Uganda Nurses and Midwives Council at 100

Associate Prof.Rose Nanyonga Clarke Vice Chancellor, Clarke Internati onal University

In November this year, I was invited to deliver a talk at the Uganda Nurses and Midwives Council’s (UNMC) 100-year anniversary about the past, present, and future education of NM and implications for regulation. This was a monumental event, and as such, it was only fitting that we adopt a bidirectional lens: reflecting on the journey thus far—noting candidly its highs and lows—while looking to the future with hope, clarity, and purpose.

A little History: There is no doubt that NM education, regulation and practice in Uganda have progressed at a steady pace since 1922. Our journey has not been so different from other countries in that the core of NM (from the outset) was (and to many still is) considered a calling. From this perspective, the educational preparation was kept to basic vocational training to enable basic skills for ensuring patient comfort (food, service, bathing and toileting, laundry etc.) (Bvumbwe & Mtshali 2018). In the early 1900s, many countries progressed NM learning to college-based education which was supported by new standards and policies. Education institutions and NM scholars focused on curricular that resulted in the mastering of skills and competencies.

It has been 10 years since the Geneva Declaration adopted at the SIDIEF General Assembly encouraged countries to adopt the undergraduate program as the entry requirement for the nursing profession. Relatedly, the Plan for Action for scaling up nursing and midwifery education and practice for the African Region 2012-2022 also provided a framework for the World Health Organization (WHO) member states to ensure quality nursing and midwifery education and training. Perhaps it’s time to plan for the workforce with these key recommendations in mind.

Significant escalation of regulation and standards of care have further driven reforms in education, regulation and practice in the 21st century.

In our context, the UNMC, recognizing that regulation is a key enabler of growth in the NM profession, has strived to keep pace with changes in the health sector that directly impact the education, training, roles, scope, and overall standards for NM practice.

The initial Nurses, Midwives and Nursing Assistant Act was established in 1964. In 1996, the Act was revised to allow diversification of cadres (ULII, 1996). This critical update was subsequently followed with some reforms in the education and training of NM.

However, it still took Uganda over 71 1922-1993) years to introduce baccalaureate degrees in nursing. The present: Uganda currently sits at a cusp of opportunities and challenges in education, practice, and regulation. The country’s workforce (101,068 per UNMC data; includes 27,112 with expired licenses) is tipped to one end with the majority (70%) of NM at the Enrolled Nursing/Midwifery Certificate level, with a moderate number at diploma level (nearly 25%), and even fewer NM with baccalaureate degrees (2.3% BNS and 2.1 Bachelor of Science in Midwifery) (UNMC, 2022). Thus, while diversification in cadres has occurred, the new categories unearth complexities in defining practice standards and the scope of practice for each level. It does also raise concerns about whether the current portfolio of the workforce is what the country needs for a rapidly changing and complex health sector.

Looking to the Future: As we look to the next 10, 20 or 100 years, key questions that the UNMC and other relevant stakeholders must grapple with in terms of the overall improvement of the portfolio of the nursing and midwifery workforce include:

1. What is the future of healthcare in Uganda?

2. What are the critical health needs of our communities?

3. How do we position nurses and midwives (and other healthcare providers) to meet the health needs of the country?

4. What kind of Nurse/Midwife should we have now and in the future?

5. What level of training?

6. And how do we align our regulatory tools to match these aspirations?

NM operate in an increasingly complex work environment with multiple competing priorities. Answering these questions will inform the next strategic undertaking in aligning vocational and professional cadres and defining specific needs for education and training, regulation, and practice. And it will enable education institutions to tailor NM curricular to current and future demands placed on nurses and midwives so that the country consistently produces a workforce fit for purpose.

Key Domains of Competencies for current and future NM include but are not limited to

1. Quality and Safety: We mvust have a nurse/midwife who can drive the cost of care down while driving the safety and quality of care up.

