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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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Call for Applications: Responsible Conduct of Research (RCR) Training Course

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An elevated shot of the School of Biomedical Sciences Building, College of Health Sciences (CHS), Makerere University. Kampala Uganda, East Africa

The Responsible Conduct of Research (RCR) Training Course, scheduled to take place from July 30th to August 1st, 2025, at the Makerere University College of Health Sciences’ Conference Room.

Background

The SUSTAIN: Advancing Makerere University Masters of Health Sciences in Bioethics program at Makerere University College of Health Sciences aims at developing and institutionalizing a mentorship program in research ethics that facilitates development of bioethics professionals and health researchers who are committed to the growth and application of research ethics in Uganda’s academic and research institutions to the highest possible degree. The Responsible Conduct of Research (RCR) course is one of the short courses that introduces trainees to a framework that involves application of established scientific, professional norms and ethical principles in the performance of all activities related to scientific research.

Course objectives

At the end of this course, trainees should be able to identify, manage and prevent research misconduct.

Course outline

Introduction to RCR; Introduction to Professionalism and Ethics; Human subject’s protection and regulatory framework in Uganda; Humane handling of animal research subjects; Conflict of interest;

Responsible laboratory practices; Mentor-mentee relationships; Collaborative research international, industry); Peer review; Research misconduct (including policies for handling misconduct); Community involvement during research in a low resource setting; Responsibility to society and environment; Responsible financial management; Data acquisition, management, sharing and ownership; Responsible authorship, publication and communication.

Target group

The Responsible Conduct of Research course is targeted at Researchers, Research administrators, Research assistants, Study coordinators, Graduate students and Student supervisors. Certificates will only be awarded to participants with 80% attendance.

Course fee: 205,000/=, or 56USD is payable.

The course fee will cater for meals and refreshments during the training period.

Payment & Registration procedure:

9030026194023, Stanbic Bank, Mulago, Makerere University Biomedical Research Center Limited

Dollar Currency:

9030026194147, Stanbic Bank, Mulago, Makerere University Biomedical Research Center Limited

Please Note: Share payment details on email/whatsup and a hardcopy deposit slip delivered on the first day of the training to Miriam Musazi, Department of anatomy, Bioethics Centre, Room C4,

Mob: +256 782 363 996/ +256 701 363 996, Email: mmusazi@gmail.com.

NB. Only those who will have paid by this date will be considered for the course

Venue: The training will take place at Makerere University College of Health Sciences’ Conference room

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Call For Applications: PhD Fellowship Training Position

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A newborn baby in an incubator in Neonatal Care Unit. Makerere University School of Public Health, Baylor Foundation Uganda, Adara Development Uganda, Nsambya Hospital, and the Ministry of Health with funding from ELMA Philanthropies national health systems strengthening initiative the Uganda Newborn Programme (UNP) launched 2022. Program uses regional approach to improve newborn care in three regions of Uganda namely Kampala, North Central and Western regions. Achievements 2025. Kampala, East Africa.

Background:

Makerere University College of Health Sciences (MakCHS), Kampala, Uganda and Global Health Uganda (GHU); in collaboration with other research consortium partner institutions, including, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya; Training and Research Unit of Excellence (TRUE), Blantyre, Malawi; University of Bergen, Bergen, Norway; University of Amsterdam, The Netherlands; and Liverpool School of Tropical Medicine (LSTM), UK have been conducting clinical research on Malaria Chemoprevention. This research has focused on Malaria Chemoprevention in vulnerable patient populations, including children with severe anaemia, children with sickle cell anaemia and pregnant women. As an example, two of our recently completed studies are “The post-discharge malaria chemoprevention in children with severe anaemia [https://pubmed.ncbi.nlm.nih.gov/33264546/] and Malaria chemoprevention in children with sickle cell anaemia [https://pubmed.ncbi.nlm.nih.gov/39718172/]”.

With support from the UK Research and Innovation (UKRI) body, the consortium is expanding these studies to children with severe acute malnutrition, by conducting a large multi-centre randomized controlled trial entitled “Chemoprevention of malaria in the postdischarge management of children with severe acute malnutrition in Malawi and Uganda”.

In Uganda, the study will be conducted at one or two of their study sites in Jinja Regional Referral Hospital, Hoima Regional Referral Hospital or Kitgum General Hospital. Makerere University College of Health Sciences (MakCHS) and Uganda and Global Health Uganda (GHU) seek to appoint a full-time PhD Fellow, on this study. This will be a 4-year post, tenured at Makerere University and hosted at MakCHS.

Expectations of the PhD fellowship:

The PhD fellow will:

  • Be a part of the main trial team, and participate fully in its implementation. However, he/she will be expected to design and develop his/her PhD research project, nested in the main trial.
  • The area of study will be around “interactions between anaemia and severe acute malnutrition (SAM) in children or the interactions between malaria and severe acute malnutrition in children”.
  • Conduct rigorous research, leading to high quality scientific publications.
  • Submit a full research concept and obtain registration in the University by end of year-one. As such, there be an initial appointment for one year, renewable upon satisfactory performance.
  • Academic mentorship and supervision will be provided by the research consortium (see above – composed of national and international researchers).
  • Doctoral scholarly support and training environment, as well as didactic training in research methods and scientific writing skills will be provided by Makerere University.
  • The funding support will cover tuition and a competitive monthly stipend for 4 years, scientific conferences fees/travel and other research-related costs.

