The State of Human Resources for Health in Zambia: Findings from the Public Expenditure Tracking and...
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Transcript of The State of Human Resources for Health in Zambia: Findings from the Public Expenditure Tracking and...
The State of Human Resources for Health in Zambia:Findings from the Public Expenditure Tracking and Quality of Service Delivery Survey, 2005/06
Oscar Picazo, Solomon Kagulura, and the PET/QSDS Team of MOH and University of Zambia (UNZA)Presentation prepared for the “Human Resources for Health Research Conference,” Mulungushi International Conference Center, Lusaka, Zambia, June 7-8, 2007
Disclaimer
This is part of a larger work on the Public Expenditure Review on the health sector in Zambia.
The report findings are unofficial, and do not reflect the views of the GRZ, the World Bank, or SIDA.
Comments received from this presentation will be incorporated in the finalization of the report.
MOH allocation to personnel expenditures Personnel expenditures in MOH budget (ZK billion) and share of
personnel expenditures to total MOH expenditures (%), 2002-2007
139.5 175.9 236.5 265.2 244.1 340.5
44 4340
46
39
50
0
50
100
150
200
250
300
350
400
2002 2003 2004 2005 2006 2007
0
10
20
30
40
50
60
PE in ZK Bn PE/MOH Exp (%)
Paradox of deepening HR crisis at a time of increasing flow of financing(Eriksson, 2006) Per capita health expenditures (US$) and share of personal emoluments to
health expenditures (%)
14
18
36
57
44
22
0
5
10
15
20
25
30
35
40
GRZ GRZ+Basket Funds GRZ+Basket+VerticalProj.
0
10
20
30
40
50
60
Introduction to the PET/QSDS Multistage sampling frame involving: provinces, districts, and
health facilities, and within them, health workers and patients Variety of instruments: specific questionnaires for health
facility, patient, health worker, DHMT
Provinces (No. of districts)
DHMTs Hospitals UHCs and RHCs
Total Facilities
Lusaka Province (3) 3 3 17 23
Copperbelt Province (4)
4 4 30 38
Southern Province (5)
5 5 25 35
Western Province (4) 4 3 28 35
Northern Province (5)
5 3 32 40
Total 21 18 132 171
Key findings
Staffing patterns and availability “Unaccounted” workers, staff absenteeism,
and tardiness Staff workload and morale Staff salary and benefits Salary management
A. Key findings on staffing patterns and availability Skewed staffing persists as reflected in the
composition of established posts Health facilities have very high rates of staff
vacancy The rate of staff turnover is worrisome,
especially in rural health clinics Health facilities are increasingly relying on
expatriate and volunteer staff
1: Skewed staffing pattern as reflected in composition of established posts% of estab’d posts
RHC UHC Hosp
ital
Clinical 63 62 62
Administrative
5 14 11
Other 31 24 28
RHCs have heaviest staffing for low-skill (other) posts
RHCs have highest proportion of clinical posts
Far more admin slots in UHCs compared to hospitals
2: High rates of staff vacancy, especially among clinical staff
53
54
56
57
58
59
60
66
66
74
79
0 50 100
Mpongwe
Namwala
Shangombo
Mpika
Chinsali
Kalomo
Nakonde
Kasama
Mufulira
Sesheka
Chilubi
33.5
19.6
23.4
43.4
37.7
53.4
53.2
0 20 40 60
Total
Other
Admin
Otherclinical
MW+nurses
COs+MLs
Doctors
3: High staff turnover especially in rural health centers
Staff Turnover RHC UHC Hospital All
Total staff 688 1,756 1,442 3,886
No. of staff who joined the facility this year
69 166 133 368
No. of staff who left the facility this year
148 172 60 380
Retired 15 20 7 42
Transferred 116 120 24 260
Resigned 10 22 14 46
Dismissed or suspended 7 10 15 32
4: Increasing reliance of hospitals on expatriate staff and HCs on volunteer staff% of Health Centers With
Volunteer Staff
32
48
0 20 40 60
RHCs
UHCs
% of Hospitals With Expatriate Staff
14
25
50
0 20 40 60
Otherexpatriate
staff
Expatriatenurse
Expatriatedoctor
B. Key findings on “unaccounted” workers, staff absenteeism, and tardiness The survey revealed inconsistency in the number of
posts actually filled A number of staff are posted in one facility but
working elsewhere Staff absenteeism is considerable; clinical staff have
the highest rates of absenteeism Staff-reported rate of absenteeism is much higher than the
rate found in the facility survey Tardiness is a much bigger problem than
absenteeism Absenteeism and tardiness erode in a major way
the actual availability of staff who are already in post
1: Inconsistency in the number of posts actually filled Total established posts: 5,038 Filled posts as a residual of vacant posts: 3,348 Filled posts reckoned from “staff count”: 3,885 Difference: 537 staff
More staff actually working than in the official payroll? Casual staff? Un-updated roster of established posts? Other reasons?
