"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

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

BACKGROUND

Maternal 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.

METHODS

This 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.

RESULTS

Direct 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.

CONCLUSION

Overall, 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.

Systems on the Edge: Developing Organizational Theory for the Persistence of Mistreatment in Childbirth

Mistreatment in childbirth is institutionalized in many healthcare settings globally, causing widespread harm. Rising concern has elicited research on its prevalence and characteristics, with limited attention to developing explanatory theory. Mistreatment, a complex systemic and behavioral phenomenon, requires social science theory to explain its persistence despite official norms that promote respectful care. Diane Vaughan's normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. Its multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance. To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan's theory and additional organizational theories. Analysis revealed that normalized scarcity at the macro-level combined with production pressures for biomedical care and imbalanced power-dependence altered values, structures, and processes in the health system. Meso-level actors struggled to achieve production goals with limited autonomy and resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. Analogical comparison with another case of organizational deviance based on literature enabled a novel approach to elaborate theory. The emergent theory sheds light on opportunities to transform systems and routinize respectful care. Theory application in additional settings and exploration of other social theories is needed for further understanding of this complex problem.

How communication can help women who experience a maternal near-miss: a qualitative study from Tanzania

OBJECTIVES

This study aimed to explore experiences of communication as an element of quality of care, among women surviving a maternal near-miss event, thus women who nearly died but survived haemorrhage, or pre-eclampsia complication during pregnancy, childbirth or within 42 days of termination of pregnancy.

DESIGN

A descriptive, phenomenological, qualitative study using semistructured interviews with women who survived a maternal near-miss in Southern Tanzania.

SETTING

The participants were recruited from two selected hospitals in Mtwara Region, where women sought child birth care and developed near-miss condition.

PARTICIPANTS

Participants for this study were women who experienced and survived a maternal near-miss event and who had lived in the study area for at least 1 year. Women were recruited using an adapted version of the WHO criteria for maternal near-miss.

DATA COLLECTION

We identified 16 women and were able to conduct 10 in-depth interviews with women at their homes, 4 weeks after they were discharged. The interviews were audiorecorded and transcribed and translated word for word from Kiswahili. Thematic analysis was used to identify emerging themes.

RESULTS

Three major themes evolved: (1) Being informed about the care and interaction, (2) Being engaged and encouraged and (3) Being afraid to ask questions. The study highlighted that good communication with women during the provision of care helped women feel grateful, supported and cared for. Women who were unconscious during care were often not informed later of what happened. This created some negative feelings and anxiety.

CONCLUSION

This study highlights the importance of communication, and of being informed of what happened and why. Empathetic communication with sufficient explanation on what happened and why created trust among women-a positive finding which should encourage the development of consistent approaches to strengthen healthcare provider communication skills.

Balancing professional autonomy and authority at the margins of a fragile state: Front-line health workers' experiences in Burkina Faso

The availability of diagnostic equipment, medical products and basic infrastructure is limited in most low-income societies. Poor motivation among health workers as well as recruitment and retention problems are key factors contributing to poor health care services in developing countries. The current paper describes how the front line cope with these difficult working conditions. Data for this study come from anthropological fieldwork in two districts of Burkina Faso and include a total of 27 unstructured and 40 semi-structured interviews with staff at dispensaries and medical centres in the two districts. Analytically, we make a distinction between their professional autonomy and their professional authority. We find that while the health workers experience a certain degree of professional autonomy, in the sense that they rely on their own clinical judgement and their discretion as decision makers and gatekeepers, their professional authority is constantly challenged when working at the margins of the state. Through improvisations and bricolaging, they compensate for the many shortcomings, but many of them feel that their skills are waning and that their professional identity threatened. Thus, massive strengthening of the front-line health worker's capacity is imperative for future improvement of health care services in Burkina Faso.

