The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe

BMC Health Services Research, Volume 13, No. 1, Year 2013

Interpretation

Background: A paradigm shift in global health policy on user fees has been evident in the last decade with a growing consensus that user fees undermine equitable access to essential health care in many low and middle income countries. Changes to fees have major implications for human resources for health (HRH), though the linkages are rarely explicitly examined. This study aimed to examine the inter-linkages in Zimbabwe in order to generate lessons for HRH and fee policies, with particular respect to reproductive, maternal and newborn health (RMNH). Methods. The study used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011. Results: The past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Human resources are constrained in managing current demand and any growth in demand by high external and internal migration, and low remuneration, amongst other factors. We find that nurses and midwives are evenly distributed across the country (at least in the public sector), though doctors are not. This means that for four provinces, there are not enough doctors to provide more complex care, and only three provinces could provide cover in the event of all deliveries taking place in facilities. Conclusions: This analysis suggests that there is a strong case for reducing the financial burden on clients of RMNH services and also a pressing need to improve the terms and conditions of key health staff. Numbers need to grow, and distribution is also a challenge, suggesting the need for differentiated policies in relation to rural areas, especially for doctors and specialists. The management of user fees should also be reviewed, particularly for non-Ministry facilities, which do not retain their revenues, and receive limited investment in return from the municipalities and district councils. Overall public investment in health needs to grow. © 2013 Chirwa et al.; licensee BioMed Central Ltd. The research is based on a mix of research methods which included secondary data and interviews with health officials. According to the Biomedical Research and Training Institute-Institutional Review Board, the study meets their criteria for exemption from ethical review. A thorough review of literature was undertaken on the themes of health financing policy, user fees, reproductive health and human resources for health in Zimbabwe. The literature review included searching peer-reviewed and grey literature in recognized electronic databases and websites. Sources for the literature included the Ministry of Health & Child Welfare (MoHCW), Department for International Development UK (DFID), United States Agency for International Development (USAID), World Health Organisation (WHO), health research institutions, mission umbrella organisations, the Centre for Disease Control (CDC) and professional associations. Key policy documents relating to user fees and HRH were also obtained and analysed. National data sets relating to staffing, staff remuneration and conditions, utilisation of services and other relevant indicators such as poverty and income levels were sought and analysed. Sources for these included the National Health Information System (NHIS), the database held by the Department of human resources (HR) in the MoHCW, and nationally published statistics produced by Zimbabwe National Statistics Agency (ZIMSTAT). Data from these sources were retrieved into an Excel spreadsheet, disaggregated to the lowest level permitted by the data. Key informant interviews (KII) were carried out with a selected number of experts and practitioners in Harare and one field site. The research district was selected because of its proximity to Harare and the fact that it contains a variety of communities, including mining and farming and new resettlement areas. A semi-structured questionnaire was drawn up for the KII. It covered the following topics: current policies on user fees; current policies on exemptions; plans to reform user fees; major constraints facing HRH; the interaction of fees and HRH; and any evidence on the impact of fees and the recent dollarisation on both users and staff. (Dollarisation was the shift from using the Zimbabwe dollar, whose value had collapsed due to hyper-inflation, to the US dollar as national currency in April 2009). The selection of the experts and practitioners was purposive. 13 individuals were interviewed – two at national level, with responsibility for human resources, and 11 at district level, in the district health office, the district hospital and health centres. Focus Group Discussions (FGDs) were held in three different types of area in the research district: 1. Low income urban area 2. Communal area 3. New resettlement farming/resettlement community The key target groups were users of RMNH services and service providers. We conducted five FGDs as follows: 1. Nurse trainees (based at the district hospital) (one group) 2. User groups consisting of women at the community level (identified through the Village Health Workers) (three groups – one per area) 3. One FGD with traditional birth attendants in a rural area The total number of participants was 43 (all female, with one exception). Topic guides were drawn up for the two groups. The topic guide for trainee nurse midwives asked about motivation for joining the profession; their views on user fees; and factors encouraging their retention and performance. The topic guide for the community level focussed on health seeking behaviour and views on quality of care; current payments for RMNH services and how affordable they are; and users’ views on fees. Quantitative data were collated and analysed using Excel. The WHO tool produced by the Making Pregnancy Safer (MPS) department was also used to project staffing needs and gaps. Qualitative data from the field were transcribed and analysed through categorisation of themes and content analysis. This was compared with findings from the literature review and policy analysis, as well as the secondary data, to reach overall conclusions and recommendations.

