Health worker shortages in Zambia: An assessment of government responses

Original Article Health worker shortages in Zambia: An assessment of government responses Jeff Gow a,b, *,GavinGeorge b,givenmutinta b, Sylvia Mwamba c, and Lutungu Ingombe c a School of Accounting, Economics and Finance, University of Southern Queensland, Toowoomba, Australia. b Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa. E-mail: gowj@usq.edu.au c Department of Economics, University of Zambia, Lusaka, Zambia. *Corresponding author. Abstract A dire health worker shortage in Zambia s national health programs is adversely impacting the quantity and quality of health care and posing a serious barrier to achieving Millennium Development Goals to improve population health. In 2005, Zambia s Ministry of Health developed a 10-year strategic plan for human resources for health to address the crisis through improved training, hiring, and retention. The plan has neither arrested nor reduced the shortage. We review the causes of the shortage, present results from a health worker survey showing that safe work conditions, manageable workloads, and career advancement opportunities matter more to respondents than financial compensation. We comment on the adequacy of government efforts to address the health worker shortage. Journal of Public Health Policy advance online publication, 18 August 2011; doi:10.1057/jphp.2011.41 Keywords: Zambia; health workers; workforce shortage Introduction Zambia is a landlocked country of 12 million people in Southern Africa. Over the last three decades, life expectancy has declined from 58 to 45 years, as maternal, child, and under five mortality rose as a result of infectious diseases including HIV/AIDS, malaria, and tuberculosis. 1 Zambia s dependency ratio is one of the world s highest: www.palgrave-journals.com/jphp/

Gow et al 47 per cent of the total population are children under the age of 15. 1 As one of the more urbanized countries in Sub-Saharan Africa (38 per cent urban dwellers), Zambia struggles with a rural urban divide characterized by inequality of investment in education, health care, and infrastructure (road, rail, and telecommunications), with rural areas lagging behind 2 and unemployment presenting a serious social problem. 3 We summarize the available literature about the worker shortage and its causes. Then we present data from Zambia s Ministry of Health (MoH) on numbers of health workers. Finally, we add health workers own views collected in a survey and from interviews in three regions. We use all four sources of information to assess the adequacy of government s responses, and to make recommendations. The Dire Health Worker Shortage MoH data from 2005 show that Zambia has only 50 per cent of the health workforce needed to deliver basic health services, with the highest vacancy rates in rural areas. 4 The staff-to-population ratios nationally are as low as one doctor per 14 500 people and one nurse per 1800 people, 5 well below the country s desired minimum of one health worker per 400 people. 6 The current shortage of over 27 000 health workers is a key impediment to Zambia meeting the global commitment to universal access to HIV/AIDS prevention, treatment, and care by 2015, as well as the health-related Millennium Development Goals (MDGs). The literature indicates that several factors contribute to this shortage: underinvestment in training institutions; migration of qualified health professionals abroad; and internal migration to jobs in the private sector or outside health altogether. 5,7 9 In 2005, the MoH initiated a policy reform process, establishing targets and strategies to achieve its goals. 4 Zambia based its targets on World Health Organization staff-to-population ratio recommendations (2.3 1000) 9 and established a strategy to recruit graduating students while retaining those employed using monetary and non-monetary inducements. 4 Each year Zambia aimed to add, from its own graduates, 100 medical doctors, 500 registered nurses, and 250 registered midwives (see Table 1), as well as 100 doctors and 300 registered nurses from other sources, mainly returning Zambians. 4 Enrolled nurses and midwives would begin work concurrent with their training. Zambia s 2