Prospective candidates must:

  • Hold Master’s of Medicine in Paediatrics and Child Health from a recognized university, and licensed to practice medicine in Uganda by the UMDPC.
  • Possess undergraduate training in Medicine and Surgery (MBChB/MBBS/MD).
  • Willingness to fully commit time and effort to their PhD studies, expected to start immediately
  • Candidate should not hold other/concurrent fellowships
  • Having publication experience will be an added advantage.
  • Be highly motivated and willing to commit to a career in research and academia.

Application procedure:

Interested applicants should submit their application and supportive documents – listed here below, in one PDF document, in an email titled “PDMC-SAM–PhD Fellowship Application” to hr@globalhealthuganda.org [and cc – chdc.desk@mak.ac.ug] by 25th July 2025. The documents should include the following:

  • An application letter (Max. 1 page)
  • Motivation statement (Max. 500 words)
  • CV (Max. 2 pages), including a list of publications
  • Two (2) recommendation letters
  • Academic transcripts and certificates for all university qualifications
  • A synopsis focusing on the proposed PhD research work, describing briefly what is already known/burden, challenges, the gaps and potential interventions (include references) [Max. 800 words].

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Makerere Hailed for Its Leadership in Health Policy and Knowledge Systems

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Partnerships for Stronger Knowledge Systems in Africa (KNOSA) East Africa Learning Forum, held July 9–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research, Kampala Uganda, East Africa.

KAMPALA, July 9, 2025Makerere University has been hailed as a continental and global leader in health policy and systems research. This recognition came during the Partnerships for Stronger Knowledge Systems in Africa (KNOSA) Learning Forum, held July 8–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research.

Delegates from Uganda, Kenya, Ethiopia, and Somalia applauded Makerere’s role in advancing evidence-informed policymaking and strengthening national knowledge systems. The forum highlighted the institution’s trusted leadership, practical research, and commitment to driving real change.

Dr. Kumanan Rasanathan, Executive Director of the WHO Alliance, praised Makerere’s long-standing role in bridging research and policy:

“You are a shining beacon on the continent and for the world,” he said. “In this moment of crisis, where every health investment must be efficient and equitable, Makerere’s leadership matters more than ever.”

He emphasized the Alliance’s 25-year partnership with Makerere: “We know Makerere University very well. My predecessors have worked with the Alliance since its inception in the 1990s. Makerere has been especially instrumental in advancing the field of health policy and systems.”

Partnerships for Stronger Knowledge Systems in Africa (KNOSA) East Africa Learning Forum, held July 9–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research, Kampala Uganda, East Africa.
Dr. Kumanan Rasanathan, Executive Director of the WHO Alliance speaking at the KNOSA East Africa Learning Forum hosted by Makerere University in Kampala, Uganda.

Dr. Rasanathan called for a move away from siloed approaches toward more adaptive, coherent systems. He reaffirmed WHO’s commitment to supporting regional initiatives like KNOSA that are driving this shift across Africa.

Partnerships for Stronger Knowledge Systems in Africa (KNOSA) East Africa Learning Forum, held July 9–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research, Kampala Uganda, East Africa.
The Vice Chancellor, Makerere University Professor Barnabas Nawangwe chats with H.E Rt. Hon. Kenneth M. Lusaka, EGH Governor Bungoma County, Kenya during the KNOSA East Africa Learning Forum at Makerere University in Kampala, Uganda on Wednesday, July 10, 2025.

In the face of current funding cuts, Dr. Christine Musanhu of the WHO Uganda Country Office echoed these sentiments with a stern call to action: “In times of uncertainty, we need national systems that not only generate evidence but also understand and communicate it in ways that drive real change.”

She warned of tightening budgets, citing an 11% cut (roughly $67 million) in global funding for Uganda’s public health programs. “We are being asked to do more with less,” she said, urging countries to reprogram resources towards high-impact, evidence-based interventions.
Adding that, “Evidence must go beyond routine data—it is a measure of transformation.”

Partnerships for Stronger Knowledge Systems in Africa (KNOSA) East Africa Learning Forum, held July 9–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research, Kampala Uganda, East Africa.
Dr. Christine Musanhu of the WHO Uganda Country Office encouraged participants attending the KNOSA East Africa Learning Forum at Makerere University in Kampala, Uganda to leave with shared purpose and concrete steps to advance the use of evidence for healthier communities.

This year’s KNOSA forum focused on sharing country-level progress, refining evaluation approaches, enhancing communication products, including scientific publications, and engaging more deliberately with Uganda’s wider policy and research ecosystem.

