Journal of Social Development in Africa (1990) 5,1,23-29 
An Overview of Health Manpower Issues in 
Relation to Equity in Health Services in 
Zimbabwe * 
RENELOEWENSON + 
ABSTRACT 
This paper presents an overview of the positions raised by contributors to the workshop on 
health manpower issues in relation to equity in and access to health services in Zimbabwe (see 
Willmore and Hall, 1989). It evaluates the extent to which policy initiatives in 1980, towards 
equity in health care, have been achieved, and the constraints to realising these policy goals. 
With 'equity' defined as the provision of care in response to need, democratic control over 
health services is necessary to allow all potential consumers of health care a role in directing 
services according to their perceived needs. Hence the paper also addresses the question of 
how far consumers of health care control or participate in the services they use. 
The sorioeconomic context of health 
The current health services in Zimbabwe reflect their socioeconomic context and the 
historical legacy of British colonialism. The country continues to be characterised by great 
inequalities in wealth, with a private doctor earning in one month what a domestic worker 
earns in four years. Despite rich national resources, a large part of Zimbabwe's wealth is still 
under foreign control. As discussed by Sanders in his opening paper to the conference (see 
Sanders paper in this issue), while many sectors have shown overall economic growth, 
inequalities in wealth have widened: the low income consumer price index (CPI) has shown 
greater relative increases than the higher income CPI, unemployment has risen, real wages 
have not increased since 1982 and urban homelessness stands at extremely high levels. While 
there has been increased investment in peasant production since 1980, lack of significant land 
reform and continued overcrowding and poverty has meant that the benefits of these 
investments have been unequally distributed, resulting in widening socioeconomic stratification 
in communal areas (Sanders,1989). 
* »n edited f arm of a paper presented to the Workshop on Health Manpower Issues in Relation to Equity in and 
Access to Health Services in Zimbabwe, June 8/9 1989, Harare, Zimbabwe. 
+ Lecturer, Medical School, University of Zimbabwe, P O Box A 178, Avondale, Harare.
24 Rene Loewenson 
By independence in 1980, this economic profile was associated with a pattern of morbidity 
and mortality that showed great differences with respect to race, geographical area and class. 
While race has been a less critical factor in determining health status than income after 1980, 
geographical (urban/rural) and class differences have persisted, with consequent effects on 
the distribution of ill health. Hence, while the largely urban, upper income groups have low 
infant mortality rates, an increased life expectancy, and suffer the degenerative diseases of 
industrialised countries, the rural majority and urban working class experience nutritional and 
communicable diseases and mortality patterns arising from inadequate diets and poor living 
and working environments. 
These economic inequalities were also reflected in differential access to health care, as 
described in detail in the paper by Sanders. Prior to 1980, geographical area, race and class 
were determinants of access, with health care fragmented in to five major providers of western 
healthcare. The division between curative and preventive care, with a lack of emphasis on 
the latter, reflected the attitude that individuals were responsible for their ill health. 
Individualising health interventions distracted attention from social causes and potential 
collective action. Equity was an issue avoided by 'blaming the victim' for their ill health and 
providing only rudimentary curative care to the majority of the population. In this oppressive 
form of health service, communities were given no real role in discussing their problems and 
in defining or controlling health interventions. 
Equity in health policy 
As expressed in the government policy paper Planning for Equity in Health (Ministry of 
Health, 1984), the independence policy of equity in health was a significant departure from 
colonial forms of health care. This policy defined qualitative changes in health care, 
including: 
redirecting the majority of resources to those most in need 
removing the rural/urban, racial and class biases in health and health care 
overcoming the fragmentation of service providers to develop an integrated, national 
health service 
ensuring accessible care to the majority, with other levels supporting this infrastructure 
integrating preventive, promotive, curative and rehabilitative care 
increasing the participation of and control by communities in their health services. 
Equity in health practice 
This policy, derived from the popular and democratic aspirations of those who fought in the 
liberation struggle, faced a number of challenges post independence. 
The continued inequalities in ownership of wealth, and in income, described above have 
continued to generate huge differences in the type and extent of morbidity in the different 
social classes in Zimbabwe. Hence, as shown by Loewenson and Sanders (1988), while 
expanded and qualitatively different health services have significantly reduced mortality and 
certain types of morbidity, the economy continues to challenge health care providers with a
Health Manpower Issues 25 
burden of nutritional and communicable disease. In attempting to respond to the massive 
demand for expansion of services, the health sector has depended on a mix of public sector 
allocations, community contributions and donor agency support. 