Zambia s health workers shortages Table 1: Health worker staffing levels 2006 2008 a Type 2006 2007 2008 Recommended establishment Shortage Doctors b 646 720 861 2300 1439 Clinical officers c 1161 1213 1828 4000 2172 Registered/Enrolled 2273 2255 2393 5600 3207 midwives d Registered/Enrolled nurses e 6096 6534 6345 16 732 10 387 Medical assistants f 2581 2334 2500 3168 668 Paramedics g 3200 3370 3090 6000 2910 a For location and duration of training for each category, see Table 2. b A doctor practices medicine after 5 years study at university. Doctors are trained at the University Teaching Hospital (UTH) affiliated with the University of Zambia (UNZA) in Lusaka, the only training institution for doctors in Zambia until 2011. c Clinical officers undertake 3 years of undergraduate study at the MoH teaching college: Chainama Hills College Hospital. Most work in primary care to diagnose and treat a wide range of common ailments. They order and interpret medical tests, prescribe or carry-out treatment, and monitor and treat chronic diseases, referring complications to doctors. In addition, they complete a 2-year long internship at an accredited hospital after graduation, before they take the Hippocratic oath and apply for registration as a doctor. d A registered midwife has graduated from an MoH teaching college following 1 year of undergraduate study and passed the national licensing exam. Enrolled midwives practise under the direction of a registered midwife following 1 year of undergraduate study at an MoH teaching college. e A registered nurse has graduated from an MoH teaching college or the UNZA following 3 years of undergraduate study and passed the national licensing exam. Enrolled nurses practise under the direction of a registered nurse following 2 years of undergraduate study at an MoH teaching college. f Medical assistants are untrained and work under the direction of any of the above categories of health workers. Their jobs do not involve medical interaction with patients for treatment. g Paramedics provide care in medical emergencies, with on-the-job training. The majority of paramedics are based in the field in ambulances. Source: Extracted from the Ministry of Health management information system database 2008. goal for 2009 was to reach a workforce of 56 000; instead the total of 27 000 left a shortage of more than 28 000. 5 Causes of the Critical Shortage of Health Workers Previous studies are not clear about factors leading to the shortage, 5,10 although it is clear these causes are multiple, crosscutting, and interconnected. 11 We summarize monetary and non-monetary causes based on the literature and Zambia s MoH database. 3

Gow et al Table 2: Intakes of training institutions (not graduates) Training area Institution Course duration (years) Annual intake Doctors UNZA/UTH 5 70 Registered nurse UNZA/UTH 3 26 Registered nurse MoH 3 385 Enrolled nurse MoH 2 299 Registered midwife MoH 1 125 Enrolled midwife MoH 1 97 Clinical officer MoH 3 140 Source: Ministry of Health (2005). Inadequate remuneration Zambian health worker salaries have historically been extremely low, even for Sub-Saharan Africa. Zambian health workers often seek better-paid jobs in developed and neighboring countries. Doctors who emigrate to the United States can earn up to 20 times more, 10 or five times more by working in Lesotho, Botswana, or South Africa. 5 Only 50 of 600 medical graduates trained in Zambia between 1997 and 2000 continued working in the Zambian public-sector as of 2005. 12 Inadequate development of new health workers Despite MoH intentions to train, recruit, and retain staff as noted above, 4 achievement fell short due to: lack of funding for health training institutions; inadequate training and accommodation facilities, equipment, and materials; and inadequate numbers of teaching staff. 10,11 Of related concern are high pre-service training attrition rates (30 per cent for doctors and nurses, between 20 and 25 per cent for other programs 4 )and a lack of infrastructure and equipment, leading to fewer graduates. See Table 2 for data on annual intakes of Zambian training institutions. The data show intake levels well below target. Bureaucratic and unresponsive management systems Ineffective management contributed to inadequate and delayed increases in remuneration commensurate with education, experience, performance, and professional responsibilities. 12 Other problems include 4

