Between 2015 and 2016 Amani Initiative together with Advocates Coalition for Development and Environment (ACODE) carried out the CODES project with an objective of Assessing the Management and Administration in Public Health Facilities of Uganda and the Implications for the Healthcare Service Delivery and Utilization.
This Policy Research Paper is an outcome of the feld activities carried out under the Community and District Empowerment for Scale-Up (CODES) project- a fve-year initiative (2012-2016) designed to reduce child deaths caused by diarrhoea, pneumonia and malaria—the three of the top childhood killer diseases in Uganda today.
The paper presents an assessment of one of the critical determinants of quality of healthcare provision – the health facility level management and administration. The paper is premised on the argument that the existing weaknesses in health facility management and administration immensely jeopardize the quality of health care service delivery in public health facilities as well as effective utilization of healthcare by the community. This is to the extent that even when the issues and challenges that require government intervention seem to be improving or being addressed at health facilities, with outstanding weaknesses in facility management and administration, the quality of care does not correspondingly improve.
The paper focuses on four (4) health facility management and administration issues;
- Time management among health workers
- Human resource management and development practices
- The role of Health Unit Management Committees (HUMCs),
- Enforcement of health workers’ professional ethics and code of conduct.
These issues were commonly mentioned across all the CODES project participating districts. The project targets 21 districts throughout the country, randomly divided into two groups: intervention districts and comparison districts. There are eight (8) intervention districts (Buhweju, Bugiri, Buvuma, Luuka, Masindi, Apac, Arua and Maracha) and eight (8) comparison districts (Kasese, Sheema, Mitooma, Iganga, Kamuli, Kiryandongo, Kole, and Albetong). An earlier two-year ‘Proof of Concept” phase (2012 and 2013) involved fve (5) districts in the central region of Uganda, namely, Mukono, Buikwe, Masaka, Bukomansimbi, and Wakiso.
In the CODES project context, the fve (5) participating districts in the ‘proof of concept’ were code-named- “Wave Zero” districts while the eight (8) intervention districts are code-named “Wave One” districts. Data was obtained from three main sources (CODES project main activities). (1) Baseline survey which was conducted in 2014 in 16 districts of Uganda in Wave One districts both intervention and comparison districts. (2) Community Dialogues which have been conducted in 13 districts both in the communities and health facilities from 2012-2014 (5 Wave Zero districts) and (8 Wave One intervention districts); (3) Dissemination workshops with District Political and Technical leaders in 13 districts (2014-2016). Additional data was elicited from government documents, journal articles and edited books.
The findings indicate that there is poor time management among health workers as evidenced by late reporting for duty and early departure from duty in health facilities, rampant cases of absenteeism and ‘presenteeism’ among health workers. This results into self-created work-overload, and creation of long queues for patients to access healthcare at health facilities which jeopardizes the quality of health care service delivery, and healthcare seeking behavior among service users.
There is poor human resource management and development practices in a number of health facilities. This is attributed to inadequate managerial skills among health facility in-charges, poor human resource development approaches by the facility in-charges, improper planning, implementation and monitoring of health-based activities by facility in-charges, and other responsible authorities such as the sub-county and district officials.
A number of health facilities are still facing challenges of staff attraction, motivation and retention. In addition, performance drivers such as induction / orientation, mentorship, and refresher training are not given the attention they deserve.
The role of Health Unit Management Committees (HUMCs) remains untapped. HUMCs are responsible for linking health facilities with the community by organizing community meeting and accounting for all the decisions at the health facilities. Unfortunately very few health facilities have functional HUMCs. Some of them had just been instituted and others had never been oriented about their roles and responsibilities. This creates a linking gap between health workers and the community especially in information sharing which compromises the ability of the community to hold the health facility accountable and ensure effective healthcare service delivery and utilization.
There is gross professional misconduct among health workers and defective enforcement of professional ethics and code of conduct at the health facilities. There are numerous cases of use of abusive / insulting language among the health workers while attending to patients, health workers charging patients illegal fees, health workers discriminating patients on the basis of economic, and social statuses, some health workers attend to patients while drunk, among others.
Amidst such circumstances, a number of health facility in-charges appear to be less bothered to rectify the situation. Yet, these unprofessional behaviors discourage patients from seeking and utilizing health services as expected and in a timely manner.
The paper presents recommendations in the perspective of policy, practice, and training/educational implications;
- Ministry of Health and District Health Office should organize periodic capacity building and training in leadership and human resource management and development for health facility in-charges. These would be short-term courses that can build their capacity in leadership and human resource management.
- Health facility in-charges need to employ appropriate innovations and motivation practices for health workers. They should be innovative to identify appropriate motivators and use them effectively and efficiently to induce individual health workers to perform their mandated duties. The in-charges need to strike a balance between the use of ‘carrot and stick’ motivators reward and penalties.
- Building a trust model in healthcare service delivery by encouraging a ‘knight’ kind of behavior among front line health workers- A ‘knight’ cadre is an individual whose principal concern is with the welfare of others instead of pursing self-interests. At the national and local government levels, the trust model requires a high degree of stewardship—leadership through policy, regulation, monitoring and coordination—- the effective trusteeship of national health.
- Strengthen supervision, monitoring and inspection for lower level health facilities by various stakeholders at different levels ranging from the Ministry of Health staff, District leadership, Health Sub-Districts, Health Unit Management Committees (HUMCs), and health facility administration (in-charge). This would ensure the quality of health care service delivery at health facilities. Supervision, monitoring and inspection require sufficient financial resources which the Ministry of Health, District local governments and Sub-counties have to commit to.
- The Ministry of Health and District Local governments should consider organizing and facilitating periodic peer to peer learning sessions for health workers. These can be either inter-district or intra-district levels. Such sessions provide opportunities for health workers to learn the best practices from their counterparts from other districts or within the same district but different places of work (health facilities).
- There is need for a coherent, coordinated and holistic approach in addressing healthcare challenges. This requires concerted efforts from all key stakeholders- Ministry of Health, District, and Sub-county officials, Health Unit Management Committees, Health facility in-charges and front line health workers. This would make it possible to address both systemic and health-facility Management and Administration challenges which are always logically interlinked.
Download the research paper:- (CODES_Amani Initiaitive)