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Poorly implemented COVID-19 incentives eroded health workers’ motivation in Africa – Study

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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.

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Davidson Ndyabahika

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MakSPH METS 2024 Annual Report

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Cover image of the MakSPH METS 2024 Annual Report featuring The U.S. Ambassador to Uganda, H.E. William W. Popp, Minister of Health, Hon. Dr. Jane Ruth Aceng and other officials. Photo: METS. Makerere University School of Public Health (MakSPH), Monitoring and Evaluation Technical Support (METS) Program, Kampala Uganda, East Africa.

I am pleased to present our annual report. Throughout the past year, MakSPH-METS Program has remained steadfast in its mission to strengthen Uganda’s capacity for HIV and TB programming through strengthening robust health information systems, surveillance, and quality improvement initiatives.

MakSPH leverages its team of expertise in public health to guide program strategies, strengthen national capacity for data collection, analysis, and use. The innovations developed are solutions for health system challenges and they generate evidence that can be used to inform policy and practice.

MakSPH-METS provides technical support to MoH, RRHs, implementing partners at different health system levels.

Our collaborative approach, working closely with the Government of Uganda and various stakeholders, has enabled us to make significant strides in building sustainable health information systems and improvingthe quality of healthcare delivery. The achievements highlighted in this report reflect our commitment to strengthen health systems through development and implementation of innovative and impactful evidence- based solutions.

As we look to the future, I am confident that the METS Program will continue to play a pivotal role in strengthening Uganda’s health systems through several initiatives.

  1. Operationalising a sustainability plan through transitioning of the developed innovations to the Ministry of Health for ownership.
  2. Disease outbreak management will be strengthened through continued capacity building for emergency response and optimization of existing integrated disease surveillance systems. The field teams will facilitate seamless coordination across health system levels to build sustainable and resilient health systems capable of effectively responding to public health emergencies.
  3. Lastly, we continue to strengthen collaboration with government, enhance coordination with implementing partners and promoting integration of health services.

Our dedicated team of professionals, combined with the unwavering support from our partners and stakeholders, positions us well to address emerging health challenges and advance our nation’s public health goals. The innovative solutions and capacity-building initiatives highlighted in this report demonstrate not only our progress but also our potential for greater impact in the years ahead.

Professor Rhoda Wanyenze
Dean – School of Publc Health, Makerere University

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KeyScope Project Job Advert: Junior Research Fellow

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Part of the team at the Makerere University Biomedical Engineering Unit under the Department of Physiology, College of Health Sciences (CHS), Kampala Uganda, East Africa.

Background

Makerere University Biomedical Engineering Unit under the Department of Physiology is glad to advertise for positions under its new Project ‘KeyScope Project: The Key to Sustainable Cancer Diagnosis and Treatment in Uganda.”

Laparoscopic surgery is considered as the standard of care for cancer treatment in high-income countries. However, this technology is rarely accessible to LMICs due to the high cost of installment, lack of maintenance personnel, unreliable electricity, and shortage of consumable supplies. To address these concerns, a unique multidisciplinary collaboration between engineers, surgeons, oncologists, and business experts from Duke University, Makerere University, Uganda Cancer Institute and University of Maryland joined efforts to develop a low-cost, durable laparoscopic system (KeySuite) for use in resource- constrained environments.

Our aims are aligned to demonstrating the local capacity to manufacture, acquire local and international regulatory approval, determine clinical performance and distribute/sell the KeyScope to the local market. Specifically, we shall improve the current design and determine the local capacity to manufacture the device, establish the clinical safety and acceptability of the product, and obtain regulatory approval from local and international accredited bodies.

Position: Junior Research Fellow

Reports to: Project Coordinator

Engagement: Full time

Duration: 1 year renewable upon satisfactory performance

Duty Station: Kampala

Roles and responsibilities

As a trainee, a Junior Research Fellow will closely work with a research team to undergo training design, manufacturing and validation of the KeyScope. This is a non-degree/no-credit training opportunity that will prepare the successful candidate for advanced studies and future industry work in an upcoming medical technology sector of Uganda and Africa at large.

