DECISION SPACE LEVELS IN ZIMBABWE’S HEALTH SYSTEM

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CHAPTER TWO LEVELS OF DECISION SPACE AND STUDY QUESTIONS

DECISION SPACE LEVELS IN ZIMBABWE’S HEALTH SYSTEM

Governance of Human Resources for Health in Zimbabwe places at four levels outlined in Fig 1 namely: the central, provincial, district, and urban council (municipal).¹⁶ However, there are two main levels of decision space namely the Principal and Agent in this system.
Decision space at the principal level vests in the Ministry of Health, and Health Services Board, and its deconcentrated field offices at provincial and district levels.^16,20 At an agent level, local governments, which are also devolved creations of the centre also enjoy decision space.³² It is through these levels that national human resource for health policy was implemented between 2009 and 2014.

DECISION SPACE AT THE PRINCIPAL LEVEL

The National Human Resource for Health Taskforce

Whilst executive authority on healthcare worker policy vests in the Minister of Health, there are also other actors at this level who facilitate such decision making. These actors make up a National Human Resource for Health Taskforce consisting the Health Services Board, Provincial Medical Officers for each of the country’s ten provinces, representatives from other Ministries (such as the Ministry of Finance), Zimbabwe Association of Church Hospitals (ZACH) and other organizations from the donor community. This taskforce was set up in 2009. The decision role of actors at this level is to formulate, support, regulate, supervise, monitor and evaluate the implementation of Human Resource for Health Policy.^20,24 One of the key roles of the Ministry of Health at this level is to collaborate with the Ministry of Finance and Economic Development (MFED) for financial support. Apart from this, the Health Services Board through the Ministry of Health and Child Care also collaborates with the Ministry of Higher and Tertiary Education (MHTE) towards the production of medical practitioners, and the Zimbabwe Association of Church Hospitals, the Health Professions Authority (HPA) and Health Professions Councils (HPC) for complementary support. In addition, there is collaboration with the the Ministry of Public Works, which provides infrastructure in health institutions, the Ministry of National Housing and Social Amenities, responsible for the construction of government buildings including health staff quarters, and the Ministry of Foreign Affairs responsible for health international relations. There is also collaboration with the donor community in the context of the Zimbabwe United Nations Development Assistance Framework^20,24.

Provincial and District Medical Offices

Executive authority in each province is vested in the Provincial Medical Officer. However, decision making is undertaken through the Provincial Health Executive consisting District Medical Officers, representatives of government ministries in the province, and provincial arms of the Zimbabwe Association of Church Hospitals (ZACH), and donor organizations. At this level, the decision role of actors is to translate national human resource for health policy priorities into provincial objectives through planning, budget allocation to government health facilities, and monitoring and evaluation. The Provincial Medical Office mirrors the Ministry of Health in the province. It is a deconcentrated arm of the ministry which facilitates policy implementation through the District Medical Office (DMO).^20,24
The District Medical Office represents the Provincial Medical Office at a district level. Decision making is undertaken through the District Health Executive. This District Health Executive (DHE) is headed by a District Medical Officer, who mirrors the Provincial Medical Office at this level. Apart from this, the executive consists of a District Nursing Officer, District Pharmacist, District Health Service Administrator and a District Environmental Health Officer. In addition, there is a District Health Management Team (DHMT) comprising of the five DHE members plus the chairperson of the Health Committee of the Rural District Council (RDC), District Council Executive Officer for Health, the District Administration, Community Health Officer and representatives of all health institutions (Sisters in Charges/Health personnel managers), including the missions in the district. The task of the DHMT is to supervise all health facilities (agents) in the district regardless of whether they are municipal/council, mission andf private clinics.^20,24

DECISION SPACE AT THE AGENT LEVEL

Urban Councils

Urban councils are devolved agents through which decision space towards the functuining of the local human resource for health system takes place. Zimbabwe has different types of urban councils namely City Councils, Municipal Councils, Town Councils and Local Boards. City Councils have the highest status in Zimbabwe, and are established in Harare, Bulawayo, Gweru, Mutare, Kwekwe and Kadoma. Apart from these are municipal councils which occupy the position below city councils in the hierarchy of local authorities. These include, Bindura, Chegutu, Chinhoyi, Chitungwiza, Gwanda, Kariba, Marondera, Masvingo, Redcliff and Victoria Falls. Urban Councils also consist of town councils. These are centres that have grown from service centres in the rural areas to a size sufficient for them to stand-alone. There are eight in number namely Karoi, Norton, Shurugwi, Zvishavane, Rusape, Chipinge, Plumtree and Chiredzi. The lowest on the hierarchy of urban councils are local boards established in settlements that have very small populations but have a potential to grow into big urban centres. Local Boards are also established where a centre has peculiar circumstances and where they would require Government assistance to sustain themselves. There are four such local boards established at Hwange, Ruwa, Epworth and Chirundu.³² The study area of this research was Epworth, a peri-urban community in south-east Harare, Zimbabwe.

THE STUDY OBJECTIVE

In this context, the objective of this study was to develop a Human Resource for Health Decision Space Mapping Analysis Conceptual Tool.¹ Using the Decision Space Approach, this tool was then used to determine how the decentralization of Zimbabwe’s Human Resource for Health Policy of 2009 to 2014 impacted the local human resource for health system in Epworth peri-urban community.

