Perceived Impact of Health Sector Reform on Motivation of Health Workers and Quality of Health Care in Tanzania: the Perspectives of Healthcare Workers and District Council Health Managers in Four Districts

Background: Literature on the impact of health sector reform (HSR) on motivation of healthcare workers (HWs) and performance in health service provision in developing countries is still limited. Objective: To describe the impact of HSR on HW motivation and performance in providing quality health care in Tanzania. Methods: Four districts selected from three regions were covered, involving in-depth interviews with HWs in public health facilities (HFs), focus group discussions with district managers and researchers’ observations. Data were analysed using a qualitative content analysis approach. Results: The cost-sharing system in public HFs and national health ‘basket’ funding system introduced in 1990s were the key HSR elements identified by the study participants as impacting on HWs motivation and performance. User-fees for public healthcare services was acknowledged as having supplemented government funds allocated to public HFs, although such facilities still experienced ‘stock-outs’ of essential medicines and other supplies, HF understaffing, low/lack of essential remuneration, shortage of and unrepaired staff houses, meagre office space, lack of transport facilities for emergency cases, minimal recognition of HWs at local primary healthcare committees and the district health service budgeting system being controlled by district and central level authorities, leaving little room for lower level stakeholders to participate. Conclusion: For the national healthcare system to succeed, HSRs will need to involve and motivate HWs who are frontline implementers of the reform strategies.Key words: Decentralisation, priority-setting, human resources, health staff morale, Tanzani

Rhetoric and Reality of Community Participation in Health Planning, Resource Allocation and Service Delivery: a Review of the Reviews, Primary Publications and Grey Literature

Introduction: This paper synthesises reports on community participation (CP) concept and its practicability in countries’ health service systems, much focus being on developing countries.Methodology: We narratively reviewed the published and grey literature traced from electronic sources and hard copies as much as they could be accessed.Findings: CP is a concept widely promoted, but few projects/programmes have demonstrated its practicability in different countries. In many countries, communities are partially involved in one or several stages of project cycles - priority setting, resource allocation, service management, project implementation and evaluation. There is tendency of informing communities to implement the decisions that have already been passed by elites or politicians. In most of the project/programmes, professionals dominate the decision making processes by downgrading the non-professionals or non-technical people’s knowledge and skills. CP concept is greatly misinterpreted and sometimes confused with community involvement. In some cases, the community participates in passive manner. There is no common approach to translate CP into practice and this perpetuates debates on how and to what extent to which the community members should participate.Conclusion: Persistent misconceptions about CP perpetuate inequalities in many countries’ health systems, suggesting more concerted measures towards making a desired difference

Women's Experiences and Views about Costs of Seeking Malaria Chemoprevention and other Antenatal Services: A Qualitative Study from two Districts in Rural Tanzania.

The Tanzanian government recommends women who attend antenatal care (ANC) clinics to accept receiving intermittent preventive treatment against malaria during pregnancy (IPTp) and vouchers for insecticide-treated nets (ITNs) at subsidized prices. Little emphasis has been paid to investigate the ability of pregnant women to access and effectively utilize these services. To describe the experience and perceptions of pregnant women about costs and cost barriers for accessing ANC services with emphasis on IPTp in rural Tanzania. Qualitative data were collected in the districts of Mufindi in Iringa Region and Mkuranga in Coast Region through 1) focus group discussions (FGDs) with pregnant women and mothers to infants and 2) exit-interviews with pregnant women identified at ANC clinics. Data were analyzed manually using qualitative content analysis methodology. FGD participants and interview respondents identified the following key limiting factors for women's use of ANC services: 1) costs in terms of money and time associated with accessing ANC clinics, 2) the presence of more or less official user-fees for some services within the ANC package, and 3) service providers' application of fines, penalties and blame when failing to adhere to service schedules. Interestingly, the time associated with travelling long distances to ANC clinics and ITN retailers and with waiting for services at clinic-level was a major factor of discouragement in the health seeking behaviour of pregnant women because it seriously affected their domestic responsibilities. A variety of resource-related factors were shown to affect the health seeking behaviour of pregnant women in rural Tanzania. Thus, accessibility to ANC services was hampered by direct and indirect costs, travel distances and waiting time. Strengthening of user-fee exemption practices and bringing services closer to the users, for example by promoting community-directed control of selected public health services, including IPTp, are urgently needed measures for increasing equity in health services in Tanzania

Feasibility and Coverage of Implementing Intermittent Preventive Treatment of Malaria in Pregnant women Contacting Private or Public Clinics in Tanzania: Experience-based Viewpoints of Health Managers in Mkuranga and Mufindi districts.

