Table 4 Summary of HRH challenges, based on key informant interviews

1

The HR establishment is not matched to its task – programmes and populations have grown but the establishment has not been adjusted accordingly. The staffing norms have not been adjusted since the 1980s and the MoHCW and HSB recognise that this is overdue. They are planning to revise using the WHO workload model, but it is hard to justify this exercise when existing positions remain vacant.

2

In addition, there has been a hiring freeze since mid 2010, so even the existing posts, if vacant, cannot be filled (except with permission from the Ministry of Finance, which takes 6–7 months to obtain) and it is difficult to transfer staff.

3

The level of salaries is universally acknowledged to be too low – below the consumption poverty line for an average family.

4

Differentials between sectors add to difficulties for government facilities – a qualified midwife earns $300 in the public sector (up to $400 including all allowances), but can get $1,000 per month in Harare city facilities, according to one key informant.

5

The retention allowance is also low - $70 per nurse – and is sometimes delayed. In addition, it is not paid to the non-professional grades, which is demotivating. The allowance, currently funded by the Global Fund, is also reducing by 25% each year, and is due to phase out in 2013.

6

There is a shortage of specialists, including doctors, midwives and specialist nurses. 60% of nurses should have qualifications in midwifery, according to one key informant, but the actual level is far below that. The provincial hospital visited, to cite one example, has no paediatrician, no obstetrician, and only one doctor and one surgeon. The last time they had a Zimbabwean specialist, according to the key informant, was over 20 years ago (they have hosted Cuban doctors, but these present language problems).

7

Migration, while reduced compared to the ‘rock bottom years’ of the mid-2000s, continues to drain trained staff, especially to South Africa and Botswana.

8

Maldistribution is also a recognised problem, reflecting poorer working conditions and earning opportunities. A rural allowance used to exist but was considered too low to be effective (25% of a small salary).

9

As a consequence of these factors, remaining staff are often overloaded, which contributes to demotivation.

10

Poor personal and working conditions are also mentioned by many staff – for example, lack of staff accommodation, lack of transport to work, dirty wards, lack of staff amenities, and no running water.

11

Shortages of key supplies (such as blood) and equipment at work also undermines their professional self-respect and ability to offer a reasonable quality of care.

12

The lack of specialists denies remaining staff the opportunity to learn and improve their skills, while trainees mention the absence of senior staff to supervise them.

13

A result-based management system exists in theory, based on annual targets and appraisals, but the system is seen as cumbersome and the increments to reward good performance are too minimal to motivate.