Participants
Eleven face-to-face semi-structured interviews were conducted with eleven health workers categorised in Table 1.
Male participants were disproportionately more than females. The imbalance in gender distribution is a reflection of more male involvement in positions of responsibility in the Ugandan health care delivery system, particularly in remote rural areas [29]. Medical officers and senior medical officers constituted almost half of interviewees. Within the Ugandan health care system, medical officers, senior medical clinical officers, medical clinical officers, nursing officers and laboratory assistants are stationed at Health Centre IV while nursing assistants, health assistants and enrolled nurses may work at both Health Centre IV or III. In this study, 5 of 11 participants were stationed at HC III. Participants at HC V were not included in this study as district hospitals did not qualify as remote rural health facilities.
ICT utilization by health workers
Eight out of the eleven participants indicated that they sometimes used computers. Of the eight health workers, six health professionals reported being able to use basic internet applications. Many interviewees were able to describe conditions of ICT use by health care providers in the health centres, describing conditions of ICT usage as characterised by little knowledge; some participants reported that they had never used computers and many could not confidently operate computers because of lack of knowledge and skills to do so. The basic knowledge they reported was applied to computer knowledge, especially in Microsoft Word application. Difficulties in using ICT by health workers became clear when all health workers and other government employees were obliged to acquire individual Tax Identification Number (TIN). A health worker in one district narrated what many of them faced due to inadequate computer knowledge.
“We had challenges when government this year 2014 tasked every employee to get Tax Identification Number (TIN). We had to pay about 10,000 – 20,000 Uganda Shillings to people who are computer and internet literate to create for us e-mails and fill in the online Uganda Revenue Authority (URA) forms.”
Despite reporting low confidence, knowledge and skills in the use ICTs, many of the interviewees had positive perceptions of the benefits of ICT in supporting health services. When asked about their understanding of the benefits of ICT in health service delivery, interviewees were able to list the following: ICT can help in monitoring surgical operations, accessing knowledge of disease management and drug management, and managing medical records and other medical documents. Participants further reported that keeping data is made easy, tracking information is simplified and access to variety of news, and disease and treatment information through internet is possible with ICTs. Study done by Olok et al [30] in hospitals in northern Uganda indicated that ICT could offer benefits in the delivery of health services. A senior health worker in one district highlighted some of the unique benefits of ICTs as below:
“I strongly believe that ICT will improve reading culture for the health workers which will improve the quality of health services in rural post-war and post-conflict northern Uganda. Further, ICTs can support learning in the health centre coupled with supporting data work. I am very sure also that internet acts as a source of reference materials which bring creativity among health staff.”
Generally, health workers in rural post-war and post-conflict northern Uganda exhibited low confidence, knowledge and skills in the use of ICTs. However, health workers have positive perceptions of the benefits of ICT in health service delivery. Regarding the ICT related challenges they faced in ICT use, interviewees were quick to recommend training in ICT and internet skills for all the health workers in rural health centres in northern Uganda to prepare them for any ICT interventions, which may come from government and other health development partners.
Improving health workers retention through ICT
Information and communication technologies were perceived by interviewees to improve retention in rural health centres in post-war conflict northern Uganda. A senior health worker in one district said: “ICT is a big boost to health workers motivation”. One health Assistant in another district said: “ICT will help motivate many of us to stay at the health centre because ICT, especially internet, makes a global home”. Since ICT is a resource that can aid the work of health workers, it can be viewed as one factor that influences them to continue working in rural health centres. A senior health worker in a district had the following to say:
“ICT will keep health workers busy; lack of ICT is the reason we leave the rural areas and move to urban so that socially, we are not disconnected. ICT will keep us together in the profession. Further, ICT brings to us health information resources such as e-books for one to update knowledge, support doctors in self learning and distance learning…we are being kept backward because we always get information last. I am very confident ICT will improve research in medicine at all levels of staffing at the rural health centres in northern Uganda.”
