worker overload is transparent
and quantifiable
• educating the public, through better-informed news media,
about financial and bureaucratic obstacles to recruiting more
health workers
• centralising management of health worker recruitment and
deployment, to address the problem of unfilled posts and
uneven distribution of health workers
• providing good-quality staff accommodation, equipped with
electric lighting and clean water supply, suitable for families.
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16
Facility infrastructure
Government facility managers and district health officers
wondered why more health centres were being constructed
when existing facilities did not work as they should. Facility
managers in the government sector told of struggling
with inadequate budgets to repair or replace decades-old
infrastructure: “The only borehole, you pump for 30 minutes
and then it stops for two hours.” Pumping water only every
second day and encouraging rainwater collection in jerrycans
and drums was a partial solution. Elsewhere, the best that could
be hoped for was to be earmarked for rehabilitation – “at least
we are in a programme” – or that “a Good Samaritan” would
help connect to a distant water source. On the other hand,
external funding coupled with well-managed in-house technical
services allowed a not-for-profit hospital manager to speak
with pride of rainwater conservation and solar power systems.
There was a marked contrast between a hospital where wards
were cleaned three times a day and one which had no water
supplies “for years”.
The impact on health workers
“The condition of the working environment is one of the
biggest challenges. So that people can work with a smile,
wake up in the morning and be happy going to work. You
enjoy your work and your profession.”
Low job satisfaction
A major concern was the state of operating theatres at health
centre IVs. Government sector managers spoke of theatres that
did not function because of poor design or shoddy construction.
They said that when a theatre was unusable, or lacked proper
equipment or anaesthetists, underemployed medical doctors
lost interest and left. Doctors blamed the lack of opportunity
to practise surgery for unwillingness to take up a medical
doctor post at a health centre IV.
For nurses working with only one paraffin lamp and limited fuel,
proper care of night-time emergency admissions was impossible:
“How can you manage to put in the intravenous line with a dim
light?” Sharing one paraffin lamp across three wards was very
hard, yet: “We just have to bear with it for the betterment of
our community.” Nurses working in bad light felt they were
failing in their duty to patients in need of scheduled treatments
during night hours. Hospital communication systems do not
work without power, and midwives can be left to bear the
brunt when a doctor cannot be called.
Risks to health workers
Working with no power or water, health workers were
naturally worried about the risks to themselves: “We are
risking our lives.” Maternity workers emphasised the risk of
contamination from infected blood when working in the dark.
Nurses feared being assaulted when working alone in unlit
wards or crossing dark compounds, a risk increased by lockless
doors, breaches in compound fences and inadequately
equipped or absent guards: “We fear to answer the door
when somebody knocks for help.” Lack of a functioning
flush toilet at the workplace forced a dangerous walk home
through a snake-infested compound.
Risks to patients
Midwives and maternity nurses emphasised the risks to women
giving birth at night. Assisting deliveries by the light of a mobile
phone or a candle begged from a patient, they were forced to
delay repairing episiotomies until daylight. Unable to read the
patient’s case notes at night, midwives could not tell if she had
HIV and thereby reduce the risk to the baby. Only a donor’s gift
of lamps relieved months of “suffering” delivering in the dark.
Infection control was near impossible when nursing staff had to
beg the little water spared by patients’ attendants to wash their
hands, so as to avoid passing on infections to the patients.
Government sector workers in rural hospitals and health centres bore the brunt of
dilapidated conditions: non-functioning operating theatres, erratic or non-existent
electric power, unreliable access to clean water, blocked sewers, broken-down
transport and no communication technology. They told of damaging effects on
job satisfaction, risks to themselves and deeply felt harm to patients.
“Just yesterday we were doing an
operation and we had to complete
stitching by torchlight”
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Participants told how expensive fuel for electricity generators
ran out at crucial moments: “Just yesterday we were doing
an operation and we had to complete stitching by torchlight.”
Sterilisation was “a huge challenge”. As generator power
must be conserved it could not be used routinely for precious
equipment, such as an ultrasound machine which mostly stood
idle despite having a trained operator. Limited generator power
did not allow refrigerated blood storage and patients could
rarely afford the costs of travel to the referral hospital, to the
distress of health workers: “I feel so sympathetic and sorry.”
