Uganda’s civil service is perhaps one of those with some of the lowest salaries in the world. This has remained the case in spite of improvements in the pay package over the last decade.

Staff working in the delivery of health services (here referred to as Medical Workers) are not spared. In fact, because of their peculiar working conditions, the Medical Workers have been among the most discontented civil servants since Uganda entered the era of misrule and mismanagement of the early 1970s.

In 1995, the Uganda Medical Workers’Union (UMWU) called for and eventually instituted a sit-down, non-violent strike as a method of pressing for better working conditions. The initial reaction from the administration of the Ministry of Health was hostile. There was a blanket condemnation of the strikers who were singled out as individual “antipeople, unethical hooligans”. The executive members of UMWU were picked and locked up, and had to report to the police station every week and later monthly for over a period of year.

However, after the dissolution of this strike, Government decided to award an extra pay increase to Medical Workers alone. Since this was in the middle of a budget year, which had seen salary increase in the whole service, it was decided that Medical workers alone receive a monthly lunch allowance. This had an effect of giving them a differential pay rise without having to appear so open and this incited workers in other sectors of the service.

Initially, lunch allowances of Ug. Shs. 66,000 for all established Medical Workers and Ug. Shs. 44,000 for support staff were introducedⁱ with effect from 1st July 1996. The administrative staff and other common cadres in the health sector did complain and eventually the lunch allowance was extended to them as well.

This seemed to quench the fire and although the Medical Workers continued to press for increase in salary, there was no real crisis until 7^th July 2003 when the Circular Standing Instruction No.2 of 2003 (CSI. 2) was issuedⁱⁱ.

Background to CSI. 2.

In 1996 the Ministry of Public Service (MOPS) undertook a Job Evaluation (JE) exerciseⁱⁱⁱ of the whole of the Civil Service in order to determine the relative job worth of each post. This tool was to be used to rank the jobs and eventually determined the correct level of remuneration for them.

The following issues (among others) emerged from the JE exercise;

(a) Most Medical jobs scored highest in the grading compared to their counterparts elsewhere in the service.

(b) The Director General of Health Services was the most highly rated officer in the Civil Service, appearing even higher than the Head of Public Service and Permanent Secretaries.

(c) Two schemes were proposed, namely the Multi-Spine Salary Structure (MSSS) and the Single Spine Salary Structure (SSSS). For both schemes, proposals for salary grades were published in the JE report as Annexes.

(d) Medical workers were informed of the JE findings and consultative workshops were held between MOPS officials and the various Medical Workers’representatives. During consultative meetings the medical workers preferred to remain with the MSSS.

The proposed pay reform entails the injection of an extra Ug. Shs. 500 bn. to the wage bill and given the sluggish nature of our economic growth, the reform was seen as a gradual one and not a “one off”intervention. From 2001 to the time of CSI no. 2 of 2003, the implementation of the recommendations was held back and only small annual salary increases continued to come with each budget speech. In 2001, there was however a big leap in salaries for Medical Officers, from about Ug. Shs.250, 000 to 500,000/= per month.

What is in CSI. 2.?

Then came CSI. 2. A Circular Standing Instruction is an instrument (correspondence) issued by the responsible Permanent Secretary (The Permanent Secretary of Ministry of Public Service) announcing a new policy on any issue introduced into the Civil Service. In this case the CSI outlined the contents of the new pay awards in the-wake of the JE exercise.

Whereas several workers received an increment in absolute terms, there were many issues in which the grading of Medical Workers’pay was at variance with the recommendations of the JE. This led to the unrest among the Medical Workers and their representative Unions gave notice that industrial action would follow if their grievances were not addressed. For purposes of elaboration I will allude to a few of these grievances:

(a) A SSSS was adapted contrary to the Medical Workers’recommendations during the consultative process.

Traditionally Medical Workers had always enjoyed a different salary schedule (B) in which selective awards/ over and above their counterparts (elsewhere in service) were offered. The Ministry of Public Service (MOPS) claims that selective awards did cause distortions and hardships in payroll management. Equally, they claimed the SSSS was easier to manage than the MSSS.

(b) Whereas several factors used in job evaluation disregarded or downplayed the uniqueness of Medical practice, the Medical Worker still scored highest in the whole service. However, when CS 2 came out, the salary scale for most Medical Workers did not always reflect this grading.

 

(c) In some cadres two adjacent but different grades of staff were merged. For example Nursing officers Grade II and Nursing Officers Graded I were bundled together under the title of Nursing Officer. The same happened to Clinical Officers, Dispensers, Orthopaedic officers etc. This meant that the entry points of this cadre would in future be the same regardless of seniority or skills.

