J._15_MOH_Transition_Plan.PDF

UNITED STATES GOVERNMENT PLAN TO ENGAGE

WITH THE GOVERNMENT OF UGANDA FOR

EFFECTIVE UTILIZATION AND ACCOUNTABILITY

FOR HUMAN RESOURCES FOR HEALTH

July 2017

CONTENTS

ACRONYMS AND ABBREVIATIONS

EXECUTIVE SUMMARY

INTRODUCTION AND BACKGROUND

KEY HUMAN RESOURCE CHALLENGES TO BE ADDRESSED

ACTIONS TO ADDRESS PRIORITY HEALTH WORKFORCE CHALLENGES

STRENGTHENING CAPACITY AT THE MOH

TRANSITIONING USG-FUNDED STAFF TO GOU EMPLOYMENT

ANNEXES

ACRONYMS AND ABBREVIATIONS

CPHL Central Public Health Laboratories

DSC District Service Commission

GOU Government of Uganda

HRH Human Resources for Health

HRHTWG Human Resources for Health Technical Working Group

HRIS Human Resources for Health Information System

HSC Health Service Commission

IP Implementing Partner

IPPS Integrated Personnel and Payroll System

MOES Ministry of Education and Sports

MOFPED Ministry of Finance, Planning and Economic Development

MOH Ministry of Health

MOPS Ministry of Public Service

OPM Office of the Prime Minister

PEPFAR President’s Emergency Plan For AIDS Relief

PNFP Private Not-For-Profit

RMNCH Reproductive, Maternal, Neonatal and Child Health

RRH Regional Referral Hospital

SHRH Strengthening Human Resources for Health activity

TA Technical Assistance

UBOS Uganda Bureau of Statistics

UNHLS Uganda National Health Laboratory Services

USAID United States Agency for International Development

USG United States Government

UVRI Uganda Virus Research Institute

WB/GFF World Bank Global Financing Facility

WISN Workload Indicators of Staffing Needs

EXECUTIVE SUMMARY

The United States Government (USG) provides support to the

Government of Uganda (GOU) to improve the quantity, quality, and utilization of the health workforce to achieve HIV/AIDS epidemic control targets and improve other health indices. This is done through a systems approach with the USAID-Strengthening Human Resources for Health (SHRH) activity implemented by IntraHealth International, in addition to the direct secondment of health staff in the central Ministry of Health (MOH) and districts through various implementing partners

(IPs).

The decision to second staff was made in response to human resources for health (HRH) challenges that were preventing an adequate response to the HIV epidemic.

However, that effort must be translated into longer-term sustainable enhancement of the human resource capacity if gains in epidemic control and improvement in the quality of health service delivery in general are to be maintained. This plan aims to integrate and mainstream the USG-seconded staff and strengthen capacity for developing, utilization and accountability for the health workforce in a sustainable manner.

HRH CHALLENGES

The HRH issues facing Uganda are complex and involve multiple central government ministries, districts, the private sector, and other stakeholders. Bureaucratic bottlenecks are common, and progress can be slow. Health worker shortages persist due to inadequate wage provision and slow uptake of available health workers. Although the overall national staffing level has improved from 53% in 2009 to 71% in 2016, it is still not adequate. The current public sector staffing structure is limited, and even if it were fully filled to 100%, the health workforce capacity would still not be sufficient to respond to the changing health needs, rapid population growth, containment of the HIV epidemic, and other pressures on the health system. The central ministry is significantly understaffed (only 44% of approved positions are filled), hindering its ability to manage the health system and provide adequate leadership.

Despite the improvements of staffing at site level, a rate of absenteeism (46%) continues to limit progress in quality service availability and utilization.

In this environment of HRH challenges, the USG currently supports 1,965 contract health workers through different implementing partners at the central MOH, regional referral hospitals (RRHs), districts and the central public health laboratories (CPHL) at a cost of $11.5 million USD per year.

Most of these contract staff were positioned to immediately respond to pressing needs related to the

HIV/AIDS epidemic control (with a focus on 90-90-90 targets), with the longer-term vision that they would be transitioned to the GOU to more permanently and sustainably improve the resilience of the health service delivery system.

TRANSITION CHALLENGES

There has been weak management and accountability for the USG-funded staff. The contract staff tend to have salaries that are significantly higher than what they would earn in the government structure, making GOU employment unattractive to high-caliber staff. The MOH relies on the contract staff, and has a structure which limits the extent to which the contract staff can be absorbed.

Most of the contract staff (1,735) are directly engaged in the HIV epidemic control and related services and if the transition is not handled well, there is a potential for disruption of essential services, including HIV services.

ACTIONS TO ADDRESS HRH AND TRANSITION CHALLENGES

The USG will provide technical assistance to the GOU to implement needed actions to address HRH challenges and successfully transition contract staff to the GOU. The MOH must submit an accurate and detailed annual costed staffing plan to the Ministry of Finance, Planning and Economic Development

(MOFPED), who in turn must commit to allocating adequate funds to increase staffing to 80% by 2018 with provisions for absorbing contract staff. Particular attention must be paid to functionalize the central MOH and its related units through strategic increases in staffing. The MOH and Ministry of

Public Service (MOPS) will scale up efforts to improve performance management of the existing workforce, reduce absenteeism, and implement automated attendance-to-duty monitoring at all levels.

