Health workers are all people engaged in actions whose primary intent is to protect and improve health. A country’s health workforce consists broadly of health service providers and health management and support workers. This includes:
- private as well as public sector health workers
- unpaid and paid workers
- lay and professional cadres.
Overall, there is a strong positive correlation between health workforce density and service coverage and health outcomes.
A “well-performing” health workforce is one that is available, competent, responsive and productive. To achieve this, actions are needed to manage dynamic labour markets that address entry into and exits from the health workforce, and improve the distribution and performance of existing health workers. These actions address the following:
- How countries plan and, if needed, scale-up their workforce asking questions that include: What strategic information is required to monitor the availability, distribution and performance of health workers? What are the regulatory mechanisms needed to maintain quality of education/training and practice? In countries with critical shortages of health workers, how can they scale-up numbers and skills of health workers in ways that are relatively rapid and sustainable? Which stakeholders and sectors need to be engaged (e.g. training institutions, professional groups, civil service commissions, finance ministries)?
- How countries design training programmes so that they facilitate integration across service delivery and disease control programmes.
- How countries finance scaling-up of education programmes and of numbers of health workers in a realistic and sustainable manner and in different contexts.
- How countries organize their health workers for effective service delivery, at different levels of the system (primary, secondary, tertiary), and monitor and improve their performance.
- How countries retain an effective workforce, within dynamic local and international labour markets.
This section on Health workforce is structured as follows:
The World Health Report 2006 - Working Together for Health identifies Zambia as one of fifty-seven countries worldwide suffering from a critical shortage of health care workers.
The crisis has arisen from a long period of under-funding to the health sector. The crisis manifests through a depleted workforce, inequitable distribution of the existing workforce, poor pay and poor work environment leading to high workloads and a de-motivated workforce. The Government of Zambia has recognized this crisis. It turned into the development of a Human Resources for Health Strategic Plan 2006-2010 which has since led to a number of measures to address and reverse the crisis.
Organization and management of human resources for health
Overview of the organization and management of human resources for health
Modes of remuneration
Salaries and other financial rewards
Problems and negotiation around remuneration issues
Stock and distribution of human resources for health
Numbers and distribution of health workers
Information about the number and distribution of health workers is only available for the public sector (which makes the bulk of health professionals – see Overview of the organization and management of HRH).
As shown in table 3.3 below, all cadres of health workers are in short supply and below the recommended establishment, whether in urban or rural areas. The urban provinces of Lusaka and Copperbelt have relatively better staffing levels than the less urban provinces of Central and Southern provinces. The remaining rural provinces (Eastern, Luapula, Northern, North western and western provinces) have a relatively more severe shortage of workers that the urban provinces. Several positions at the health centre level, especially in the rural areas and remote rural health centres are served with under-skilled staff. The personnel emolument (PE) ceilings in the recruitment of new staff to the civil service puts a restriction on the numbers and pace at which the recommended establishments can be addressed.
Specific stock and distribution information
There are an estimated 12,085 health care workers in Zambia our of a total establishment of 22,608; this representing a shortfall of 11,304 (50%) (2008 Annual Health Statistical Bulletin, MoH). Of the total health care workers, the distribution by provinces loosely mirrors facilities and less so to population ratios (see table Table 3.7 below). However, the density of health workers (0.8 per 1,000 population) still falls short of the WHO recommended 2.5 health care workers per 1,000 population. This is higher in urban areas than in rural the rural areas.
The urban bias in the distribution of the human resources for health stock reflects the high density of health facilities in urban areas, coupled to health workers refusing to serve in rural areas due to poor socioeconomic infrastructure. The underlying factors to these geographical inequities in development outcomes are historical in nature and well beyond the control of the Ministry of Health acting alone.
The Ministry of Health has taken some measures to respond to this by firstly acknowledging the problems for what it is. In response, the 72 districts have been classified into 4 categories, namely A (Most urban), B, C, and D (most rural) (see Tables 3.7 and 3.8). Cash incentives are utilized for stimulating a voluntary reallocation of the staff to rural and disadvantaged areas (especially to category C and D districts). In addition to this, the forthcoming results-based financing approach (see Performance appraisal and non-financial incentive schemes) should provide a complementary tool to motivate and retain health workers in rural areas. The cumulative effects from these two initiatives will hopefully help to address inequitable imbalances in the Zambian health workforce.
Estimated unemployment rates among health care professionals
Unemploymnet rates are unknown at the moment as there is no such classification in unemployment national data, and no study linking graduated health workers and actually employed health workers.
A formal mechanism to track training with absorption into the health system is now under discussion, in the framework of the forthcoming Recruitment and Bonding System (see a August 2009 presentation of the related Technical Working Group for more information).
