HR in a Ugandan hospital

A short version of this article was published by HR Magazine January 2011 and can be found at—personal-rather-personnel/

Like Coca-Cola?

Quite a bit recently has been written about HR outside of US or Europe.  However, the focus has been on the big trans-national businesses, the IBMs, HSBC’s.  Even the big Non-Governmental Organisations (NGOs) like Oxfam and SCF seek to standardize procedures and norms across different nations.  But down at the level of local NGOs and faith based bodies, what’s it like?  What does their Human Resources look like?

My wife and I have worked in a faith based hospital in rural Uganda in 2008-2010.  Though quite remote, it is not a small place, comprising of a 240 bed hospital, >300 staff, a primary school, school of nursing, a hydro-power company, a large child sponsorship programme, and sundry other projects.   I was responsible for group finances, some HR and sit on management.

HR as a discipline

With staff ranging from night watchmen to medical specialists, what kind of HR do we need?  After all, it is said with some justification, that Africans are experts in human relations.  But hospitals like these are complex, drawing educated staff from well beyond the local area. HR procedures and supporting framework exist, within the Hospital Constitution and in a separate Terms and Conditions.  They are not water-tight, but they cover the basics.  The real problem is implementation.

The Hospital group had no HR department nor HR officer.  The day to day functions are shared amongst senior staff with the bulk going to the Hospital Chief Administrator, salary and pay issues to Hospital Finance Manager, and training to the Medical Superintendent (the CEO).  All decision making lies with the Management Team which includes the senior staff already mentioned, plus five more, in collective sessions and  most issues go straight to the top, including all Disciplinaries, all changes to pay, all larger training issues.  Very little is dealt with by individual managers.

The Recruitment-Appraisal-Departure Cycle

To say no one has a Job Description (JD) and Person Specification (PS) is not true.  Job Descriptions are understood and the notion of signing off your JD with your line manager clearly exists in the Terms and Conditions.  But JDs are used mainly for higher grades and more specialist positions.  JDs were created for all positions six years prior, but remained dust free and unused on the Hospital file-server.

Formal Person Specifications are not understood and do not exist except where I created them. Yet when it comes to recruitment, an implicit PS comes into play.  Formal qualifications are paramount.  When I wanted to recruit from Kampala someone with a degree but no practical experience for a position perceived as for a diploma, not degree, holder, people were not happy.  “She’ll not stay” or “you will have to offer graduate level pay”.  Yet the applicant was willing to settle for less than “graduate level” pay for the sake of getting some practical experience, even in this remote corner of Uganda.  On another occasion when I wished to recognise in pay and grade someone who had only O’ levels for a job that in theory required A’ levels, but had two years of excellent work to show, there was real reluctance.

Recruitment is not like in UK.  We did advertise in a national newspaper, but many applicants come via word-of-mouth.  And no one took references seriously.  Though short-listing is done by the recruiting manager often alone, the decision to hire, like the decision to fire, is often done by the whole of management.  When one of the interviewers knows any of the applicants personally a “declaration of interest” is by no means automatic.  Whereas in a European context knowing the applicants is seen as a danger, here it is seen as a virtue: by knowing an applicant you are in a better position to judge whether they are worth hiring or not.  In Europe all adverts indicate salary or salary range but in Uganda none do and judging starter salaries is hit-and-miss, there are no published salary surveys.  People do know what the competitive rates of pay but entirely though friends and hearsay.

Appraisals were known of but not used.  The prospect of reflective self assessment, followed by a discussion and possible assessment/scoring by your line manager appals both appraiser as well as the person to be appraised.   Indeed, there is no tradition of active management of staff, of local goal setting, receiving feedback and team building.  This is not as silly as it sounds.  Group identity emerges organically, though kinships and ordinary friendship, not though departmental or operational identity.  Furthermore, staff did (only too readily) bring their work problems to your door as soon as they arise.

Disciplinaries and the probation period existed on paper, but not in real life. There was a deep rooted fear of open conflict. New jobs for the ones ejected were not plentiful; did you really want the responsibility of getting a kinsman sacked?  What will his wife and seven children do?  Humanitarian and social concern weakens the challenge of bad performance and dilutes sanction.  I was involved in a case where a supervisor sought dismissal of someone still within their probation period.  He clearly stated that retaining the probationer would make his own position untenable.  If Management retained the probationer the supervisor would resign from being supervisor.  In the event, Management did not agree to dismissal yet still heavily leaned on the supervisor to change his mind and stay on.

Volunteer Expertise: Living With Practical Fluidity?

Recruiting and managing foreign volunteers presents different issues.  Management was always reluctant to turn away volunteer expertise.  This arises from both the sense of poverty and a practical fluidity.  Practical fluidity?  When seeking a job in a UK or international organisation you expect to be given a detailed job description and person specification, perhaps with associated KPIs.  With many smaller NGOs and faith based bodies the job description may be sketchy or even missing altogether.  There was a general idea of job aims but the applicant was expected to carve out the role for themselves.  Fluid reality can work as long as: firstly, the applicant appreciates this; secondly, there is a general idea of job aims; and thirdly, if the general idea of job aims does not work out there is general support for working out something with the new arrival.

