The identified facilitators and barriers to health worker transition emerging from this study are presented based on the five CFIR-derived domains; a) Process of Implementation b) Characteristics of the intervention b) Inner setting c) Outer setting and d) Characteristics of Individuals.
Process of Implementation
Table 5 shows the milestones in the process of implementation of the health worker transition process. Implementation happened at three major levels; a) national-level policy planning and coordination b) Sub-national level programmatic supervision c) Facility-level implementation.
Table 5: Milestones in the HW transition implementation process
|
Level & Stakeholders
|
Key actions
|
National
|
MoU between PEPFAR and GoU
Harmonization of salaries
Inter-sector transition meetings around a road map
Developing a transition road map
|
District
|
Joint Planning by regionally-based IPs & District actors.
Determining district HRH needs
Wage bill analysis
Health worker recruitment and deployment
|
Health facility level
|
Health worker orientation
HW performance management during the contract phase
|
National-level stakeholder engagement and transition planning
At the national-level the process involved consensus building meetings between PEPFAR and Government of Uganda (GoU) high-level actors around absorption of the recruited workforce after phasing out of support. This culminated in a formal Memorandum of Understanding (MoU) between the two parties. The MoU stipulated that PEPFAR would provide funds for the recruitment process and salary support for the initial 2 years and GoU would subsequently enroll the recruited health workers on the public sector payroll as soon as fiscal space allowed. Inter-sector meetings were convened incorporating the relevant line Ministries of Health, Finance and Public Service. PEPFAR was represented by its overall national coordinating agency-an international NGO, which consulted with relevant program officers at the United States embassy in Uganda. In 2013, a health worker transition implementation plan and road map was jointly agreed through a consultative process involving the two parties. Salary harmonization was key point whereby PEPFAR would pay the recruited workforce (during their two-year contract phase) salaries that were equivalent to public sector salary scales. With the exception of payment of a housing (accommodation) allowance to the contract workforce, PEPFAR’s pay structure was well aligned with that of the Uganda Government.
The PEPFAR national coordinating agency continually monitored the transition process and regularly shared insights and progress reports with Ministry of Health’s Human Resources for Health Technical Working Group (TWG).
At the district-level, regionally-based PEPFAR implementing partner (IPs) organizations in the 87 focus- districts in Uganda held transition planning meetings that engaged district-level actors such as District Health Teams, Chief Administrative Officers (CAOs) and District Human Resource Officers as well as District Service Commissions (DSCs) which make personnel selection decisions. During such meetings, a transition road map at the district-level and the roles of the varied stakeholders were agreed upon. District health teams in conjunction with District Human Resources Offices determined the health worker cadres to be recruited based on the needs of individual districts. Table 4 shows that the bulk of health workers recruited across case-study districts were midwives, nurses and clinical officers. These vacancies were advertised in national newspapers and through district and health facility notice boards. The processes of initial formal recruitment were led by the districts with the financial support of PEPFAR provided through its regionally-based IPs. Across all districts, contract staff were vetted by the District Service Commissions to ensure that they met the Uganda public service standards for recruitment. The IPs managed contracts and payrolls during the two-year contract phase for the transition workforce. In most of the 87 focus-districts an independent PEPFAR contractor was mentioned as the personnel contracts and payroll management agency. The District Health Teams together with IPs monitored performance of contract health workers through instruments such as time sheets which were a basis for approving salaries and later on absorption.
