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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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Digital Mobile Technologies to Study Tuberculosis: A Multi-Discplinary Program

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An aerial view of the Makerere University School of Public Health construction site on the Main Campus. To the Right is the Infectious Diseases Institute (IDI) and in the background are Dag Hammaskjold Hall (Green roof) and University Hall (Brown tiles).

A TRAINING PROGRAM SPONSORED BY FOGARTY INTERNATIONAL CENTER NATIONAL INSTITUTES OF HEALTH, USA

INFORMATIONAL SESSION

Makerere University School of Public Health under D43 multi-disciplinary training program in digital mobile technologies to study tuberculosis that was recently funded by the NIH, through the University of Georgia (UGA) has an opportunity for funding of a masters’ research thesis. This is available to two (02) first year students of the Graduate programmes offered at Makerere University who have progressed to concept proposal development stage of their graduate program. These should be in good academic standing and have or are about to complete year 1 in Academic Year 2023/24. The support will start at the beginning of Academic Year 2024/25, i.e., end of August 2024 when the students are starting their year 2.  Students of geography and or digital health related courses are encouraged to apply, females too.  Students will be provided with secondary data to address the following, or similar, issues relating to tuberculosis (TB):

  1. Characterizing mobility patterns between urban and rural areas of Uganda using archived cell-phone (CDR) metadata
  2. Correlation between self-reported geolocated mobility patterns of TB patients and CDR data
  3. Differences in mobility patterns of TB patient’s pre-diagnosis and post-diagnosis
  4. Gender differences and relationship between IGRA and TST in a prospective cohort
  5. Patterns of change in serial IGRA test results by sex, age, HIV status
  6. Temporal changes in contact, mobility and geographic networks in TB converters and non-converters
  7. Ecological Momentary Assessment (EMA) of social contacts and location patterns of movement by residents at risk for TB infection

Interested students are encouraged to attend an information session on Wednesday 17th July 2024 at MakSPH Annex Kololo where details about the research questions and funding opportunity will be provided to prospective applicants. Prospective applicants will be required to work with their mentors and training grant personnel to develop a 2-5-page concept that will be vetted for possible funding by training faculty of the training program.

Interested students should register their attendance with the training Coordinator, Mr Ivan Mutyaba by sending an email expressing interest in attending the session to imutyaba@musph.ac.ug by close of business on Thursday, 11th July 2024.

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METS Newsletter June 2024

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Makerere University School of Public Health (MakSPH) Dean, Prof Rhoda Wanyenze (Left), MoH Director General, Dr. Henry Mwebesa (Right) and other stakeholders join Dr. Amy Boore (2nd Right) to cut cake at her farewell event. Golden Tulip Hotel, Kampala Uganda, East Africa.

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 June 2024 Newsletter

  • Tracking Trends in HIV Outcomes: The Implementation of HIV Case-Based Surveillance
    • METS in partnership with the Ministry of Health (MoH) and various implementing partners, is spearheading the HIV Case-Based Surveillance (CBS) initiative across Uganda. By February 2024, CBS had been activated in 504 health facilities, with 349 sites (69%) actively transmitting data.
    • Trends of New HIV Diagnosis: An analysis trends over a 20-year period (2000-2022) revealed an increase in new HIV diagnosis over time, peaking in 2014 and 2018, before starting to decline. Diagnoses among females consistently exceeded those among males each year.
    • Case-Based Surveillance (CBS) complimenting other HIV surveillance programs: CBS provides valuable insights into infection patterns and highlights the need for targeted interventions, particularly among females. Next steps include continued scale up of CBS implementation to reach 80% of ART sites; improving data transmission from facility to the national repository to achieve at least 90% of the CBS activated sites; and strengthening data analytics and use of the data for program improvement.
  • Enhancing HIV Prevention Data Collection Through Bootcamps
    • METS in collaboration with HISP Uganda held a workshop in Mbarara to update the Health Management Information System (HMIS) tools for PrEP (Pre-Exposure Prophylaxis) in the HIV Prevention Tracker. The workshop focused on digitizing paper forms to efficiently collect data on key and priority populations.
  • Electronic Medical Records (EMR) upgrades in Eastern Uganda
    • The two-week activity kicked off with a week-long training session at Northeast Villa in Kumi focused on the enhancements of UgandaEMR+, including improved point-of-care (POC) functionalities and data visualization techniques.
    • The initiative successfully trained over 15 AIDS Information Centre (AIC) staff members, including M&E leads, IT personnel, data officers, and M&E managers, in the practical use of UgandaEMR+. Additionally, the two facilities, Ochero HCIII and Kapelebyong HCIV, were upgraded and their staff trained on the new system.
  • Tribute to Dr. Joshua Musinguzi (9/09/1963 – 7/06/2024)
    • Dr. Joshua Musinguzi’s efforts to minimize HIV incidence and death strategically focused on translating knowledge into policies and actions, which has helped Uganda manage the HIV epidemic.
  • Gallery
    • Bidding farewell to Dr. Amy Boore, Program Director, Division of Global Health Protection – CDC
    • Analysing the UgandaEMR Clinical Laboratory Module
    • UgandaEMR+ training for USAID SITES
    • Training for clinicians at Ruharo Mission Hospital on SARI and ILI
    • HIV Treatment Services (HTS) Implementers Meeting

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Job Opportunity at MakSBSREC: Assistant Administrative Officer

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The Davies Lecture Theatre (Right), School of Biomedical Sciences (Blue) and other buildings at the College of Health Sciences (CHS), Mulago Campus, Makerere University, Kampala Uganda, East Africa.

Makerere University is pleased to announce a vacancy for the position of Assistant Administrative Officer (REC Administrator) within the School of Biomedical Sciences Research Ethics Committee (MakSBSREC). This is an excellent opportunity for qualified individuals to contribute to the ethical oversight of research involving human participants.

Position Details:

  • Job Title: Assistant Administrative Officer (REC Administrator) – MakSBSREC
  • Reports to: Chairperson MakSBSREC
  • Engagement: Full-time
  • Duration: 1 Year, renewable upon satisfactory performance
  • Duty Station: Kampala

Qualifications, Desired Skills, and Experience:

  • Bachelor’s degree in Social Sciences and Humanities, Medicine and Surgery, Ethics and Human Rights, or any related field.
  • Master’s degree in Bioethics (an added advantage).
  • Up-to-date training in Human Subject Protection or Good Clinical Practice.
  • Proficiency in English (both spoken and written).
  • Prior experience in regulatory work in research studies or projects.
  • Excellent communication, organizational, and interpersonal skills.
  • Ability to work independently with minimal supervision and meet deadlines.

How to Apply:

Qualified and interested candidates are invited to submit a soft copy of their application documents and a motivation letter to deansbs.chs@mak.ac.ug with the subject line “Application for the position of Assistant Administrative Officer (REC Administrator)”. Address your application to the Dean, School of Biomedical Sciences.

Deadline for submission: July 2, 2024, by 5:00 pm Ugandan time.

Please provide a reliable 24-hour phone contact. Only short-listed candidates will be contacted for interviews.

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