Abbreviations

CPH Chinhoyi Provincial Hospital DMO District Medical officer GMO Government Medical Officer HMO Hospital Medical Officer HCH Harare Central Hospital HRH Human Resources for Health HSB Health Service Board HTF Health Transition Fund MoHCC Ministry of Health and Child Care OI Opportunistic Infections PCN Primary Care Nurse RGN Registered General Nurse SCN State Certified Nurse SHO Senior House Officer SRMO Senior Resident Medical Officer WHO World Health Organization WISN Workload Indicators of Staffing Needs UBH United Bulawayo Hospital ZIMASSET Zimbabwe Agenda for Sustainable Socio Economic Transformation

Written and Compiled by: Bernard Nkala (Health Service Board) Bernard Gotora (Health Service Board)

Funded by:

GoZ i Acknowledgements

The Health Service Board (HSB) and Ministry of Health and Child Care (MoHCC) would like to extend its gratitude and appreciation to all representatives of various organisations and individuals who made invaluable contributions before, during and after the implementation of WISN in Zimbabwe. We are grateful to the Health Development Fund and Treasury for funding the WISN Study in Zimbabwe. The study was successful owing to the technical expertise and guidance provided by WHO Country Office working with the Afro Regional Technical Team.

The WISN in Zimbabwe would not have been a success without the guidance and direction of the Steering Committee for implementing the WISN study in Zimbabwe and the WISN Expert Work- ing Group who developed the data collection tools. The Technical Taskforce immensely contributed in coming with the WISN results for the studied facilities. The contribution of Messrs Nkala Bernard and Gotora Bernard in writing this study report would not go unnoticed.

The Board and the Ministry would like to thank all the stakeholders who contributed in coming up with study report.

The WISN Expert Working Group

The implementation of WISN study in Zimbabwe was coordinated in the following structures outlined in the table below.

Technical experts

Name Level of Support

Dr. Adam Ahmat WHO AFRO Regional Technical Support Team

Dr. Awases Magdalene WHO AFRO Regional Technical Support Team

Mrs. Jennifer Nyoni WHO AFRO Regional Technical Support Team

Dr. Stanley M. Midzi WHO Zimbabwe Country Ofﬁce

Dr. W. Okello WHO Zimbabwe Country Representative

ii WISN Main Study Report 2017

WISN Expert Working Group appointed by Health Service Board

Name Category

Ebi Bukutu Nursing

J. Banwa Radiography

Bothwel Chafanza Nursing

Chidziva Erica Clinical Scientist

Chivese Panganayi Pharmacy

Dr. Lilian Dodzo Midwife

Dr. Mudavanhu Justice Doctors

Gomo Vivian Clinical Scientist

Kanyemba N. Regina Principal Nursing Tutor

Kondowe Elen Nursing

Kufakunesu Lilian Midwife

Machingauta Bonfase Pharmacist

Machokoto Unice PCN

Madzikwa Newman Pharmacist

Maguranyanga Elen Radiography

Mashanda Curthbert Laboratory Scientist

Matiyenga Diamond DNO

Mudenge Boniface Laboratory

Muyedziwa U. Radiography

Professor Charles Maposa Pharmacy

Samungure Stewart Nurse Tutor

Siyame Ernet Nursing - Mental Health

Zanga Admire Ultra Sonographer

Zvavamwe Pegy Pharmacy

Dr Makoni Doctor

Kambarami Doctor

iii The WISN Steering Committee

Name Designation Station

Ms. R. R. Kaseke Executive Director ( Core Chair) HSB

Major General Dr. G. Gwinji (Rtd) Secretary for Health and Child Care ( Core Chair) MoHCC

Mudyradima Robert Principal Director MoHCC

Mothobi Muriel Registrar Nurses Council of Zimbabwe

Mr. Mafa Simangaliso President Nurses Association

Dr. Edwin Sibanda Assistant Director Bulawayo City Health

Mr. Musungwini Enock Deputy Secretary General HPA

Dr. Chasokela Cynthia Director Nursing Services MoHCC

Dr. Mahomva Egnes President ZIMA

Dr. Stanley Midzi WHO Focal Person WHO

Dr. Gibson Mhlanga Principal Director MoHCC

MR. Stanley Makarau Principal Director MoHCC

The WISN Technical Taskforce Team

Name Designation Station

Zhou Nonah Nesu General Manager ( Core Chair) HSB

Jane Mudyara Director Human Resources ( Core Chair) MoHCC

Dr. Kuretu Admire Provincial maternal & Child Health ofﬁcer Mashonaland East

Mangeya Mirriam PNO Chitungwiza Central Hospital

Shonge Jane Work Study Ofﬁcer Harare City Health

Nkala Bernard Deputy General Manager HSB

Ivans Chingamuka IT Manager Parirenyatwa Hospital

Bernard Gotora Human Resources Ofﬁcer HSB

Dr. Puggie Chimberengwa Medical Superintendent Gwanda Provincial Hospital

Dr. Celestino Dhege Medical Superintendant Marondera Provincial Hospital

Michael Matiyashe ICT Ofﬁcer HITRAC

Muposha Edward Human Resources Ofﬁcer HSB

Manwere Peggy Human Resources ofﬁcer MoHCC

Kudakwashe Sylivia Human resources Ofﬁcer MoHCC

iv WISN Main Study Report 2017

Abstract

Human Resources for Health (HRH) are essential in improving access to quality Health Care hence countries need to continue prioritizing and scaled up such. There are many HRH planning tools that can be utilised by organizations and Workload Indicators of Staffing Need (WISN) is one of the tools that help to calculate staff requirements based on workload on cadres at facility level. In Zimbabwe, the Board and Ministry adopted WISN for the Health Sector in 2012 and received technical support from WHO to conduct main study focusing on the five staff categories namely; Doctors, Pharmacy, Nurses, Laboratory and Radiography. The main WISN study was conducted in 2016 – 2017 subsequent receiving funding from Health Development Fund and Treasury. The main objective of implementing WISN in the Ministry of Health and Child Care was to identify health facilities with staff shortages in relation to workload, determine how best to improve current staffing and to proffer recommendations in addressing HRH planning challenges for the public health sector.

A total of 12 facilities were randomly selected amongst country’s 10 Districts and 9 provinces as a representative sample for all levels of care starting from Rural Health facility, District, Province and Central level facilities. The main study was directed by the Steering Committee co-chaired by the Board and the Ministry, the Technical Working Group that implemented the study and Expert Working Group that developed the data collection tools including setting activity standards for respective cadres that were studied. The WISN study results were validated by WHO AFRO Technical Experts taking cognisance of the local circumstances at which the health services were being delivered. The following are the study findings reflecting staff calculations based on WISN software.

v Annexure 1: WISN result for Harare Central Hospital, Zimbabwe 2017

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Doctors Anaesthetist 4 5 25 20 0.20 21 Cardiothoracic Surgeon 3 0 1 1 0.00 ENT Surgeon 3 1 3 2 0.32 General Surgeon 4 5 11 6 0.45 7 Neuro Surgeon 1 0 1 1 0.00 Obstetrician and Gynaecologist 3 3 19 16 0.16 16 Ophthalmologist 3 1 6 5 0.17 3 Orthopaedic Surgeon 5 1 7 6 0.14 2 Paediatric Surgeon 0 1 6 5 0.17 6 Paediatrician 3 2 34 32 0.06 31 Physician 3 4 22 18 0.18 19 Pathologist 2 1 3 2 0.33 1 Psychiatrist 3 1 20 19 0.05 17 Urologist 3 0 10 10 0.00 7 Nursing Intensive Care Nurse 0 64 123 59 0.52 123 Mental Health Nurse 0 29 36 7 0.81 36 Midwife 0 234 294 60 0.80 294 Nurse Anaesthetist 0 8 17 9 0.47 17 Oncology Nurse 0 0 8 8 0.00 8 Operating Theater Nurse 0 95 88 -7 1.08 88 Ophthalmic Nurse 0 1 8 7 0.13 8 Paediatric Nurse 0 153 146 -7 1.05 146 Registered General Nurse 992 338 316 -22 1.07 Renal Nurse 0 11 4 -7 2.75 4 Laboratory 0 Medical Laboratory Scientist 46 22 50 28 0.44 4 SCMLT 11 11 38 27 0.29 27 Pharmarcy 0 Dispensary Assistant 6 6 11 5 0.55 5 Pharmacist 8 8 15 7 0.53 7 Pharmacy Technician 7 7 14 7 0.50 7 Radiography Diagnostic Radiographer 19 16 15 -1 1.07 Total 1129 1028 1351 323 0.76 222

vi WISN Main Study Report 2017

Annexure 2: WISN Results for United Bulawayo Hospital, Zimbabwe 2017

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Anaesthetist 3 1 8 7 0.13 5 Cardio-Thoracic Surgeon 1 0 1 1 0.00 ENT Surgeon 2 0 1 1 0.00 Hospital Medical Ofﬁcer 40 68 30 38 2.27 General Surgeon 3 3 6 3 0.50 3 Neuro-Surgeon 1 0 1 1 0.00 Obstetricians and Gynaecologist 3 1 16 15 0.06 13 Ophthalmologist 1 2 9 7 0.22 8 Orthopaedic Surgeon 2 1 4 3 0.25 2 Paediatricians 3 0 5 5 0.00 2 Pathologist 3 3 3 0 1.00 Physician 3 2 8 6 0.25 5 Psychiatrist 0 0 3 3 0.00 3 Radiologist 3 0 1 1 0.00 Urologist 1 1 1 0 1.00 Nursing Intensive Care Nurse 29 40 11 0.73 40 Midwife 101 104 3 0.97 104 Nurse Anaesthetist 5 4 -1 1.25 4 Oncology Nurse 3 3 0 1.00 3 Operating Theater Nurse 37 25 -12 1.48 25 Ophthalmic Nurse 15 36 21 0.42 36 Psychiatric Nurse 0 4 4 0.00 4 Registered General Nurse 601 320 219 -101 1.46 Renal Nurse 0 1 1 0.00 1 Laboratory Medical Laboratory Scientist 23 6 7 1 0.86 SCMLT 10 4 5 1 0.80 Pharmarcy 0 Dispensary Assistant 6 5 5 0 1.00 Pharmacist 10 3 5 2 0.60 Pharmacy technician 10 8 13 5 0.62 3 Radiography Radiographer 9 9 9 0 1.00 Ultra-Sonographer 2 0 4 4 0.00 2 X-Ray Operator 4 3 1 -2 3.00 Total 744 630 582 -48 1.08 263

vii Annexure 3: WISN results for Masvingo Provincial Hospital, Zimbabwe 2017

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Doctors General Surgeon 1 1 2 1 0.50 1 Government Medical Ofﬁcer 12 11 25 14 0.44 13 Obstetrician and Gynaecologist 1 0 3 3 0.00 2 Ophthalmologist 1 1 1 0 1.00 Anaesthetist 1 0 2 2 0.00 1 Nursing Intensive Care Nurse 9 13 4 0.69 13 Mental Health Nurse 3 5 2 0.60 5 Midwife 59 50 -9 1.18 50 Nurse Anaesthetic 5 2 -3 2.50 2 Operating Theatre Nurse 12 12 0 1.00 12 Ophthalmic Nurse 1 1 0 1.00 1 Registered General Nurse 188 103 160 57 0.64 Laboratory Medical Laboratory Scientist 6 3 6 3 0.50 SCMLT 3 5 8 3 0.63 5 Pharmacy 0 Dispensary Assistant 3 3 2 -1 1.50 Pharmacy Technician 4 4 3 -1 1.33 Pharmacist 3 3 3 0 1.00 Radiography 0 Radiographer 3 2 3 1 0.67 Ultra-sonographer 0 0 2 2 0.00 2 X-ray operator 0 1 1 0 1.00 1 Total 226 226 304 78 0.74 108

Annexure 4: WISN results for Chinhoyi Provincial Hospital, Zimbabwe 2017

Nursing WISN Main Study Report 2017 Intensive Care Nurse 0 3 7 4 0.43 7 Mental Nurse 0 9 12 3 0.75 12 Midwife 0 47 58 11 0.81 58 Nurse Anaesthetist 0 7 3 -4 2.33 3 Operating Theatre Nurse 0 5 9 4 0.56 9 Ophthalmic Nurse 0 3 3 0 1.00 3 Registered General Nurse 259 185 180 -5 1.03 Laboratory Medical Laboratory Scientist 9 4 11 7 0.36 2 Pharmacy 0 Dispensary Assistant 2 1 2 1 0.50 Pharmacy Technician 6 6 2 -4 3.00 Pharmacist 2 1 2 1 0.50 Radiography 0 Radiographer 4 4 6 2 0.67 2 X-Ray Operator 1 1 1 0 1.00 Total 297 289 326 37 0.89 112

Annexure 5: WISN results for Tsholotsho District Hospital, Zimbabwe 2017

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Doctors Government Medical ofﬁcer 3 2 7 5 0.29 4 Nurses Mental health nurse 0 2 4 2 0.50 4 Midwife 0 20 35 15 0.57 35 Nurse anaesthetist 0 2 1 -1 2.00 1 Operating theater nurse 0 4 2 -2 2.00 2 Ophthalmic nurse 0 4 5 1 0.80 5 Registered general nurse 86 38 28 -10 1.36 Pharmacy Dispensary Assistant 2 2 3 1 0.67 1 Pharmacy Technician 2 2 5 3 0.40 3 Laboratory 0 SCMLT 0 1 3 2 0.33 3 Radiography Radiographer 1 0 1 1 0.00 X-ray Operator 3 1 1 0 1.00 Total 97 78 95 17 0.82 58

ix Annexure 6: WISN results for Beitbridge District Hospital, Zimbabwe 2017 Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Government Medical Ofﬁcer 3 3 11 8 0.27 8 Nursing Mental Health Nurse 0 1 4 3 0.25 4 Midwife 0 38 67 29 0.57 67 Nurse Anaesthetic 0 1 2 1 0.50 2 Operating Theatre Nurse 0 2 4 2 0.50 4 Ophthalmic Nurse 0 2 1 -1 2.00 1 Registered General Nurse 82 40 58 18 0.69 Pharmacy Dispensary Assistant 1 1 1 0 1.00 Pharmacy Technician 3 3 4 1 0.75 1 Pharmacist 1 1 3 2 0.33 2 Laboratory Medical Laboratory Scientist 3 1 3 2 0.33 SCMLT 2 1 3 2 0.33 1 Radiography Radiographer 1 0 1 1 0.00 X-ray operator 2 2 1 -1 2.00 Total 98 96 163 67 0.59 90 Annexure 7: WISN results for Howard Mission Hospital, Zimbabwe 2017

