7 August 2018

Uganda: New Digital Software Reduces Absenteeism in Health Centres

In May last year, Evelyne Kyohirwe, a mother of four and a resident of Kigomba in Kasambya Sub-county, Kakumiro District, died by the roadside during of labour in attempt to reach Kakumiro Health Centre IV.

Kyohirwe had reportedly spent the previous day at Kasambya Health Centre III but did not get medical attention as there was no one to attend to her. The health workers had all reportedly gone for an unauthorised weekend holiday.

Another mother in 2016 had a still birth after she was neglected by health workers at Kitanda Health Centre III in Bukomansimbi District. The residents accused the health workers of always reporting late and leaving early.

Similar reports of patient negligence have happened across the country despite the existence of various monitoring units, such as the State House Health Monitoring Unit and the Parliament Health Committee, established to oversee the operations of the health facilities.

Although these were all efforts to curb health worker absenteeism as a key barrier to accessing quality healthcare particularly in public health facilities, many preventable deaths, especially of mothers and newborns have continued to occur in the absence of health workers.

The health workers are said to either be moonlighting in other private hospitals or running personal side-businesses.

In public health facilities, it is not uncommon for a health worker to arrive at their workplace as late as midday and leave before 5pm despite the designated time of those working day shift being 9am up to 5pm.

The monitoring tool

Other health workers assigned to work night and weekend shifts are also fond of the same vices due to poor supervision at both the facility and local government level. The poor patients, who cannot afford private services, are left stranded.

In 2014, findings indicated that 52 per cent of health workers in the public sector were not showing up, or came to work but left early to collect dual pay at another health facility, according to a report by IntraHealth.

IntraHealth is a non-government organisation focusing on health workers' role in improving the health of women and children.

It is upon this background, therefore, that government through Ministry of Health came up with the data information software used to monitor staff.

The integrated Human Resource Information System (iHRIS), is a computerised Human Resources (HR) management tool consisting of electronic databases for storing, reporting, and analysing that enables to design and manage a comprehensive HR strategy.

The system, currently implemented by IntraHealth in all the 122 districts in the country, links all HR data from the time a health worker enters pre-service training in the public sector to when he or she leaves the workforce in a particular district.

Overall, the goal of the computerised iHRIS is to contribute to better management of workers to ensure availability of the right number of the workers with the right competencies in the right place, doing the right job at the right time.

Under the system, Dr Steven Nsabiyunva, the Kisoro District health officer, says each health facility in-charge manages the registration book where only those who arrive before 9am sign and after which it is withdrawn until evening when they are signing out.

The same health workers are mandated to sign in the book before departure in the evening at the designated time. The same applies to health workers who work night and weekend shift, Dr Nsabiyunva explains.

"The information is then entered into the software system on a monthly basis and shared with the respective district health officers and the District Service Commission to take action against those who either abscond or arrive late," Dr Nsabinyuma states.

With such information, he explains, that the system helps to track employees who leave work before the assigned time of their shift. This, he says, has put health workers under pressure to work hard.

"About five health workers have lost their jobs since the implementation of the system in 2014. Some of them just disappear the moment they are given letters to meet the District Service Commission for disciplinary action," Dr Nsabiyunva reveals.

Consequently, absenteeism in Kisoro fell from 25 per cent in 2014 to 7 per cent in 2018, which has improved health service delivery in the region, he notes further.

Other local government authorities say the monitoring system also helps facilities and districts analyze attendance to make evidence-based decisions including appropriate staff rewards and sanctions that improve performance, retention, and health service delivery.

Mr Albert Tumusiime, the Rubirizi District biostatistician, says they are able to track the training their staff go through; "so that people know who is trained in what so that we have a balanced capacity."

Similarly, absenteeism in the district has fallen to 8 per cent from 18 per cent in 2014 because health workers, who previously moonlighted in private health facilities, have since resigned their second jobs, Mr Tumusiime notes.

In the Eastern district of Namayingo, Mr Ali Kizito, the biostatistician, notes that "It is a mere click of button that every data you can get."

District authorities have also indicated that they are able to track staff excesses and shortages, sort out health workers who are due to retire, set up a recruitment plan, and vacancies which also enables timely procession of files for those who are due to retire.

Ms Theresa Peduni, the in-charge of Nakatiti Health Centre IV in Amolatar District, says the system has helped to instill discipline among the staff.

"With this new system (iHRS), they (healthworkers) are able to understand when we tell them what to do," Ms Peduni states.

Reduction in number of cases

Absenteeism in the district, according to the Dr Alex Ogwom, the assistant health officer, has fallen by 44 per cent from 50 per cent in 2015 to 6 per cent presently, something that has been attributed to the iHRS tool.

The tool, which has made a transition from a paper only system to an electronic system, has helped to display the shortage of health workers and make a case for increased investment in human resource in the health sector, according to Mr Vincent Oketcho, the country director of IntraHealth-Uganda.

"The government has since found an addition Shs49b we have used to recruit 7211 health workers across the country and this has greatly improved the staffing levels especially at health centre IIIs and 1Vs," Mr Oketcho notes.

The 2015 bi-annual Human Resource for Health report indicates that the country has a staffing gap rate of 28 per cent while the ratio of health workers to patients stands at 1:50 per 1000 as of 2013.

However, according to the World Health Organisation guidelines, a country with less than 2:28 health workers per 1,000 patients is regarded to be in severe health workers' shortage.


Challenges. The system, however, needs to be strengthened through the installation of biometric machines to monitor automatically the arrival and departure time of health workers, according to Mr Tonny Opura a clinical officer at Atuti Health Centre III.

"Some staff are fond of reaching late but sign a different time earlier than their arrival. And also the authorities sometimes do not punish those who go against the rules." Mr Opura notes.

Policy. Equipment maintenance, internet speeds, staff turnover which creates skills gap and absence of a policy to move HR processes from hardcopy to online process, iHRIS interoperability with other health information systems, are also still challenges, the beneficiaries say.

Countrywide, the iHRS system currently enrolled in all the 112 districts has since seen the rate of absenteeism fall from 50 per cent in 2015 to 11.9 per cent in 2017 , according to IntraHealth unapproved statistics.

Albeit the challenges, health workers have also proved that the new monitoring system has greatly simplified their work.

Ms Agnes Bagaya, a nursing officer at Mushumba Health Centre III, says: "the system has helped to reduce the heavy workload since our colleagues are now available during their work schedules."


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