Council Health Management Team Research Articles

Pivotal role of CHWs in prevention, early detection and control of outbreaks: neglected key primary players; a call to action

Pivotal role of CHWs in prevention, early detection and control of outbreaks: neglected key primary players; a call to action

Improving comprehensive emergency obstetric and newborn care in Tanzania: A qualitative study

AimThe purpose of this qualitative study was to explore how health care professionals, managers and community members experienced the implementation of a training program in comprehensive emergency obstetric and neonatal care training in rural Tanzania. BackgroundGiven the high rates of maternal and newborn mortality in Tanzania, the government committed to improving maternal health by increasing access to health care; improving reproductive, maternal, newborn health; reducing maternal and neonate mortality; and increasing the number of public health centers with emergency obstetric and neonatal care. To address the gap in emergency obstetric and neonatal care amongst the health workforce, five health care facilities in rural Tanzania participated in a 3-month specialized training program. The training was geared to increase access to skilled deliveries, prevent maternal and neonate deaths, and reduce referrals to district hospitals. MethodsTwenty-four focus group discussions were held with members of Council Health Management Team, Health Facility Management Team, staff who received training, and community members. Data collection and analysis was guided by content analysis and the World Health Organization's availability, accessibility, acceptability, and quality framework. FindingsParticipants reported acquiring necessary skills that enabled them to provide quality and safe obstetric and newborn care. Five themes emerged from the analysis 1) competent and confident health care teams, 2) renewed commitment to teamwork, 3) community confidence and trust in the health team, 4) mentorship as a critical element of success, and 5) enhancing training and practice. These five emerging themes demonstrate enhanced confidence and trust by the community and increased competency of health care teams to support mothers through pregnancy and birth at the health centre. ConclusionThe competencies acquired by health care providers demonstrate an increase in staff commitment and teamwork. There is an increased number of deliveries in health centres, a declining trend of maternal and neonate deaths and referrals to other health centres because the health care providers are capable of competently and confidently providing emergency obstetric and neonatal care services.

Assessment of Implementation of the Star Rating System in Primary Health Facilities: Experience from Tanzania

Introduction: The Star Rating Assessment (SRA) system was established by the Tanzanian government as a method to improve the quality of healthcare. To identify factors influencing SRA implementation, we looked at the deployment of SRA Systems in Kibaha Town and Rufiji District Councils. Methods: To comprehend the experiences of distinct healthcare professionals and Quality Improvement Teams (QITs) on implementation of SRA, we used a descriptive cross-sectional study methodology. Focus Group Discussions (FGDs) and in-depth interviews (IDIs) were used to gather data, which was then evaluated using qualitative content analysis. Results: According to the study’s findings, the majority of group discussion participants were not aware of the SRA system, the QIT members were unaware of their responsibilities for implementing Quality Improvement Plans (QIPs), and the Council Health Management Teams (CHMT) members were not including QIP follow-up in their quarterly supportive supervisions. Shortage of staff, financial resources, insufficient staff training on the SRA system, and insufficient support from CHMT were among the stated difficulties experienced during the deployment of the SRA system. Discussion: The provision of high-quality healthcare in the study sites has improved as a result of the introduction of the SRA system. Nonetheless, there is a need to support healthcare facilities during implementation and provide them with greater training on the standards assessed by SRA.

Building leadership and managerial capacity for maternal and newborn health services

