Hospital reimbursement mechanisms in the reformed Zambian health system

The Zambian health reforms have created a purchasing agency, the 'Central Board of Health' (CBoH) at the centre of the health system. The CBoH purchases services from second and third level referral hospitals (those above the district hospital level), and from district health boards (primary care and district hospital services). Both public and NGO hospitals contract with the CBoH in this way, and the contracts offer an opportunity for the two types of hospitals to be regulated, supervised and managed jointly and consistently.This paper is based on research funded by the World Health Organisation, the International Council ofNurses and the Royal College of Nursing of the United Kingdom. Whilst the primary focus is on the UK,general lessons related to international recruitment and migration of nurses are also highlighted.There is general agreement amongst all stakeholders in the UK that nursing shortages have become a majorfactor constraining health care delivery in the National Health Service in the UK. In order to overcomethese skills shortages, four areas of government initiative are underway: attracting more applicants to nurse education; encouraging returners to nursing employment; improving retention through improved careerstructures and flexible working practices; and recruiting nurses from abroad. NHS Plan targets for increased staffing have been one major factor in focusing attention on international recruitment.There has been a significant growth in the level on inflow of nurses from other countries to the UK.Registration data on annual admissions of nurses from non-UK sources shows a fivefold increase since theearly 1990s. In 2000/01 a total of 9,694 initial entrants on the UK Register were from all overseas sources.This figure has risen to approximately 15,000 in 2001/02, which equates to almost half of all new nursesentering the UK Register in the year.Registration data highlights that a total of more than 30,000 new non-UK nurses have registered in the UKin the last three years. The Philippines, South Africa and Australia have been the main sources.The trend in significant growth of recruitment of nurses from non-EU countries has not been matched byany growth in inflow from the countries of the European Union. In recent years the EU has reduced insignificance as a source of nurses entering the UK.The Department of Health in England issued guidance on ethical international recruitment practices in 1999requiring NHS employers to avoid direct recruitment from designated countries such as South Africa andthe West Indies. Registration data suggests that the 1999 guidelines may have had some short-term impactin reducing recruitment from South Africa and the Caribbean, but that this recruitment activity may havethen been displaced to other developing countries. The Department has issued a strengthened Code forinternational recruitment in late 2001.The pull factor of meeting NHS Plan staffing targets is likely to mean that the UK, particularly England,will continue to be active in recruiting from international nursing labour markets, partly as a result of newtargets having been set for 2008. UK government policy initiatives to increase the number of nursingstudents, and to improve retention and return rates, can have a positive effect. However, the growth in thenumber of UK nurses who can retire is likely to challenge the capacity of the NHS to retain the requirednumbers of nurses. When coupled with the likelihood of liberalisation of global labour markets, this pointsto a continuing high profile for the UK in international nursing labour markets.sch_iihpub368pub1