Human Resource for health and effective service delivery in Uganda:  Where is the missing link

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OPINION

By Dr Davis Malowa Ndanyi

Human resource is a critical function in every organisation, it plays a pivotal role in getting all resources to function. Human resource for health (HRH) comprises not only medical staff but also non-medical workers who play a critical role in ensuring that all the parts in a health facility are put together to function effectively.

It should be noted that the health sector is not only dependent on her technical human resource but it also relies on a precise application of the skills, knowledge and expertise of her non-medical work force to ensure patient security and health, equally the World Health Organisation continues to make interventions to support the human resource for health (both medical and non-medical) initiatives among member countries (WHO, 2010).

The role of human resource for health has never been put in the lime light until recently when it has picked the ears of African governments, many developing countries are facing human resource for health challenges such as inadequate salaries for health workers, low staff retention, inadequate specialised skills for some health conditions, poor planning for health care, staff absenteeism and attrition etc. (Martinez J., et al, 2008).  The extent of the human resource for health constraints has been largely noticed in the Sub Saharan Africa where there is high disease burden and where the Sustainable Development Goals (SDGs) seem to be beyond reach.

Interestingly, much as the bigger constraint of human resource for health is so prevalent in the African countries, there is lack of documented statistics in terms of categories, patterns of distribution, patterns of practice and attrition rates.  Absence of this important information makes it difficult for these countries to come up with realistic HRH policies and work plans, because it is through an enabling policy guideline that a country is able understand the existing skills gaps, by cadre of profession in order to accordingly, enhance pay or design appropriate retention strategies.

It is therefore important to initiate a systematic documentation of all skill gaps so as to make viable mitigation measures health facility by health facility, district by district and country by country, by so doing it becomes easy to plan and forecast for the medium and long term projections for the HRH initiatives (WHO, 2005). 

Dussault G., et al (2008), argue that in most of the remote areas the HRH challenge is real, to the extent that some facilities are run by ‘Nursing Aids’, these un trained workers who are hired to support the trained medical workers, due to shortage of staff, some of these Nursing Aids are deployed to man health centres in the remote areas, hence pausing a very precarious situation to patients, no wonder there are many cases of mortality.

Ugandan’s health sector is structured under a decentralised system, where the human resources for health is acquired, developed and its exit managed by the respective local governments.  The decision to decentralise was largely to strengthen health system’s functions and enhance service delivery to the peripheral or local communities (Wesam M., et al 2020).  The World Health Organisation (WHO) identifies four key functions of the health system namely; stewardship, financing, creating resources, and provision of services.

It was envisaged that decentralisation of human resource for health was meant to empower local leaders to manage the planning function, develop and implement budgets and above all take control of the decision making space and financing of all human resource for health activities. 

To the contrary, however, most of the powers remained at the centre where it is the central government to provide indicative planning figures at every budgeting season, implying that the local governments have to work within the budget estimates provided without powers to review major budgeting decisions. 

This approach of the centre retaining much of the planning powers undermined the spirit of decentralisation and hence has had far reaching consequences to the human resource for health strategy in areas like, inability to determine attractive pay to her health workers, inability to design attractive retention strategies, and also inability to plan attractive terminal/retirement packages for human resource for health (Wesam et al 2020).

In Uganda, the constraints of human resource for health have not been unique from other countries, constraints like inadequate staffing, inadequate salaries, brain drain, lack of critical skills for some specialised conditions, and of course lack of infrastructure like housing for staff, inadequate medicines and sundries all these compounded together leave the state of human resource for health demoralised and trying to ‘mungo park’ or part time from one health facility to another in order to make ends meet.  

It is also true that the strategies to address these challenges differ from country to country as each country manages its constraints in its unique way, a similar strategy may be implemented and tested by one facility and yet it may not work for another facility.

In a nutshell, Uganda like other developing countries is grappling with numerous HRH challenges which need deliberate interventions to mitigate the worse disease burden that the communities are faced with.  The interventions should be able to address the health facility challenges focusing holistically on the HRH and other pertinent enablers within the health facility.

In sum the following are the challenges facing human resource for health in Uganda;

1. Inadequate infrastructure. There are limited or no infrastructure in some health facilities especially in the rural areas, basic health infrastructure such as hospital/medical equipment, beds, ambulance and transportation facilities, operating theatres, first aid kits, microscopes e.t.c are lacking in most of the rural health facilities hence affecting health work performance.
2. Health work morale and job satisfaction. Government has progressively enhanced pay for health workers and scientists, we strongly appreciate government for this gesture. Despite these strides some health workers continue to ignore their core schedules to take on ‘mongo parking’ practises, which is a highly discouraged behaviour.
3. Progressive disease burden. There are numerous cases such as malaria, Hiv/Aids, tuberculosis, maternal and neonatal complications, diarrheal diseases, pneumonia and malnutrition etc that cause challenges to the management of diseases and hence straining the already stifled health budgets.
4. Geographical imbalance. This happens in both the staffing and infrastructural deployment, where you will find the rural health workers running to the urban areas and equally allocation of equipment being biased towards the urban centres.
5. Limited training opportunities. Continuous professional development is essential to all professions, to the contrary in Uganda due to limited resources it is left to individual employees to venture on their own. The most appropriate approach could be for government to plan regularly and send out calls for continuous professional development to health workers.
6. Inadequate health workers in some critical specialisations. Specialisations like medical oncologist, nuclear medicine, cardiology, cancer radiology, medical physics, nephrology, etc continue to be a night mare in most of the health facilities in Uganda. Most health facilities operate at less than 50% staffing levels.
7. Policy and governance issues. In Uganda there are many power centres which do not talk to each other, hence causing un necessary implementation and coordination gaps.
8. Brain drain. Most health workers prefer to work abroad if any single opportunity arises, even when they are trained by government, they run abroad for greener pastures and hence affecting the already limited staffing levels on ground.

Possible mitigations for human resource for health

1. a) Undertake baseline surveys within government health facilities to establish the HRH constraints that prevent effective health service delivery.
2. b) Conduct capacity building trainings in soft skills in order to impart knowledge, skills and attitude to HRH at various health facilities, to address mind-set challenges.
3. c) Conduct continuous mentorship and coaching to reinforce acquisition of knowledge and skills among human resource for health to improve health service delivery in the health facilities.
4. d) Carryout mid-term assessment/tracer studies to evaluate the impact of the capacity building trainings undertaken in health facilities in order to inform better planning.
5. e) A need for urgent recruitment of qualified staff across all health facilities to at least 70% staffing levels.
6. f) Urgent need to enhance pay for the other human resource for health staff who have never been enhanced.
7. g) Increase the budget for essential medicines and sundries for all health facilities, to mitigate the current drug-stock outs.

The Author of this Article is both an ACADEMIC AND A HUMAN RESOURCE MANAGEMENT PRACTITIONER