LITERATURE REVIEW
2.11 THE ZAMBIAN CONTEXT
2.11.1 National Health Reforms
The Zambian government introduced health sector reforms in 1991.The main aim of the reforms was to restructure the health services through improved structure, leadership, accountability and partnerships (MOH, 1991). In 1996, the National Health Services Act made the Ministry of Health responsible for the legal and policy framework for health institutions and boards and for regulatory mechanisms. The Central Board of Health (CBOH) became responsible for health delivery and policy implementation.
Administrative functions such as procurement of drugs were assigned to the Central Board of Health (DFID, 2003). among the resulting achievements were more decentralized authority to manage district health services, participatory structures, increased resource flows to the districts, a basic health care package and a purchaser (MOH) - provider (CBOH) split (Cohen et aI., 2003). However, Cohen and his colleagues argue that a number of challenges remained which included an adverse economic environment, limited improvement in service delivery, limited access for poor
and disadvantaged groups including the youth, women and terminally ill patients, low quality care, and reliance on external funding among, others. The reforms introduced community participation in the management and delivery of health care services through the creation of hospital and district health boards, neighborhood health committees at district and health center levels (MOH, 1991).
The vision of the Ministry of Health in Zambia is "to provide Zambians with equity of access to cost effective, quality health care as close to the family as possible" (MOH, 1991). To achieve this vision and national health priorities, the MOH developed a Basic Health Care Package (BHCP) as a means of fulfilling the intention of providing the people in Zambia with access to basic health care as close to the family as possible.
However, a decision was taken to in 2004 to dissolve the Central Board of health and repeal the National Services Act of 1995 due to what was perceived as lack of role clarity between the Central Board of Health (CBOH) and health ministry with "service delivery not drastically improving and health indicators declining" despite high health sector expenditures (MOH, 2006 p. 1).
2.11.2 The human resource situation
Although no comprehensive studies have been conducted on migration of health care professionals in Zambia, anecdotal information on the human resource crisis in the country indicate what is referred to as economic migration which is reported to have led to the departure of qualified staff. Itis assumed that this has led to deterioration in
working conditions, pointing out that this in turn, has lead to further migration as it serves
as an incentive for others to leave (MOH, 2004a). An earlier World Bank Review
Mission on the Zambian Health Sector (December, 1999) estimated staff turnover rates of between 12-20 per cent. However, this figure included rates for CDEs who are a less stable component of the health workforce.
Another major contributing factor to attrition is loss of health workers through deaths attributed to HIV/AIDS,which is reported to affect health care workers in equal
proportions to the population at large, leading to other consequences.The paper (MOH, 2004c) cited some of these consequences as absenteeism of staff due to caring for dependents who include the sick and orphans,attending to funerals and sick leave by staff themselves some of whom may be infected. The paper further gave a total of 225 HIV/AIDS related deaths among health workers recorded in the first half of 2004.
Voluntary separation from the public sector also contributed to staff attrition from the
health sector. A voluntary separation package (VSP) was offered to employees in the public sector as part of efforts to reduce the size of the civil service (government
workers).This affected health workers in the public sector who responded like any other government employees. Although it became clear that major shortages of staff had began to occur in some of the health care facilities,no action was taken to suspend the scheme and revisit its implications on the staffmg needs of the heath sector. Although no data is available on the overall impact of this scheme,anecdotal evidence showed that departure of staff made it difficult to maintain acceptable standards in the provision of health care
(MOH, 2004a).The report cited the national tertiary hospital, the University Teaching Hospital (UTH) where over 75% of the nurses had left.
A paper on an analysis of the human resources situation in the health sector in Zambia describes what is currently obtaining as:
"a human resources crisis in the Zambian Health Service, which, like a creeping
paralysis, is inexorably undermining the ability of the Ministry of Health (MOH) to delivervital health services "
The MOH conceded in this analysis stating that the problem was not new and that numerous reports had been written drawing attention to what was referred to as the 'looming catastrophe'(MOH, 2004a).
Globally, nursing and midwifery personnel comprise more than 50 per cent of the labour force in many developing countries (O'Brien-Pallas et al., 1997). Nursing and midwifery services comprise a large component of health service provision and account for the majority of health care personnel (WHO, 2002 p.28). Nurses and midwives are responsible for preventive, curative and rehabilitative care and in turn, improved health systems performance (ICN, 2004 p.5). The situation in Zambia is not different. nurses comprise the majority of the health workforce. From experience, they function at every level of the health care system and provide a wide range of services within their broad scope of practice as provided by the Nurses and Midwives Act. Records at the General Nursing Council of Zambia show that the country has trained a total of 5,619 registered
nurses and 11 916 enrolled nurses from 1968 to end of 2002. Out of these numbers, 2,642
,
and 4,680 nurses have undergone one year training in registered and enrolled midwifery respectively. However, only a total of 9,536 (54.4%) renewed their practicing licenses in 2002 out of the trained total of 17,535 (GNC, 2002).
The assumptions for this state of affairs are that some nurses have left the country while others have died and may be others did not just renew their practicing licenses. The numbers attributed to any of these possibilities are not known, as there is currently no system of tracking down nurses who have died, retired or left the country for whatever period or purpose.
From the experience of the researcher, the General Nursing Council of Zambia (GNC), as the regulatory body for the nursing profession, issues verification statements to nurses wishing to register outside the country. Nurses request for verification of their professional status most commonly for employment purposes. Records of those who seek verification of their qualifications and registration with the GNC show an upward trend, indicating an increase in the number of nurses intending to register with foreign Nursing Councils or other nursing regulatory bodies. South Africa and the United Kingdom appear to have been the most sought after countries during the years 1997-2002. The records show a sharp decline for South Africa application for registrations in the last two years. The trend towards the UK almost doubled with numbers applying to register in the USA also increasing. The number of applicants to Botswana appears to be consistent.