Ministry of Health Government of the Republic of Zambia. National Training Operational Plan 2013 to 2016

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1 Ministry of Health Government of the Republic of Zambia National Training Operational Plan 2013 to 2016

2 Foreword This Operational Plan aims to summarize the current situation in health training institutions across the country and evaluate the progress made against the 2008 National Training Operational Plan (NTOP), including improvements in infrastructure and changes in enrolment at individual schools. Furthermore, the document provides information for increasing the overall training capacity of various critical health care providers in line with the national scale-up plan for health care workers in Zambia. The Operational Plan is an effort made by Ministry of Health in collaboration with cooperating partners to address the human resources in health crisis that Zambia is experiencing. It is specifically targeted towards increasing the number of graduates from health training institutions, both grantfunded and non-grant-funded. The training institutions covered in this operational plan include government, mission, and privately owned Nursing and Midwifery Schools, Biomedical and Paramedical Colleges, Medical Schools and private Universities. It is envisaged that implementation of the activities in this document will facilitate the achievement of our vision of providing cost-effective, quality health services as close to the family as possible. NTOP implementation will contribute towards attainment of health related Millennium Development Goals (MDGs) and other national health priorities in a cle an, caring and competent environment. This will ensure equity of access in health service delivery and contribute to the human and socioeconomic development of the nation. The Ministry of Health wishes to encourage all stakeholders to continue their strong commitment to the implementation of this operational plan over the next four years, as a part of the greater effort to address Zambia s HRH crisis. Hon. Dr. Joseph Kasonde Minister of Health Lusaka May,

3 Acknowledgements The 2012 assessment and development of the updated National Training Operational Plan ( ) was successful due to the active support and dedication of many different stakeholders involved in Zambia s health sector. I wish to recognize the dedication of all those involved, both directly and indirectly, whose contributions and insights helped to ensure that this Plan is of the highest quality. The Plan was developed through a participatory and consultative approach, with contributions and insight from management and staff across many different levels of the Ministry of Health; General Nursing Council (GNC); Health Professions Council of Zambia (HPCZ); the University of Zambia (UNZA School of Medicine); Ministry of Science Technology and Vocational Training, the Cooperating Partners and the principal tutors in every health training institution across Zambia both public and private. Special thanks go to staff in the Ministry of Health. On behalf of the Ministry of Health, I also wish to acknowledge the financial and technical support of the Swedish International Development Agency, as well as the Clinton Health Access Initiative (CHAI), who provided the financial and technical assistance for the development of the operational plan. I thank them for their zeal and commitment to the collection and analysis of data. I am aware that the implementation of this Plan will pose many challenges, but with the commitment and cooperation of all stakeholders, both those mentioned here, and other unnamed contributors, I strongly believe that the goals outlined in this Plan may be attained. Dr. Peter Mwaba Permanent Secretary Ministry of Health 2

4 Table of Contents Foreword...1 Acknowledgements...2 Table of Contents...3 List of Tables and Figures... 4 List of Acronyms... 5 Executive Summary.. 6 Introduction...8 Objectives of the National Training Operational Plan PART ONE: 2008 NTOP Evaluation. 10 Background...10 Methodology...12 NTOP assessment tool development...12 Data Collection...13 Analysis and Reporting...13 Findings and Results of Data Analysis...13 Focus area 1 Health Care Worker production...13 Student Enrollment Numbers...13 Graduate Numbers...16 Focus area 2 Quality of Education...19 Focus area 3 - Infrastructure...21 Focus Area 4 Finance NTOP RECOMMENDATIONS...25 PART TWO: NTOP 2013 to Operational Plan 2013 to ANNEXES Map of Training Institutions Training Institution Profiles NTOP Survey Tool Cost of Training, by Cadre List of Assessed Infrastructure Projects from Contracted Quantity Surveyor Tracking of 2008 NTOP Recommendations: Progress from 2008 to Estimated Student Enrollment Numbers for Health Training institutions

5 List of Tables and Figures Figure 1: Healthcare worker gap to funded establishment, 2012 data...8 Figure 2: Health workforce projection, 2014 to Figure 3: Increases in HCW enrollments and graduates, , and HCW projections based on current growth rates, Figure 4: Enrollment, by Cadre, , compared to 2007 Baseline and Target set in 2008 NTOP Report Figure 5: Pre-Service vs. In-Service Enrollment, vs targets, by Cadre Table 1: Numbers of annual graduates per cadre, Table 2: Health Worker Graduate Projections 2013 to Figure 6: Number of TIs operating within GNC tutor: student minimum ratio of 1: Figure 7: Achievement of 2012 enrolment targets by 2008 NTOP Funded TIs.. 22 Table 3: NTOP infrastructure project budget and expenditure.. 23 Table 4: Category of TI by NTOP Project Funding Status, comparing Activities and Expenditures 23 Table 5: TIs operating parallel programs.25 4