Nine years later, we pose the question: How far have we moved toward equity in health 
and what problems do we face? 
The racial distribution: Race is no longer a deciding factor in most aspects of health status 
or access to care. It continues to play a role in that most whites are in the high income groups 
and most blacks are poor. Class has become a more important determinant of health outcomes, 
interacting with urban/rural status. 
Geographical patterns of health: The rural/urban dichotomy in health care distribution 
continues to exist. While an active programme of construction and upgrading of rural 
facilities has taken place, manpower distribution continues to be biased towards urban areas. 
According to Dr Richard Laing, of the Manpower Development Section of the Ministry of 
Health, there are less than 10 Zimbabwean GMO's in rural areas, forcing the ministry to rely 
heavily on expatriate doctors to fill these posts. In the public sector, only 50% of the GMO 
posts in the provinces are filled, with 97 doctors altogether compared to the 109 serving Harare 
alone (Laing 1989). Conditions of service are poor in rural areas, a problem highlighted by 
the Hospital Doctors Association as a factor in the reluctance of Zimbabwean doctors to do 
ruralservice. TheZimbabweAssociationofChurchRelatedHospitals(ZACH)reports some 
of the worst conditions: mission hospitals are often remote, with poor roads and inadequate 
transport facilities. Their staff are often more poorly paid than those in other health sectors 
and lack apromotion and pension structure integrated with other sections of the public service. 
The rural/urban dichotomy is increased by the continued existence of multiple providers 
of care. The differing conditions in the mission services cited above is one example of this 
fragmentation. Private company health services in agroindustries and mines often do not 
follow Ministry of Health primary health care policies and only provide curative care to those 
in employment. Private health services, discussed in more detailed later, are biased towards 
urban practice. Local authority care in large scale fanning rural council areas is poorer than 
in peasant district council areas. There has been little rural council financial allocation to 
developing social services, and contribution from workers is undermined by their nonresident 
status and insecure tenure (Loewenson,1988). 
This geographical bias has been justified in the past by pointing to the referral of patients 
from rural primary care to the sophisticated central urban hospitals in Harare and Bulawayo. 
This function as quaternary referral centres has justified the latter facilities absorbing a large 
proportion of the health budget, of manpower and of laboratory and other services. The 
Hospital Doctors Association has also used this referral system to justify their view that almost 
all doctors should be placed at central urban facilities (HDA.1989). In reality, as the study by 
Sanders et al (quoted in the paper by Sanders,1989) shows, the referral system does not 
operate for almost all medical conditions, and about half of those coming to central facilities 
come from within 10km, often using the quaternary referral centre as a frontline service. 
Hence a hospital like Parirenyatwa sees the primary care complaints of the higher income 
residents of Harare at about six times the cost allocated to a rural resident visiting a district 
hospital.
26 Rene Loewenson 
Tl Z \ V1 °fS f°r 3 Cl0Se review of utilisation «* 
L t TS' r l"g ^ Heed fOf ^ Pr°vision 
p 
^tion highlighted the importance of the 
S J int° *C w medical «"*«*»» as a means of better 
to perform their role in district facilities (MSA.1989). 
Class as a factor in equity in health 
by class is summarised in the 
allocation of manpowef wTm „ Z S j ^ r 
t l q U O t e d ^ ^ ft is also evident in ^ 
urban areas, together with StateRe JT ^ ? concentration of 'high cost' doctors in 
low income grLpsprim^pSS 
(SCN's). The President of me SPN A y .P°°r l y p a i d S t a t e C e r t i f i e d N u r s e s 
althoughless trained than SRNs, cany o u S u T 0 f f Z™b*»i P°inted out ^ SCN'S' 
toearningaceilingsalaryequivSnTrf ,^°fcuratlvework in rural areas. Inaddition 
leaveallowanceofsR^rdhtT^^^^ 
suchasmeseaddtomedistribuUroSerS,1;? C°ndlUonsgenerally- Manpower factors 
it costs Z$92 per patient i n P a r k e n y a r a H o S t ^ ^ 1 0 ^ " 0 6 ^ 3 ^ ^ ^ 
hospital, despite the likelihood 2 ™ P f - ' a b o u t ^ ^ t o f o u r t i m s s * * i n a d i s t r i c t 
severity (Sa^l989;S£Sl^??1 O B ' ^ ^ ""*" ^ te °f a "^ 
Added to these social d i f f e e S s t h e ^ ^ S"" W ° r W Bank'1983>- 
private sector care. This has been c r i t L ^ d f , 6 WUhm ^ Public ^ ^ i s ** effect of 
The private sector was s p e c i f i c a l l y ^ S S ^ f ^ ^ n ^ t e r of Health in Zimbabwe. 
