THE REPUBLIC OF UGANDA
MINISTRY OF HEALTH
S T R E N G T H E N I N G U G A N D A’ S S Y S T E M S F O R T R E AT I N G A I D S N AT I O N A L LY
ADDRESSING HUMAN RESOURCE REQUIREMENTS FOR
SUSTAINABLE AND QUALITY HIV CARE AND TREATMENT
Healthcare providers at Mubende Regional Referral Hospital attend a meeting to discuss sustainability of services in anticipation of project
closure. ©URC 2015
Background facilities and districts, towards the absorption of the health work-
A
ers into the government systems testing and counseling (HTC) for
ccording to the World Health Organization (WHO) large numbers of clients, regular laboratory monitoring for HIV-
Framework for Action - Strengthening Health Systems to positive patients and continual clinical monitoring and treatment
Improve Outcomes, a strong health workforce is respon- for patients.
sive, fair and efficient to achieve the best health outcomes pos-
sible, given available resources and circumstances (i.e., there are
sufficient staff, fairly distributed; they are competent, responsive USAID/SUSTAIN Strategic Approach
and productive). The project objective is to increase stewardship by the MOH to
provide sustainable quality HIV care and treatment, laboratory,
In 2006, WHO estimated a shortage of four million trained health- elimination of mother-to-child transmission (eMTCT), and tuber-
care workers globally. In 2011, only 63% of public sector posts in
Uganda were filled (Human Resources for Health Audit Report).
Also, the distribution among higher-level professional cadres was It is in this context that the USAID/Strengthening Uganda’s
skewed toward urban areas. Systems for Treating AIDS Nationally (SUSTAIN) project
has been working to expand and improve the quality of HIV
HIV places a significant burden on healthcare systems in Uganda services at 19 public healthcare facilities across Uganda. In
which are already struggling to adequately staff health facilities order to achieve this, the project provided human resources
and provide comprehensive HIV services. The USAID-SUSTAIN (HR) management support to hospitals to address ongoing
project supports human resources for health comprising of staffing challenges for HIV service delivery and to improve
approximately 700 health workers. The staff are seconded to human resources management practices in order to achieve
Health Centres (HCs) II, III, and IV, general hospitals, public and the best possible results within the existing framework. The
private not for profit (PNFP) health facilities spread over 70 dis- ultimate goal is for the Ministry of Health (MOH) and hospitals
tricts, and at regional referral hospitals in the country. The sup- to increasingly take ownership for the HIV services that they
port to the PNFP facilities is up to over 400 health workers, while provide by the end of the project in December 2016.
over 200 are at public facilities. The project works with the GOU
OCTOBER 2017
Authors: Irene B. Seguya, Julian Natukunda and Gladys T. Tugume
The USAID Strengthening Uganda’s Systems for Treating AIDS Nationally (SUSTAIN) project supports the Uganda Ministry of Health to strengthen sustainable
and innovative approaches for HIV and TB service delivery at selected healthcare facilities. This project is made possible by the support of the American
people through the United States Agency for International Development (USAID). The content of this publication does not necessarily reflect the views of
USAID or the United States Government. For more information, please visit www.sustainuganda.org.
SUSTAIN – Supported Healthcare Facilities culosis (TB)/HIV services. To achieve this, the project col-
laborates with the MOH and key stakeholders, including
hospital leadership, to work towards:
u Achieving key milestones toward hospitals running
Kaabong GH the services independently without project support.
Hospitals are supported to address ongoing staffing
Kotido HC IV
Arua RRH challenges for HIV service delivery and improve
Abim GH
hospitals’ HR management practices.
Gulu RRH
Moroto RRH u Building leadership capacity and supporting
Lira RRH Matany H
the hospitals to maximize staff efficiency and
Tokora HC IV productivity.