6 List of Acronyms BSc CHAI CI CM CME CPD CPs DEM DNS EM EN FTE GNC GRZ HCWs HMIS HPCZ HRH MCDMCH MDGs MoE MoEST MoH MSc NEPI NTOP NHRHSP PSMD RN RM SIDA SOM TEVETA TI UNZA WHO Bachelor of Science Clinton Health Access Initiative Clinical Instructors Certified Midwives Continuing Medical Education Continuing Professional Development Cooperating Partners Direct Entry Midwife Department of Nursing Sciences Enrolled Midwife Enrolled Nurse Full-time Equivalent General Nursing Council Government of the Republic of Zambia Health Care Workers Health Management Information System Health Professions Council of Zambia Human Resources for Health Ministry of Community Development Mother and Child Health Millennium Development Goals Ministry of Education Ministry of Education, Science and Technology Ministry of Health Master of Science Nurse Education Partnership Initiative National Training Operational Plan National Human Resource for Health Strategic Plan Public Service Management Division Registered Nurse Registered Midwife Swedish International Development Cooperation Agency School of Medicine Technical Education, Vocational and Entrepreneurship Training Authority Training Institution University of Zambia World Health Organisation 5

7 Executive Summary Zambia continues to suffer from a significant shortfall of all health workers, operating at only 43% of its funded establishment (FE) target for clinical Health Care Workers (HCWs). Furthermore, it is likely that the current FE target significantly underestimates what Zambia s need for HCWs will be by Because the best means of increasing the number of HCWs working within Zambia is to increase the nation s HCW training outputs, it is critical that this is prioritized by all stakeholders working within this arena. This National Training Operational Plan (NTOP) 2013 to 2016 report was developed to address the gap between Zambia s current rate of HCW production and the demand for additional HCWs to serve the total health needs of the fast-growing Zambian population. The report consists of an introduction to the NTOP, its main objective and the means to achieving this objective. The remainder of the document is subdivided in to two parts. Part one consists of the findings from an evaluation of the 2008 NTOP, and results of data analysis with recommendations for how to move forward in scaling up HCW production. Part two consists of a high level costed operational plan for implementing the key NTOP 2013 to 2016 recommendations. This plan is time bound and includes output indicators and targets. The overall objective of the NTOP 2013 to 2016 is to have a clear step-wise implementation plan for solving the Zambian HRH crisis by The 2008 NTOP evaluation showed that the overall enrollment target for 2012, set back in 2008, has been reached. However, some critical cadres, including midwives, clinical officers and environmental health staff have fallen short of their specific targets. Enrollment increases are in part due to selfsponsor students, allowing TIs to scale up without additional funding from government, or enrollments at private TIs. Self sponsored students are frequently required to procure their own accommodation, a strategy that has not been taken up by nursing/midwifery schools, restricting their capacity to scale up. Data on student to tutor ratios was gathered; fewer than 30% of TIs assessed were working within the present tutor: student minimum ratio. Many TIs cited a lack of qualified tutors available and problems with staff appointments. This is a major constraint for TIs who wish to scale-up student enrollments but still ensure that they are maintaining minimum educational quality standards. The current status of all planned 2008 NTOP infrastructure projects was assessed. The project types that had the highest completion rates included the construction of classrooms (66% of projects complete), student accommodations (62%), and teacher accommodations (58%), as well as the furnishing of various facilities (74%). Of the projects that were not completed, the poorest rates of completion were found in the construction of lecture theatres (17% of projects complete) and skills labs (25%). The key recommendations coming out of the 2008 NTOP evaluation are as follows: Curriculum reviews: to ensure all nurses and clinical officers have core competencies in emergency obstetric and newborn care. E-learning: to be scaled up for pre-service training, in-service training and continuing medical education (CME) / continuing professional development (CPD). Two student intakes per year combined with staff development to ensure adequate numbers of skilled teachers for theoretical knowledge and practical skills acquisition. 6

8 Day scholars so accommodation available at the training institution is not the limiting factor for enrolment scale up. It is believed that if the above key recommendations from the NTOP 2013 to 2016 are fully implemented at all the training institutions (TIs) for all different cadres, the Zambian HRH crisis can be resolved by With an overall estimated investment of USD $43,827,572 over the next four years, there can be a 147% increase in the number of students enrolled annually in present health training institutions, from 3818 enrolled in 2012, to an expected 9450 enrolled in With an additional investment of USD $15,094,340 over the next three years, there could be an additional 1000 students enrolled annually at a new large scale National Training Institute in Lusaka. Furthermore if bonding / provisional licensing for all HCWs for a designated period of time can be adopted as policy, then increased numbers of new graduates will be available for deployment to vacant positions in public health facilities. 7

