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

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.

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• Dima Health