Transport is essential if the referral system is to work as
intended, and is crucial when a facility cannot provide the
intended services because of lack of infrastructure, power,
equipment, supplies or qualified staff.
Health workers showed pride in their facility when it had a
functioning ambulance to transport referred patients or could
rely on an ambulance sent on request from a higher-tier facility.
On the other hand, working in a facility with no patient transport
was deeply upsetting because many patients just could not
afford to pay their own transport costs: “They say they will go
to the hospital but they go home and later you find out that
they died.” Health workers’ distress was acute when a health
centre patient was referred direct to a distant regional referral
hospital. They knew that patients were deterred not only by
the travel costs but also by the prospect of a strange hospital
and an alien language.
Commonly, budgets did not stretch to fuel the vehicle for referrals.
It was widely acknowledged that patients were asked to pay
towards fuel but that was often beyond the reach of people
in poor communities. The negative impact on nurses and
midwives cannot be exaggerated. They came into nursing to
save lives, to use their knowledge to benefit their communities.
For them it was very hard and frustrating to stand by unhappy
and helpless, knowing that a mother and baby would die
because the vehicle lacked fuel. Nor was it a good experience
to see patients return to the facility “in a terrible condition
and very weak” or with complications because of the lack of
fuel for referral. Health workers also found it frustrating when
mechanical problems were left unattended.
A managerial concern in the government sector was that
effective referral systems require a means of communication
from lower- to higher-level facilities. Health workers seemed
resigned to using their personal mobile phones and paying for
calls from their own pockets to contact referral hospitals.
Because of the constraints on providing transport, it was
unusual to hear of a vehicle being used to bring patients to a
health facility. Staff in a government sector hospital were proud
that it provided an ambulance service to bring in emergency
patients, and noted how relations with the community
benefited as a result. There was also praise and gratitude
expressed for a project that supported pregnant women’s
transport costs, resulting in more facility-based deliveries.
The impact on attitudes,
behaviour and practices
Health workers spoke of their distress over how a lack of electric
power, water and transport affected the quality of service.
They wanted to do their best for patients but had to protect
themselves too. They explained how patient perceptions of
rudeness arose from the lack of power and water. The fear of
infection influenced their approach to patients: “Sometimes
we come in with a scared heart” or “Sometimes you shy
away from risk and the patient thinks you are rude, but it is
the working conditions.” They also acknowledged that the
frustrations of working in the dark caused impatience and
delays that patients construed as neglect.
The impact on community relations
It was said that patients refused to be admitted for treatment
when the toilets did not work and they were not able to bathe,
thus damaging the reputation of the facility. A lack of toilets
forced staff to return home, fuelling patients’ beliefs they were
not at work, and putting them at risk of being blamed by local
political leaders for leaving the workplace while on duty.
Recommendations from participants include:
• investment in good operating theatre facilities and their
staffing in a small number of health centre IVs, and
showcasing them as good practice before embarking on
more building and rehabilitation work
• meetings between management and frontline staff to
identify and act on infrastructure deficits that can be
remedied locally
• staff involvement in direct action to remedy infrastructure
problems.
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18
Equipment and medical supplies
Health workers praised facilities with good diagnostic equipment, such as X-ray
and ultrasound, and a commitment to a well-equipped establishment: “It’s a good
place, that’s why I have stayed so long.” Elsewhere, working with inadequate
equipment was a huge challenge, damaging workers’ professional fulfilment,
the quality of services and community relationships. The difficulties were acute
in the government sector, but present too in parts of the not-for-profit sector.
The impact on health workers
Government sector medical doctors and nurses told of
interruptions in supplies of oxygen and blood; missing canulas,
needles, giving sets and sutures; minimal availability of urine-
testing kits and family planning supplies; insufficient dressing
packs; and absent or faulty diagnostic equipment. Rural
midwives in the government sector told how they struggled
to provide a service with no delivery kit, cord clamp, sucker,
gauze or cotton wool and just one pair of scissors. Working
without protective wear – gloves, aprons, gumboots, shoes,
masks – was a huge risk, especially for midwives working in
the dark: “You are bathed in blood.” Lacking gloves, midwives
even used their own clothes and plastic bags to grasp the
baby during delivery. Workers in some rural facilities in the
government sector provided their own work clothes as, it was
said, the Ministry of Health no longer supplied uniforms.