9 Introduction In the last five years, the Ministry of Health (MoH) of the Government of the Republic of Zambia (GRZ) and cooperating partners (CPs) have initiated and implemented a number of interventions resulting in an increased capacity to produce more health care workers (HCWs)nationally and deploy them more equitably within the public health sector, including: Reopening closed nursing schools; Expanding the physical capacity of existing training institutions to increase student intake; Introducing new training programmes, including a pre-service Certified Midwives and a preservice Post-Basic nursing degree and distance learning for nurses and midwives; Opening new private training institutions; and Placing HCWs into vacant positions to ensure a more equitable distribution across the country Many of the above interventions were as a result of a National Training Operational Plan (NTOP) initiated in These efforts have increased the number of HCWs working in Zambia s public sector, and have been accompanied by increases in budgetary funds directed at both improving HCW salaries and increasing the number of available positions within the government s funded establishment (FE) for health workers. However the nation continues to suffer from a significant shortfall of all health workers, operating at only 43% of its clinical HCW target of 39,360 1, as shown in Figure 1 below. Figure 1: Healthcare worker gap to funded establishment, 2012 data 42,000 36,000 30,000 24,000 18,000 12,000 6, % 36% 48% Doctors Current MoH Target Clinical Officers 46% 100% 41% 28% Midwives Nurses Pharmacy Lab Other HCWs 43% Total Clinical Given the estimated enrollment numbers per training programmes collected from all HCW training institutions across the country (see annex 7), adjusted for various attrition factors, the current funded establishment positions target is expected to be exceeded by 2020 as shown in Figure 2 below. However, the estimated enrollment numbers are dependent on the TIs completing present infrastructure projects which have been budgeted for in the coming few years. It also assumes that nursing schools take on additional day scholars who find their own accommodation outside of the TI. The enrollment numbers also include 6000 students predicted to be enrolled in to e-learning preservice programmes. 1 Ministry of Health, Human Resources for Health Strategic Plan , WHO need-based target staffing methodology 8

10 Figure 2: Health Workforce Projection, MoH Human Resources for Health Strategic Plan, ; excludes data from

11 Objectives of the National Training Operational Plan The overall objective of the NTOP 2013 to 2016 is to have a clear step-wise implementation plan for solving the Zambian HRH crisis by The specific objective of this NTOP is to increase the enrollment of HCW trainees so that the gap between HCW production and demand for HCWs is eliminated by The means to achieving the above objective, which the NTOP 2013 to 2016 report will facilitate, include: Having a shared understanding by all HRH stakeholders, as to the strategic direction required for resolution of the Zambian HRH crisis. Identifying necessary resources for implementation of activities, including financial contributions and technical expertise. Seeking participation and commitment to the NTOP 2013 to 2016 implementation from GRZ and health CPs. Creating effective coordination and communication structures, to assign roles and responsibilities for NTOP 2013 to 2016 implementation. PART ONE: 2008 NTOP EVALUATION Background In early 2008, the MoH produced an Annual Training and Development Plan for HCWs which set targets for increasing each of the specific health cadres. To develop a costed, step-wise implementation strategy, a National Training Operational Plan (NTOP) assessment was carried out. This involved field visits to health Training Institutions (TIs) across Zambia. That assessment helped all stakeholders to understand the training capacities of TIs; the challenges they faced to scaling up student numbers; what optimization strategies could be utilised to maximize HCW production with existing resources available, and what further investments could be made to address specific TI barriers to training scale-up. Based on NTOP 2008 findings, the MoH agreed on cadre specific training scale-up targets, and with support from CPs they embarked on a rigorous rehabilitation and construction programme at 27 selected health TIs (NTOP implementation Phase 1). Partially donor supported, MoH s 2008 Capital Investment Plan (CIP) ZMK 32 billion (approximately USD 9 million) was invested in 26 nursing schools and 1 biomedical school during 2008/2009. The investments ranged from refurbishments to building new infrastructure (classrooms, lecture theatres, student hostels, staff housing) or investing in teaching aids, vehicles etc. Unfortunately a number of other investments prioritized in the 2008 NTOP were never completed due to shortfalls in funding from 2009 onwards. It was against this backdrop that a National Human Resources for Health (HRH) consultative meeting was convened in January The focus for the meeting was to discuss how to increase Zambia s 10

12 health workforce in the public sector. Among the key points raised was the need to refocus on improving training outputs from health TIs, as highlighted in Objective B of the National Human Resources for Health Strategic Plan (NHRHSP). Included in the meeting s discussions were concerns about the inadequate, up-to-date information on TI activities, and to what extent the 2008 NTOP had actually been implemented. Following development of the NHRHSP a group was tasked to assess the 2008 NTOP to better understand the current situations of Zambia s health TIs and assist them in generating pragmatic, sustainable solutions to challenges in increasing training outputs, whilst maintaining minimum quality standards. The 2012 NTOP assessment was carried out in 42 health TIs across Zambia; 19 GRZ, 8 Mission and 15 Private Schools. While there are 47 TIs registered with both the General Nursing Council (GNC; training schools for nurses and midwives) and Health Professions Council of Zambia (HPCZ; training schools for all other health cadres), only 42 were training students at the time of the field assessments in May-July The remaining five institutions were not yet completed / functional, or still awaiting full accreditation to train students, and thus were not surveyed as a part of this study. The NTOP assessment tool collected data across the following areas: Program Overview (Enrollment and Graduate numbers), Staffing Information, Quality of Education, Infrastructure, Equipment, and Finances. The overall objectives of the 2008 NTOP evaluation were: 1. To obtain a comprehensive assessment of ALL health training schools (GRZ, Mission, and Private) to provide school-specific requirements for each TI to meet training scale up targets set by MoH in To compare budgets for specific projects allocated for financial support at the 27 targeted training schools in the initial NTOP, against what financial support was actually received and what activities were actually carried out. 3. To determine options for strategic potential investments at various training institution that would assist MoH in meeting HRH funded establishment staffing targets. 4. To identify innovative strategies for optimizing the use of existing resources in TIs, that can allow scale-up in the number of students trained and share lessons learned from TIs that have done so successfully. 5. To identify the 2008 NTOP s impact to date, and which further investments could win the greatest gain in increasing HCW numbers, for the level of investment made. This 2008 NTOP evaluation aims to provide an overview of individual training institutions activities to date, present key issues facing TIs, both at the individual and collective levels, and offer recommendations for maximizing health institutions enrollment capacities. 11