BackgroundStrengthening leadership and management is important for building an effective and efficient health system. This paper presents the findings from a L&M capacity building initiative which was implemented as part of a larger study aimed at improving maternal and newborn outcomes within primary health facilities in the Morogoro, Tanzania.MethodsThe initiative, involving 30 stakeholders from 20 primary health facilities, 4 council health management teams and the regional health management team in the Morogoro region, provided leadership and managerial training through two 5-day in-person workshops, onsite mentoring, and e-learning modules. The initiative was evaluated using a pre-post design. Quantitative instruments included the ‘Big Results Now’ star-rating assessments and a team-developed survey for health providers/managers. The ‘Big Results Now’ star-rating assessments, conducted in 2018 (19 facilities) and 2021 (20 facilities), measured overall facility leadership and management capability, with comparisons of star-ratings from the two time-points providing indication of improvement. The survey was used to measure 3 key leadership indicators - team climate, role clarity/conflict and job satisfaction. The survey was completed by 97 respondents at baseline and 100 at follow up. Paired t-tests were used to examine mean score differences for each indicator. Triangulated findings from focus groups with 99 health providers and health management team members provided support and context for quantitative findings.ResultsStar-ratings increased in 15 (79%) of 19 facilities, with the number of facilities achieving the target of 3 plus stars increasing from 2 (10%) in 2018 to 10 (50%) in 2021, indicating improved organizational performance. From the survey, team climate, job satisfaction and role clarity improved across the facilities over the 3 project years. Focus group discussions related this improvement to the leadership and managerial capacity-building.ConclusionImproved leadership and managerial capacity in the participating health facilities and enhanced communication between the health facility, council and regional health management teams created a more supportive workplace environment, leading to enhanced teamwork, job satisfaction, productivity, and improved services for mothers and newborns. Leadership and managerial training at all levels is important for ensuring efficient and effective health service provision.

Improving disease surveillance data analysis, interpretation, and use at the district level in Tanzania

ABSTRACT An effective disease surveillance system is critical for early detection and response to disease epidemics. This study aimed to assess the capacity to manage and utilize disease surveillance data and implement an intervention to improve data analysis and use at the district level in Tanzania. Mapping, in-depth interview and desk review were employed for data collection in Ilala and Kinondoni districts in Tanzania. Interviews were conducted with members of the council health management teams (CHMT) to assess attitudes, motivation and practices related to surveillance data analysis and use. Based on identified gaps, an intervention package was developed on basic data analysis, interpretation and use. The effectiveness of the intervention package was assessed using pre-and post-intervention tests. Individual interviews involved 21 CHMT members (females = 10; males = 11) with an overall median age of 44.5 years (IQR = 37, 53). Over half of the participants regarded their data analytical capacities and skills as excellent. Analytical capacity was higher in Kinondoni (61%) than Ilala (52%). Agreement on the availability of the opportunities to enhance capacity and skills was reported by 68% and 91% of the participants from Ilala and Kinondoni, respectively. Reported challenges in disease surveillance included data incompleteness and difficulties in storage and accessibility. Training related to enhancement of data management was reported to be infrequently done. In terms of data interpretation and use, despite reporting of incidence of viral haemorrhagic fevers for five years, no actions were taken to either investigate or mitigate, indicating poor use of surveillance data in monitoring disease occurrence. The overall percentage increase on surveillance knowledge between pre-and post-training was 37.6% for Ilala and 20.4% for Kinondoni indicating a positive impact on of the training. Most of CHMT members had limited skills and practices on data analysis, interpretation and use. The training in data analysis and interpretation significantly improved skills of the participants.

Perceived Usefulness, Competency, and Associated Factors in Using District Health Information System Data Among District Health Managers in Tanzania: Cross-sectional Study.

BackgroundTanzania introduced District Health Information Software (version 2; DHIS2) in 2013 to support existing health management information systems and to improve data quality and use. However, to achieve these objectives, it is imperative to build human resource capabilities to address the challenges of new technologies, especially in resource-constrained countries.ObjectiveThis study aimed to determine the perceived usefulness, competency, and associated factors in using DHIS2 data among district health managers (DHMs) in Tanzania.MethodsThis descriptive cross-sectional study used a quantitative approach, which involved using a self-administered web-based questionnaire. This study was conducted between April and September 2019. We included all core and co-opted members of the council or district health management teams (DHMTs) from all 186 districts in the country. Frequency and bivariate analyses were conducted, and the differences among categories were measured by using a chi-square test. P values of <.05 were considered significant.ResultsA total of 2667 (77.96%) of the expected 3421 DHMs responded, of which 2598 (97.41%) consented and completed the questionnaires. Overall, the DHMs were satisfied with DHIS2 (2074/2596, 79.83%) because of workload reduction (2123/2598, 81.72%), the ease of learning (1953/2598, 75.17%), and enhanced data use (2239/2598, 86.18%). Although only half of the managers had user accounts (1380/2598, 53.12%) and were trained on DHIS2 data analysis (1237/2598, 47.61%), most claimed to have average to advanced skills in data validation (1774/2598, 68.28%), data visualization (1563/2598, 60.16%), and DHIS2 data use (1321/2598, 50.85%). The biggest challenges facing DHMs included the use of a paper-based system as the primary data source (1890/2598, 72.75%) and slow internet speed (1552/2598, 59.74%). Core members were more confident in using DHIS2 compared with other members (P=.004), whereas program coordinators were found to receive more training on data analysis and use (P=.001) and were more confident in using DHIS2 data compared with other DHMT members (P=.001).ConclusionsThis study showed that DHMs have appreciable competencies in using the DHIS2 and its data. However, their skill levels have not been commensurate with the duration of DHIS2 use. This study recommends improvements in the access to and use of DHIS2 data. More training on data use is required and should involve using cost-effective approaches to include both the core and noncore members of the DHMTs. Moreover, enhancing the culture and capacity of data use will ensure the better management and accountability of health system performance.

