Though the recent health reforms which include decentralisation of health services and creation of ‘minihospitals’at every sub-county indicate that Government is committed to improving the state of health services in this country, not much has been done to retain and motivate staff. For the past 30 years, health workers working in the Public Service have suffered from poor remuneration with subsequent massive brain drain to South Africa, U.S.A, Canada, U.K and Saudi Arabia and various other places.

The few who have chosen to stay, have either abandoned the Public Sector entirely, and have either joined U.N agencies, faith-based NGOs, or have opted for full time private practice. The majority of those who continue to work for Government are forced to supplement their meagre salaries through ‘moonlighting’(dual employment) in private clinics. The result has been a grossly understaffed health service with overworked and demoralised health workers, often showing negative attitudes to their patients and their work.

Following the strikes of the 1990s, Government set up a Commission of Inquiry to look into the grievances of health workers. The Commission comprised of representatives of the Ministries of Health and Public Service, Uganda Medical Association and the Uganda Medical Workers Union. In addition to low salaries, health workers complained about gross delays in appointments, confirmations and promotions. Other concerns were related to lack of accommodation, transport and protective gear.

Recommendations of the Commission included establishment of a constitutional body comprising of experienced health professionals whose main task would be address the delayed appointments, confirmations and promotions. The Health Service Commission has done a commendable job in this regard and in developing recruitment guidelines for the districts. Indeed, its continued existence as an autonomous body will be vital in ensuring a quality Health Service.

Another recommendation of the Commission was to evaluate and appropriately grade jobs in the Health Service with the aim of improving the remuneration of health workers hence the Job Evaluation Exercise whose report was eventually completed and passed by Cabinet in 2000.

The Job Evaluation of Health Workers

There have been several attempts by Government to carry out Job Evaluation of Public Servants. These date back to the Public Salaries Commission under J. Bikangaga (19731974) and the Public Service Salaries Review Commission under Professor Turyamuhika (1980-1982).

However, whereas the Bikangaga Commission emphasised equity as the principle criterion to reward work done, the Turyamuhika Commission substituted equity with parity or equality. As a result of the Turyamuhika Commission Report, the entire Health Service suffered with all the jobs being severely downgraded, right from the level of the Senior Medical Consultant who until then had, been at par with the Principle Judge of the High Court.

The Job Evaluation exercise carried out by the Ministry of Public Service and completed in 2000, set out to replace equality with equity. However, this proved impossible because the same instrument was used to evaluate all the sectors of the Public Service i.e. Health, Teaching, etc. This means that the peculiarities of the various Sectors were erroneously not taken into consideration.

Yet the nature of work in the Health Service has peculiarities that are not found in any other sector of the Public Service. For example, one of the most important unique factors in Health Service is that the health worker has responsibility for life, an asset that has infinite value. This was not factored into the instrument. Yet the responsibility for money and other physical assets was factored in.

The abnormal and asocial working hours of jobs in the Health Service is an essential element globally recognised when remunerating health workers. Yet though factored in, it was given a weighting of only 8% and was, worse still, lumped together with the carrying of heavy weights (physical effort) which health workers rarely do.

Mental effort, which in the Health Service should be weighted more than 30%, was given only 12%. Furthermore, whereas in the Teaching Service, the teacher-pupil ratio was considered, the health worker-patient ratio was not considered.

Another concern raised by the health workers is the failure to recognise the long duration of training that health workers need to qualify to practice. For example, the medical doctor needs 5 years in medical school and one year of internship making it a total of 6 years. Whereas, the teacher requires only 3 years and the lawyer needs a total of 5 years.

Response of health workers to the Job Evaluation Report 2000

One of the Terms of Reference for the Ministry of Public Service team that carried out the Job Evaluation 2000 was consultation and participation of stakeholders. Unfortunately, all efforts by various stakeholders in the Health Sector to point out right from the outset when the instrument was being developed, the above irregularities, their concerns were totally ignored. Among these stakeholders were key ones such as the Health Service Commission, the Mulago Hospital administration, the Uganda Medical Association and the Uganda Medical Workers Union.

Though, on the whole, health workers scored highest, some cadres such as the nurses, scored unreasonably low. The Uganda National Association of Nurses and Midwives are of the view that there was inadequate sensitisation of nurses regarding the objectives of the Job Evaluation especially as it coincided with a retrenchment exercise carried out by the same Ministry of Public Service.

A key objective of the Job Evaluation had been to eliminate salary structure distortions which had been created by a number of factors including selective awards given to the Medical and Allied Health Workers and the Teachers. Another contributory factor was the introduction of monetisation of benefits and another was the need to maintain a reasonable salary compression ratio.