Education and training
The basic training takes 7 years for doctors; 3 years for clinical officers and registered nurses; 2 years for enrolled nurses. For the latter, another 1 year was required to specialize in midwifery. However as of 2009, there is now a direct entry registered midwifery qualification.
Basic training mainly focuses on the acquisition of technical skills. There is much less emphasis on teaching the primary health care qualitative dimensions of the provider / patients relationships. This component is part of the post-graduate courses and in-service training workshops.
In addition to basic training, doctors have an average of 3 years to get an MMed post-graduate degree at the University of Zambia, and a similar duration for postgraduate courses outside the country. Nurses without a midwifery training take up another one year to specialize in midwifery. Clinical Officers can take up another 2 years to qualify to become Medical Licentiates (Assistant Medical Officers), and thus acquire additional competences in surgery and obstetrics. The basic degrees mentioned earlier are pre-requisites to specialization.
The qualification from the basic training generally entitles one to practice with a temporary licence from regulatory bodies such as the Medical Council of Zambia (MCZ) or the General Nursing Council of Zambia (GNC). Upon certification from supervisors (upon approved clinical rotations that last up to one year), a candidate is then given a permanent licence to practice unsupervised, and this licence is renewed annually.
There are no differences in the training of medical staff being trained in or working in quasi-public, private for-profit and private not-for-profit institutions
Educational institutions by type of training programmes
The School of Medicine at the University of Zambia is the only institution graduating doctors in Zambia. Similarly, Chainama College of Health Sciences is the only option for students willing to graduate as clinical officer. Nurses have the choice between 25 public / mission nursing school distributed throughout the country.
Zambian degrees generally benefit from a good international recognition. Doctors and registered nurses qualified in Zambia are accepted for registration and post-graduate training in the USA, the UK, South Africa, Zimbabwe, Australia, New Zealand and many other countries.
Number of graduates
For some years the production of health workers proven to be inadequate to meet the growing needs for human resources in the country and to bridge the gaps caused by departures (pensions, deceased, leave abroad, dismissals, others).
Chronic under investments in the training institutions contributed to this state of affairs with some schools having closed their doors.
In 2008 the government drew up an operational plan for training institutions in response to the severe human resources crisis it faces, with a view to invest and scale up the training of health workers (attach The Training Institutions Operational Plan). The plan is largely donor funded, and this source of funding has proven unstable and unpredictable, with many of the targeted training institutions now scaling down their ambitions or closing down again.
The shortage in human resources is most severe for doctors, pharmacists and midwives, with a 50% vacancy rate in the Zambian health system (see Specific stock and distribution information)
Standards setting for professionals and educational institutions
Two para-statal units have the duty to regulate the practice and professional conduct of staff: the General Nursing Council (GNC) for nurses and midwives; and the Medical Council of Zambia (MCZ) for all other health staff. Their activities include registration of graduates, setting of standards of conduct and monitoring.
Most Zambian training programmes conform to agreed international standards, usually in line with the British standards, for historical reasons.
Policies impact on human resources standards to some extent. For example, in 2007 and 2008, the policy to urgently scale-up the training of midwives led to development of a direct entry midwifery training, rather than through first getting a basic nurse training and then upgrading to a 1 year midwifery training after a period of service.
There are different institutions setting educational standards for different cadres. The University of Zambia (through the school of medicine) oversees and supervises the training curriculum of nurses and clinical officers. GNC and MCZ also have a role to play in education. Training institutions under responsibility of the Ministry of Health have their standards set by the ministry (Nurses and clinical officers). Similarly, the Ministry of Education facilitates the setting of standards for the training institutions under its responsibility, through bodies such as the senate (for universities) or curriculum review committees drawn from the teaching staff and identified experts in the field.
Teaching institutions make ongoing efforts to adapt their standards and make sure that they respond to professional needs. As an illustration, it is not rare that students from Zambian schooling medical school institutions are sent abroad to verify whether their level matches with the requirement of foreign teaching institution with an international perspective.
The set standards are adhered to and respected by all teaching facilities in the country. This is important for accreditation and registration purposes of graduates, since the regulatory statutory bodies are part of the standard setting committees.
Planning for human resources for health
The Directorate of Human Resources and Administration is the MOH authority in charge of HR planning. Their plans require approval by the Public Service Management Division (PSMD) of the Government cabinet office for alignment with the ceiling agreed on within the IMF policies.
HR planning and previsions have been recently improved with the creation of a data bank of all health workers on public sector payroll in August 2009. It is updated monthly through the feed-in from newly posted HR Officers at provincial and district levels.
