Mothers are taken through postnatal counselling at Kisenyi Health Centre IV in Kampala in April 2021. PHOTO/RACHEL MABALA
A third of health workers in major public hospitals are not attending work adequately with some appearing for only three months in a whole year yet receiving full payment. This information is contained in a new value-for-money audit by the Office of the Auditor General (OAG), which also shows that about Shs1.5b was paid to ghost workers and absconders in the 12 facilities sampled.
The December 2023 audit report covered three financial years 20219/2020 to 2021/2022, to specifically assess the trend of activities in the management of health professionals in the health sector. It was done in three specialised hospitals, three national referral hospitals, and six regional referral hospitals.
The audited facilities include Mulago National Referral Hospital (NRH), Mulago Specialised Women and Neonatal Hospital (SWNH), Kawempe NRH, Kiruddu NRH, Uganda Cancer Institute (UCI), and Uganda Heart Institute (UHI). Others are Hoima, Gulu, Lira, Masaka, Mbale, and Jinja Regional Referral Hospitals (RRHs).
“Failure to monitor attendance and performance of health professionals facilitates absenteeism where I noted that from the 12 facilities sampled, four facilities had incomplete or no record of attendance to work,” the Auditor General wrote.
The four facilities without this important record include Mulago NRH, which employs more than 1,300 staff, Mulago SWNH, UCI, and Hoima RRH. But UCI was among three facilities which submitted their staff performance report to the Health Service Commission (HSC).
“Analysis of the manual and biometric attendance register of the remaining eight facilities in the 2021/2022 financial year revealed that only Uganda Heart Institute (UHI) had 100 percent attendance to work,” the report reads further.
“In the remaining seven facilities (Kawempe and Kiruddu NRHs, Jinja, Gulu, Masaka, Lira, and Mbale RRHs) on average 32 percent of staff did not adequately attend to work (some staff worked for less than three months in a whole year, others worked for less than 15 days in a month while others did not work at all),” the report reads further.
According to the OAG, absenteeism, besides affecting access to quality services, increases the workload on the committed workers and is costing taxpayers billions of shillings, the money paid to ghost workers or those who abscond.
“The failure to monitor attendance led to non-detection of 104 doubtful workers in the sampled facilities and payment of a total of Shs1.5b to them during the study period,” the report reads.
“These included staff who had died, those who absconded, and those unknown to Heads of departments or units among others.”
In our ranking, which is based on the data signaling the availability of health workers, UHI is the best, followed by Kawempe, and Kiruddu comes third. Mbale RRH came fourth and was followed by Masaka and Gulu. Lira RRH ranks sixth with poor attendance in 49 percent of the 330 staff. This was followed by Jinja RRH.
Hospitals speak
Dr Rosemary Byanyima, the acting executive director of Mulago NRH, said they have mechanisms for monitoring their staff, especially senior doctors, to ensure they are delivering services to patients.
“Mulago Hospital is very busy, so you find a consultant on Monday, he is giving lectures; on Tuesday he is doing major ward rounds; on Wednesday he is in theatre; on Thursday is running an outpatient clinic, and on Friday he is doing some research,” she said in an interview.
“But we expect them to put in some more time in clinical work. And even the research they are doing, we want to see the outcome. So, we expect them to be disciplined but we also have mechanisms of making sure they are running the clinics, ward rounds, and doing surgeries as they are expected to do,” she added.
Dr Jolly Nankunda, a consultant paediatrician and deputy director of Mulago SWNH, said they have officers whose work is specifically to monitor the consultants and specialists to ensure they are offering services.
Dr Ibrahim Bwaga, the director of Masaka Hospital, said:
“We have a biometric machine, a clock-in machine, we emphasise handover and then registration in the registers.”
Still, for the facilities which didn’t have full data on attendance, their management told the OAG that:
“The failure to monitor attendance was due to Covid-19 restrictions where staff could not register manually.”
Scrutiny of attendance records
The OAG said further scrutiny of the attendance records at various facilities revealed that even in the period before and after Covid-19, attendance to work by health professionals was still poor. Management at the Health Ministry further explained to the OAG that they procured an electronic tracking system known as the EAFYA Electronic Medical Records (EMR) system, which would be used by clinicians when seeing and managing patients starting the 2023/2024 financial year.
“The system will show the number of patients handled and will be viewable at the ministry level and would eliminate loopholes in the biometric systems where some staff had been clogging in without any work done,” the ministry told OAG.
However, the OAG said the system in place is not being used well. “The monitoring and supervision systems instituted to monitor attendance and performance of staff in the selected health facilities were not fully utilized, and this has led to poor attendance by staff, absenteeism, and payment of salaries to doubtful workers,” the report reads.
Recommendations by the OAG
In the recommendation, the OAG said: “The top management at the Ministry of Health should put in place mechanisms to ensure adherence and utilization of both the IHRS (Integrated Human Resource Information System) and (Integrated Facility and Health Management Information System) IHMS by all health facilities.” These systems are already in place in many health facilities.
