Abstract
BackgroundDespite 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.MethodsThe 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.ResultsThe 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.ConclusionFindings 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.
Highlights
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
Ngufor describes how health staff in Cameroon perceived reforms as a punishment inflicted on the nation by the International Monetary Fund (IMF) and the World Bank and as a result developed a laissez faire attitude to their work resulting in reduction of consultation times and absenteeism [4]
The paper is based on a study conducted in 2004 examining mechanisms of effect through which selected health sector reforms have impacted on human resources in the national contexts of Bangladesh and Uganda
Summary
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 following paper seeks to trace these mechanisms of effect and examines health workers' responses to the changes in their working environments by taking a 'realistic evaluation' approach [13]. A number of studies have considered the effects of reforms on the health workforce [[1,2,3,4,5] and [6]] and highlight the importance of human resources to the success of reform objectives [7] as well as the complexity of human resource management in the context of reforms [8,9] These studies have pointed out that human resource issues need to be a primary consideration in reform design, suggesting that reforms can only be implemented successfully where there is consensual participation on the part of the workforce. This led to the stalling and delay of the reform process [10,11]
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