Pilot-testing service-based planning for health care in rural Zambia.

BACKGROUND: Human resources for health (HRH) planning in Zambia, as in other countries, is often done by comparing current HRH numbers with established posts, without considering whether population health needs are being met. Service-based HRH planning compares the number and type of services required by populations, given their needs, with the capacity of existing HRH to perform those services. The objective of the study was to demonstrate the effectiveness of service-based HRH planning through its adaptation in two rural Zambian districts, Gwembe and Chibombo. METHODS: The health conditions causing the greatest mortality and morbidity in each district were identified using administrative data and consultations with community health committees and health workers. The number and type of health care services required to address these conditions were estimated based on their population sizes, incidence and prevalence of each condition, and desired levels of service. The capacity of each district's health workers to provide these services was estimated using a survey of health workers (n=44) that assessed the availability of their specific competencies. RESULTS: The primary health conditions identified in the two districts were HIV/AIDS in Gwembe and malaria in Chibombo. Although the competencies of the existing health workforces in these two mostly aligned with these conditions, some substantial gaps were found between the services the workforce can provide and the services their populations need. The largest gaps identified in both districts were: performing laboratory testing and interpreting results, performing diagnostic imaging and interpreting results, taking and interpreting a patient's medical history, performing a physical examination, identifying and diagnosing the illness in question, and assessing eligibility for antiretroviral treatment. CONCLUSIONS: Although active, productive, and competent, health workers in these districts are too few to meet the leading health care needs of their populations. Given the specific competencies most lacking, on-site training of existing health workers to develop these competencies may be the best approach to addressing the identified gaps. Continued use of the service-based approach in Zambia will enhance the country's ability to align the training, management, and deployment of its health workforce to meet the needs of its people.

Evaluation of recruitment and retention strategies for health workers in rural Zambia.

BACKGROUND: In response to Zambia's critical human resources for health challenges, a number of strategies have been implemented to recruit and retain health workers in rural and remote areas. Prior to this study, the effectiveness of these strategies had not been investigated. The purpose of this study was to determine the impacts of the various health worker retention strategies on health workers in two rural districts of Zambia. METHODS: Using a modified outcome mapping approach, cross-sectional qualitative and quantitative data were collected from health workers and other stakeholders through focus group discussions and individual interview questionnaires and were supplemented by administrative data. Key themes emerging from qualitative data were identified from transcripts using thematic analysis. Quantitative data were analyzed descriptively as well as by regression modelling. In the latter, the degree to which variation in health workers' self-reported job satisfaction, likelihood of leaving, and frequency of considering leaving, were modelled as functions of participation in each of several retention strategies while controlling for age, gender, profession, and district. RESULTS: Nineteen health worker recruitment and retention strategies were identified and 45 health care workers interviewed in the two districts; participation in each strategy varied from 0% to 80% of study participants. Although a salary top-up for health workers in rural areas was identified as the most effective incentive, almost none of the recruitment and retention strategies were significant predictors of health workers' job satisfaction, likelihood of leaving, or frequency of considering leaving, which were in large part explained by individual characteristics such as age, gender, and profession. These quantitative findings were consistent with the qualitative data, which indicated that existing strategies fail to address major problems identified by health workers in these districts, such as poor living and working conditions. CONCLUSIONS: Although somewhat limited by a small sample size and the cross-sectional nature of the primary data available, the results nonetheless show that the many health worker recruitment and retention strategies implemented in rural Zambia appear to have little or no impact on keeping health workers in rural areas, and highlight key issues for future recruitment and retention efforts.

Role analysis of the nurse/midwives in the health services in Sub-Saharan Africa.