Evaluation of the Direct Health Facility Financing Program in Improving Maternal Health Services in Pangani District, Tanzania.

BackgroundMaternal morbidity and mortality remain significant public health concerns globally, with Tanzania reporting 398 deaths per 100,000 live births annually. While national level data provide some insights into the issue, a focus on sub-national levels is required because of differences in contexts such as rural-urban disparities in maternal mortality. This study examined Direct Health Facility Financing (DHFF) and its effects on the quality of maternal health services in Pangani, a rural district in Tanzania.MethodsThis study was conducted in Pangani district of Tanga region in Tanzania. The study used both qualitative and quantitative methods, including 16 in-depth interviews with the council health management teams, facility in charges, maternity nurse in charge, and 5 focus group discussions with community health governing committee members. The number of deliveries that occurred in health facilities, as well as medical supplies, equipment, and reagents purchased by the facilities, were compared using descriptive statistics before and after the DHFF implementation.ResultsDirect disbursement of funds from the central government through the Ministry of Finance and Planning to the primary health facilities reduced delays in procurement, improved community outreach services, and improved community leaders’ engagements. Deliveries occurring at health facilities increased by 33.6% (p < 0.001) one year after the HDFF implementation. Various medicines, delivery kits, and some reagents increased significantly (p < 0.05). However, the lack of computers and poor internet connectivity, an insufficient supply of medical equipment and unstable stock of the Medical Stores Department increased the difficulty of obtaining the missed items from the selected prime vendor.ConclusionOverall, this study shows a positive impact of the DHFF on maternal health service delivery in Pangani district. Specifically, an increase in the number of medical supplies, equipment, and reagents necessary to provide maternal health services contributed to the observed increase in facility deliveries by 33.6%. Moreover, the system minimizes unnecessary delays in the procurement processes of required drugs, supplies, and other facility reagents. To maximize the impact of the HDFF system, lack of computers, unstable internet, limited knowledge of the staff about the system, and inadequate health workforce should be addressed. Therefore, strengthening the DHFF system and staff training in-service and on the job is essential for smooth implementation.

Use of Data in Health Planning Process:

Introduction&#x0D; In Tanzania, the provision of primary health care services is vested to Local Government Authorities. Council Health Management Teams prepare Comprehensive Council Health Plans to guide the provision of health services within the authorities. The purpose of this study was to describe the process of preparing CCHPs, including the data sources used.&#x0D; Methods&#x0D; Three focus group discussions were conducted with 15 CHMT members. Participants were selected using convenience sampling. Thematic analysis was conducted after discussions that were translated into English and transcribed.&#x0D; Results&#x0D; The focal person and coordinators for the Health Management Information System were cited as the main sources of data for planning. District Health Information System (DHIS2) was the main source of data used in planning although there were some indicators reported, which were far from reality, and therefore, considered unreliable.&#x0D; Conclusion&#x0D; CHMT members should be trained in the basic analysis, and use of DHIS2 data. This would improve their data analysis, and use skills since are imperative to developing a culture of data use in planning.