Bureaucratic bottlenecks will be addressed by efforts to increase coordination and strengthen HR capacity while the MOPS works to improve efficiency in recruitment. Health workforce shortages shall be examined in an MOH-led labor market analysis while the MOH and MOPS work on necessary revisions to current approved staffing structures. The MOH will review the HRH Strategic Plan 2005-

2020 and produce a revised plan for 2019-2029. In response to the needs of the health system, the

Ministry of Education and Sports (MOES) will develop training projections to prioritize meeting the actual health workforce needs for the country. It is expected that the GOU will fully take on the USG-funded contract heath staff by the end of Fiscal Year 2019/202 in a phased approach. The MOH will be responsible for coordinating stakeholders for accountability and achievement of goals.

ACCOUNTABILITY ON COMMITMENTS

The MOH will prepare monthly, quarterly, and annual reports on recruitment and transition activities beginning July 2017, and organize quarterly USG/MOH HRH joint meetings to review progress on commitments and identify bottlenecks and strategies for improvement. An inter-ministerial/multi-stakeholder task force will organize quarterly meetings to coordinate actions, and the HRH Technical

Working Group (HRH TWG) will hold monthly meetings to coordinate with other stakeholders and harmonize HRH plans.

INTRODUCTION AND BACKGROUND

This plan developed by the USG aims to strengthen multi-stakeholder engagement to enhance the

GOU’s utilization and accountability for the health workforce. It addresses broad health workforce issues as well as specific challenges related to transitioning contract health staff funded by the USG and seconded to the GOU to enhance service delivery and HIV epidemic control. The purpose of the plan is:

1. To facilitate the GOU to reorganize and strengthen the human resource capacity at the central MOH and health facilities to achieve sustainable and quality health service delivery and management.

2. To enhance accountability by the MOH for the health workforce both in government and private sectors.

3. To transition and integrate the health staff funded by the USG into approved staffing structures at the central MOH and health facilities (both public and private) to enhance the resilience of the health care delivery system so it effectively responds to changing health needs and sustain HIV epidemic control.

The USG currently provides support to the health workforce through the Strengthening Human

Resources for Health (SHRH) mechanism implemented by IntraHealth International which provides technical assistance to both the public and private sector to strengthen human resource recruitment, performance management and pre-service training of health workers. In addition, the USG funds and seconds contract health workers through a Cooperative Agreement with the MOH, and through various implementing partners to the MOH headquarters, and government and private not-for-profit

(PNFP) health facilities. This USG support has significantly contributed to improvement in staffing levels especially in the districts. The overall national staffing level improved from 53% (2009) to 71%

(2016), resulting in increased service coverage and progress in HIV epidemic control. However, the human resource capacity at MOH headquarters remains unacceptably low, with staffing level at 44%. In

June 2017, the cumulative total number of USG-funded staff seconded to the government not yet absorbed was 1,965 while the staffing levels in both government and PNFP health facilities remained low. The total national staffing level was 71% in December 2016.

The cost of maintaining the large number of USG-funded staff is estimated at $11.5M per year—an unattainably large figure. Currently, delivery of priority health services like maternal, neonatal and child health (MNCH), clinical and preventive services for malaria, TB, and HIV/AIDS is dependent on programs, projects and specialized institutions with staff funded by the USG and other development partners. The USG will work with the GOU to take necessary actions to reorganize and fill approved staffing structures at the MOH and health facilities to mitigate the potential reversal of the current achievements in health service coverage and HIV epidemic control in the event that USG funding decreases or stops.

The MOH headquarters restructuring has been done by the MOPS and the new structure was approved by Cabinet in August 2016. The restructuring of the RRHs has not yet been done, while the lower level health facilities were restructured in 2005. The current public health sector staffing structures (including the new MOH structure) are perceived to be limited and even if they were fully filled to 100% the health workforce capacity would still not be adequate to respond to the changing health needs, compounded by rapid population growth and the HIV epidemic. The MOH plans to conduct a detailed labor market analysis to determine the actual human resource needs that would provide evidence for more realistic staffing structures. The restructuring of the RRHs and the lower-level health facilities is considered high priority by both the MOPS and MOH. The MOH is also in dialogue with the MOPS on further restructuring of the MOH headquarters in the near future. Based on the evidence from the labor market study and the revised staffing structures the MOH plans to review the current HRH Strategic

Plan 2005 – 2020 and develop the next 10-year HRH Strategic Plan 2019 – 2029.

The ongoing process of implementing the revised MOH headquarters staffing structure approved in

2016, and the planned revision of staffing structures for the RRHs and lower-level health facilities in

2018 by the MOPS, provide an opportunity for ensuring that adequate provisions are made in the structures for delivery of quality health services sustainably, including transitioning of the USG-funded staff into GOU employment. The MOH is the process of establishing the Uganda National Health

Laboratory Services (UNHLS) to replace the Central Public Health Laboratories (CPHL) as semiautonomous institution. A draft bill to establish UNHLS has been submitted to Parliament. The move to establish the UNHLS, with an approved staffing structure and government funding, will streamline the laboratory services network and the utilization of USG funded staff and their transitioning to the GOU. The GOU has secured World Bank funding under the Global Financing Facility (GFF) to improve Reproductive, Maternal, Neonatal and Child Health (RMNCH). The MOH plans to use part of the WB/GFF Project funds for scholarships to train 400 health workers in priority areas. The WB/GFF support will contribute to the availability of skilled health workers critical for saving lives of mothers and children.