Absenteeism and tracking staff work
Commenting on the issue of absenteeism, Dr Sarah Byakika, the commissioner for planning at the Health Ministry, said they have rolled out software and are providing health facilities with necessary facilities and equipment to track staff work.
“The current electronic medical record system we are rolling out tracks a patient from the time they enter a health facility to the time they receive medicine and also the health workers who handled the patient,” she said. This new system, the commissioner explained, will show which doctor or nurse worked and how many mothers a nurse delivered to gauge their efficiency.
Performance plan and report
According to the OAG report, a review of the 2018/2019 and the 2019/2020 Auditor General reports on the statutory audit of the selected facilities revealed several shortcomings in the appraisal systems and performance management.
“Only three facilities (UHI, Masaka, and Mbale RRHs) had signed performance agreements and submitted performance reports to the Health Service Commission,” the report reads.
The report further indicates that staff in UCI, Jinja, Masaka, and Mbale RRHs prepared performance plans, and staff in UCI, Masaka, Lira, Gulu, Hoima, and Mbale RRHs fully completed performance appraisals, whereas three facilities partially completed. In the report, the Auditor General recommended clear mechanisms for punishing and rewarding health workers to address the vices.
"I advised the accounting officers to put in place punitive measures to non-compliant staff in a bid to ensure timely preparation of performance plans, appraisals, and appraisal reports," the report reads.
Recover Shs1.5 Billion
“The accounting officer of Mulago NRH, Jinja, Gulu, Lira, Hoima, and Mbale RRHs should clean the hospitals’ payrolls and recover all monies paid to the ghost staff,” the OAG recommended.
The report accused Mulago NRH of making such payments to 87 “doubtful employees” worth Shs1.2b. Lira RRH followed with Shs136m, Hoima RRH (Shs29.7m), Jinja RRH (Shs22.2m), Mbale RRH (Shs22m), and Gulu RRH (Shs3.9m).
Addressing absenteeism
This 2023 audit report comes about a year after the Health Ministry asked hospital directors to take immediate action to address staff absenteeism, especially after salary enhancement in 2022. In the new directive, Dr Henry Mwebesa, the Director General of Health Services at the ministry, asked the hospital directors to submit, within seven days, a report showing the clear output of each medical officer, specialist, and consultant in the facilities.
Dr Mwebesa said during a supervision tour of selected hospitals across the country, they discovered that one of the consultants was showing up for duty only eight days a month.
“This is the consultant whose salary has been enhanced [from Shs6m] to Shs12m. What is in this country? I keep asking them, ‘Can you do that in a private facility? Why would you do that in a government hospital and get away with it?’ Our problem is still on governance, those who supervise the health workers,” Dr. Mwebesa noted.
Prosecute the absentees
In another tour at Mulago SWNH, Dr Charles Ayume, the outgoing head of the Parliamentary Health Committee, proposed that health workers who are absconding from duty should be prosecuted.
“These doctors that are undergoing internship have to be mentored, so if you are a consultant and you are giving the hospital one day a week, shame on you! That is a very big shame, and that is criminal. Because at the end of the day, the intern who is going out of the facility is going to be half-baked, so that is unacceptable, it is criminal, and I think such people should be prosecuted,” the Koboko Municipality MP argued.
Impacts and suggested solutions
Research reports show that absenteeism deprives patients of their right to access care, pushing them to drug shops and clinics – many providing substandard care. According to Members of Parliament, some of these government doctors are not at the workplace because they are working in private health facilities.
Presidential directive
The President's new move to dismiss the Masaka hospital’s consultant orthopedic surgeon, Dr Godfrey Pariyo Bonane, over absenteeism allegations has reignited debates on effective solutions to service delivery gaps in public health facilities.
In an October 16 letter addressed to the Minister of Public Service, Mr Mululi Mukasa, President Museveni ordered the issuance of revised Public Standing Orders to make it easier to punish civil servants who absent themselves from duty without sound reasons.
In the case of Dr Pariyo, who, according to Masaka hospital, won the court case where he was accused of absenteeism, Mr. Museveni said he was going to dismiss Dr Pariyo in the public interest.
Dual practice debate
Dr Tom Aliti, the Health Ministry’s commissioner for health sector partners and multi-sectoral coordination, said government doctors should be allowed to work in private hospitals as long as it is not interfering with schedules in public facilities.
Ms. Grace Kiwanuka, the executive director of the Uganda Healthcare Federation, said: “We have a duality of practice in Uganda where a health worker works in both public and private facilities. The misconception is that these people push patients to private facilities, which is not the case.”
"But people end up coming to private facilities because all the commodities are there and the operating hours are favourable for that health worker.”
“If a patient shows up at night, is everybody there to provide a service? Because they know in private facilities, the staff will always be there. We need to find a way of having that complementarity to make sure government recognises where they can get the service at the particular time the patient needs it,” she added.