Makerere University Vice Chancellor Prof. Barnabas Nawangwe, while sharing the institutional vision, called for African universities to lead from the front in addressing health and development challenges: “We can do all the research in the world, but unless it moves beyond our laptops and lecture rooms into real decision-making spaces, it won’t change lives.”

He noted that Makerere contributes over 80% of Uganda’s academic output and praised MakSPH and the College of Health Sciences (MakCHS) for innovations that have shaped responses to HIV, Ebola, and COVID-19. “Our work, backed by partnerships with government and global collaborators, is proof that African universities must lead from the front.”

Partnerships for Stronger Knowledge Systems in Africa (KNOSA) East Africa Learning Forum, held July 9–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research, Kampala Uganda, East Africa.
Makerere University Vice Chancellor, Prof. Barnabas Nawangwe, applauds country teams and university partners during the KNOSA Learning Forum for their dedication to building a stronger, more resilient Africa. He emphasized the vital role of universities in low-income countries in driving socio-economic development.

Professor Nawangwe urged deeper collaboration within KNOSA: “Our continent is interconnected. We cannot afford to work in silos. We are stronger together.”

Dr. Aku Kwamie, the unit head at the WHO-Alliance, noted that there is a need for partners to shift their thinking regarding policy. She particularly shared three critical transitions to institutionalize evidence use: embedding knowledge within institutions, not just individuals; linking research directly to decision-making; and advancing from isolated academic work to system-level thinking. These shifts, she noted, are essential for embedding evidence into routine governance.

Partnerships for Stronger Knowledge Systems in Africa (KNOSA) East Africa Learning Forum, held July 9–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research, Kampala Uganda, East Africa.
Dr. Aku Kwamie, the unit head at the WHO-Alliance, during the the KNOSA East Africa Learning Forum hosted by Makerere University in Kampala, Uganda.

Professor Freddie Ssengooba, a Health Policy and Knowledge Systems expert at MakSPH, reaffirmed Makerere University’s regional leadership in the field and stressed the urgency for African countries to take full ownership of their health systems considering the shifting funding landscape:

“Health policy and knowledge systems research may not be as prominent as epidemiology or disease control,” he said, “but it’s central to how we harvest and connect knowledge with policy and resources. When the vaccine is here and the evidence is clear, that’s when they come to us, asking, “How do we achieve over 80% coverage?”

Partnerships for Stronger Knowledge Systems in Africa (KNOSA) East Africa Learning Forum, held July 9–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research, Kampala Uganda, East Africa.
Professor Freddie Ssengooba, a Health Policy and Knowledge Systems expert at MakSPH speaking during the on-going KNOSA East Africa Learning Forum at Makerere University in Kampala, Uganda.

He praised KNOSA for helping elevate the field’s relevance: “There’s real appreciation for the work we do—not just with Uganda’s Ministry of Health, but across the region.”

Recalling the early collaboration with WHO, he said, “Back in 1997–98, a few of us, myself included, responded to an initial call and began what has now become a long-standing relationship with the WHO Alliance.”

“The Alliance is building capacity across Africa to ensure that research doesn’t stop at findings but goes on to shape decision-making and society,” he disclosed.

Professor Rhoda Wanyenze, the Dean of MakSPH, is currently ambitiously driving her colleagues, staff, and partners to embrace the culture of evidence use. She reiterated the School’s commitment to leading in evidence translation: “I’ve often told the Vice Chancellor—we at the School of Public Health are not in an ivory tower. We are deeply connected to real-world problems.”

Partnerships for Stronger Knowledge Systems in Africa (KNOSA) East Africa Learning Forum, held July 9–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research, Kampala Uganda, East Africa.
Professor Rhoda Wanyenze, Dean of Makerere University School of Public Health, delivers her remarks at the KNOSA East Africa Learning Forum in Kampala, Uganda. She highlighted the School’s deep engagement with policy and practice, noting that over 80% of staff serve on national, regional, or global technical committees—underscoring MakSPH’s commitment to producing grounded research that informs real-world solutions.

To her, the need for a clear framework to improve engagement with decision-makers and address uneven success in research translation has never been greater than now: “Yes, we publish in high-impact journals. But the question is, what change happened because of your evidence?”
“I would love to see the School lead in developing a framework that showcases what we’ve done well and identifies where we can grow.”

She also acknowledged Prof. Ssengooba’s influence in broadening the lens on knowledge management: “You’ve challenged us to think beyond institutions, to consider networks and systems. That’s a gap we must fill.”

Partnerships for Stronger Knowledge Systems in Africa (KNOSA) East Africa Learning Forum, held July 9–10, 2025, hosted by Makerere University School of Public Health (MakSPH) with support from the WHO Alliance for Health Policy and Systems Research, Kampala Uganda, East Africa.
Participants of the KNOSA East Africa Learning Forum alongside members of the WHO Alliance for Health Policy and Systems Research in a group photo with Makerere University leadership at the Forum meeting in Kampala, Uganda.

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Davidson Ndyabahika

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