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To phase out Enrolled Nurses or not: Can Uganda’s human resource policies learn anything from a stakeholder engagement? A reflection on the SPEED policy dialogue on HRH in Uganda

Posted on Tuesday, 10 May 2016

Justine Namakula from ReBUILD's team at Makerere University School of Public Health reflects on a recent policy dialogue on human resources for health in Uganda, organised by the SPEED programme.

In September 2015, the second Uganda National health sector development plan (2015/6- 2019/20) was published. This document clearly stipulates Universal Health Coverage as one of the ultimate goals for the plan and also highlights health workforce as one of the key yet scarce and heavily challenged resources required to help the country attain this goal. This is also emphasized as a priority in the global health workforce crisis key messages.

Over the years, numerous policies have been drawn out or documented in a bid to improve the health workforce situation in the country. The ‘decision’ of phasing out Enrolled Nurses is one among many. Such decisions have in most cases come with many unintended consequences, sometimes even taking the health workforce back in time. One of the causes of such scenarios is the inadequate engagement of various stakeholders and learning from their perspectives.

Based on this background and on request from the Permanent Secretary of the Ministry of Health in Uganda, the Supporting Policy Engagement for Evidence-based Decisions (SPEED) initiative, at Makerere University School of Public Health, organised a policy dialogue on phasing out Enrolled Nurses from the health workforce. The dialogue held on 10th February 2016 at Metropole Hotel, Kampala attracted a number of policy makers within the Ministry of Health, professional councils, academics, retired experts on HRH, district health officers, Enrolled Nurses from various districts as well as medical doctors.

 Stakeholders were requested to deliberate and provide their perspectives in relation to 1) assessing advantages and disadvantages of phasing out Enrolled Nurses 2) examining the implications of implementing the decision in Uganda’s health system.

The discussions among stakeholders drew a lot of emotions and debate.  As a participant observer, I noted that stakeholders’ contributions were greatly influenced by their on-job experiences, past experiences and expertise in relation to Human Resources for Health (HRH), positions within district health offices or facilities and positions within Ministry of Health.  The outcomes of the discussions are the focus of the rest of this blog.

Why we should revisit the decision on phasing out Enrolled Nurses?

a) To prevent deepening of staffing shortages within existing human resources

It was argued that Enrolled Nurses make up about 40% of health workforce in Uganda.  Hence, they support the health workforce pyramid. This implies that phasing Enrolled Nurses out of the HRH structure would create a large staffing or ‘digging new holes’ for which the government does not necessarily have a short-term plan for replacement. Additionally, this would increase the burden of workload for the few cadres that would have remained and leave more people not able to access health services.

A former expert on HRH likened the decision to phase out Enrolled Nurses to ‘killing embryonic stages of the health sector’ in the name of professionalising the nursing profession.

b) Wastage of resources used in training

It was noted that in 2002, Nursing schools were asked to start training certificate for comprehensive nurses. Majority of these have not yet been deployed and now the decision is to phase them out.  This is a huge waste of investments for the trained persons, the schools and funders.

If we decide to legitimize the decision, how best can the decision be implemented?

The following strategies were suggested in order to better implement the decision to phase out Enrolled Nurses.

 a)  Should be a slow phased-out process

Majority of the stakeholders advised that the decision should be a slow phased-out process rather than what Dr. Margaret Mungherera termed as a ‘hope, step and jump’ speed.

b) Engage health training institutions

 Engagement of health training institutions should be emphasised given their role in production of this health workforce.  Particularly, it was mentioned that the training institutions need to revise their curricula, drop that of Enrolled Nurses and instead start retraining for diplomas. This strategy, although very attractive, raised a number of concerns including the need to monitor capabilities of health training institutions and also the dilemma of having competent health workforce with desired skills versus those with merely a paper diploma without the calling to serve.

Among other suggestions highlighted were; need for improved professional support supervision which is currently poor and better remuneration for the Enrolled Nurses given their contribution to the health sector.

 

Overall, a reflection on the dialogue on HRH made me understand that; policy making is not a one-off event but rather a complex process, with various stakeholders who may have varying interests. Finally, HRH challenges in Uganda are very complex whose solutions may instead end up creating more unforeseen problems.  Stakeholder engagement therefore acts as a feedback loop to enable us begin to understand the complex-web of connections.

 

Justine Namakula is the Project Officer for ReBUILD Uganda and team lead for the health workforce incentives study under the same project. Makerere University School of Public Health is a partner institution to this project which is under the overall ReBUILD research consortium.  She is also a PhD student at the Institute for Global Health and development at Queen Margaret University, Edinburgh

Twitter: @JNamakulaM

Tags: health workers, human resources for health, HRH, Uganda health system, registered nurses, SPEED