The human resource for health situation in Zambia: deficit and maldistribution

Using the "March 2008 payroll data base", that lists all public servants on the payroll of MoH and of NHS facilities, we analysed data on the distribution of health workers by category and post, province, type of health facility and health care level. Figures on the number of inhabitants were obtained from the Zambia 2000 "census of population and housing", and extrapolated using expected growth rates for each province. Population figures for district level were not available.

The results of this analysis are explained in light of the literature available, and of findings from in-depth interviews by three of the authors (PF, SS & FG) with key informants and personal observations carried out in the context of another parallel study (P Ferrinho, M Sidat, F Goma, G Dussault: Task-shifting - opinions and experiences of health workers in the Mozambican and Zambian National Health Services, submitted to Human Resour Health 2011).

The Zambian health sector has shown capacity for HRH innovation. Examples are initiatives such as upgrading the level of training (new degree courses launched or projected, e.g. BSc Nursing), facilitating direct access to diploma level specialist training (e.g. clinical officer, psychiatry, midwifery and mental health nursing), creating new cadres to formalize task delegation from higher level cadres (e.g. dispensers, counsellors and licenciates), informal task shifting (in early 2001, the Zambian law was amended to authorize nurses to prescribe and to insert drips [11]). There were efforts to identify tasks required to meet needs and to adapt training programs to include them; an example is that of training clinical care specialists, who are physicians who receive further training to assume clinical management functions and to provide hands-on supervision to front line workers (Director HRH Administration, MoH, personal communication, May 2008). However some of the new occupations are not recognised by professional councils, e.g. dressers, care givers, psychosocial counsellors, dispensers, medical technologists. Direct entry to advanced training reduces the back-to-school attrition associated with the loss of personnel who leave their post to train and often do not return to the public sector [4].

Although Zambia trains generalist cadres with internationally recognized degrees (e.g. doctors and registered nurses), other cadres are only recognized locally or regionally (e.g. Zambia enrolled nurses, clinical officers, clinical licentiates). An example of the policy of training cadres only recognized locally or regionally is that of clinical licenciates. In 2002, the MoH initiated a two-year programme of retraining clinical officers with three years of experience or more, to the level of clinical licentiates, capacitating them with surgical and obstetric skills, and more advanced skills in paediatrics and internal medicine. This training prepares them for operating autonomously in rural hospitals or in large health centres where there are no doctors. They spend six months at the Faculty, do clinical training for 20 months, and then return for 1 month to write exams. After completion, they serve a 1 year internship. These locally recognised cadres are either substitutes or assistants to other cadres; there is a long tradition of these in Zambia that predates independence (Head, Department of Community Medicine, personal communication May 2008). They are a sort of insurance against the loss of medical skills to emigration. The same reasoning applies to two categories of nurses: Registered professional nurses, internationally recognised, have higher emigration rates than enrolled nurses, who are only locally recognized [12].

In spite of these innovations, there is a shortage of skilled nurses who assume roles not only as providers of nursing care, but also as substitute to other health workers. This creates tensions which do not always help to achieve the best mix of nursing cadres and leads to misunderstandings that lead to the failure and lack of continuity of many training initiatives, such as the two year training of Zambia enrolled nurses or the six month training of nurse assistants, which were proposed by the MoH but opposed by the Union (President of Zambian Union of Nursing, personal communication May 2008).

The emigration of physicians and nurses is part of the general emigration of qualified workers, which in the early 2000's was estimated at 10% of qualified workers in Zambia, 16% in Tanzania, 26% in Angola, 36% in Madagascar, 42% in Mozambique, and 48% in Mauritius. For nurses, the rate was 9.2% in Zambia, 12% in Angola, 17% in Malawi, 19% in Mozambique 24% in Zimbabwe, 28%% in Madagascar, and 63% in Mauritius. It is for physicians that the rate of emigration is particularly high: 57% in Zambia's, surpassed only by Malawi (59%), Angola (71%) and Mozambique (75%) [13].

The driving forces for migration to other countries and exit of the public sector are many: low remuneration, poor working conditions, absence of career development mechanisms, civil strife and political instability, fear to contract diseases such as HIV/AIDS and policies that encourage labour export like in the Philippines [14]. Some of these factors are present in Zambia, and may explain why out of 1,200 doctors trained in Zambia since the late 1960s, only 391 are still practicing in the Zambian public sector, a decrease that cannot be explained by normal attrition resulting from retirement or death [15]. A 2006 survey of 50 health staff in Lusaka province identified different reasons for potential migration. Low salaries are an important factor driving nurses and clinical officers to look for better paying jobs outside the public sector. Salary had less importance for doctors than inadequate diagnostic equipment and supplies. Work overload and long working hours due to shortage of health staff were also identified as push factors [15].