Facilitators and barriers to effective supervision of maternal and newborn care: a qualitative study from Shinyanga region, Tanzania

ABSTRACT Background: Despite routine supportive supervision of health service delivery, maternal and newborn outcomes have remained poor in sub-Saharan Africa in general and in Tanzania in particular. There is limited research evidence on factors limiting the effectiveness of supportive supervision in improving the quality of maternal and newborn care. Objective: This study explored enablers of and barriers to supportive supervision in maternal and newborn care at the district and hospital levels in Shinyanga region in Tanzania. Methods: This study employed a qualitative case study design. A purposeful sampling approach was employed to recruit a stratified sample of health system actors: members of the council health management team (CHMT), members of health facility management teams (HMTs), heads of units in the maternity department and health workers. Results: This study identified several barriers to the effectiveness of supportive supervision. First, the lack of a clear policy on supportive supervision. Despite the general acknowledgement of supportive supervision as a managerial mechanism for quality improvement at the district and lower-level health facilities, there is no clear policy guiding it. Second, limitations in measurement of progress in quality improvement; although supportive supervision is routinely conducted to improve maternal and newborn outcomes, efforts to measure progress are limited due to shortfalls in the setting of goals and targets, as well as gaps in M&E. Third, resource constraints and low motivation; that is, the shortage of resources – CHMT supervisors, health staff and funds – results in irregular supervision and low motivation. Conclusion: Besides resource constraints, lack of clear policies and limitations related to progress measurement impair the effectiveness of supportive supervision in improving maternal and newborn outcomes. There is a need to reform supportive supervision so that it aids and measures progress not only at the district but also at the health facility level.

The Influence of Human Resource Practices on Job Satisfaction in Decentralized Health Service Delivery: A Case of Shinyanga Region in Tanzania

The study examined the influence of Human Resource (HR) practices on job satisfaction in the decentralized health service delivery in Shinyanga region, Tanzania. The influence of HR practices on job satisfaction is vastly examined by different scholars. Their findings revealed mixed results ranging from significant positive to adverse influence on job satisfaction. Thus, to bridge the knowledge gap, this study examined the specific HR practices in the specific area context. The specific HR practices tested in this study included human resource planning (HRP), supervision, performance appraisal, training and compensation. The region was selected because over different periods of time, it experienced unsatisfactory performance in health service delivery. This was reflected by inability of the region to attain 50% of the Mellenium Development Goals related to health and lowest achievements in health service delivery as reflected in the preparatory stage in launching the Results Based Financing in which the region ranked the last in the then 21 regions of the country. An explanatory Survey research design with mixed research approach was employed for the study. The survey data were collected from 287 respondents and supplemented by the qualitative data. The study found that all the five HR practices had some chances on job satisfaction. However, HRP and supervision revealed significant chances of having job satisfaction implying that they were effectively undertaken. Nevertheless, these practices were constrained by the ineffective employees’ participation in HRP and the inability of the Council Health Management Teams (CHMTs) to provide supportive supervision in health facilities. It was thus recommended to enhance employees’ participation in HRP and supervision for improving job satisfaction. Likewise, it is also important for the facilities to continuously appraise human resource performance and use the results in making human resource decisions.

Towards improved health service quality in Tanzania: contribution of a supportive supervision approach to increased quality of primary healthcare

BackgroundUniversal Health Coverage only leads to the desired health outcomes if quality of health services is ensured. In Tanzania, quality has been a major concern for many years, including the problem of ineffective and inadequate routine supportive supervision of healthcare providers by council health management teams. To address this, we developed and assessed an approach to improve quality of primary healthcare through enhanced routine supportive supervision.MethodsMixed methods were used, combining trends of quantitative quality of care measurements with qualitative data mainly collected through in-depth interviews. The former allowed for identification of drivers of quality improvements and the latter investigated the perceived contribution of the new supportive supervision approach to these improvements.ResultsThe results showed that the new approach managed to address quality issues that could be solved either solely by the healthcare provider, or in collaboration with the council. The new approach was able to improve and maintain crucial primary healthcare quality standards across different health facility level and owner categories in various contexts.ConclusionTogether with other findings reported in companion papers, we could show that the new supportive supervision approach not only served to assess quality of primary healthcare, but also to improve and maintain crucial primary healthcare quality standards. The new approach therefore presents a powerful tool to support, guide and drive quality improvement measures within council. It can thus be considered a suitable option to make routine supportive supervision more effective and adequate.