Amudat H
Soroti RRH
Key Activities and Interventions
C
Hoima RRH
Mbale RRH onducting a human resources assessment
to determine workload based staffing needs
for HIV service delivery: In 2011, the project
Fort Portal RRH
Mubende RRH KAMPALA Jinja RRH conducted a human resources assessment to determine
Kawolo GH the service structure, levels of staffing and workload-
based staffing requirements at HIV/AIDS clinics in
Masaka RRH comparison to national guidelines. Using record reviews,
time-task analysis and time-utilization observations,
the project documented the existing workforce and
workload, and identified current and future staffing
Kabale RRH
Type of Healthcare Facility Key Areas of Support requirements for key service provider positions. The
RRH Regional Referral Hospital Human Resources for Health findings were used to inform managers to develop
GH General Hospital
strategies for streamlining services and using staff time
HC IV Health Center Level IV
as effectively and efficiently as possible.
H Hospital
Piloting the modified human resource information
SUSTAIN Facilities and Supported system at four hospitals: Having established staffing
levels as well as service structures, the project used the
districts for VMMC and HRH HR assessment findings to develop workload-based
staffing recommendations for clinical staff, counselors,
laboratory and dispensing staff. The project worked fur-
ther with the Uganda Capacity program to pilot the use of
Kaabong GH a modified human resources information system (HRIS).
Kotido HC IV
USAID/SUSTAIN then guided senior hospital personnel
Arua RRH responsible for staff allocation through the use of the
Gulu RRH
Abim GH HRIS to track staff skills. Additionally, the project encour-
Moroto RRH aged the rotation of staff in order to build and expand
Lira RRH Matany H
health workers’ skills in providing HIV services. Using the
Tokora HC IV HRIS has provided access to updated staffing informa-
tion. As a result, it is now possible to correctly determine
Amudat H
Soroti RRH
needs and advocate for staff to run the HIV clinic.
Hoima RRH
Mbale RRH Strengthening capacity of facility and MOH central
staff in leadership and management: In collaboration
with the faculty of Health Sciences of Uganda Martyrs
Fort Portal RRH KAMPALA Jinja RRH
Mubende RRH University (UMU), the project organized a three-month
Kawolo GH
part-time certificate course on leadership development
for health managers in Uganda. The course, conducted
Masaka RRH between March and August 2012, covered six main areas
of emphasis on leadership, including: leadership develop-
ment, leadership skills and styles, emotional intelligence
for effective leadership, advocacy and negotiation skills.
Kabale RRH
Type of Healthcare Facility Key Areas of Support Management topics were also covered, such as com-
RRH Regional Referral Hospital Human Resources for Health
munication skills (including one-on-one and group com-
GH General Hospital
munication skills), problem solving skills, performance
HC IV Health Center Level IV
H Hospital
management, effective delegation, team building and
development and conflict management, among others.
The training was attended by Hospital Directors and
2 Addressing Human Resource Requirements for Sustainable and Quality HIV Care and Treatment
u Staff Management Plan. This document
addresses key aspects of HR manage-
ment beginning with the offer of employ-
ment, through managing performance
and, ultimately, separation of staff from
employment with the hospital.
USAID/SUSTAIN orientated hospital manag-
ers through a series of meetings with man-
agement teams, both centrally, and at the
hospitals. Project technical advisors dem-
onstrated the use of the documents and
templates which were provided in soft copy
for the hospitals to adapt them as needed.
The project also provides ongoing guidance
on use of the tools when requested.
Key Achievements and
Progress To-date
F
ulfilled key HIV service delivery
A laboratory technician prepares to draw a blood sample at Kotido Health Center IV. ©URC 2015 roles by MOH staff: Following the
HR assessment, a key action on the
hospitals’ sustainability action plans was
to designate MOH heads of HIV services.
Hospitals nominated staff to take leadership
of HIV services, including the nurse in-
charge of the HIV clinic, eMTCT, HTC
and voluntary medical male circumcision
(VMMC) focal persons. To date, 10 out of 11
clinics providing comprehensive HIV care
and treatment have designated MOH heads
of HIV clinics. Additionally, all eMTCT, HTC
and 9 of the 12 VMMC focal persons at all
11 supported facilities in this category are
MOH staff.
