Abstract
BackgroundThe implementation of decentralisation reforms in the health sector of Tanzania started in the 1980s. These reforms were intended to relinquish substantial powers and resources to districts to improve the development of the health sector. Little is known about the impact of decentralisation on recruitment and distribution of health workers at the district level. Reported difficulties in recruiting health workers to remote districts led the Government of Tanzania to partly re-instate central recruitment of health workers in 2006. The effects of this policy change are not yet documented. This study highlights the experiences and challenges associated with decentralisation and the partial re-centralisation in relation to the recruitment and distribution of health workers.MethodsAn exploratory qualitative study was conducted among informants recruited from five underserved, remote districts of mainland Tanzania. Additional informants were recruited from the central government, the NGO sector, international organisations and academia. A comparison of decentralised and the reinstated centralised systems was carried out in order to draw lessons necessary for improving recruitment, distribution and retention of health workers.ResultsThe study has shown that recruitment of health workers under a decentralised arrangement has not only been characterised by complex bureaucratic procedures, but by severe delays and sometimes failure to get the required health workers. The study also revealed that recruitment of highly skilled health workers under decentralised arrangements may be both very difficult and expensive. Decentralised recruitment was perceived to be more effective in improving retention of the lower cadre health workers within the districts. In contrast, the centralised arrangement was perceived to be more effective both in recruiting qualified staff and balancing their distribution across districts, but poor in ensuring the retention of employees.ConclusionA combination of centralised and decentralised recruitment represents a promising hybrid form of health sector organisation in managing human resources by bringing the benefits of two worlds together. In order to ensure that the potential benefits of the two approaches are effectively integrated, careful balancing defining the local-central relationships in the management of human resources needs to be worked out.
Highlights
The implementation of decentralisation reforms in the health sector of Tanzania started in the 1980s
We present the findings from an exploratory qualitative study of the impact of the shifting centralisation-decentralisation reforms on health worker recruitment in Tanzania
The quantity and quality of public services may improve [9,17,21,37]. We investigated how these and other mechanisms have unfolded in the specific context of recruitment of health workers in Tanzania
Summary
The implementation of decentralisation reforms in the health sector of Tanzania started in the 1980s. Urban areas seem to offer a wider range of economic opportunities because health workers can engage in private practice and other income generating activities to supplement their salaries. There have been a number of studies from both high and low income countries that attempt to analyse the most central factors for effective recruitment of health workers to remote places [1,2,3,4]. Most of these studies have focused on the attributes of particular locations where the challenge is greatest. We shall argue that the hindrances and/or opportunities inherent in the health sector organisation (centralised or decentralised) may have substantial implications on recruitment, distribution and retention of health workers
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