“Once the government employs you, it forgets you”: Health workers’ and managers’ perspectives on factors influencing working conditions for provision of maternal health care services in a rural district of Tanzania

Human Resources for Health

Anna-Karin Hurtig²  Isabel Goicolea²  Mughwira Mwangu³  Angwara Kiwara³  Gladys Reuben Mahiti³  Dickson Ally Mkoka¹ 

[1] Department of Clinical Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania;Department of Public Health and Clinical Medicine, Unit of Epidemiology and Global Health, Umeå University, Umeå, 901 85, Sweden;Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

关键词: Tanzania;    Rural health facilities;    Maternal health services;    Governance of human resource for health;    Health worker;    Working conditions;   

Others  :  1225501
DOI  :  10.1186/s12960-015-0076-5

 received in 2014-11-29, accepted in 2015-09-08,  发布年份 2015

【 摘 要 】

Background

In many developing countries, health workforce crisis is one of the predominant challenges affecting the health care systems’ function of providing quality services, including maternal care. The challenge is related to how these countries establish conducive working conditions that attract and retain health workers into the health care sector and enable them to perform effectively and efficiently to improve health services particularly in rural settings. This study explored the perspectives of health workers and managers on factors influencing working conditions for providing maternal health care services in rural Tanzania. The researchers took a broad approach to understand the status of the current working conditions through a governance lens and brought into context the role of government and its decentralized organs in handling health workers in order to improve their performance and retention.

Methods

In-depth interviews were conducted with 22 informants (15 health workers, 5 members of Council Health Management Team and 2 informants from the District Executive Director’s office). An interview guide was used with questions pertaining to informants’ perspective on provision of maternal health care service, working environment, living conditions, handling of staff’s financial claims, avenue for sharing concerns, opportunities for training and career progression. Probing questions on how these issues affect the health workers’ role of providing maternal health care were employed. Document reviews and observations of health facilities were conducted to supplement the data. The interviews were analysed using a qualitative content analysis approach.

Results

Overall, health workers felt abandoned and lost within an unsupportive system they serve. Difficult working and living environments that affect health workers’ role of providing maternal health care services were dominant concerns raised from interviews with both health workers and managers. Existence of a bureaucratic and irresponsible administrative system was reported to result in the delay in responding to the health workers’ claims timely and that there is no transparency and fairness in dealing with health workers’ financial claims. Informants also reported on the non-existence of a formal motivation scheme and a free avenue for voicing and sharing health workers’ concerns. Other challenges reported were lack of a clear strategic plan for staff career advancement and continuous professional development to improve health workers’ knowledge and skills necessary for providing quality maternal health care.

Conclusion

Health workers working in rural areas are facing a number of challenges that affect their working conditions and hence their overall performance. The government and its decentralized organs should be accountable to create conducive working and living environments, respond to health workers’ financial claims fairly and equitably, plan for their career advancement and create a free avenue for voicing and sharing concerns with the management. To achieve this, efforts should be directed towards improving the governance of the human resource management system that will take into account the stewardship role of the government in handling human resource carefully and responsibly.