In the government sector there was widespread frustration at
not being able to work effectively: “What really hinders my
work is lack of some equipment” and “The equipment does
not allow you to do what you are supposed to do.”
Nurses spoke about thwarted professional fulfilment. Willing to
work to the best of their ability, they felt “handicapped” and
“disappointed”. As a result, work was neither enjoyable nor
happy: “If I am provided with what I am supposed to use, I can
enjoy the work” or “You can’t really be happy in such conditions,
but would be happier with equipment to do your best.”
Frontline medical doctors spoke of “struggling with the minimum”
and of feeling “deflated” by poorly maintained equipment such
as X-ray machines with blown bulbs or no chemical to print the
film: “You wake up and have the same problem, you go home,
you come back and it has not changed.”
Doctors wanting the satisfaction of doing their best for their
patients spoke of frustrations such as a lack of diagnostic
equipment or facility for blood counts. Managers recognised
that medical doctors “eventually lose morale” when they are
unable to operate on a patient because oxygen or sutures
are missing, and that being unable to apply knowledge was
“very demotivating”.
Failing their patients greatly distressed nurses and doctors.
Patients died because of the lack of essential supplies: “We
would have saved that life if we had oxygen. It stresses you.”
A lack of diagnostic equipment cost lives too: “The patient
probably would have survived if you were able to investigate.”
Government sector workers faced a dilemma when the facility
ran out of supplies. User charges were abolished in 2001 in all
government facilities except private wings in hospitals, and
health workers told of prohibitions on asking patients to go and
buy missing items: “It is very annoying, you go home dissatisfied.”
The medical doctor has a duty towards the patient’s health:
“What do you do? Ask the patient to buy or see them get worse?”
The other option was “to be kind” and refer the patient to
a higher-level facility. Participants spoke against the policy:
“I don’t feel it wrong to ask a patient to buy needles in order
to help them,” and it was clear that patients in some facilities
were being asked to buy supplies. It was hard to ask a patient
to buy items that should have been provided free of charge:
“I don’t want to be the one to say go and look for a canula.”
Participants in facilities with relatively good supplies welcomed
relief from the stresses of telling patients to buy their own. They
also expressed pride in a facility that did not force patients to
spend what money they had on intravenous fluids, canulas,
gloves, dressings and the like. There was praise for imaginative
management that solved temporary supply problems by
borrowing from other facilities.
The impact on attitudes,
behaviour and practices
Participants working in the private and not-for-profit sectors
spoke frankly about the effects of shortages they had seen
during their time in government facilities. They told of nurses
forgetting what they had been taught in training schools and
some not working as a result, thus projecting a bad image to
the community which in turn made nurses feel not respected
and prompted them to leave. Participants in the government
sector did not identify these effects. However, there was a
suggestion that nurses were reluctant to come to work and
19. Our Side of the Story: Ugandan health workers speak up
19
face patients and their relatives knowing
that essential supplies were lacking:
“Staff don’t want to come in and look
at a mother with a dying child and no
canula to give intravenous fluids.”
The impact on community
relations
Health workers felt blamed for the lack
of supplies and resented accusations
of theft. The patient’s attitude changed
when asked to buy supplies: “You feel
bad when somebody is not appreciating
what you are doing.” Patients’ carers
were sometimes angry and violent,
such as the husband who hit a midwife
when asked to buy gloves.
There were fears of personal
repercussions if the rule was disregarded
and the patient was asked to buy
supplies: “The Government is going to
see you as a bad person.” Staff in one
facility were stressed by the arrest of a
health worker who asked a patient to
buy essential supplies. The view there
was that local political candidates had
set the arrest in motion to discredit the
incumbent leader.