Training institutions were not able to produce graduates to their full capacity due to chronic under-investment (see Number of graduates). The capacity at some was even reduced due to shortage of tutors, accommodation and equipment. An Training Institution Operational Plan has been set in 2008 (attach doc) for scaling up the production of HRH by attracting more tutors to training institutions and improving and expanding the infrastructure.
Doctors and health professionals career path
Two main options are offered to nurses ambitioning improvement in their career paths
- Either climbing the administrative scale (1st level to 2nd and 3rd level, management teams at district, provincial and central level)
- Or getting some form of specialization. Nevertheless, apart from gradual professional evolution, chances of getting a Government specialization sponsorship are competitive and stiff. Some prefer to seek sponsorships outside the government, which could intensify the existing brain drain.
The professional career path for a doctor is pretty much defined by a standard bureaucratic setup. There is no real stimulus to move across hospitals, clinics and departments. Similarly, all administrative movement are subject to official authorization. In these conditions, the recently-graduated doctor typically starts from being an intern with the rank of a Junior Resident Medical Officer (JRMO). After one year of successful internship, one is promoted to the rank of Senior Resident Medical Officer (SRMO). From this point, the doctor needs to specialize in one of the field before getting to the rank of Registrar, and then rising to Senior Registrar before reaching the top rank of consultant. This career progression structure applies at a secondary and tertiary level hospital. At a level 1 hospital, the lucky ones can become a medical Officer and then rising to District Medical Officer (DMO). They then enter the administrative health world and may start longing at provincial or MOH positions. In these circumstances, conditions offered by international agencies or foreign institution obviously exert a certain attraction.
Work conditions have been and are still an issue. Work conditions must be approved by the Cabinet office, outside the control and influence of the MoH. The failure to rectify grievances over the unattractive working conditions appears often as a major and significant reason for leaving the public health sector.
Migration of health workers
Migration and brain drain are major issues in the country. As an illustration, 15% of the nurses trained from 1992 to 2003 were working outside Zambia  . The problem is believed as being more serious for doctors and specialist. Many recruiting agents have now settled in Zambia to entice willing health workers to apply for work abroad. In addition, many international NGOs also recruit heath workers from the public health system as shown in a 2008 case study on HRH conducted by WEMOS. Finally others migrate to well-paying jobs in other industries or go into self employment. Cumulative effects have led to increased migration rates among health workers
The rate of staff turnover in the Zambian health system is worrisome, especially in rural health clinics. According to a recent survey on public expenditure tracking and quality of service delivery conducted in 2007  , at rural health centres (RHCs), out of 688 staff assessed, 69 were "incoming" (10.0 percent) while 148 were "outgoing" (21.5 percent) giving a net loss of 11.5% of staff. The corresponding proportions for (a) urban health centres (UHCs) (1,756 staff), were "incoming" (9.4 percent) and "outgoing" (9.8 %), and (b) hospitals, (1,442 staff), were "incoming" (9.2 percent) and "outgoing" (4.2 percent). Hospitals are able to retain their staff better (with a net gain of 5%) than RHCs and UHCs. Few new staff opt to go to RHCs while over twice as many of those in-post leave RHCs.
The issue of health worker migration is also an equity issue. In the affected countries, it takes away health workers from the already under-served areas to go into urban areas, better paying jobs offered by international organizations, or abroad. For the latter, recipient countries tend to deploy them to their rural under-served areas as a measure to correct their own imbalances in health worker distribution  .
Priorities and ways forward
The main weaknesses and bottlenecks regarding efforts to address the health workforce crisis in Zambia is the failure to translate the generated political will into actions that are backed by appropriate budgetary allocations. For this to happen, a multi-sectoral approach is required between the Ministry of Health, the Ministry of Finance and National Planning as well as with Cabinet Office (Public Service Management Division – PSMD). The recent 2010 MTEF ceilings and Frameworks disseminated for public review and comment by the Ministry of Finance and National Planning indicate that consensus on a multi-sectoral approach is yet to be reached.
Endnotes: References, sources, methods, abbreviations, etc.
- ↑ The world health report 2006: working together for health (7.11Mb). Geneva, World Health Organization, 2008
- ↑ Source: WHO-Afro/CHESSORE study on the migration of health workers in the African Region – The Zambia Case Study (2003))
- ↑ Ministry of Health; The Zambia public expenditure tracking and quality of service delivery survey (PET/QSDS) in the health sector - findings and implications. MoH, World Bank, SIDA and University of Zambia (2007)
- ↑ WHO (AFRO), EQUINET, ECSA-HC, SADC (2009) Impacts of health worker migration on health systems in east and southern Africa Report of a regional research methods meeting, 14-16 July 2009, Harare, Zimbabwe. WHO AFRO, EQUINET: Harare