 

(d) Some cadres came out with a salary level below their previous salary because of the flaws of the CSI 2.

 

(e) The Director General of Health Services, who scored highest among all evaluated posts ended up with a salary below that of PS’s who scored less.

 

(f) Both DGHS and Senior Consultants were omitted from the list of specified officers, which in the past these were at par with judges and other specified officers.

 

(g) That while the Medical Worker had always been ahead of his/her equivalents in service and enjoyed a lunch allowance of 66,000/= per month in addition, the new salary structure consolidated lunch allowance in the structure and made this difference shrink (in some cases to below the figure of the lunch allowance).

 

(h) Since consolidation of salaries, the Medical Worker’s take home salary had become too meager to cater for basic needs such as housing, meals while on duty, transport to work and telephone calls when on call. These were supposed to be paid out as duty facilitation allowances but they were not.

 

(i) Issues such as risk, mental exertion and responsibility for life, overtime, insecurity due to night travel to and from duty etc., had not been given enough “weighting”during the JE exercise although they were said to have been factored in.

 

(j) For the Medical worker to be able to continue working, there were expenses he had to incur especially on housing, telephone and transport and even when these exceeded the pay, they were not re-reimbursed.

The Medical Workers argued that if the level of their salary was to remain at its present level i.e. Ug. Shs. 200,000 for U7 and Ug. Shs. 1.5 m for Senior Consultants, then duty facilitation and other allowances should be paid monthly to a given package of Ug. Shs. 550,000 for U6 –U8, Ug. Shs. 3,650,000 for U4 –U5 and Ug. Shs. 7,200,000 for U1 to U3.

From the time of CSI. 2 to date the Medical Workers have through their various representatives sent various memoranda^{iv v vi vii} to various levels requesting for better terms.

What are the Medical Workers up to?

Given the delicate nature of these negotiations, this is not the best time to go deeply into the debate as the matter can be equated to one being “subjudice”however, a few observation need to be made;

• What the Medical Workers need is a living wage and enough facilitation to reach and leave their places of work without hardship.
• The Medical Workers know that the current economy may not readily support a market rate wage by regional standard but what they demand is recognition by the community and sympathy from the responsible Ministry (MOPS) because of their humble but vital contribution to society. Provision of duty facilitation to medical workers should not be seen as a favour but an obligation if they are to be expected to perform efficiently.
• The prolonged neglect of these modest requests by the MOPS has caused gross hemorrhage and brain drain of the medical workforce. For example, while over 5000 Ugandan Medical doctors do exist on paper only 800 can be traced in active service in the health sector. For nurses the figure is 5000 out of about 30,000 trained by the Government. The explanation for the difference is mass exodus of the human resource to “greener pastures”.
• When dealing with a human resource that is in high demand, one should not have to wait until they threaten to institute industrial action. Sometimes they may opt for the slow, peaceful but more devastating sit-down strikes when they are physically at work but have no commitment to the their patients. In the case of the medical sector, this has been complicated by the emergence of dual practice. It is now possible for a medical worker in a public health facility to legally operate a clinic, laboratory, surgery or nursing home. This means he is not fully available to the patients. While he is away, nobody covers his duties. It becomes morally impossible for the employer to impose sanctions on such a worker because of poor remuneration.
• Poor remuneration of Medical workers has led to the emergency of dual employment, which has promoted the culture of a “piece meal”input. This promotes inefficiency.
• While appreciable financial resources have been injected into the programme areas of the health sector, Public Service regulations do not allow topping up of wages of Medical Workers using donor funds. Yet technical advisors in the same service are paid on international salary scales from these funds.
• It was expected that after Civil Service Reform, there would be a small, efficient, motivated and well-remunerated service. The service is truly small (40% of establishment) but their wages did not appreciably go up. In fact, one wonders why 40 people doing the work of 100 people should not collect the wages for the 100? Alternatively why can’t the savings from the 60 absentee workers not be used to hire other people to provide relief to the 40?
• In the Manifesto of the President^viii, he has spoken against the democratization of suffering and has called for “selective awards”. This is already working for the judicial and legal officers, and is now being proposed for the Medical, Education, Security and scientific officers but it is not very popular with the traditional bureaucracy. During the negotiations, the Medical Workers put a question to Government, “Are you opposed to the President’s Manifesto?”
• The persistent degrading of the position of the DGHS as well as the unexplained stripping of the senior consultants fringe benefits is a demoralization to a profession that has since time immemorial been universally recognized as noble. Why should the medical professional be placed below the lawyer?