Participants’ recommendations include:
• encouragement to international
donors to supply large items of
equipment directly
• more attention to the maintenance
of essential equipment
• management consultation with
frontline workers to identify and
act on equipment shortfalls,
alongside empowerment of
workers through educating them
on how the supply system works.
Attending a weekly mother-and-baby group.
Children and pregnant women are the largest
groups of health facility patients.
Our Side of the Story: Ugandan health workers speak up
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20. Our Side of the Story: Ugandan health workers speak up
20
The drug supply situation
Outside the government sector, medicine supplies were generally
thought adequate to treat most conditions. A sufficient supply
brought health workers the satisfaction of working effectively,
as well as pride in an efficient facility that logged all movements
of medicines. The not-for-profit sector was not immune to
shortages, however; in one facility shortages were said to be
due to loss of revenue because it gave impoverished patients
drugs on credit.
In parts of the government sector there was some
acknowledgement that government efforts to improve the
delivery system of the central medical store had brought
improvements in supplies of essential medicines. It was also
noted that drug supply increased after a government stamp
on packets was introduced. There was enthusiasm that better
supplies now benefited patients: “Now we have enough drugs,
I would not say all drugs, and inpatients get the drugs the
doctors prescribe.”
There was a sharp contrast between praise for medicine
supplies in better-stocked facilities and disgruntlement among
workers elsewhere. Health workers said some essential drugs
were used up in a matter of weeks, or even days: “They bring
one tin of quinine tabs for the whole unit” and “Just five tins of
Panadol which the department can use up in one day.”
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. Shortages were
said to be made worse by patients taking unfair advantage of
brief periods of plenty, but with no testing equipment it was
hard to refuse drugs to patients who claimed the common
complaint of malaria. And it had been noted that patients
turned up with a different patient record book every day of
the week in order to stock up with drugs at home.
Government facilities typically could not stretch their budgets
to purchase drugs in the private market, and were forced to sit
and wait for the next delivery from the central medical store.
However, one hospital dedicated a quarter of its private wing
income to medicines.
The impact on health workers
and the quality of care
Health workers said they felt “disappointed” and that the lack
of drugs “demoralises” them. Job satisfaction suffered when
they were unable to give patients the drugs they needed. Their
presence in the workplace sometimes seemed futile: “You are
here, and there is nothing to give the patients. You are just
sitting waiting for them, then tell them to go back as there is
no drug.” Especially hard to bear was being forced to tell poor
patients to buy their medication in the private market: “I hate
the situation of being helpless before the patient when they
can’t afford to buy drugs” and “You feel you have not done
much for the patient when they have to buy.”
It seemed like fobbing off the patient: “You tell them to buy,
but the patient is expecting answers.” It was hard to be seen
as letting down patients keen to have family planning supplies
who could barely afford the transport to the facility: “You feel
so bad, it seems as if you are deceiving them and they lose
confidence.” Self-esteem suffered when drugs were not available:
“They look at you and think the health workers are bad, and yet
it is the government not us” or “Their eye looks at the nurse
and that doesn’t make me able to be the nurse I want to be.”
The biggest source of distress for health workers was the
impact on patients, and they spoke emotionally about how
they felt for their patients when no medicines were available.
In the case of antiretroviral drugs against HIV, which should
be taken for the rest of a person’s life, it was very hard to
see patients go for up to six months without treatment.
Medicine supplies
Medicine shortages and ‘stock-outs’ emerged as one of the biggest challenges for
government health workers. Unable to give their patients the drugs they needed,
health workers grieved for their patients’ suffering and became demoralised by
the futility of their roles. They struggled with disappointed or angry patients and
their limited understanding of the reasons for shortfalls in supplies. They were
deeply hurt by accusations of stealing drugs, the lack of trust the public had in
health facility staff, apparent press hostility and by what they saw as politically
motivated moves to discredit them.
A patient at Masindi district hospital, Uganda. Working with inadequate
and missing equipment is a huge challenge for health workers.