13 Methodology NTOP assessment tool development The assessment tool was developed through collaboration between representatives of the MoH Directorates of Human Resources, Planning and Policy, Clinical Care Services and Diagnostics, Public Health and Research, and the Clinton Health Access Initiative (CHAI). The 2012 NTOP evaluation was originally intended to measure the extent to which 2008 NTOP funded activities occurred at the original 27 health training schools targeted in phase one of the training operational plan. However, as the process moved forward, stakeholders agreed that information was needed from all functional health TIs, either public or private to fully understand the capacity that could be utilized in a national scale up of HCWs. A desk review of all TI assessments carried out prior to the 2008 NTOP was conducted, and the 2008 NTOP report was reviewed to establish a qualitative baseline detailing the greatest challenges faced by TIs at that time. The 2008 NTOP data collection tool was then updated to ensure that the data collected was comprehensive. Quantitative date was collected through the data collection tool, whilst qualitative data was also collected through stakeholder interviews. Stakeholders feedback was requested and incorporated, and a pilot to test the assessment tool was conducted in selected training schools around Lusaka. The questionnaire was adapted based on learning from the pilot assessment, and a physical checklist was developed to assess the status of the projects planned for within the 2008 NTOP (see questionnaire and physical checklist in Annex 3). The final assessment tool collected data on the following thematic areas: Theme Contact Information Program Overview Details Overview of the training school s information, and key contact persons. Current details on the programs available at the school, estimated number of applicants versus the enrollment numbers. Student Details Overview of enrollment and graduate numbers over the past 5 years ( ). Staffing Information Quality of Education Infrastructure Number of full time staff; number of staff transferred, retired and/or confirmed over the last 3 years; ratios of tutors/lecturers to the number of students. Information on the use of current classroom space, any innovative (non classroom) based teaching methods being used, ratios of equipment (skills laboratory, computers, textbooks etc.) to the number of students; Checklist of infrastructure at the schools (those funded by NTOP - what has been completed/incomplete or delayed or modified activities), numbers student or staff- having benefited from the NTOP activities, information on accommodation and transport. 12

14 Data Collection Five assessment teams of at least 4 people, including representatives of the Directorates of Human Resources and Administration, Planning and Policy, Clinical Care Services and Diagnostics or Public Health and Research, and the Clinton Health Access Initiative conducted the assessment, together with the Provincial Clinical Care Specialist and the Provincial Nursing Officer from each Provincial Health Office. Each team was assigned assessment areas based on geographical distribution of the health training schools, and each visited from 4 to 14 schools. The teams visited all 42 active health training institutions across the 10 provinces of Zambia, including all GRZ, Mission and Private TIs. More detailed physical checks of infrastructure were done at the 27 TIs who benefited financially from the initial NTOP 2008/09 phase 1. Four TIs were excluded, as they had not yet started training HCWs at the time the survey was conducted. These included Senanga School of Nursing, Cavendish University, and 2 other new TIs in Central and Lusaka Provinces. Survey questions were posted to the TI s Principal Tutor or Training School Administrator, as well as Tutors and Department Heads. Analysis and Reporting Data collected was analyzed and cleaned, and additional qualitative information collected during discussions with TI staff, was used to fill data gaps, clarify ambiguities or enhance the information provided by the survey. Profiles for each individual TI were then prepared, summarizing each training school s progress and achievements, especially in reference to the NTOP Phase I, and highlighting key areas of need. Findings and Results of Data Analysis Focus area 1 Health Care Worker production Student Enrollment Numbers Zambia s health training institutions have made significant progress since 2008 in increasing the number of students enrolled in and graduating from health care training institutions nationwide. This is illustrated by the graph below; as the average training program is between 2-3 years, one can see this lag in the number of graduates from the time of enrollment. 13

