Effects of Global Health Initiatives on Health Systems Development, Uganda
The Effects of Enhanced Availability of Funding from Global Health Initiatives on the Distribution, Retention and Motivation of Health Workers in Uganda
The Global Fund (GF), Presidential Emergency Fund for AIDS Relief (PEPFAR) and World Bank’s Multi-country AIDS Program (MAP) form the Global Health Initiatives (GHIs) that are the focus of this study. Broadly these GHIs have sought to expand the coverage of HIV/AIDS intervention in Uganda – likely with a wide range of effects upon the health system. For these GHIs to be effective and sustainable in fighting HIV, they require a workforce of sufficient size, distribution and performance.
This research is an attempt to understand better how the GHIs are structured and how they work at the national and sub-national levels and how they influence the health sector workforce. This information would enable the national leadership and global community to better steer the GHIs, with more effective influence and impact.
The general objective of this study was to evaluate the effects of the enhanced availability of funding from GHIs on the health care system at the national and sub-national levels; and within organizations and individual health workers.
The specific objectives were:
- To assess how the GHIs influence the national, district and health facilities by altering such variables (system levers) as available resources, payment (disbursement) mechanisms, job market and training for health workers, and program implementation designs.
- To establish the effect of the GHIs on the national and district health systems in terms of equity in distribution, training and recruitment of the health workforce.
- To assess the organizational responses to GHIs and how they affect the staff profile, retention and organizational work environment i.e. systems for inputs, incentives and support.
- To assess the coping behaviours and motivation of the health workers in response to the effects of the GHIs experienced by health facilities such as workload, training, time allocation between tasks, dual job holding and the equity in the distribution of job benefits.
Objectives 1 to 3 provided the scope to understand the upstream influences of the GHIs at the national and district levels while objectives 4 and 5 were intended to illuminate the GHI effects that trickle down to the health facilities and the health workers within them.
Key findings:
GHI Mechanisms and Complexity. Attempts to assess the effects of GHIs on the national health system are complicated by the complex mechanisms that GHIs use to provide resources and their capacity to adjust and adopt new ways of doing business. Among the major complexities found in the evaluation of GHI effects are related to the capacity for the GHI to contribute resources to a pool (basket) funds, their integration with government systems and the tendency to provide overlapping support.
GHI Influences at the National and District Level. For Global Fund and MAP, national level administrative structures – i.e. project management units – were established to manage the project activities. For PEPFAR, a more diverse set of recipients were being coordinated by the US embassy to ensure coherent implementation of programs. Among the common features of the GHIs was the selection of the recipients of GHI funds for implementation of 49
programs. For Government ministries and local governments (districts), Global Fund and MAP required the recipients to produce work plan with a budget as the basis for disbursements of funds.
Capacity building. Improving the skill base of the workforce to implement HIV activities has been a prominent form of support. Most GHI grants had funds for short-term training of the health workforce and volunteers at the community level as a basis for the delivery of HIV programs. In the short-term, the proliferation of training programs for the workforce has raised both opportunities and challenges. Although the training is vital to workforce skills development and perceptions of career advancement, they have been too frequent and a major source of health worker absenteeism from work.
Additional financial resources. Although this study had anticipated a marked increase in the resources for workforce recruitment, the findings shows that there was limited recruitments among health facilities providing HIV services. There is indication that there are more administrative workforce and structures associated with GHI managements especially for PEPFAR programs.
GHI effects on the size of the workforce. There was some evidence of GHI support for the recruitment and salary payments for the workforce. However, this was practiced at a very low scale and limited mostly to the large-size non-state provider of HIV services. The predominant practice of GHIs was to use in-service workforce to provide new HIV services.
GHIs trickle down to facility level. GHIs were designed to have quick results by scaling-up HIV services. Although Global Fund and MAP programs were visible at the national level, their mechanisms were less prominent at the facility level largely due to their design that engendered more up-stream activities and greater integration within national health system.
Project description
Programme: Effects of Global Health Initiatives on Health Systems Development
Research title: The Effects of Enhanced Availability of Funding from Global Health Initiatives on the Distribution, Retention and Motivation of Health Workers in Uganda
Thematic Research Area: Cross Cutting
Grantee Country: Uganda
Grantee Institution: Makerere University Institute of Public Health
Program Coordinator/Principle Investigator: Dr Freddie P Ssengooba
Start date: June 2007
Status of grant: Completed in February 2009