However problems could and did arise when practical fluidity clashed with poverty perception.  A UK volunteer charity offered the Hospital a community health nurse.  A senior (UK volunteer) nurse was keen to ensure that the potential new volunteer came to the Hospital’s School of Nursing especially as she herself would be leaving soon after.  The Hospital was keen to use the new volunteer for public health work in the community too. However, the new Principal Tutor said very early on that she did not have enough work for the new volunteer nurse.  Opportunities in community health were examined in detail and several key people who had an interest were identified.  Modest money was found from UK.  But getting practical action rather than just promises of action proved virtually impossible.  The new volunteer ended up driving out to hillside villages on her own rather than in a multi-disciplinary team. In the end, with only small work in the School of Nursing and public health the new volunteer left prematurely. One wonders whether in reality the cries for help are louder than the real opportunities for help.  And the oft heard comment in this sector “it will take you a little while to work out what really needs doing” means no more than “this is a poor country, now you are here go and find something useful to do and chuck some of your own money into it if it needs some cash input”.


The Hospital group has a fairly well laid out salary structure with twelve grades.  Though it did not follow on from any Mercer or Hay style job evaluation it was a sensible and was recognised as such. However supplementary allowances had grown over the years to give overwhelming complexity.  Some of this was not documented, but resided in the memories of a small number of longer serving senior staff. Extra allowances had been created over the years for extra tasks or special initiatives – many of which remained long after the special initiative ceased or been mainstreamed.  This expectation of extra allowances flowed from private donor initiatives but also from the big players like USAID.  On first encounter this simply seems greedy but as basic salaries here were low it was an understandable response.  Nevertheless, it weakened the work ethic.

Should the salary scales have been drastically simplified and made transparent?  Yes indeed. But as elsewhere there will be winners and losers and the only way to prevent losers from facing hardship and industrial unrest is to chuck a lot of money at the problem.  Losers will not lose but winners will do very nice indeed.  the hospital did not have the money.  Therefore this Heath-Robinson system will have to creak on.

Sickness, Leave, Days-Off

The Hospital really was 24/7.  Even during the tragic times of Idi Amin and subsequent civil war it did not close.  The staff were allowed eight days off a month in lieu of weekends and thirty days annual leave a year.  Unlike in UK people will willingly work twenty days or more without a single day off and then took a long break.  Many staff had family and family farms at a distance and so used the longer breaks to go to them.  In itself this is a sensible response to quite different lifestyle constraints than in Europe.  A problem arises when you tried to get people to book well in advance their times off, to the convenience of their colleagues and the Hospital’s operations.  Staff were extraordinarily resistant to being pressured to collaborate with colleagues.  Some managers did not try to do this at all and in the subsequent free-for-all they too were free to take off time according to their own family needs. This then took priority over the Hospital’s operational needs.

Sick absences were not like UK either.  Many staff had chronic conditions (diabetes, ulcers, AIDS) or reoccurring conditions (e.g. malaria) and were more willing to attend work when unwell than we are, leading to a curious sort of presenteeism.  They would rather be at work with friends than lie lonely in their sick beds.

Training and Staff Development

Staff had a real interest in training and staff development for short training and longer accredited courses.  The reason for the interest was that recruitment was generally qualifications rather than experience driven.  Getting diplomas and degrees was the Royal-Road to bigger salaries here or elsewhere. Training however,  was and is expensive and staff cannot afford it by themselves.

A complex and professionally demanding institution like a multi-specialist hospital like ours had a huge need for on-going training.  The Hospital had no training budget but funding was available either from church based private philanthropists or from institutional aid agencies like DfID or USAID.  This was a real boon to the Hospital and subsequently to patient care.  There was no formal Training Needs Assessment though, as with many things, senior managers knew very well where the potential training crisis points were.  However, too much was dependent on “what does the donor want to give to”.  This could become acute where the donor knows the likely recipient and the distinction between institutional and personal gift becomes blurred.  Once I made a strong case that a training proposal to upgrade someone’s skills should only be considered if the Management agreed how that person’s position should be upgraded upon completion of the training.  But Management were unwilling to make a commitment for the future (upgrading the person’s post), yet was also unwilling to decline the financial offer at hand (upgrading the person’s skills).  Doing nothing indeed seemed sagacious to them. We did have cases of joined up thinking.  A church which gave big money had the foresight to fund not only a new theatre complex but also training for a new surgeon specialist.

Knowing Where You’re Going: Management Information

We had computers, a network, servers, satellite and internet to the outside world.  Staff IT skills were not strong but they were fairly widespread and improving.  Yet there was no HR-MIS.  The nearest thing was the payroll, a DIY Access based system which recorded name, grade, pay details and department.  We had no computer records for turnover statistics, no sick absence data, no dates of entry, contact details, nearest of kin, length of service, gender or age information.  I had produced grade and departmental staff numbers from downloads from the payroll system.  From paper records I calculate staff turnover at fewer than 10%, which seems high and shocking to senior staff here.  In fact this was not high by Ugandan standards.

In the past, so much HR work had been done on a highly personalised basis by senior staff acting as matriarchs or patriarchs.  Managers’ powers of recall are amazing.  Much that an MIS could provide they already have a good feel for.  But as the Hospital grew in size, what was manageable for 100 staff is no longer possible now we have more than 300.


So much needs to change.  Yet force feeding managers with a porridge of CIPD Guidelines or HR rules would be the lazy recommendation.  Best practice offered will be politely accepted and like the six year old JDs, will remain undisturbed on a shelf or fileserver after the deliverer had returned to Heathrow or Charles De Gaulle airports.  There has to be a desire to use the best of the Ugandan personalised approach, combined with a rigorous implementation of existing procedures.  That need not mean Westernisation, but would mean moving from a village enterprise mind-set to practices already to be found in the big businesses existing in Uganda.

Bill Lovett June 2010, small revisions June 2015

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s