KEY HUMAN RESOURCE CHALLENGES THAT NEED

TO BE ADDRESSED

UNDERFUNDING OF THE HEALTH WORKFORCE

Health care delivery is highly labor-intensive and the government needs to develop appropriate financing mechanisms and mobilize adequate funding to fill and maintain approved staffing structures. However, the wage budget allocation by MOFPED has always been less than needed. In the fiscal year 2016/17 , only 24 districts were allocated wage allocation to recruit new health workers. Even where wage is available, the cost of the recruitment process is not funded. Districts are often unable to recruit and have to return the money allocated for wage for new staff because of lack of funds for advertisements and allowances for District Service Commissions (DSCs) to recruit. The PNFPs depend on user fees to finance the health workforce which is not adequate, and is supplemented by secondment of staff by GOU. 1ECUE

HEALTH WORKER SHORTAGES

Although 71% of approved positions are filled nationally, there is a persistent shortage of health workers critical for priority health services like pharmacists, dispensers, laboratory technicians, and anaesthetic officers (Table 2). This is due to inadequate supply and the difficulty in attracting and retaining them especially in remote rural districts. The PNFP sector tends to be worse than public sector in staffing for health professional cadres (Table 1).

TABLE 1: STAFFING SITUATION SUMMARY (PUBLIC AND PNFP), 2016

Cost Centre

No. of Units

Norms

Filled

% Filled

Total health work force

Public Sector (central and DLG combined)

3,052

61,315

43,277

71%

PNFP (UCMB, UPMB and UMMB*)

18,191

13,188

73%

Total Health Workforce

3,648

79,506

56,465

Total of registrable health professionals

Public Sector (central and DLG combined)

3,052

48,522

35,083

72%

PNFP (UCMB, UPMB and UMMB)

8,945

5,887

66%

Total registrable health professionals

3,648

57,467

40,970

TABLE 2: STAFFING IN THE PUBLIC SECTOR BY CADRE, JUNE 2016

Cadre Total Norms Filled Vacant % Filled

Lab Technologists/Technicians/ Assistants 3,020 2,447 573 81%

Public Health Dental Officers 365 276 89 76%

Registered and enrolled midwives 11,706 8,815 2,891 75%

Orthopedic Officers 346 227 119 66%

Psychiatric Clinic. & Psych Social Workers 174 106 68 61%

Theatre Assistants 421 238 183 57%

Health Inspectors 3,683 1,925 1,758 52%

Doctors (Consultants, MOSG, MOs) 2,156 1,047 1,109 49%

Radiographers and Imaging Staff 248 121 127 49%

Physio. & Occupational Therapists 253 114 139 45%

Health Educators 298 123 175 41%

Pharmacists 112 45 67 40%

Dispensers 423 169 254 40%

Ophthalmic Clinical Officers 290 104 186 36%

Anesthetic Officers 878 238 640 27%

LOW PRODUCTIVITY AND ACCOUNTABILITY FOR THE HEALTH WORKFORCE DUE TO

SYSTEMS INEFFICIENCIES

The MOH is inadequately staffed to provide effective leadership and accountability for the health workforce and the available health workers are not equitably deployed. Equipment and supplies are inadequate to sustain the engagement of the health workers. They are not adequately supervised, their morale is low, and the rate of absenteeism is high.

TABLE 3: TREND IN ABSENTEEISM BY CAUSE, 2015 AND 2016

Absenteeism Rate (2015) Rate (2016)

Absence with or without approval 68.8% 46%

Absence without approval 50% 13.7% Source: HRH annual surveys- 2015& 2016

NB: The annual absenteeism surveys adapt the Uganda Bureau of Statistics (UBOS) & World Bank methodology to better understand the absenteeism problem, underlying causes, and effective HRM strategies to address it. The survey studies attendance patterns of health workers for a period of six working days to gain an insight on the overall attendance behavior.

For the six days, the survey team conducts one unannounced visit to the health facilities and reviews attendance records of the health facilities over the previous 5 working days. In the 2016 survey, a total of 367 health facilities in 55 districts from all the eight sub-regions were surveyed (Northern, West Nile, Karamoja, Central, Western, Southwestern, East, East

Central), although only 353 health facilities were later included in the final analysis following data cleaning. Of these, 47.8%

(169) were HC IIs, 35.9% (127) were HC III, 11.3% (40) were HC IVs, 3.9% (14) were General Hospitals and 1% (3) were regional referral hospitals. Overall 83% (293) of the health facilities were government and 16.9% (60) were PNFP.

Since 2015, the MOH and local governments have been implementing an absenteeism tracking system and sanctions against non-compliant health staff in a total of 758 health facilities (including 14 RRHs) in

112 districts to address absenteeism. Between 2015 and 2016, there has been visible reduction in absenteeism (Table 3). The absenteeism tracking is yielding results and the system should be scaled-up throughout the country, including the MOH headquarters. Critical to the success of the system has been the high level of multi-stakeholder engagement led by the MOH involving the Office of the Prime

Minister (OPM), the Health Monitoring Unit under the President’s Office, USG, UNICEF, and local governments.

BUREAUCRATIC BOTTLENECKS IN THE RECRUITMENT AND MANAGEMENT OF THE

HEALTH WORKFORCE

Approved and funded structures in the MOH and districts take too long to be filled largely due to lengthy bureaucratic processes and procedures involving multiple stakeholders. The MOH determines staff needs, develops recruitment plans, submits the positions to be filled to Health Service Commission

(HSC), and ultimately deploys health workers recruited. The MOPS defines the employment terms and conditions for health workers, staffing structures, and approves plans to fill positions. The MOPS appoints staff who are heads of departments and above after recruitment by HSC and approval by the

President. The MOPS also appoints and provides technical guidance DSCs. The HSC recruits health workers for MOH headquarters and central level institutions and RRHs, while the DSCs recruit health workers for local governments (LGs). The MOFPED mobilizes and allocates resources for the health workforce recruitment and remuneration. The MOES plans, coordinates and manages pre-service education and training of health workers. The LGs are responsible for the management of district health staff in accordance with national and local standards, and overall administrative oversight of health workers in the district. They also recruit health workers through the DSC, and ensure their remuneration and general welfare.

