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Abstract Background The Ministry of Health (MoH) in Zambia is operating with fewer than half of the human resources for health (HRH) necessary to meet basic population health needs. Responding urgently to address this HRH crisis, the MoH plans to double the annual number of health training graduates in the next five years to increase the supply of health workers. The feasibility and costs of achieving this initiative, however, are unclear. Methods We determined the feasibility and costs of doubling training institution output through an individual school assessment framework. Assessment teams, comprised of four staff from the MoH and Clinton Health Access Initiative, visited all of Zambia's 39 public and private health training institutions from 17 April to 19 June 2008. Teams consulted with faculty and managers at each training institution to determine if student enrollment could double within five years; an operational planning exercise carried out with school staff determined the investments and additional operating costs necessary to achieve expansion. Cost assumptions were developed using historical cost data. Results The individual school assessments affirmed the MoH's ability to double the graduate output of Zambia's public health training institutions. Lack of infrastructure was determined as a key bottleneck in achieving this increase while meeting national training quality standards. A total investment of US$ 58.8 million is required to meet expansion infrastructure needs, with US$ 35.0 million (59.5%) allocated to expanding student accommodation and US$ 23.8 million (40.5%) allocated to expanding teaching, studying, office, and dining space. The national number of teaching staff must increase by 363 (111% increase) over the next five years. The additional recurring costs, which include salaries for additional teachers and operating expenses for new students, are estimated at US$ 58.0 million over the five-year scale-up period. Total cost of expansion is estimated at US$ 116.8 million over five years. Conclusions Historic underinvestment in training institutions has crippled Zambia's ability to meet expansion ambitions. There must be significant investments in infrastructure and faculty to meet quality standards while expanding training enrollment. Bottom-up planning can be used to translate national targets into costed implementation plans for expansion at each school.

Abstract Background The Ministry of Health (MOH) in Zambia is currently operating with fewer than half of the health workers required to deliver basic health services. The MOH has developed a human resources for health (HRH) strategic plan to address the crisis through improved training, hiring, and retention. However, the projected success of each strategy or combination of strategies is unclear. Methods We developed a model to forecast the size of the public sector health workforce in Zambia over the next ten years to identify a combination of interventions that would expand the workforce to meet staffing targets. The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. We model, using Excel (Office, Microsoft; 2007), the effects of changes in these variables on the projected number of doctors, clinical officers, nurses and midwives in the public sector workforce in 2018. Results With no changes to current training, hiring, and attrition conditions, the total number of doctors, clinical officers, nurses, and midwives will increase from 44% to 59% of the minimum necessary staff by 2018. No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010, without including training expansion, is sufficient to meet staffing targets by 2018 for any cadre except midwives. Training enrolment needs to increase by a factor of between three and thirteen for doctors, three and four for clinical officers, two and three for nurses, and one and two for midwives by 2010 to reach staffing targets by 2018. Necessary enrolment increases can be held to a minimum if the rates of retention, graduation, and public sector entry increase to 100% by 2010, but will need to increase if these rates remain at 2008 levels. Conclusions Meeting the minimum need for health workers in Zambia this decade will require an increase in health training school enrolment. Supplemental interventions targeting attrition, graduation and public sector entry rates can help close the gap. HRH modelling can help MOH policy makers determine the relative priority and level of investment needed to expand Zambia's workforce to target staffing levels.