The strategic action planning was seen as a process of bringing together ideas and resources to strengthen procedures and operations, ensuring that health workers and other stakeholders were focused on common goals, and that a target was set (Sadeghifar 2015). The strategic action plan was the result of a thorough consultative process, as all-important stakeholders – professional nurses and healthcare users (Phase 1), national health directors (Phase 2) and members of parliament (Phase 4) – were actively involved during the development thereof. The process applied by the researcher was in line with accepted strategic action planning procedure. The researcher conducted a literature control for every strategy, which was then thoroughly discussed during validation. The researcher applied the systems model as theoretical framework (Fig. 1), using its components to develop the strategies. The components of the systems model (Rajan 2015) are inputs, processes, outputs and outcomes. Thus, in developing the draft strategic action plan, the strategies were analysed and formulated, aligning each strategy with its systems model component. The first strategy in the strategic action plan was to develop health infrastructure (Table 1).
Developing health infrastructure in rural areas
All healthcare services depend on the existence of a basic health infrastructure and this has been described as critical to the healthcare delivery system (Smith 2015). This was agreed by the participants who identified the strategy and those who validated the strategic action plan. They maintained that the development of health infrastructure is essential and that health facilities should be built within 5 km walking distance in villages, while existing health facilities should be maintained and rehabilitated. The findings were consistent with a study done in Uganda by the Institute for Health Metrics and Evaluation (Institute for Health Metrics & Evaluation (IHME) 2014) to evaluate the Ugandan healthcare system, which found that the utilisation of healthcare facilities improved when healthcare users had to travel smaller distances. Health infrastructure provides communities and the nation with the ability to prevent and control disease, promote public health, and prepare and act against disease outbreaks and chronic (ongoing) challenges related to the health of citizens (World Bank 2016). As a result, the members of parliament (i.e. the participants validating the strategic action plan) indicated a willingness to take the responsibility of tabling a motion in parliament to prioritise building health facilities in villages that lack health infrastructure and have a population of 6000 or smaller, and to prioritise the supply of medical drugs at rural health facilities.
Provision of medical drugs to rural health facilities
According to McKeever et al (2013) medical drugs are necessary to save lives, prevent disease complications, reduce mortality rates and reduce the length of hospital stays (Gray 2014). According to the systems model, medicines are an important part of the material resources input. Challenges related to medicines included inconsistent or short supply at rural health facilities (Mkoka et al 2014). Because of this, action was recommended to establish partnerships with national and international medical drug producers and non-government organisations, and to introduce health levies and local taxes for the procurement of medical drugs in order to facilitate a constant medicine supply pipeline. The findings are similar to a study in Zimbabwe by Jamison et al (2013), who suggested that medical drug supply in the rural health facilities was a challenge that could be addressed through partnerships between the government, private companies, national and international drug producers, and non-government organisations in Zimbabwe. The national health directors suggested the same, after recognising that a lack of sufficient funding for medical drugs from the central government was deterring expectations of improved medical drug availability in rural health facilities. This method has also worked well in some countries like Netherlands, as reported in a study conducted by De Vrueh and Crommelin (2017) on future of pharmaceuticals in public-private partnerships. The major factor contributing to the shortage of medical drugs in Zimbabwe was the lack of health workers who had experience in ordering the medicines, and this might have contributed to the national health directors proposing to capacity-build professional nurses on logistics management, focusing on ordering and managing medical drugs at health facilities14. This also facilitates the development and retention of human resources.
Development and retention of human resources in rural health facilities
Human resources form an essential part of the inputs (systems model) required to enhance the accessibility of healthcare (Mkoka et al 2013). Human resources management is the organisational role that regulates issues associated with employees. It includes recruitment, performance management, organisational development, remuneration, employee motivation, and training (Nyandoro et al 2016). The strategy on the development and retention of human resources aimed to address critical shortages of health workers, especially professional nurses, who are key providers of healthcare services in rural areas. As a result, the introduction of incentives like transport and hardship allowances and promoting the career growth of health workers were recommended as actions for retaining the skills in rural health facilities. The study’s findings are similar to those of a study in Tanzania by Mkoka et al (2013) who propounded that offering opportunities for career growth (advancement) to health workers to improve their competencies and skills contributed to their retention. When health workers are trained, adequately skilled and retained at their respective health facilities, access to health services will be enhanced. In a study in Zimbabwe by Nyandoro et al (2016), the findings indicated that incentives like rural transport and hardship and housing allowances assisted in addressing staff shortages in rural areas. Of particular importance, as noted by the professional nurses, is the workload versus the number of health workers. Thus, a review of the workload at rural health facilities is crucial.
Reviewing the workload of health workers at health facilities and addressing shortages
Human resources are inequitably distributed between urban and rural areas and between primary, secondary and tertiary levels of care (Bonfim et al 2016). There are legitimate concerns about balancing the workload and shortages in human resources in health service delivery. Hence, participants agreed to conduct a workload/staff-need assessment in Zimbabwe. Workloads and shortages can be determined by means of the Workload Indicator for Staff Needs (WISN). Okoroafor et al (2019) describes WISN as a method that calculates the number of health workers based on health facility workload. It uses a form of activity analysis (activity standards), together with measures of utilisation and workload to determine staffing requirements. A study conducted in Namibia by McQuide et al (2013), who applied the WISN, found that the country’s health facilities had appropriate numbers of professional nurses. However, the nurses were very inequitably distributed between the different types of health facilities, with the total professional nurse workforce in Namibia skewed towards hospitals. This type of inequitable distribution could also be the case in Zimbabwe, as some health facilities had four professional nurses while others were manned by only two nurses. In addition to conducting the WISN, it was important to assess the availability of material resources, including medical equipment at the health facilities, as the provision of adequate material resources is essential.
Provision of adequate material resources to the health facilities
This strategy aimed to improve service delivery to an ever-increasing population with limited or reducing material resources. Hence action was recommended with regard to the procurement and delivery of basic medical equipment (according to the WHO’s standard list) to rural health facilities with or without shortages. The findings of this study in respect of material resources agree with the findings of a study done in South America by Bonfim et al (2016). Equipment and medical supplies form an essential part of service delivery at rural health facilities and contribute to improvement in the capacity of the healthcare delivery system.
Improving the capacity of the healthcare delivery and management systems
The healthcare system functions when financial resources are available to pay salaries, medical drugs, ambulance operations, and other logistics expenditure (Asante et al 2016). The strategy in this study focused on improving the capacity of the healthcare delivery and management systems.
According to researchers in Tanzania, financial resources are required to finance healthcare systems, including healthcare assets and finances which form an integral part of the inputs (systems model) needed to provide access to healthcare (Mkoka et al 2014). The availability of financial resources influences service delivery. In order to strengthen healthcare systems, multi-year funding systems for paying medical drugs, equipment, salaries and allowances are needed (Rajan et al 2014). The financial policies should include funding mechanisms like performance-based health facility grants that ensure the sustainable provision of essential materials and health workers. Strengthening the harmonisation and co-ordination of all the systems model inputs into all health programmes is essential to improve the capacity of the healthcare delivery system. The members of parliament, together with the national directors, recommended an action to align the health regulations, statutory instruments, and health policies with the new constitution to improve policies that enhance accessibility to healthcare in rural areas (Table 1). The other action they agreed on was to provide training on leadership and financial and resource management to health workers at rural health facilities, in order to translate knowledge into policy and practice, as suggested by research evidence.