Specifically the Fellow will;

  1. Participate in the local construction of the KeyScope through material assessment and selection, developing a product manufacturing plan, and carrying out an impact assessment.
  2. Aid in the establishment of clinical safety and acceptability of the KeyScope through the use of a feasibility study to secure approvals, recruit patients and surgeons.
  3. Contribute to the process of attaining regulatory approval from a certified body for the KeyScope.
  4. Contribute to the development of a commercialization plan under training and mentorship of a Business Developer.
  5. Actively engage in project documentation, questionnaire and ethics protocol development, journal article writing and publication, report writing.
  6. Conduct key informant interviews, administer questionnaires, and verbatim transcription of interview recordings.
  7. Participate in data collection and analysis using digital and paper-based tools.
  8. Participate and contribute to teaching and student mentorship.
  9. Engage with the research partners and stakeholders.
  10. Any other activities as assigned by the Principal Investigator, and Project Coordinator (Immediate Supervisor) from time to time.

Qualifications:

  1. Completed a Bachelor’s Degree in Biomedical Engineering or any closely related field and at least awaiting graduation in not more than 6 months from an accredited University in Uganda.
  2. If completed, candidate must not have graduated more than 1 year ago.
  3. Academic qualifications of having attained or expecting at least expecting a second-class upper division degree.
  4. Experience in Human-Centered Design skills and Design Thinking will be highly considered.
  5. Prior experience in working with international multidisciplinary teams and organizations.
  6. Experience of previous work on laparoscopy is a plus.
  7. Evidence of prior interest for research, design, innovation and medical device manufacturing.
  8. Applicant should have a desire to work with different fabrication techniques.
  9. Ability to multitask and perform duties in learning environment with minimum supervision
  10. Excellent scientific writing skills and a good command of communication skills.

How to Apply:

All suitably qualified and interested candidates should submit a one-page cover letter, one-page writing sample, CV (maximum 3 pages) with relevant certificates, transcripts & two reference letters as a single digitally signed PDF file addressed to the Project PI and emailed to keyscopeu01@gmail.com by 17:00hours on 18th April 2025. Indicate, “KeyScope Project” in the subject line. Those awaiting graduation should send their most recent testimonials. Only shortlisted applicants will be contacted.

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Karolinska’s Department of Global Public Health Admins Visit MakSPH

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Therese Lind, Head of Administration at Karolinska Institutet (KI)’s Department of Global Public Health (3rd Right) with the delegation and staff from MakSPH during the visit on 24th March 2025. Makerere University School of Public Health (MakSPH) hosting delegation from Karolinska Institutet (KI) Department of Global Public Health led by Therese Lind, head of administration for a two-day administrative exchange, part of 25 years of a flourishing partnership, 23rd-24th March 2025, Kampala Uganda, East Africa.

Makerere University School of Public Health (MakSPH) is honored to host a distinguished delegation from Karolinska Institutet (KI) for a two-day administrative exchange, part of our 25 years of a flourishing partnership between Makerere University (Mak) and Karolinska Institutet.

Fostering Administrative Synergies

The visiting team, led by Therese Lind, head of administration at KI’s Department of Global Public Health, comprising HR specialist Sofia Öhlund-Fingal, Sonia Hammi, project manager, Kseniya Hartvigsson, communications officer CESH, and Anna Hansson, project manager, Grants Office—engaged in:

  • Discussions on research administration and financial management
  • Knowledge sharing on operational challenges and best practices
  • Exploring funding opportunities with major donors

The visit covered grants management, procurement, financial systems, and joint application strategies to enhance efficiency and academic exchanges. The team also toured key university facilities, including the historic Main Building, the state-of-the-art MakSPH auditorium, and the construction site, to witness the institution’s growth.

A Legacy of Collaboration

Since 2000, this partnership, Mak-KI, has yielded:

  • 49 PhD graduates through the Sida-supported doctoral program
  • Reciprocal exchanges benefiting 254 students and 153 faculty members
  • ⁣The Centre of Excellence for Sustainable Health, established during the pandemic

This visit reinforces our commitment to strengthening institutional capacity and driving impactful research. We extend our sincere appreciation to the KI team and look forward to continued collaboration.

Davidson Ndyabahika

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