Evidence on healthcare managers' experience on operational feasibility of malaria intermittent preventive treatment for malaria during pregnancy (IPTp) using sulphadoxine-pyrimethamine (SP) in Africa is systematically inadequate. This paper elucidates the perspectives of District Council Health Management Team (CHMT)s regarding the feasibility of IPTp with SP strategy, including its acceptability and ability of district health care systems to cope with the contemporary and potential challenges. The study was conducted in Mkuranga and Mufindi districts. Data were collected between November 2005 and December 2007, involving focus group discussion (FGD) with Mufindi CHMT and in-depth interviews were conducted with few CHMT members in Mkuranga where it was difficult to summon all members for FGD. Participants in both districts acknowledged the IPTp strategy, considering the seriousness of malaria in pregnancy problem; government allocation of funds to support healthcare staff training programmes in focused antenatal care (fANC) issues, procuring essential drugs distributed to districts, staff remuneration, distribution of fANC guidelines, and administrative activities performed by CHMTs. The identified weaknesses include late arrival of funds from central level weakening CHMT's performance in health supervision, organising outreach clinics, distributing essential supplies, and delivery of IPTp services. Participants anticipated the public losing confidence in SP for IPTp after government announced artemither-lumefantrine (ALu) as the new first-line drug for uncomplicated malaria replacing SP. Role of private healthcare staff in IPTp services was acknowledged cautiously because CHMTs rarely supplied private clinics with SP for free delivery in fear that clients would be required to pay for the SP contrary to government policy. In Mufindi, the District Council showed a strong political support by supplementing ANC clinics with bottled water; in Mkuranga such support was not experienced. A combination of health facility understaffing, water scarcity and staff non-adherence to directly observed therapy instructions forced healthcare staff to allow clients to take SP at home. Need for investigating in improving adherence to IPTp administration was emphasised. High acceptability of the IPTp strategy at district level is meaningless unless necessary support is assured in terms of number, skills and motivation of caregivers and availability of essential supplies

Psychosocial, Behavioural and Health System Barriers to Delivery and Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy in Tanzania - Viewpoints of Service Providers in Mkuranga and Mufindi Districts.

Intermittent preventive treatment of malaria in pregnancy (IPTp) using sulphurdoxine-pyrimethamine (SP) is one of key malaria control strategies in Africa. Yet, IPTp coverage rates across Africa are still low due to several demand and supply constraints. Many countries implement the IPTp-SP strategy at antenatal care (ANC) clinics. This paper reports from a study on the knowledge and experience of health workers (HWs) at ANC clinics regarding psychosocial, behavioural and health system barriers to IPTp-SP delivery and uptake in Tanzania. Data were collected through questionnaire-based interviews with 78 HWs at 28 ANC clinics supplemented with informal discussions with current and recent ANC users in Mkuranga and Mufindi districts. Qualitative data were analysed using a qualitative content analysis approach. Quantitative data derived from interviews with HWs were analysed using non-parametric statistical analysis. The majority of interviewed HWs were aware of the IPTp-SP strategy's existence and of the recommended one month spacing of administration of SP doses. Some HWs were unsure of that it is not recommended to administer IPTp-SP and ferrous/folic acid concurrently. Others were administering three doses of SP per client following instruction from a non-governmental agency while believing that this was in conflict with national guidelines. About half of HWs did not find it appropriate for the government to recommend private ANC providers to provide IPTp-SP free of charge since doing so forces private providers to recover the costs elsewhere. HWs noted that pregnant women often register at clinics late and some do not comply with the regularity of appointments for revisits, hence miss IPTp and other ANC services. HWs also noted some amplified rumours among clients regarding health risks and treatment failures of SP used during pregnancy, and together with clients' disappointment with waiting times and the sharing of cups at ANC clinics for SP, limit the uptake of IPTp-doses. HWs still question SP's treatment advantages and are confused about policy ambiguity on the recommended number of IPTp-SP doses and other IPTp-SP related guidelines. IPTp-SP uptake is further constrained by pregnant women's perceived health risks of taking SP and of poor service quality