21. Our Side of the Story: Ugandan health workers speak up
21
Our Side of the Story: Ugandan health workers speak up
21
22. Our Side of the Story: Ugandan health workers speak up
22
Health workers cared passionately about the consequences
for poor patients: “Few can afford even 2,000 shillings [US$1],
so day after day they walk here and wait. Walk 15, 20km
despite the pain.” They felt the pain too when patients
became more unwell while waiting for their families to raise
money to purchase medication.
Hospital doctors spoke of how they were forced to refer
admitted patients who could not afford to buy medicines, or
just keep them in a bed without medication. The quality of
care also suffered when the patient could afford only cheaper,
inferior drugs which then failed to improve their condition,
resulting in referral, an option many patients could not afford.
The impact on community relations
“It puts a lot of strain on community relations.” Health workers
said it was hard to make patients and other community
members understand why drugs were not always available.
They acknowledged that people sick and in pain had little
appetite for words of explanation, and that the complexities
of the supply system were beyond the understanding of some
people without education. But they also told of angry, bitter
patients who cursed them and refused to listen.
In the past, Ugandan healthcare users maintained a belief
that government health facilities lacked medicines even when
receipts increased. According to health worker participants,
there now appears to be a prevailing belief that health facilities
are well supplied with medicines: “People say why don’t you give
us drugs?” A particular problem arose when a health facility
changed ownership from not-for-profit to government and the
previously superior supply of medicines could not be maintained.
Health workers said that communities served by government
facilities assumed health workers took the drugs: “Patients think
you steal” and “patients call us thieves.” They said that patients
believed that health workers took government supplies to stock
their own clinics and drug shops, to which patients were then
sent to buy medicines. It was acknowledged that such abuses
had occurred. Indeed, good supplies in one hospital were
attributed to the fact that few of its nurses ran private clinics
and drug shops. Health workers regretted the lack of trust put
in them and the effect on community attitudes: “When drugs
are not there, they tend to hate nurses.” In contrast, it had
been observed that patients’ attitudes towards health workers
improved when given supplies of drugs to last several days. It
was especially upsetting to be directly accused of theft when
a patient demanded a drug that the clinician knew was not
appropriate for their condition.
There was widespread indignation at accusations of stealing
non-existent medications: “What are they supposed to be
stealing?” or “What kinds of drugs can we steal? Paracetamol?
Because that’s the only drug in the hospital!” and “How can
they take things that are not there!” Health workers 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 the patients: “It is
making us lose morale for what we are supposed to do.”
Health workers resented negative stories in the print media,
TV and radio, believing that journalists blew up single incidents
unfairly to give an exaggerated picture of the extent to which
frontline health workers were guilty of pilfering drugs.
A stakeholder concurred: “We can’t brand all health workers
as thieves just because someone has stolen a tin of aspirin.”
Stakeholders noted that press stories about health workers
stealing drugs had increased with the work of the Medicines and
Health Supplies Delivery Monitoring Unit, an autonomous unit
set up in October 2009 within the President’s Office. While there
was support for its efforts to expose poor working conditions as
well as abuses, the view was expressed that it was unhelpful to
create a media story around every case of wrongdoing the unit
uncovered: “They tried to create publicity instead of dealing
with the real issue of what is causing the stock-outs.”
There was also hurt and indignation when top public figures
spoiled the professions’ reputations by stating publicly that
health workers are thieves: “How can any patient value a
doctor, value a nurse, when they say such things about us!”
It was felt that government conspired to make out that all
health workers were thieves although, in the opinion of
health workers, top managers and not frontline workers were
the chief culprits. Public accusations by the President were
especially damaging to health workers’ self-esteem.
“Patients get angry because the politicians tell them drugs
are provided.” Views were expressed that politicians
deliberately mislead the public: “Government makes them
believe they have sent drugs” and “The public is being
hoodwinked!” But for a public servant it would be “suicide”
to contradict political masters.
“What kinds of drugs can we steal?
Paracetamol? Because that’s the
only drug in the hospital!”