Zambia s health workers shortages the lack of effective and regular assessments of health workers satisfaction, ineffective handling of grievances, and the inability to offer flexible benefit packages to suit staff needs, 11 as well as the lack of in-service training opportunities for skill and position upgrading. Despite centrally managed recruitment, and significant involvement from other agencies, the MoH has been unable to fill all funded positions because of recruitment inefficiencies. 13 Geographic maldistribution Zambia s health worker shortage is particularly evident in rural areas. Although in Lusaka, the doctor-to-population ratio is 1:6247, it is 1:65 763 in the Northern province. 4 Urban areas may be preferred as they provide more services, employment for spouses, and the opportunity for full- or part-time private sector health work. Survey and Interviews: Methods After the study team analyzed nationwide quantitative data on staffing levels by worker type and region from the human resource data base of the Zambian MoH, we conducted a survey and interviews of health workers in 2008. This qualitative aspect of our work addressed health workers views on remuneration and non-monetary incentives aimed at addressing the shortage. Study area/setting Our study team collected data in three regions representing extremes in working conditions and, potentially, satisfaction for health workers. Those posted to rural areas considered hardship areas due to relative inaccessibility, harsh weather conditions, sparse population, and economic disadvantage are meant to be advantaged through payment of allowances and professional training opportunities beyond those offered to their urban counterparts. Lusaka, the urban capital, represented the favorable area while rural Monze, Southern province, and rural Nyimba, Eastern province, represented hardship areas. We randomly selected private and voluntary health facilities in each region. We constituted a stratified sampling frame by region and type in line with policy relevance as shown in Table 3. 5

Gow et al Table 3: Sampling frame Sample facilities: Sample size Sample facilities Tertiary hospital Provincial hospital District hospital Health clinic Non-institutional interviews: Urban Lusaka Public 1 0 0 4 Private 0 0 2 2 NGO 0 0 2 2 Rural district Monze Public 0 0 1 2 Private 0 0 0 2 NGO 0 0 1 2 Rural district Nyimba: Public 0 0 1 2 Private 0 0 0 0 NGO 0 0 3 1 Total 1 0 10 18 Sampling frame We drew the sample of health workers for the structured questionnaires from a stratified and random selection of representative facilities. Sample sizes We asked the health workers from the categories appearing in Table 4 to complete our questionnaire. Respondents from Lusaka accounted for 48 per cent, Southern province 35 per cent, and Eastern province 17 per cent. Most doctors worked in Lusaka while lower skilled employees, worked in remote areas. Of the total (234) most were enrolled nurses/midwives (58 per cent) or paramedics (24 per cent). Medical assistants, doctors, dental therapists, and clinical officers accounted for 7, 6, 3, and 2 per cent, respectively. We conducted informal interviews with a random sample of 10 per cent of those completing the survey to ensure that they understood the questions. The vast majority expressed confidence that they had; and their 6

Zambia s health workers shortages Table 4: Sample size by job type and region Job type Lusaka Monze Nyimba Total Registered and enrolled nurse 38 51 27 116 Medical assistant 3 8 3 14 Clinical officer 1 3 0 4 Paramedics 42 8 6 56 Registered and enrolled midwife 21 9 3 33 Doctor 6 1 0 7 Total 111 80 39 234 answers, while differing from one another, were consistent with having understood the questions. Survey instrument We designed the survey instrument by adapting the Immpact Toolkit entitled Health Worker Incentives Survey from the University of Aberdeen. 14 We collected data in late 2008. Results Health Workers Views Inadequate remuneration Because public employers pay Zambian health workers such low salaries, we asked respondents if they supplemented their income. Twenty per cent of respondents in all categories engaged in private health work; 80 per cent did not. Specifically, 35, 26, and 27 per cent of the medical assistants, paramedics, and registered midwives/nurses, respectively, engaged in additional work for private health providers. Public doctors typically worked in private surgeries on their days off, while nurses and midwives worked in private clinics and hospitals. These opportunities exist mainly in larger cities. Lusaka (urban) health workers engaged in private health work most frequently. In Monze, only 12 per cent of health workers (all types) engaged in private health work; 12 per cent of both registered and enrolled nurses engaged in private work in that province. No one in Nyimba reported finding private health practice for income supplementation (Table 5). 7