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Doctors Government Medical Ofﬁcer 3 3 16 13 0.19 13 Nursing Midwife 0 12 53 41 0.23 53 Nurse Anaesthetist 0 2 2 0 1.00 2 Operating Theatre Nurse 0 1 10 9 0.10 10 Registered General Nurse 36 17 55 38 0.31 19 Pharmarcy Dispensary Assistant 0 0 2 2 0.00 2 Pharmacy Technician 0 0 4 4 0.00 4 Pharmacist 0 0 10 10 0.00 10 Laboratory SCMLT 2 1 7 6 0.14 5 Medical Lab Scientist 3 1 4 3 0.25 1 Radiography X-Ray Operator 0 0 2 2 0.00 2 Total 44 37 165 128 0.22 121

x WISN Main Study Report 2017 Annexure 8: WISN results for Kariyangwe, Mission Hospital, Bikita, Chihota Rural Hospitals, Senkwazi and Lupote Clinics, Zimbabwe 2017

Kariyangwe, Mission Hospital

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Midwife 3 7 4 0.43 7 Registered general nurse 8 5 14 9 0.36 6 Total 8 8 21 13 0.38 13

Bikita Rural Hospital Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Midwife 8 11 3 0.73 11 Registered General Nurse 29 9 18 9 0.50 Total 29 17 29 12 0.59 11

Chihota Rural Hospital

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Midwife 3 5 2 0.60 5 Registered general nurse 18 15 5 -10 3.00 Total 18 18 10 -8 1.80 5

Senkwazi Clinic

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Registered general nurse 3 3 5 2 0.60 2

Lupote Clinic

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Registered general nurse 3 3 6 3 0.50 3

Grand Total 2433 3057 624 0.80 1008

xi The study results show some institutions experiencing high workload while some facilities had no workload pressure at all hence a decision might be required on possibility to move some cadres to areas with shortages before considering increasing staff based on WISN staff calculations. Although WISN calculated staff requirements for tertiary institutions, there is need to first address the distortions in the referral system where central hospitals are experiencing artificial workload. In addition there is need to lobby government to consider lifting the freeze on recruitment to fill vacant posts so as to allow the Ministry to be able to fill all the vacant posts. Once the vacant posts are filled, then the Board may consider implementing WISN results for the Health sector. The following recommendations were drawn from the WISN study and are for consideration in the HRH planning process for the Health sector.

1. The staff establishment for the Ministry is still not operating at full capacity coupled with lot of vacant posts. Therefore there is need for the Board to lobby with Treasury for the unfreezing and filling of all current vacant posts for the five categories studied (Doctors, Nurses, Laboratory, Radiography and Pharmacy) before the review of the staff establishment based on WISN results.

2. In future, resources permitting, the Board and MoHCC needs to study other remaining cadres based on a clearly defined prioritization of HRH at all levels of care. The Board may need to also consider studying all other remaining facilities that were not studied covering all levels of care so as to get a true of the staff establishment of the Ministry. There is need to conduct that another WISN study at least two years after implementation of the initial study results.

3. Capacitating health facilities with resources for optimum utilization of existing Health professional as well as service provision.

4. Integrating existing Health Information system and Human Resources for Health information system for future staff planning.

5. Introduction of sustainable staff retention framework driven by Government of Zimbabwe to reduce vacancy rates for specialist cadres.

6. The Board needs to develop a training plan that will sustain implementation of WISN staff calculations on specialty areas.

In conducting the study there some challenges which affected the speedy implementation of the study plans. The lack of a comprehensive electronic integrated health information system complicated the data collection process. Inadequate financing for the study which, delayed the commencement of the WISN study after pilot, resulted in the exclusion of other staff categories and limited the scope of the study to a few selected sites.

xii WISN Main Study Report 2017 Table of Contents

Abbreviations ...... i Acknowledgements ...... ii Abstract ...... v List of Tables ...... 2 List of Figures ...... 3 1. Introduction and Background information...... 4 1.1. Introduction ...... 4 1.2. Human Resources for Health (HRH) situation in Zimbabwe ...... 6 1.3. WISN Implementation in Zimbabwe Health Sector ...... 8 1.4 The WISN Process in Zimbabwe ...... 11 1.5 Objectives of WISN study in Zimbabwe ...... 11

2 WISN MAIN STUDY METHODOLOGY ...... 12 2.1 The Identification of study group/Target and Study facilities ...... 12 2.2 Data Collection ...... 12 2.3 Data validation and Analysis ...... 13

3. WISN STUDY RESULTS AND FINDINGS ...... 16 3.1 Harare Central Hospital ...... 16 3.2 United Bulawayo Hospitals (UBH)...... 21 3.3 Masvingo Provincial Hospital ...... 26 3.4 Chinhoyi Provincial Hospital ...... 30 3.5 Tsholotsho District Hospital ...... 33 3.6 Beitbridge District Hospital ...... 36 3.7 Howard Mission Hospital ...... 38 3.8 Kariyangwe Mission Hospital ...... 40 3.9 Bikita Rural Hospital ...... 41 3.10 Chihota Rural Hospital ...... 42 3.11 Senkwazi Clinic ...... 42 3.12 Lupote Clinic ...... 43

4. DISCUSSION OF WISN: ZIMBABWE HEALTH SECTOR ...... 44 4.1 Implications of WISN in the Health Sector ...... 44

5. CROSS CUTTING ISSUES ...... 47 6. RECOMMENDATIONS ...... 47 7. STUDY LIMITATIONS ...... 48 8. CONCLUSION ...... 48 9. ANNEXURE ...... 48 10. WISN STAFF GALLERY...... 55

1 LIST OF TABLES

Table 1:1 Health workforce distribution per 10 000 population as at 2013 ...... 4

Table 1:2 MoHCC HRH vacancy levels for selected cadres ...... 8

Table 2:1 Data Collection Deployment ...... 13

Table 3:1 WISN Results for Doctors HCH, Zimbabwe 2017 ...... 16

Table 3:2 WISN Results for Nurses, HCH, Zimbabwe, 2017 ...... 18

Table 3:3 WISN Results for Laboratory, Pharmacy & Radiography, HCH, Zimbabwe, 2017...... 20

Table 3:4 WISN Results for Laboratory, Pharmacy & Radiography, HCH, Zimbabwe, 2017...... 21

Table 3:5 WISN Doctors, United Bulawayo Hospitals, Zimbabwe, 2017 ...... 23

Table 3:6 WISN Results for Nursing staff, UBH, Zimbabwe, 2017 ...... 25

Table 3:7 WISN Results Laboratory, Pharmacy & radiography UBH, Zimbabwe, 2017 ...... 26

Table 3:8 WISN Results Doctors, Masvingo Provincial Hospital, Zimbabwe, 2017 ...... 27

Table 3:9 WISN Results Nurses, Masvingo Provincial Hospital, Zimbabwe, 2017 ...... 28

Table 3:10 WISN Results Laboratory, Pharmacy and Radiography Masvingo Provincial Hospital, Zimbabwe, 2017...... 30

Table 3:11 WISN Results Doctors, Chinhoyi Provincial Hospital, Zimbabwe, 2017 ...... 31

Table 3:12 WISN Results Nurses, Chinhoyi Provincial Hospital, Zimbabwe, 2017 ...... 32

Table 3:13 WISN Results Radiography, Laboratory and pharmacy, Chinhoyi Provincial Hospital, Zimbabwe, 2017 ...... 33

Table 3:14 WISN Results Tsholotsho District Hospital, Zimbabwe, 2017 ...... 36

Table 3:15 WISN Results for Selected cadres, Beitbridge Hospital, Zimbabwe, 2017 ...... 38

Table 3:16 WISN Results, Howard Mission Hospital, Zimbabwe, 2017 ...... 40

Table 3:17 WISN Results Nurses, Kariyangwe Mission Hospital, Zimbabwe, 2017 ...... 41

Table 3:18 WISN for Nurses, Bikita Rural Hospital, Zimbabwe, 2017 ...... 42

Table 3:19 WISN Results For Nurses, Chihota Rural Hospital, Zimbabwe, 2017 ...... 42

Table 3:20 WISN Results Nurses, Senkwazi Clinic, Zimbabwe, 2017 ...... 43

Table 3:21 WISN Nurses Lupote Clinic, Zimbabwe, 2017 ...... 47

2 WISN Main Study Report 2017

LIST OF FIGURES

Figure 1:1: Doctors, Midwives and Nurses Trend in SADAC ...... 7

Figure 1:1:2Overview of WISN Road Map ...... 9

Figure 1:3 WISN process followed in Zimbabwe...... 10

Figure 2:1 WISN Selected sites ...... 12

3 1. Introduction and Background information

1.1. Introduction

The importance of Human Resources for Health (HRH) in improving access to quality Health Care delivery continues to be prioritized and scaled up at global, regional and national levels. The global shortage of Human Resources for Health continues to negatively affect health service delivery in many countries. Socio-economic factors and political factors are the major contributor to the global shortage as health professionals exit from source countries in pursuit of better conditions of service and entry into receiving countries leading to higher attrition in the former. The increasing disease burden has also contributed to staff shortages thereby negatively affecting health service delivery in source countries. The Table below shows a comparison of selected Health Workforce distribution against population at global, regional (Africa) and national (Zimbabwe) levels.

Table 1:1 Health workforce distribution per 10 000 population as at 2013

Cadre Global Regional National Zimbabwe

Physicians 13.9 2.7 0.8

Pharmacy 4.5 0.8 0.4

Nursing and Midwifery 28.6 12.4 13.4

Source: Atlas of Africa Health Stats 2016

In response to this challenge, WHO developed the Global Code of Practice on the International Recruitment of Health Personnel in order to reduce the negative effects of health worker migration. The High Level Commission on Health and Economic Growth (HEEG Commission 2016) noted that there was need to invest in the Health Workforce to help in the achievement of the Sustainable Development Goals SDG. Documents such as the AU Agenda 2063 (2014 – 2023), ECSA Resolutions of the Health Ministers Conferences (2004-2015) and SADC Regional Indicative Strategic development plan (2005 – 2020) offer the regional direction on how HRH can be planned for using various health workforce planning tools.

The Global HRH Strategy (2030) provides the strategic direction to countries in HRH planning towards the achievement of the Sustainable Development Goals and Universal Health Coverage. Among the strategies the focus by member countries is to; contribute to effective health coverage and strengthened health systems at all levels through evidence-informed policies on human resources for health; address shortages and improve distribution of health workers aligned with the current and future needs of the population and the health; build the capacity of institutions at all levels for effective leadership and governance in human resources for health as well as to strengthen data on human resources for health, for monitoring and ensuring accountability for the implementation of national, regional strategies, and the Global Strategy.

The WHO HRH Observer issue number 3 of 2010 notes that, “there are several Health Workforce Planning tools used to manage HRH” globally, regionally and nationally to project future staffing requirements which include,

(i) The workforce-to-population ratio method: This is a projection of future numbers of required health workers based on proposed thresholds for workforce density (e.g. physicians per 10 000 population). This approach does not require too much data,

4 WISN Main Study Report 2017

but does not to adequately address other key variables, aside from population growth, that can affect the type and scale of future health services provision and the associated work force. This approach is based on the assumption that there is homogeneity at the levels of the numerator (all physicians are equally productive and will remain so) and of the denominator, (all populations have similar needs, which will remain constant). Such assumption is clearly risky.

(ii) The health needs method: This is a more in-depth approach that explores likely changes in population needs for health services, based on changes in patterns of disease, disabilities and injuries and the numbers and kinds of services required to respond to these outcomes. This approach entails collecting and analyzing a range of demographic, socio-cultural and epidemiological data.

(iii) The service demands method: This approach draws on observed health services utilization rates for different population groups, applies these rates to the future population profile to determine the scope and nature of expected demands for services, and converts these into required health personnel by means of established productivity standards or norms. This approach also requires consideration of multiple variables, as well as collecting and using the data relevant to these variables.

(iv) The service targets method: This is an alternative approach that specifies targets for the production (and presumed utilization) of various types of health services and the institutions providing them based on a set of assumptions, and determines how they must evolve in number, size and staffing in accordance with productivity norms.

(v) WISN: The workload indicators of staffing needs (WISN) methodology: is a tool developed and field-tested by WHO for setting activity (time) standards for health personnel and translating these into workloads as a rational method of setting staffing levels in health facilities (WHO, 1998). Imbalances between staffing and workload often reflect that staffing depends on facility capacity (e.g. number of in-patient beds) and not on service utilization. Ministries of health are paying increasing attention to approaches for improving efficiency in the deployment of staff and the WISN methodology incorporates a mixture of professional judgment and work activity measurement to determine workload-based staffing norms.

The WISN method has been used to improve HRH planning in other countries, such as Bangladesh, Turkey, Uganda and Indonesia (Hossain and Alam, 1999; Namaganda, 2004; Ozcan and Hornby, 1999, Kolehmainen- Aitken, RL et al, 2009). Countries such as Botswana, Ghana, Kenya and Namibia implemented the WISN tool and in the past have shared their WISN experiences whilst countries such as DRC, Egypt, and Rwanda were at various stages of implementing WISN (WHO Human Resources for Health Observer Series No 15). Zimbabwe in 2012 also made a policy decision to adopt the WISN tool based on the learning experiences from the above mentioned countries, to address its HRH staffing challenges in the health sector.

