_{By Okeya John & Davidson Ndyabahika}

As the COVID-19 pandemic swept across Africa, it brought with it a wave of unprecedented challenges, impacting economies, social dynamics, and political structures. National healthcare systems were particularly strained, prompting governments to implement various strategies to combat the virus and its repercussions. Among these measures were the introduction of incentives, both financial and non-financial, aimed at boosting the morale of health workers and bolstering the capacity of healthcare systems to respond to health emergencies.

Due to COVID-19’s increased risks and demand on healthcare workers working in already overburdened health systems, incentive packages must be strengthened. Researchers conducted a multi-country qualitative study in DRC, Nigeria, Senegal, and Uganda with funding from the Bill and Melinda Gates Foundation and Gates Ventures/Exemplars in Global Health. The study examined pandemic-related workplace incentives. In 60 virtual interviews via phone and Zoom, ministry officials, policymakers, and health care providers provided important viewpoints.

Entitled “Health Workforce Incentives and Dis-Incentives During the COVID-19 Pandemic: Experiences from Democratic Republic of Congo, Nigeria, Senegal, and Uganda,” the research conducted by healthcare experts delved into the realm of incentive mechanisms, their allocation, and the inadvertent dis-incentives experienced by the health workforce amidst the pandemic response efforts.

The researchers were from Makerere University School of Public Health (Uganda), University of Kinshasa (DRC), University of Ibadan (Nigeria) and University of Dakar (Senegal). The research team comprised Suzanne Kiwanuka, Ziyada Babirye, Steven Kabwama, Andrew Tusubira, Susan Kizito, Rawlance Ndejjo, Marc Bosonkie, Landry Egbende, Berthold Bondo, Mala Ali Mapatano, Ibrahima Seck, Oumar Bassoum, Mamadou Leye, Issakha Diallo, Olufunmilayo Fawole, Segun Bello, Mobolaji Salawu, Eniola Bamgboye, Magbagbeola David Dairo, Ayo Steven Adebowale, Rotimi Afolabi, and Rhoda Wanyenze,

In their work, the scientists authoritatively note that: “Health worker incentives during the COVID-19 response were mostly unplanned, predominantly non-financial, and invariably implemented. Across these countries, there were neither guiding frameworks nor standard pre-determined packages of financial and non-financial incentives for health workers during emergencies.”  

Before the outbreak of the COVID-19 pandemic in December 2019, “Africa already had weak health systems,” they note, citing that the pandemic exposed this challenge, increasing work overload for health workers, mental stress, infections and deaths, who in turn, needed incentives to adequately work to respond and deliver good health outcomes during the emergency.

However, due to the dire working conditions, the Word Health Organization (WHO) had warned that frontline healthcare workers were most at risk of acquiring the deadly COVID-19 virus. In their report, WHO highlighted that between January 2020 and May 2021 alone, over 80,000 to 180,000 health and care workers respectively, had died of COVID-19 globally, calling for urgent need to reverse the tide.

From this study, Senegal faces a doctor and nurse shortage with only 0.38 healthcare workers per 1,000 people, well below the WHO recommendation. By December 2021, Senegal had recorded 75,055 COVID-19 cases and 1,890 deaths, including five health workers. Similarly, Uganda, with approximately 2.58 healthcare workers per 1,000 people, reported 146,030 COVID-19 cases and 3,306 deaths, including 37 health workers.

The researchers also noted that the DRC had 1.05 healthcare workers per 1,000 people, with 79,632 cases and 1,225 deaths, including 35 health workers. Nigeria faced a similar challenge, with 2.0 healthcare workers per 1,000 people, 243,450 cases, and 3,031 deaths by December 2021, including seven health workers. These findings stressed the strain on Africa’s fragile healthcare systems in responding to the COVID-19 pandemic.

“These challenges and consequences resulted in health workers either absconding from duty or in extreme circumstances, resigning from the health profession and opting for alternative professions,” the researchers note in their review of the COVID-19 response in Africa. They state that elsewhere by this time, measures had already been mounted to motivate health workers, necessitating a similar response in the continent.

In the countries where the study was conducted, the strategies adopted by governments and development partners to counter declining health worker motivation included offering financial rewards like allowances and salary increments, and non-financial incentives like adequate provision of medicines and supplies, on the job trainings, medical care for health workers, social welfare including meals, transportation and housing, recognition, health insurance, psychosocial support and increased supervision.

The researchers found that the financial rewards were a big motivating factor for the health workers in these countries in sustaining the health systems and COVID-19 efforts, while the non-financial incentives also contributed to improved health worker determination.