23. Our Side of the Story: Ugandan health workers speak up
23
Participants’ recommendations include:
• improved transparency at the point of medicine delivery,
with the opening of boxes witnessed by the chairperson of
the health unit management committee, the elected chair
of the local community, the government internal security
officer, police and patients
• supportive paperwork to show what has been ordered
and delivered
• efforts to inform local leaders about the supply situation
and ensure they use the information responsibly
• outreach to communities to explain the real situation
through Village Health Teams, staff visits such as child
immunisation days and talks to patient groups at the facility.
Politicians stop playing games
on the right to health
A story is often told of a politician who delivered
a truck laden with ‘medicines’ to a health centre
in his constituency. The truck was reportedly
containing all the medicines that this health centre
needed at the time. In a country where getting
medicines in public facilities is intermittent and
health workers are reviled for ‘stealing’ medicines,
this politician was an angel straight from heaven.
Now, long after the speeches and pleasantries had
ended, and the MP had gone, it was time to open
the boxes. But alas, the boxes were full of saline
solution. […] There was no way medics at the
facility would tell people the next day that there
was no medicine. To the politician he had scored
a political goal. But in the process, the health
workers had been put in a tight position.
Daily Monitor, 16 February 2011
“How can a patient value a doctor,
value a nurse, when they say such
things about us!”
24. Our Side of the Story: Ugandan health workers speak up
24
Pay
The frontline workers and managers participating in the research said they did not
join their professions just for the money. They wanted to use their training to help
others, prevent and cure illness and save lives: “I became a nurse not so much
because I am interested in money, though money is also important. I feel it really
was a vocation.” In any case, salaries were simply not attractive enough: “With so
little money, nurses must want to care and help patients, just to keep going.” Money
was never an overriding factor for job satisfaction, though among frontline doctors
there were expectations of earning enough to “help build yourself up” and feel
good about helping people at the same time. Yet there were some strongly held
views among participants that some of the recent generation of health workers
entered the profession with no genuine vocation for it and became disaffected
because salaries were so low.
Staff in rural health facilities said that despite long working
hours with little chance to rest, they worked over weekends
and on public holidays for the sake of the patients. They even
volunteered their help unpaid on top of their regular work, out
of commitment to patients’ welfare, for instance in HIV clinics.
Low salaries were of course a concern, and there were many
calls for better financial compensation. But it is very striking
that when asked about what had to change to make things
better for them, health workers emphasised improvements
in the infrastructure that would result in better care and
treatment for patients. Frustration with equipment and
supplies outstripped frustration over salaries.
The impact on health workers
Health workers felt undervalued because salary levels did
not match their needs and social expectations. The pay
was felt to be unfair and not to represent an appropriate
return for what they put in.
Money worries
Health workers said salaries were not enough to cover the
costs of ordinary daily living, to allow them to pursue a career
or to meet social expectations. They said that money worries
got in the way of doing their best work and even contributed
to bad practices. Managers said inadequate pay was one of
the biggest challenges to healthcare delivery.
Nursing staff spoke heatedly about their struggles to survive
on low pay and support their dependants, see their children
through education, pay for a roof over their heads, settle
essential bills and afford transport to work. Financial worries
added to the stresses of long hours and little rest, the burden
of having too many patients, the frustrations of not having
enough medical supplies and lack of appreciation in the
workplace: “If better paid, a nurse will work with patients with
love and happiness knowing that rent and bills are paid.”
In areas where demand for housing had pushed up rents,
health workers found housing costs hard to meet or were
forced to pay high transport costs to reach more affordable
accommodation. Paying US$1.50 or more a day for transport
was very hard to afford on a nursing assistant’s salary.
In Uganda, income is needed not just to meet daily living costs.
There are extended families to support: participants had up to
15 children depending on them. One of the satisfactions of
earning is being in a position to support the study costs of a
family member. As educated people, health professionals
naturally want a good education for their children. Public
primary and secondary education is free, but schools often
impose fees for lunch, uniforms and building development, and
many Ugandans favour the private schools that comprise over a
quarter of the secondary education sector. Worry about school
fees pervaded health workers’ lives. A participant spoke heatedly
about the impossibility of affording university fees of US$900 a
semester with three children and a monthly salary of US$330.
“Society expects so much from you.
