Health worker incentives during and after the conflict in Northern Uganda: A document review

^{By Justine Namakula, Sophie Witter & Freddie Ssengooba
August 2014}

Introduction
The dynamics of the health workforce in fragmented post-conflict situations is inadequately understood. However, this information is key to restoring a well coordinated and functioning health system. The post-conflict period may sometimes provide a window for policy reforms to address long-standing human resources for health (HRH) challenges. This study aims to understand the evolution of government and donor policies supporting health workers during and after the conflict in Northern Uganda, and to derive recommendations on how to improve their effectiveness and sustainability. This report covers one component of a wider ReBUILD research project, which also included in-depth interviews with health workers, key informant interviews and stakeholder mapping.

Methods

A total of 59 documents, largely government health policy documents were reviewed. The search focused on: health policies and overarching legal documents; HRH-specific policies, national plans, strategies, audit reports and annual health sector performance reports, programme documents (by local and international NGOs as well as donor agencies with a focus on HRH incentives); and mid-term and end of project evaluations of particular interventions on health worker incentives in post-conflict Northern Uganda. Apart from one document (the constitution of the Republic of Uganda), all documents which were reviewed had a publication date between 1999 and 2014 and were in English. The study also included print and electronic media articles on HRH incentive issues in Uganda for the period 2011- 2014.

After identification, data was extracted using a matrix developed by the research team and analysed in order to identify recurrent themes, areas of convergence and divergence of ideas, practices and findings, and significant gaps. This report is based on this document review.

Findings

HRH challenges during and after the conflict in Northern Uganda

There are numerous challenges for human resources for health in Uganda during and after the conflict in Uganda. These can be categorised into recruitment challenges, distribution challenges, retention challenges, and performance challenges (pay, motivation, management 4 etc.). While these challenges cut across the country, the conflict in northern Uganda exacerbated them.

Policy responses to the HRH challenges during and after the conflict

Over time, the Ministry of Health and its health development partners have developed numerous policy frameworks and interventions in response to HRH challenges countrywide. Many of the policies are linked to other national overarching frameworks and are often built upon earlier policies. The policy responses are categorized into nationwide policies as well as policy and programme responses specific to Northern Uganda. Although most of the broad health sector policies mention something about health worker incentives, the actual incentive package is rarely specified. In general, the main focus of most policy responses is training of health workers and health worker remuneration. A few of the policies focus on improving staff living conditions. Prominent activities are related to building health centers and housing units for health workers in the areas formally ravaged by war. Additionally, most documents focus on the effects of the policies on the broader health system. However, they are silent on how these responses were supposed to or have improved health worker performance and how the health workers perceived them.

Effectiveness of policies to date

A few of those policies (the HSSPs, the PRDP and all the donor funded responses in Northern Uganda) have been reviewed mid-term or annually while others seemed not to be evaluated at all. This category includes the motivation strategy, the national health policy and hard to reach allowance policy.

There are pockets of improvements. However, these are still far from the planned targets both at national level and in conflict-affected areas. Hence, the (identified) HRH challenges have persisted. Effectiveness of the policies has mainly been hindered by limited funding, limited capacity of some actors, poor coordination, and limited or lack of support and supervision, among other factors.

Lessons learnt

• Implementation of effective incentive policies and responses requires a sector wide approach but this in turn requires good coordination skills, well built capacity and commitment from all actors involved.
• For incentive policies to work, they need to be holistic rather than piece meal.
• If the capacity of the districts is strong, then they will participate better in implementation of the incentive policies at the local government level. This is crucial given that all policies are implemented under the decentralisation framework.
• The effort invested in implementing HR incentives responses needs to match that invested in their planning, otherwise resources will be wasted.
  
• It is not the number of policies that are put in place overtime that is most important, rather it is the impact that these policies have on reduction of HRH challenges in the country that is most important. Proper planning of HRH interventions and policies needs to go hand in hand with making funding available, if anything is to be implemented.
• When evaluating the impact of policy responses, it is not enough to count numbers. We also need to consider the things that may be challenging to count but are crucial. For instance, health workers experiences and views on how these responses affect performance and motivation need to be solicited.

Read the full report: Health worker incentives during and after the conflict in Northern Uganda:  A document review