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Retention incentives for health workers
Equinet
September 30, 2008

http://www.equinetafrica.org/bibl/docs/DIS65HRchimbari.pdf

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Executive summary

This paper investigates the impact of the framework and strategies to retain critical health professionals (CHPs) that the Zimbabwean government has put in place, particularly regarding non-financial incentives, in the face of continuing high out-migration. The outmigration of CHPs to countries in the region or overseas remains one of Zimbabwe's most pressing problems. The movement of staff is not only from lower to higher levels in the public sector, or from public to private institutions. Now even lower-level staff are leaving in increasing numbers for other countries in the region or beyond. Their departure confronts the assumption that these newly trained staff would replace experienced staff who had already emigrated. The paper examines the impacts of non-financial retention incentives being applied, and makes recommendations aimed at enhancing the monitoring, evaluation and management of the incentives by the Zimbabwe Health Service Board (ZHSB), the institution responsible for administering them.

The work was implemented within the regional programme on incentives for health worker retention in the Regional Network for Equity in Health in East and Southern Africa (EQUINET) in co-operation with the Regional Health Secretariat for East, Central and Southern Africa (ECSA). The programme is co-ordinated by University of Namibia, Namibia, with support from University of Limpopo and Training and Research Support Centre, and the ECSA Technical Working Group on Human Resources for Health. The study sought to investigate the causes of migration of health professionals; the strategies used to retain health professionals, how they are being implemented, monitored and evaluated and their impact, in order to make recommendations to enhance the monitoring, evaluation and management of non-financial incentives for health worker retention.

The ZHSB's strategic plan for 2005-2010 provides a good framework for monitoring and evaluating the incentives programme for CHPs in Zimbabwe, but faces problems with availability of data for its implementation. While efforts are underway to strengthen data collection, this constraint also affected the study. Our research included a desk review, field data collection through a non-interventional, descriptive cross-sectional survey and a review workshop. Our field study included public, private and faith-based health institutions from urban and rural settings in three administrative provinces (Mashonaland West, Matebeleland South and Masvingo) and two major cities (Harare and Bulawayo) in Zimbabwe, and focused on critical health professionals (CHPs), namely doctors, nurses, pharmacists, radiographers, laboratory technicians, dentists, opticians, nutritionists and therapists. Key informant interview was done in each of the participating stakeholder institutions, with 21 informants interviewed. A questionnaire addressing all research questions was administered to representatives of each category of CHPs, with 196 questionnaires completed in total. Five focus group discussions (FGDs) were held with different groups of trainees, focusing on their perceptions of the retention packages, with up to 20 participants in each FGD. A half-day workshop was held to discuss the findings.

The field survey results showed that Zimbabwe is losing the most experienced CHPs, but that even newly qualified staff aspire to migrate to gain experience. CHPs are well positioned in terms of career structure and those that have diversified by venturing into non-medical business ventures appeared to be less likely to migrate. Migration was found to be taking place at all levels (primary, district, provincial, central and private sector) of the health delivery system. Most CHPs from Zimbabwe migrate to South Africa, Botswana, Namibia, Australia, United Kingdom and New Zealand.

The major factor driving out-migration was found to be the economic hardship that the CHPs are facing due to the deterioration of the country's economy. Other factors identified, including poor remuneration, unattractive financial incentives and poor working conditions, relate directly to this. The efforts of the ZHSB to mitigate this have been frustrated by a number of challenges. Hyper-inflation has rapidly eroded the value of the financial retention incentives awarded by the ZHSB, while negative economic growth rate and funding limitations have limited construction of and availability of staff housing, the award of vehicle use entitlements to deserving staff and the operation of the vehicle loan scheme, the latter becoming inoperative in 2006. A national shortage of fuel added to transport costs, eroding the transport allowances awarded to staff without vehicles.

Some practices added to falling morale: Bonding staff to retain them is unpopular and tends to promote desertion of staff without giving the contractual notice period. While not rejected as a concept, staff view it as punitive in the current context of the unsustainable remuneration packages experienced during the bonding period. The selective award of allowances to health workers has a demoralising effect on those that do not receive them, particularly in circumstances where the working hours and conditions are similar. The exclusion of CHPs in the Ministry of Higher and Tertiary Education from the mandate of the ZHSB has created serious disparities in remuneration between staff in the ministry and those under the ZHSB.

The retention package offered by the ZHSB appear not to have much impact on the ground. Many interviewees indicated that the package was not attractive and some said they were not aware of it. The private and municipal health institutions seemed to have more functional retention packages than the public (government) health institutions, whose budgets made implementation of the packages difficult. Many factors undermining implementation of the package are beyond the control of the ZHSB. While the ZHSB has a clear implementation and monitoring strategy, it faces challenges in sustaining the retention package due to funding. It was unclear how government would focus on the needs of CHPs when there are many critical staff in other sectors deserving attention.

There is some latitude for review, and the paper makes recommendations, drawing also on options raised in the field study. With the current hyperinflationary environment, we suggest that non-financial incentives that are not directly eroded by inflation could be given greater attention, including in partnership with non government organizations and communities served by CHPs. Retention strategies should target all staff categories, including those in training institutions, given the tendency for staff at all levels to migrate.

Staff working under similar conditions should get the same allowances on a sliding scale based on their grades. Remuneration of CHPs in the Ministry of Higher and Tertiary Education and those under the ZHSB should be harmonized. Efforts could be made to improve the professional mix in the hierarchy of the Ministry of Health and Child Welfare, and modules on management included in the training curriculum of health professionals.

The bonding of staff as a retention measure should be reviewed so that it does not appear to be punitive. Development of defined career paths and opportunities for continuing education were considered to be better 'bonding' strategies, which, while not legally binding, were already more effective in retaining staff.

We suggest that managing health worker incentives calls for the ZHSB to have greater decision making latitude. This would need to be further explored and may involve legal review. Further the efforts to improve data collection by the ZHSB need support. The ZHSB should be able to document the actual number of CHPs leaving the country and the countries they go to. This calls for multi-country arrangements that will facilitate exchange of information on the registration of foreign CHPs in participating countries.

The World Health Assembly Code that is being developed may help address this problem, but will need to go beyond the code to address the problems in operationalising such arrangements, including strengthening the databases at country level to support this information exchange.

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