Can we avoid digging one hole to fill another? Framing the Health Workforce Challenges for Effective Solutions in Uganda

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By Freddie Ssengooba

“A problem clearly stated is a problem half solved.” (Brande 1948) and “For every complex problem there is a solution that is concise, clear, simple, and wrong” (Mencken 1956). In the attempt to solve the health workforce dilemmas in the health systems in Uganda, many alternative diagnoses are being offered. In the past five to ten years, Uganda has witnessed a wide spectrum of diagnoses for health workforce performance. Alongside each diagnosis, a solution is provided. The solutions have included 1) the export of health workers to solve labour-market distortions; 2) large-scale recruitment drive to address shortages in public health facilities; 3) expanding training programs to fix performance and workforce shortages; 4) to reduce absenteeism, of health workers, “presenteesim” is being enforced or incentivized; 5) programs to empower communities and clients are being scale-up to demand accountability and observe patients’ rights from the frontline health workers; and 6 ) performance-based financing (paying according to results) is also being debated as a solution to mitigate the problem of inefficiency in the production of health care services. These are a few examples of solutions that are at the policy making table in Uganda. All are aimed at improving health workforce performance.

As a result, a market-place with many potential solutions is created – all solutions are competing for the attention of policy makers in Uganda. Each solution has its salespersons (advocates) all calling for expedient decision making from the ‘terrified’ policy makers. The situation is similar in many countries in the African region. The beauty with competing solutions is that the policy makers can buy ideas from the market-place according to the price and taste for each solution. This is the phenomenon that economists like calling the “invisible hand”. The problem of this approach is that policy makers have limited tools to assess the costs, supply capabilities and the full benefits and risks of the solutions they are being encouraged to buy. Unlike in naïve textbooks of economics, where the buyer is assumed to have the money, the need and information about the benefits of a commodity such as an iPhone, the market for health workforce solutions is not driven by these basics in economics. The reality is that salespersons for most workforce solutions also hold the funds to pay for the solution (in the short-term) if policy makers make the “right” choice. For instance, the World Bank or USAID may award a concessional loan or a grant to Uganda if the performance-based financing solution is adopted as a national policy for remunerating health workers. It is like the Coca Cola company advertising for its soft drinks at the same time paying the persons that choose to drink its products. Unlike the Coca Cola example, workforce solutions require policy changes to the health system. Once adopted, these solutions affect the very foundations on which the health system is built. By reconfiguring the foundation of the entire health system, solutions for health workforce improvement require careful insights and robust customization to local contexts. This arises, partly from the fact that workforce solutions have complex interconnections among themselves and with other health system objectives. One solution is effective if several other solutions are also being activated at the same time. For instance, the perceived solution of exporting Ugandan health workers to Trinidad and Tobago would solve the problem of poor wages for medical doctors in Uganda but it would make it impossible for communities and clients to demand quality health care services. Exporting health workers would also require concurrent investments to expand training programs if the stock of health workers in the country is to meet the expected service needs for Ugandans. Training programs may fail to produce adequately prepared workers if the most experienced professionals to support the training programs are depleted due to export. The government can attempt massive recruitment to fill the gaps in the public facilities, but this will, as always, lead to shortages in the non-state health sector – as the available pool of health workers shift to public service payroll. The Director of Lacor hospital in Gulu district described this practice as “digging one hole to fill another”. Hasty and partial solutions from feeble diagnoses are responsible for a big share of the blame for this practice. In short, addressing the health worker problem requires that policy makers select and implement a comprehensive package of solutions. Piece-meal approaches are known to generate inefficiencies through distortions and unintended consequences in the health system.

How can Uganda avoid the practice of digging one hole to fill another? How feasible is it to identify and implement a comprehensive package of health workforce solutions? Are these packages going to achieve effective scale-up in poor countries like Uganda? These (and more) are vital questions to be addressed under the SPEED project. From the outset, it is clear that one ministry – the Ministry of Health, does not have the capacity or mandate to address all these problems. It will require the efforts of many sectors to come together to identify the package of solutions that is required to increase, stabilize, motivate and boost the productivity of health workforce. Ministries of Labour and Foreign Affairs are vital for the export solution. Ministries of Education and Public Service are necessary for expanding training programs. For performance-based financing to work, ministries of Health, Public Service, Local Governments and Finance are all required to play vital roles. Indeed the government alone cannot address all the solutions effectively (see chapter 4 in this report). The non-state actors in the health system are legitimate partners that need to be at the table when identifying the set of solutions to be undertaken. From this perspective, pooling resources from a wide network of sectors and stakeholders; and distributing tasks across the network of role-bearers both within and outside government is likely to boost the feasibility and sustainability of implementing a broader set of workforce solutions. To achieve these system-wide actions, SPEED project is committed to building a common vision and synergistic activities across the action networks for complex problems exemplified here by the workforce challenges in the health system. Platforms for purpose-driven engagement and dialogues are being established to create a shared vision, to identify the solution packages and together learn how to improve the implementation of these solutions. Ultimately, the SPEED Project aims to accelerate the policy and implementation processes for the attainment of universal health coverage and health system resilience in Uganda and beyond.

Dr. Freddie Ssengooba is an Associate Professor of Health Policy and Systems Management at Makerere University School of Public Health. He is also the Team Lead for the SPEED initiative.

He can be contacted on sengooba@musph.ac.ug . You can also follow him on Twitter: @fssengooba

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