15 Figure 3: Increases in HCW enrollments and graduates, , and HCW projections based on current growth rates, % Annual Increase Enrolments Graduates % Annual Increase Total % Increase Compound Annual Growth Rate (CAGR) Enrolled % 9.2% Graduated % 7.7% Both enrollments and graduates increased significantly over this period. It is important to note, however, that these rates of increase are unsustainable, and enrolment figures will eventually plateau. The percentage increase in each number varies by cadre, as demonstrated in figure 4 below. 14

16 Figure 4: Enrollment, by Cadre, , compared to 2007 Baseline and Target set in 2008 NTOP Report Overall, the enrollment target set in the 2008 NTOP has been reached. However, a few cadres, including midwives, environmental health staff and nutritionists have fallen short of their targets. While the number of nurses enrolled increased substantially, significant increases in enrollments have also been seen in non-nursing programmes. These increases are partly due to the implementation of programs where students are able to self-sponsor, or pay for their own education, thus allowing the training institution to increase enrollment without additional funding from government. Self sponsored students are frequently required to procure their own accommodation, or to pay more for housing within the institution than sponsored students. This strategy has not been taken up by nursing schools, as they still attempt to provide housing for all students, creating issues in implementing such parallel nursing programmes. When looking at the increased number of enrolments over the past years, it is also important to consider the contribution of the 11 private schools (26% of the total TIs) that have opened since They have collectively contributed 23 % of the increase in the number of students enrolled and 16% of the increase in the number of graduates from 2008 to These schools often have 15

17 smaller capacities than the public institutions, with intakes averaging between 20 and 55 students per year, and therefore do not contribute proportionally to overall enrollments and outputs. It is also worth noting that the number of students includes both pre-service and in-service students. This is especially noticeable for certain fields, including midwifery, which includes both direct-entry Certified Midwifery (2 years) and direct-entry Registered Nursing/Midwifery (3.5 years), as well as inservice Enrolled & Registered Midwifery programmes (1 year upgrades). A majority of Nurse Tutors are also in-service trainees, as are all Specialist Nurses and Medical Licentiates. As a result, the actual number of health workers that enrolled in 2012 and will be entering the system as NEW health workers is 3299, over 400 below the 2012 target. Figure 5: Pre-Service vs. In-Service Enrollment, vs targets, by Cadre Graduate Numbers There has been a 33% increase overall in annual number of healthcare worker graduates between 2008 and However, this increase largely depends on the cadre. Some cadres, such as nurses, had significant increases in enrollment following investments resulting from the 2008 NTOP, the 16

18 results of which have been felt in recent years. Doctors, on the other hand, have a training period of 7 years, so graduate numbers for 2012 are dependent on enrollment in 2005, and the impact of any increase in enrollment, such as the increase from 56 to 118 between 2009 and 2010, will not be felt until The number of clinical officers and medical licentiates also decreased, however, this change was due to a program scale-up with the expectation of funding, and then when that funding did not come through from GRZ, programs were forced to reduce their numbers. Table 1: Numbers of annual graduates per cadre, Cadre % increase change from 2008 to 2012 Compound Annual Growth Rate (CAGR) Doctors % -0.6% Nurses % 11.0% Midwives % 9.4% Clinical Officers % -8.8% Other % 4.8% TOTAL % 7.7% While this significant increase in nurses and midwives is critical given the focus on MDG 4 and 5 targets, by providing HCWs with the skills to save unnecessary loss of life in mothers and young children, as mentioned above, a large portion of the increase in nurses is in specialty nurses, all of whom are in-service trainees. Specialty nurses have a reduced chance of serving in rural areas, as there are few positions for them on the funded establishment in these areas. As a result, the rate of new HCWs graduated is likely less than the 7.7% annual increase presented in Figure 3. For some cadres the length of the training programme means that there is a significant lag time between enrolment and graduation, which is why both enrolment and graduation numbers need to be taken in to consideration when doing workforce planning. HCW graduate projections based on the number of students that are currently enrolled, by cadre, is shown below in table 2 and paints a clear picture of the health workers in the pipeline. Currently, if graduation rates remain consistent at 90%, projections indicate that 500 doctors will graduate between 2015 and 2019, over 500 biomedical science professionals will graduate between 2013 and 2016, and over 3,400 nurses and 600 clinical officers will graduate between 2013 and

19 Table 2: Health Worker Graduate Projections Cadre Program Length TOTAL Post Basic Nurse - Masters Medical Doctor Post Basic Nurse - Bachelors Pharmacist Biomedical Scientist Environmental Health Scientist Physiotherapist Clinical Officer General Dental Technologist Environmental Health Technologist Laboratory Technologist Pharmacy Technologist Physiotherapy Technologist Radiography Technologist Registered Nurse Nutritionist Certified Midwife Enrolled Nurse Medical Licentiate Registered Midwife Clinical Officer Specialists Enrolled Midwife Registered Nurse Specialists Dental Therapist General Counsellor With addition of enrolments at new TIs accredited in 2012, but enrolled first students after the NTOP assessment was completed. These include Cavendish University, City University College of Science and Technology and Kabwe College of Health Sciences 18