The salary compression ratio is the relationship between the highest and the lowest paid points in the Public Service. Until then the Head of State had been used as the highest paid point yet that salary and that of Public Service Employees are not determined using the same mechanism. The objective was to revert to using the Head of the Public Service as the highest paid point.

Another objective of the Job Evaluation exercise, which did not become apparent until later was to overcome administrative difficulties being experienced in the Ministry of Public Service, related to the existing Multi-Spine Salary Structure. The Multi-Spine Salary Structure is where each Sector in the Public Service such as Health and Teaching, has its own schedule. Whereas in the Single Spine Salary Structure, all sectors are lumped together using one schedule.

The advantage of the Multi-Spine Salary Structure is that it is a flexible framework for addressing pay-related career issues as they affect the various occupational categories. Another advantage is that selective awarding in the Multi-Spine Salary Structure will not cause distortions. This means that the Multi-Spine Salary Structure is the most ideal for ensuring equity. It is also advantageous for the Health Service where selective awards are inevitable.

It is interesting to note that the greatest support for affirmative action for health workers continues to come from the highest level of Government who is H.E the President of Uganda, Mr. Yoweri Kaguta Museveni. He states as follows: Doctors too, have a got a very tedious and sometimes dangerous job, as tragically shown by the recent Ebola epidemic. Previously, doctors had become infected with AIDS from handling the blood of sick people. Somebody stands for the whole day carrying out four operations, for instance. This is a very tedious and moral burden on these lifesavers. Therefore, the theory of ‘democratic suffering’needs to be tempered with some form of positive discrimination, based on realistic job evaluation (President Yoweri Museveni’s Election Manifesto, 2001-pages 58 to 59).

The only disadvantages of the Multi-Spine Salary Structure are merely administrative difficulties, which are mainly around managing the pay structure, as different rates will apply to different sectors. In addition, there will be difficulties in assimilating pay levels across occupational categories and computerisation of the payroll.

At the risk of failing to achieve equity, which had been the key objective of the Job Evaluation, the Ministry of Public Service chose to focus on the minor administrative issues and therefore, recommended to Cabinet, the Single Spine Salary Structure as the best option.

Health Workers’Response to the Circular Standing Instruction No. 2 of 2003.

On 7^th July 2003 the Circular Standing Instruction No. 2 signed by the Permanent Secretary of the Ministry of Public Service was released and disseminated countrywide. In the Circular, were new salary scales and salaries based on a Single Spine Salary Structure. An outcry was immediately made by health workers all over the country and the Uganda Medical Workers Union (U.M.W.U) threatened to initiate a strike if the concerns were not addressed.

Concerns raised included lowering of entry salary points and scales for various cadres, merging of grades and fears that Lunch Allowance had been abolished. Negotiations between the representatives of U.M.W.U and the Ministry of Public Service began shortly after. The employee side have since been joined by the Uganda Medical Association, while the Government side now includes representatives of the Office of the Solicitor General, the Ministries of Labour, Finance and Health and the Health Service Commission.

It was mutually agreed that the implementation of the Circular for health workers is temporarily suspended pending, a clear articulation of the concerns of the U.M.W.U, after wide consultation with all stakeholders in the Health Sector.

A task force of stakeholders in the Health Sector met to study the Job Evaluation Report, the Circular Standing Instruction No. 2 of 2003 and to make proposals to Government.

Finally, the U.M.W.U presented the Report to Government as the position of the Health Workers.

Recommendations of the Health Workers as presented to Government

1. There is need to review the Job Evaluation Exercise to cater for peculiarities of Health Workers.
2. Salary entry points for the various cadres in the Health Service should be raised as recommended in Job Evaluation Report 2000 and not lowered as had been done in some cases, by the Circular Standing Instruction No.2 of 2003.
3. Health Workers should be given duty facilitating allowances such as Responsibility for Life, Risk Allowance and Overtime/On-call Allowance.
4. Basic salaries should be raised to more acceptable levels.
5. The Negotiating Machinery that had been recommended by the Job Evaluation Report 2000, should be established to facilitate on a more permanent basis, negotiations between Health Workers and Government.
6. The Health Service Commission should be represented on the Job Evaluation Implementation Team and the Job Evaluation Appeals Committee again, as had been recommended in the Job Evaluation Report 2000.
7. The Multi-Spine Salary Structure is the most ideal for Health Workers. However, if the Single Spine Structure is to be adopted, Health Workers should be placed among the Special Category as to allow for selective awards with out creating unwanted distortions in the salary structure.

As negotiations between health workers and Government continue, it is important for all concerned to remember that in addition to good health policies, a quality national Health Service requires a well motivated Human Resource.

Copyright 2003 - Department of Health Sciences of Uganda Martyrs University