allocationofhealthresources. A p J M t E o f I S n ^ f a 198° M diStOrti"g ^ 
in 1984 that the state subsidisedVriv^^^??f f* DrH^bertUshewokunze, estimated 
million (Loewensonan andd Sander Sanderss 
l O S s t l O S s t ^^ 
y * Care directly y ^ indirectly b y y Z$17 
1 4 1 7 d i J 1417doctor 
e P I i ! V a t e S e C t o r a b s o b b l 0 0 0 f i b b ' S>andasignificantOToix)rtioJ;e
f
PIi!VateSeCtorabsorbsaboutl000ofzimbabwe's 
population, primarily in the higher income ^ ^ b i U ' t 0 S e r v e a sma11 s e c t i o n of *e 
the system of medical aid payments Its exn -PS"- ^ P f i v a t e s e c t o r is larSely supported by 
aid membership by 60% since 1980 much f T™ * &US i n d i c a t e d by *e increase in medical 
equity in health by absorbing scarce manno Sin"r b a n w o*ers. The private sector distorts 
in access to health care, and has also beerTT' fCC f ° r s e r v i c e m a k e s i n c o m e a f a C t°r 
interventions, and possible abuse of free cl • with encouraging excessive tests and 
preventive and promotive aspects of health " private s e c l o r 8enerally ' S " ^ 8 
practitioners and patients has been reDorted ?"v ThC a t t r a c t i o n to Pr i v a t e c316 for 
incorporating features of continuity dJZt^- m its &Tsond, individualised care, 
y' tatallsato». efficiency and reduced waiting times.
Health Manpower Issues 11 
However, while the recommendation that the public sector absorb some of these features has 
been made, the issue remains how to control the huge flow of health resources to the small 
private sector market, in a society where both the providers and consumers of private care are 
an influential and vocal group. 
These problems indicate that features of the health service highlighted in 1980 as 
undermining equity in health care continue to exist Despite great efforts by the public sector 
to meet the challenge of providing for health needs, socioeconomic factors continue to bias 
the delivery of care. While not a comprehensive assessment of the material limitations to 
equity in health care, the features described above indicate that we still have many challenges 
to face in distributing health care in response to need. 
Democratic control of health services 
There are other issues raised in Planning for Equity in Health which are also critical to 
ensuring that service is responsive to need. One area is the issue of democratic control over 
health services. Health policy makers in 1980 called for greater control by, and communication 
between, all levels of health workers within the health sector, together with community 
decision making in health interventions. 
In practice, the democratic control of health services has been greatly enhanced by the 
formation of district health teams and health executives, creating a mechanism for collective 
planning by health workers at the same level, as well as the exchange of ideas between health 
cadres and other representatives in local authorities. Social control over health care is, 
however, still limited by a number of factors: 
Communities are not homogeneous and those represented on decision making bodies are 
often the more powerful and higher income sections of the communities covered. 
VHW's were once intended to be agents of community control and facilitators in making 
the health sector more accountable to communities. They have now been taken over 
by the Ministry of Community Development and are paid by the government, giving them 
a perceived role as civil servants. 
There are no structures for patients to exert an influence over curative care, such as ward 
committees in hospitals. 
The mass organisations (such as the co-operative and trade union movements) haveplayed 
little role in the organisation of health care. 
The district health team reflects intersectoral interests, but is not necessarily democratic. 
The democratisation of health care also implies changing the ideology of health care, 
demystifying the causes of ill health, and giving people a vital role in solving health problems. 
The extent to which the health sector has moved from biomedical to socioeconomic 
explanations for ill health, and from curative to preventive care is variable. It appears to have 
depended greatly on the orientation of the District and Provincial health manpower. Despite 
programmes such as the VHW programme, consumers still appear to be poorly organised and 
relatively weak in expressing collective health care demands.
