June 23rd 2016 the SPEED project held a breakfast meeting (its 20th engagement meeting) at Metropole Hotel, Kampala to validate findings from the study on the implications of the phasing out of enrolled nurses in Uganda. As way of background, the East African Community in 2014 in order to harmonize nursing training and practice in the region tasked member countries to phase out certificate level nurses such that the lowest nursing cadres (in the region) is a diploma holder. Last year during a meeting of the Human Resources for Health Technical Working Group at Ministry of Health, the Permanent Secretary requested Makerere University School of Public Health, SPEED project to examine the implications of that policy decision on attainment of health system goals especially Universal Health Coverage (UHC).
This was the third consultative meeting on the issue, the first one having been held in February this year and the second one in June. The SPEED activity team leader, Dr. Suzanne Kiwanuka, thanked participants for committing time to be a part of the event. She briefed the participants on the background of the study and urged them to actively participate and genuinely provide input into the draft study report.
Dr.Suzanne Kiwanuka introducing the objectives of the breakfast meeting
Dr. Aloysius Ssennyonjo, SPEED Project Manager shared the key findings from the study. Notable highlights included:
- Uganda adopted the global agenda of achieving Universal health coverage as highlighted in the newly adopted Health Sector Development Plan (2015/16-2019/20).
- Uganda has a history of investing and abrupt phasing out of health work cadres such as comprehensive nurses, nursing assistants and other community health workers. These have led to several unpleasant ramifications.
- There are several perspectives on the phasing out decision; some view it as a blessing whereas others consider it to be a “serious” problem.
- To one side, phasing out is considered an opportunity for harmonization and standardization of nursing training, policies and practice in the East African region. It is also seen as a step towards enhancing professionalization of the nursing cadre to enhance quality of graduates and ultimately of the services provided by them. Furthermore, the phasing out policy offers business opportunities for the training institutions which are likely to increase when enrolled nurses start scrambling to retrain.
- One the other hand, phasing out nurses seems discordant with the new sector goal of achieving UHC. This is particularly so because the underlying context of inadequate numbers, mix and distribution of health workers in Uganda is a recognized binding constraint to health system performance. Nurses form the biggest proportion of health workers in Uganda and enrolled cadres comprise the biggest proportion of nurses. Phasing out therefore shrinks the most numerous group of health workers undermining health systems performance towards UHC.
- Relatedly, the decision to phase-out certificate nurses brings forth several costs to the individuals, the system and the country: First, there will be costs for upgrading the enrolled cadres that must be borne by either the individuals, their sponsors or government. Secondly, there are costs due to disruptions in service delivery when nurses start rushing to upgrade. Thirdly, there are costs due to increased wage bill as diploma level nurses are paid higher than what certificate level nurses receive. Lastly, there are envisaged costs to the country due to efflux of nurses to other countries if they are not absorbed into the system and/or if the remuneration packages in the region are not harmonized as well.
Similar and related views and issues were raised during the plenary and panel discussions that followed the presentation of key findings. Key points raised by the contributors included the following:
- Is it phasing out really? There is need to reframe the agenda from “phasing out” to a less scary concept of ‘transitioning’. This would encourage buy-in from other stakeholders especially government.
- There is a need to clearly delineate and articulate the problem being addressed by the policy proposal: Is the problem quality of training or of the services delivered by the enrolled cadres? It was noted that several health facilities in the country are served by registered nurses who upgraded but are still recruited as enrolled due to limited scheme of service and temporary ban on recruitment. In that case, if quality has remained low at the facilities managed by registered cadres, will upgrading all enrolled cadres guarantee quality improvement? Thus, there is need to focus on other determinants of health workforce and health system performance.
- Many related questions still need answers: What is the road map for attainment of UHC in Uganda? What is the basic service package that should be delivered in order to achieve UHC? What are the characteristics of the basic nursing cadre needed to deliver these services? How are the roles of other sectors in human resource development being harnessed and steered by the health sector?
- The name of the cadre may not be important after all; it is his or her ability to deliver the set package of services at the respective levels of the health system. Therefore, improving the quality of training may be the masterstroke to enhancing the performance of the nursing cadres. The curriculum should be reviewed to ensure the requisite knowledge and skills are imparted and the core competencies are acquired by all training to be nurses. Relatedly, the capacity of the training institutions should be strengthened. For example, there is only one health tutor training school in Uganda; many more other should be set up to boost the numbers of qualified tutors.
- The model of training is important to minimize disruptions to the service delivery during the upgrading phase. The Aga Khan model of bringing people to Kampala every weekend was noted to be costly and to favor individuals working in Kampala. The model of training institutions creating regional satellite training centers at big hospitals was proposed. However, the model would require piloting and building the capacity of these facilities should be paramount to ensure quality training.
- The extent of the knowledge of the costs for example related to retraining and wage bill was still deficient. There is need to do more robust modeling to inform better the case for phasing out or not.
- With the non-existence of opportunities for registered nurses to be employed as such in the public service, there is an urgent need for advocacy to expand the scheme of service for nurses in the country. The fact that many registered nurses are still employed as enrolled nurses defeats the essence of upgrading and is a big de-motivator for retraining. Relatedly, there is need to advocate for increased budgetary allocation for remuneration of health workers in general owing to the frequent arguments in government on the ceiling on the wage bill.
- There is need to extend the discussion of implications of phasing out these nursing cadres from UHC to the broader question of achieving the SDG agenda. Then, there will be a need to examine the potential influence of this decision on achieving the new development goals.
- The nursing profession needs to develop and there is justification for upgrading. However, these efforts need to be cognizant of the realities of the barriers created by the current entry eligibility criteria and the many related costs such as training costs. Scholarships should be negotiated with the development partners to support those who will not be able to fund their studies.
A panel of experienced professionals providing input to the discussion
By and large, this was a very insightful breakfast meeting. Indeed the participants raised many other important issues that should enrich the policy paper being worked on. As a way forward, the SPEED team will update the document to reflect the additional insights. Ultimately, the final document will reflect the diverse perspectives that this issue warrants consideration before making the final decision.