A case for investing in nurses and midwives; Reflections from Uganda

By Irene Atuhairwe, BScN, MPH and Tracy Kobukindo, BScN, MPH

As the world geared up for the celebration of the International Day of the Midwife on May 5, and the International Day of the Nurse on May 12, we reflect on the impact of the first quarter of 2020, a year that was declared by WHO as the International Year of the Nurse and Midwife (YONM).

According to WHO, 2020 is meant to "celebrate the work for nurses and midwives, highlight the challenging conditions they often face, and advocate increased investments in the nursing and midwifery workforce." 

In a sad twist, celebrating during YONM has become less palatable given the COVID-19 pandemic that has seen nurses and midwives (among other health workers) all over the world, risk or lose their lives at the frontline.

As of May, over 1,000 frontline healthcare workers, globally, have died from caring for patients with COVID-19; 221 are nurses. Rather than celebrating during 2020, the pandemic has highlighted the challenging working conditions for nurses and midwives which have sadly cost lives.

The challenges posed by the Covid-19 pandemic have brought to light the critical importance, and the role, of nurses and midwives not just in pandemics but across the health care service delivery system as a whole.  According to WHO, the world needs six million more nurses and midwives to achieve global health targets within the Sustainable Development Goals (SDGs). This comes at a time when investment in nurses and midwives in Uganda in the past has not been given due attention, despite the fact that they make up seventy-five percent of the health workforce.

The Uganda Nurses and Midwives Council reports that 43% of nurses and midwives work in rural Uganda, where 80% of the population lives. It is, therefore, highly likely that, for many Ugandans, a nurse or midwife will be the only healthcare provider they will interact with during their lifetime and are dependent on them for all their healthcare needs.

One would think that given their critical role, investment in nurses and midwives would go without say, but this is not yet the case. Nurses still work long hours, spend thrice more time with a patient but are the least paid. These are some of the hurdles nurses and midwives are still facing, even in their year - the International Year of the Nurse and Midwife.

In light of the epidemic, some nations have started compensating for a previous lack of investment through monetising incentives for nurses and midwives to continue working at the frontline. The China Global Television Network reported that Ghana removed taxes for health workers and provided allowances worth fifty percent of their basic pay last month. Ironically, it took a pandemic to improve their pay.  

The Nurse's role in Universal Health Coverage

Universal Health Coverage (UHC) is a strong component of the WHO constitution and is key in achieving the Sustainable Development Goals (SDGs). In September 2019, heads of state and representatives of various governments committed to achieving UHC by 2030. This, if it were attainable, would be impossible without investing in and involving nurses and midwives, who by virtue of training and skills are key care providers in the rural areas (community nurse) and urban specialised wards (critical care). 

Bachelors trained nurses and midwives are uniquely placed to improve the health outcomes of a population. Research shows that having highly trained nurses and midwives improves health outcomes such as a reduction in mortality and reduced hospital stays.

According to research done by Dr. Linda Aiken in 2008, in the United States, an increase of only 10% Baccalaureate Nurses translated into a 10% reduction in mortality rate. Similar studies in other countries have shown reduced hospital stay and improved adherence to treatment where a bachelors' trained nurse was present.

But the presence of a nurse and midwife affects more than the patient's outcome, it also has spillover effects on the economy and gender equality. According to the Triple Impact of Nursing Report by the All-Party Parliamentary Group on Global Health, investing and developing the nursing and midwifery sector will have a triple-effect impact on ensuring better health for all, gender equality and stronger economies.

Nurses and midwives by virtue of their training and roles have the ability to provide person-centred care that is unique to the nursing and midwifery sector.

Investment Now

Investment Now is a global call to action and Uganda should not be left behind. Investing in nurses and midwives is no longer a debatable topic but instead a call to action to ensure quality patient outcomes and the resilience of health systems.  The success of Investment Now could very well determine how well we recover from pandemics such as this one in the future.

It will enable countries to achieve Universal Health Coverage and stronger economies. Without a healthy population, it is impossible to achieve a strong economy. The first step of Investment Now should be the meaningful engagement of nurses and midwives in policy discussions, formulation, and analysis.

Uganda has about 70,167 nurses and midwives registered with the Uganda Nurses and Midwives Council. These numbers may be deceptive and it's important to note that only 48,000 are in employment. Whereas we have made some strides in "pre-investment" activities, we have a very long way to go.  In 2018, the Nursing Now campaign was launched to uplift the status of nursing and midwifery worldwide, with Uganda among the Pilot countries.

As a country with more than 70,000 registered nurses and midwives comprising 75% of the health workforce, we must challenge ourselves to invest more in our own nurses and midwives, empower, uplift and motivate, and recognise their contribution towards the health sector.

For the Government of Uganda and all stakeholders, to achieve Universal Health Coverage, successfully battle Covid-19 and similar epidemics, we need to make deliberate efforts to invest in the nursing and midwifery sector. We offer five possible strategies to achieve this;

1.  Wide implementation of the schemes of service for nurses and midwives for better wages is a priority. This will incentivise nurses and midwives through provision of a conducive and enabling policy framework and environment that will see nurses and midwives perform to their full potential.

2.  Wide implementation of the schemes of service will enable bachelors prepared nurses and midwives to engage in direct clinical care and therefore improve health outcomes of the Ugandan population.

3.  Take deliberate efforts to meaningfully involve nurses and midwives in leadership, policy formulation and decision making at the national level at the ministry of health. This can be through appointments to leadership positions, actively seeking their contribution and bringing them to the table for policy discussions and formulation. This will not only ensure feasible policy formulation but also wider and sustainable implementation.

4. Fill available nursing and midwifery leadership positions as soon as they fall vacant. This will go a long way to strengthen leadership and advocacy of this sector. Leadership gaps create uncertainty, a lack of direction, vision, and accountability that is detrimental to the motivation, drive, and success of the profession.

5. Initiate active recognition of nurses' and midwives' contribution to global health through positive media coverage and at the workplace of nurses and midwives to inspire the profession and improves public images. The example of Nurse Doris Okudinia, who wheeled a patient from a Health Centre IV to a Referral Hospital to save her life, comes to mind and such selfless acts from nurses should continue to be recognised and publicised.