Retention of medical doctors at the district level: a qualitative study of experiences from Tanzania

BackgroundRetention of Human Resources for Health (HRH), particularly doctors at district level is a big challenge facing the decentralized health systems in poorly resourced countries. Tanzania, with 75% of its population in rural areas, has only 26% of doctors serving in rural areas. We aimed to analyze the experiences regarding the retention of doctors at district level in Tanzania from doctors’ and district health managers’ perspectives.MethodsA qualitative study was carried out in three districts from June to September 2013. We reviewed selected HRH documents and then conducted 15 key informant interviews with members of the District Health Management teams and medical doctors working at the district hospitals. In addition, we conducted three focus group discussions with Council Health Management Team members in the three districts. Incentive package plans, HRH establishment, and health sector development plans from the three districts were reviewed. Data analysis was performed using qualitative content analysis.ResultsNone of the districts in this study has the number of doctors recommended. Retention of doctors in the districts faced the following challenges: unfavourable working conditions including poor working environment, lack of assurance of career progression, and a non-uniform financial incentive system across districts; unsupportive environment in the community, characterized by: difficulty in securing houses for rent, lack of opportunities to earn extra income, lack of appreciation from the community and poor social services.Health managers across districts endeavour to retain their doctors through different retention strategies, including: career development plans, minimum financial incentive packages and avenues for private practices in the district hospitals. However, managers face constrained financial resources, with many competing priorities at district level.ConclusionsRetention of doctors at district level faces numerous challenges. Assurance of career growth, provision of uniform minimum financial incentives and ensuring availability of good social services and economic opportunities within the community are among important retention strategies.

Community member and policy maker priorities in improving maternal health in rural Tanzania.

To determine community member and policy maker priorities in improving maternal health in rural Tanzania. The present participatory action research project was conducted in Rorya District, Mara Region, Tanzania, between November 20 and 25, 2015. A convenience sample of four community and one policy maker discussion groups were held to identify factors impacting on maternal health. The inclusion criterion for community members was a recent personal or partner experience with childbirth, or experience as a village leader. The policy maker participants were enrolled from all members of the District Council Health Management Team. There was considerable overlap in priorities expressed by community members and policy makers. The most common priorities were to improve the transportation options for women to get to the health facility, the availability of supplies in the health facilities, and healthcare provider attitudes toward women, and to increase the number of skilled healthcare providers. Policy makers also prioritized improved health education of women, improved access to health facilities, and increased power in decision-making for women. Community members and policy makers have similar priorities for improving maternal health, which involve both social and structural changes.

Can formalizing links among community health workers, accredited drug dispensing outlet dispensers, and health facility staff increase their collaboration to improve prompt access to maternal and child care? A qualitative study in Tanzania

BackgroundIn Tanzania, progress toward achieving the 2015 Millennium Development Goals for maternal and newborn health was slow. An intervention brought together community health workers, health facility staff, and accredited drug dispensing outlet (ADDO) dispensers to improve maternal and newborn health through a mechanism of collaboration and referral. This study explored barriers, successes, and promising approaches to increasing timely access to care by linking the three levels of health care provision.MethodsThe study was conducted in the Kibaha district, where we applied qualitative approaches with in-depth interviews and focus group discussions. In-depth interview participants included retail drug shop dispensers (36), community health workers (45), and health facility staff members (15). We conducted one focus group discussion with district officials and four with mothers of newborns and children under 5 years old.ResultsRelationships among the three levels of care improved after the linkage intervention, especially for ADDO dispensers and health facility staff who previously had no formal communication pathway. The study participants perceptions of success included improved knowledge of case management and relationships among the three levels of care, more timely access to care, increased numbers of patients/customers, more meetings between community health workers and health facility staff, and a decrease in child and maternal mortality. Reported challenges included stock-outs of medicines at the health facility, participating ADDO dispensers who left to work in other regions, documentation of referrals, and lack of treatment available at health facilities on the weekend. The primary issue that threatens the sustainability of the intervention is that local council health management team members, who are responsible for facilitating the linkage, had not made any supervision visits and were therefore unaware of how the program was running.ConclusionThe study highlights the benefits of approaches that link different levels of care providers to improve access to maternal and child health care. To strengthen this collaboration further, health campaign platforms should include retail drug dispensers as a type of community health care provider. To increase linkage sustainability, the council health management team needs to develop feasible supervision plans.