AI Digest

Study Justification:

– The study aims to examine the inter-linkages between user fees and human resources for health (HRH) in Zimbabwe, specifically in relation to reproductive, maternal, and newborn health (RMNH).
– The paradigm shift in global health policy on user fees in the last decade has highlighted the negative impact of fees on equitable access to essential healthcare in low and middle-income countries.
– The study seeks to generate lessons for HRH and fee policies in Zimbabwe by analyzing the implications of changes to fees on the financial burden for clients of RMNH services and the terms and conditions of key health staff.

Highlights:

– The burden of payments for RMNH services has shifted onto households in Zimbabwe, making it difficult for families to afford these services.
– Implementation of exemption rules for user fees is patchy and confused, leading to further financial challenges for clients.
– Human resources for health are constrained by factors such as high external and internal migration, low remuneration, and limited distribution of doctors in certain provinces.
– The study finds that there are not enough doctors in four provinces to provide more complex care, and only three provinces could provide cover for all deliveries taking place in facilities.
– The analysis suggests a strong case for reducing the financial burden on clients of RMNH services and improving the terms and conditions of key health staff.
– Differentiated policies are needed for rural areas, especially for doctors and specialists.
– The management of user fees should be reviewed, particularly for non-Ministry facilities, which do not retain their revenues and receive limited investment in return.
– Overall public investment in health needs to grow.

Recommendations:

– Reduce the financial burden on clients of RMNH services.
– Improve the terms and conditions of key health staff.
– Increase the number of health staff, particularly doctors, and address the distribution challenges.
– Review the management of user fees, especially for non-Ministry facilities.
– Increase public investment in health.

Key Role Players:

– Ministry of Health & Child Welfare (MoHCW)
– Department for International Development UK (DFID)
– United States Agency for International Development (USAID)
– World Health Organisation (WHO)
– Health research institutions
– Mission umbrella organizations
– Centre for Disease Control (CDC)
– Professional associations

Cost Items for Planning Recommendations:

– Staff recruitment and training
– Salary and benefits improvements for health staff
– Infrastructure development and maintenance
– Equipment and supplies procurement
– Implementation of exemption policies
– Public awareness campaigns
– Monitoring and evaluation systems
– Research and data collection

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a mix of research methods, including secondary data and interviews with health officials. The study also includes a thorough review of literature on relevant themes. However, the abstract does not provide specific details about the sample size or methodology used in the interviews and focus group discussions. To improve the strength of the evidence, the researchers could provide more information about the sample size, selection criteria, and data analysis methods used in the qualitative research. Additionally, including more specific details about the literature review process, such as the search terms used and inclusion/exclusion criteria, would further enhance the evidence.

