Elsevier

Social Science & Medicine

Volume 49, Issue 7, October 1999, Pages 849-865
Social Science & Medicine

Informal economic activities of public health workers in Uganda: implications for quality and accessibility of care

https://doi.org/10.1016/S0277-9536(99)00144-6Get rights and content

Abstract

This paper reports the results of a study in Uganda of the ‘informal’ economic activities of health workers, defined as those which earn incomes but fall outside official duties and earnings. The study was carried out in 10 sub-hospital health facilities of varying size and intended role and used a variety of quantitative and qualitative methods. The paper focuses on those activities which are carried out inside public health facilities and which directly affect quality and accessibility of care. The main strategies in this category were the leakage of drug supply, the informal charging of patients and the mismanagement of revenues raised from the formal charging of patients. Few of the drugs supplied to health units were prescribed and issued in those sites. Most health workers who have the opportunity to do so, levy informal charges. Where formal charges are collected, high levels of leakage occur both at the point of collection and at higher levels of the system.

The implications of this situation for the quality and accessibility of services in public health facilities were assessed. Utilisation levels are less than those expected of the smallest rural units and this workload is managed by a handful of the expected staff complement who are available for a fraction of the working week. Even given these few patients, drugs available after leakage were sufficient to cover less than half of those attending in most facilities. Evidence on staff motivation was mixed and better motivation was associated with better performance only in a minority of units.

Informal charging was associated with better performance regarding hours worked by health workers and utilisation rates. Drug leakage was associated with worse performance with respect to both of these and unsurprisingly, with drug availability. Short term strategies to effect marginal performance improvements may focus on the substitution of strategies based inside health units (such as informal charging) for those based outside (facilitated by drug leakage). In the long term, only substantially higher funding of the sector can be expected to facilitate major change, but alone will be insufficient. Investment strategies supported by appropriate policy development has to be informed by understanding and monitoring of the ‘informal’ dimension of health sector activity.

Introduction

Uganda's years of civil strife are well known to the outside world. Clearly, such disruption would not leave health services unscathed. Since Uganda's health service was the envy of Africa in the 1960s, the effects were all the more extreme. Between 1973 and 1982, the crude mortality rate, infant mortality rate and child mortality rate all increased whereas in other African countries they declined significantly (Macrae et al., 1994). In 1986, the value of the public health budget was only 6.4% of its 1970 level (Macrae et al., 1994). While the political and economic situations have recovered fast over the past decade, it is far from clear that health service recovery has been commensurate. Donor efforts have been substantial. By the period 1986–1988, donor aid flows to the health sector had reached US$40 million compared to only US$5 million in 1982–1983 (Macrae et al., 1994) and have continued to grow. However, the effects of such efforts are mixed. Uganda's is now one of the most donor dependent health sectors in the world with the effect that Ugandans have lost some control over health sector development and have little stake in accountability for some key health sector resources. The hyper-inflation of the war years caused civil service salaries to plummet in real terms but the economic strategies pursued over the last decade have accorded this issue low priority and it has been one of the last to be tackled. Substantial pay increases were awarded to some other sectors of the civil service, but health workers were not included and have received relatively moderate increases to date.

The legacy of these developments in the form of poorly motivated health workers, poor accountability for health sector resources, informal charging of users of public health facilities and health worker absenteeism, caused by parallel working, is well known to Ugandans and has been documented in a descriptive way in two districts by Jitta and van der Heijden (1993). Similar situations have been described in other countries (Liu et al., 1994, Roenen and Ferrinho, 1997, Witter and Sheiman, 1997) but comprehensive research faces particular difficulties given the secrecy implicit in the nature of the activities. Nevertheless, if they are as widespread as popularly reported, they are of crucial importance for the health services. The situation described by Jitta and van der Heijden implies that much of what seems to have been achieved (specifically a free or nominally charging health service; relatively good geographical accessibility; and a quality of care commensurate with the well-trained health workforce and the extensive essential drug programme) is chimeric. Further implied is that any health sector policy must take realistic account of how it will be mediated through such an environment if it is to achieve its objectives.

User charges have been semi-formally introduced in most health facilities in Uganda. The situation at the time of this study was that individual health facilities set up health unit management committees (HUMCs) which set their own policy with respect to charges and the management and use of revenues. (National guidelines have since been introduced.) A minority of health units have not yet introduced formal charges.

This paper reports from a research project which has aimed to provide a detailed and quantified assessment of the extent and implications of the ‘informal’ activities of health workers, defined as those economic activities (those which yield income) which fall outside official duties and earnings. A simple theoretical framework guiding the research is described in Fig. 1.

Three sets of factors are likely to play important roles in determining health workers' choice of economic activities:

  • environmental factors such as the local economy and employment opportunities and the range of competing health facilities;

  • health workers characteristics such as their age and sex and their aspirations and expectations;

  • national and district health policy such as the level and structure of user charges, how the revenues are managed and allocated and supervision and training policy.

The economic activities are likely to have important implications for the quality and accessibility of services at public health facilities.

This paper focuses on the lower part of the framework. Its objectives are to describe the nature and extent of the informal activities within the public health facilities and to assess their implications for the quality and accessibility of care in those facilities. Additionally, in its conclusions the paper considers how policy can influence quality and accessibility of care through influence on informal activities (the upper right part of the framework).

Specifically, the paper reports the findings responding to the research questions:

  • 1.

    To what extent are different informal activities practised? The activities which had previously been identified (Jitta and van der Heijden, 1993) and were confirmed in our own pilot study guided the research design. These were the informal charging of patients who used public health facilities; the outside sale of drugs and other supplies which had been supplied to the public facilities; and the misappropriation of formal user charge revenue.

  • 2.

    What are the implications of each of these activities for quality and accessibility of services at public health facilities? The types and extent of economic activities were viewed as playing a major role in determining the quality and accessibility of care at public facilities through influence on the time health workers allocate to providing care in the facility, the drugs available at the facility and the price of obtaining them; the level of informal charges at the facility and the health workers' attitudes to delivering services and to patients.

Section snippets

Study design

The study was carried out in ten health centres and dispensaries in two districts of Uganda, one each in the southwestern (district 1) and southeastern (district 2) regions of the country. These ten health centres were sampled purposively to represent a range of sizes and facilities expected to be available.

Inherent sensitivity permeates attempts to research the activities discussed here. In the light of this, all types of health services research methods are inadequate in isolation. The study

The extent of informal economic activities within the public health facilities

On the basis of all the information derived from the qualitative methods (interviews and focus group discussions) and the questionnaires, the main informal economic activities identified in the ten health facilities were mismanagement of drug supply, informal charging, mismanagement of user charges, offering treatment in health workers' homes, ownership of clinics and drug shops, part-time work in other jobs (most commonly private clinics), agriculture and trade.

For many health workers, it was

Discussion and conclusions

The informal economic activities of public health workers are extensive in all respects addressed by this paper: Few of the drugs supplied to health units are prescribed and issued there (the median leakage rate was 76%), the estimates of leakage made err on the side of underestimation and do not include sale rather than free issuing of drugs within health facilities. Most health workers who have the opportunity levy informal charges, which according to patients sometimes amount to between five

Acknowledgements

The research described in this paper was funded by the European Commission under the Scientific and Technical Cooperation with Developing Countries programme. The Health Economics and Financing Programme is financed by the UK Department for International Development.

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