title: The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe.
abstract: BACKGROUND
  A paradigm shift in global health policy on user fees has been evident in the last decade with a growing consensus that user fees undermine equitable access to essential health care in many low and middle income countries. Changes to fees have major implications for human resources for health (HRH), though the linkages are rarely explicitly examined. This study aimed to examine the inter-linkages in Zimbabwe in order to generate lessons for HRH and fee policies, with particular respect to reproductive, maternal and newborn health (RMNH).
  
  
  METHODS
  The study used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011.
  
  
  RESULTS
  The past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Human resources are constrained in managing current demand and any growth in demand by high external and internal migration, and low remuneration, amongst other factors. We find that nurses and midwives are evenly distributed across the country (at least in the public sector), though doctors are not. This means that for four provinces, there are not enough doctors to provide more complex care, and only three provinces could provide cover in the event of all deliveries taking place in facilities.
  
  
  CONCLUSIONS
  This analysis suggests that there is a strong case for reducing the financial burden on clients of RMNH services and also a pressing need to improve the terms and conditions of key health staff. Numbers need to grow, and distribution is also a challenge, suggesting the need for differentiated policies in relation to rural areas, especially for doctors and specialists. The management of user fees should also be reviewed, particularly for non-Ministry facilities, which do not retain their revenues, and receive limited investment in return from the municipalities and district councils. Overall public investment in health needs to grow.
authors.affiliation: Biomedical Research and Training Institute, Harare, Zimbabwe. ychirwa@brti.co.zw
authors.forename: Yotamu
authors.initials: Y
authors.lastname: Chirwa
authors.forename: Sophie
authors.initials: S
authors.lastname: Witter
authors.forename: Malvern
authors.initials: M
authors.lastname: Munjoma
authors.forename: Wilson
authors.initials: W
authors.lastname: Mashange
authors.forename: Tim
authors.initials: T
authors.lastname: Ensor
authors.forename: Barbara
authors.initials: B
authors.lastname: McPake
authors.forename: Shungu
authors.initials: S
authors.lastname: Munyati
mesh_terms: D002662:Child Health Services / Q000191:economics / Q000458:organization & administration; D003153:Community Health Services / Q000191:economics / Q000458:organization & administration*; D017281:Cost of Illness; D003695:Delivery of Health Care / Q000191:economics* / Q000458:organization & administration; D005251:Fees, Medical; D005260:Female; D017048:Health Care Costs; D006295:Health Resources / Q000191:economics / Q000458:organization & administration; D006297:Health Services Accessibility / Q000191:economics* / Q000458:organization & administration / Q000706:statistics & numerical data; D006301:Health Services Needs and Demand / Q000191:economics; D006801:Humans; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000191:economics / Q000458:organization & administration; D034121:Reproductive Health Services / Q000191:economics / Q000458:organization & administration; D012456:Salaries and Fringe Benefits; D016526:Workload; D015030:Zimbabwe