Decentralisation of Health Systems and the Fate of Community Health Fund in Tanzania: Critical Review of High and Low Performing Districts

The deterioration of health services provision in Tanzania from 1980s to 1990s made decentralization of health service provision through the Health Sector Reform (HSR) a necessity. HSR aimed at bringing better utilization of scarce resources, improved quality of health services, increasing user access and cutting rising costs. It is through HSR that health insurance schemes were introduced. Community Health Fund (CHF) came as a result of such efforts. The efficiency and effectiveness of CHF rests on district councils which are responsible for ensuring better performance of CHF. Although the Government of Tanzania targeted 85% of the population to be members of CHF, enrollment has remained as low as 9.2% by 2014. The most sticking problem is the variation in enrollment in different districts. There are districts with higher performance in CHF enrollment like Iramba (54%) and Bariadi (40.9%). Whereas, there are districts with very low enrollments in CHF like Liwale (8%), and Rungwe (6.5%). This paper is an effort to shed some light on this phenomenon ofperformance variation of CHF enrolment in districts. It argues that poor performing districts are constrained by their own weaknesses such as poor management and leadership capacities of Council Health Management Team (CHMT) and lack of motivation among health facility staff and allied health workers. Also, poor sensitization and mobilization of people to join CHF, as well as poor quality healthcare to people has deterred performance of CHF in some districts. The papers’ conclusion apart from offering recommendation also adds to the broader ongoing debate of decentralization process mainly through health insurance.

Do Management and Leadership Practices in the Context of Decentralisation Influence Performance of Community Health Fund? Evidence From Iramba and Iringa Districts in Tanzania.

Background: In early 1990s, Tanzania like other African countries, adopted health sector reform (HSR). The most strongly held centralisation system that informed the nature of services provision including health was, thus, disintegrated giving rise to decentralisation system. It was within the realm of HSR process, user fees were introduced in the health sector. Along with user fees, various types of health insurances, including the Community Health Fund (CHF), were introduced. While the country’s level of enrolment in the CHF is low, there are marked variations among districts. This paper highlights the role of decentralised health management and leadership practices in the uptake of the CHF in Tanzania. Methods: A comparative exploratory case study of high and low performing districts was carried out. In-depth interviews were conducted with the members of the Council Health Service Board (CHSB), Council Health Management Team (CHMT), Health Facility Committees (HFCs), in-charges of health facilities, healthcare providers, and Community Development Officers (CDOs). Minutes of the meetings of the committees and district annual health plans and district annual implementation reports were also used to verify and triangulate the data. Thematic analysis was adopted to analyse the collected data. We employed both inductive and deductive (mixed coding) to arrive to the themes. Results: There were no differences in the level of education and experience of the district health managers in the two study districts. Almost all district health managers responsible for the management of the CHF had attended some training on management and leadership. However, there were variations in the personal initiatives of the top-district health leaders, particularly the district health managers, the council health services board and local government officials. Similarly, there were differences in the supervision mechanisms, and incentives available for the health providers, HFCs and board members in the two study districts. Conclusion: This paper adds to the stock of knowledge on CHFs functioning in Tanzania. By comparing the best practices with the worst practices, the paper contributes valuable insights on how CHF can be scaled up and maintained. The study clearly indicates that the performance of the community-based health financing largely depends on the personal initiatives of the top-district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers and health facilities. More important, there is need for the MoHSW to provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance.

District health manager and mid-level provider perceptions of practice environments in acute obstetric settings in Tanzania: a mixed-method study.

BackgroundIn sub-Saharan Africa, the capacity of human resources for health (HRH) managers to create positive practice environments that enable motivated, productive, and high-performing HRH is weak. We implemented a unique approach to examining HRH management practices by comparing perspectives offered by mid-level providers (MLPs) of emergency obstetric care (EmOC) in Tanzania to those presented by local health authorities, known as council health management teams (CHMTs).MethodsThis study was guided by the basic strategic human resources management (SHRM) component model. A convergent mixed-method design was utilized to assess qualitative and quantitative data from the Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers project. Survey data was obtained from 837 mid-level providers, 83 of whom participated in a critical incident interview whose aim was to elicit negative events in the practice environment that induced intention to leave their job. HRH management practices were assessed quantitatively in 48 districts with 37 members of CHMTs participating in semi-structured interviews.ResultsThe eight human resources management practices enumerated in the basic SHRM component model were implemented unevenly. On the one hand, members of CHMTs and mid-level providers agreed that there were severe shortages of health workers, deficient salaries, and an overwhelming workload. On the other hand, members of CHMTs and mid-level providers differed in their perspectives on rewards and allocation of opportunities for in-service training. Although written standards of performance and supervision requirements were available in most districts, they did not reflect actual duties. Members of CHMTs reported high levels of autonomy in key HRH management practices, but mid-level providers disputed the degree to which the real situation on the ground was factored into job-related decision-making by CHMTs.ConclusionsThe incongruence in perspectives offered by members of CHMTs and mid-level providers points to deficient HRH management practices, which contribute to poor practice environments in acute obstetric settings in Tanzania. Our findings indicate that members of CHMTs require additional support to adequately fulfill their HRH management role. Further research conducted in low-income countries is necessary to determine the appropriate package of interventions required to strengthen the capacity of members of CHMTs.