A Health Assistant in a district explained how ICT would help him stay and work in a rural health facility:
“I know there is little knowledge about ICTs but I also know that we can use it for entertainment, e-mails, e-learning and linking to other doctors around the country; browse treatments and manuals from other health facilities and medical universities around the world…we will be able to enrol for health management course, which is now a necessity for all health workers in Uganda.”
It appears clear that ICT introduction at rural health facilities might boost the retention of health workers in rural post-war conflict northern Uganda. Thus on the contribution of ICT to health care provider retention in northern Uganda, a senior health worker in a district said:
“I am certain computers and internet can motivate doctors to stay at one place because they will be sure to get information, leisure, entertainment and so on…staff mobility can reduce, I think by up to 60% … our stay will become easier and simpler especially when patients are not around; and also treatment of some sicknesses can be aided by access to the Internet. When computers and internet are available on site, then there will be no unnecessary movement because we will be in a global interconnected village through ICT.”
One health centre actually had tried an innovative way to keep their staff at the health facility through the use of television. A senior health worker in the health facility concerned explained how she tried the use of digital satellite television (Dstv) to keep staff at the health centre and had this to say:
“For me, ICT is a very viable way for staff retention. Here, almost all the weekend health staff travel to town leaving only those on call at the centre. As a trial, I decided to install Dstv at the centre, which has helped me to keep almost all staff at the health centre. I expect availability of computers and internet to even do much better on staff retention than my Dstv.”
Barriers to the implementation of ICT in rural health centres
Though ICT appears to contribute to the retention of health care providers in rural areas, many challenges might slow down it use, such as inadequate ICT knowledge and skills of health workers; poor internet connectivity; inadequate computers; inadequate electricity supply; lack of internet Modems; expensive access to outside computer centres; inadequate space for ICT; lack of ICT policy and inadequate ICT officers. For example a health worker in one district had this to say:
“Many of our staff can not confidently operate computers and they lack information, knowledge and skills to do so…the staff cannot also use computer applications and they need training.”
For internet access for example, health workers had to travel long distances to look for places with strong internet connectivity. A senior medical officer narrated this on poor internet network:
“Internet is not available at the health centre and not even at the trading centre. I think we truly have problems going to the district headquarter to look for internet. Whenever we go to the town about 47 km from the health centre, we travel together with medical students to access internet in town. The frequency of our travels is every after two days”. It is very difficult to predict how long this method can keep us going. All network services around are very poor although we have some kind of access to MTN and Airtel networks.”
Similar views were shared by a health worker in one of the remotest districts in northern Uganda.
“I think there is really urgent need to install ICT in this health centre. Imagine we are forced to travel 49 km to town just to do photocopying. Access to ICT facilities is very poor in this district in general and the only option now is to go to a town in a neighbouring district.”
Some health centres visited have computers, though inadequate and some in poor working conditions. Five health centres out of the 11 visited had no computers. A health worker in a district had this to say:
“For Health workers in this health centre, I do not think if any of us has ever used computers and internet. We have no computers here and health workers are not at all exposed to computer usage. We know the benefits of ICT but we can only turn these benefits to health services when computers are available and all of us know how to operate it. I can tell you that there is only one place here at a sub-county office where people access computer and internet services, but the ICT facility is not reliable and it is not accessible to all health workers.”
Inadequate electricity supply also presents challenges to ICT implementation, as most rural areas in northern Uganda are not electrified. After the armed conflict in northern Uganda, many health centres received solar system as the main power supply. A senior health worker in a district explained:
“The main source of power supply at health centres after the war was solar. We are still continuing to use solar but many of the batteries have expired. The government main grid you see here is not yet functioning but electricity service poles are being installed. Some solar systems which we have are broken down. We currently run a generator which is again very expensive to sustain because of the expensive fuel.”
Apart from the challenges that impede the availability and use of ICT facilities, the theft of existing infrastructures apparently affects rural health facilities in northern Uganda. A health worker said:
“This health centre had four new computers but unfortunately two were stolen before the gate was constructed. I can tell you that there is rampant stealing of computers from health centres. Just two week ago, one computer was reported stolen from a nearby health centre.”