Understanding the Rural–Rural Migration of Health Workers in Two Selected Districts of Tanzania

Globally, rural–urban migration has been the focus in addressing the question of availability of health workers in rural areas. Often, the rural–rural migration of health workers, another important dimension is neglected. This study aimed to analyze the magnitude and the underlying factors for rural–rural migration of health workers in two rural districts of Tanzania. An exploratory comparative cross-sectional study adopting both quantitative and qualitative approaches was carried out in two districts of Kilwa in Lindi region, southern Tanzania, and Rombo in Kilimanjaro region, northern Tanzania. In a quantitative approach, 174 health workers (both clinicians and nonclinicians) filled in a self-administered questionnaire between August 2015 and September 2016. For the qualitative sub-study, 14 key informants that included health facilities in-charges and district health managers from the two districts were interviewed. In addition, three focus group discussions were conducted with members of the health facilities committee, in the two districts. Over 40% of health workers migrated from one workstation to another between 2011 and 2015. Close to 70% of the migrated health workers, migrated within the same districts. The proportion of health workers migrated was higher in Kilwa compared to Rombo. However, the difference was not statistically significant. The major underlying factors for migration in both districts were: Caring for the family and Unfavorable working and living conditions. In Kilwa, unlike Rombo, rejection by the community, superstitious beliefs, and lack of social services, were the other major factors underlying migration of the health workers. While addressing rural–urban migration, attention should be paid also to the rural–rural migration of health workers. Lastly, addressing the migration of health workers is a multi-dimensional issue that needs the engagement of all stakeholders within and beyond the health sector.

Task sharing and performance of Caesarean section by the Assistant Medical Officers in Tanzania: What have we learned?

Background:

Since the 1960s, Tanzania adopted the task shifting which was later termed task-sharing strategy in efforts to address the critical shortage of health workforce. However, poor maternal health indicators have remained a big challenge despite this strategy having introduced mid-level cadres (Assistant Medical Officers) capable of performing roles that otherwise were performed by doctors at the district level.

Objective:

To analyse lessons from the performance of Caesarean section by Assistant Medical Officers (AMOs) in Tanzania as part of the task sharing strategy.

Methods:

An exploratory qualitative case study was carried out where 10 key informant interviews with AMOs and 4 focused group discussions with AMO trainees were conducted in 4 selected districts and 2 AMO training schools in Tanzania. With the aid of Nvivo10 qualitative software, content analysis was performed to the gathered data.

Results:

Performance of the Caesarean section by the AMOs is motivated by the support from various stakeholders towards improving the performance of Caesarean section. Frustrating work environment and poor incentive system are major demotivators to the performance of the Caesarean section by the AMOs.

Conclusions:

More than 5 decades since the introduction of AMOs through task sharing, the performance of caesarean section by these cadres face more demotivators than the motivators. Efforts should be focused on improving the work environment and provision of appropriate incentives to the AMOs. Also, more stakeholders should be engaged to support the performance of caesarean section by the AMOs for realisation of the objectives of task sharing strategy.

Referral and admission to intensive care: A qualitative study of doctors' practices in a Tanzanian university hospital

BACKGROUND

Intensive care is care for critically ill patients with potentially reversible conditions. Patient selection for intensive care should be based on potential benefit but since demand exceeds availability, rationing is needed. In Tanzania, the availability of Intensive Care Units (ICUs) is very limited and the practices for selecting patients for intensive care are not known. The aim of this study was to explore doctors' experiences and perceptions of ICU referral and admission processes in a university hospital in Tanzania.

METHODS

We performed a qualitative study using semi-structured interviews with fifteen doctors involved in the recent care of critically ill patients in university hospital in Tanzania. Inductive conventional content analysis was applied for the analysis of interview notes to derive categories and sub-categories.

RESULTS

Two main categories were identified, (i) difficulties with the identification of critically ill patients in the wards and (ii) a lack of structured triaging to the ICU. A lack of critical care knowledge and communication barriers were described as preventing identification of critically ill patients. Triaging to the ICU was affected by a lack of guidelines for admission, diverging ideas about ICU indications and contraindications, the lack of bed capacity in the ICU and non-medical factors such as a fear of repercussions.

