Research

Health sector reforms and human resources for health in Uganda and Bangladesh: mechanisms of effect

Freddie Ssengooba^1* , Syed Azizur Rahman^2* , Charles Hongoro^3* , Elizeus Rutebemberwa^1* , Ahmed Mustafa^4* , Tara Kielmann^5* and Barbara McPake^5*

¹  Health Policy, Planning & Management, Makerere University, Institute of Public Health, Republic of Uganda

²  Department of Public Health and Policy, Health Policy Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom of Great Britain and Northern Ireland

³  Health Systems Trust, 1st Floor Riverside Centre, Belmont & Main Road, Rondebosch, 7700, Republic of South Africa

⁴  Ministry of Health and Family Welfare, Dhaka, People's Republic of Bangladesh

⁵  Institute for International Health and Development, Queen Margaret University College, Corstorphine, EH12 8TS, United Kingdom of Great Britain and Northern Ireland

author email corresponding author email* Contributed equally

Human Resources for Health 2007, 5:3doi:10.1186/1478-4491-5-3

Published:	1 February 2007

Abstract

Background

Despite the expanding literature on how reforms may affect health workers and which reactions they may provoke, little research has been conducted on the mechanisms of effect through which health sector reforms either promote or discourage health worker performance. This paper seeks to trace these mechanisms and examines the contextual framework of reform objectives in Uganda and Bangladesh, and health workers' responses to the changes in their working environments by taking a 'realistic evaluation' approach.

Methods

The study findings were generated by triangulating both qualitative and quantitative methods of data collection and analysis among policy technocrats, health managers and groups of health providers. Quantitative surveys were conducted with over 700 individual health workers in both Bangladesh and Uganda and supplemented with qualitative data obtained from focus group discussions and key interviews with professional cadres, health managers and key institutions involved in the design, implementation and evaluation of the reforms of interest.

Results

The reforms in both countries affected the workforce through various mechanisms. In Bangladesh, the effects of the unification efforts resulted in a power struggle and general mistrust between the two former workforce tracts, family planning and health. However positive effects of the reforms were felt regarding the changes in payment schemes. Ugandan findings show how the workforce responded to a strong and rapidly implemented system of decentralisation where the power of new local authorities was influenced by resource constraints and nepotism in recruitment. On the other hand, closer ties to local authorities provided the opportunity to gain insight into the operational constraints originating from higher levels that health staff were dealing with.

Conclusion

Findings from the study suggest that a) reform planners should use the proposed dynamic responses model to help design reform objectives that encourage positive responses among health workers b) the role of context has been underestimated and it is necessary to address broader systemic problems before initiating reform processes, c) reform programs need to incorporate active implementation research systems to learn the contextual dynamics and responses as well as have inbuilt program capacity for corrective measures d) health workers are key stakeholders in any reform process and should participate at all stages and e) some effects of reforms on the health workforce operate indirectly through levels of satisfaction voiced by communities utilising the services.