20 Focus area 2 Quality of Education With a scale-up in healthcare worker training numbers, it is crucial to ensure that the quality of training remains high. There are now more students in the classroom than ever before, and TIs have been pushed to continue scaling up without a proportional increase in government funding or resources, both infrastructure and otherwise. Some infrastructure expansion has occurred (ex. additional classrooms, lecture theatres, hostels) but the enrollment expansion has been that much greater than the infrastructure expansion. There are concerns as to whether the quality of education being provided may have changed, and TIs must work to ensure that they meet standards set. One major factor that dictates the quality of the education provided is the presence of a sufficient number of tutors and lecturers to teach the large student population in both theory and clinical practice. Initial data collected in 2008 NTOP compared to the 2012 NTOP survey revealed that the number of tutors increased from 253 to 413, an increase of 160 tutors (63%), but still short of the 2008 NTOP goal of 171 additional tutors. The schools that were not surveyed in 2008 reported 30 tutors in 2012, bringing the total number of health TI tutors to 443, a shortfall of 114 tutors needed nationally for TIs to meet the minimum tutor: student ratios, as required by the health regulatory bodies (discussed below). The number of clinical instructors also increased significantly between 2008 and 2012, with a 100% increase seen at all 2008 NTOP TIs (from 66 to 132), reaching a combined total of 199 in 2012 at all TIs throughout Zambia. However, this value is still far from the over 820 Clinical Instructors required according to GNC and TEVETA required ratios for this cadre. It is worth noting, however, that this increase is not necessarily representative of the true increase in the number of tutors, as many TIs hire part time tutors, lecturers, and clinical instructors. Unfortunately the magnitude of this shortfall cannot be assessed with the data gathered in this report, as although TIs reported on both full-time and part-time staff, they did not report the number of hours that the part-time staff worked within each individual TI. All TIs are required to meet minimum standards intended to ensure that a certain quality of education is maintained. These standards include a specific number of students per tutor or lecturer, minimum academic requirements for student admission, and minimum levels of physical equipment and infrastructure per students admitted. Those TIs that do not meet these minimum standards may be placed on probation by their respective regulatory body (GNC or HPCZ) and then re-assessed at the end of this probation period. If the TI still does not meet these minimum standards, the school may be closed. For example, the GNC has the following minimum tutor to student ratios: Overall, for each TI 1 : 20 Theoretical sessions 1 : 50 Small group/practical sessions 1 : 10 Clinical 1 : 10 19

21 Data on student to tutor ratios was gathered through the NTOP survey; only 29% of TIs assessed were working within the present tutor: student minimum ratio. Figure 6: Number of TIs operating within GNC tutor: student minimum ratio of 1: % of all TIs do not meet the required ratio of 1: Met Unmet GRZ/Mission Private Nursing Non-Nursing Urban Rural TI Type Current Average Tutor: Student Ratio Tutors Needed Tutors Present Gap GRZ/Mission 1 : Private 1 : Nursing 1 : Non-Nursing 1 : Urban 1 : Rural 1 : ALL TIs 1 : Private TIs reported the lowest tutor: student ratios, however, they also reported a higher percentage of part-time staff than GRZ/Mission institutions, so this value may be artificially high. The Non-nursing TIs, on average, also met the required tutor: student ratio; the average among urban TIs fell just above the required ratio. When asked for reasons why they were unable to meet these minimum ratios, many TIs cited a lack of qualified tutors available, problems with staff appointments, with either a lack of funded positions on the establishment to employ the necessary number of tutors, or a promotion/transfer process that leads to delays in the disbursement of staff remuneration. This is a major constraint for TIs who wish to scale-up student enrollment numbers but still ensure that they are maintaining minimum educational quality standards. Although an insufficient number of qualified instructors persists, graduation pass rate trends at nursing TIs have remained largely stable over recent years, averaging 87% between 2008 and Given that the national licensing exams for nurses and midwives are set and regulated by the GNC with few fundamental changes from year to year, this rate can be used as a measure of consistency in the quality of education provided. Comprehensive historical pass data was not available from 20

