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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.
A qualitative study design was chosen using in-depth interviews with health workers and district health managers, observations and document review to explore factors influencing working conditions for providing maternal health care services in rural Tanzania. This study was conducted in the Kongwa district in the Dodoma region of Tanzania. The district has typical rural characteristics with a moderate level of socio-economic development and is fairly accessible in terms of transport and communication networks. The major economic activities are agriculture characterized by small farming and livestock keeping. The district has a dry Savannah type of climate which is characterized by low and unpredictable unimodal rainfall, persistent desiccating winds and low humidity. Transport system consists of unpaved roads which are hardly accessible during rainy season. The headquarters which bears the same name of the district is located about 89 km east of Dodoma town. While electricity is available in very few areas, access to clean water is still a problem in many villages. The district has 14 wards, 67 villages and 286 hamlets. The total population of the Kongwa district is 309 973 people as per the 2012 population census projection [45]. The health care system in Kongwa consists mainly of government-owned facilities, with very few health facilities owned by the private sector and non-governmental organizations (NGOs). The government-owned facilities include 1 district hospital located in the district centre, 4 rural health centres and 32 dispensaries. A review of the Comprehensive Council Health Plans and district health reports indicated that by the end of 2012 the district had a total of 327 health workers working in these facilities out of 664 that were required. All these facilities provide antenatal care (ANC), delivery care and postpartum care. Caesarean section is provided in one rural health centre and at the district hospital. As in many other district, women with high-risk pregnancies and those with complications are identified by health workers during ANC at dispensaries and rural health centres and are referred to the district hospital where they can stay at the maternal waiting home (locally known as Chigonela) located at the district hospital while waiting for delivery. The maternal waiting home allows immediate access to emergency delivery at the district hospital, such as caesarean section. In-depth interviews and observations were conducted during four phases between December, 2011, and May, 2013. In the first phase (December 2011), initial exploratory interviews with five members of the Council Health Management Team (CHMT) resulted in the emergence of issues related to health workers’ shortage that needed further exploration. In the second phase (February-April, 2012), 18 health facilities were visited and structured observations were conducted using an observation checklist focusing on health facility structure (status, source of light, running water, latrines and delivery room), drug and staff house availability and status. The choice of facilities was done to capture the geographical variation of the district and different types of health facilities (1 hospital, 3 health centres and 14 dispensaries) from both central and rural parts of the district. The third phase (February, 2013) involved in-depth interviews with 15 health workers (1 assistant medical officer, 5 nurses, 4 clinical officers, 4 medical attendants and 1 laboratory technician) working in the 18 health facilities that were previous observed by the first author. Selection of informants was purposely done to include different categories of service providers. An interview guide was used with questions to explore informant’s perspective on working conditions focusing on working environment, living conditions, managements’ responses to their claims, career advancement, training opportunities and means they use to communicate their concerns. The guide was developed based on existing literature related to working conditions, prolonged experience of the first author in the study setting and informal discussion with health workers prior to the study. Probing questions on how these issues affect the health workers’ role of providing maternal health care were employed. Follow-up interviews with seven managers directly responsible for human resources management (five members of CHMT, two informants from District Executive Director’s (DED) office) were done during phase 4 (May, 2013) to explore on how health workers’ concerns are dealt at the managerial level. The first author together with the research assistant collected data, and all interviews were audiotaped. Field notes and memos were written up both during and immediately after the interviews. Documentary reviews were conducted to supplement the data. Documents reviewed include the Human Resource for Health Strategic Plan (2008-2013), health sector strategic plans, council health planning documents (2008-2012), local-government-related policy documents and Tanzania maternal-health-related policies. These documents were reviewed to gain an insight on the structure and function of the Local Government Authority (LGAs) in relation to human resource for health and how health-related policies and local government’s documents address various health workers issues in rural settings. Audiotaped interviews were first transcribed by the first author and translated from Kiswahili to English. The interviews were analysed using qualitative content analysis, following Graneheim and Lundman [46]. The transcripts and field notes were first analysed manually by reading and re-reading to become familiarized with the data. Transcripts from health workers and managers were analysed for identification of text (meaning units) related to informants’ perspectives on provision of maternal care, health workers’ experiences related to working environments, living conditions, dealing with staff welfare and staff management in general. Then codes were extracted from these condensed-meaning units. The codes from health workers’ and managers’ transcripts were further analysed in order to distinguish similarities and differences. Then similar codes were sorted together to form categories reflecting the manifest content of the text. Trustworthiness in the study is achieved when the findings are worth believing [47]. According to Graneheim and Lundman [46], trustworthiness in a qualitative study is assessed using four criteria namely credibility, transferability, dependability and confirmability. Credibility in this study was ensured through triangulation of different study informants with various experiences who shed light on the research question from a variety of aspects. To enhance credibility and dependability, the data collected from interviews were triangulated with those from field notes, document reviews and observations of health facilities during the analysis process, and categories and themes were shared among the co-authors with different backgrounds and degrees of familiarity with the setting who gave critical comments and suggestions. To confirm that the findings reflected informants’ perspectives rather than researchers’ understanding of the problem, the presented findings were supported by codes and quotes. Transferability was enhanced by describing the study context, process for data collection and analysis. The study was ethically approved by the Senate Research and Publication Committee of Muhimbili University of Health and Allied Sciences. Permission to conduct the study was given by the Dodoma Regional Administrative Secretary (RAS). Informed consent was obtained after the researchers explained the purpose of the study. Participants were informed of their right to refuse participation in the study and were assured of the confidentiality of the collected information.
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