Margaret E. Kruk

In 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). This 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. The 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. The 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.

Surgical interventions are often considered complex procedures to be undertaken by highly trained surgeons, but such specialists are rare in many low-income countries (LICs). However, many common surgical problems in resource-limited settings do not require the intervention of specialized staff. Significant documentation demonstrates that cost-effective surgical interventions can be undertaken in LICs with the innovative use and deployment of trained staff, including emergency care for trauma and obstetrical needs. Despite this documentation, surgical workforce innovations that use nonspecialized cadres often meet with resistance from established surgeons and their professional associations. The most important barrier to the safe provision of preoperative, intraoperative, and postoperative surgical and anesthesia services in LICs is the shortage of trained staff. The well-documented reasons for this scarcity include the following (Chu and others 2009; FAIMER Institute 2008): Low number of medical school graduates. Inadequate initial and ongoing training. Poor salaries and working conditions. Inability to motivate and retain staff in remote and rural areas. Staff attrition due to retirement, death, or resignation, and the consequences of brain drain. The reluctance of governments to invest in human resources compounds the effects of these factors. Current financial constraints, such as those in Tanzania, for example, have forced governments to announce freezes in employing new human resources for health. Sub-Saharan Africa is most affected by the global shortage of human resources for health (Chankova, Muchiri, and Kombe 2009; Mills and others 2008; WHO 2006). Two countries profiled in this chapter, Mozambique and Tanzania, experienced this crisis some years ago (Liese and Dussault 2004; Mills and others 2008; Smith and Henderson-Andrade 2006). In other countries, despite years of interventions to overcome the scarcity of doctors, the shortage has worsened as the result of population growth, presenting a major challenge to the ability of these countries to achieve the health-related Millennium Development Goals (MDGs) (Anand and Barnighausen 2004; Liese and Dussault 2004) (box 17.1). Available doctors tend to concentrate and work in urban areas and in regional or even national hospitals, limiting access for rural populations, who often constitute up to 75 percent of national populations. A major reason for Sub-Saharan Africa’s high maternal mortality is that few infants are born in the presence of skilled attendants. The lack of skilled birth attendants contributes to the 5 million to 6 million maternal deaths, stillbirths, and newborn deaths each year worldwide. In 19 of the 52 Sub-Saharan African countries that reported data, fewer than 50 percent of births were attended by skilled health personnel. The World Health Organization (WHO) estimates that 80 percent of births need to be attended by an adequately equipped and skilled birth...

Patients’ reported opinions of the health system need to be understood in order to provide patient-centered care. We investigated determinants of women’s ratings of the quality of care during their most recent facility delivery.

Although qualitative studies have raised attention to humiliating treatment of women during labour and delivery, there are no reliable estimates of the prevalence of disrespectful and abusive treatment in health facilities. We measured the frequency of reported abusive experiences during facility childbirth in eight health facilities in Tanzania and examined associated factors. The study was conducted in rural northeastern Tanzania. Using a structured questionnaire, we interviewed women who had delivered in health facilities upon discharge and re-interviewed a randomly selected subset 5–10 weeks later in the community. We calculated frequencies of 14 abusive experiences and the prevalence of any disrespect/abuse. We performed logistic regression to analyse associations between abusive treatment and individual and birth experience characteristics. A total of 1779 women participated in the exit survey (70.6% response rate) and 593 were re-interviewed at home (75.8% response rate). The frequency of any abusive or disrespectful treatment during childbirth was 343 (19.48%) in the exit sample and 167 (28.21%) in the follow-up sample; the difference may be due to courtesy bias in exit interviews. The most common events reported on follow-up were being ignored (N = 84, 14.24%), being shouted at (N = 78, 13.18%) and receiving negative or threatening comments (N = 68, 11.54%). Thirty women (5.1%) were slapped or pinched and 31 women (5.31%) delivered alone. In the follow-up sample women with secondary education were more likely to report abusive treatment (odds ratio (OR) 1.48, confidence interval (CI): 1.10–1.98), as were poor women (OR 1.80, CI: 1.31–2.47) and women with self-reported depression in the previous year (OR 1.62, CI: 1.23–2.14). Between 19% and 28% of women in eight facilities in northeastern Tanzania experienced disrespectful and/or abusive treatment from health providers during childbirth. This is a health system crisis that requires urgent solutions both to ensure women’s right to dignity in health care and to improve effective utilization of facilities for childbirth in order to reduce maternal mortality.