22 non-nursing cadres, however, so no conclusions can be drawn regarding the pass rates of other cadres. Focus area 3 - Infrastructure Following the 2008 NTOP report and planning cycle, there were 132 projects planned for the years of Investments planned ranged from construction, expansion, and outfitting of training infrastructure such as classrooms, student accommodations, faculty housing, and staff offices and skills laboratories. During the NTOP 2012 field assessment a checklist was developed to assess the current status of all planned 2008 NTOP infrastructure projects. Survey findings showed that: 120 projects received funding from MoH 78 projects were completed and are currently in use 42 projects were incomplete or delayed (27 of these are awaiting the completion of infrastructure work, 15 have been stalled indefinitely) 12 projects did not receive funding from MoH and thus were not begun The projects types that had the highest completion rates included the construction of classrooms (66% of planned projects complete), student accommodations (62%), and teacher accommodations (58%), as well as the furnishing of various facilities (74%). Of the projects that were not completed, the poorest rates of completion were found in the construction of lecture theatres (17% of planned projects complete) and skills labs (25%), as well as the purchase or repair of vehicles (20%). Only 5 TIs completed all of their infrastructure projects, for a total of 18 projects. These TIs include: Chipata School of Nursing & DEM Eastern Kabwe School of Nursing & Midwifery Central Kalene School of Nursing Northwestern Mufulira School of Nursing & Midwifery Copperbelt Ndola School of Nursing & Midwifery, & Theatre Copperbelt In addition to these TIs, there were 19 that completed a portion of their infrastructure projects, for a total of 60 out of 114 projects (52%). There were four additional schools, School of Medicine, Chainama Hills College, Evelyn Hone College, and Solwezi Nursing School, that were evaluated in the 2008 NTOP report, but not included in the Phase I funding cycle for projects. Because there were no subsequent phases of funding after 2008, none of the projects that were identified as necessary to these training institutions were ever funded. These 37 additional projects were not included in the 132 listed above. 21

23 Findings demonstrated that there was little correlation between the completion of projects and a proportional increase in enrollment by Among schools that received NTOP funding, those that showed the highest enrolment increases were the TIs that strategically completed all components of a project, including construction, appropriate outfitting, and furnishing. Of the 23 TIs that received 2008 NTOP funding, 10 reached enrolment targets laid out for 2012, and 13 did not. Figure 7: Achievement of 2012 enrolment targets by 2008 NTOP Funded TIs TIs that did not reach the 2012 enrolment targets set in the 2008 NTOP may not yet have achieved their full enrolment potential, as there were a number of delays in project execution, including lengthy procurement processes and other delays in construction. Three schools (Chainama, Evelyn Hone, and School of Medicine) made the greatest contribution to increasing enrolment without receiving any funding through the NTOP. These schools did receive funds from other sources, both from the government and from outside contributors, to complete specific projects. All three of these TIs are large, urban schools, located in Lusaka, and had greater potential for expansion due to their locations and their ability to address accommodation and financial constraints by taking on self-funded day scholars. Public transport is also more easily accessible allowing day scholars to reach the TI for classes each day. Focus Area 4 Finance The total budget for the planned infrastructure projects outlined in the 2008 NTOP was estimated at ZMK 28.1billion, equivalent to USD $5.51 million 4. Recipients surveyed during 2012 NTOP assessment field visits reported that they had received a total of ZMK 27.8 billion ($5.45 million) for the projects. Of the 132 planned infrastructure projects that were a part of the 2008 NTOP, 120 received at least a portion of designated funds (91%) and 12 (9%) of projects were not given any of the funding planned through NTOP allocated grants ( i.e., ZMK 27.8 billion funded, at least in part, NTOP Report 22

24 120 of the 132 planned projects). Overall reported expenditure by TIs on NTOP 2008 infrastructure projects was ZMK 31.6 billion ($6.19 million), with an additional ZMK 3.8 billion ( $746,916) funded by financial support outside of NTOP, needed to complete these 120 projects. Table 3: NTOP infrastructure project budget and expenditure ZMK USD Total budget for planned billion $5.51 million NTOP infrastructure projects TIs received (2012 survey) 27.8 billion $5.45 million Overall reported expenditure 31.6 billion $6.19 million by TIs on NTOP 2008 infrastructure projects Balance from financial support outside of NTOP 3.8 billion $746,916 The below table illustrates the monies spent by TIs that completed all of their proposed projects, completed a portion of their projects, or those that were included in the 2008 NTOP but received no funding. Table 4: Category of TI by NTOP Project Funding Status, comparing Activities and Expenditures (ZMK,000s) # of TIs Planned Activities NTOP Budget (ZMK) Completed Activities Actual Investment Investment vs. NTOP Budget TIs that were fully funded and completed all projects , , TIs that were partially funded and completed some projects , ,739 +3,978 TIs that were included in the 2008 NTOP but received no funding** 4 37** 93,878** 0 0 N/A **Note: Chainama College of Health Sciences, Evelyn Hone College, and School of Medicine (included under TIs that were included in 2008 NTOP but received no funding ) NTOP projects and budget costs are estimates detailed in the 2008 NTOP report, and were not formally costed or budgeted for in Phase I of NTOP projects Although the TIs that completed all of their projects did so within their original budgets, those that completed only a portion of their projects exceeded the funds budgeted for 114 projects on the completion of just 60 projects. These higher-than-expected costs were in part due to rising costs in construction materials, as well as fluctuations in the strength of the Zambian currency in international markets. Student Funding Historically, most students have been sponsored by GRZ to study in their chosen area (the % of costs covered range from 25% to 75% of the total cost of training, depending on the course of study), with 23