28 Rene Loewenson 
Within the health sector, health workers have a strong hierarchical organisation. There are 
many professional associations, some of these being split into different interest groups (such 
as the SRN/SCN division in the nursing profession, and the many associations representing 
doctors). At the workshop on Equity in Health Services, health workers at all levels 
complained that they had no influence over ministry policy and that the dialogue between 
themselves and the Ministry of Health was poor. As government workers, health cadres have 
no industrial relations body recognised in terms of the Labour Relations Act 1985 to negotiate 
for improved working conditions and wages. In addition, the many professional divisions in 
the sector weaken any coherent approach to manpower issues. Hence, for example, while 
doctors use their associations to advance their own interests, as in the case of the recent doctors 
strike, their demands do not consider overall changes in conditions for health manpower. This 
has ripple effects: the wage increases recently awarded to the doctors, for example, have 
created expectations amongst other health manpower - while awarding a large salary increase 
to 400 public sector doctors is possible, giving similar relative increases toll 000 nurses is 
more difficult. The impact of uncoordinated approaches to changes in working conditions and 
wages in any one group of health workers destabilises industrial relations in the health sector. 
The powerful lobbying force of doctors appears to ensure that demands are met, while the nine 
year long grievances of the SCN' s about salary and career structures continue to be ignored. 
The health profession and economic change 
If health is, as is generally recognised, a product of socioeconomic conditions, what is uie 
responsibility of health workers in transforming the economy towards one which contributes 
towards improvements in health? 
The economic context of health implies at least an intersectoral approach to health care, 
with health issues absorbed into policy and action in a number of other areas, such as in 
agricultural production, education, economic planning and so on. The experience of the past 
nine years in Zimbabwe shows that equity in health care cannot be isolated from general 
socioeconomic trends. This raises questions of the relationship between the health sector and 
other areas of the economy. What role does a nutrition department play in agricultural and 
food pricing policies? What role does a maternal and child health unit play in issues like 
maternity leave,socialsecurityandchildlabour?Whatrelationshipshouldhealthprofessionals 
have with organisations representing those whose health needs are greatest, such as peasant 
organisations and trade unions? 
Conclusion 
In summary, therefore while the health sector has made significant advances in expanding 
and distributing health care to those in need, it continues to face the challenge of multiple 
providers (not all of whom share the policy view of equity in health care), a rural/urban 
dichotomy.andsocial class differentials in health status and accesstocare. While theprocess 
has begun, there ,s a need for greater democratic control over services by the community, as
Health Manpower Issues 29 
well as by different levels of health care providers. The sector also needs to find more 
effective ways of playing a role in transforming an economy which continues to generate a 
highly unequal distribution of morbidity and mortality. 
References 
ChitigaP (1989) "The Case of the State Certified Nurse", paper presented for the SCN 
Association of Zimbabwe to the Workshop on Health Manpower Issues in Relation to 
Equity in and Access to Health Services in Zimbabwe, Harare, June 1989. 
Hospital Doctors Association (1989) "The role of the Doctor in Health Services: The HDA 
View", talk to the Workshop on Health Manpower Issues in Relation to Equity in and 
Access to Health Services in Zimbabwe, Harare, June 1989. 
Laing R (1989) 'The Role of the Doctor in Health Services: A Public Sector View", talk 
to the Workshop on Health Manpower Issues in Relation to Equity in and Access to Health 
Services in Zimbabwe, Harare, June 1989. 
Loewenson R (1988) "Labour Insecurity and Health" in Social Science and Medicine, 
27(7), 733-741. 
Loewenson R and Sanders D (1988) "The Political Economy of Health and Nutrition" in 
Zimbabwe's Prospects, Stoneman C (ed), Macmillan, UK. 
Sanders D (1989) "Equity in Health: Zimbabwe Nine Years On", paper presented to the 
Workshop on Health Manpower Issues in Relation to Equity in and Access to Health 
Services in Zimbabwe, Harare, June 1989. 
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in and Access to Health Services in Zimbabwe, Workshop Report, Journal of Social 
Development in Africa, School of Social Work, Harare. 
World Bank (1983) Population, Nutrition and Health Sector Review, Washington. 
Zimbabwe Medical Students Association (1989) 'The Role of the Doctor in Health 
Services: A Medical Student View", talk to the Workshop on Health Manpower Issues 
in Relation to Equity in and Access to Health Services in Zimbabwe, Harare, June 1989.