Gow et al Table 5: Income supplementation by job type: Public sector Job type Yes (%) No (%) Doctors 14.3 85.7 Clinical officers 25.0 75.0 Registered and enrolled nurses 27.3 72.7 Registered and enrolled midwifes 13.0 87.0 Paramedics 26.8 73.2 Total 19.2 80.8 Source: Survey data. Non-governmental organizations (NGOs) contributed to public sector losses by offering public sector workers higher salaries: for enrolled and registered nurses salaries ranged from 23 per cent to 46 per cent higher, respectively, than for equivalent government positions. Lacking link of professional advances to compensation Forty percent of respondents had not been promoted or received increased remuneration as a result of improved skills or performance in the past 5 years. Inadequate support structures Public sector employment is less desirable than non-governmental work for many reasons including: poor governmental adherence to regulatory frameworks for safer working conditions; unchanging job descriptions in each health worker category despite changes in practices and use of more advanced technologies; lack of programmes to support fair and manageable workloads; high levels of job demands and stress; and inflexible work arrangements. Opportunities for career advancement Most health workers reported that public sector employment offered an unattractive career structure. Even so, 75 per cent said that the better established career paths and employment stability in public jobs served as incentives to remain despite inadequate means to improve skills, add new experiences, or to win recognition by promotion and increasing 8

Zambia s health workers shortages remuneration. Better training opportunities in the public sector attracted workers 12 and helps explain why large numbers remained in the public sector, adding private assignments rather than leaving their public jobs. Until 2008 public sector career advancement opportunities favored doctors at the expense of other health workers. 11 Inadequate in-service education opportunities Although the MoH planned to increase the productivity and performance of health workers by improving pre-service training quality, 4 respondents reported less than adequate in-service education opportunities, development, and career advancement, especially for rural workers. Government s Response to the Health Worker Shortage Decentralization of the health sector Zambia s decentralization process (1995 2005) created autonomous District Hospital Boards in rural areas. Conditions of service through Board employment were intended to be better than those of the MoH. 13 But faulty implementation of changes, especially in recruitment, led to dissolution of District Boards in 2006 and re-assumption of responsibility for hiring by the MoH. Inefficiencies in recruitment and promotion remain. Retention scheme development for rural-based medical officers In 2003 Zambia s MoH initiated a retention scheme, by increasing rural health worker salaries and improving working conditions first for doctors, then subsequently for nurses, clinical officers, and laboratory technicians. 15 The MoH then increased transportation allowances and offered new training opportunities. In exchange, workers committed to 3 years of service in rural areas. Although salaries did not increase, the MoH added a monthly rural hardship allowance based on district characteristics. Compensation doubled for workers in extreme rural districts and increased by 50 per cent for those in peri-rural districts. Ministry data show the success of the retention scheme: Eighty-eight doctors completed 3-year contracts and 65 per cent of those renewed 9

Gow et al for a second 3-year term. The MoH enrolled 15 doctors in 2003 and expanded to 94 in 2008, with a target of 150 in 2008. Renewal of and increased funding for training schools Zambia recognized only in 2008 that it had invested too little in all of its health worker categories and training institutions over many years, especially doctor and nurse training. It increased funding to all healthrelated training institutions but especially the provincial Ministry of Health Schools of Nursing and Midwifery and the UTH in Lusaka. By increasing funding across the board in 2009, intakes to prepare all categories of health workers also increased (see Table 2). This critical aspect of the national strategy is too new to evaluate. Elements include improving infrastructure at the UTH in Lusaka and increasing spending on teaching staff and infrastructure at the MoH teaching institutions. Nursing schools aim to double their intake of students by 2013. The most important development occurred in April 2011 when a second Zambian medical school opened, the Copperbelt University School of Medicine in Ndola. Its initial intake of students totaled 50 (40 medical and 10 dental). Discussion and Recommendations MoH strategies to improve retention, graduation, and public sector entry rates are not likely to be sufficient for Zambia to reach the 2015 staffing targets in any worker categories. Zambia will, however, reduce the magnitude of the challenge, especially by increasing enrollment and graduation rates for doctors. Training new health workers is the most expensive option, given the delay from enrollment to graduation and workforce participation. Enrollments would need to increase dramatically across all categories of health workers. Zambia has not yet assessed the cost of supporting dramatic increases in enrollments, with the longest-term investment for clinical officers and doctors. There are other policy options. Zambia could reduce training times and change training methods. For instance, a strategy where students either accelerate study (by increasing intensity of effort) or where partial training leads to release to the health sector while students complete training on-the-job, could produce staff more quickly. It could 10