AIM: To describe the tasks and the roles of nurses and midwives in Sub-Saharan African health services. BACKGROUND: The current roles of nurses and midwives in the African region of the World Health Organization have not been empirically established, with only studies from two countries found (South Africa and Mozambique). This makes it difficult to establish whether current nursing/midwifery education programmes and regulations adequately address the needs in the health services. DESIGN: A descriptive quantitative study. METHODS: A survey questionnaire was administered to ambulatory and hospital services. Data were collected between June-December 2010, with completed responses from 734 nurses from nine African countries (five Anglophone and four Francophone). RESULTS: The highest reported role functioning in both settings was for 'General Care and Treatment'. The lowest role functioning reported in both settings was in the role 'Maternal and Child Health' and in 'The Provision of Mental Health Care'. The reported role performance in Anglophone countries was significantly greater than in Francophone countries. CONCLUSION: The development of competency in nursing/midwifery roles other than medical surgical roles (general assessment and care) should receive more attention in curricula. Special attention needs to be given to Francophone countries, where the professions of nursing and midwifery are poorly developed.

Doubling the number of health graduates in Zambia: estimating feasibility and costs.

BACKGROUND: The Ministry of Health (MoH) in Zambia is operating with fewer than half of the human resources for health (HRH) necessary to meet basic population health needs. Responding urgently to address this HRH crisis, the MoH plans to double the annual number of health training graduates in the next five years to increase the supply of health workers. The feasibility and costs of achieving this initiative, however, are unclear. METHODS: We determined the feasibility and costs of doubling training institution output through an individual school assessment framework. Assessment teams, comprised of four staff from the MoH and Clinton Health Access Initiative, visited all of Zambia's 39 public and private health training institutions from 17 April to 19 June 2008. Teams consulted with faculty and managers at each training institution to determine if student enrollment could double within five years; an operational planning exercise carried out with school staff determined the investments and additional operating costs necessary to achieve expansion. Cost assumptions were developed using historical cost data. RESULTS: The individual school assessments affirmed the MoH's ability to double the graduate output of Zambia's public health training institutions. Lack of infrastructure was determined as a key bottleneck in achieving this increase while meeting national training quality standards. A total investment of US$ 58.8 million is required to meet expansion infrastructure needs, with US$ 35.0 million (59.5%) allocated to expanding student accommodation and US$ 23.8 million (40.5%) allocated to expanding teaching, studying, office, and dining space. The national number of teaching staff must increase by 363 (111% increase) over the next five years. The additional recurring costs, which include salaries for additional teachers and operating expenses for new students, are estimated at US$ 58.0 million over the five-year scale-up period. Total cost of expansion is estimated at US$ 116.8 million over five years. CONCLUSIONS: Historic underinvestment in training institutions has crippled Zambia's ability to meet expansion ambitions. There must be significant investments in infrastructure and faculty to meet quality standards while expanding training enrollment. Bottom-up planning can be used to translate national targets into costed implementation plans for expansion at each school.

Meeting human resources for health staffing goals by 2018: a quantitative analysis of policy options in Zambia.

BACKGROUND: The Ministry of Health (MOH) in Zambia is currently operating with fewer than half of the health workers required to deliver basic health services. The MOH has developed a human resources for health (HRH) strategic plan to address the crisis through improved training, hiring, and retention. However, the projected success of each strategy or combination of strategies is unclear. METHODS: We developed a model to forecast the size of the public sector health workforce in Zambia over the next ten years to identify a combination of interventions that would expand the workforce to meet staffing targets. The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. We model, using Excel (Office, Microsoft; 2007), the effects of changes in these variables on the projected number of doctors, clinical officers, nurses and midwives in the public sector workforce in 2018. RESULTS: With no changes to current training, hiring, and attrition conditions, the total number of doctors, clinical officers, nurses, and midwives will increase from 44% to 59% of the minimum necessary staff by 2018. No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010, without including training expansion, is sufficient to meet staffing targets by 2018 for any cadre except midwives. Training enrolment needs to increase by a factor of between three and thirteen for doctors, three and four for clinical officers, two and three for nurses, and one and two for midwives by 2010 to reach staffing targets by 2018. Necessary enrolment increases can be held to a minimum if the rates of retention, graduation, and public sector entry increase to 100% by 2010, but will need to increase if these rates remain at 2008 levels. CONCLUSIONS: Meeting the minimum need for health workers in Zambia this decade will require an increase in health training school enrolment. Supplemental interventions targeting attrition, graduation and public sector entry rates can help close the gap. HRH modelling can help MOH policy makers determine the relative priority and level of investment needed to expand Zambia's workforce to target staffing levels.