5 1.2. Human Resources for Health (HRH) situation in Zimbabwe

Zimbabwe has a population of over 13 million people with the country’s two metropolitan provinces having high population densities compared to the eight rural provinces (Population Census Report: 2012). The Government of Zimbabwe work towards having the highest possible level of health and quality of life for all citizens, to be achieved through the concerted efforts of the government, individuals, communities and organizations which will allow them to participate fully in the socio-economic development of the country (NHS, 2016 – 2020 ). The national government strives to attain this vision through guaranteeing every Zimbabwean access to comprehensive and effective health services. Obviously these health comes would require vibrant contemporary policy interventions that will ensure effective and efficient utilization of the available HRH.

The review of existing data and evidence regarding the performance of the Zimbabwean’s health sector shows that the masses still faces a double burden of epidemic diseases of communicable and non-communicable diseases. Non-communicable diseases are emerging as foremost cause of morbidity and mortality amongst both the rich and the poor in the country. These challenges are compounded by health systems constraints correlated to shortages of critical health workforce amongst health institutions across the country.

Guided by the international and regional strategies on health issues, Zimbabwe developed its National Health Strategy (2016 – 2020) informed by the ZIMASSET document (2013 – 2018) which clearly picked out the need to review the staff establishment for the health sector as part of the quick wins that should have been achieved before the end of year 2016. The National Health Strategy (2016 – 2020) is to direct the improvement of health services delivery on five-year cycles and is expected to guide the HRH planning and utilization of Health workforce through the HRH policy developed by HSB in 2010. The HRH policy sets the tone for the provision of the HRH in response to the needs indicated in the National Health Strategy.

In Zimbabwe, similarly to other countries in Sub-Saharan Africa, health service delivery continues to be hindered by shortage of Human Resources for Health (HRH). The Ministry articulated the NHS (2016 – 2020) policy to provide equity of access to health services however, the lack of qualified health personnel in several areas has inadvertently led to inequitable service provision mostly due to the unequal distribution of health care workers across the country. The shortage of HRH has also affected the full implementation of the Primary Health Care (PHC) s trategy as well as provision of specialist care. Many factors have contributed to the critical shortage of health workers including insufficient capacity for HRH planning, absence of benchmarks on how best to improve the current staffing situation and making decisions in an integrated manner to address HRH requirements.

The World Health Organization recommends a minimum staff-population ratio of 2.5 (doctors, nurses and midwives) per 1000 people. The staff-population ratio in Zimbabwe is 1.2 per 1000 in the public sector falling below the recommended minimum standard (Global Health Observatory Data, 2017). Zimbabwe’s doctors situation still currently fall below the minimum threshold of 23 doctors per 10 000 population that was recommended by the WHO as sufficient to achieve coverage of primary healthcare needs. Obviously such a gap has dare consequences on achievement of health outcomes as envisaged by the government. As such, the country can be considered as still facing an HRH crisis since the ratios fall under the recommended minimum threshold.

In 1985, the World Health Organization declared that the Zimbabwean healthcare system was among the best in the developing world. However, indications are that most of the gains

6 WISN Main Study Report 2017 after independence have been reversed by constant shortage of requisite and adequate health personnel to address the ever increasing burden of communicable and non-communicable diseases. Soon after 1995 the availability of health professionals (Doctors and Pharmacy) began to take a sharp decrease despite training output channeled from medical training institutions in the country. The historical trend of doctors, Midwives and Nurses situation in the SADAC block is reflected in the figure below.

Figure 1:1: Doctors, Midwives and Nurses Trend in SADAC

South Africa

Botswana

Zimbabwe

According to CIA World Fact sheet, Zimbabwe along with other SADAC states, physician density (physicians/1,000 population) in 2009 – 2015 was below one compared to other countries like Cuba 7; Greece 6; Switzerland 4; Libya 2; South Africa 1. Zimbabwe has suffered immensely from a brain drain of healthcare physicians since 2008 when the country experienced unprecedented economic decline. Indications are that the health sector in the country is deteriorating at alarming rates with some hospitals having an estimated unprecedented patient-doctor ratio of 1:8 000, well above the 1:500 recommended by the World Health Organization. This implies that the health institutions are currently experiencing high workloads as they are operating below the average number of health professionals required. Unfortunately, this has also occurred at an era when the disease burden is mounting especially due to the coming on of HIV/AIDS, TB and other infectious and non-infectious diseases. On the other hand, the increasing burden has led to heavy workloads resulting in staff suffering ‘burn out’ and getting frustrated due to the inability to provide quality care (Masango et al, 2008).

The Health Service Board and the Ministry of Health and Child Care (MoHCC) continued to face a challenge to drop the average vacancy rates from above 12% in 2013 to below 10% an ideal target that was set to be achieved by 2015.

7 Table 1:2 MoHCC HRH vacancy levels for selected cadres

Period Nurses Pharmacy Doctors %

2013 14% 27% 37%

2014 15% 34% 33%

2015 17% 30% 35%

2016 14% 32% 33%

Source: HSB Annual Reports 2013 – 2016

The MoHCC, Missions and Council health facilities establishments were last comprehensively reviewed in 1983 (MoH Data). Over the years, the creation of additional posts has been guided by requests and submissions from provinces and central hospitals largely relying on estimates, which have in some cases not been able to create/recommend the staff requirements that can cope with the increased workload. Due to population increase, emerging dual burden of communicable and non-communicable diseases, chronic illnesses and health related emergencies/outbreaks, effort was made to holistically review the staff establishment but the review was done without a scientific methodology. All the efforts to address the high vacancy rates were hampered by lack of effective HRH planning tools that would provide tangible data to be used in forecasting the required health personnel at all levels of care.

Given the above challenges, the Ministry of Health and Child Care (MoHCC) establishment is no longer coping with these emerging challenges and increased workloads hence the need to adopt a scientific HRH planning tool that would help the Board and Ministry to address HRH crisis in the sector. Obviously adoption of such a planning approach would go a long way to support the implementation of the envisaged National Health Strategy (2016 – 2020) health outcomes.

1.3. WISN Implementation in Zimbabwe Health Sector

Since 2001 the review of the staff establishment has continued to be done on an adhoc basis after a series of lobbying Treasury who then granted authority to create posts for what was only termed critical shortage areas at any given time. Given the limited fiscal space, both the Health Service Board and MoHCC have found it difficult to convince Treasury on the need to review the staff establishment thus the HSB and MoHCC felt the need to adopt an approach that would bring scientific evidence to determine the staffing needs.

The National Health Strategy (2016-2020) cites the growing pressure to reduce vacancy rates for specialized skills which include Doctors, Nursing specialties in the Ministry of Health and Child Care and the grant aided Mission and Rural District health facilities (Public health sector).

In 2012 the HSB and MoHCC adopted WISN out of the various health workforce planning tools. WISN is a human resources management planning tool developed by the World Health Organization (WHO) to help determine the staffing requirements per specific category based on workload at a given health facility. The HSB and MoHCC received funding support from the Health Transition Fund (HTF) now Health Development Fund (HDF) and Ministry of Finance and Economic Development to implement the WISN program in Zimbabwe. Under the technical guidance from WHO, preparatory work was done from 2012 including training of key stakeholders (professional bodies, training institutions, Ministry of Finance and Economic Development, Human Resources Information System (HRIS) Information Technology

8 WISN Main Study Report 2017 experts, Partners and employers - the Health Service Board and the Urban Local Authorities).

The key stakeholders were trained with anticipation that they would be instrumental in spearheading the implementation process. In addition, the WISN implementation structures were put in place including appointment of the Steering Committee, Technical Taskforce and Experts Working Group (EWG). The implementation of WISN in Zimbabwe took a phased approach as guided by the availability of resources. After extensive consultations, implementation of WISN in Zimbabwe commenced on selected 5 categories namely Doctors, Nurses, Pharmacy, Laboratory and Radiography. A pilot study that was conducted in 2015 gave the Board and the Ministry lessons and experiences that assisted in the development of realistic workload standards that were used in the main study in 2016. A total of six (6) pilot study sites (5 sites in Mashonaland East and Harare Maternity Hospital) were selected based on the availability of data.

The figure below summaries the WISN work flow process used in the Zimbabwean health sector.

Figure 1:1:2 Overview of WISN Road Map

Source: Zimbabwe WISN, 2016

9 The WISN method lists several advantages that can be realized when member states choose to implement the tool. However, some limitations of the WISN method need to be noted also. In selecting WISN tool for Zimbabwe, the following advantages were noted amongst others; i. WISN results would help the Zimbabwean Health sector to determine how best to improve the current staffing situation and set better priorities for allocating new staff or transferring existing staff. It would assists to identify inequities in current staffing of health facilities or areas and decide which health facilities or areas should receive the highest priority. ii. WISN can help determine a better way to allocate new functions and transfer existing functions to different health worker categories (task shifting). iii. WISN calculations use current professional standards for performing a particular component of work allows you to see which facilities the current professional performance is low in comparison with other facilities. By using improved professional standards in the WISN calculations, the Board/Ministry can calculate how many extra staff would be required in a particular cadre to achieve these new standards. iv. WISN assists to plan future staffing of health facilities. Instead of current workload data, in the WISN calculations one can use data on anticipated workloads of planned future services. This allows one to calculate how many health workers of a particular type would be required to deliver future services. v. WISN helps to examine the impact of different conditions of employment on staff requirements. They include changes in the length of the working week, increased vacation or different in-service training policies, for example.

Source: WHO WISN User Manual (2010)

The figure below highlights the WISN tasks and the structures that were involved in the planning and implementation of WISN in Zimbabwe.

Figure 1:3 WISN process followed in Zimbabwe TASK RESPONSIBLE TECHNICAL AND FINANCIAL SUPPORT Country request for WISN support The Ministry of Health and Child Care requested WHO to assist with the understanding of the HSB and MOHCC tool, including resource implications of the process Preparation for briefing with senior WHO facilitated the briefing as requested management, selected partners and HSB and MOHCC relevant stakeholders Briefing with technical Team (WHO) Led by ministry of health in collaboration with Health Service Board and ministry of WHO country office HSB and MOHCC health only or ministry of health with core partners) Development of draft concept note Based on the orientations from senior HSB and MOHCC management briefing indicating the objectives and targets of the process Preparation of training of trainers, Ministry of health in collaboration with partners HSB and MOHCC including resource mobilization and WHO WISN training of trainers, including Training of trainers facilitated by WHO development of a draft HSB and MOHCC implementation strategy Appointment of relevant of WISN Relevant committees appointed by Health Committees HSB and MOHCC Service Board 10 Implementation of the roadmap or Financial support from ministry of health and strategy partners Technical guidance from WHO or experts during TTF the various phases of the roadmap, such as development of activity standards, piloting, data collection, and entering data in the WISN tool Review of the establishment Bidding of posts submitted to Ministry of HSB and MOHCC Finance and Economic Development

TASK RESPONSIBLE TECHNICAL AND FINANCIAL SUPPORT Country request for WISN support The Ministry of Health and Child Care requested WHO to assist with the understanding of the HSB and MOHCC tool, including resource implications of the process Preparation for briefing with senior WHO facilitated the briefing as requested management, selected partners and HSB and MOHCC relevant stakeholders Briefing with technical Team (WHO) Led by ministry of health in collaboration with Health Service Board and ministry of WHO country office HSB and MOHCC health only or ministry of health with core partners) Development of draft concept note Based on the orientations from senior HSB and MOHCC management briefing indicating the objectives and targets of the process Preparation of training of trainers, Ministry of health in collaboration with partners HSB and MOHCC including resource mobilization and WHO WISN training of trainers, including Training of trainers facilitated by WHO WISN Main Study Report 2017 development of a draft HSB and MOHCC implementation strategy Appointment of relevant of WISN Relevant committees appointed by Health Committees HSB and MOHCC Service Board

Implementation of the roadmap or Financial support from ministry of health and strategy partners Technical guidance from WHO or experts during TTF the various phases of the roadmap, such as development of activity standards, piloting, data collection, and entering data in the WISN tool Review of the establishment Bidding of posts submitted to Ministry of HSB and MOHCC Finance and Economic Development

1.4 The WISN Process in Zimbabwe

The implementation of WISN in Zimbabwe involved extensive preparation process as well as engagement of a number of stakeholders essential to influence the success of implementation and adoption of the WISN results.

1.5 Objectives of WISN study in Zimbabwe

WISN in Zimbabwe set out broadly to determine Health Worker distribution, planning and management across public health facilities and specifically to;

1.5.1 Identify health facilities with staff shortages in relation to workload. 1.5.2 Determine how best to improve current staffing 1.5.3 Identify where there is workload pressure amongst the five cadres at all levels of care 1.5.4 Plan for future staffing and to proffer recommendations in addressing HRH planning challenges for the public health sector.

11 2. WISN MAIN STUDY METHODOLOGY

The WISN study in Zimbabwe followed a defined method as guided by WHO WISN user manual.

2.1 The Identification of study group/Target and Study facilities

A total of 5 cadre categories were studied namely the Doctors, Pharmacy, Nursing, Radiography and Laboratory because these were identified as the core required professionals for achievement of basic health outcomes.

The sampling frame was all public health facilities (government, mission and rural district council) at all levels of care with data high completeness for 2014. A multi stage clustering stratified random sampling was done for Rural health center, District, Mission and Provincial institutions. For the Central hospital, convenience sampling was utilized to select high volume and low volume study facilities. The MoHCC Health Information unit was engaged to assist in sampling the facilities based on the completeness of data, level of care and volume of work. The following sites were studied.