All appointments to the positions of head of department and above have to be approved by the

President of Uganda. One recruitment cycle takes at least three months from the time the vacancies are submitted for clearance to the point the individual employee reports for duty both for the MOH and districts. This is further compounded by the limited capacity of the DSC and HSC to keep pace with the recruitment needs, delays by MOH and districts to submit vacant positions to be filled and delays in clearance of the submissions by the MOPS. Due to the lengthy bureaucratic process and the associated delays, even the limited wage budget may not be fully absorbed by the end of the financial year and the funds are returned to the treasury.

HEALTH WORKFORCE PRODUCTION

There is mismatch between production and the needs for the health workforce. The production of nurses is in excess of what is required, for example there are over 10,000 comprehensive nurses not employed while there are critical shortages of pharmaceutical cadres and anaesthetic officers. Table 4 shows the average annual output for selected health workers. Underpinning the mismatch is the lack of long term projection of health workforce requirements based on an analysis of health needs.

Compounding the mismatch is the rapid growth of the private sector. Of the 169 health training institutions in the country, 49 (29%) belong to the GOU while the remaining 120 belong to the private for profit (PFP) or private not for profit (PNFP) sectors (Table 5).

TABLE 4: AVERAGE ANNUAL OUTPUT OF SELECT

CADRES, 2016

Cadre Annual Output

Nurses 5,498

Midwives 2,816

Pharmacy Technicians 83

Clinical officers 577

Anesthetic Officers 26

Medical laboratory scientists 140

Lab Technologists 371

Lab Technician 1,202

Doctors* 302

Pharmacists* 86

Dentists* 10

Biomedical Lab Scientists* 40

Environmental Scientists* 112

Biotechnology* 15

Bachelor in Public Health* 45

TOTAL 11,323

*2014 data

TABLE 5: HEALTH TRAINING INSTITUTIONS BY

OWNERSHIP

Type of Health

Training

Institution

GOU PNFP PFP TOTAL

Nursing/Midwifery 14 33 39 86

Allied Health

Professions 30 13 32 75

University Medical

Schools 5 1 2 8

TOTAL 49 47 73 169

% OF TOTAL 29% 28% 43%

COMPLEXITY OF THE HRH CHALLENGES

HRH challenges are complex and are interconnected as in Figure 1. They require multi-stakeholder engagement to provide comprehensive solutions that are well coordinated. Failure by one stakeholder to fulfill its tasks creates challenges for other stakeholders in addressing the HRH issues.

Weak management of training and education of health workers leads to mismatch between supply and demand of the health workforce. There is critical shortage of pharmaceutical cadres while there is excess supply of nurses. It is essential that the stakeholders are well coordinated to accomplish their mandates harmoniously.

USG-FUNDED CONTRACT HEALTH STAFF CHALLENGES

Although the GOU recruits health workers every year, it is constrained by inadequate funds for wage and recruitment costs including advertisement and allowances for DSC members. This leads to persistent shortage of qualified health workers critical for HIV epidemic control both at site and above-site levels. Given the urgency to achieve the global UNAIDS targets of 90-90-90 towards HIV epidemic control, it became necessary for PEPFAR to complement GOU efforts to accelerate availability of health workers for HIV/AIDS services. Accordingly, USG implementing partners recruited and seconded health workers to the MOH headquarters and affiliated central institutions like CPHL and Uganda Virus

Research Institute (UVRI), as well as RRHs and lower-level government and PNFP health facilities. Other health staffs were also recruited through a Cooperative Agreement between the USG and MOH. In order to further accelerate availability of health workers at site level, PEPFAR provided support for recruitment of 2,213 health workers for district and PNFP health facilities. PEPFAR support prioritized cadres critical for HIV/AIDS services (doctors, clinical officers, midwives, nurses, dispensers, pharmacists and laboratory staff, including administration and support staff).

Cumulatively a total of 3,154 health workers have been recruited with PEPFAR support. The health workers are employed on one year contracts, renewable subject to availability of funds and satisfactory performance. Of the 3,154 contract health workers 2,213 were recruited through HSC, DSC and PNFP, and their basic salary is aligned to salary scales of GOU and PNFP to ease transitioning to GOU and

PNFP. A total of 642 health workers have been absorbed into the GOU and PNFP employment (see

Figure 3), while 547 have left to take other employment. A total of 1,965 contract health workers are still to be transitioned to the GOU. However the absorption of the contract health workers has been slow and there are a number of challenges to be addressed in the transition:

1. Dependence of the MOH on USG-funded contract staff in the midst of high vacancy rates in critical technical areas. The human resource capacity of MOH is inadequate for effective leadership and accountability.

Only 338 (44%) of a total of 777 approved staffing positions in the central MOH structure are filled.

Out of a total of 397 technical positions in the technical departments of MOH, only 212

(53%) are filled.

Out of a total of 49 positions in human resource management department, only 27 (55%) are filled. The HR management capacity at MOH is inadequate for timely response to the

HR changes necessary for MOH to deliver on its mandate.

The approved staffing structure of the MOH headquarters is not adequate and can only absorb 24 of the 230 USG funded contract staff critical for the MOH to deliver and account for its mandate. A total of 16 (66.7%) of the 24 positions are for Medical Officers.

2. Mismatch between the USG funded staff and the structure of MOH. A total of 115 (50%) of the

230 USG-funded contract staff at the MOH headquarters and affiliated central level institutions have job titles and qualifications that do not match central MOH-approved structure and qualifications.