2: Some staff are posted in one facility but work elsewhere Number of staff
13
20
3
0
0
1
0
5
10
15
20
25
RHC UHC Hospital
Clinical Other
3: High rates of staff absenteeism, especially among clinical staff
9.6
1.4
4.2
14.1
13.8
20.1
31
0 10 20 30 40
Total staff
Other staff
Admin.staff
Otherclinical staff
MW+nurses
CO + ML
Doctors Composition of Absentees (%)
3.4
1.7
5.8
0.6
1.4
1
1.9
0.7
3.9
3.7
3.9
4.4
1
0.3
1.1
1.9
0 5 10 15
All
Hospital
UHC
RHC
Off. & unofficial leave
Outreach or sup'n
LT/ST training
Posted here, working elsewhere
Staff reported rate of absenteeism is much higher than the rate found in the facility survey Count of staff from facility
survey showed absenteeism rate of 9.6 percent
But health worker survey shows for the previous month: 30% of RHC staff were
absent (6 days/month) 16% of UHC staff were
absent (8 days/month) 16% of hospital staff were
absent (3 days/month) 21% of all staff were absent
(5 days/month)
Reasons for Absences (%)
40
189
33
Sick self
Sick relatives
Extra job to attend to
Others
4: Even higher rates of staff tardiness
Reasons for Tardiness (%)
35
1717
31
Longtravel time
Sickrelatives
"On-call"previousdayOthers
RHC UHC Hospital
All
% of staff tardy
37 47 47 43
Ave. no. of days/mo.
tardy
3 4 3 4
5: Absenteeism and tardiness erode actual availability of staffWorking days lost due to absenteeism per month
3,250
Working days lost due to tardiness per month
588
Total working days lost per month
4,108
Full-time equivalent (FTE) staff
187
187 FTEs are enough to staff: 2 hospitals @ 90
staff/hospital, or 4 UHCs @ 42
staff/UHC, or 21 RHCs @ 9
staff/RHC
C. Key findings on staff workload and morale Half of the staff complained of long hours worked,
because of the workload and their need to augment their meager incomes
Despite the reported long hours worked, the amount of time being spent by staff on direct patient care is being squeezed by other tasks
About half of the staff surveyed have low morale Health staff are engaged in various income-
augmenting economic activities, inside and outside the health facility
1: Staff perception of long hours worked (%)
52
59
52
53
47
41
48
47
0% 20% 40% 60% 80% 100%
All
Hospital
UHC
RHC
Too little
Just right
Too much
2: Amount of time spent on direct patient care Average no. of hours worked in a week by type of task, 2006
29.6
30.6
33
25.3
6.5
6.9
6
6.5
3.2
2.1
2.4
5.2
2.9
1.2
1.6
6
0 10 20 30 40 50
All
Hospitals
UHC
RHC
Patient careAdministrativeSocial mobilizationTrainingOthers
3: Low staff morale % of staff who are satisfied/dissatisfied
4
2
3
7
40
31
38
49
12
13
15
9
36
45
34
32
7
9
10
3
0% 20% 40% 60% 80% 100%
All
Hospitals
UHC
RHC
Highly satisfiedSatisfiedIndifferentDissatisfiedHighly dissatisfied
4. Income-augmenting activities of staff
5 18 11 39 29 10 9
3
9
6
05
1015202530354045
012345678910
% of staff
Ave. hours
