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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 contribut-
ed 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
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 viii 58 11 0.81 58
Ophthalmologist 1 0 2 2 0.00 1
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
xWISN 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
xiThe 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 con-
sideration 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.
xiiWISN 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
1LIST 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
2WISN 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
31. 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,
4WISN 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.
51.2. 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
6WISN 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.
7Table 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
8WISN 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
9The 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
10HSB 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 WISN Main Study Report 2017
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.
112. 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.
12WISN 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 collec-
tors.
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.
13The 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 profession-
al 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.Anothermajorobservationthatwastakentotheexpertworkinggroupwasonpossibilityof
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 pregnan-
cy 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
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