2. Knowledge Development: We need a nurse/ midwife who is not just a consumer of knowledge for evidence-based practi ce; but can engage meaningfully in developing and disseminati ng nursing/midwifery knowledge and science through research and innovati on.

3. ICT in Health: We must have a nurse who is not averse to the uti lizati on and integrati on of informati on technology in the care/management of pati ents and preventi on of disease—but one who will run to it and readily embrace it.

4. Healthcare Reforms: We need a nurse/midwife who can lead the next generation of healthcare reforms

5. Business of Healthcare: Key factors driving healthcare reforms in Uganda include healthcare disparities, demographic shifts, dual burden of disease, resource scarcity and unsustainable costs of care, access issues, suboptimal outcomes, improvement in quality of care, fee-for-service systems, insurance-driven health systems etc. To be a major player in shaping healthcare reforms, we need a NM who understands the business of healthcare

6. Accountable: We need a nurse/midwife who is accountable for their own actions, while working autonomously, and as an equal partner within interdisciplinary teams

7. Visionary/Strategi Leader: We need a nurse/midwife who is strategic; can envision the future including understanding challenging environments, the burden of disease including NCDs, different modes of care, shifting demographics, innovation, rapidly evolving demographics etc.

8. Cultures of Health: We need a nurse/midwife who can lead the primary healthcare agenda and who is engaged in building a culture of health and developing effective nursing practices for eliminating gaps and disparities in health care.

9. Compassionate: And we need them to do all these things while remaining compassionate, evidence-based and person-centred.

10. Wellness: Above all we need a nurse/midwife whose well-being to execute these duties is highly prioritized in government budgets year after year for the next century (NAM, 2021)

In Sum: Nurses and midwives constitute the largest health workforce. From a business perspective, this strength also translates into the largest expenditure an issue that continues to plague the capacity of the profession to garner necessary investment and funding. This subsequently has an impact on the capacity to rigorously pursue the production of an efficient workforce with relevant competencies—a critical role of not just the nursing and midwifery education sector, but also the regulator (Bvumbwe & Mtshali, 2018).

Of note, it is important to rapidly address intractable challenges that continue to stand in the way of pragmatic strategies for advancing the nursing and midwifery agenda:

• To build on what the country has achieved so far and to drive future transformation, there is need to bolster strategic leadership at all levels.

• Transitioning from vocationally trained nurses and midwives (who are the majority) to basic and higher degrees requires innovative curricula, education investment and funding, and enabling regulation—these are critical ingredients. Past-century experiences of underinvestment in these groups of professionals will not yield the type of NM the country seeks to have.

• Documented critical shortages of regulatory staff need urgent attention

• There is need to address the continuing inadequate productive capacity of NM training institutions—including critical shortages of learning resources and investing in faculty development for nursing and midwifery education, training, and research (Mitchell et al., 2014).

• Nurses and midwives are part of the human capital development agenda for Uganda. A key group for achieving Universal Healthcare Coverage. If the country wants better, highly qualified (both in quantity and quality), efficient nurses and midwives, they must be empowered to practice to the full extent of their training. It is all going to take coordination, collaboration, and support. And I hope that as we reflect in this centennial, we can all make some commitments and engage in the required heavy lifting.

References

UNMC (2022). UNMC 100 years anniversary. November 2022. Centenary Magazine

Uganda Legal Information Institute (1996). Nurses and Midwives Act 1996. Accessed at https://old.ulii.org/ug/legislation/consolidated-act/274 Bvumbwe, T., & Mtshali, N. (2018). Nursing education challenges and solutions in Sub Saharan Africa: an integrative review. BMC nursing, 17(1), 1-11. Mitchell, A., Zuber, A., Quain, E., Hall, C. M., Foradori, L., & Lim, C. K. (2014). Building capacity of training institutions and Ministries of Health in sub-Saharan Africa: The PEPFAR approach. Annals of Global Health, 80(3).