Working in a decentralized system: a threat to health workers' respect and survival in Uganda

This article contributes to the sparse empirical material on the position of health workers within health sector reform. Using qualitative data gathered in 1999, it shows how staff at rural health units in Tororo and Busia Districts experienced the reforms during the first 5 years of decentralization in Uganda. The analysis builds on a framework proposed by Franco et al. to examine the relation between health sector reform and health worker motivation. However, it diverges from their objective description of the factors determining motivation, giving more emphasis to the subjective perspective of the health workers. The categorical distinction between organizational and cultural/community factors was less relevant for them as actors. Two themes cross-cut their lives inside and outside the health facilities: professional identity, which entailed recognition by both the organization and members of the community; and 'survival strategies', which were necessitated by the desire to maintain a status and lifestyle befitting a professional. Reform weakened workers' positions as professionals and hindered facility-based 'survival strategies' that helped them get by on poor salaries. With an overall fall in remuneration, they were more motivated than ever to establish supplementary sources of income outside the formal government health care system.