Table 4: Cadres of health workers transitioned from PEPFAR to Government of Uganda
HEALTH WORKER CADRE
|
No. of transitioned HWs
|
% by HW cadre N=694
|
Enrolled Nurse
|
275
|
39.6
|
Enrolled Midwife
|
204
|
29.4
|
Medical Laboratory Technician
|
54
|
7.8
|
Medical Clinical Officer
|
50
|
7.2
|
Biostatistician
|
35
|
5.0
|
Medical Officer
|
30
|
4.3
|
Nursing Officer Nurse
|
14
|
2.0
|
Medical Laboratory Technologist
|
13
|
1.9
|
Enrolled comprehensive Nurse
|
8
|
1.2
|
Nursing Officer Midwife
|
6
|
0.9
|
Dispenser
|
3
|
0.4
|
Pharmacist
|
1
|
0.1
|
Medical Records Assistant
|
1
|
0.1
|
Laboratory Assistant
|
0
|
0.0
|
Anesthetic Officer
|
0
|
0.0
|
Total
|
694
|
99.9
|
At the facility-level, contract staff were oriented in public service structures and processes by their immediate supervisors. The district health teams and facility service managers were instrumental in providing supervision and appraisal of contract staff. This formed the basis of selection of health workers on contract who were to be absorbed onto the public pay roll.
Characteristics of the intervention
District wage bill budget analysis support
Technical support for district wage bill analyses was extended by the coordinating PEPFAR implementing organization to districts. This was reported as a facilitator for HW transition in ‘high absorber’ districts. Although there was a widely held perception, among actors within the district administrations that their budgets could not accommodate any new personnel recruitments, technical support in scrutinizing district wage bills revealed unutilized funds in the wage bill that were subsequently deployed to absorbing the contract workforce in the transition MOU with PEPFAR.
‘PEPFAR helped us analyze the wage bill budget. There was some confusion with the Ministry of Public service and Ministry of Health and here at the district. We were in the dark. So, PEPFAR came and analyzed and found that we had a balance (funds for salaries) which we were not using. At least we would find there was something (fiscal space) for recruitments’ [KII, District Official Iganga].
Conversely, in ‘low absorber’ districts participants reported that they did not receive technical support in wage bill analyses. Hence, donor support in wage bill analyses emerged as a distinguishing feature between the two categories of ‘high absorber’ and ‘low absorber’ districts.
However, Fig. 1 shows that even across the ‘high absorber’ districts there were still a significant number of contract staff who were not enrolled onto the public sector payroll. Wage bill ceilings limited the ability of districts to absorb a higher number of contract staff.
We observed that ‘low absorber’ districts had a higher number of their contract staff seconded to PNFPs (Private Not-For-Profits) such as mission hospitals which had an even weaker absorption capacity (at 30%) compared to district local governments (at 55%).
‘The absorption has been very slow in PNFPs because these did not have money to absorb them. Most PNFPs were comfortable offering services with low cadre staff and do not have a budget to hire high cadre staff. But PEPEFAR hired these staff for the HIV response but health facilities do not have income to maintain them. So transition in PNFP is very challenging’ (KII, National-Level official)
Figure 2 shows the number of health workers absorbed between 2012 and 2017. Secondary analyses of HRIS and PEPFAR data bases revealed that over 500 of the recruited workforce were not absorbed in GoU service after transition. Across case-study districts, a number of health workers left government service before they were formally absorbed. In the focus group discussions, health workers indicated that variable delays in accessing the public payroll after their 2-year PEPFAR contracts had run out, a lack of private accommodation (especially in rural Northern Uganda) and challenging work environments such as chronic stock-outs of supplies contributed to the reduction of the pool of workforce available for absorption. Many opted for alternative employment - mostly private sector providers.