Supply-related drivers of staff motivation for providing intermittent preventive treatment of malaria during pregnancy in Tanzania: evidence from two rural districts

BACKGROUND: Since its introduction in the national antenatal care (ANC) system in Tanzania in 2001, little evidence is documented regarding the motivation and performance of health workers (HWs) in the provision of intermittent preventive treatment of malaria during pregnancy (IPTp) services in the national ANC clinics and the implications such motivation and performance might have had on HWs and services' compliance with the recommended IPTp delivery guidelines. This paper describes the supply-related drivers of motivation and performance of HWs in administering IPTp doses among other ANC services delivered in public and private health facilities (HFs) in Tanzania, using a case study of Mkuranga and Mufindi districts. METHODS: Interviews were conducted with 78 HWs participating in the delivery of ANC services in private and public HFs and were supplemented by personal communications with the members of the district council health management team. The research instrument used in the data collection process contained a mixture of closed and open-ended questions. Some of the open-ended questions had to be coded in the form that allowed their analysis quantitatively. RESULTS: In both districts, respondents acknowledged IPTp as an essential intervention, but expressed dissatisfaction with their working environments constraining their performance, including health facility (HF) unit understaffing; unsystematic and unfriendly supervision by CHMT members; limited opportunities for HW career development; and poor (HF) infrastructure and staff houses. Data also suggest that poor working conditions negatively affect health workers' motivation to perform for ANC (including IPTp) services. Similarities and differences were noted in terms of motivational factors for ANC service delivery between the HWs employed in private HFs and those in public HFs: those in private facilities were more comfortable with staff residential houses, HF buildings, equipment, availability of water, electricity and cups for clients to use while taking doses under direct observed therapy than their public facility counterparts. Employees in public HFs more acknowledged availability of clinical officers, nurses and midwives than their private facility counterparts. More results are presented and discussed. CONCLUSION: The study shows conditions related to staffing levels, health infrastructure and essential supplies being among the key determinants or drivers of frontline HWs' motivation to deliver ANC services in both private and public HFs. Efforts of the government to meet the maternal health related Millennium Development Goals and targets for specific interventions need to address challenges related to HWs' motivation to perform their duties at their work-places

Analysis of Cost Impact of HIV/AIDS on Health Service Provision in Nine Regions, Tanzania: Methodological Challenges and Lessons for Policy

Background: Tanzania is one of African countries that have since 1983 been facing the human immuno-deficiency virus-acquired immune-deficiency syndrome (HIV-AIDS) pandemic, thereby, drawing attention to the general public, the governmental and non-governmental organizations and government’s partner development agencies. Due to few socio-economic studies done so far to evaluate the impact this pandemic, a study was designed and undertaken in 2001 to analyse how this disease had impacted on health service provision in Tanzania from a cost perspective.Methods: The study involved a review of health service management information documents at selected health facilities in nine regions within mainland Tanzania, interviews with health service workers (HWs) at selected health facilities and health managers at district and regional levels as well as focus group discussions with people living with HIV/AIDS (PLWA).Findings: We noted that on average, HIV/AIDS caused 72% of all the deaths recorded at the study hospitals. The health management information system (HMIS) missed some data in relation to HIV/AIDS services, including the costs of such services which limited the investigators’ ability to determine the actual costs impact. Using their experience, health managers and HWs reported substantial amounts of funds, labour time, supplies and other resources to have been spent on HIV/AIDS preventive and curative services. The frontline HWs reported to face a problem of identifying the PLWA among those who presented multiple illness conditions at HF levels which means sometimes the services given to such people could not be separated for easy costing from services delivered to other categories of the patients. Such respondents and their superiors (i.e. Health managers) testified that PLWA were being screened and receiving treatment. HWs were concerned with spending much time on counselling PLWA, attending home-based care, sick-leaves and funeral ceremonies either after their relatives or co-staff have died of AIDS, lowering time for delivering services to other patients. HWs together with their superiors at district and regional levels reported increasing shortages of essential supplies, office-working space and other facilities at HF levels, although actual costs of such items were not documented.Conclusion: The cost impact of HIV/AIDS to the health sector is undoubtedly high even though it is not easy to establish the cost of each service delivered to PLWA in Tanzania. As adopted in the present study, designers of methods for analysing impacts of diseases like this should consider a mixture of both quantitative and qualitative techniques. Meanwhile concerted measures are needed to improve health service record keeping so as enhancing data usability for research and rational management decision-making purposes