It’s impossible to convince people
that you don’t have money when
you are a doctor”
25. Our Side of the Story: Ugandan health workers speak up
25
Failing to meet social expectations
As a health professional there are also social expectations to
meet. Family, friends and social associates assume you are well
off, and it was shaming to reveal how meagre the salary actually
was. Medical doctors especially felt embarrassed when they
could not afford to contribute large sums of money at functions
held to raise funds for wedding or funeral expenses. They were
also expected to help with school fees or medical costs: “Society
expects so much from you. It’s impossible to convince people
that you don’t have money when you are a doctor.” The pressure
came from the community expecting a nurse or doctor to be “at
a certain level” and seeing them as not responsive to community
problems. It was also hard for doctors to face the disbelief of
patients begging them to pay for life-saving treatment that
should have been freely available: “You look in their eyes and
see the hurt and the disappointment.”
Medical doctors and senior nurses spoke of unaffordable
lifestyle aspirations such as a house that befits their status.
Doctors wanted to be in a position to afford a decent house
rather than put up with low-standard government sector
accommodation on site.
Disrespect
“In Uganda respect comes with how much you earn.” It was said
that patients “look down on nurses” when they know how little
they are paid. Rural nursing assistants who were especially poorly
paid said this would be a barrier to enlisting the help of the local
community to advocate for higher salaries: “It’s our secret.”
Thwarted professional ambitions
A widespread and serious concern was unaffordable further
training: “I have to sponsor my own study yet I am serving
the nation!” Health workers spoke, often passionately, about
thwarted ambitions to improve their skills and knowledge.
Nursing assistants wanted to train as enrolled nurses or midwives,
and enrolled nurses and midwives to train as registered nurses
and midwives. Registered nurses wished to add midwifery to
their qualifications or go to degree level. Doctors wished to
bring their knowledge up to date and train as specialists.
Unfair pay
Participants regularly 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. They pointed to other medical jobs that required the
same length of training yet were more highly paid: “Nursing
is one of the lowest-paid medical professions.” Doctors
pointed to the much higher salaries of other professionals:
“We send our children to the same schools, buy our food at
the same markets.” It was dispiriting to see their university
contemporaries earning so much more yet working less hard.
The fact that medical doctors are paid less than secretaries and
drivers in some statutory agencies underscored the lack of value
attached to the medical profession in Uganda. There were some
strong feelings, notably among managers and practising doctors,
that low pay reflected a lack of political will at ministerial and
presidential level to invest in healthcare. There was some anger
about public spending on political campaigns, the military and
a presidential jet, and about wastage through corruption, while
healthcare was grossly underfunded.
Salaries were doubly unfair because they did not reflect the
long hours many health workers put in: “You can give your
family neither time nor money.” Nor did salary levels take
account of the risks of infection health workers faced. Not
being rewarded for doing the same work as higher-grade staff
was thought grossly unfair. It sometimes seemed to hospital
nurses that doctors did little while they did all the work.
Nurses complained that after paying for additional training to
upgrade their skills, they lingered for years on their previous
salary until promotion was granted.
Another area of perceived unfairness was the disparity in
salaries offered by the government, not-for-profit and private
sectors. Not-for-profit sector workers pointed to their longer
hours, and it was commented that unlike some government
health workers they worked the hours they were paid for.
It was pointed out that not-for-profit and private facilities
were free to decide their own salary levels and acknowledge
seniority in their own way, resulting in lower pay than in
government settings. A particular grievance was the absence of
a senior clinical officer grade in a not-for-profit facility. A further
concern was that the government’s salary enhancement for
employment in hard-to-reach areas seemed not to have been
adopted systematically in the not-for-profit sector.
26. Our Side of the Story: Ugandan health workers speak up
26
Rarely was it said outright that health workers are exploited,
although there were views that unfair advantage is taken of
their professional ethics and dedication to patients: “Nurses
are trained to love and serve, to forswear hard conditions,
and no matter how little we are paid we have to have that
love.” Indeed, among managers there was some intolerance
of frontline workers’ complaints about low salaries and an
attitude that commitment to the work regardless of the pay
was praiseworthy: “Patients have to get a service, poorly paid
or not.” Yet managers were among the most vocal critics of
salary levels: “The salary is deplorable!” Overall, participants
appeared more resigned than militant about unfair pay,
though there was some anger that the Government cited
the Hippocratic Oath to prevent doctors from protesting.
