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HEALTH WORKER SHORTFALL: IMPACT IN UGANDA. Right to Health: Challenges in funding, health systems and universal access in development polities Madrid, June 01 2010 Sandra Kiapi, Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda ( www.aghauganda.org ). Presentation Outline .

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HEALTH WORKER SHORTFALL: IMPACT IN UGANDA

Right to Health: Challenges in funding, health systems and universal access in development polities

Madrid, June 01 2010

Sandra Kiapi,

Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda (www.aghauganda.org)


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Presentation Outline

  • HRH Staffing Levels and Distribution;

  • HRH Production Capacity

  • Staff Attrition and Turnover;

  • HRH Management and Regulatory Systems;

  • Health Worker Concerns;

  • Key Conclusions and Recommended actions


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About AGHA

  • AGHA’s Mission is to raise the awareness of all health care providers and the communities they serve in Uganda about the human rights aspects in health….


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1. HRH Staffing Levels and Distribution

  • Uganda among the 57 countries with critical shortage of HRH

  • Staffing levels low by all standards:

    • WHO - Staff Ratio of 1: 1818 vs. 1: 439

      2,919 Physicians working in the country which is equivalent to1: 8,373) people if spread throughout the country;

      20, 165 nurses and midwives= 1: 1,212

    • MoH, AHSPR 2008/2010 – average of 56% approved positions filled by qualified health workers.


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Staffing Levels, cont’d

  • Significant shortage of certain categories of staff;-

    Medical Officers (MOs), and specialized cadres-psychiatrists

  • Gross Mal-distribution:

    • 70% of MOs, 80% of Pharmacists and 40% on Nurses/Midwives are based in urban areas with 12% of the Pop;

    • Significant variation in district staffing levels (30% to 90%);

    • Majority of staff are located in Central Region (over 60% of MOs)



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Doctors/MOs in 2002

  • 1,349 in Kampala

  • 505 in Wakiso

  • 99 in Jinja

  • ….

  • Total 2,919 (60% in central region where about 12% of the population lives

  • )


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Case Study: Kaabong in NE Uganda

  • Kaabong district approved Posts filled average of 39.4% in 2007/08

  • 8 Midwifes (6 in the district hospital) for 257,174 in 9 sub-counties

  • Watchmen stepping in to prescribe! (ACSD exercise 2008)


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Case Study: Kotido 2007/2008

  • Out of the 118 health jobs advertised

  • only 41 responded all of whom were interviewed and offered the jobs.

  • Of these only 36 accepted and took up the posts.

  • Only 29 of these were new people

  • of which only 6 were professional health workers; the rest were support and administrative staffs.

  • All these a midst a promise of 30% incentive of 6 months in a lump



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2. HRH Production Capacity

  • Uganda has potential to produce adequate numbers of health workers – GoU, PNFPs and Private;

  • Mismatch between training and health needs;

  • Production not keeping pace with growing demands – much worse for certain cadres;

  • Competence and Skills of Graduates


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


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3. Staff Attrition and Turnover Worker to Population Ratios and Numbers by Option

  • Contrary to common perceptions, overall attrition rate is not high in the public sector;

  • 1.2% in public and 13% in the PNFP sectors;

  • Varied by districts;

  • Attrition quite low for national referral Hospital Mulago;

  • Absconding and retirement are the major cause of loss of staff;

  • Attrition is highest for medical officers and Dispensers;

  • Noted increase from 2005.



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


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



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


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Job Stability: Intent to Leave/Stay between 2002 to 2007 in PNFP Facilities

  • Greater job stability in the public sector (53%) compared to PNFPs (21%)- over 10 years;

  • Physicians intent to leave current jobs in two years (43%) and country (31%);

  • Nurses least likely to leave - intent to stay over 3 years (83%);

  • Residents in the North expressed least desire to leave;

  • 60% Public and 47% PNFP workers intent to stay indefinitely;

  • Only 8% intended to leave ‘as soon as possible;

  • UCMB had highest number (33%) intent on leave within 2 years;

  • Salary, involvement in the facility, manageable workload, flexibility and opportunity for promotion reduced odds to leave.


