Research for building pro-poor health systems during the recovery from crisis;
An investigation into Health Financing, Incentives for Health Workers and Rural Deployment and Posting of Human Resources for Health in Zimbabwe
The ReBUILD Research Programme Consortium:
ReBUILD started in 2011 focusing on two of the six WHO health systems building blocks, health financing and Human Resources for Health. The programme was funded by the Department for International Development (DFID), United Kingdom, and initially focused on four post-conflict/post-crisis settings: Cambodia, Sierra Leone, northern Uganda and Zimbabwe. The research and engagement activities in each of those settings was led by national partners, supported by the UK programme partners – Queen Margaret University in Edinburgh and the Liverpool School of Tropical Medicine. In each setting, the research and engagement was designed to be relevant to national policy priorities for equitable health systems. The programme also synthesized findings across all of the settings to learn and share broader lessons about health systems development after conflict and crisis. More information on this wider, cross-cutting and synthesis work on the core research areas can be found here.
ReBUILD: Research for building pro-poor health systems during the recovery from crisis: An investigation into Health Financing, Incentives for Health Workers and Rural Deployment and Posting of Human Resources for Health in Zimbabwe
Funder: UK Department of International Development (DFID) through Liverpool School of Tropical Medicine (LSTM)
Award Period: 2011-2019
Principal Investigator: Dr. Shungu Munyati
Research Coordinator: Yotamu Chirwa
Projects Leads and Researchers: Stephen Buzuzi, Wilson Mashange, Pamela Chandiwana, Mildred Pepukai
ReBUILD started in 2011 focusing on two of the six WHO health systems building blocks, health financing and Human Resources for Health. The project was funded by the Department for International Development (DFID), United Kingdom. In Zimbabwe five sub- studies were carried out.
Sub-study 1- The Impact of user fees on health care seeking behaviour and financial protection during the crisis period in Zimbabwe.
Human Resources for Health
Sub-study 2 – The incentive environments for Human Resources for Health in Zimbabwe.
Sub-study 3 – Rural Posting/Deployment of Human Resources for Health in Zimbabwe
Sub study 4- Gender mainstreaming in rural posting and deployment systems in the health sector in Zimbabwe Results Based Financing
Sub study 5- Adoption, scale up and integration of result based financing in Zimbabwe divided into two sections which included
The political economy of Results based Financing: the experience of the health system in Zimbabwe
Results-based financing as a strategic purchasing intervention: what can we learn from the experience of Zimbabwe
All the studies were underpinned by the quest to explore the hypothesis that there are particular opportunities for the shaping of health systems during the post-crisis transition, so that they deliver health services more effectively to the poorest women, men, girls and boys on a long term basis.
Aims and Goals
The broad goal of the ReBUILD project was to deliver new knowledge to inform the development and implementation of pro-poor health system in Zimbabwe which is recovering from a political, social and economic crisis so that once again it can deliver health services more effectively to the poorest people.
In the Health Financing sub-study the key objectives were:
To assess the impact of changes in user fees charging regimes on the utilization (changes in health-seeking behaviour etc) of health care services by poor households since 1990 in Zimbabwe.
To observe changes in average budget share, marginal budget expenditure, price and income elasticity of health expenditure, and marginal rate of substitution between health expenditure and food consumption
To provide recommendations for a policy intervention on health subsidy to support the rural poorest households.
In the Incentive Environments research sub-study some of the specific objectives include:
To describe the HRH policies, the reasons for their introduction, how they have been implemented and the effects of the policy changes prior to the crisis, during the crisis and during the post crisis period.
To identify and analyze the various measures put in place by the Zimbabwe government to achieve health workers attraction, retention, their equitable distribution and enhanced HRH performance.
To analyse trends in health worker availability, distribution, attrition, and performance during the crisis and post crisis period.
In the Rural Posting/Deployment research sub-study some of the specific objectives include:
To identify ways to improve deployment systems to rural areas used by large employers of health personnel post crisis in Zimbabwe.
To assess the impact of the key changes in deployment policy and systems on the staffing of rural areas.
To identify lessons learnt in the development of deployment policy and systems in post crisis situations.
Gender mainstreaming in rural posting and deployment systems in the health sector in Zimbabwe
To identify the different equal opportunities policies relating to deployment and posting that have been used since 2000 across government and in particular in the health sector.
Assess the implementation of Equal Opportunities policies and practices in staff posting and deployment in the health sector since 2000.
Assess the impact of Equal Opportunities policies and practices on male and female health workers.
To identify lessons for improved implementation of Equal Opportunities Policy and the National Gender Policy in the posting and deployment of health workers in rural areas.
Adoption, scale up and integration of result based financing in Zimbabwe
To explore the political economy dynamics that led to the adoption, adaption, implementation and scale-up of results-based financing (RBF) in Zimbabwe;
To understand the extent to which the strategic purchasing elements of RBF have been tailored to institutional constraints in Zimbabwe, and how these arrangements are integrated (or not) within and affect the health system’s purchasing function;
To document lessons learned (on design, implementation, sustainability and suitability to context) and make recommendations on how they can be used to guide future RBF or related interventions, in Zimbabwe and more broadly in the Africa region.