Support in convening district personnel recruitment committees
PEPFAR support helped in unlocking the inherent and long-standing organizational barriers to expansion of the existing district health workforce in ‘high absorber’ cases. A lack of basic operational funds for supporting the lengthy procedures required for hiring new staff was a constraint raised across all case-study districts. District Service commission (DSCs) are standing committees that make personnel selection decisions and are meant to sit every three months. However, the DSCs were widely reported to be dysfunctional owing to a chronic inability to raise monetary allowances for paying the non-full time DSCs which are comprised of retired senior public servants. Running district job adverts in national newspapers was said to be prohibitively expensive which further impeded personnel recruitments. PEPFAR provided the necessary funding to kick-start recruitment processes in form of paying for newspaper job adverts, providing monetary allowances to DSCs and sent observers to meetings where job interviews were conducted which enhanced transparency and objectivity in the selection processes. United States embassy program officers in Uganda reported that PEPFAR had committed $ 9,333,891 for the health worker transition programme in 2012 alone and an additional $ 4,494,149 in 2015. District-level informants described the nature of PEPFAR support they received:
‘PEPFAR helped with providing the recruitment funds. It provided sitting allowances to enable District Service Commissions to convene as well as providing allowances to committee members during the interview of candidates. They facilitated most of the activities utilizing our own technical staff’ (KII, District Official, Sheema District).
Transparency in recruitment of the transitioned health workforce
A number of health workers reported that before the PEPFAR intervention, DSCs had a reputation of questionable objectivity in the selection of personnel due to a widely-held perception that nepotism and bribery were common in district personnel recruitment decisions. Given this context, the selection of PEPFAR-supported health workers through transparent and merit-based processes lent special legitimacy to transition workforce which enhanced their absorption prospects into public service. District and facility-level managers perceived PEPFAR-supported personnel as having been recruited through rigorous and objective procedures.
‘I look at it as a good strategy for recruiting staff. This issue of our local politics of you are going to recruit this one’s daughter (nepotism), you are going to solicit bribes… those ones didn’t surface anywhere. It was a purified process that government didn’t have any reason whatsoever to object to their absorption. Someone recruited by an NGO interested in health you can’t doubt their qualifications, you can’t doubt their capabilities and then I think it also eliminated this issue of tribalism (ethnic biases) in recruitments [KII, District Official, Tororo].
The transitioned workforce was perceived as competent and suitable for absorption into government service. The two-year contract phase funded by PEPFAR allowed facility-level managers to identify resilient and dependable HWs for absorption. In addition, this phase also provided HWs with an opportunity to be inducted and initiated into government systems and work environments.
‘When they came the health workers on contract exhibited professionalism in their work. They were good people and immediately, they started working. The quality of service, was realized by the community. I think there is a visible change in the hospital since they came in [KII, District Official, Apac].
Outer setting
Multi-sectoral engagements in transition process
At an institutional level, multi-stakeholder engagements involving actors at the national, sub-national and facility-levels were identified as a major transition facilitator by participants in ‘high absorber’ districts.
At national-level, PEPFAR was involved in multi-sectoral engagements of high-level actors with authority for approving health worker recruitments in relevant central government sector ministries such as Finance, Public Service and Health.
A transition road map and memorandum of understanding (MoU) was agreed between PEPFAR and sector ministries in which PEPFAR undertook to provide salary support of the new workforce recruits for two years while Uganda Government would enroll these health workers onto the public sector payroll as soon as fiscal space permitted. This facilitated buy-in from influential actors in sector ministries. At the sub-national level, PEPFAR implementing organizations in varied geographic sub-regions spearheaded engagement with sub-national actors such as District Health Officers and Chief Administrative Officers (CAOs). MoUs was signed between regionally-based PEPFAR implementing organizations and the districts under their purview.
‘We had several interactions. Ministry of Health invited us. As a district, we are supposed to implement Ministry of Health policies. The policy was such that PEPFAR would recruit those health workers on contract and with time, the districts, with help of Ministry of Health and Finance would avail a wage bill to absorb them. So that was the understanding. First between Ministry of Health and PEPFAR, then we as implementing partners as districts and local government. That’s how we came on board’ (KII District Official Sheema).
Crucially, PEPFAR worked within established Uganda Government recruitment process and structures. Districts determined the cadres that would be hired based on their needs. District Service Commissions (DSCs) made the ultimate hiring decisions. This lent legitimacy to the cohort of health workers recruited with PEPFAR support.