3. Mismatch between the deployments of USG-funded staff and the existing vacancies in MOH structure. Of the 24 vacancies in the central MOH structure, only 12 are available in the same departments/units where USG contract staffs (with matching qualifications/jobs) are currently working, while the remaining 12 are in other departments/units. This means that only 12 USG contract staff can be absorbed in the same departments where they are currently working.

Most of the vacancies are for Senior Medical Officers

4. Some salaries paid by the USG to the contract staff are more than four times the salaries of their government counterparts in equivalent positions and responsibilities. A senior medical officer on USG contract earning Ush7.0m per month will find it difficult to transition to government employment with salary of Ushs1.5m per month (See annex tables 15 & 16).

5. A significant number of USG funded staff are in central level units like CPHL while there is shortage of skilled service providers in critical technical areas in hospitals

Only 3,875 (69.6%) of a total of 5,571 approved staffing positions in the 14 Regional

Referral Hospitals are filled

Only 3,155 (80%) of a total of 3,938 approved technical positions in the 14 Regional

Referral Hospitals are filled.

HIV viral load estimation is only conducted centrally by USG-funded staff at the CPHL.

Specimens have to be transported from all over the country, as health facilities do not have the capacity to conduct analysis at the facility level.

6. Recruitment and deployment of contract staff is guided by the urgency to achieve PEPFAR targets. Absorbing and mainstreaming them into the government employment may disrupt their dedication to HIV services. The qualifications of some of the contract staff are specific to HIV epidemic control and related services. As a result, some of the contract staff are not aligned to the positions in the GOU staffing structure and cannot be immediately absorbed. This will require careful analysis to ensure that staff transitioning does not interrupt services and slow down or reverse the progress towards HIV epidemic control.

7. Slow absorption of the contract health workers by both the GOU and the PNFP due to inadequate wage availability. This is further compounded by the way the staff were recruited into the GOU service. The staff recruited by the HSC and the DSC on government salary scale were more likely to be absorbed compared to those recruited directly by the IPs or hospitals as seen in figure 3.

8. Contract staff at the MOH are not effectively supervised and managed by responsible GOU staff, and there is concern that their impact is not easily visible to the senior management of

MOH. The MOFPED also raised concern that there is no formal MOU between GOU and

USG regarding secondment of contract workers with clear commitments and roles.

FIGURE 2: PEPFAR STAFF ANNUAL ABSORPTION TREND (DECENTRALIZED LEVEL)

FIGURE 3: PEPFAR STAFF ABSORPTION STATUS BY RECRUITMENT MECHANISM

NB: A total of 122 USG staff were recruited through Hospital management at 11RRHs and 5 GHs by SUSTAIN, IDI, & Mildmay, MUWRP.

418 470

Sept-15 Sept-16 August-17

Absorbed

Not Absorbed

57 38

DSC/HSC Hospital IP PNFP

Absorbed

Not Absorbed

ACTIONS TO ADDRESS PRIORITY HEALTH

WORKFORCE CHALLENGES

HEALTH WORKFORCE FINANCING

Adequate funding of wage and other personnel costs, and enhanced HRH systems efficiency are essential for the absorption and retention of contract health workers by GOU and the PNFP. The underfunding of the health workforce is a priority challenge that can only be addressed sustainably by the GOU and the PNFP. The key strategy for this to happen is evidence-based advocacy for increased government budget allocation for the health workforce. This will entail detailed HRH needs analysis and costing to guide resource allocation by the districts and MOFPED. Cost saving measures like e-recruitment will also be necessary given the limited resources available.

1. The MOH will prepare detailed, annual costed staffing plans to determine the funds required for the wage and recruitment costs to fill the approved structures of MOH, RRH, and other central level units to achieve at least 80% staffing level by July 2018.

2. The MOH will facilitate districts and partners to prepare detailed annual costed staffing plans to determine the funds required for the wage and recruitment costs to fill the approved structures of health facilities in districts to achieve at least 80% staffing level by July 2018. MOH will consolidate the staffing plans and budgets and submit to MOFPED through MOPS.

3. Ministry of Finance, Planning and Economic Development will integrate the budgets for the MOH and district staffing plans in the Budget Framework Paper and commit to allocate funds to achieve and maintain health staffing at all levels to at least 80% by 2018.

4. The USG will accordingly reduce its funding of health staff for the MOH headquarters, as GOU increases its wage budget and salaries of contract workers are rationalized toward GOU salary scales for equity, by 50% by July 2018 and stop seconding contract staff to MOH headquarters by

July 2019.

5. The USG will continue to provide TA to HSC, MOH and the four Regional e-Recruitment Hubs at

Fort Portal, Mbarara, Moroto, Arua, Lira and Mbale to fully operationalize the e-Recruitment

System by March 2018 to cut the cost of advertisement and business processes at the HSC.

LOW HEALTH WORKFORCE PRODUCTIVITY AND ACCOUNTABILITY

The current absenteeism rate of 46% undermines any improvements in staffing numbers and does not encourage increased investments in the health workforce. The GOU should institute all measures to accelerate reduction in absenteeism of health workers and increase productivity and accountability for the health workforce. Health workers should be deployed according to workload and continuously monitored to enhance productivity and avoid redundancy which encourages absenteeism.

1. MOH will collaborate with the MOPS to ensure that the performance management and absenteeism tracking systems introduced in 758 health facilities in 112 districts and 14 RRHs with USG support through the USAID-Strengthening Human Resources for Health Activity are extended to the MOH headquarters and fully functional to strengthen utilization and accountability for the health workforce at all levels by September 2018. The MOH will link attendance to duty monitoring system to DHIS-2 so that attendance to duty can be related to health service outputs. MOH and local governments will recognize and reward the staffs based on their performance.

