Report of ReBUILD's 'life history' study of serving health workers in four districts of the Acholi sub-region in northern Uganda, as part of ReBUILD's wider work on health worker experiences and incentives during and after conflict.
Understanding the dynamics of the health workforce is key to developing a well coordinated and functioning health system. This is even more pronounced when a country is recovering from a prolonged period of conflict. To improve health worker retention in rural areas we must examine the experiences and perceptions of frontline health workers. This can enable us to establish an effective policy environment for quality service delivery.
The study aimed to understand the livelihoods of health workers along with their coping strategies for dealing with conflict. We also examined public incentive policies both during and after the conflict in northern Uganda.
Using a life history approach, 26 case studies were conducted with serving health workers in four districts of the Acholi sub-region in northern Uganda; Gulu, Kitgum, Amuru and Pader. To our knowledge, this is the first time that a life history approach has been used to investigate the lives of health workers in low and middle-income settings.
Our research was structured around the various stages of health workers' career paths. We discussed their motivation to join the health work force, their experiences at initial and subsequent trainings, job selection, and any specific motivators and challenges that they experienced. We also sought their experience of any incentive policies they had encountered during their careers.
The research highlights the desire for professional status, particularly the want to wear a uniform, in attracting staff to join the medical profession. Other factors contributing to their decision included their innate caring personality, influences from role models within the participants' social network, their previous encounters with health workers and the need to 'pay back' to society. Feasibility was also an issue with the proximity to hospitals and convents being cited a decision-making factor. The study also revealed loyalty within a sector if a person had undertaken volunteering, training and had received their first job in this sector.
The report highlights conflict as a major contextual factor which affected both the lives and career choices of health workers. Participants recalled traumatic situations and innovative coping strategies during conflict, as well as stressing the commitment and resilience of some health workers throughout this period. Strategies for coping with the conflict included task shifting, disguising themselves, hiding amongst the community and finding innovative ways to work with limited supplies. They also deployed psychological strategies such as fatalism and relying on their faith.
During the conflict, health workers also had to manage without absent or delayed salary. Many devised alternative means of generating income such as alcohol brewing and selling food stuffs. Respondents highlighted how many others relied on hand-outs from the community as well as allowances from NGOs.
In general, the findings suggest the importance of selecting and favouring health workers with a higher level of intrinsic motivation. In difficult times, when working conditions are tough, salary is erratic and formal structures of promotion and recognition cannot function well, motivation is key. Strong leadership, supportive professional relationships, good links to the community and small in-kind rewards appear to have incentivised these staff to stay in turbulent times.
The study highlighted the existence of a crowded policy environment within which health workers operate. Efforts are needed to evaluate such policies from the perspective of the health workers.