Improved HR management practices:
Project guidelines have improved manage-
ment of staff in the following ways:
USAID/SUSTAIN staff, Hospital Director and members of the hospital management team u Recruitment exercises have been
during the HR sustainability plan meeting at Gulu RRH. ©URC 2016
conducted in a justifiable manner. Staff
meeting the required competencies are
selected at the interviews and copies
Superintendents, Senior Principal Nursing provides support to these managers. of the recruitment documentation are
Officers, Hospital Administrators, and The project also developed two key shared with the project to enable audits
staff in-charge of key HIV service delivery guiding documents for the hospitals of the processes.
departments. The overall purpose of the to ensure that HR management best
u Employees are issued job descriptions
course was to enable health managers practices are followed and, most
on recruitment along with designated
to gain greater insight into the concept importantly, performance management
supervisors and expected standards
of effective and visionary leadership, de- for the staff is effective. These include: of performance, as described in the
velop leadership skills and understand
u Health Workers Recruitment Plan. guidelines. The employees receiving HR
how these skills can be used to improve salary support grants are successfully
This guide describes key steps
the performance of healthcare and other managed as part of the hospital staff.
and activities to be undertaken by
health-related organizations. Following the
hospitals during the recruitment u Disciplinary action is carried out
training, HIV services have been led by the
of staff, typically to fill agreed according to the recommended steps,
hospital leadership, including supported
upon staff positions. Its aim is to with only requests for oversight support
HR and operational grants with oversight
ensure recruitment activities are from USAID/SUSTAIN.
from USAID/SUSTAIN.
transparent, justifiable and processes u The managers critically examined the
Supporting the health workforce: The are well documented. It includes tools, and when pertinent, incorporated
project provides HRH support for over samples/templates for short listing, MOH templates. For example, MOH
700 health workers in 165 health facilities candidate evaluation, reference appraisal forms were added given the
across the country. The hospital staff are and background checks and job expected standards for conducting
managed internally, and USAID/SUSTAIN descriptions. appraisals.
Addressing Human Resource Requirements for Sustainable and Quality HIV Care and Treatment 3
Spotlight
Integrating Quality Improvement and HR Management: Performance Improvement for HIV Testing and Counseling
Intervention: In 2013, USAID/SUSTAIN conducted a Figure 1. HR change package elements and activities
human resources performance improvement (HRPI)
Sharing details of the hospitals’ overall
activity to address challenges relating to staffing and HTC targets with all staff involved in
service delivery
HR management that affect productivity and efficiency Aligning departmental HTC goals with
overall hospital targets
of HTC services at three hospitals: Entebbe General
Hospital and Fort Portal and Mubende Regional Referral
Hospitals (RRH).
Through the HRPI, these hospitals focused on one key
quality improvement (QI) indicator for HTC: reaching the
target number of HTC conducted, particularly in the out-
patient department. The activity was built around the HR
performance framework, which describes that employ- Putting systems in place for regular
ees who have internal motivation, external affirmation performance monitoring
and performance support will be fully engaged in their
work and are more likely to remain in their positions, Results: Over the course of the QI project, the three hos-
work productively and perform well. pitals registered increases in staff engagement. Mubende
RRH, which achieved the greatest expansion of HTC
u From March to August 2013, project staff and
services, experienced the greatest improvement in staff
consultants guided the hospitals to work through
engagement. The HRPI demonstrated that integrating HRH
an HR-focused change package to address three
improvement strategies in QI interventions can help hospi-
elements (see Figure 1).
tals reach their HTC targets by the following key steps:
u Each hospital appointed an HRH focus team com-
u Involving unit in-charges in the departmental target
prising of representatives from all units involved in
setting: This effort creates clarity on the task at hand
HTC and enrolment into HIV care, as well as in HR
and improves ownership of their assigned portion.
management. The activities were coordinated by
the Senior Principal and Principal Nursing Officers u Addressing staff motivation: Negative attitudes among
at the hospitals and led by Nurses In-charge who individual staff members create barriers to the achieve-
were responsible for organizing shifts and tasks. ment of HTC targets.
u Data were collected from the participating hospitals u Use of and sharing data: Consistent and regular
(as well as two others serving as controls) on the support helps QI teams develop confidence to collect,
HTC QI indicator and selected HR measures. analyze and share data to track their progress.
Figure 2. Key results in reaching HIV testing and counseling targets, Apr - Aug 2013
300
Entebbe Fort Portal
Mubende Target
250
% of Weekly HTC Target Achieved
200
150
100
50
0
April May June July August
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