The methodology for the five sub-studies was supported by a systems approach, recognising that multiple chains of impact are occasioned by intervention. Macro level change reverberates at micro level, requiring research to measure and link variables at multiple levels and to seek out voices that may be easily marginalised from debate but offer key insights into poverty reduction. Hence the research designs for the five sub studies depicted the following methodological components:
detailed documentation of context in order to understand its interaction with system intervention
a mix of quantitative and qualitative approaches, capable of capturing wide ranging types of variables and relationships between them
careful sampling strategies that ensure gender, disability, ethnicity and poverty can be analysed
frequent use of time series data that recognise impacts are not static ‘before’ and ‘after’ measurements but continually emerging
General emphasis on human responses to intervention and consideration of both perceived and objectively measured change, recognizing that the former informs further response to the intervention.
The sub-studies relied on document review, key informant interviews, in-depth interviews, job histories, life histories and routine staffing data as techniques for gathering data. There is a retrospective component in all the sub-studies.
Summary of findings
Sub study 1: Understanding the impact of user fees on poor households in Zimbabwe
Lack of coherence in the implementation of the exemption policy (Policy and practice are different); health facilities make decisions that have negative implications on patients’ access to services in order to continue providing services.
Not all vulnerable groups are covered by the exemption despite the existence of a comprehensive list of the vulnerable groups due to poor resourcing of the scheme.
Poor drug supply situation linked to a mix of public and private service provision and increased out of pocket expenditure for patients; financial protection focusing on NCDs within the health system has been ignored
Patients making healthcare decisions (e.g. forego diagnostic tests, delay treatment, ignore sickness, reduce drug doses) that are not best for their health because they cannot afford to pay for the services.
Equity cannot be achieved without adequate government funding of the exemption scheme
User fees have been gradually increasing since 2009 impacting on patients’ access to health services and commodities.
Sub Study 2: Understanding health worker incentives in post crisis settings: Zimbabwe
Rationalization of remuneration and retention of Health Workers to ensure fair comparability with the public sector
Going beyond short term retention schemes through formulation of sustainable and permanent attractive remuneration of Health Workers Equal treatment of cadres in the health sector especially looking at
Incentives can work to retain health workers
Appropriate utilization of available skills within the health sector
Poor harmonization of retention schemes
Equal treatment of cadres in the health sector especially looking at:
Lack of support from the MoHCC, Ministry of Finance and Ministry of Local Government in ensuring the availability of funds for remuneration of health workers
Non financial incentives and the fair administration as well as sustainable funding
Sub Study 3: Rural Deployment and Posting of Human Resource for Health.
The Faith Based Organization (FBO) deployment system for core staff was more effective than the government and rural district councils systems.
In government and rural district councils posting staff to rural areas was and still is a problem.
Government and rural district councils’ deployment systems failed to adapt to changes during and after the crisis. Currently government health facilities are unable to sustain core health system functions compared to the FBO, which has a resilient core workforce that can be deployed to and retained in hard to reach areas, during crises.
Sub Study 4: Gender mainstreaming in Rural Posting and Deployment systems in the health sector in Zimbabwe.
Qualitative analysis showed that barriers to career progression were embedded within social norms. Complimentary quantitative research showed that a third (35.3%) of women reported loss of training opportunities through delayed training or deferring exams (post basic training or further studies) to the following year due to child care responsibilities, which had negative implications for their promotion and career progression/advancement.
According to the existing policy (Public Service Regulations, 2000), access to training in Zimbabwe is based on seniority and years in service. Men tended to be more ‘impatient’ with the system than women, and opted for self-funding training courses which gave them an advantage over women during interviews for promotion.
Human resource managers preferred to deploy men to very rural area, with the belief that men will stay in the post longer and not request a transfer. The absence of doctors in rural areas meant male nurses learnt to do some procedures usually performed by doctors. This exposure gave men more experience in a senior position within facilities. The experience ultimately resulted in career enhancement and opportunities for promotion to leadership positions.
Reports and Publications:
Sub study 1
Understanding health worker incentives in post-crisis settings: policies to attract and retain health workers in rural areas in Zimbabwe since 1997, a document review
Understanding health worker incentives in post-crisis settings: policies to attract and retain health workers in Zimbabwe: Key informant interviews https://rebuildconsortium.com/resources/research-reports/understanding-health-worker-incentives-in-post-crisis-settings-policies-to-attract-and-retain-public-health-workers-in-zimbabwe-kii-report/
Understanding health worker incentives in post-crisis settings: lessons from health worker in-depth interviews and life histories in Zimbabwe. ReBUILD RPC Research Report https://rebuildconsortium.com/resources/research-reports/understanding-health-worker-incentives-in-post-crisis-settings_zim-idi-report/
Understanding health worker incentives in three districts of Zimbabwe: survey report
Deployment of Human Resources for Health in Zimbabwe: Synthesis report
For more publications and reports please visit the ReBUILD Website on www.rebuildconsortium.com