【 授权许可】

   
2015 Mkoka et al.

【 参考文献 】

• [1]World Health Organization. The human resources for health crisis. Global Health Workforce Alliance. http://www. who.int/workforcealliance/about/hrh_crisis/en/ webcite
• [2]Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Serv Res. 2008; 8:19. BioMed Central Full Text
• [3]Bangdiwala SI, Fonn S, Okoye O, Tollman S. Workforce resources for health in developing countries. Public Health Rev. 2010; 32:296-318.
• [4]The World Health Organization 2010 Global Policy Recommendations – Increasing access to health workers in remote and rural areas through improved retention. WHO, Geneva; 2010.
• [5]Naicker S, Plange-Rhule J, Tutt RC, Eastwood JB. Shortage of healthcare workers in developing countries – Africa. Ethn Dis. 2009; 19:1-60-64-60.
• [6]O’Brien P, Gostin L. Health worker shortages and global justice. The Milbank Memorial Fund, New York; 2011.
• [7]Dussault G, Dubois CA. Human resources for health policies: a critical component in health policies. Hum Resour Health. 2003; 1:1. BioMed Central Full Text
• [8]Analysis of the constraints in human availability (training, recruitment, deployment and retention) especially in hard to reach areas. Final Report Submitted to the Ministry of Health and Social Welfare. 2009.
• [9]Wyss K. An approach to classifying human resources constraints to attaining health-related Millennium Development Goals. Human Resource Health. 2004; 2:11. BioMed Central Full Text
• [10]Prytherch H, Kakoko DC, Leshabari MT, Sauerborn R, Marx M. Maternal and newborn healthcare providers in rural Tanzania: in-depth interviews exploring influences on motivation, performance and job satisfaction. Rural Remote Health. 2012; 12:2072.
• [11]Manongi RN, Marchant TC, Bygbjerg IC. Improving motivation among primary health care workers in Tanzania: a health worker perspective. Hum Resour Health. 2006; 4:6. BioMed Central Full Text
• [12]Dieleman M, Harnmeijer JW. Improving health worker performance: in search of promising practices. WHO Department of Human Resources for Health, Geneva; 2006.
• [13]Dieleman M, Gerretsen B, van der Wilt GJ. Human resource management interventions to improve health workers’ performance in low and middle income countries: a realist review. Health Res Policy Systems. 2009; 7:7. BioMed Central Full Text
• [14]Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D, Ditlopo P. Motivation and retention of health workers in developing countries: a systematic review. BMC Health Serv Res. 2008; 8:24. BioMed Central Full Text
• [15]Working together for health: the World Health Report 2006. World Health Organization, Geneva; 2006.
• [16]Alliance GHW. The Kampala declaration and agenda for global action. Global Health Workforce Alliance and World Health Organization, Kampala, Uganda; 2008.
• [17]Leshabari MT, Muhondwa EPPY, Mwangu MA, Mbembati NAA. Motivation of health care workers in Tanzania. A case study of Muhimbili National Hospital. East Afr J Public Health. 2008; 5(1):32-7.
• [18]Dieleman M, Hilhorst T. Governance and human resources for health. Human Resource Health. 2011; 9:29. BioMed Central Full Text
• [19]Dieleman M, Shaw DMP, Zwanikken P. Improving the implementation of health workforce policies through governance: a review of case studies. Human Resources Health. 2010; 12(9):10.
• [20]KIT. Responsible governance for improved human resources for health: making the right choice. http://www. kit.nl/health/wp-content/uploads/publications/1646_Summary%20of%20conference%20proceedings.pdf webcite
• [21]Kaplan AD, Dominis S, Palen JGH, Quain EE. Human resource governance: what does governance mean for the health workforce in low- and middle-income countries? Hum Resour Health. 2013; 11:6. BioMed Central Full Text
• [22]United Nations Population Fund. Skilled attendance at birth. UNFPA. http://web. lb.unfpa.org/mothers/skilled_att.htm webcite
• [23]Bhutta ZA, Lassi ZS, Mansoor N. Systematic review on human resources for health interventions to improve maternal health outcomes: evidence from developing countries. Division of Women and Child Health, Aga Khan University; 2010.
• [24]Adegoke AA, van den Broek N. Skilled birth attendance-lessons learnt. BJOG. 2009; 116:33-40.
• [25]Graham WJ, Bell JSI, Bullough CHW. Can skilled attendance at delivery reduce maternal mortality in developing countries? Studies Health Services Organisation Policy. 2000; 17:97-130.
• [26]Nnebue CC, Ebenebe UE, Adogu PO, Adinma ED, Ifeadike CO, Nwabueze AS. Adequacy of resources for provision of maternal health services at the primary health care level in Nnewi, Nigeria. Niger Med J. 2014; 55(3):235-241.
• [27]Graner S, Mogren I, Duong Le Q, Krantz G, Klingberg-Allvin M. Maternal health care professionals’ perspectives on the provision and use of antenatal and delivery care: a qualitative descriptive study in rural Vietnam. BMC Public Health. 2010; 10:608. BioMed Central Full Text
• [28]Chodzaza E, Bultemeier K. Service providers’ perception of quality of emergency obstetric care provided and factors identified which affect the provision of quality care. Malawian Med J. 2010; 22(4):104-111.
• [29]Bradley S, McAuliffe E. Mid-level providers in emergency obstetric and newborn health care: factors affecting their performance and retention within the Malawian health system. Human Resource Health. 2009; 7:14. BioMed Central Full Text
