The findings emerging from this study are presented based on the domains of individual, organizational  as well as community-level drivers.
Individual-level facilitators of retention which emerged from this study are categorized under monetary and non-monetary incentives.
Overall, job security was identified by HWs as the most important incentive for opting to remain in public sector employment. It was widely perceived that continued employment in the Uganda public service system ensured stable and guaranteed monthly income. Anticipated regular income after retirement through pension earnings was an additional incentive for HWs.
‘For me I think being absorbed into public service was a blessing because when we were with PEPFAR, we were not sure of job security. But at least now we know we are on a permanent job’ [FGD HWs, South Western Uganda].
Similar sentiments were expressed by a health worker from Eastern Uganda who alluded to how job security facilitated peace of mind and secured long-term employment.
‘What motivates me number one is job security. When compared to working for an NGO, like I told you, PEPFAR keeps giving you annual rolling contracts. After one year, you keep wondering where I am I going? Am I going back to my rural village? But now, with local government, the job security is there. As long as you perform well, your job employment is guaranteed. It is you to say I am tired’ [FGD HWs, Eastern Uganda].
In our focus groups with HWs, they indicated that the opportunity of having a ‘permanent and pensionable’ job was a cherished one. This was triangulated with data from in-depth interviews from facility managers who concurred that having a public service job is a precious one in Uganda in the context of prolonged delays in recruitment for public sector jobs in Uganda.
Health workers praised the PEPFAR HIV workforce expansion intervention for providing them with an entry point into public service, which many considered rare in Uganda due to prolonged delays in recruitment owing to long-standing wage bill ceilings.
‘I am happy about the transition because it’s very hard to get a job in the public service in Uganda. So PEPFAR made it easy for us to just ‘cross’ [FGD HWs, Southwestern Uganda].
Another related notion to steady income was the frequently cited advantage of securing salary loans from banks and other financial institutions because of the perceived stability of public sector employment and reliable monthly payroll payments.
‘You can go to the bank and get a loan…they can deduct it from your salary since it is paid regularly without any interruptions, and that loan can solve other problems, and you can venture into other businesses’ [FGD HWs, Northern Uganda].
‘Because of the salary loan many of us are able to do some digging and gardening because our land is fertile, and you can borrow or rent some piece of land’ [FGD HWs Central Uganda].
With respect to mid-cadre HWs, particularly nurses and midwives, the public sector often pays more and is seen as a more attractive employment option when compared to the private sector. Indeed, most mid-level health workers cherished the opportunity of finally joining the Ugandan public service and noted they had longed for it.
‘I feel excited about working for the government of Uganda because this is what I was longing for’ (FGD HWs, Eastern Uganda).
District health teams and national-level ministry officials concurred with HWs in relaying the notion that opportunities for entry in the Ugandan public service were rare and hence public sector jobs were highly prized.
‘Jobs are not easily available in public service. They are very difficult to get. There are many people out there looking for a job… some of these people they recruited them when they had been on ‘the street’ (unemployed) for a long time looking for the opportunity’ (KII District Official, Eastern Uganda).
‘Even for us, being employed in public service, it is a motivation factor. Being somehow permanent (in public service). Because when you are on contract, they can say, ‘the contract is not going to be renewed’. So, if there is something worth fighting for, it is being fully recruited and appointed in the public service’ [IDI, District Official, South Western Uganda].
An important driver of health worker retention was the existence of social ties in the districts in which many of the 694 health workers were absorbed. Indeed, most absorbed HWs called these ‘home districts’ or hailed from that broader ethnic sub-region. Health workers expressed satisfaction in being able to work in their home districts, where they could serve their ‘own’ kinsmen. For hard-to-reach areas in parts of select districts (Kasese, Nwoya, Napak and Apac), which experience difficulty in attracting and retaining health workers due to being remote and isolated, health workers from those areas looked at themselves as the only ones willing to serve in those conditions.
‘People were not willing to come and work here. Different people were employed and did not report for work. So for us, we saw and said that if we do not help our own indigenous people, who will help these people? That is why I am still in the local government otherwise, there were very many different opportunities. South Sudan is just very near, even going to Kampala I would just get a new job’ [FGD, HW Northern Uganda].
Working in home districts or broader sub-regions enabled health workers to supplement their income by tending to food gardens in rural districts and drawing upon their blood relations for financial or in-kind support, such as food provisions, during occasional government salary delays.
‘Working near home has given me hope of working somehow comfortably because even if you don’t have what to eat, you rush home and get some food supplies’ [FGD, HW South Western Uganda].