The incentives, although a success, however in their strength lied the weaknesses. The multi-country study reveals that the incentives had the double effect of creating disincentives and demotivating healthcare workers. This was occasioned by the lack of personal protective equipment, transportation to health facilities during lockdown, long working hours, harassment by security forces and perceived unfairness in access and adequacy of the rewards.

The study got its findings from virtual key informant interviews with the staff at ministries of health, policy makers, and health workers. In the study report, health managers and workers in DRC, Nigeria, Senegal, and Uganda confirmed that health workers received monetary benefits as a means of motivation for their effort towards the continuity of health services.

In Senegal, incentives were reported to mostly be financial. However, in DRC, although the salaries of the health workers involved in COVID-19 testing were reported to be similar to all other staff in response committees like epidemiological surveillance, case management, and communication, the government moved to temporarily waiver taxes to bait the COVID-19 health workers during the pandemic.

“Since financial incentives were mostly administered in an ad-hoc manner, some health workers felt they were unfairly distributed and complained about the lack of transparency in the allocation of these incentives. In Nigeria, it was reported that payments did not meet the health worker expectations, while in Uganda, it was reported that allowances were given selectively to some health workers such as those involved in contact tracing, COVID 19 testing, and COVID 19 isolation units but not to others.” The study report reads in part.

Respondents also revealed that although allowances were availed, there was dissatisfaction caused by delays and non-payment. In Uganda for example, the recruitment of additional 700 staff on contract although initially perceived positively, their irregular dismissal following budget shortfalls created discontentment and immense pressure for the government.

Accordingly, the authors observe that the incentive packages in the four African countries were inconsistent, lacked transparency, adequacy, and equity. “Therefore, there is a need to develop guiding frameworks within which governments and partners can deliver incentives and reduce dis-incentives for the health workforce during emergencies.”

The study suggests that during health emergencies like COVID-19, increased risks and workloads should mandate the provision of safety gear and adequate supplies. However, the researchers caution that both financial and non-financial incentives can have unintended consequences if perceived as unfair in their implementation.

They also call for incentives to be pre-determined, equitable and transparently provided during health emergencies ‘because arbitrarily applied financial and non-financial incentives become dis-incentives’, while still holding that the financial incentives are only useful in as far as they are administered together with non-financial incentives such as supportive and well-resourced work environments.

“Governments need to develop guidelines on incentives during health emergencies with careful consideration of mitigating potential dis-incentives. The harmonization of roles across state and non-state sector players in incentivizing the health personnel during health emergencies is paramount.” The study affirms.

Find the detailed scientific study here.

View on MakSPH

The Monitoring and Evaluation Technical Support (METS) Program is a 5-year CDC-supported collaboration of Makerere University School of Public Health (MakSPH), the University of California San Francisco (UCSF) and Health Information Systems Program (HISP Uganda).

Highlights of the METS March 2024 Newsletter

• Development of National Electronic Medical Records (EMR) Implementation Guidelines
  • To date, multiple Electronic Medical Records (EMR) systems have been rolled out to health facilities without implementation guidelines to inform the standard EMR process/clinical workflows within a typical health facility, minimum requirements for various EMRs to integrate and exchange patient information, insurance and billing workflows, human resources management, among others.
  • METS Program and USAID/SITES organized a five-day stakeholder workshop on 26^th February to 1^st March 2024, to develop and validate the EMR Implementation Guidelines for Uganda.
• Improving the Quality of Voluntary Medical Male Circumcision
  • In February 2024, the METS Program, in collaboration with the Ministry of Health (MoH), Centers for Disease Control and Prevention (CDC), and Implementing Partners (IMs), conducted targeted onsite mentorship across 56 safe male circumcision sites in CDC-supported regions of Uganda.
  • Key findings highlighted the overall facility performance score of 78%, with 5 out of 8 thematic areas scoring above 80%. Notably, 99% of circumcised males had received Tetanus vaccines.
• Innovation To Strengthen National Health Care Quality Improvement
  • The 10^th National Health Care Quality Improvement (QI) conference brought together health service providers from various parts of the country to share experiences and what they are doing to improve service delivery to patients.
  • The Minister of Health, Hon. Dr. Jane Ruth Aceng, called for solutions that will provide answers especially in areas of governance and leadership, health workforce, information systems, service delivery, financing, special groups, and health products.
  • METS made a presentation on improved service delivery models focusing on empowering young women to stay HIV-free with the help of the Determined Resilient Empowered AIDS-free Mentored and Safe (DREAMS) initiative.
• Gallery
  • Makerere University School of Public Health (MakSPH) launches state-of-the-art auditorium
  • Deploying latest EMR Version at Hoima RRH
  • Training of KCCA staff on use of Point of Care (POC) EMR
  • Stakeholder Workshop on Development of EMR Implementation Guidelines

View on METS

A study whose results were recently published in Food Science Nutrition, a peer-reviewed journal for rapid dissemination of research in all areas of food science and nutrition has revealed that there is a growing preference for wholesome meals, highlighting its numerous health benefits.