‘All recruitment of contract staff was done by district service commissions (DSCs). So when it comes to absorption, such health workers are regularized because they were already recognized as legitimate staff hired through competent structures’ [KII, National- Level official].
Inner setting
Prioritization of health workers in district personnel recruitments
The prioritization of health workers in district personnel recruitments was a key distinguishing feature between ‘high absorbers’ and ‘low absorbers’ cases. In ‘high absorber’ districts such as Kasese and Sheema, participants were unequivocal in relaying the notion that their district administrations deliberately prioritized the health workforce in recruitments. In the ‘high absorber’ cases, whenever some fiscal space in the district wage bill emerged, slots for health workers were ‘ring- fenced’ as the overall priority- taking the shape of an informal recruitment policy.
‘In fact we had to trade off some cadres, those ones who were not extremely needed or useful we had to keep them off in order to bring in the more useful staff like the midwives and clinical officers’ (KII, District Official, Apac)
‘You may have the wage bill but how are you going to prioritize the cadres of peoples you are going to recruit? You may say my entire Health Centre IIs need a security guard. You may recruit like 20 porters. I know they are needed there but is it a priority? (KII, District Official, Sheema).
Although we found that ‘high absorber’ districts prioritized health workers in their wage bill, national-level informants reported that this was further reinforced by formal written memos from central government Ministries of Public Service and Health to the district political and technical leadership asking that they prioritize the absorption of PEPFAR-supported workforce in the available wage bills .These memos were written in March 2013 as a result of the protracted engagements by PEPFAR and high-level actors in sector ministries which were in line with the jointly developed health worker transition road map.
Characteristics of Individuals
Presence of transition ‘Champions’
The presence or absence of transition ‘champions’ differentiated between ‘high absorber’ and ‘low absorber’ districts.
Whereas ‘high absorber’ districts reported the presence of internal transition ‘champions’, their absence in participant discourses in ‘low absorber’ districts was unmistakable.
Transition ‘champions’ were individuals who went above and beyond the call of duty of their positions to promote the absorption of health workers onto the public pay roll. These champions were reported at both the district and facility-levels. The presence of champions at multiple levels created synergies in promoting health worker absorption in ‘high absorber’ districts. The frequently cited champions include influential actors such as Chief Administrative Officers (CAOs) of host districts, District Health Officers (DHOs) and Hospital administrators who actively pushed for the recruitment and absorption of health workers and enrollment on the government payroll.
‘We had a smooth transition because the team in XXX (District) is very proactive. They don’t operate like they are in government. The CAO (Chief Administrative Officer) was an experienced man so he was quick to come in and push the recruitment process along. Much more than it normally is. The District Human Resource Officer was very active. They did their work in a timely way and actively pushed to have the HWs absorbed. Issues of health workers were prioritized. Actually, the first batch of health workers we even gave them appointment letters before their contracts were over’ [KII, District Official, Iganga].
Champions tirelessly worked to expedite processes in the context of the typically lengthy administrative procedures in the Ugandan public sector. They acted as ‘persistence enhancers’ for health workers and even appropriated district finances to create ‘stop-gap’ monetary allowances for health workers before they were able to access the public payroll.
Actors at the facility-level were frequently cited as transition champions. Facility in-charges were motivated by a need to avoid losing skilled health workers who had been posted at their health facilities as contract staff. As such, they were instrumental in ensuring timely appraisal of contract health workers but also engaged in active follow-up with the District Service Commissions at the district administration headquarters for absorption of health workers to avoid losing their contract staff. Facility in-charges in ‘high absorber’ districts actively engaged their transition workforce in activities such as surgical camps and community outreaches to enable them secure some field monetary allowances to sustain them as they awaited enrolment on the payroll which was characterized by prolonged delays in several of the case-study districts.
‘The salaries could delay for two to three months. We have PHC (primary health care) funds earmarked to this facility.
We used some of this to buy them basics such as soap and sugar that could also help them to persist and endure’ [KII, Facility in-charge, Nwoya District].