Figure 2:1 WISN Selected sites Level Name of Institution District Province/Central Hospital Rural Health Centre/ Senkwanzi Kwekwe Midlands Clinic Lupote Hwange Matabeleland North

Chihota Marondera Mashonaland East

Rural Hospital Bikita Bikita Masvingo

Kariangwe Binga Matabeleland North Mission Hospital Howard Mazoe Mashonaland Central

Tsholotsho Tsholotsho Matabeleland North District Hospital Beitbridge Beitbridge Matabeleland South

Masvingo Masvingo Masvingo Provincial Hospital Chinhoyi Makonde Mashonaland West

Central United Bulawayo Hospitals Bulawayo Central Harare Central Hospital Harare

2.2 Data Collection

The Data collection tools for the various categories of staff were developed, pre tested and validate with the involvement of the EWG, TTF and data collectors to come up with workload components and activity standards. The data collection tool was piloted at Harare Central Hospital (Maternity) Marondera Provin- cial Hospital, Mutawatawa District Hospital, Luisa Guidotti Mission Hospital, Beatrice Rural Hospital and Karimbika Rural Health Centre. The piloted health facilities covered both high and low workload facilities as guided by the Ministry’s Health Information Unit. Nurses were engaged and trained as data collectors. Nurses were selected since they understood the data sources and health care processes. The formation of data collection teams also followed the WISN workload distribution envisaged in conducting the study.

12 WISN Main Study Report 2017 Table 2:1 Data Collection Deployment

Number of Data Number of Team Area of Study Collectors Supervisors 1 Harare Central Hospital 20 2

2 United Bulawayo Hospitals 15 2

3 Masvingo Provincial Hospital, Beitbridge District

Hospital and Bikita Rural Hospital 8 2

4 Chinhoyi Provinical Hospital and Howard Mission Hospital 6 2

5 Tsholotsho district hospital, Kariyangwe Mission Hospital, Sengwasi and Lupote clinic 6 2

On arrival at study sites meetings were held with the hospital authorities, health information systems staff, HR staff, and representatives of the cadres being studied to sensitize them on the WISN process.

Data collectors used the prepared data collection tool for each cadre under study to collect 2016 annual statistics with guidance from supervisors drawn from TTF. Information was collected from Health Information Systems, primary source documents and also observations to verify activity standards. Meetings were held prior and during data collection with the carders to verify the completeness accuracy and consistence of the data which was being collected.

The TTF verified the collected data to check missing entries, duplications and also made sure that annual workload statistics that where being collected was defined in the same way at all study sites by data collectors.

2.3 Data validation and Analysis

The EWG which had defined the workload components and set the activity standards for each staff category was re-engaged after the data collection exercise to validate and approve any changes to service standards made during the data collection exercise and ensure that the changes were appropriate and reasonable.

Data was then analyzed using the WISN Multilingual version 2.2.167.1 software to calculate the required staff, ratios and the cost implications for every staff category. The analysis of WISN results was at every stage done in consultation with the WHO Regional Technical Support Unit based in Zimbabwe. Upon finalizing the preliminary WISN results/ findings, it was necessary for the WISN results/ findings to be finally validated by WHO and cleared for final use by the Zimbabwe government in its HRH planning process. This stage was essential as it was meant to create mutual understanding between the Board, Ministry and WHO on the study findings as well as ascertain credibility on the WISN study conducted for the Zimbabwe Health sector.

The WISN Technical Taskforce submitted the MoHCC WISN study findings to WHO AFRO WISN expert Team for validation. The validation process was undertaken in 21 November 2017 through a Team-Viewer teleconference from Kintele, in Brazzaville and the following Technical inputs were raised and were to be attended to before utilization of WISN results for Zimbabwean health sector.

2.3.1 Calculation of Average Working Time ( all cadres)

The WHO AFRO WISN Experts had noted that there was no uniformity in the calculation of Leave categories. The software calculations had indicated varying figures of 12 days in some 11 days. The WISN Technical Taskforce had erred in the process of calculating available working time by not considering entitlements and inputting varying figures for public holidays. The WISN Technical Taskforce concurred to the error in calculating Available working time for all staff categories. The AWT rule for calculating AWT was adhered to and all staff categories studied was adjusted accordingly.

13 The primary scenario noted was that Nurses do not have Public Holidays as their roasters are designed in such a manner that caters for continuity in service delivery during such holidays. There was a challenge in the calculation of training days for nursing category whilst in other studied categories the issue was taken care of on continuous professional development standard.

2.3.2 DOCTORS: - WORKLOAD STATISTICS CALCULATION

The WHO AFRO WISN Technical Experts initially observed that there was variation on time allocation from Consultations at Out-patient Department (OPD). The observation culminated was to revisit time allocated for each activity for Doctors from 25 minutes to possibly 10 minutes. Experts (Doctors) were consulted on time taken to conduct consultations and the Experts noted that consultations done at OPD – district level is different from those done at Provincial level. Therefore consultations seem to vary from level to level to cater for complications of the cases attended to at any given time. In a normal situation a Doctor should take amply time to do a consultation without being compelled to consider covering large number of patients per day. During the same validation process it was observed that the ward rounds standard of 15 minutes by doctors was rather too high. It was recommended that the time be reduced to at most 6 minutes. The Doctors (Experts) felt that the time for conducting ward rounds is fair being placed on 15 minutes taking consideration of local circumstances. In order to meet professional standards expected by the Ministry, doctors felt it would be fair to state average 15 minutes taking other variables i.e. age, language of patients consulting. Part of the considerations was to harmonize the activities done by doctors noting the he variances that continued to distort the staff calculations. Another major observation that was taken to the expert working group was on possibility of averaging the service standards for Anesthetists doctors of which after consultations it was not that it was not possible.

2.3.3 NURSE- MIDWIFE

Workload Statistics on Monitoring labour encompass all small activities. The 420 minutes allocated for monitoring labour was noted as too high. The WHO AFRO WISN Technical Experts felt the midwife will not be with one patient for a continuous period of 420 minutes.

The debate was that it should be the time taken for the actual monitoring labour not time taken for the patient to give birth. Consultations with Expert working group to rectify recommendations noted that monitoring of labour does not start from nowhere. A midwife may start by admitting the mother into the early labour ward or labour ward, a process which takes almost 30 minutes or more. Monitoring of labour encompasses many small activities which include even health educating the woman on what is expected of her during the process of labouring. In a normal situation, the midwife-patient ratio in a labour ward should be 1:1 but in many situations because of inadequate staffing levels, a midwife does not care for only one woman in labour thus she cannot be with one woman continuously but this does not mean that she will not be doing anything. The duration of time taken by a midwife on one woman in labour depends on the number of pregnancy e.g. a woman with first pregnancy may be in labour for a longer period of time than the one with subsequent pregnancy.

Labour is divided into stages and first stage of labour takes about 6-8 hrs for subsequent pregnancy and about 10-14 hours for a first-time mother and this is when monitoring of labour is done. The second stage of labour lasts for 45-90 minutes when the woman is expected to push the baby out and this time is not included in the 420 minutest. The average duration of first stage of labour which requires the midwife to monitor the woman takes about 7 hours on average which is 420 minutes. Out of the 420 minutes, the midwife monitors labour every 30 minutes checking fetal heart for 1 minute, contractions for 10 minutes, checking pulse for 1 minute, testing of urine for +_5 minutes and cervical dilatation is checked every 4 hours in normal labour but

14 WISN Main Study Report 2017 every 2 hours in complicated labour. Therefore, it means out of every 30 minutes, the midwife is with the woman for about 20 minutes and uses the rest of the time to document her findings. This means that the midwife does not have much time away from the woman and it becomes worse if monitoring more than one woman and may even fail to monitor labour on either of the woman every 30 minutes.420 minutes is not including time of giving birth. The only other thing that a midwife can do besides monitoring of labour is to attend to another patient or take a healthy break but during that time another midwife is covering her. The Experts Working Group advised that reducing the time may not be possible so as to minimize leaving room to compromise the quality of care to the woman in labour.

The validation process also observed that the hand-over time of 60 minutes by nursing cadres was rather exaggerated and may need to be reduced. In response to the observation the Experts advised that hand-over for nurses/ midwives are different to the one done by doctors. The doctor usually takes less minutes given the fact that he/she usually depends on work done by the midwife and in most cases deals with cases that involved complications. In a normal situation a midwife handles all deliveries that do not involve complications. Therefore reduction of handover time may be difficult because it is determined by the number of patients in a ward. In a ward with a bed capacity of 30 and fully occupied, 60 minutes may not be adequate if proper handover is given. Handover involves giving the written reports for all patients and then physically moving from one patient to the other to do physical handover of the patients, handover of drugs or important items and it may even take more than 60 minutes. Handover report can only be reduced if the bed capacity is low. Handover of women in labour takes time because midwives will have to move around and listen to fetal heart to confirm the verbal reports.

The WHO AFRO WISN Technical Experts raised concern on Obstetrician and gynecologists and Midwife having to share some activities hence the time allocated to those activities in the data collection tool should be reduced. In response to the recommendation /observation, the Experts representing the categories reiterated that though activities are shared by midwives and doctors but not at the same time. The midwife does most of the work and a doctor only comes when there is a problem. Midwives are the ones who responsible for monitoring labour and postnatal care of a mother and her baby. Sharing of activities may be evident at some levels such as at a central hospital where there may be a doctor in the ward not at health facilities where midwives are in control and there is provision of midwife-led maternity services. However, if ever there is sharing of activities, it is not equal the midwife does most of the activities.

2.3.4 PHARMACIST AND PHARMARCY TECHNICIANS

During the validation process by WHO Technical Expert it was alleged that there was overlapping of activities between the pharmacists and pharmacy technicians hence these activities needed to be revisited and clarified.

The Experts Working Group from Pharmacy category revisited the data collection tool and separated the activities done by the technical, dispensary and pharmacists at different levels of care. In making considerations, the main point of emphasis was the high vacancy levels of pharmacists at lower levels of care hence in some cases the work is currently being done by technicians or dispensary Assistants but on acting capacity.

The validation of WISN results gave the Board and the Ministry an opportunity to revisit the software calculations and managed to come up with validated results summarized in Annexure 1 – 8.

15 3. WISN STUDY RESULTS AND FINDINGS

3.1 Harare Central Hospital

Harare Central hospital is a government quaternary referral hospital. However it also operates as a secondary referral hospital for the greater part of the residential areas.

DOCTORS

The table below presents a summary of the WISN findings for the cadres studied

Table 3:1 WISN Results for Doctors HCH, Zimbabwe 2017 Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Anaesthetist 4 5 23 -20 0.20 Cardiothoracic Surgeon 3 0 1 -1 0.00 ENT Surgeon 3 1 3 -2 0.38 General Surgeon 4 5 11 -6 0.45 Neuro Surgeon 1 0 1 -1 0.00 Obstetrician and Gynaecologist 3 3 19 -16 0.16 Ophthalmologist 3 1 6 -5 0.17 Orthopaedic Surgeon 5 1 6 -5 0.18 Paediatric Surgeon 0 1 6 -5 0.18 Paediatrician 3 2 34 -32 0.06 Physician 3 4 22 -18 0.19 Pathologist 2 1 3 -2 0.33 Psychiatrist 3 1 20 -19 0.05 Urologist 3 0 10 -10 0.00 Source: Zimbabwe WISN 2017

Anaesthetist The authorized establishment for the institution was four however there were five government anesthetists in-post. The department was also serviced by two University Consultants and 19 Registrars. The calculated requirement was 25 indicating that for government posts the institution was under staffed by 20.

Cardiothoracic Surgeon The authorized establishment for the institution was three and in-post was zero. The department was not operational. Out patient data on patients referred to PGH was utilized to calculate the required staff and the data collected indicated that 1 Cardio- thoracic Surgeon was required.

ENT Surgeon The institution had an authorized establishment of three ENT surgeons and there was one

16 WISN Main Study Report 2017

specialist in post. There is no additional staff required since the WISN calculated requirement was the same as the established posts.

General Surgeons The authorized establishment was four. There were five general surgeons in post with one post held against the pulmonologist specialist post. The institution has a total 50 beds for the general surgeons that include the burns Unit. The calculated requirement was eleven indicating that for government posts the institution was under established by seven.

Neuro Surgeon The institution had an authorized establishment of one which was vacant. The department was not operational in 2016 and the statistics that were used to calculate the staff requirement were collected from the statistics/records/ source documents of patients referred to PGH hence might not reflect the actual need. The WISN calculated staff requirement was one.

Obstetrician and Gynecologist The authorized establishment was three and all the posts were filled. They also had seven University Consultants and four Senior Registrars who were offering obstetrics and Gynaecology services. The institution has a fully functional Maternity Hospital which has 180 maternity and 42 Gynaecology beds. The calculated requirement for the institution was 19 indicating that for government posts the institution was under staffed by 16.

Ophthalmologist The establishment for the institution was three of which one was filled in the fourth quarter of 2016. The annual workload for the other three (3) quarters was collected from statistics of patients referred to PGH. WISN calculated staff requirement was six reflecting a deficit of three posts.

Orthopedic Surgeon The authorized establishment for the institution was five and one was in-post. Two Senior Registrars were performing part of the orthopedic workload. The hospital has a bed capacity of 53 for Orthopedic patients. The WISN calculated staff requirement was seven.

Pediatric Surgeon The institution had no authorized establishment for pediatric surgeon. There was one Pediat- ric Surgeon in post who held the Pediatrician post. There were three University Consultants contributing to the workload. The institution had a 350 bedded Pediatric Hospital which includes an operational pediatric theatre. WISN calculated staff requirement was six.

Pediatrician Three authorized established posts were allocated to the institution and two were filled. The other post was filled by the Pediatric Surgeon. Part of the workload is currently being carried by an additional four university Consultants and two Senior Registrars. In addition the institution has a bed capacity of 100 for neonates. The WISN calculated staff requirement is 34 and 31 additional posts are needed.

17 Physician The authorized establishment for the Hospital was three and four posts were filled with one Physician held against another vacant specialist post. Two University Consultants and three Senior Registrars were carrying the additional workload. The hospital has nine wards with a capacity of 176 beds for physicians. WISN calculated staff requirement was 22 and 19 additional government posts are required.

Pathologist The institution had an establishment of two Pathologists of which one was in post. WISN calculated staff requirement was three with additional staff required of two.