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Intent to Leave by Cadre between 2002 to 2007 in PNFP Facilities

  • Intent To Leave By Cadre


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4. HRH Management and Regulatory Systems between 2002 to 2007 in PNFP Facilities

  • Review of HRM based on Actionable Governance Indicators:

    • Complex fragmented HRM system;

    • Not linked to performance in service delivery;

    • Strong safeguards on due process;

    • Low in terms of effectiveness and efficiency;

    • Characterized by delays: recruitment, payroll, confirmation, promotion etc.


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HRH Mgt is a Serious Underlying HRH Problem between 2002 to 2007 in PNFP Facilities

  • Scores based on HRH for Health Action Framework:

    • HRH Mgt Systems:- 63

    • Leadership:- 56

    • Policy:- 48

    • Finance:-36

    • Education:- 27

    • Partnership:- 15

    • Others:- 13 – mainly issues beyond the health sector e.g. external migration.


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Absenteeism between 2002 to 2007 in PNFP Facilities


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5. Health Worker Concerns between 2002 to 2007 in PNFP Facilities

  • Job Satisfaction:

    • 50% indicated overall satisfaction; PNFP (52%) and Public (49%);

    • Morale at workplace better for the PNFPs (55%) compared to public (42%);

    • Medical Officers least satisfied (27%) compared nurses (50%);

    • 30% felt supervisors did not show care and doubted supervisor competence.

  • Compensation:

    • Consider salary package unfair (86%);

    • Considered Family Health Care (87%), Salary (85%) and Allowance (80%) important;

  • Low Job Security:

    • Public (58%), UMMB (53%), UCMB (44%) and UPMB (37%)


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Health Worker Concerns between 2002 to 2007 in PNFP Facilities

  • Working Conditions:

    • Manageable workload (52%);

    • Availability of supplies (56%) - Public 36% and PNFPs (75%);

    • Availability of Equipment (52%) - Public (27%) and PNFPs (76%);

    • Access to electricity (55%) – Public (37%);

    • Flexibility – Public (61%) and PNFPs (57%)

    • Abuse (21%) – Public (24%) and PNFPs (22%)

  • Living Conditions:

    • Poor transportation (72%);

    • Poor access to good schooling (64%);

    • Poor access to shops and entertainment (65%)

    • Poor or unreliable electricity at home (65%)


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Access to Drugs, Supplies between 2002 to 2007 in PNFP Facilitiesand Equipment (%)


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Health workers concerns in the Media between 2002 to 2007 in PNFP Facilities


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6. Conclusions and Recommendations between 2002 to 2007 in PNFP Facilities

  • The main problems regarding HRH stem from gaps in management which have led to:

  • Low staffing and maldistribution

  • Attrition and Brain Drain

    Recommendations

  • There is need for improvements in HRH Management and overall strengthening to Health system

  • There is need to improve working and living conditions particularly in Hard to Reach Areas so as to retain;-(Retention Strategy, 2009, HRH SP 2005-2020)

  • CSOs advocacy HRH issues.


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Acknowledgments/Bibliography between 2002 to 2007 in PNFP Facilities

  • Ministry of Health (MoH), Annual Health Sector Performance Report (AHSPR), 2008/2009, Uganda

  • MoH, Uganda Bureau of Statistics, (UBOS) Uganda Service Provision Assessment Survey, (March 2008),

  • World Bank, Public Expenditure Review, Uganda (2008)

  • Intra health Capacity project, Intent to Stay Study, Uganda (2008)

  • AGHA/HWAF Research on Staffing Levels, September, 2009

  • Doctors With Africa (CUAMM), Uganda, Presentation by Dr. Peter Luchoro, to HWAF April 2009.


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