Research for stronger health systems during and after crisis

Zimbabwe

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ReBUILD's core research in Zimbabwe is being carried out by the Biomedical Research and Training Institute in Harare.

The team is working towards supporting the priorities of the country’s health system managers which include tackling the shortage of human resources, evolution and effects of health financing policy (changing rimes of user fees) on access to health for poor households and supporting primary health programmes. One of the main challenges facing the health system is diminished fiscal capacity to finance all key dimensions of health service delivery, drugs, sundries, equipment, infrastructure and human resources for health.

The latest available data shows that in the mid-1990s vacancies for doctors and nurses were 60% and 45% respectively. The number of registered doctors in the country declined from about 1600 to about 800 in the intervening period. However, with the dollarization of the economy, many health workers have returned to the workplace. Task shifting towards nursing aides during the crisis years has declined as health worker supply improved as a result of new incentive policies and dollarization induced economic stability, in the post crisis period. A net improvement in conditions and terms has been realised in the post crisis period evident in decreased vacancy rates for Environmental Health Practitioners, nurses and midwives. However the vacancies for Medical Officers are still below the expected levels because of persisting poor terms and conditions.

 

In Zimbabwe there is strong support for the development of evidence-based strategies in health service delivery from both the Ministry of Health & Child Care (Technical Working Groups on health e.g. UHC, HRH), University of Zimbabwe College of Health Sciences, development partners and non-state providers of health services. We are committed to producing research that is useful to policy makers and will work closely with them to help facilitate the translation of research into policy and practice. Zimbabwe is well positioned to seize opportunities to establish effective new systems through sustained engagement with policy makers and key stakeholders. The ReBUILD research process embeds a Research Uptake and Communication plan in all three research projects being conducted in Zimbabwe.

Understanding changes in health financing policy and poor households’ expenditure on health

The Zimbabwe government’s commitment to pursue equity initiatives to address the existing inequalities was shaken by the political and economic crisis that the country experienced since the 1990s. Budget allocations to the health sector and public health care expenditure per person declined. Our research uncovers the impact of reforms (changes in user fees charging regimes) in health financing policy such as the fee exemption for the poorest households, the effects of the coping strategies of service providers on patients’ access to healthcare before and after dollarization. Our focus was on assessing how the user fees charging practices related to the poor households and their gendered effects. User fees were introduced place in the 1990s but exemption was almost universal and they were withdrawn. However, the emergency situation has resulted in the re-establishment of user fees in the health sector with unknown implications for health service access.

Exploring the development and effects of health worker policies on incentives and rural posting.

The shortage of health workers in the rural areas is a key concern for all stakeholders who are focussed on building the health system. Not enough is known about the living and working conditions of staff in rural localities or how we could make postings in rural areas more attractive. ReBUILD research, through the health workers’ incentives study is making important contributions through providing information on health worker terms and conditions in different sectors (government, municipal, Faith Based Organisations (FBOs), rural district council). The urban-rural differentials with respect to incentives as espoused in new policies were interrogated and yielded evidence that will help strengthen health worker incentive policies as well as informing the formulation of sustainable remuneration mechanisms to attract and retain health workers especially in underserved rural areas. This links up with another study which analysed existing posting and deployment policies for health workers in the public sector and a large FBO health services provider. The two studies’ objectives were to better understand how to create incentive environments for health workers to support access to rational and equitable health services and to identify ways to improve deployment systems to rural areas used by large employers (public and FBOs) of health personnel in Zimbabwe.

The latest available data shows that in the mid 1990s vacancies for doctors and nurses were 60% and 45% respectively. The number of registered doctors in the country declined from about 1600 to about 800 in the intervening period. However, with the dollarization of the economy, many health workers have returned to the workplace. Task shifting towards Nursing Aides is ongoing and a new cadre trained for example in microscopy is planned for rural areas.

Informal charging is not a documented problem in Zimbabwe but dual practice was an important economic strategy for public health workers during the crisis. User fees were in place in the 1990s but exemption was almost universal and they were withdrawn. However, the emergency situation has resulted in the re-establishment of user fees in some hospitals with unknown implications for health service access.

In Zimbabwe there is strong support for the development of evidence-based strategies in health service delivery from both the Ministry of Health & Child Welfare and from University of Zimbabwe College of Health Sciences. We are committed to producing research that is useful to policy makers and will work closely with them to help facilitate the translation of research into policy and practice. Zimbabwe is well positioned to seize opportunities to establish effective new systems and the current progress in task shifting including the training of a new cadre of health workers may reflect this.

Understanding changes in health financing policy and poor households’ expenditure on health

Our research will uncover the impact of reforms in health financing policy such as the fee exception for the poorest and for TB patients, the effect of user fees in hospitals and dollarization. Our focus will be on assessing how these policy changes relate to the poor households and their gendered effects. In 2010 the Biomedical Research and Training Institute conducted a household health expenditure survey which will enable a disaggregated analysis of the overall health related financial burden and its implications for rural and urban women, boys, girls and poor households. Future research will build on this analysis.

Exploring the development of health worker policy

The shortage of health workers in the rural areas is a key concern for all stakeholders who are focussed on building the health system. Not enough is known about the living and working conditions of staff in rural localities or how we could make these postings more attractive. ReBUILD research will look into this as well as the effect of new policies, the make-up of parallel health markets and the role of the non-state sector. Our objective is to better understand how to create incentive environments for health workers to support access to rational and equitable health services.