Abstract

The research is based on a mix of research methods which included secondary data and interviews with health officials. According to the Biomedical Research and Training Institute-Institutional Review Board, the study meets their criteria for exemption from ethical review. A thorough review of literature was undertaken on the themes of health financing policy, user fees, reproductive health and human resources for health in Zimbabwe. The literature review included searching peer-reviewed and grey literature in recognized electronic databases and websites. Sources for the literature included the Ministry of Health & Child Welfare (MoHCW), Department for International Development UK (DFID), United States Agency for International Development (USAID), World Health Organisation (WHO), health research institutions, mission umbrella organisations, the Centre for Disease Control (CDC) and professional associations. Key policy documents relating to user fees and HRH were also obtained and analysed. National data sets relating to staffing, staff remuneration and conditions, utilisation of services and other relevant indicators such as poverty and income levels were sought and analysed. Sources for these included the National Health Information System (NHIS), the database held by the Department of human resources (HR) in the MoHCW, and nationally published statistics produced by Zimbabwe National Statistics Agency (ZIMSTAT). Data from these sources were retrieved into an Excel spreadsheet, disaggregated to the lowest level permitted by the data. Key informant interviews (KII) were carried out with a selected number of experts and practitioners in Harare and one field site. The research district was selected because of its proximity to Harare and the fact that it contains a variety of communities, including mining and farming and new resettlement areas. A semi-structured questionnaire was drawn up for the KII. It covered the following topics: current policies on user fees; current policies on exemptions; plans to reform user fees; major constraints facing HRH; the interaction of fees and HRH; and any evidence on the impact of fees and the recent dollarisation on both users and staff. (Dollarisation was the shift from using the Zimbabwe dollar, whose value had collapsed due to hyper-inflation, to the US dollar as national currency in April 2009). The selection of the experts and practitioners was purposive. 13 individuals were interviewed – two at national level, with responsibility for human resources, and 11 at district level, in the district health office, the district hospital and health centres. Focus Group Discussions (FGDs) were held in three different types of area in the research district: 1. Low income urban area 2. Communal area 3. New resettlement farming/resettlement community The key target groups were users of RMNH services and service providers. We conducted five FGDs as follows: 1. Nurse trainees (based at the district hospital) (one group) 2. User groups consisting of women at the community level (identified through the Village Health Workers) (three groups – one per area) 3. One FGD with traditional birth attendants in a rural area The total number of participants was 43 (all female, with one exception). Topic guides were drawn up for the two groups. The topic guide for trainee nurse midwives asked about motivation for joining the profession; their views on user fees; and factors encouraging their retention and performance. The topic guide for the community level focussed on health seeking behaviour and views on quality of care; current payments for RMNH services and how affordable they are; and users’ views on fees. Quantitative data were collated and analysed using Excel. The WHO tool produced by the Making Pregnancy Safer (MPS) department was also used to project staffing needs and gaps. Qualitative data from the field were transcribed and analysed through categorisation of themes and content analysis. This was compared with findings from the literature review and policy analysis, as well as the secondary data, to reach overall conclusions and recommendations.

Materials

N/A

Innovations

Based on the description provided, here are some potential innovations that could improve access to maternal health:

1. Financial Risk Protection: Develop innovative financial models or insurance schemes that provide financial protection for mothers and newborns, reducing the burden of out-of-pocket expenses for reproductive, maternal, and newborn health services.

2. Human Resources for Health (HRH) Policies: Implement policies to improve the terms and conditions of key health staff, such as nurses, midwives, and doctors, to address the constraints in managing current and future demand for maternal health services.

3. Distribution of Health Staff: Develop strategies to ensure an equitable distribution of health staff, especially doctors and specialists, across different provinces and rural areas, where access to maternal health services may be limited.

4. User Fee Management: Review and improve the management of user fees, particularly for non-Ministry facilities, to ensure that revenues are retained and reinvested in improving the quality and accessibility of maternal health services.

5. Public Investment in Health: Increase overall public investment in health to support the growth and improvement of maternal health services, including infrastructure, equipment, and training programs for health staff.

These innovations aim to address the financial barriers, human resource constraints, and distribution challenges identified in the study, ultimately improving access to maternal health services in Zimbabwe.

AI Innovations Description

The research study titled “The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe” highlights the need to improve access to maternal health by addressing the financial burden on clients and improving the terms and conditions of healthcare staff. The study used a mix of research methods including secondary data analysis, key informant interviews, and focus group discussions.

The study found that the burden of payments for reproductive, maternal, and newborn health (RMNH) services in Zimbabwe has shifted onto households, making it difficult for families to afford these services. Additionally, human resources for health (HRH) are constrained in managing the current demand and any growth in demand due to factors such as high migration rates and low remuneration. The distribution of healthcare staff, particularly doctors, is uneven across the country, posing challenges in providing complex care and ensuring coverage for all deliveries taking place in facilities.