Explaining retention of healthcare workers in Tanzania: moving on, coming to 'look, see and go', or stay?

BackgroundIn the United Republic of Tanzania, as in many regions of Sub-Saharan Africa, staff shortages in the healthcare system are a persistent problem, particularly in rural areas. To explore staff shortages and ways of keeping workers in post, we ask, (a) Which cadres are most problematic to recruit and keep in post? (b) How and for what related reasons do health workers leave? (c) What critical incidents do those who stay face? (d) And why do they stay and cope?MethodsThis is a multi-method paper based on analysis of data collected as part of a cross-sectional health facility study supporting maternal and reproductive health services in the United Republic of Tanzania. Qualitative data were generated through semi-structured interviews with Council Health Management Teams, and Critical Incident Technique interviews with mid-level cadres. Complementary quantitative survey data were collected from district health officials, which are used to support the qualitative themes.ResultsMid-level cadres were problematic to retain and caused significant disruptions to continuity of care when they left. Shortage of highly skilled workers is not only a rural issue but also a national one. Staff were categorised into a clear typology. Staff who left soon after arrival and are described by ‘Look, See and Go’; ‘Movers On’ were those who left due to family commitments or because they were pushed to go. The remaining staff were ‘Stayers’. Reasons for wanting to leave included perceptions of personal safety, feeling patient outcomes were compromised by poor care or as a result of perceived failed promises. Staying and coping with unsatisfactory conditions was often about being settled into a community, rather than into the post.ConclusionsThe Human Resources for Health system in the United Republic of Tanzania appears to lack transparency. A centralised monitoring system could help to avoid early departures, misallocation of training, and other incentives. The system should match workers’ profiles to the most suitable post for them and track their progress and rewards; training managers and holding them accountable. In addition, priority should be given to workplace safety, late night staff transport, modernised and secure compound housing, and involving the community in reforming health services culture and practices.

Task Shifting in Rural Tanzania: Characteristics and Quality Implications of Semi-Skilled Health Staff Serving in Lindi and Mtwara Regions

Background: Due to severe and critical shortage of health professionals lower level health facilities in Tanzania, notably Dispensaries, depend on medical attendants/semi-skilled health workers for service provision. This paper reports on characteristics of these semi-skilled health staff, their performance of tasks, and related implications for quality of health services in Lindi and Mtwara regions. Methods: This was essentially a cross-sectional, descriptive fact finding study. Its implementation followed a triangulated methodological approach. That is, both quantitative and qualitative approaches in data collection and analysis were employed. Results: About two thirds, 146 (61.4%), of the studied Medical Attendants had a primary level of education. Most of them at most attended a one year course in basic nursing; Kilwa and Liwale districts lead by far in having more than half of the studied facilities manned entirely by Medical Attendants. Examination of their scheme of service versus the tasks they engage in indicated glaring gaps calling for interim quality improvement measures. Current supervisory visits by members of the Council Health Management Team (CHMT) are mainly administrative – offering limited or no clinical support. Conclusion: The situation of delivery of health services by semi-skilled staff in the rural Dispensaries amounts to an unmanaged task shifting. The implications of this fact on quality of services rendered to the poor rural residents are overwhelming. There is need for the Ministry of Health and Social Welfare to develop a policy and guideline that will recognize the important role played by Medical Attendants and shed light on how their work performance can be improved.

“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

BackgroundIn 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.MethodsIn-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.ResultsOverall, 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.ConclusionHealth 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.