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Ssengooba, Freddie; Rahman, Syed Azizur; Hongoro, Charles; Rutebemberwa, Elizeus; Mustafa, Ahmed; Kielmann, Tara; McPake, Barbara
Publisher: Springer Nature
Journal: Human Resources for Health
Languages: English
Types: Article
Subjects: RA1-1270, Public Administration, R5-920, Public aspects of medicine, Medicine (General), Research, RA, Public Health, Environmental and Occupational Health



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.


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.


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.


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.

  • The results below are discovered through our pilot algorithms. Let us know how we are doing!

    • 1. Wiskow C: The effects of reforms on the health workforce. Background paper to the World Health Report 2006; funded by DFID 2006.
    • 2. Alwan A, Hornby P: The implications of health sector reform for human resources development. Bulletin of the World Health Organization 2002, 80:56-60.
    • 3. Franco LM, Bennett S, Kanfer R: Health sector reform and public sector health work motivation: A conceptual framework. Social Science and Medicine 2002, 54:1255-1266.
    • 4. Ngufor GF: Public service reforms and their impact on health sector personnel in Cameroon. In ILO/WHO Public service reforms and their impact on health sector personnel: Case studies on Cameroon Geneva: International Labour Organization/World Health Organization; 1999.
    • 5. Kohlemainen-Aitken RL: Decentralization and Human Resources: Implications and Impact. Human Resources for health Development Journal 1998, 2:1.
    • 6. Mutizwa-Mangiza D: The Impact of Health Sector Reform on Public Sector Health Worker Motivation in Zimbabwe. In Major Applied Research 5, Working Paper 4 Bethesda, MD: Partnerships for Health Reform Project, Abt Associates Inc; 1998.
    • 7. Rigoli F, Dussault G: The interface between health sector reform and human resources in health. Hum Resour Health 2003, 1:9 [http://www.human-resources-health.com/content/1/1/9].
    • 8. Ambegaokar M: Managing people in the health sector: Considering district team performance contracts in Cameroon. HPU, London School of Hygiene and Tropical Medicine. London; 2004.
    • 9. Martineau T, Buchan J: Human resources and the success of health sector reform. In American Public Health Association (APHA) Washington DC; 2000.
    • 10. Humedes N, Ugalde A: Human resources: the Cinderella of health sector reform in Latin America. Human Resources for Health 2005, 3:1.
    • 11. Schlette S: Public service reforms and their impact on health sector personnel in Colombia. In ILO/WHO Public service reforms and their impact on health sector personnel: Case studies on Cameroon Geneva: International Labour Organization/World Health Organization; 1998.
    • 12. Abzalova R, Wickham C, Chukmaitov A, Rakhipbekov T: Reform of Primary Health Care in Kazakhstan and the Effects on Primary Health Care Worker Motivation: The Case of Zhezkazgan Region. Major Applied Research 5 Working Paper 3, Partnerships for Health Reform 1998.
    • 13. Pawson R, Tilley N: Realistic Evaluation London: SAGE Publications; 1997.
    • 14. McPake B, Blaauw D, Sheaff R: Recognising patterns: health systems research beyond controlled trials. In HSD Working Paper London: LSHTM; 2006.
    • 15. UNDP: Human Development Report. New York: UNDP; 2004.
    • 16. DFID: Bangladesh Health Briefing Paper DFID Health Systems Resource Centre: London; 1999.
    • 17. Normand C, Iftekhar MHM, Rahman SA: Assessment of the Effects of Unification on Health and Family Planning Services. Study Report. Ministry of Health & Family Welfare Government of Bangladesh & London School of Hygiene & Tropical Medicine, University of London 2002.
    • 18. Rahman A: The Study to Assess Implementation of HPSP using Essential Services Package (ESP). Dhaka, Health Economics Unit, Ministry of Health and Family Welfare 2003.
    • 19. Normand C, Reza Hasan AH, Rahman SA, Iftekhar MHM: Study on Enhancing Health System Performance using Procurement and Supply of Goods under Health and Population Sector Programme. HSD Programme, Policy & Research Unit, Ministry of Health & Family Welfare Government of Bangladesh & London School of Hygiene & Tropical Medicine, University of London 2002.
    • 20. Routh S, Shams-El A, Jahan SA, Begum A, Thwin AA, Baqui AH: Developing Alternative Service Delivery Strategies for MCH-FP Services in Urban Areas: Findings From an Experiment. International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR, B). Dhaka 1997.
    • 21. MTR/APR: Mission Team Report 2001:76-78.
    • 22. Corkery: Public Service Reforms and their impact on health sector personnel in Uganda Geneva, ILO and WHO; 2000.
    • 23. Jeppsson A: Financial priorities under decentralization in Uganda. Health policy and Planning 2001, 16(2):187-192.
    • 24. Okutho G: The way forward. In Post Conflict Uganda: Towards an effective Civil Service Edited by: Langseth P, Mugaju J. Kampala: Fountain Publishers; 1996.
    • 25. Okutho G: Civil Service Reform in Southern and Eastern Africa - Uganda Ministry of Public Service; 2004.
    • 26. Orech M: Civil Service Reform in the context of structural Adjustment Kampala: Ministry of Public Service; 1995.
    • 27. Kanyesigye EK, Ssendyona GM: Payment of Lunch Allowance: A Case Study of the Uganda Health Service. Joint Learning Initiative working paper 4-2 Global Health Trust 2004.
    • 28. MOFP&ED: Background to the Budget Ministry of Finance, Planning and Economic Development. Kampala; 1994.
    • 29. MOH: Health sector Strategic Plan 2000/01 - 2004-05: Midterm Review Report Ministry of Health. Kampala; 2003.
    • 30. Konde KJ, Okello D: User Fees in Government Health Units in Uganda: Implementation, Impact and Scope. Small Applied Research Paper No. 2, Partnership for Health Reform Abt Associates Inc: Bethesda; 1998.
    • 31. Acaya G: Increased Utilization Reduced Quality: the Result of Abolition of Cost-Sharing in Busia. Uganda Health Bulletin 2001, 7(4):49-53.
    • 32. Karamagi HC: In Whose Interest Does the State Act? A Review of the User-fee Policy changes in Uganda. Uganda Health Bulletin 2001, 7(2):34-37.
    • 33. Nzabanita A, Nganwa A: Progress Report on Decentralization of Health Services below the District Level in Uganda Ministry of Health. Entebbe; 1999.
    • 34. MOH: Health Sub-District in Uganda. Concept paper. Kampala 1999.
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