Titled; Lactating mothers’ perceptions and sensory acceptability of a provitamin A carotenoid–iron-rich composite dish prepared from iron-biofortified common bean and orange-fleshed sweet potato in rural western Uganda,” this study was conducted among pregnant and breastfeeding mothers seeking care at Bwera General Hospital, in Kasese district, western Uganda, between 4th and 15th of August 2023.

Researchers in a 2019 study published in BMC Pregnancy and Childbirth among pregnant and breastfeeding women in Northwest Ethiopia discovered that pregnant and breastfeeding women bear the highest burden of this deficiency due to heightened physiological demands for iron and vitamin A. These demands increase significantly during pregnancy to meet fetal needs and continue during lactation to support breastfeeding.

The 2020 report on Developments in Nutrition among 204 countries and territories for 30 years since 1990 highlights the substantial impact of dietary iron deficiency and vitamin A deficiency on women of reproductive age in low- and middle-income countries across Africa and Asia. These micronutrient deficiencies are of paramount concern in public health nutrition due to their adverse effects.

A 2022 study published in The Lancet Global Health reveals that progress in addressing anemia among women of reproductive age (15–49 years) is inadequate to achieve the World Health Assembly’s global nutrition target of reducing anemia prevalence by 50% by 2030 in low- and middle-income countries, including Uganda.

Breastfeeding mothers require a higher intake of iron, ranging from 10–30 mg/day, compared to 8 mg/day for adult males. To help meet this increased need, the World Health Organization (WHO) recommends iron supplementation programs during the postpartum period, starting immediately after delivery and continuing for the first 6 weeks.

On the other hand, the WHO advises against vitamin A supplementation during the postpartum period, as it offers no noticeable health benefits to either the mother or the infant. Instead, it encourages breastfeeding mothers to maintain a diversified diet that includes vitamin A-rich foods. However, it’s important to highlight that supplementing with vitamin A and iron during this time could enhance the content of these nutrients in breast milk.

In rural Uganda, breastfeeding mothers often face deficiencies in vital nutrients particularly vitamin A and iron. This is as a result of over reliance on plant-based local foods, like sweet potato and non-iron biofortified common bean like Nambale, which lack sufficient amounts of provitamin A and iron, respectively.

To improve vitamin A and iron intake among breastfeeding mothers, Uganda’s government, in collaboration with HarvestPlus, a global program dedicated to ending hunger through providing nutrient-rich foods launched biofortification programs. These initiatives introduced orange-fleshed sweet potato rich in provitamin A and iron-biofortified common bean as staple food in Uganda.

As part of his postdoctoral study, Dr. Edward Buzigi, a Nutritionist and Food security expert, at University of Kwa-Zulu Natal, South Africa, evaluated the perceptions and sensory acceptability of a dish made from a combination of orange-fleshed sweet potato and iron-biofortified common bean, known for their high levels of provitamin A carotenoids and iron.

The aim was to determine whether the test food could replace the traditional white-fleshed sweet potato and non-iron biofortified common beans, which lacks these essential nutrients.

Ninety-four breastfeeding mothers took part in the study comparing two foods. Participants assessed the taste, color, aroma, texture, and overall acceptability of both the test and control foods using a five-point scale. Ratings ranged from “dislike very much” to “like very much,” with attributes deemed acceptable if participants rated them as “like” or “like very much.”

Also, focus group discussions were held to explore participants’ thoughts on future consumption of the test food alongside statistical analysis done using the chi-square test to compare sensory attributes between the two food options, while the qualitative data from focus group discussions were analyzed using thematic analysis.

Findings revealed that taste, color, and aroma were satisfactory to the mothers and showed no significant difference between test food and control food. Mothers had favorable views of the taste, aroma, and color of orange-fleshed sweet potato and iron-biofortified common bean but expressed concerns about the soft texture of orange-fleshed sweet potato. Despite this, breastfeeding mothers expressed positive attitudes towards consuming orange-fleshed sweet potato and iron-biofortified common bean, as long as it was accessible, affordable, and easy to prepare.

Dr. Buzigi lecturers at the Department of Community Health and Behavioural Sciences at Makerere University School of Public Health in Uganda.

Read the scientific article here;  https://onlinelibrary.wiley.com/doi/full/10.1002/fsn3.4053

View on MakSPH