Zambia s health workers shortages decrease the time the MoH takes to recruit and hire graduates and reduce the number of nurses who leave the workforce for up to 2 years at a time for advanced training (usually for specialization in a particular illness or obtaining management skills). Zambia could implement more task shifting rational redistribution of some clinical tasks from doctors or clinical officers to nurses and midwives. In the short run, nurses and midwives would be caring for significantly more patients, but task shifting to medical assistants could relieve the burden on nurses. Nurse and clinical officer-centered care have resulted in good clinical outcomes in Zambia in pediatric HIV care in primary health care clinics in Lusaka. 16 Similar results are reported in Rwanda where nurses have provided pediatric antiretroviral therapy, and in Kenya with family planning services. 17 Task shifting can maintain quality while increasing efficiency and improving access and affordability. 18 In a pilot in Rwanda, expanding the role of nurses in HIV services reduced the demand for doctors time in providing HIV services by 76 per cent. 19 If Zambia could replicate these results, the expansion of doctor training enrolment, while necessary, could be tempered. Reductions in attrition through increased salaries, better working conditions, and more opportunities for career advancement also promise to reduce shortages. Improving working conditions could benefit retention and motivation. 20 22 Survey results reinforce the attractiveness of improving working conditions and of more responsive management. Those surveyed trade off low salaries for better conditions of service, in order of importance, safe work conditions, manageable workloads, and opportunities for career advancement (provision of skill improvement programs, recognition of achievements, and regular opportunities for promotion). Addressing disparity between demand and supply of health workers in Zambia requires an increase in health training, hiring of new staff, and retention of existing staff. Supplemental interventions aimed at reducing attrition and increasing graduation and public sector entry rates can help address the disparity. 23 Conclusion Inadequate funding, support, and infrastructure in Zambia has over many years resulted in a neglected health system with poor facilities 11

Gow et al and workers who feel undervalued. The motivation and commitment of existing health workers will be enhanced by improving their conditions of service. While increased salaries would be welcomed, they are not the primary motivating factor of health workers. Even with significant gains in training enrollments, retention, graduation, and public sector entry, Zambia is likely to operate with a shortage of human resources for health for at least the next decade unless alternative means of addressing this shortage are introduced. About the Authors Jeff Gow (PhD) is a professor in the School of Accounting, Economics and Finance, University of Southern Queensland, Toowoomba, Australia and a Research Associate at the Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa. Gavin George (M Phil) is a senior researcher at the Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu- Natal, Durban, South Africa. E-mail: georgeg@ukzn.ac.za Given Mutinta (B Theo) is a junior researcher in the Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu- Natal, Durban, South Africa. E-mail: mutinta@ukzn.ac.za Sylvia Mwamba (B Ec, M Ec) is a lecturer in the Department of Economics, University of Zambia, Lusaka, Zambia. E-mail: sylvia.mwamba @unza.zm Mr Lutungu Ingombe (B Com) is a lecturer in the Department of Economics, University of Zambia, Lusaka, Zambia. E-mail: lutangu.ingombe@unza.zm References 1. Ministry of Health/National AIDS Council. (2009) Zambia Country Report. Lusaka, Zambia: Ministry of Health. 2. Central Statistical Office Summary Report. (2003) Census of Population and Housing. Lusaka, Zambia: Central Statistics Office. 12

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