The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe

Abstract

BackgroundA paradigm shift in global health policy on user fees has been evident in the last decade with a growing consensus that user fees undermine equitable access to essential health care in many low and middle income countries. Changes to fees have major implications for human resources for health (HRH), though the linkages are rarely explicitly examined. This study aimed to examine the inter-linkages in Zimbabwe in order to generate lessons for HRH and fee policies, with particular respect to reproductive, maternal and newborn health (RMNH).MethodsThe study used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011.ResultsThe past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Human resources are constrained in managing current demand and any growth in demand by high external and internal migration, and low remuneration, amongst other factors. We find that nurses and midwives are evenly distributed across the country (at least in the public sector), though doctors are not. This means that for four provinces, there are not enough doctors to provide more complex care, and only three provinces could provide cover in the event of all deliveries taking place in facilities.ConclusionsThis analysis suggests that there is a strong case for reducing the financial burden on clients of RMNH services and also a pressing need to improve the terms and conditions of key health staff. Numbers need to grow, and distribution is also a challenge, suggesting the need for differentiated policies in relation to rural areas, especially for doctors and specialists. The management of user fees should also be reviewed, particularly for non-Ministry facilities, which do not retain their revenues, and receive limited investment in return from the municipalities and district councils. Overall public investment in health needs to grow.

Results-based financing as a strategic purchasing intervention: some progress but much further to go in Zimbabwe?

“…While infrastructure is distributed relatively equitably in Zimbabwe, staffing is less so, especially for doctors [37]. While RBF does not directly influence this, it may have incentivised some staff to move from district hospitals to RHCs, especially in areas where RHCs were funded through RBF and district hospitals through flatrate subsidies (as the staff incentives were better at the RHC level in these areas).…”

“…Zimbabwe has offered MCH services at primary level without user fees since the 1990s [37]. At secondary care level, mothers and children and those over 65 years of age do not pay for services.…”

“…RDCs previously collected revenues from their health facilities [37] and there was some reluctance to stop this source of fund-raising. Mission facilities were also dependent on user fees.…”

Traditional Birth Attendants and Policy Ambivalence in Zimbabwe

“…The Poverty Assessment Study Survey [18] showed that a lack of available money was the main reason for patients not seeking treatment for illness/injuries. Chirwa et al [44] highlight that the implementation of the user fees policy has been erratic and administratively complicated and has lead to compromised equity in service resulting in a 30 percent decline in use of rural health centres.…”

“…This is likely to be one factor behind the high rate of home deliveries. Chirwa et al [44] observed that users are being charged for primary care in rural areas, not least because under the policy of decentralisation the majority of clinics are managed by local authorities, which are able to set their own charging policies. Rural and urban clinics collect fees but do not retain them.…”