• [30]World Health Organization. Health workers and the MDGs: inextricably linked. Global Health Workforce Alliance. http://www. who.int/workforcealliance/knowledge/resources/Mubashar_Sheikh_web.pdf webcite
• [31]Global Health Workforce Alliance. Achieving the MDGs by investing in human resources for health. In Health Workforce Advocacy Initiative. 2010. http://aaahrh. org/pdf/execsum.pdf webcite
• [32]Human Resource for Health Strategic Plan 2008 – 2013 [INTERNET]. [http://ihi.eprints.org/798/1/MoHSW.pdf_%2823%29.pdf]. Available from: [http://ihi.eprints.org/798/1/MoHSW.pdf_%2823%29.pdf] webcite Ministry of Health and Social Welfare.
• [33]WHO. Achieving the health-related MDGs. It takes a workforce. http://www. who.int/hrh/workforce_mdgs/en/ webcite
• [34]WHO. Tanzania to employ more health workers. Global Health Workforce Alliance. http://www. who.int/workforcealliance/media/news/2013/tanzaniaemployhw/en/index.html webcite
• [35]Munga MA, Mæstad O. Measuring inequalities in the distribution of health workers: the case of Tanzania. Hum Resour Health. 2009; 7:4. BioMed Central Full Text
• [36]Primary Health Services Development Programme 2007–2017. Dar es Salaam: Ministry of Health and Social Welfare. 2007.
• [37]Simba D, Mwangu N, Msamanga G. Rationalizing human resource deployment in the wake of reforms: the need for measuring health workers workload. Tanzania Med J. 2004; 19:2.
• [38]Munga M, Songstad NG, Blystad A, Mæstad O. The decentralisation-centralisation dilemma: recruitment and distribution of health workers in remote districts of Tanzania. BMC Int Health Human Rights. 2009; 9:9. BioMed Central Full Text
• [39]Local government reform programme: policy paper on local government reform. URT: PMO-RALG, Dar es Salaam, Tanzania; 1998.
• [40]Human resource for health. Country profile 2012/2013. URT: MOHSW. 2013.
• [41]Mselle LT, Moland KM, Mvungi A, Olsen BE, Kohi TW. Why give birth in health facility? Users’ and providers’ accounts of poor quality of birth care in Tanzania. BMC Health Services Res. 2013; 13:174. BioMed Central Full Text
• [42]Penfold S, Shamba D, Hanson C, Jaribu J, Manzi F, Marchant T et al.. Staff experiences of providing maternity services in rural southern Tanzania - a focus on equipment, drug and supply issues. BMC Health Serv Res. 2013; 13:61. BioMed Central Full Text
• [43]Songstad NG, Rekdal OB, Massay DA, Blystad A. Perceived unfairness in working conditions: the case of public health services in Tanzania. BMC Health Serv Res. 2011; 11:34. BioMed Central Full Text
• [44]Kwesigabo G, Mwangu MA, Kakoko DC, Warriner I, Mkony CA, Killewo J, et al. Tanzania’s health system and workforce crisis. J Public Health Policy. 2012;33.
• [45]2012 population and housing census. Population distribution by administrative areas. National Bureau of Statistics, Dar es Salaam and Office of Chief Government Statistician, Zanzibar; 2013.
• [46]Graneheim UH, Lundman B. Qualitative content analysis in nursing research concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004; 24:105-112.
• [47]Dahlgren L, Emmelin M, Winkvist A. Qualitative methodology in international public health. Print and Media, Umeå University; 2004. ISBN 91–7305. 680-4
• [48]Mkoka DA, Goicolea I, Kiwara A, Mwangu M, Hurtig AK. Availability of drugs and medical supplies for emergency obstetric care: experience of health facility managers in a rural district of Tanzania. BMC Pregnancy Childbirth. 2014; 14:108. BioMed Central Full Text
• [49]Pearson L, Shoo R. Availability and use of emergency obstetric care services: Kenya, Rwanda, Southern Sudan and Uganda. Int J Gynecol Obstetrics. 2005; 88:208-215.
• [50]Hernández A, Dahlblom K, Hurtig AK, Sebastián MS. Translating community connectedness to practice: a qualitative study of midlevel health workers in rural Guatemala. ISRN Nursing. 2012; 2012:648769.
• [51]Zulu JM, Kinsman J, Michelo C, Hurtig AK. Hope and despair: community health assistants’ experiences of working in a rural district in Zambia. BMC Human Resources Health. 2014; 12:30. BioMed Central Full Text
• [52]Kuusi S. Aspects of local self-government: Tanzania, Kenya, Namibia, South Africa, Swaziland and Ghana. North–South Local Government Co-operation Programme. The Association of Finnish Local and Regional Authorities. The Association of Finnish, Helsinki; 2009.
• [53]Frumence G, Nyamhanga T, Mwangu M, Hurtig AK. The dependency on central government funding of decentralized health systems: experiences of the challenges and coping strategies in the Kongwa District. Tanzania BMC Health Services Res. 2014; 14:39. BioMed Central Full Text
• [54]Mkoka DA, Kiwara A, Goicolea I, Hurtig AK. Governing the implementation of emergency obstetric care: experiences of rural district health managers. Tanzania BMC Health Services Res. 2014; 14:333. BioMed Central Full Text
• [55]Improving health workforce performance, issues for discussion: session 4: high-level forum on the health Millennium Development Goals. World Health Organization, Geneva; 2003.
• [56]Adler-Milstein J, Singer SJ, Toffel MW. Managerial practices that promote voice and taking charge among frontline workers. Harvard Business School Technology & Operations Mgt. Unit Working Paper No. 2011.11-005.