Psychiatrist The institution had an authorized staff establishment of three posts of which one was filled. One government Consultant, two University Consultants and eight Registrars shared the workload. The Unit has a bed capacity of 110 for psychiatric patients. The WISN calculated staff requirement was 20 therefore the institution would require 17 additional posts.

Urologist The institution’s authorized establishment was three posts, which were all vacant. The hospital has a total of 33 Urology beds. Six General Surgeon Registrars were performing part of the Urology workload. The WISN calculated staff requirement is ten. Hence there is need to create seven additional posts.

NURSING STAFF

The authorized staff establishment for the whole hospital for Registered General Nurses was 992 and 59 were vacant. The posts were not broken down by specialty at national level. However the institution allocated the filled 933 RGN posts (as at 2016) to various departments in a manner that ensured that all service areas were covered.

Table 3:2 WISN Results for Nurses, HCH, Zimbabwe, 2017 Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Intensive Care Nurse 0 64 123 -59 0.52 Mental Health Nurse 0 29 36 -7 0.81 Midwife 0 234 294 -60 0.80 Nurse Anaesthetist 0 8 17 -9 0.47 Oncology Nurse 0 0 8 -8 0.00 Operating Theater Nurse 0 95 88 7 1.08 Ophthalmic Nurse 0 1 8 -7 0.13 Paediatric Nurse 0 153 146 7 1.05 Registered General Nurse 992 338 316 22 1.07 Renal Nurse 0 11 4 7 2.75

Source: Zimbabwe WISN 2017

18 WISN Main Study Report 2017

From the above table, the nursing categories show an overstaffing by 43 and other specific disciplines had a total understaffing of 150.

Intensive Care Nurse (I.C.N) The hospital had allocated 64 RGNs to the Intensive Care Unit (ICU) and 39 of them are qualified ICNs and 11 already undergoing training. The institution has several ICU units in the Paediatric and Neonatal wards namely adult ICU and High Dependency care, pediatric and neonatal. The WISN calculated staff requirement for the I.C.N department is 123.

Mental Health The institution allocated 29 RGNs of which 16 are qualified mental Health Nurses whilst 2 are undergoing training. WISN calculated staff requirement is 36. Therefore the institution needs to create 36 posts for the institution’s mental health unit.

Midwives The institution had allocated 234 RGNs who are qualified Midwives and four RGNS are undergoing Midwifery training. The shortage of staff was being covered by locum nurses and student midwives. The WISN calculated staff requirement is 294 and therefore the institution needs to create 294 midwifery posts.

Nurse Anesthetist The institution allocated eight RGNS who are all qualified nurse anesthetists and one was undergoing training. SRMOs on rotation and 19 Anaesthetist Registrars also covered part of the workload. WISN calculated staff requirement is 17 therefore 17 posts are required.

Oncology Nurse The Institution had no Oncology nurse. WISN calculated that the Oncology services require eight nurses. Therefore the institution requires eight posts to be created.

Operating Theatre Nurse (OTN) Ninety-five RGNs were allocated for the operating theatre nursing duties manning seven adult, four pediatric and two maternity theatres. Of these 33 RGNS are qualified and two were undergoing training. WISN calculated staff requirement was 88. The workload for the operating theatres was affected by shortage of medicines in 2016.

Ophthalmic Nurse The institution was operating without an Ophthalmologist for three quarters of 2016 thereby limiting ophthalmic services. There was only one qualified ophthalmic nurse offering out-patient services. WISN calculated staff requirement is 8 therefore there is need to create 8 posts.

Pediatric Nurse One hundred and fifty-three RGNs were allocated to the Paediatric hospital. There are 10 qualified paediatric nurses and 14 are undergoing training. The Paediatric hospital has 350 beds and 100 neonates beds. The WISN calculated staff requirement is 146, therefore, the institution requires 146 paediatric nurse posts created.

19 Registered General Nurses Out of the 992 RGN posts at the hospital, 338 RGNs were providing nursing services to units that did not have designated specialist nurses. The WISN calculated staff requirement for RGNs was 316.

Renal Nurse The institution allocated 11 RGNs to perform Renal nursing duties. It was noted that peritoneal dialysis was not being done at the institution and patients were being referred to Parirenyatwa Group of Hospitals. The WISN calculated a staff requirement of 4, therefore there is need to create an establishment for renal nurses.

Medical Laboratory Scientist,Phamarcy and Radiography Table 3:3 WISN Results for Laboratory, Pharmacy & Radiography, HCH, Zimbabwe, 2017 Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Medical Laboratory Scientist 46 22 50 -28 0.44 SCMLT 11 11 38 -27 0.29 Dispensary Assistant 6 6 11 -5 0.55 Pharmacist 8 8 15 -7 0.54 Pharmacy Technician 7 7 14 -7 0.50 Diagnostic Radiographer 19 16 15 1 1.07 Source: Zimbabwe WISN 2017 Medical Laboratory Scientist (MLS) The authorized establishment for MLS is 46 and 11are occupied by qualified Medical Labora- tory Scientists and the further eleven posts are occupied by SCMLT. The WISN calculated staff requirement is 50. There is need to create four additional post.

State Certified Medical Laboratory Technicians (SCMLT) Authorised establishment is 11 and all posts are filled. The WISN calculated staff requirement is 38. There is need to create 27 new posts.

PHARMACY

Dispensary Assistant The authorised establishment is six and there are six Dispensary Assistants in post. The WISN calculated staff requirement was 11. The institution need to create five additional posts.

Pharmacist The department has eight authorised posts which are all filled. The WISN calculated staff requirement was 15. The department may need seven additional posts.

Pharmacy Technician All the seven (7) authorized posts are filled. WISN calculated a staff requirement of 14. The institution requires seven (7) additional posts.

20 WISN Main Study Report 2017

RADIOGRAPHY (Diagnostic Radiographer)

The authorized establishment is 19, with 16 posts filled. The Computerized Tomography (CT) scan at Harare Central Hospital was not working in 2016. WISN calculated staff requirement is 15.

3.2 United Bulawayo Hospitals (UBH)

UBH is a 650 bedded government quaternary referral. Some Districts in Matabeleland South use it as a tertiary referral hospital because of its geographical location.

DOCTORS

Table 3:4 WISN Doctors, United Bulawayo Hospitals, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Anaesthetist 3 1 8 -7 0.13 Cardio-Thoracic Surgeon 1 0 1 -1 0.00 ENT Surgeon 2 0 1 -1 0.00 Hospital Medical Ofﬁcer 40 68 30 38 2.27 General Surgeon 3 3 6 -3 0.50 Neuro-Surgeon 1 0 1 -1 0.00 Obstetrician and 3 1 16 -15 0.06 Gynaecologist Ophthalmologist 1 2 9 -7 0.22 Orthopaedic Surgeon 2 1 4 -3 0.25 Paediatricians 3 0 5 -5 0.00 Pathologist 3 3 3 0 1.00 Physician 3 2 8 -6 0.25 Psychiatrist 0 0 3 -3 0.00 Radiologist 3 0 1 1 0.00 Urologist 1 1 1 0 1.00 Source: Zimbabwe WISN 2017 Anaesthetist The institution’s authorized staff establishment for Anesthetists is three and there was one in post. The WISN calculated staff requirement was eight reflecting workload pressure hence there might be need to create five additional posts.

Cardiothoracic Surgeon There are two authorized posts which are vacant. The WISN calculated staff requirement was one. There might be need to maintain the existing establishment.

Ear, Nose and Throat (ENT) The facility has an authorized staff establishment of two which were vacant. WISN

21 calculated a staff requirement of one.

Hospital Medical Officer (HMO) The authorized establishment for the HMOs was 40 and there were 68 in post as at December 2016. A total of 28 posts were being held against Registrar vacant posts. The calculated WISN staff requirement was 30.

General Surgeon The institution had three established posts which were all filled. The WISN calculated staff requirement is six. There is workload pressure and there might be need to create three additional posts.

Neurosurgeon The authorized establishment is one and there is none in-post. The WISN calculated staff requirement is one. There is no pressure.

Obstetrics and Gynecology There were three authorized posts and one was filled. The WISN calculated staff requirement was 16. UBH caters for a bigger population because clients from Matabeleland South Province are referred directly to UBH which is geographically convenient.

Ophthalmologist The institution has an establishment of one post but there were two Ophthalmologists in post. One was held against a vacant post. The WISN calculated staff requirement is nine. The eye unit at UBH is catering for the Southern Region.

Orthopedic Surgeon There were two authorized posts of which one was filled. WISN calculated a staff requirement of four. There was workload pressure and there might be need to create two additional posts.

Pediatrician The authorized establishment was three and there were none in post. The WISN calculated staff requirement was five. There was workload pressure and there might be a need to create two additional posts. Workload was calculated based on Pediatric services statistics.

Pathologist The institution had three established posts which were vacant. WISN calculated a staff requirement of three. There was no workload pressure. The services were being provided by visiting pathologists from the Zimbabwe Republic Police (ZRP).

Physician There were three established posts and two were filled. The WISN calculated staff requirement was eight. There was workload pressure and there might be a need to create additional five posts.

22 WISN Main Study Report 2017

Psychiatrist There was no authorized staff establishment for Psychiatrist. WISN calculated a staff requirement of three. Psychiatry services were being provided by psychiatric nurses working in other units.

Radiologist The authorized establishment was three and they were all vacant. The WISN calculated staff requirement was one therefore there was no workload pressure. The department was not fully functional. The services were being provided by a private specialist.

Urologist There was one authorized post that was filled. WISN calculated a staff requirement of one. There was no workload pressure.

UBH - NURSES

The authorized staff establishment for the whole hospital for nurses was 601. The posts were not broken down by specialty at national level. Five hundred and ten (510) of the filled posts were allocated to various departments according to need. Table 3:5 WISN Results for Nursing staff, UBH, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Intensive Care Nurse 29 40 -11 0.73 Midwife 101 104 -3 0.97 Nurse Anaesthetist 5 4 1 1.25 Oncology Nurse 3 4 -1 1.00 Operating Theatre Nurse 37 25 12 1.48 Ophthalmic Nurse 15 36 -21 0.42 Psychiatric Nurse 0 4 -4 0.00 Registered General Nurse 320 219 101 1.46 Renal Nurse 0 1 -1 0

Source: Zimbabwe WISN 2017

The above table shows an overstaffing by 114 nurses and other specific disciplines had a total understaffing of 40.

Intensive Care Nurse A total of 29 Nurses were allocated to work in the intensive care and High Dependence Unit and five were qualified ICN Nurses. WISN calculated Staff requirement for intensive care nurses was 40.

23 Midwife

The health facility allocated 101 midwives to offer midwifery services. WISN calculated a staff requirement of 104 midwives. There is need to create 104 posts.

Nurse Anesthetist

The Hospital allocated five Nurses to work as Nurse Anesthetists. WISN calculated staff requirement was four. There might be need to maintain the allocated staff since they assist the Doctor Anesthetist as a standard requirement.

Oncology Nurse

A total of three trained oncology nurses were providing oncology service at the institution. WISN calculated staff requirement was three. There was no designated oncology unit at the institution.

Operating Theatre Nurse

There were 37 nurses allocated to provide theatre services at the institution. WISN calculated staff requirement of 25 Operating Theatre Nurses. There is need to create 25 Operating Theatre Nurses posts.

Ophthalmic Nurse

The institution had allocated 15 Ophthalmic Nurses to provide services. The WISN calculated staff requirement was 36. UBH has a fully functional eye unit which offers theatre services in the southern region (Bulawayo, Matabeleland North and South Provinces).

Mental Health Nurse

The hospital had no psychiatric unit but had 15 qualified mental health nurses who offer mental health services. WISN calculated staff requirement was four. Data was collected from primary source documents.

Registered General Nurse (RGN)/ State Certifies Nurse (SCN)

The health facility allocated 320 RGNs to offer general nursing services. The WISN calculated staff requirement was 219. There might be need to redistribute the 101 posts to other specialty areas.

Renal Nurse

UBH had no renal unit and no nurses were allocated to provide the services. The WISN calculated staff requirement was one. There is need to create posts for renal services.

24 WISN Main Study Report 2017

Table 3:6 WISN Results Laboratory, Pharmacy & radiography UBH, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Medical Laboratory Scientist 23 6 7 -1 0.86 SCMLT 10 4 5 -1 0.80 Dispensary Assistant 6 5 5 0 1.00 Pharmacist 10 3 5 -2 0.60 Pharmacy technician 10 8 13 -5 0.62 Radiographer 9 9 9 0 1.00 Ultra-Sonographer 2 0 4 4 0.00 X-Ray Operator 4 3 1 2 3.00

Source: Zimbabwe WISN 2017

LABORATORY

Medical Laboratory Scientists

The Health facility has an authorized establishment of 23 and six were in post. WISN calculated a staff requirement of seven. The laboratory was not fully functional in 2016.

SCMLT

There were 10 established posts for SCMLT and four were filled. WISN calculated a staff requirement of five.

Pharmacy

Dispensary Assistant There was an authorized establishment of six with five in post. WISN calculated a staff requirement of five. There might be need to redistribute the vacant post.

Pharmacist There were 10 authorised established posts and three were filled. The WISN calculated staff requirement was five.

Pharmacy Technician The institution had an authorised establishment of 10 and eight were in post. The WISN calculated staff requirement was 13, reflecting that there was workload pressure.

RADIOGRAPHY

Diagnostic Radiographer There was an authorised establishment of nine with nine posts filled. WISN calculated a staff requirement of nine. There is no pressure.

25 Ultrasonographer There were two established posts, which were vacant. The WISN calculated staff requirement was four, there might be need to create two additional posts.

X-Ray Technician/Operator The authorised staff establishment for the institution was four and two were in post. WISN calculated a staff requirement of one.

3.3 Masvingo Provincial Hospital

Masvingo is a government tertiary referral hospital in the south east part of the country and has a bed capacity of 272.