25 the expectation that the health graduates will work in public health facilities after their training. Unfortunately to date, there is no compulsory service / bonding system to compel pre-service graduates to service government health facilities on graduation. Students that are awarded a government grant/scholarship are funded through a larger GRZ grant given to the TI that partially covers the training costs of each sponsored student. It should be noted, that a student who is GRZ sponsored still is required to pay a designated amount in student fees. The amount that each student is required to pay is dependent on both the program of study and the TI, as different TIs choose to allocate their grants to cover training costs in different ways. A few schools have also been able to successfully implement means testing, and are thus able to award government grants to students based on financial need. However, the increased demand for enrolment in health TIs has led to the development of additional programs, including those at private TIs and those self sponsored programs at GRZ TIs, where GRZ sponsored students and self-sponsored students are taught together. Much like those attending private institutions, self-sponsored students cover their own training costs to the TI, including teaching, food, and accommodation costs if living in school hostels While the amount charged to a self-sponsored student is enough to cover the per student cost to the TI, it is also important to note that, because the teacher salaries are paid directly by GRZ, rather than paid for by the TI with GRZ grant money, TIs that have self-sponsored students do not pass the salary costs along to them. Thus, even the self-sponsored students can be considered to have at least a portion of GRZ sponsorship if they train in a public TI. Additionally, some schools may use the self-sponsored student s fees to cover both the cost of their training and subsidize other plans that the TI is interested in pursuing. For example, the fees paid per year of a GRZ-sponsored student pursuing a course in Medicine (MBChB), offered at the School of Medicine, are approximately ZMK 13.2 million, whereas the costs paid by a self-sponsored student in the same course are ZMK 28.6 million. Because the total cost per year to train a doctor is ZMK 14.9M (including tutor salaries, school overheads, and all school fees), the remaining 13.7 million per selfsponsored student, per year, may be allocated to other programs. This has allowed the School of Medicine to increase their IT infrastructure, fund their community based activities, and so on. The cost to train a Clinical Officer, on the other hand, is approximately ZMK 15.8 million per year for 3 years. The fees for a GRZ sponsored student are ZMK 4.3 million per year, in comparison to ZMK 10 million for a self-sponsored student. Neither of these fees covers the entire annual cost of training, thus, the self-sponsored student is also, in part, being sponsored by government. Further costs of training can be found in Annex 5. Self-sponsoring should also not be confused with parallel programming, which means that an additional intake of students is taken on by a TI and run in parallel. This could mean one intake is taught in the morning and the other intake in the afternoon. Alternatively it could mean that a double intake is taken on at the beginning of a programme, taught the theoretical foundation courses in tandem, but then subsequent practical and theoretical courses are taught in an alternating but parallel fashion, so twice as many students can graduate from any one TI at the same time. Both the normal and parallel programme should have a mix of GRZ sponsored, self-sponsored or scholarship/donor sponsored students to ensure that the quality of the training offered for either programme remains comparable. 24

26 The assessment found that the following 5 TIs are now accepting self-sponsored students. 16% of the students enrolled in 2012 (587 of the 3599 total) are self-sponsored students. The details are as follows: Table 5: TIs operating parallel programs Training Institution NTOP Funds recipient Parallel Programme # of students enrolled in 2012 Chainama College of Health Sciences No Clinical Officers General 100 (50 in Jan, 50 in June) Evelyn Hone No Physiotherapists and P. Technologists 79 Natural Resources Development College No Nutritionists 68 Dental Training School Yes Dentists, Dental Therapists and Technologists 40 (take parallel students every 2yrs) Department of Nursing Studies No BSc. Nurse, Distance learning students NTOP Recommendations The recommendations in the following tables were generated from the findings of the NTOP assessment. Information was gathered from key stakeholders at the surveyed health training institutions, Health Professions Council of Zambia, General Nursing Council, CPs, and the Ministry of Health. These recommendations have been structured to assist decision-makers to operationalize the training-related aspects of the Human Resources for Health Strategic Plan They have been designed so that stakeholders are able to see where gaps exist in regard to training systems and infrastructure, as well as various other programme needs. The progress made on the 2008 NTOP recommendations and the current status found in 2012 are listed in annex 6. Updated cost estimates (done by the Quantity Surveyor in 2013) for specific NTOP infrastructure projects are listed in annex 5, and these have been added to the individual TI profiles (annex 2) specifically identified with a double asterix **. It is the hope that this NTOP will help funders, both GRZ and external contributors, to identify where investments within the health training sector should be made. While at times, these recommendations may reach beyond the NHRH SP Strategic Objective B: Increase training outputs harmonized to the sector s needs, all of the recommendations 25

27 presented here are related to training, be it pre-service, in-service, or the entry of health training graduates into the public sector following training. Due to the scope of the NTOP assessment, these recommendations do not attempt to operationalize most of the interventions laid out in NHRH SP s other three strategic objectives on recruitment & placement, performance & productivity, and systems strengthening. Other assessments and analyses may be required to provide the same level of detail on how to operationalize these other NHRH SP strategic objectives. As the Community Health Assistant program and the NEPI supported Registered Nurse Midwife program were both pilot training programmes in 2012, they were not evaluated as part of this process. Scales up plans for these cadres are therefore not included in the NTOP 2013 to 2016 operational plan. 26