Emigration of health workers from Zambia is partly financed by Zambia's policy of offering Voluntary Separation Packages: these are early retirement lump sum payments promoted by the government, which are used towards migration costs [12].

Working conditions are important for motivating health workers to be productive and to meet quality standards. Huddart et al [11] reported survey results showing that 100% of doctors, 80% of nurses and 92% of clinical officers wanted improvements in the cleanliness and maintenance of public health facilities. All categories of staff identified poor management of human resources as a contributory factor to issues of leave, accommodation and communication not being appropriately dealt with. This probably contributes to the high attrition rates of health personnel observed in the Zambian health sector.

This situation can be changed without significant costs as staff in the Zambian public health sector respond positively to performance-based awards [16]. Staff motivation improves substantially with even small gestures of support and encouragement from district supervisors. For example, non-financial awards are as motivating, if not more, than financial awards and do not generate as much conflict, suspicion, or frustration. Staff also feels encouraged by knowing that their performance is monitored and that this served to target support responding to their actual needs. District managers suggest that a performance-based award program, linked to the district performance management system, helps to guide them in their work, provides direction for supervisory visits and assists in monitoring health facility and district performance [16]. Many health workers generate complementary income by other activities; this is more common in urban than in rural settings (32% and 9% of staff respectively) [17]. Besides the amount of income, other considerations are important, namely the issue of regularity of payment. In the Zambian public sector up to 15% of staff do not always receive their salary and 80% complained of late payments; and 10% of staff had to pay a so-called expediter fee to obtain their salaries [17].

Attrition rates are also an important cause of health workforce imbalances [4]. In 2003, physicians had the highest attrition rate (9.8%) followed by nurses (5.3%), pharmacists (4.6%) and laboratory technicians (3.5%) [2]; there are differences in urban and rural attrition rates, leading to net losses of staff in rural areas (Eastern, Luapula, Northern, and Western provinces) and net staff gains in the most urbanized areas (Copperbelt and Lusaka provinces) [17]. Reasons for health personnel attrition include death (38%), resignation (32%), dismissal (12%), retirement (10%) or end of contract (8%) [5]. Feeley et al (2004) [18] estimated the cost to the public healthcare system of personnel losses due to HIV/AIDS. If transfers to other public sector institutions are excluded, the annual loss of health professionals at the sites studied was 217 out of 2,333 filled positions, an annual attrition rate of 9%. Excluding transfers, losses accounted for 21% of physician vacancies, 14% of clinical officer vacancies and 16% of nurse vacancies. In the 12 months ending in October 2003, deaths represented a significant proportion of all terminations (over 20%); death rates were 0.4% for doctors, 2.8% for clinical officers and 3.5% for nurses working at the study sites. For doctors, mortality is not the main reason for attrition, nor the most important factor contributing for the high vacancy rates. But for clinical officers and nurses, death is the single largest reason for loss. The average age at death for all health professionals was 37.7 years. The graduation of clinical officers would have to increase 80% and of nurses 50% to offset observed mortality. In the final year of employment, those who were absent because of illness recorded an average of 28 additional days of leave. Costs associated with this additional leave, plus death or retirement related payments averaged $4,056 for a doctor, $2,678 for a clinical officer and $3,674 for a nurse. In the short to medium term, the reduction of attrition and vacancies must take into account the effective treatment of AIDS, which is an important cause of absenteeism, burnout, illness and death [19‐22].

Over the years, there has been a steady growth of the private healthcare sector, resulting into various forms of private-public partnerships, which include the sharing of medical equipment and technologies, referral of patients, human resources and facilities.

Right-sizing of the public sector facilities and the gradual increase of "for-profit" and "not-for-profit" private health service providers presents significant policy implications in terms of their involvement in the delivery of public health services. The private sector is a major source of drain of health workers from the public sector, particularly of laboratory personnel, pharmacists and doctors (Director HRH Administration, MoH, personal communication, May2008). Private salaries are more than double government ones for physicians, triple for laboratory technicians, and one third higher for midwives. NGOs are paying between 23% and 46% more than the government [23].

With the exception of the Churches Health Association of Zambia (CHAZ), other private sector participation in health service delivery in Zambia has been modest. CHAZ is an umbrella Christian NGO that supports 135 member institutions (hospitals, rural health centres, and community-based initiatives). It complements government efforts in the delivery of health care. A memorandum of understanding states that the MoH is mandated to provide CHAZ with trained HRH, and to pay their salary. The MoH deploys the staff, through the provincial health authorities. Issues of planning and performance assessments are dealt with the District Health Offices. The MoH also provides operational funds according to the number of beds. CHAZ provides infrastructure (according to the prototypes defined by the Government), complements Government efforts in logistics, provides expatriate HRH, and assumes the management of operations according to Government standards (Director HRH, CHAZ, personal communication, May.2008)