Table 3:7 WISN Results Doctors, Masvingo Provincial Hospital, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR General Surgeon 1 1 2 -1 0.50 Government Medical Ofﬁcer 12 11 25 -14 0.44 Obstetrician and Gynaecologist 1 0 3 -3 0.00 Ophthalmologist 1 1 1 0 1.00 Anaesthetist 1 0 2 -2 0.00

Source: Zimbabwe WISN 2017

DOCTORS

General Surgeon

The authorized establishment was one which was filled. WISN calculated a staff requirement of two. There may be a need to create an additional post.

Government Medical Officer

There are 12 established posts of which 11 were in post. The GMOs provide coverage to generally all units i.e. Antenatal ward, Labour and delivery, Post-natal ward, Neonatal Unit, female and male medical wards, pediatric, OPD, causality, Family and Child health and theatres. The WISN calculated staff requirement is 25. The institution may require 13 additional posts.

Obstetrician and Gynecologist

The authorized establishment was one and there were none in post. WISN calculated a staff requirement of three. There may be need to create two more posts. Most of the Obstetrics and Gynecology specialist services were provided by the Medical Superintendent.

26 WISN Main Study Report 2017

Ophthalmologist

There was one established post which was filled. The WISN calculated staff requirement is one. There is no pressure. There might be need to review the establishment noting that the incumbent is based at Morgenster Mission Hospital which is about 40 km away from Masvingo and has a fully equipped eye unit.

Anaesthetist The authorized establishment is one and the post was vacant. The WISN calculated staff requirement of two. The staff requirement calculations were based on workload statistics of the anaesthetized patients.

Masvingo Provincial Hospital Nurses

The authorized staff establishment for the hospital for nurses was 188. The institution had 192 RGNs in post; the additional 4 RGNs were seconded from various health facilities within the province. The posts were not broken down by specialty at national level. The available nurses were allocated to various departments according to need.

Table 3:8 WISN Results Nurses, Masvingo Provincial Hospital, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Intensive Care Nurse 9 13 -4 0.69 Mental Health Nurse 3 5 -2 0.60 Midwife 59 50 9 1.18 Nurse Anaesthetic 5 2 3 2.50 Operating Theatre Nurse 12 12 0 1.00 Ophthalmic Nurse 1 1 0 1.00 Registered General Nurse 188 103 160 -57 0.64

Source: Zimbabwe WISN 2017

From the above table, the nursing categories show an overstaffing by 12 and other specific disciplines had a total understaffing of 63 nurses.

Intensive care Nurse

The institution allocated 9 nurses to the High Dependency Unit (HDU). It should be noted that there is no intensive care unit at the facility. WISN staff calculation indicated that the unit requires 13 intensive care nurses. The institution may need 13 posts.

Mental Health

Three nurses were allocated to provide mental health services at the institution. The WISN calculated staff requirement is 5 indicating need to create 5 posts.

27 Midwife

The allocated staff for provision of midwifery services was 59. However the institution has 96 qualified midwives practicing as RGNs. The WISN calculated staff requirement was 50, therefore indicating a need to create 50 posts.

Nurse Anaesthetist

There were five RGNs allocated to offer anesthetic services. There are three functional theatres at the hospital which can run concurrently. The WISN calculated a staff requirement of two.

Operating Theatre

The hospital allocated 12 RGNs to provide operating theatre services. The institution has four qualified Operating Theatre Nurses. The WISN calculated staff requirement was 12. There is no pressure.

Ophthalmic Nurse

One RGN was allocated to offer ophthalmic services. There is no functional ophthalmic unit at the institution. The WISN calculated staff requirement is one. There is no pressure.

Registered General Nurse (RGNs)

The institution had 103 nurses allocated to provide general nursing services. WISN calculated staff requirement is 160. Therefore there may be a need to create 57 additional posts.

MASVINGO LABORATORY

Table 3:9 WISN Results Laboratory, Pharmacy and Radiography Masvingo

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Medical Laboratory Scientist 6 3 6 -3 0.50 SCMLT 3 5 8 -3 0.63 Dispensary Assistant 3 3 2 1 1.50 Pharmacy Technician 4 4 3 1 1.33 Pharmacist 3 3 3 0 1.00 Radiographer 3 2 3 -1 0.67 Ultra-Sonographer 0 0 2 -2 0.00 X-ray operator 0 1 1 0 1.00

Source: Zimbabwe WISN 2017

Medical Laboratory Scientist

The authorized establishment for the institution is six with three in post. The WISN calculated

28 WISN Main Study Report 2017 staff requirement was six therefore the staff establishment was sufficient.

State Certified Medical Laboratory Technician (SCMLT)

There are three established posts for SCMLTs. Two posts were held against Laboratory Scientists posts. The institution had five SCMLTs in post. WISN calculated a staff requirement of eight. There might be a need to create five additional posts.

PHARMACY MASVINGO

Dispensary Assistant

The authorized establishment for the dispensary assistant was three of which all posts were filled. WISN calculation indicated that two Dispensary Assistants were required for the hospital. There might be need to maintain the establishment of three posts.

Pharmacy Technician (PT)

The authorized establishment for PT was four and all posts were filled. The WISN calculated staff requirement was three.

Pharmacist

The institution had an authorized establishment of three posts which are filled. WISN calculated a staff requirement of three. There is need to maintain the establishment of three posts.

RADIOGRAPHY

Radiographer

There are three established posts of which two are filled. WISN calculated a staff requirement of three which reflects that there is no workload pressure for the cadre.

Ultrasonographer

There is no authorized establishment for the cadre and there is no one in post. The calculated WISN staff requirement was two. It should be noted that ultrasonography services were being offered by the Diagnostic Radiographer.

X-Ray Operator

The institution had no establishment for X-Ray Operator but there was one in post seconded from Chivi District Hospital. WISN calculated a staff requirement of one. There might be need to create posts for the respective cadre.

29 3.4 Chinhoyi Provincial Hospital

Chinhoyi is a government tertiary referral institution that serves Mashonaland West province with a bed capacity of 422.

DOCTORS

Table 3:10 WISN Results Doctors, Chinhoyi Provincial Hospital, Zimbabwe, 2017

Source: Zimbabwe WISN 2017

Government Medical Officer

The authorized staff establishment for GMO was twelve and existing staff was thirteen. The WISN calculated staff requirement was twenty two, therefore there might be need to create ten additional posts.

Obstetrics and Gynecology

The authorized staff establishment was one and none in post. WISN calculated a staff requirement of five. There might be need to create four additional posts to cater for the workload. Most of the Obstetrics and Gynecology specialist services were provided by the Medical Superintendent.

Ophthalmologist

The establishment for the institution was one which was filled in the fourth quarter of 2016 and the services were being done by Ophthalmic Nurses. WISN calculated a staff requirement of two. There might be need to create 1 additional post.

Chinhoyi Provincial Hospital Nurses

The authorized staff establishment for the hospital for nurses was 259. The institution had 256 RGNs in post and three vacant posts. The posts were not broken down by specialty at national level. The filled posts were allocated to various departments according to need.

30 WISN Main Study Report 2017

Table 3:11 WISN Results Nurses, Chinhoyi Provincial Hospital, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Intensive Care Nurse 0 3 7 - 4 0.43 Mental Health Nurse 0 9 12 -3 0.75 Midwife 0 47 58 - 11 0.81 Nurse Anaesthetist 0 7 3 4 2.33 Operating Theatre Nurse 0 5 9 -4 0.56 Ophthalmic Nurse 0 3 3 0 1.00 Registered General Nurse 259 182 180 15 1.03

Source: Zimbabwe WISN 2017

From the above table, the nursing categories show an overstaffing by 9 and other specific disciplines had a total understaffing of 22.

Intensive care Nurse

The institution allocated three nurses to the High Dependency Unit (HDU). There are 6 beds for Intensive care services. WISN staff calculation indicated that the unit requires seven intensive care nurses. The institution may require seven posts.

Mental Health Nurse

The institution allocated nine nurses to provide mental health services at the institution. The WISN calculated staff requirement was twelve and the allocated posts may be adequate for the unit.

Midwife

The institution allocated 47 nurses to provide midwifery services. WISN calculated staff requirement was 58 midwives, there might be need to create eleven additional posts.

Nurse Anesthetist

There are seven nurses allocated to offer anaesthetic services. WISN calculated a staff requirement of three. There might be need to retain the allocated posts within the unit.

Operating Theatre Nurse

The hospital allocated five nurses to provide operating theatre services. WISN calculated a staff requirement of nine. There might be need to create nine posts.

31 Ophthalmic Nurse

Three nurses were allocated to offer ophthalmic services. The WISN calculated staff requirement was three. Therefore there is no workload pressure.

Registered General Nurse (RGN)

The institution had 185 nurses allocated to provide general nursing services. WISN calculated staff requirement was 180. There might be need to redistribute the 5 posts to other specialties.

Table 3:12 WISN Results Radiography, Laboratory and pharmacy, Chinhoyi Provincial Hospital, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Radiographer 4 4 6 -2 0.67 X-Ray Operator 1 1 1 0 1.00 Medical Laboratory Scientist 9 4 11 - 7 0.36 Dispensary Assistant 2 1 2 -1 0.50 Pharmacy Technician 6 6 2 4 3.00 Pharmacist 2 1 2 -1 0.50

Source: Zimbabwe WISN 2017

Radiographer

There are four established posts for Radiographers which are all filled. WISN calculated staff requirement of six and there may be need to create two additional posts.

X-Ray Operator

The institution had one authorized post for X-Ray Operator which was filled WISN calculated a staff requirement of one which reflects that there is no workload pressure.

LABORATORY STAFF

Medical Laboratory Scientist

The authorized establishment was nine with an in post of four. WISN calculated a staff requirement of eleven. There may be need for two additional posts.

PHARMACY STAFF

Dispensary Assistant (Pharmacy)

There were two authorized posts for Dispensary Assistant and one was filled. WISN calculated a staff requirement of two; therefore there is no workload pressure.

32 WISN Main Study Report 2017

Pharmacy Technicians

The institution had an authorized establishment of six posts which were all filled. The WISN calculated staff requirement is two hence there is no workload pressure.

Pharmacist

The authorized establishment for pharmacist was two and one was in post. WISN calculated a staff requirement of two. There is workload pressure hence there might be need to create posts.

3.5 Tsholotsho District Hospital

Tsholotsho District Hospital is a government secondary referral hospital in Matabeleland north province with a capacity of 140 beds.

Table 3:13 WISN Results Tsholotsho District Hospital, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Government Medical ofﬁcer 3 2 7 -5 0.29 Mental health nurse 0 2 4 -2 0.50 Midwife 0 20 35 -15 0.57 Nurse anesthetist 0 2 1 1 2.00 Operating theater nurse 0 4 2 2 2.00 Ophthalmic nurse 0 4 5 -1 0.80 Registered general nurse 86 38 28 10 1.36 Dispensary Assistant 2 2 3 -1 0.67 Pharmacy Technician 2 2 5 -3 0.40 SCMLT 0 1 3 -2 0.33 Radiographer 1 0 1 -1 0.00 X-ray Operator 3 1 1 0 1.00 Source: Zimbabwe WISN 2017 DOCTORS

Government Medical Officer

The authorized staff establishment for the hospital was three and two were in post. WISN calculated a staff requirement of seven. There is need to fill the vacant post and create four additional posts.

33 NURSING STAFF

The District hospital had an authorized establishment of 86 nurses. The posts were not distributed according to specialty areas at national level. The 70 filled posts were allocated to various departments according to need.

Mental Health Nurse

Two nurses were allocated to provide mental health services for the institution. The WISN calculated staff requirement was four mental health nurses. There is need to create four mental health nurse posts.

Midwife

The Institution had allocated 20 Midwives to provide midwifery services. The WISN calculated staff requirement was 35 Midwives, reflecting a need to create 35 midwifery posts.

Nurse Anaesthetist

The institution allocated two Nurses to provide anaesthetic services. WISN calculated a staff requirement of one and there is need to create one nurse anesthetist posts.

Operating Theatre Nurse

There were four Nurses allocated to provide theatre services. The WISN calculated staff requirement was two. There is need to create two operating theatre nursing posts.

Ophthalmic Nurse

The allocated staff for provision of Ophthalmic services was four. WISN calculated staff requirement was five. There is need to create the 5 ophthalmic nurse posts.

Registered General Nurse (RGN)

The institution allocated 44 nurses to provide general nursing services. The WISN calculated staff requirement was 28.

PHARMACY STAFF

Dispensary Assistant

The hospital had an authorised staff establishment of two which were filled. The WISN calculated a staff requirement of three posts. There might be need for creation of one post.

34 WISN Main Study Report 2017

Pharmacy Technician

The hospital had an authorized establishment of two posts which were filled. WISN calculated a staff requirement of five. There might be need to create three additional posts.

LABORATORY STAFF

State Certified Medical Laboratory technician (SCMLT)

There was no authorized establishment for the State Certified Medical Laboratory Technician. However, the institution had three SCMLTs in post utilizing medical laboratory scientist posts. The WISN calculated requirement was three.

RADIOGRAPHY STAFF

Radiographer

The hospital had an authorised staff establishment of one which was vacant. WISN calculated a staff requirement of one. There is no workload pressure.

X-Ray Operator

The authorized staff establishment was three and there was one X- ray operator in post. The WISN calculated a staff requirement of one.

35 3.6 Beitbridge District Hospital

Beitbridge District Hospital is a government secondary referral hospital in Matabeleland South province with a capacity of 140 beds.