Some facility in-charges relayed the notion that ‘local hires’ from the districts were more resilient, with perceived better retention outcomes, compared to HWs recruited from outside the district. The latter was deemed unfamiliar with the ‘local terrain’ in rural districts.
‘What we have observed over time is that health workers who have rural backgrounds especially those who are natives of this district tend to build resilience in overcoming local hardships compared to those from outside this region of Uganda who give up when the going gets tough because they have no social ties as persistence enhancers’ [IDI, District Official, Northern Uganda].
The perception that HWs who grew up in rural areas would suffer less attrition in rural districts compared to those who didn’t have this background was common among district health team members and facility in-charges.
Most HWs reported being attracted to remaining in public service due to opportunities for advancing in their careers, given the clear and established structures for promotion and growth in the public health sector. Some of the 86 HWs transitioned from PEPFAR support and absorbed into the public sector payroll had already risen through the ranks in their health facilities of transition through meritorious promotion.
‘In the public service there is a clear path for rising through the ranks and getting promoted progressively. In private hospitals you can remain on the same rank for ages but when you work in public service you keep growing over the years’ [FGD, HW Northern Uganda].
A medical officer or physician absorbed by a district in Northern Uganda in 2015 had risen to the position of Medical Superintendent or head of the district hospital. In Eastern Uganda, a PEPFAR-recruited laboratory technician had been promoted to the position of head of laboratory services at the district hospital. Another laboratory technician based at a district hospital in Northern Uganda had been assigned to supervise laboratories at lower-level health facilities.
‘I have been assigned as laboratory sector mentor for this district. I visit the labs of lower health centres to mentor their staff on maintaining good standards and maintenance of their equipment to ensure increased durability’ [FGD, HW Northern Uganda].
Several previously PEPFAR-supported health workers had been designated heads of the ART clinics in health facilities, where they were eventually absorbed.
Opportunities for further training
Absorbed health workers indicated they opted for service in the public sector owing to what was perceived as the inherent opportunities for in-service training in the form of seminars and workshops. In addition, study participants reported that unlike in the private sector, there are many more opportunities for study scholarships and formal study leaves in the public health sector. Employment in public service was associated with prospects for gaining new skills and additional academic qualifications, which would enhance opportunities for securing new positions in the public service on promotion and, ultimately better pay.
‘The other issue is that private for-profit facilities have no training. I don’t remember attending any trainings while in private facilities, but ever since I joined the government, there have been so many trainings at the local, regional and national level, and I have interfaced with so many people of various cadres [FGD HWs, Eastern Uganda].
‘For me, what has helped me remain with the government is that it has helped me build my career because, like he said, I have attended so many trainings, known friends and met various health workers in the country. Uganda’s government is good at capacity building. You came in with a lower level of education but after you are confirmed in service, they can offer you leave and let you go and study, but NGOs it is very rare for them to give you study leave’ [HW FGDs, Northern Uganda].
Flexibility in public sector work environments
A section of the 86 HWs who participated in our study had private sector work backgrounds. These HWs indicated that in the private health sector, they were under more stringent supervision regimes while noting that the public health sector is a lot less stringent. Key factors for HWs opting to join and remain in government employment included flexibility in reporting time for work, relaxed supervision by superiors, opportunities to reschedule work or exchange work hours with colleagues. Likewise, they noted that public facilities availed spare time to supplement the low salaries paid to HWs by the government. All the preceding observations were critical factors for HWs opting to join and remain in government employment. All health workers disliked strict supervision by the immediate supervisor, timesheets and frequent performance appraisals during the 2-year PEPFAR transition phase. The notion that public service work environments had less-intensive supervision regimes compared to the private sector which was raised in a number of focus groups with HWs was triangulated with reports from district health teams.
‘They have a lot of freedom in government service. Nobody is watching over their backs so much’ [IDI, District Official, Eastern Uganda].
‘For me, I like working for the Uganda government because of the liberty you have. In private organizations, you are not allowed to fall sick, you don’t lose someone (bereavement), and you don’t go on maternity leave. When we were under contract, it was tiresome having to sign timesheets, what, what. But now we are free. But we thank them because they are the ones who brought us, and now the government is treating us well’ [HW FGDs, Western Uganda].
On the other hand, some facility in-charges observed that some of the absorbed PEPFAR workforces had slackened in their work ethic compared to when they were under the contract phase, where performance was very closely monitored.
The role of orientation in enhancing HW retention
Absorbed health workers indicated that during their 2-year contract phase under PEPFAR support, they were initiated and oriented into Uganda’s public sector work methods, processes and guidance on personal conduct. The contract phase under PEPFAR enabled health workers to practice at public facilities, where they were to be absorbed. This phase was described as a phase of adjustment to the context characterized by multiple challenging operational contexts at the health facility and the broader environment. At absorption, health workers were familiar with the government work environment, including the constraints common in public facilities, particularly the chronic shortage of essential commodities and heavy workloads to which they had adjusted.