2. The USG will continue to provide TA to MOH to implement automated attendance to duty monitoring at all levels to enhance health worker productivity.

3. Moving forward the MOPS, MOH and districts will adopt the use of the Work Load Indicator of

Staffing Needs (WISN) methodology in prioritizing recruitment and flexible deployment of staff at all health facilities to enhance efficient use and productivity of the health workforce.

4. MOPS will integrate the Human Resource Information System (HRIS) with the Integrated

Personnel and Payroll (IPPS) management information system and oversee its sustained function and use. Reliable data is essential for tracking and accountability for the health workforce.

5. The USG will provide TA to the MOH to develop tools and skills for regular analysis of the impact of changes in staffing levels at the MOH and health facilities on the quality, utilization and coverage of health services.

BUREAUCRATIC BOTTLENECKS IN RECRUITMENT OF HEALTH WORKERS

Currently one recruitment cycle takes at least three months to complete, from the declaration of open positions to the time the employee reports for duty. This means that the service commissions can only recruit once in a financial year, and in some cases are not able to absorb the wage budget allocated in the financial year. This also delays the uptake of new graduates who turn to alternative employment, causing artificial shortage in supply of some of the rare health cadres, and is part of the delays in transitioning contract health workers to GOU. A system for information sharing and platform for continuous stakeholder consultation, coordination of efforts and mutual accountability are critical for reducing delays in decision making and action.

1. The MOPS will review and reorganize the business process in recruitment to remove bureaucratic bottlenecks that prolong the recruitment process and delay the filling of positions in the approved structures.

2. The USG will provide TA to establish a multi-stakeholder task force to analyze the business processes in recruitment of health workers by HSC and DSCs and address unnecessary bottlenecks to eliminate systems inefficiencies.

3. The USG will provide TA for innovations and expanded use of technology in the recruitment system to increase efficiency, building on the e-recruitment system and HRIS.

4. The USG will prepare a formal framework for structured engagement with MOH, MOPS, MOFED and local governments to strengthen human resource capacity at the MOH and health facilities, clarifying roles and mechanisms for accountability on commitments.

5. The MOH will constitute a Multi-stakeholder Coordination forum to review annual recruitment plans, progress of implementation and resolve bottlenecks identified. The Multi-stakeholder Forum will meet twice a year, in October and April.

HEALTH WORKFORCE SHORTAGE

Underpinning the health workforce shortage is the inadequate capacity at the MOH headquarters for continuous HRH needs analysis, planning and implementing interventions to address any HRH challenges promptly. The current HRH Strategic Plan (2005 – 2020) was developed 12 years ago. It has not been evaluated for its continued relevance. The health needs change with time, compounded by the rapid population growth. The current staffing structures are not based on evidence from comprehensive needs analysis and are therefore not adequate for the health needs. Beyond the traditional health workers there is critical role for other professionals like biomedical engineers, health economists and managers. The HRH Strategic Plan 2005 – 2020 needs to be revised to address these and other emerging needs that will be identified. There will also be need to learn lessons from neighboring countries.

1. The USG will provide technical assistance (TA) to the MOH in the HRM department to enhance capacity in the use of appropriate computer packages and tools for HRH and wage analyses to facilitate accurate projections and timely submission of vacant posts to be filled based on the available wage.

2. In light of changing health needs and demands for the health workers, the MOH will conduct a labor market analysis in 2018 and the USG will provide TA required to support the labor market analysis to generate evidence for development of a responsive health workforce strategy. The labor market analysis will critically examine the health workforce dynamics and associated factors of compensation and benefits.

3. Based on the labor market analysis report, the MOH and MOPS will revise the staffing structures of the MOH and health facilities. The USG will provide TA to the MOH and MOPS to undertake the revision of the staffing structures to provide evidence for the development of the health workforce strategy. The restructuring will also examine the compensation of health workers and ensure salary equity.

4. In light of the changes in health needs, technology and health service delivery standards over the last 12 years, the health sector HRH Strategic Plan 2005 – 2020 will be reviewed and updated.

With TA support from the USG, the MOH will review the HRH Strategic Plan 2005 – 2020 and develop a comprehensive 10-year HRH Strategic Plan 2019 – 2029 by July 2018. The new HRH

Strategic Plan to be developed will be comprehensive and will go beyond the traditional health workers to include paramedicals, engineers, economist and managers and administrators, among others.

5. The MOES will develop 5-year (2019 – 2024) training projections to guide enrollment of trainees in both GOU and private health training institutions based on the HRH priorities in the HRH Strategic Plan to be developed. The MOES will collaborate with MOH and Health

Professionals Councils and Examination Boards to ensure that training is effectively regulated and standards are enforced to produce quality graduates that meet the priority health needs.

STRENGTHENING STAFFING CAPACITY AT THE MOH

In the 2015/16 – 2019/20 Health Sector Development Plan (HSDP), Uganda aimed to reach 80% staffing at all levels in the health system. This cannot be achieved and sustained unless human resource capacity at the

MOH headquarters is urgently addressed so that it provides the necessary leadership and management for the human resource processes to achieve and maintain the desired staffing targets. For the MOH to function effectively and efficiently, it needs to have its structure completely filled. However this may not be practical in the short run, given the current low level of staffing at 44%, constraints related to wage, and the risk that high caliber health workers needed that may be difficult to find on the market. Accordingly, 3 scenarios are proposed here for the way forward.