The impact on attitudes,
behaviour and practices
Health workers and managers were encouraged to say what in
their view explained behaviour regularly criticised in the Ugandan
media, including being rude to patients, stealing medicines
and supplies, not turning up or coming late to work, and taking
money from patients. Health workers acknowledged that these
bad practices did happen in some places: “It’s poverty. You get
a salary of US$200, you pay school fees of around US$150, you
get stuck. You don’t have transport to take you to work, you
don’t have food in the house, you don’t have anything, children
are crying, your parents need you to keep them. That’s what
drives people to do those things.” But they also argued that
the media exaggerated the scale of such practices by unfairly
generalising a single instance to all health workers: “It spoils the
reputation of all nurses, it pains and discourages us so much.”
One of the hottest topics in the Ugandan media is the apparent
disappearance of essential medicines and medical supplies
between the central store and patients in government health
facilities. Theft on the part of health workers is only one
explanation for shortfalls in supplies. Participants acknowledged
that theft did occur within some health facilities. In their view,
the explanation lay with low pay and money worries: “They
are not stealing medicines because they are evil – their income
does not satisfy their needs.” Delays in salary payment were
implicated too: “They steal for survival.”
In no way was stealing condoned. Some participants were upset
that patients were deprived of already scarce supplies. Others
were bewildered that health workers could put their own
interests before those of patients. Only rarely did participants
believe that greed led health workers to steal. Some health
workers thought that pilfering of medicines happened only on
a small scale and that drugs were taken for personal or family
needs and not to sell. But there were also views that helping
yourself had become a habit, with reports of staff openly
justifying selling supplies on the grounds that the facility did
not reward them well enough.
Participants with experience of closely managed facilities spoke
of tighter administrative practices that helped to safeguard
medicines. Workplace cultures that accepted stealing were
also noted. The suggested solutions were tighter management
to reduce opportunities for abuse, and holding staff to their
codes of employment. Peer influence to change behaviour
was seldom proposed.
Taking money from patients is a sensitive topic which some
health workers were understandably reluctant to discuss.
Soliciting bribes from patients was thought to be rare and was
unacceptable because it would add to patients’ poverty. If it
did occur, it was attributable to low pay: “If paid a satisfactory
salary I think they would not get money from the patients.”
There was also a view that worries about surviving on
retirement pensions drove health workers to ask for bribes.
It was observed that in some settings patients expected to
give staff some inducement to attend to them. Such mistrust
was hurtful and offensive, and it was suggested that the
distance between workers and patients widened as a result.
Participants told of scams whereby patients were robbed of
their money by conmen masquerading as health workers, and
of angry patients subsequently attacking legitimate staff.
Health workers distinguished accepting “appreciation” from
demanding money and some acknowledged a temptation to
accept unsolicited money from patients as compensation for
ill-paid, exhausting work. It was suggested that some see
health workers accepting appreciation and wrongly conclude
that a bribe has been taken.
It was widely believed that urban health workers were forced
to work in two or even three jobs to make ends meet, with
government sector employees also working in private clinics or
private hospitals. One unfortunate consequence, it was said,
was to reinforce patients’ suspicions that health workers steal
drugs from their workplace to sell in private clinics. Moonlighting
was often known, or suspected, to explain absences: “Most
people, when they don’t turn up for work you find they are
running a clinic somewhere.” It was said that absenteeism
was not a problem in areas where private treatment or drugs
were unaffordable. Exhaustion from doing too many jobs was
thought to cause behaviour patients saw as rude.
Rural areas were said to offer many fewer opportunities for
side employment, but there it seemed that health workers
were sometimes forced to take time out to tend crops to
feed their families. It was noted that before decentralisation,
rural workers regularly saw to their vegetable gardens before
leaving for work, when salaries arrived late or not at all. It was
suggested that this habit continued.
“If the pay was more, the nurses
would respect their work more”
