Health sector reforms: what influences health worker responses?

In the past 20 years, a number of developing country governments have attempted to reform their health sectors in order to improve performance. These reforms have often failed to include the participation of the health workforce in planning and decision-making. How do these have unintended effects on health?

Bangladesh and Uganda have attempted many health sector reforms with the aim of improving their health system’s performance and delivery of care. Both countries have extremely low per capita spending on health and both face challenges in meeting the Millennium Development Goals. In 1991, Bangladesh became a democracy after 20 years of military rule and launched a wide programme of reforms. Uganda introduced a series of reforms in the early 1990s in an attempt to rebuild the health sector after it collapsed in the 1970s.

To date there has been little research on the mechanisms through which health sector reforms either enhance or discourage the workforce’s motivation and performance. This study looks at how such reforms affect health workers. It examines the context of reform objectives and the response of health workers to changes in their workplace, through case studies in Bangladesh and Uganda. Interviews were held with 700 individual health workers and focus groups and key interviews were held with health managers, institutions and professionals in 2004.

The study found that:

• Reform planners failed to take the role of context into account in both Bangladesh and Uganda, assuming that health staff would passively implement the reforms. 
• Unification efforts in Bangladesh gave rise to a power struggle and led to mistrust between the former family planning and health divisions, with the family planning staff believing they had “lost out” to health staff. 
• However, the workforce felt positive as they had hope that their salary payments would be paid more promptly due to changes in payment schemes.
• Rapid decentralisation with poor human resources management left Ugandan health workers insecure. Local authorities in power were influenced by resource shortages and nepotism.
• Closer ties to local leaders in the community had a positive effect on health workers. Leaders could lobby the government on their behalf for financial and human resources.

The researchers report that while staff may have been demoralised and resources in short supply, shifting authority and supervision to the rural districts affected communities positively as they assumed an active role in shaping health service provision. The study lists five key recommendations:

• Reform planners should design reform objectives that improve health services for communities by encouraging a favourable response from the workforce.
• Reform planners should carefully analyse the context of the health system when designing reform objectives to identify elements that either support or present barriers to reform initiatives.
• Reform programmes should be flexible so that problems can be easily identified and resolved.
• Health workers should be involved in all stages of the reform process, and should understand the purpose of change and have confidence in the consultation process on which it is based.
• In evaluating the impact of reforms, an important criterion is that health workers’ motivation and performance is affected by how they perceive their relationship with the community.

Source(s):
‘Health sector reforms and human resources for health in Uganda and Bangladesh: mechanisms of effect’, Human Resources for Health 5(3), by Freddie Ssengooba, Syed Azizur Rahman, Charles Hongoro, Elizeus Rutebemberwa, Ahmed Mustafa, Tara Kielmann and Barbara McPake, 2007 Full document.

Funded by: Alliance for Health Systems Policy Research and UK Department for International Development (Health Systems Development Knowledge Programme KP11, MIS Number: 700620046)

id21 Research Highlight: 18 April 2007

Further Information:
Tara Kielmann
Institute for International Health and Development
Queen Margaret University
Corstorphine
EH12 8TS
UK

Tel: +44 (0)131 317 3735
Fax: +44 (0)131 317 3494
Contact the contributor: tkielmann@qmu.ac.uk

DFID Health Systems Development Programme

Other related links:
DFID R4D project record: Health Systems Development Knowledge Programme

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