Table 3:14 WISN Results for Selected cadres, Beitbridge Hospital, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Government Medical Ofﬁcer 3 3 11 -8 0.27 Mental Health Nurse 0 1 4 -3 0.25 Midwife 0 38 67 -29 0.57 Nurse Anaesthetic 0 1 2 -1 0.50 Operating Theatre Nurse 0 2 4 -2 0.50 Ophthalmic Nurse 0 2 1 1 2.00 Registered General Nurse 82 40 58 -18 0.69 Dispensary Assistant 1 1 1 0 1.00 Pharmacy Technician 3 3 4 -1 0.75 Pharmacist 1 1 3 -2 0.33 Medical Laboratory Scientist 3 1 3 -2 0.33 SCMLT 2 1 3 -2 0.33 Radiographer 1 0 1 -1 0.00 X-ray operator 2 2 1 1 2.00

Source: Zimbabwe WISN 2017

DOCTORS

Government Medical Officer

There was an authorised staff establishment of three and they were filled. WISN calculated a staff requirement of eleven. There might be need to create eight additional posts.

NURSING STAFF

The District hospital had an authorised establishment of 82 Registered General Nurses. The posts were not distributed according to specialty areas at national level. There were 84 nurses in posts which were allocated to various departments according to need.

Mental Health Nurse

One nurse was allocated to provide mental health services for the institution. The WISN calculated staff requirement was four. There is need to create posts for mental health nurses.

36 WISN Main Study Report 2017

Midwife

The Institution had allocated 38 Midwives to provide midwifery services. The WISN calculated a staff requirement of 67 Midwives. There is need to create Midwifery posts.

Nurse Anaesthetist

The institution allocated one nurse to provide anaesthetic services. The WISN calculated a staff requirement of two nurses and there is need to create one nurse anesthetist posts.

Operating Theatre Nurse

There were two nurses allocated to provide theatre services. The WISN calculated staff requirement was four, showing the need for theatre nurse posts.

Ophthalmic Nurse

The allocated staff was two and WISN calculated a staff requirement of one Ophthalmic nurse.

Registered General Nurse (RGN)

The institution allocated 40 nurses to provide general nursing services. WISN calculated a staff requirement of 58 RGNs.

LABORATORY STAFF

Medical Laboratory Scientist

The authorised staff establishment was three with one post filled. The WISN calculated staff requirement was three. There might not be any need to create additional post.

State Certified Medical Laboratory Technician

The authorised staff establishment for the hospital was two with one post filled. The WISN calculated staff requirement was three. Therefore there might be need to create one additional post.

PHARMACY STAFF

Dispensary Assistant

The hospital had an authorized establishment of one post which was filled. WISN calculated staff requirement of one. There might not be any need to create additional post.

Pharmacy Technician

There was an authorised staff establishment of three posts which were all filled. The WISN calculated staff requirement was four. There might be need to create one additional posts.

37 Pharmacist

The hospital had an authorized establishment of one post which was filled. WISN calculated a staff requirement of three. There is need to create two additional posts.

RADIOGRAPHY STAFF

Radiographer

There was one authorized post which was vacant. WISN calculated staff requirement of one. There was no workload pressure. The statistics were collected from the primary source documents for the X-ray Operator.

X-Ray Operator

There were two authorised established posts which were filled. The WISN calculated staff requirement was one.

3.7 Howard Mission Hospital

Howard Mission Hospital is a secondary referral hospital in Mashonaland Central Province with a capacity of 178 beds.

Table 3:15 WISN Results, Howard Mission Hospital, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Government Medical Ofﬁcer 3 3 16 -13 0.19 Midwife 0 12 53 -41 0.23 Nurse Anaesthetist 0 2 2 0 1.00 Operating Theatre Nurse 0 1 10 -9 0.10 Registered General Nurse 36 17 55 -38 0.31 Dispensary Assistant 0 0 2 -2 0.00 Pharmacy Technician 0 0 4 -4 0.00 Pharmacist 0 0 10 -10 0.00 SCMLT 2 1 7 -6 0.14 Medical Lab Scientist 1 1 4 -3 0.25 X-Ray Operator 0 0 2 -2 0.00 Source: Zimbabwe WISN 2017

38 WISN Main Study Report 2017

DOCTORS

Government Medical Officer

There were three authorized posts for the hospital which were filled. WISN calculated a staff requirement of 16. There is need to create 13 additional posts.

NURSING STAFF

The Mission hospital had an authorised grant aided establishment of 36 nurses. The posts were not distributed according to specialty areas at national level. The 32 filled posts were allocated to various departments according to need.

Midwife

The Institution had allocated 12 nurses to provide midwifery services and the WISN calculated a staff requirement of 53 midwives. There is need to create midwifery posts.

Nurse Anaesthetist

The institution allocated two nurses to provide anaesthetic services. The WISN calculated a staff requirement of two.

Operating Theatre Nurse (OTN)

There was one operating theatre nurse allocated. The WISN calculated staff requirement was ten. There is need to establish operating theatre nurse posts.

Registered General Nurse (RGN)

The institution allocated 21 nurses to provide general nursing services. The WISN calculated a staff requirement of 55 RGNs.

PHARMARCY STAFF

Dispensary Assistant

The hospital had no authorized staff establishment. The WISN calculated a staff requirement of two. There is need to create two posts.

Pharmacy Technician

There was no authorized staff establishment. The WISN calculated staff requirement was four. There is need to create four posts.

39 Pharmacist

There was no authorized staff establishment. The WISN calculated staff requirement was ten. There is need to create the required posts.

LABORATORY STAFF

Medical Laboratory Scientist

The authorised staff establishment was one post which was filled. The WISN calculated staff requirement was four. There might be need to create one additional post.

State Certified Medical Laboratory Technician

The authorized staff establishment for the hospital was two with one in post. The WISN calculated staff requirement was seven. Therefore there might be need to create five additional posts.

RADIOGRAPHY STAFF

X-Ray Operator

There was no authorised establishment of x-ray operator however there was one X-ray Operator who was employed by the Mission hospital. The WISN calculated staff requirement was two. There is need to create X –ray Operator posts.

3.8 Kariyangwe Mission Hospital

Kariyangwe Mission Hospital is a hospital in Matabeleland North Province with a capacity of 16 beds.

Table 3:16 WISN Results Nurses, Kariyangwe Mission Hospital, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Midwife 3 7 -4 0.43 Registered General Nurse 8 5 14 -9 0.36 Source: Zimbabwe WISN 2017

The Mission hospital had an authorised establishment of eight nurses. The posts were not distributed according to specialty areas at national level. The eight filled posts were to the general nursing services and midwifery according to need.

40 WISN Main Study Report 2017

Midwife

The Institution had allocated three Midwives to provide midwifery services. WISN calculated a staff requirement of seven midwives, reflecting a need to create midwifery posts.

Registered General Nurse (RGN)

The institution allocated five nurses to provide general nursing services. WISN calculated a staff requirement of 14 RGNs. There is need to create six additional posts.

3.9 Bikita Rural Hospital

Bikita Rural Hospital is a peri-urban hospital in Masvingo Province with a capacity of 37 beds.

Table 3:17 WISN for Nurses, Bikita Rural Hospital, Zimbabwe, 2017 Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Midwife 8 11 -3 0.73 Registered General Nurse 29 9 18 -9 0.50

Source: Zimbabwe WISN 2017

The Rural hospital had an authorised establishment of 29 nurses. The posts were not distributed according to specialty areas at national level. Although the 29 posts were filled, only 17 nurses were at Bikita Rural hospital and the rest were distributed to other health facilities within the district due to shortage of accommodation at the hospital.

Midwife

The Institution had allocated eight Midwives to provide midwifery services; the WISN calculated a staff requirement of 11 midwives. There is no need to create new posts for Midwives.

Registered General Nurse (RGN) The institution allocated nine nurses to provide general nursing services. The WISN calculated a staff requirement of 18 RGNs.

41 3.10 Chihota Rural Hospital

Chihota Rural Hospital is a rural hospital in Mashonaland East Province with a capacity of 40 beds.

Table 3:18 WISN Results For Nurses, Chihota Rural Hospital, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Midwife 3 5 -2 0.60 Registered General Nurse 15 5 10 3.00

Source: Zimbabwe WISN 2017 The rural hospital had an authorised establishment of 18 nurses. The posts were not distributed according to specialty areas at national level. The 18 filled posts were divided between general and midwifery nursing services according to need.

Midwife

The Institution had allocated three nurses to provide midwifery services, WISN calculated a staff requirement of five midwives, reflecting a need to create midwifery posts.

Registered General Nurse (RGN)

The institution allocated 15 nurses to provide general nursing services. The WISN calculated a staff requirement of five RGNs, reflecting an excess of ten posts.

3.11 Senkwazi Clinic

Senkwazi Hospital is a rural health center in Midlands province.

Table 3:19 WISN Results Nurses, Senkwazi Clinic, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Registered General Nurse 3 3 5 -2 0.60

Source: Zimbabwe WISN 2017

Registered General Nurse (RGN)

The health facility had an authorized establishment of three nurses which were filled. WISN calculated staff requirement was 5 RGNs. There is need to create two additional posts.

42 WISN Main Study Report 2017

3.12 Lupote Clinic

Lupote Clinic is a rural district council clinic in Matabeland North Province.

Table 3:20 WISN Nurses Lupote Clinic, Zimbabwe, 2017

Cadre Authorized Staff WISN WISN calculated WISN Ratio Establishment in post Calculated staff staff Difference (AE) (SP) Requirement (WCR) (WCD) SP - WCR Registered General Nurse 3 3 6 -3 0.50

Source: Zimbabwe WISN 2017 Registered General Nurse (RGN) WISN Nurses

The health facility had an authorized establishment of three nurses which were filled. WISN calculated staff requirement was six RGNs. There is need to create three additional posts.

43 4. DISCUSSION OF WISN: ZIMBABWE HEALTH SECTOR

4.1 Implications of WISN in the Health Sector

4.1.1 Introduction

WISN largely depend on accuracy of data for meaningful results to be obtained for HRH planning. There are a number of implications that can be drawn from WISN results and such provide insight into policy planning on HRH as well as informing evidence based intervention strategies. WISN results especially ratio can be used to examine implications of staff numbers at various health facilities for strengthening provision of quality of health care. Therefore reviewing such implications would focus the efforts put in place to review existing staff establishment for the Ministry of Health and Child Care.

4.1.2 Doctors

High Vacancy rates particularly for specialist areas such as Neuro Surgeon, Pathologists, Cardiothoracic and Radiology affected service provision. Workload statistics used for those specialist areas with a high vacancy rates were not at the optimum. This affected the calculated staff requirements. Workload statistics for calculation of staff requirement for some specialist areas such as Obstetrics and Gynaecology, physicians, paediatricians, general surgeons, orthopaedic surgeons were readily available. University specialists and Registrars were complimenting Government specialists at central hospitals. In the long term, relying on support from university staff may not be sustainable.

In the process of the study, the pediatric surgeon post for Harare Central Hospital was identified and studied and the staffing needs for the specialty area were calculated. The calculated requirement for General Surgeons and anesthetists at UBH was lower due to underutilization of theatres as there were no surgical specialists in those hospitals. Data may need to be extrapolated using number of theatres, duties and intuition in order to be able to calculate the correct required staff.

At provincial level, high vacancy rates for specialists affects the provision of service delivery, referral system and WISN calculated results. It may be important that the Ministry makes efforts to fill vacant specialist doctors’ posts, supported by training interventions. Although WISN calculated results reflect on the need to review staff establishment for many specialist areas, this should be supported by resource capacitating the respective institutions.

WISN results for GMOs at all levels of care indicated that there was need to increase GMOs posts. It is envisaged that once the establishment is reviewed and posts are filled, service provision will be enhanced. The ENT calculated staff requirement at UBH was based on data collected from the outpatient records hence workload might not be reflection of the need on the ground.

4.1.3 Nurses

The WISN study gave us the opportunity to come up with workload components, activity standards by specialty and calculated staffing needs which addresses the establishment which lumped all nurses under RGN posts. The WISN results confirm the need for creation of additional

44 WISN Main Study Report 2017

RGNs and nursing specialist posts.

Workload of different levels of care may not be used to benchmark nursing staffing requirements for facilities that were not studied. The Ministry need to rely on workload statistics in order to come up with optimum number of nurses required per each health facility. Going forward, focus should be to study each cadre across the health sector to determine the staff requirement. Tanzania in their WISN study covered all the cadres in every facility.

During the study, it was noted that operating theater nurses at Harare Central hospital were doing none nursing duties like SSD packing. These scenarios possess an artificial shortage on nursing workload. The calculated staff requirement for OTN at HCH was lower than the allocated staff, there is need to maintain the theatre nurses in post noting that in 2016 the theatres were affected by the intermittent shortage of theatre medicines which impacted negatively on the annual workload.

4.1.4 Pharmacy

WISN calculated varying staff requirement for Pharmacy cadres across all levels of care indicating the need to decrease the establishment. However, there might be a need to maintain the existing establishment taking cognizance of other economic factors that affected workload statistics of the Dispensary, Assistant Pharmacist, Pharmacy and Technician. Therefore, the institutions should consider filling vacant posts and in the long run review the necessity to vary the establishment for pharmacy cadres.

4.1.5 Laboratory

The operations of most of the laboratories at institutions were affected by lack of reagents and in some obsolete machinery. Most of the laboratory services are manual and there is need to capacitate laboratories with automated equipment, which will reduce the service standards with consequential reduction in workload. There were high vacancy rates for laboratory scientists and this will continue to affect service delivery if not attended to. The Ministry would need to review HRH policies to be able to lure and retain qualified laboratory personnel into the public health sector.

4.1.6 Radiography

WISN staff calculations reflected that most of the institutions do not have workload pressure on radiography services. In some institution lack of equipment affected annual workload statics hence might have calculated less staff required. The staff establishment for radiography does not provide for emerging specialties in Radiography (e.g., ultrasonography, nuclear medicine) therefore there is need to unbundle the establishment to cater for specialties.

4.2 WISN Data

Various data sources can be used when conducting a WISN study. In conducting WISN, Zimbabwe used primary source documents that were complimented by the MoHCC health information (HIS) and the Human resources Information system (HRIS). In a similar WISN study conducted in Namibia they utilized the national available Health information (HIS, ePMS, PMIS,HRIS, EDT and HCT databases) (Source: Ministry of Health, Namibia 2015). The decision to use primary source documents was influenced by the realization that the MoHCC had inadequacies in the HIS that could not address the requirements of WISN data tool.

