2011年-世界发展银行全球_The_Human_Resources_for_Health_Crisis_in_Zambia___An_Outcome_of_Health_Worker_Entry_Exit_and_Performance_within_the_National_Health_Labor_Market_112页_8mb

Summary of The Human Resources for Health Crisis in Zambia

Core Content

This report examines the human resources for health (HRH) crisis in Zambia, analyzing the entry, exit, and performance of health workers within the national health labor market. It highlights the challenges in HRH stock, distribution, and performance and identifies key factors influencing these dynamics, such as centralized management, training capacity, compensation, and HIV/AIDS prevalence.

Main Points

1. Health Outcomes in Zambia

• Despite some improvements since the 1990s, health outcomes remain poor.
• Under-five mortality rate in 2007 was 119 per 1,000 live births, higher than the regional average.
• Maternal mortality ratio (MMR) in 2007 was 591 per 100,000 live births, and would need to drop by 45% to meet the MDG target.
• Skilled birth attendance has remained relatively constant at around 47% for the past two decades.
• Infectious and parasitic diseases, particularly HIV/AIDS, malaria, and diarrheal diseases, account for over half of all deaths in Zambia.

2. HRH Stock

• The stock of health workers in Zambia is low, with 1.05 per 1,000 people, below international benchmarks.
• Clinical cadres make up just over half of the total HRH stock.
• Nurses dominate the clinical workforce, comprising over 60%, while doctors make up only 7%.
• Approved establishment in the public sector is not met:
  • Doctors: 42% of approved positions
  • Nurses: 46%
  • Midwives: 48%

3. Public/Private Sector Distribution

• Public sector dominates HRH, with ~80% of health workers working in it.
• Non-profit private sector accounts for ~20%, while for-profit is <1%.
• Private sector offers higher salaries, which attracts health workers, but is underdeveloped and regulated in a way that hinders expansion.

4. Geographical Distribution

• Health workers are heavily concentrated in urban areas.
• Rural areas suffer from severe maldistribution, with some districts having as few as 0.13 per 1,000 population.
• Higher-level cadres (e.g., doctors) are disproportionately located in urban centers.
• Rural facilities depend on centralized funding to hire workers, and management weaknesses hinder effective recruitment and retention.

5. HRH Performance

• Absenteeism is high, especially among higher-level cadres in the public sector and urban areas.
• 45.2% of doctors, 25.5% of medical assistants, and 22.9% of nurses were absent from their posts in 2007.
• Dual practice and low motivation contribute to absenteeism.
• Competency issues exist, particularly in delivering antenatal care, child health services, and HIV/AIDS treatment.
• Training and equipment deficiencies are key factors in low competency.

6. Equity in Health Service Provision

• Wealthier populations have better access to health services than the poor.
• Antenatal care and delivery attendance show a strong pro-rich gradient.
• Poorer women are less likely to receive antenatal care.
• Children with diarrhea or cough/fever receive similar care across income groups, suggesting equity in some services.

7. Core Factors Affecting Labor Market Dynamics

• Centralized HRH management limits local autonomy and responsiveness.
• Inadequate training capacity leads to low production of skilled health workers.
• Poor working conditions and low monetary compensation contribute to high attrition and low motivation.
• HIV/AIDS is a major cause of mortality and also leads to high exit rates among health workers.

8. Available Financing for HRH

• The health sector budget is below the Abuja target.
• Donor funding accounts for ~33% of health sector spending in 2007.
• Earmarked funding restricts flexibility in HRH allocation.
• Wage bill has declined over time, partly due to donor restrictions.

Key Findings

• Low HRH stock and inadequate distribution are major barriers to achieving health-related MDGs.
• Inflow of health workers is low, especially for higher-level cadres, due to limited training capacity.
• Outmigration of health workers, particularly doctors, is driven by low pay and aggressive recruitment by foreign countries.
• Poor performance is linked to inadequate monitoring, lack of accountability, and dual practice.
• Equity issues persist, with poor populations having less access to health services despite availability.
• HIV/AIDS is a critical factor in both mortality and HRH attrition.

Conclusion

The report concludes that the labor market dynamics of HRH in Zambia are shaped by centralized management, low training capacity, inadequate compensation, and HIV/AIDS. These factors hinder the availability and performance of health workers, limiting access to health services for the poor, and impeding progress toward the MDGs. The government's commitment to HRH is evident, but systemic challenges require policy reforms and sustainable financing to improve the situation.

Data and Timeframe

• Most data covers 2005–2008.
• 2007 and 2006 are key years for census data and performance metrics.
• 2010 data shows HIV treatment coverage is still below universal access.

Recommendations

• Strengthen HRH training institutions to increase the supply of skilled workers.
• Decentralize HRH management to improve local responsiveness.
• Improve working conditions and monetary compensation to reduce attrition.
• Enhance in-service training and equity in service delivery to address performance and access gaps.
• Ensure adequate and flexible funding to support HRH development and service delivery.