In countries with high maternal and newborn morbidity and mortality, reliable access to quality healthcare in rural areas is essential to save lives. Health workers who are satisfied with their jobs are more likely to remain in rural posts. Understanding what factors influence health workers’ satisfaction can help determine where resources should be focused. Although there is a growing body of research assessing health worker satisfaction in hospitals, less is known about health worker satisfaction in rural, primary health clinics. This study explores the workplace satisfaction of health workers in primary health clinics in rural Tanzania.

Rigorous implementation science can improve efforts to scale up effective health interventions.

In the past decade, “big push” global health initiatives financed by international donors have aimed to rapidly reach ambitious health targets in low-income countries. The health system impacts of these efforts are infrequently assessed. Saving Mothers, Giving Life is a global public-private partnership that aims to reduce maternal mortality dramatically in one year in eight districts in Uganda and Zambia. We evaluated the first six to twelve months of the program’s implementation, its ownership by national ministries of health, and its effects on health systems. The project’s impact on maternal mortality is not reported here. We found that the Saving Mothers, Giving Life initiative delivered a large “dose” of intervention quickly by capitalizing on existing US international health assistance platforms, such as the President’s Emergency Plan for AIDS Relief. Early benefits to the broader health system included greater policy attention to maternal and child health, new health care infrastructure, and new models for collaborating with the private sector and communities. However, the rapid pace, external design, and lack of a long-term financing plan hindered integration into the health system and local ownership. Sustaining and scaling up early gains of similar big push initiatives requires longer-term commitments and a clear plan for transition to national control.

To measure the extent, determinants and results of bypassing local primary care clinics for childbirth among women in rural parts of the United Republic of Tanzania. Women were selected in 2012 to complete a structured interview from a full census of all 30076 households in clinic catchment areas in Pwani region. Eligibility was limited to those who had delivered between 6 weeks and 1 year before the interview, were at least 15 years old and lived within the catchment areas. Demographic and delivery care information and opinions on the quality of obstetric care were collected through interviews. Clinic characteristics were collected from staff via questionnaires. Determinants of bypassing (i.e. delivery of the youngest child at a health centre or hospital without provider referral) were analysed using multivariate logistic regression. Bypasser and non-bypasser birth experiences were compared in bivariate analyses. Of 3019 eligible women interviewed (93% response rate), 71.0% (2144) delivered in a health facility; 41.8% (794) were bypassers. Bypassing likelihood increased with primiparity (odds ratio, OR: 2.5; 95% confidence interval, CI: 1.9-3.3) and perceived poor quality at clinics (OR: 1.3; 95% CI: 1.0-1.7) and decreased if clinics recently underwent renovations (OR: 0.39; 95% CI: 0.18-0.84) and/or performed ≥ 4 obstetric signal functions (OR: 0.19; 95% CI: 0.08-0.41). Bypassers reported better quality of care on six of seven quality of care measures. Many pregnant women, especially first-time mothers, choose to bypass local primary care clinics for childbirth. Perceived poor quality of care at clinics was an important reason for bypassing. Primary care is failing to meet the obstetric needs of many women in this rural, low-income setting.

A discrete choice experiment was conducted to investigate preferences for job characteristics among nursing students and practicing nurses to determine how these groups vary in their respective preferences and to understand whether differing policies may be appropriate for each group.