Prospects, achievements, challenges and opportunities for scaling-up malaria chemoprevention in pregnancy in Tanzania: the perspective of national level officers

OBJECTIVES: To describe the prospects, achievements, challenges and opportunities for implementing intermittent preventive treatment for malaria in pregnancy (IPTp) in Tanzania in light of national antenatal care (ANC) guidelines and ability of service providers to comply with them. METHODS: In-depth interviews were made with national level malaria control officers in 2006 and 2007. Data was analysed manually using a qualitative content analysis approach. RESULTS: IPTp has been under implementation countrywide since 2001 and the 2005 evaluation report showed increased coverage of women taking two doses of IPTp from 29% to 65% between 2001 and 2007. This achievement was acknowledged, however, several challenges were noted including (i) the national antenatal care (ANC) guidelines emphasizing two IPTp doses during a woman's pregnancy, while other agencies operating at district level were recommending three doses, this confuses frontline health workers (HWs); (ii) focused ANC guidelines have been revised, but printing and distribution to districts has often been delayed; (iii) reports from district management teams demonstrate constraints related to women's late booking, understaffing, inadequate skills of most HWs and their poor motivation. Other problems were unreliable supply of free SP at private clinics, clean and safe water shortage at many government ANC clinics limiting direct observation treatment and occasionally pregnant women asked to pay for ANC services. Finally, supervision of peripheral health facilities has been inadequate and national guidelines on district budgeting for health services have been inflexible. IPTp coverage is generally low partly because IPTp is not systematically enforced like programmes on immunization, tuberculosis, leprosy and other infectious diseases. Necessary concerted efforts towards fostering uptake and coverage of two IPTp doses were emphasized by the national level officers, who called for further action including operational health systems research to understand challenges and suggest ways forward for effective implementation and high coverage of IPTp. CONCLUSION: The benefit of IPTp is appreciated by national level officers who are encouraged by trends in the coverage of IPTp doses. However, their appeal for concerted efforts towards IPTp scaling-up through rectifying the systemic constraints and operational research is important and supported by suggestions by other authors

Knowledge and malaria treatment practices using artemisinin combination therapy (ACT) in Malawi: survey of health professionals

<p>Abstract</p> <p>Background</p> <p>Malaria still remains a life-threatening disease worldwide causing between 190 and 311 million cases of malaria in 2008. Due to increased resistance to sulphadoxine-pyrimethamine (SP), the Ministry of Health in Malawi, as in many sub-Saharan African countries, changed the malaria treatment policy to use artemisinin-based combination therapy (ACT). In order to optimize the correct use of this drug, and protect against the development of the parasite's resistance, it is important to assess the knowledge and practices of medical practitioners on the use of ACT and its impact on adherence to new treatment policy guidelines.</p> <p>Methods</p> <p>A cross-sectional survey was conducted to assess the knowledge and perceptions of Malawian medical doctors and pharmacists on the use of ACT and the drivers of treatment choice and clinical treatment decisions. Medical doctors and pharmacists who are involved in managing malaria patients in Malawi were recruited and a self-administered questionnaire was used to obtain information on socio-demographic characteristics of the study participants, knowledge on ACT, source of information on ACT and methods used to decide on the treatment of patients with malaria.</p> <p>Results</p> <p>Most of the participants (95.7%) know at least one form of ACT, 67.4% reported that different forms of ACT have different characteristics, 77.3% reported that there are special formulations for children. The most commonly mentioned ACT was artemether-lumefantrine (AL), by 94.6% of the participants and 75.0% of the participants indicated that they prefer to prescribe AL. 73.9% of participants had ever received information on ACT. However, only 31.5% had received training on management of malaria using ACT. There were 71.7% respondents who had heard of ACT causing side effects. Only 25.0% of the participants had received training on how to report SAEs.</p> <p>Conclusion</p> <p>It was found that most of the participants know about ACT and treatment guidelines for malaria. However, most of the participants have not received any training on how to use ACT and how to report adverse effects arising from the use of ACT. There is need for more training of health care professionals to ensure correct and effective use of ACT.</p