45 The patient record management system at district, provincial and central hospitals did not make it easy in the data collection process. Availability of a synchronized accurate and exhaustive electronic database would have been cost effective in conducting the study. It would also have enabled the study to cover all health care facilities at reasonable costs. The use of the nursing staff in the data collection and having clearly defined WISN structures especially in the supervision of WISN activities enhanced the quality of data used in the WISN calculations.

4.3 Ministry Staff Establishment

WISN study gives the Board and the Ministry with an opportunity to interrogate the Health delivery system whether it is still effective enough to continue to be strengthened. Although WISN study through sampling, managed to calculate staff requirements for all levels of care, the results might not be a true reflection of the staffing requirements on the ground. The workload that was used at tertiary institutions carries a lot of distortions due to dysfunctional referral system in the country. The high workload experienced by most of tertiary institutions includes some cases that could have been dealt with at district and provincial level but had to be referred to tertiary institutions. Many at times this is necessitated by inadequate infrastructure and ill preparedness of the lower level institutions to deal with minor cases that by design could have been finalized at provincial and district levels.

The burden of workload at tertiary institutions is also worsened by the lack of adequate district hospitals within the major urban that service directly the local communities. As a result tertiary institutions in urban towns were now receiving patients directly without being referred. In the long term there is need for establishment of adequate district hospitals and local authority facilities in major cities Bulawayo and Harare in order to strengthen the referral system that currently is distorted.

However given the fact that a study has been conducted, if the Board and Ministry decide to use the study findings, they need to first seriously interrogate the staff calculations where there are indications that staff compliment that need to be increased for example specialists staff requirements at provincial hospitals. If these are addressed, staff calculations for the higher level institutions i.e. central hospitals would subsequently be reduced. In order for WISN to be relevant in addressing inadequacies of staff establishment for tertiary level institutions, it would be ideal that first priority be given to secondary level institutions and possibly have WISN study conducted for all provincial and Mission level hospitals. Once that has been done, in the long run it would give a near true reflection of workload experienced at tertiary hospitals.

The establishment for specialists at central hospitals is being complimented by the University of Zimbabwe teaching staff and that has its own challenges. The majority of the specialists are employed and governed by the University which in some instances have different working conditions of service (i.e. working hours, semester breaks) hence this might pose challenges in the long run. The government cannot the majority of the specialists servicing at its own central hospitals but being employed by another employer (UZ). WISN calculated the staff requirements for specialists using the workload of UZ specialists which might not necessarily reflect the actual staff requirements if the specialists were GoZ employed and fully dedicated to the institutions. In essence the workload could have been higher than what was used to calculate the staff requirements.

4.3.1 Treasury freeze on recruitment and filling of vacant posts

Treasury announced a freeze on recruitment and appointment for filling all vacant posts since 2012. This policy meant that the Ministry could not recruit and fill its establishment. WISN study

46 WISN Main Study Report 2017 has shown that there is need to expand establishment for some of the studied cadres i.e nurses, pharmacy and Laboratory. Therefore the government might need to first address the policy on freeze for the health sector so that all vacant posts are first filled before WISN study results could be utilized. 5. CROSS CUTTING ISSUES

5.1 Currently the ministry relies on locums to cover for the staff shortages at institutions. The table below summaries locum payments made form 2015 – 2017 and the average distribution of expenditure between the cadres. Average % Average % Average % Table 3.22Locum Locum PaymentsAmount 2015 – paid 2017 $ Distribution payments Distribution Distribution Doctors Nurses Paramedics 2015 6 630 701 2016 8 841 823 16 % 80 % 4 % 2017 14 419 493

The table above reflects that most of locum funds are going towards paying nurses. The Board and Ministry might need to look at the figures and decide on whether this is sustainable in the long run given the fact that there are some nurses who finished their training and are unemployed. This step might need to be considered fist before deciding on implementing WISN staff calculations. Relying on locum might be expensive and might not be sustainable. Therefore, the review of establishment would be economic and promote effective service delivery.

5.2 The clearly defined workload components and activity standards and their integration with performance management framework will assist in the maximum utilization of HRH. This should be supported by the development and review of HRH policies on recruitment, deployment, training and development and retention.

6. RECOMMENDATIONS

6.1 The staff establishment for the Ministry is still not operating at full capacity coupled with lot of vacant posts including those of critical health personnel required for the health system to be effective in dealing with the needs of the public. Therefore there is need for the Board to lobby with Treasury for the unfreezing and filling of all current vacant posts for the five categories studied (Doctors, Nurses, Laboratory, Radiography and Pharmacy) before implementation of the holistic review of the staff establishment based on WISN results.

6.2 In future, resources permitting, the Board and MoHCC needs to study other remaining cadres based on a clearly defined prioritization of HRH at all levels of care. The Board may need to also consider studying all other remaining facilities that were not studied covering all levels of care so as to get a true reflection that would assist in total review of the staff establishment of the Ministry. Although the resources are not permitting to do a holistic review of establishment, the Board and Ministry need to first implement the current WISN study results before doing another study. Implementation of the current study would mean that the subsequent study would be able to review w the impact of WISN to the health sector.

47 6.3 There is need to conduct that another WISN study at least two years after implementation of the initial study results.

6.4 Capacitating health facilities with resources for optimum utilization of existing Health professional as well as service provision.

6.5 Integrating existing Health Information system and Human Resources for Health information system for future staff planning.

6.6 Introduction of sustainable staff retention framework driven by Government of Zimbabwe to reduce vacancy rates for specialist cadres.

6.7 The Board needs to develop a training plan that will sustain implementation of WISN staff calculations on specialty areas.

7. Study limitations

The lack of a comprehensive electronic integrated health information system complicated the data collection process. Inadequate financing for the study which, delayed the commencement of the WISN study after pilot, resulted in the exclusion of other staff categories and limited the scope of the study to a few selected sites.

8. Conclusion

The WISN results are a reflection of the workload for the studied health facilities for 2016. Most of the staff categories studied showed evidence that there was understaffing and workload pressure, the results also showed that there were high vacancy levels in most study sites.

9. Annexure

48 WISN Main Study Report 2017

Annexure 1: WISN result for Harare Central Hospital, Zimbabwe 2017

49 Annexure 2: WISN Results for United Bulawayo Hospital, Zimbabwe 2017 Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Anaesthetist 3 1 8 7 0.13 5 Cardio-Thoracic Surgeon 1 0 1 1 0.00 ENT Surgeon 2 0 1 1 0.00 Hospital Medical Ofﬁcer 40 68 30 38 2.27 General Surgeon 3 3 6 3 0.50 3 Neuro-Surgeon 1 0 1 1 0.00 Obstetricians and Gynaecologist 3 1 16 15 0.06 13 Ophthalmologist 1 2 9 7 0.22 8 Orthopaedic Surgeon 2 1 4 3 0.25 2 Paediatricians 3 0 5 5 0.00 2 Pathologist 3 3 3 0 1.00 Physician 3 2 8 6 0.25 5 Psychiatrist 0 0 3 3 0.00 3 Radiologist 3 0 1 1 0.00 Urologist 1 1 1 0 1.00 Nursing Intensive Care Nurse 29 40 11 0.73 40 Midwife 101 104 3 0.97 104 Nurse Anaesthetist 5 4 -1 1.25 4 Oncology Nurse 3 3 0 1.00 3 Operating Theater Nurse 37 25 -12 1.48 25 Ophthalmic Nurse 15 36 21 0.42 36 Psychiatric Nurse 0 4 4 0.00 4 Registered General Nurse 601 320 219 -101 1.46 Renal Nurse 0 1 1 0.00 1 Laboratory Medical Laboratory Scientist 23 6 7 1 0.86 SCMLT 10 4 5 1 0.80 Pharmarcy 0 Dispensary Assistant 6 5 5 0 1.00 Pharmacist 10 3 5 2 0.60 Pharmacy technician 10 8 13 5 0.62 3 Radiography Radiographer 9 9 9 0 1.00 Ultra-Sonographer 2 0 4 4 0.00 2 X-Ray Operator 4 3 1 -2 3.00 Total 744 630 582 -48 1.08 263

50 WISN Main Study Report 2017

Annexure 3: WISN results for Masvingo Provincial Hospital, Zimbabwe 2017

Annexure 4: WISN results for Chinhoyi Provincial Hospital, Zimbabwe 2017

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Doctors Government Medical Ofﬁcer 12 13 22 9 0.59 10 Obstetrician and Gynaecologist 1 0 6 6 0.00 5 Ophthalmologist 1 0 2 2 0.00 1 Nursing Intensive Care Nurse 0 3 7 4 0.43 7 Mental Nurse 0 9 12 3 0.75 12 51 Midwife 0 47 58 11 0.81 58 Nurse Anaesthetist 0 7 3 -4 2.33 3 Operating Theatre Nurse 0 5 9 4 0.56 9 Ophthalmic Nurse 0 3 3 0 1.00 3 Registered General Nurse 259 185 180 -5 1.03 Laboratory Medical Laboratory Scientist 9 4 11 7 0.36 2 Pharmacy 0 Dispensary Assistant 2 1 2 1 0.50 Pharmacy Technician 6 6 2 -4 3.00 Pharmacist 2 1 2 1 0.50 Radiography 0 Radiographer 4 4 6 2 0.67 2 X-Ray Operator 1 1 1 0 1.00 Total 297 289 326 37 0.89 112 Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Doctors Government Medical Ofﬁcer 12 13 22 9 0.59 10 Obstetrician and Gynaecologist 1 0 6 6 0.00 5 Ophthalmologist 1 0 2 2 0.00 1 Nursing Intensive Care Nurse 0 3 7 4 0.43 7 Mental Nurse 0 9 12 3 0.75 12 Midwife 0 47 58 11 0.81 58 Nurse Anaesthetist 0 7 3 -4 2.33 3 Operating Theatre Nurse 0 5 9 4 0.56 9 Ophthalmic Nurse 0 3 3 0 1.00 3 Registered General Nurse 259 185 180 -5 1.03 Laboratory Medical Laboratory Scientist 9 4 11 7 0.36 2 Pharmacy 0 Dispensary Assistant 2 1 2 1 0.50 Pharmacy Technician 6 6 2 -4 3.00 Pharmacist 2 1 2 1 0.50 Radiography 0 Radiographer 4 4 6 2 0.67 2 X-Ray Operator 1 1 1 0 1.00 Total 297 289 326 37 0.89 112

Annexure 5: WISN results for Tsholotsho District Hospital, Zimbabwe 2017

52 WISN Main Study Report 2017 Annexure 6: WISN results for Beitbridge District Hospital, Zimbabwe 2017

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Government Medical Ofﬁcer 3 3 11 8 0.27 8 Nursing Mental Health Nurse 0 1 4 3 0.25 4 Midwife 0 38 67 29 0.57 67 Nurse Anaesthetic 0 1 2 1 0.50 2 Operating Theatre Nurse 0 2 4 2 0.50 4 Ophthalmic Nurse 0 2 1 -1 2.00 1 Registered General Nurse 82 40 58 18 0.69 Pharmacy Dispensary Assistant 1 1 1 0 1.00 Pharmacy Technician 3 3 4 1 0.75 1 Pharmacist 1 1 3 2 0.33 2 Laboratory Medical Laboratory Scientist 3 1 3 2 0.33 SCMLT 2 1 3 2 0.33 1 Radiography Radiographer 1 0 1 1 0.00 X-ray operator 2 2 1 -1 2.00 Total 98 96 163 67 0.59 90 Annexure 7: WISN results for Howard Mission Hospital, Zimbabwe 2017 Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Doctors Government Medical Ofﬁcer 3 3 16 13 0.19 13 Nursing Midwife 0 12 53 41 0.23 53 Nurse Anaesthetist 0 2 2 0 1.00 2 Operating Theatre Nurse 0 1 10 9 0.10 10 Registered General Nurse 36 17 55 38 0.31 19 Pharmarcy Dispensary Assistant 0 0 2 2 0.00 2 Pharmacy Technician 0 0 4 4 0.00 4 Pharmacist 0 0 10 10 0.00 10 Laboratory SCMLT 2 1 7 6 0.14 5 Medical Lab Scientist 3 1 4 3 0.25 1 Radiography X-Ray Operator 0 0 2 2 0.00 2 Total 44 37 165 128 0.22 121

53 Annexure 8: WISN results for Kariyangwe, Mission Hospital, Bikita, Chihota Rural Hospitals, Senkwazi and Lupote Clinics, Zimbabwe 2017

Kariyangwe, Mission Hospital

Bikita Rural Hospital

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Midwife 8 11 3 0.73 11 Registered General Nurse 29 9 18 9 0.50 Total 29 17 29 12 0.59 11

Chihota Rural Hospital

Senkwazi Clinic

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Registered general nurse 3 3 5 2 0.60 2

Lupote Clinic

Cadre Authorized Staff WISN Required WISN Additional Establishment in post Calculated staff additional Ratio posts Requirement Staff Registered general nurse 3 3 6 3 0.50 3

Grand Total 2433 3057 624 0.80 1008

54 WISN Main Study Report 2017

WISN STAFF GALLERY

Messers Bernard Nkala & Gotora The Data Collectors with Mrs Shonge Bernard Core writers of the WISN Report the Supervisor during field Work 2017

Process of Data verification by Data The WISN Data Collectors Collectors Field Work

The WISN Technical Task Force and WISN Data Collectors & Technical WISN Experts Team at ZIPAM during Taskforce feedback Meeting 2017

55 WISN STAFF GALLERY

Data Capturing process by the WISN Mr Evans Chingamuka (WISN ICT Team 2017 Expert) & Mrs Peggy Manwere during field work

Data Collectors verifying Workload Preparations for field work for the Pilot Statistics at a Health Facility Study 2016

Data Collector in Matabeleland North WISN Data Collectors & Technical Field Work Taskforce Members 2017