Table 6 summarizes 3 potential scenarios for improving staffing at the central level. The first proposes to fill every vacancy; the second would target the HSDP goal of 80% staffing overall; and the third more modestly targets 80% staffing in key divisions of MOH. It should be noted that the financial requirements for staffing are for wage only, exclusive of recruiting costs and any other benefits outside of wage.

Scenario 2 is preferred as it is aligned to the commitments in the HSDP and can be realistically achieved within the time line of 2018.

TABLE 6: RECRUITMENT SCENARIO SUMMARY FOR CENTRAL MOH

Scenario Description Number to be Recruited

Additional Wage Need

UGX

Additional Wage Need USD

Resulting Staffing Level

Scenario 1 100% Staffing all departments 439 4,280,335,780 1,222,953 100% Scenario 2 80% Staffing Overall 284 3,038,493,500 868,141 80% Scenario 3 80% Staffing in Key

Divisions/Departments 92 1,548,844,500 442,527 55%

SCENARIO 1: FILL ALL VACANT POSITIONS

Currently, the GOU is spending $1,173,507 annually on filling approved posts and $145,136 on posts that are filled but not included in the current structure (excess). An additional $1,222,953 would be needed every year to fully fill all vacant and approved positions (Table 7).

TABLE 7: SCENARIO 1 – FILL ALL VACANT POSITIONS

Description Number of Posts Annual UGX Annual USD

Current Filled 338 4,107,273,336 $ 1,173,507

Current Excess 51 507,974,580 $ 145,136

Positions to fill 439 4,280,334,864 $ 1,222,953

Total 828 8,895,582,780 $ 2,541,595

SCENARIO 2: IMPROVE OVERALL STAFFING TO HSDP TARGET OF 80%

To achieve the HSDP target of 80% staffing overall, 284 staff would need to be recruited. For this analysis, we considered the functionality of each division department and prioritized recruiting technical and managerial staff in each division. Table 8 shows the estimated additional wage requirement needed to reach the target. A total of 155 vacancies would remain.

TABLE 8: SCENARIO 2 – MEET HSDP TARGET OF 80% STAFFING OVERALL

Description Number of Posts Annual UGX Annual USD

Current Filled 338 4,107,273,336 $ 1,173,506.67

Current Excess 51 507,974,580 $ 145,135.59

Positions to fill 284 3,038,493,500 $ 868,141.00

Total 673 7,653,741,416 $ 2,186,783.26

SCENARIO 3: IMPROVE SELECT DIVISION STAFFING TO 80%

Another approach to improved functionalization functionality in the MOH would be to focus on the divisions and departments that are currently understaffed and most critical for improving quality service delivery that are currently under-staffed at this time (Table 9).

TABLE 9: PRIORITY DIVISIONS AND DEPARTMENTS

AIDs control division Department of Maternal and Child Health

TB/leprosy control division Office of the Director of Clinical Services

Department of Planning and Policy Department of Health Infrastructure

Department of Diseases Prevention and Control Division of Electro-mechanical/Bio-medical engineering

Malaria Control Division Department of Integrated Epidemiology & Surveillance

Nutrition Division ICT unit

Wabigalo Workshop Division of Health Centers

Division of nursing Division of Midwifery

Diagnostics/National health laboratory services Division of Public Health Nursing

Human Resource Development section Department of Pharmacy

Supply Chain and Logistics Division Office of the Director of Public Health

Department of Community Health Department of Quality Assurance and Inspectorate

Department of Health Promotion, Communication and Environmental Health

Targeted recruitment would be carried out to bring their staffing level up to the 80% target. To achieve this, 92 staff would need to be recruited at an annual cost of $442,527 USD (Table 10). This increase would also improve the overall MOH staffing level to 55%. There would remain 347 vacancies to be filled in two phases.

TABLE 10: SCENARIO 3 – PRIOIRTY DIVISIONS AND DEPARTMENTS REACH 80% HSDP TARGET

Description Number of Posts Annual UGX Annual USD

Current Filled 338 4,107,273,336 $ 1,173,507

Current Excess 51 507,974,580 $ 145,136

Positions to fill 92 1,548,844,500 $ 442,527

Total 481 6,164,092,416 $ 1,761,169

TRANSITIONING USG-FUNDED STAFF TO THE

GOVERNMENT OF UGANDA EMPLOYMENT

USG CONTRACT STAFF TO BE TRANSITIONSED

Of the cumulative total of 3,154 health workers recruited with PEPFAR support, 1,965 have yet to be transitioned to the GOU. They were meant to be transitioned within a period of 3 years, but the absorption has been slow, a significant number of the contract staff has been lost, and there is fear of losing the 1,965 remaining without a clear plan enacted to ensure that they will be absorbed and definite actions taken to do so. The loss of these health workers whose skills have been enhanced for HIV services through the years will disrupt the momentum for HIV epidemic control. There are multiple stakeholders (MOH, MOPS, MOFPED, HSC, DSC, Local Governments, PNFP Bureaus, USG) involved whose roles must be clarified and coordinated to minimize bureaucratic delays in the transitioning of the contract health workers. Transitioning the USG contract staff refers to transfer of responsibility for funding the staff position from USG to the GOU. It is not limited to transitioning the particular individual holding the contract position. In transitioning staff the incumbent contract holder may transition to GOU employment in the same or equivalent position or another individual may be offered the position by GOU. In the event that an incumbent contract staff is not offered the job or the position of the contract staff is no longer considered relevant by either GOU or USG or both, the contract will be terminated. Table 11 lays out the time frame for the transition, the details of which and the he tasks for the various stakeholders are specified after.