Based on these findings, the study recommends several actions to improve access to maternal health:

1. Reduce the financial burden on clients of RMNH services: This can be achieved by implementing policies to reduce or eliminate user fees for these services, making them more affordable for families.

2. Improve the terms and conditions of healthcare staff: Addressing issues such as low remuneration and poor working conditions can help attract and retain skilled healthcare professionals, ensuring adequate staffing levels and quality care.

3. Develop differentiated policies for rural areas: Given the challenges in healthcare staff distribution in rural areas, it is important to develop targeted policies to address the specific needs of these regions, especially in terms of recruiting and retaining doctors and specialists.

4. Review the management of user fees: The study suggests reviewing the management of user fees, particularly for non-Ministry facilities, to ensure that revenues are retained and reinvested in improving healthcare services.

5. Increase public investment in health: Overall public investment in health needs to grow to support the improvement of maternal health services, including infrastructure, equipment, and training of healthcare staff.

These recommendations aim to address the financial barriers and human resource challenges that hinder access to maternal health services in Zimbabwe. By implementing these recommendations, it is expected that access to maternal health will be improved, leading to better health outcomes for mothers and newborns.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, a mixed-method approach could be used. This approach would involve both quantitative and qualitative data collection and analysis. Here is a brief description of the methodology:

1. Quantitative data collection:
– Collect data on the current financial burden on clients of reproductive, maternal, and newborn health (RMNH) services in Zimbabwe. This could include information on user fees, affordability, and household expenditure on healthcare.
– Collect data on the current terms and conditions of healthcare staff, including remuneration, working conditions, and job satisfaction.
– Collect data on the distribution of healthcare staff, particularly doctors, across different regions in Zimbabwe.
– Collect data on the current public investment in health, including infrastructure, equipment, and training of healthcare staff.

2. Qualitative data collection:
– Conduct key informant interviews with healthcare officials, policymakers, and stakeholders to gather insights on the current challenges and potential impact of the recommendations.
– Conduct focus group discussions with users of RMNH services to understand their perspectives on the financial burden and the quality of care.
– Conduct interviews with healthcare staff to gather their opinions on the current terms and conditions and the potential impact of improving these conditions.

3. Data analysis:
– Analyze the quantitative data to determine the extent of the financial burden on clients, the distribution of healthcare staff, and the current public investment in health.
– Analyze the qualitative data to identify common themes and patterns related to the financial burden, terms and conditions of healthcare staff, and the potential impact of the recommendations.

4. Simulation modeling:
– Use the quantitative data and findings from the qualitative analysis to develop a simulation model.
– The simulation model should incorporate the main recommendations, such as reducing or eliminating user fees, improving the terms and conditions of healthcare staff, developing differentiated policies for rural areas, reviewing the management of user fees, and increasing public investment in health.
– The model should simulate the potential impact of these recommendations on improving access to maternal health, taking into account factors such as affordability, availability of healthcare staff, and quality of care.

5. Scenario analysis:
– Conduct scenario analysis using the simulation model to explore different scenarios and their potential impact on improving access to maternal health.
– This could involve varying the implementation of the recommendations, such as different levels of user fee reduction or different strategies for improving the terms and conditions of healthcare staff.
– Analyze the results of the scenario analysis to identify the most effective strategies for improving access to maternal health.

By using this methodology, policymakers and stakeholders can gain insights into the potential impact of the main recommendations on improving access to maternal health in Zimbabwe. This information can inform decision-making and help prioritize interventions to address the financial barriers and human resource challenges in the healthcare system.

Author

Dima Health

Statistics:

Citations: 5

Identifiers:

DOI: 10.1186/1472-6963-13-197

Research Areas:

Community Interventions, Environmental, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Zimbabwe

Study Approach:

Mixed-methods, Qualitative, Quantitative, Systematic Review

Participants Gender:

Female