Research questions and study aims

In this study, the Decision Space Approach was used to answer the central research questions that included:

• What is the range of actual exercised decision making authority (decision space) over six human resource for health policy functions that included: human resources planning and financing; production, training and development; deployment, retention, utilization and management; human resource for health information and research; labour relations; and health and safety in Epworth peri-urban community between 2009 and 2014?
• What choices (innovations) were made by the agent (Epworth Local Board) with their decision space (range of decision making authority) over the six human resource for health policy functions?
• What were the policy outputs and outcomes (impact) of the choices made on the local human resource for health system in Epworth between 2009 and 2014 towards the health system reform agenda?

To achieve above mentioned objective and provide answers to the questions above, the study had three specific aims. These included:

• Define the range of choice the local board of Epworth was able to exercise over the six human resource for health policy functions;
• Determine what they did or failed to do with range of choice; and
• Explore policy outputs and outcomes from choices towards human resource for health reform in Epworth between 2009 and 2014.

The objective, research questions and study aims were complemented by the goals of Zimbabwe’s Human Resource for Health Policy of 2009 to 2014 which were outlined in the Human Resource for Health Strategic Plan of 2010 to 2014.^24,25

DECLARATION 
DEDICATION 
ACKNOWLEDGEMENTS 
EXECUTIVE SUMMARY
FIGURES.
LIST OF ABBREVIATIONS
CHAPTER ONE INTRODUCTION AND POLICY BACKGROUND 
1.1 INTRODUCTION
1.2 THE GLOBAL POLICY CONTEXT
1.2.1 The Primary Health Care Approach
1.2.2 Ouagadougou Declaration of 2008
1.2.3 The Kampala Declaration and Agenda for Global Action
1.2.4 The African Union and Southern Africa Development Communit
1.2.5 From the Millennium Development Goals towards the Sustainable Development Agenda
1.3 POLICT CONTEXT IN ZIMBABWE
1.3.1 Plan for Equity in Health and the First Health for all Action Plan of 1985 to 1990
1.3.2 The Second Health for all Action Plan of 1991 to 1995
1.3.3 National Health Strategy of 1997 to 2007
1.3.4 The National Health Strategy 2009-2014
1.4 THE ORGANIZATION OF HEALTH SERVICE DELIVERY IN ZIMBABWE
1.4.1 Regulations on health care provision in Zimbabwe
1.4.2 Local Boards and the legal frameworks in Zimbabwe .
CHAPTER TWO LEVELS OF DECISION SPACE AND STUDY QUESTIONS 
2.1 DECISION SPACE LEVELS IN ZIMBABWE’S HEALTH SYSTEM
2.1.1 DECISION SPACE AT THE PRINCIPAL LEVEL
2.1.2 DECISION SPACE AT THE AGENT LEVEL
2.2 THE STUDY OBJECTIVE
2.2.1 Research questions and study aims
CHAPTER THREE LITERATURE REVIEW AND THE FRAMEWORK OF ANALYSIS 
3.1 LITERATURE REVIEW
3.1.1 Human Resource for Health Reform in Health Systems
3.1.2 Human Resource for Health Decision Space Analysis .
3.1.3 Towards the Human Resources for Health Reform Agenda ..
3.2 DEFINING KEYS TERMS IN THIS STUDY ..
3.2.1 The Decision Space Approach
3.2.2 Indicators of decision space .
3.2.3 Key issues in studying health system reform using decision space
3.3 FRAMEWORK OF ANALYSIS
3.3.1 PRINCIPAL AGENT APPROACH
CHAPTER FOUR  THE PROBLEM AND STUDY SIGNIFICANCE
4.1 STATEMENT OF THE PROBLEM
4.2 SIGNIFICANCE OF THIS STUDY
CHAPTER FIVE METHODOLOGY
5.1 RESEARCH DESIGN
5.2 QUALITATIVE STUDY
5.3 QUANTITATIVE STUDY AT THE AGENT LEVEL
5.4 DATA PRESENTATION METHODS
5.5 DATA ANALYSIS METHODS
5.6 AUTHORIZATION AND ETHICAL CLEARANCE
CHAPTER SIX PRESENTATION OF FINDINGS 
6.1 SUMMATIVE PROFILE OF STUDY PARTICIPANTS
6.2 AN OVERVIEW OF THE LOCAL HEALTH SITUATION IN EPWORTH
6.3 ORGANIZATION AND DECISION MAKING LEVELS
6.4 DECISION MAKING AUTHORITY AND POLICY OUTCOMES
CHAPTER SEVEN DISCUSSION OF FINDINGS 
7.1 TOWARDS HUMAN RESOURCE DECISION SPACE MAPPING ANALYSIS
7.2 HUMAN RESOURCE DECISION SPACE, INNOVATIONS AND IMPACT
CHAPTER EIGHT  CONCLUSIONS AND RECOMMENDATIONS
8.1 CONCLUSIONS
8.2 RECOMMENDATIONS
REFERENCE LIST 
ANNEXURES .
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