‘When they came in, orientation was done so that they know the government working system’ [IDI, District Official, Northern Uganda].
We observed variabilities in the long-term service intentions of the cadre of health workers. Mid-cadre staff, such as nurses and midwives, indicated a stronger inclination to continue long-term in the public health sector compared to other health worker cadres. Upper-rung health workers such as physicians and pharmacists demonstrated a higher affinity for seeking alternative employment soon.
‘You can imagine working for this paltry monthly salary ($285) in this remote and rural part of Uganda where there are no good schools for my children or even a decent bar to go to in the evening. Yet my peers are earning big monies working for foreign NGOs in the capital. Of course when I get a better paying opportunity I will not hesitate to leave’ [HW FGDs, Western Uganda].
For pharmacists and radiographers, district health teams expressed an inability to attract this cadre of health workers despite repeated job adverts and that the few who reported only remained in their posts for a short time.
‘Our district being in a rural setting, those high calibre cadres like physicians, the pharmacists, it was a challenge to attract and retain those people. For medical officers, we had a very serious gap. It was only recently when we got a pharmacist, and actually for a short time, and he also went away’ [IDI District, Northern Uganda].
Quest for challenging professional work
A section of health workers preferred GoU service, because, relative to their work experience in for-profit clinics, working in public facilities offered a more challenging and diverse work experience, enabling them to optimize their competencies and training.
‘What has made me stay in government is to obtain more experience because I am handling many patients, so many cases compared to private facilities because sometimes we see few patients and become inexperienced. …I have received so many trainings in TB and …it has helped me improve on the knowledge gap, and I have come across so many cases which I didn’t encounter when I was in training’ [HW FGDs, Eastern Uganda].
Work environment barriers to long-term retention
Although participating HWs had been retained in the public health sector for at least 3 years after their official absorption, their long-term intentions to remain in the GoU service were uncertain. At individual level, HWs, particularly for upper cadres such as physicians and pharmacists, identified barriers to long-term retention that include low pay and the availability of better alternative jobs elsewhere.
At the organizational-level, HWs expressed general dissatisfaction with the chronic stock-out of essential commodities common at district hospitals. Basic supplies needed in their routine practice, such as surgical gloves, gauze, and even common essential medicines, were frequently out of stock. HWs indicated this was a constant source of frustration of being unable to optimize their professional competencies to deliver services to patients seeking care.
‘Inconsistent supplies are a headache. Today supplies are available. Tomorrow they are not there, and yet you can’t work when they are not there. Everything is out of stock, the medicines, the gloves, they can come in and in three weeks and we are out of stock. Supplies which are provided on a quarterly basis only last three weeks’ [FGD, HW, Eastern Uganda].
Furthermore, HWs reported a scarcity of rent accommodation as a barrier to long-term retention in the public sector. The shortage of rent accommodation was especially prominent in rural Northern Uganda. HWs in districts in this region expressed an inability to secure rental housing near district hospitals and having to travel several 100 km away daily to their workstations. This category of HWs indicated a willingness to seek alternative employment when the opportunity presented itself. Some HWs who had hospital-provided staff housing said that overcrowding and congestion were a consistent challenge. HWs described the discomfort of sharing housing units meant for single occupants. In the focus groups, HWs raised poor housing conditions and the critical shortage of rental accommodation in some parts of Uganda as threats to long term retention which was corroborated in our in-depth interviews with district health teams.
‘Another challenge is accommodation. When you go to housing for HWs at the district hospital, you find four doctors in one house. All HWs at the hospital are sharing. Someone is in the bedroom, and another is sleeping in the sitting room” [IDI, District Official, Southwestern Uganda].
HWs also voiced concerns about the heavy workloads they were subjected to due to persisting staffing gaps at district hospitals. While several HWs exhibited remarkable fortitude in enduring hardships in district hospitals, a section of HWs expressed a likelihood of leaving if better employment opportunities, with higher pay, became available.
‘If I get another job, I can leave without even resigning or wasting time simply because the payment is low and irregular. If I get another job with an NGO, I will also leave government employment because with big NGOs pay better’ [HW FGD, Northern Uganda].
Delays in confirmation in public service were frequently cited as a source of demotivation. In several study districts such as Sheema, Iganga and Mubende, HWs expressed unease and insecurity with delays in confirming them in government service. The delay in formal confirmation in public service after completing the 2-year probation period emerged as another threat to long-term retention.