D. Key findings on staff salary and benefits Salary levels of professional and clinical
workers are highly compressed, and a variety of allowances are being used to decompress overall payroll
The cash allowances and in-kind benefits are varied but highly fragmented, and cater only to a small proportion of staff
1: Problem of compressed salaries Composite monthly salaries and allowances (ZK million) of
clinical/professional health workers, 2005
0.981
1.142
1.142
1.142
1.142
1.142
1.683
2.43
2.688
3.072
3.778
0.255
0.285
0.355
0.355
0.355
0.355
0.892
0.97
0.973
1.049
2.456
0 1 2 3 4 5 6 7
Lab technician
Pharmacy technician
Lab technologist
Clinical officer
Midwife
Nurse
Sr. nurse
Tutor
Lab scientist
Pharmacist
Doctor
Salary Allowances
2: Highly-fragmented cash allowances…. The more generous allowances only cater to a small segment of the
workforce
247
89
213
256
97
225
182
57
121
171
0
50
100
150
200
250
300
Educ'l
Reten
'n s
chem
e
Transp
ort al
low
.
Top-ups
Food
Rural h
ardsh
ip
Oth
ers
Cloth
ing
On-c
all a
llow.
Housing
051015202530354045
Ave. amt. rec'd (ZK1,000) % of staff who received
… and in-kind benefits % of staff who received
0
10
20
30
40
50
60
70
80
90
E. Key findings on salary management Some staff experience problems of –
Delays in salaries Nonpayment of salaries Less-than-full salaries
A tenth of the staff reported paying “expediter’s fee” to obtain their salaries
1: Problem of delay in receipt of salaries
Percent of Staff RHC UHC Hospital All
% who received all salaries on time
28.7 16.7 19.8 21.9
% who experienced delays in receipt of salaries
71.3 83.1 80.2 78.1
Ave. no. of months delay 1 1 1 1
2: Problem of non-receipt of salaries
Percent of Staff RHC UHC Hospital All
% who received all salaries due the past 12 months
85.4 87.7 82.3 85.4
% who did not receive all salaries due the past 12 months
14.6 12.3 17.8 14.6
Ave. no. of months not paid 4 3 5 5
Reasons cited by staff for delay or nonpayment of salaries (%)
49
65
50
33
4
0
7
6
4
0
0
11
14
0
14
28
29
35
29
22
0 20 40 60 80
All
Hospital
UHC
RHCSystemic delay
Employer has nofunds
Salary withheld toservice outstandingdebts
Nonpayment notexplained
Other reasons
3: Problem of missing portion or unauthorized deduction of salariesPercent of Staff RHC UHC Hospital All
% who received all salaries net payable
90.9 86.0 75.0 84.5
% who received less than net payable salary, without consent or understanding
9.1 14.0 25.0 15.5
Ave. amount of salary
missing (ZK)
72,444 239,133 244,278 189,015
% who recovered missing portion of salary
18 0 25 21
4: Problem of paying “expediter’s fee” to obtain salariesPercent
of Staff
RHC UHC Hos
pital
All
% who paid ‘expe-diter’s fee’ to obtain salary
6 8 13 10
Percent of staff
RHC UHC Hospital
All
% who received salaries in cash
11 10 10 10
% who had salaries automatic-
ally deposited
in the bank
88 90 90 90
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