The State of Human Resources for Health in Zambia: Findings from the Public Expenditure Tracking and Quality of Service Delivery Survey, 2005/06

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The State of Human Resources for Health in
ZambiaFindings 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

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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.

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MOH allocation to personnel expenditures

• Personnel expenditures in MOH budget (ZK billion)
  and share of personnel expenditures to total MOH
  expenditures (), 2002-2007

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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 ()

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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
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Key findings

• Staffing patterns and availability
• Unaccounted workers, staff absenteeism, and
  tardiness
• Staff workload and morale
• Staff salary and benefits
• Salary management

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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

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1 Skewed staffing pattern as reflected in
composition of established posts
of estabd 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

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2 High rates of staff vacancy, especially among
clinical staff
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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
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4 Increasing reliance of hospitals on expatriate
staff and HCs on volunteer staff
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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

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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?

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2 Some staff are posted in one facility but work
elsewhere

• Number of staff

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3 High rates of staff absenteeism, especially
among clinical staff
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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)

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4 Even higher rates of staff tardiness
RHC UHC Hospital All
of staff tardy 37 47 47 43
Ave. no. of days/mo. tardy 3 4 3 4
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5 Absenteeism and tardiness erode actual
availability of staff
Working 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 _at_ 90 staff/hospital, or
• 4 UHCs _at_ 42 staff/UHC, or
• 21 RHCs _at_ 9 staff/RHC

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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

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1 Staff perception of long hours worked ()
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2 Amount of time spent on direct patient care

• Average no. of hours worked in a week by type of
  task, 2006

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3 Low staff morale

• of staff who are satisfied/dissatisfied

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4. Income-augmenting activities of staff
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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

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1 Problem of compressed salaries

• Composite monthly salaries and allowances (ZK
  million) of clinical/professional health workers,
  2005

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2 Highly-fragmented cash allowances.

• The more generous allowances only cater to a
  small segment of the workforce

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and in-kind benefits

• of staff who received

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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 expediters
  fee to obtain their salaries

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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
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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
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Reasons cited by staff for delay or nonpayment of
salaries ()
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3 Problem of missing portion or unauthorized
deduction of salaries
Percent 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
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4 Problem of paying expediters fee to obtain
salaries
Percent of Staff RHC UHC Hos pital All
who paid expe-diters 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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