Understanding health worker incentives in post-crisis settings – a document review of Zimbabwe

Authors: Yotamu Chirwa, Wilson Mashange, Pamela Chandiwana, Stephen Buzuzi, Shungu Munyati, Brian Chandiwana and Sophie Witter

Introduction

Zimbabwe’s health sector is weighed down by a host of challenges caused by a decade of economic, social and political crisis. Ensuring the availability of human resources for health (HRH) in the aftermath of such a severe socio-economic crisis is a complex process. This document review examines HRH policies formulated from 1997 to date. It discusses the reasons why the policies were introduced, how they have been implemented and the effects of the policy changes prior to the crisis, during the crisis and in the post-crisis period. The document and literature review contributes to a wider study that aims to understand incentive environments for HRH post-crisis and their effects on health worker distribution. It will hopefully contribute to better decision-making for health workforce policies in post-conflict and post-crisis settings.

Research methods

Documents from the government of Zimbabwe, Ministry of Health and Child Welfare/Health Services Board and international development partners (e.g. WHO, DFID, USAID, UNICEF) were reviewed. Documents were acquired from the websites of these organisations or directly from their offices when the required documents could not be accessed online. WHO statistical databases e.g. the Global Health Observatory data repository, were also reviewed. A number of bibliographic databases were searched using HINARI, Google e-books and Google Scholar to identify academic resources on HRH in Zimbabwe. Online resources for international organisations were searched and grey literature and relevant references in sourced literature were checked. Research publications and discussion papers were also reviewed. The initial search terms were human resources for health, HRH attraction, retention, equitable distribution and HRH performance management combined with Zimbabwe. The web search was widened to include maldistribution of HRH, brain drain in the health services sector, economic crises, and health systems. In total, we identified 76 documents to include in the study.

Findings

The documents acknowledged that there was an HRH crisis in Zimbabwe from pre- independence. When independence was gained, the crisis worsened as a result of the equity in health policy, which saw rapid expansion of health services to previously neglected rural areas. The documents reviewed show that a progressive deterioration in the situation of HRH was apparent right up to the late 1990s, the period agreed to be the beginning of the intensification of the economic meltdown. In 1999 the presidential review commission into the health sector pointed out that there was a need to review health sector management through the establishment of a commission separate from the public service commission. However, the recommendations of the commission were not implemented with urgency, resulting in deterioration of the entire health system.

Most policies related to HRH attraction, retention and remuneration introduced in the early years of the crisis suffered from poor funding and lack of support from other government ministries. Literature and reports of the HSB indicate that the Ministry of Finance and the Ministry of Public.

Service inhibited progress towards improving conditions of the health workforce, citing public service regulations and lack of financial resources as their reasoning. It was argued that singling out the health service might create problems for the government. Hence there were policy inconsistencies related to this, exemplified by the increases in allowances and reversals of these increases after short periods of implementation.

Recruitment and retention became a challenge as attrition of health workers grew. Vacancies for senior staff amassed in the public sector, as experienced staff in underserved areas would be moved to fill in the vacant posts in large, mostly urban facilities, leaving underserved areas with unfilled posts. Generally this trend has continued in the post-crisis period, leaving the public, mission and rural district council facilities with less experienced and motivated cadres. The performance management system introduced to reward health workers did not improve matters as it was poorly implemented. It was abandoned and another system, the Results Based Management, was introduced in 2005. This system was rolled out slowly and seems to be suffering from the same challenges faced by its predecessor. In general, the document review indicates that as recruitment became difficult, the remaining health workers had to contend with heavy workloads that worsened the level of motivation and spurred resignations. Information on private practice was limited, but available works indicate that many doctors engage in private practice well beyond the permitted levels. HRH challenges mean it is impossible to enforce the regulations as this would drive away the few doctors coming as senior consultants to public sector facilities. Training is a very important aspect of retention but literature indicates that corruption has set in, in the mediation of training opportunities and access to manpower development funds. There is a general feeling that medical doctors are favoured more by the existing training and promotion policies.

The effects of the policies have been varied with most pre-crisis and crisis policies having had no impact because of lack of wide consultation, poor funding and lack of monitoring and evaluation. The policies on retention, including the introduction of allowances and improvement of existing allowances, had differential effects. In the short term, increases raised the levels motivation but because the policies were not funded well, the long term effects were negative.

Conclusions

Attracting and retaining HRH continues to pose serious challenges to the health sector in post-crisis Zimbabwe. Numerous policies formulated since 1997, when the crisis began to manifest, through the crisis and up to the post-crisis period have had limited impact on the HRH challenges. Poor funding of policies is cited as a key cause of policy failure during and after the crisis. Some of the literature asserts that the migration of health workers with managerial skills made it difficult to implement policies that would have helped retain health workers, e.g. performance appraisals. Evaluation and monitoring of previous policies has not been a priority. New policies have been crafted because the previous ones needed to be replaced. However, where evaluations have been done, the findings of the evaluation seem not to have been referred to in the next policy. Rivalries between different ministries led to the failure of HRH policies, through arguments against initiatives to make HRH conditions better. The most important outcome from this document review is that remuneration stands out as the single most important factor influencing health worker behaviour. The attrition of HRH in Zimbabwe is a complex problem that requires the formulation of strong policies, sustainable funding and greater intersectoral coordination in the implementation of policies.

Lessons learnt

• Training opportunities have become a demotivating factor because of the perception that selection is not based on merit.
• Successful implementation of reforms require much more time for planning, informing and consulting health workers, and mobilising political support than was available in the Zimbabwean context.
• Successive policies have lacked a consultative process and the political buy-in from other ministries, hence the failure to secure funding for the implementation of many policies.
• Attrition rates have reduced following the implementation of the short-term retention scheme, suggesting that incentives can work to retain skilled HRH if they are professionally managed.
• Staff numbers have been reduced through emigration to other countries and also internal migration to other sectors, though this is less well documented.
• The public sector can best improve working conditions by learning from the other sectors that are attracting HRH from the public sector.
• The phased withdrawal of the emergency retention scheme has begun to revive the brain drain. There is the need for the MoHCW to work on securing replacement funding to sustain the retention allowance quickly before the attrition gains momentum.
• There is need for intensive capacity development to ensure that the human resources function is carried out by individuals with the right competencies.
• Policies should be monitored and evaluated and the findings from such processes should be made available to a wide audience rather than to a select few.

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