TABLE 11: USG CONTRACT STAFF TRANSITION PLAN

USG Contract staff Category Time Frame (starting GOU FY

2017/18)

Total

2017/18 2018/19 2019/20

MOH Level USG contract staff

a) Transition 164 USG funded technical contract staff at MOH to central MOH approved structure on government payroll by 2020

24 0 140 164

b) Transition 66 USG Admin & support contract staff recruited at

MOH to MOH approved structure on government payroll by 2020

66 0

c) Transition 70 USG technical contract staff recruited at Central level (69 CPHL & 1 UHSC) but deployed in health facilities to GOU payroll by 2020

0 0 70 70

d) Transition 79 USG admin & support contract staff recruited at

CPHL but deployed in health facilities to GOU payroll by 2020

0 0 79 79

Subtotal MOH 90 0 289 379

Mulago National Referral

a) Transition 8 USG technical staff in Mulago NRH to Mulago NRH approved structure by 2018

8 0 0 8

b) Transition 1 USG admin staff in Mulago NRH to Mulago NRH approved structure by 2018

1 0 0 1

Subtotal Mulago NRH 9 0 0 9

RRH USG contract staff

a) Transition 274 USG technical staff in RRHs to RRH by 2017 274 0 0 274

b) Transition 19 administration and support staff in RRH to RRH structures by December 2017

19 0 0 19

Subtotal RRH 293 0 0 293

District level USG Contract staff

a) Transition 1,259 USG funded Technical contract staff in districts to district approved structure on government payroll by 2020

420 420 419 1,259

b) Transition 25 USG Admin & support contract staff in districts to district approved structure by December 2017

25 0 0 25

Subtotal districts 445 420 419 1,284

Grand total 837 420 708 1,965

NB: For MOH level USG contract staff, absorption has been projected to happen in year one (FY18) and the rest in year 3 (FY20) after revision of MOH structure and establishment of CPH/UNHLS structure

Whenever GOU positions are advertised, USG/IPs will proactively encourage contract staff to apply.

USG will drop equivalent numbers of PEPFAR staff for equivalent positions advertised by GOU. As contract staff transition to GOU payroll, the number of staff that will be in need of USG support will decline. Table 12 shows the number of staff who will need to be fully funded for each fiscal year (i.e. not transitioning in that year), and the number of staff who will need partial funding as they will transition during that year. For details by location of staff, see Annex Table 13.

TABLE 12: CONTRACT STAFF FUNDING NEEDS 2017-2021

YEAR FULLY

FUND

PARTIALLY FUND

(TRANSITION DURING YEAR)

2017/2018 1194 771

2018/2019 774 420

2019/2020 0 774

2020/2021 0 0

WAGE REQUIREMENTS FOR ABSORPTION OF USG STAFF (PNFP AND PUBLIC)

There are wage implications for the absorption of PEPFAR-supported staff. As discussed previously, in many instances there are not one-to-one alignments of USG staff to open or available positions in the approved structure. However, a number of USG staff have qualifications (i.e. medical doctors) that could allow them to be absorbed elsewhere in the system outside of their current position if necessary.

Some USG staffs do not have analogous positions in the structure (i.e. the job they are currently doing does not exist in the structure). For those contract staff who are of a cadre that are absorbable anywhere in the system, a wage analysis was carried out to see how much it would cost on an annual basis as per GOU standard salaries. The table below shows by level how many staff have qualifications that would enable them to be absorbed somewhere in the GOU system.

TABLE 13: CONTRACT STAFF WITH EQUIVALENT GOU POSITIONS BY LEVEL (PNFP AND PUBLIC)

Level With GOU equivalent position

Without GOU equivalent Position

TOTAL

Central 199 31 230

Districts 1253 31 1284

RRH 277 16 293

NRH 9

CPHL

148 148

UMMB 1

TOTAL 1739 226 1965

For the central MOH, it should be noted that departments such as the UVRI are not yet formalized in the system, therefore there are a number of staff who may be determined to be essential at a later date, and their positions would need to be budgeted for.

Table 12 below separates the contract staff in the central MOH into those who could fill a position somewhere in the system, and those for whom jobs currently do not exist. For those with equivalent positions, the annual wage need for them is calculated in UGX and USD. For the GOU to pay for the

199 contract staff with equivalent GOU positions, an additional UGX 2,483,994,240 would be needed on an annual basis to support them.

For the decentralized USG-supported staff (those in districts, RRHs, NRH, CPHL in the districts, and

UMMB), of the 1,735 decentralized staff, 1,540 have jobs that are within the structure. Notably, of the

195 that are out of structure, 148 are from CPHL – these are the much-needed hub riders and hub-coordinators. As it is assumed that their functions will be taken over in the GOU system as the CPHL is analyzed further, the wage needs for the contract staff outside of the structure have also been calculated. The table below shows the additional annual wage requirements (first in UGX then USD) for decentralized contract staff both in the current structure and outside of it, as it may be determined that some out-of-structure staff are indeed essential to a strong and functioning health system. The detailed wage requirements by district can be found in Annex table 17-20 for the decentralized contract staff in districts, RRH, NRH and CPHL.

TABLE 14: CENTRAL LEVEL WAGE REQUIRMENTS FOR ABSORPTION

Central Department/Division

Number of Contract Staff Annual Wage Need for those WITH GOU Equivalent Positions

With Equivalent

GOU

Positions

Without Equivalent Positions

Total UGX USD

AIDS Control 16 1 17 239,433,264 $ 68,410

CPHL Central 98 2 100 1,200,480,648 $ 342,994

UVRI 34 25 59 287,482,092 $ 82,138

Division of Health Informatics and Technology 7 7 106,268,820 $ 30,363

Health Education Division 2 2 33,283,704 $ 9,510

Health Infrastructure…