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 7th 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
- There is need to review the Job Evaluation Exercise to cater for peculiarities
of Health Workers.
- 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.
- Health Workers should be given duty facilitating allowances such as Responsibility
for Life, Risk Allowance and Overtime/On-call Allowance.
- Basic salaries should be raised to more acceptable levels.
- 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.
- 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.
- 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.