Transitioning health workers from PEPFAR contracts to the Uganda government payroll

Abstract

Although increasing public spending on health worker (HW) recruitments could reduce workforce shortages in sub-Saharan Africa, effective strategies for achieving this are still unclear. We aimed to understand the process of transitioning HWs from President’s Emergency Plan for AIDS Relief (PEPFAR) to Government of Uganda (GoU) payrolls and to explore the facilitators and barriers encountered in increasing domestic financial responsibility for absorbing this expanded workforce. We conducted a multiple case study of 10 (out of 87) districts in Uganda which received PEPFAR support between 2013 and 2015 to expand their health workforce. We purposively selected eight districts with the highest absorption rates (‘high absorbers’) and two with the lowest absorption rates (‘low absorbers’). A total of 66 interviews were conducted with high-level officials in three Ministries of Finance, Health and Public Service (n = 14), representatives of PEPFAR-implementing organizations (n = 16), district health teams (n = 15) and facility managers (n = 22). Twelve focus groups were conducted with 87 HWs absorbed on GoU payrolls. We utilized the Consolidated Framework for Implementation Research to guide thematic analysis. At the sub-national level, facilitators of transition in ‘high absorber’ districts were identified as the presence of transition ‘champions’, prioritizing HWs in district wage bill commitments, host facilities providing ‘bridge financing’ to transition workforce during salary delays and receiving donor technical support in district wage bill analysis—attributes that were absent in ‘low absorber’ districts. At the national level, multi-sectoral engagements (incorporating the influential Ministry of Finance), developing a joint transition road map, aligning with GoU salary scales and recruitment processes emerged as facilitators of the transition process. Our case studies offer implementation research lessons on effective donor transition and insights into pragmatic strategies for increasing public spending on expanding the health workforce in a low-income setting.

‘Writing budgets for meetings and teas?’: a multitheoretical analysis of intragovernmental coordination for multisectoral action for health in Uganda

“…Being a low-income country, resources available to the government are limited, and the country has a heavy donor reliance. 47 Accordingly, coordination issues and priorities are shaped heavily by global and regional agendas and actors. 48 The study mainly focused on the 2015–2020 period, which coincided with the National Development Plan (NDP) II, the Health Sector Development Plan and at the international level, the sustainable development goals (SDGs).…”

“…The ministries have ministers as their political heads and are supported by a bureaucracy of technical officials. Being a low-income country, resources available to the government are limited, and the country has a heavy donor reliance 47. Accordingly, coordination issues and priorities are shaped heavily by global and regional agendas and actors 48.…”

Understanding Uganda’s early adoption of novel differentiated HIV treatment services: a qualitative exploration of drivers of policy uptake

“…At sub-national level, we sought district health team leaders and district health officers (DHOs) who provide district HIV programming leadership. This was important as Uganda’s decentralized health system means responsibility for service provision has been devolved to sub-national units [ 37 ]. At the meso-level, we elicited provider perspectives on the operational context underpinning uptake of differentiated HIV treatment services at the facility and community levels.…”

Drivers of retention of the HIV workforce transitioned from PEPFAR support to the Uganda government payroll

“…Although PEPFAR initially focused on supporting Uganda’s emergency response to the HIV epidemic, especially through the roll-out of ART country-wide, it became evident that health system constraints would remain a fundamental impediment to attaining UNAIDS’ 95–95–95 targets in Uganda [ 5 , 6 ].…”

“…To achieve HIV epidemic control, PEPFAR supported the recruitment of critical health workers (HWs) to boost the Government of Uganda (GoU)’s efforts to strengthen the HIV workforce [ 6 ].…”