CONCLUSION

Critically ill patients may not be identified in general wards in a Tanzanian university hospital and the triaging process for the admission of patients to intensive care is convoluted and not explicit. The findings indicate a potential for improved patient selection that could optimize the use of scarce ICU resources, leading to better patient outcomes.

Women's Satisfaction With and Perceptions of the Quality of Postabortion Care at Public-Sector Facilities in Mainland Tanzania and in Zanzibar

BACKGROUND

In 2015, the government of Tanzania began to strengthen the quality of postabortion care (PAC). Limited research has been conducted to understand clients' perceptions of public sector provision of PAC. Accordingly, we carried out a mixed-method study between April and July 2016, using client surveys and in-depth interviews, both implemented immediately following PAC. Results were used to help guide the government's initiative.

METHODOLOGY

We assessed the quality of PAC in 25 public-sector facilities through a client survey of 412 women. Questions included satisfaction with client-staff interaction, counseling, provider competence, postabortion family planning, accessibility of care, and the facility environment. Based on responses, we developed and validated a scale representing women's overall satisfaction with the quality of care. We conducted bivariate analysis to identify the levels of care associated with clients' ranking of individual and composite measures of the quality of care. We used multivariate ordinal logistic models to assess the relative influence of multilevel factors on clients' overall satisfaction. We coupled our survey with qualitative analysis of in-depth interviews with 30 PAC clients.

RESULTS

Clients reported moderately high levels of satisfaction with the quality of PAC, with an overall mean score of 2.6 on a 4-point scale. Bivariate analysis identified several areas for improvement, including family planning counseling and provision, especially at regional hospitals; pain management; and reduced use of sharp curettage. The factors most strongly associated with satisfaction were advanced parity, receiving care at lower-level facilities, brief waiting periods, and manual vacuum aspiration for treatment of incomplete abortion. Qualitative analysis illuminated how client-provider interactions; pain; desire for counseling and information, especially on family planning; and congested facility environments shape clients' perceptions of the care they received.

CONCLUSIONS

Although clear areas for improvement in public-sector provision of PAC existed at all sites, women were less likely to report satisfaction with care at referral facilities owing primarily to inadequate counseling, delays in receiving PAC treatment after admission, and poor emphasis on postabortion fertility, family planning information, and contraceptive provision. PAC programs should ensure availability of a wide range of contraceptive methods and high-quality family planning counseling, especially at tertiary facilities.

Factors affecting early identification of pregnant women by community health workers in Morogoro, Tanzania

BACKGROUND

It is recommended that Antenatal Care (ANC) be initiated within the first trimester of pregnancy for essential interventions, such folic acid supplementation, to be effective. In Tanzania, only 24% of mothers attend their first ANC appointment during their first trimester. Studies have shown that women who have had contact with a health worker are more likely to attend their first antenatal care appointment earlier in pregnancy. Community health workers (CHWs) are in an opportune position to be this contact. This study explored CHW experiences with identifying women early in gestation to refer them to facility-based antenatal care services in Morogoro, Tanzania.

METHODS

This qualitative study employed 10 semi-structured focus group discussions, 5 with 34 CHWs and 5 with 34 recently delivered women in three districts in Morogoro, Tanzania. A thematic analytical approach was used to identify emerging themes among the CHW and RDW responses.

RESULTS

Study findings show CHWs play a major role in identifying pregnant women in their communities and linking them with health facilities. Lack of trust and other factors, however, affect early pregnancy identification by the CHWs. They utilize several methods to identify pregnant women, including: asking direct questions to households when collecting information on the national census, conducting frequent household visits and getting information about pregnant women from health facilities.

CONCLUSIONS

We present a framework for the interaction of factors that affect CHWs' ability to identify pregnant women early in gestation. Further studies need to be conducted investigating optimal workload for CHWs, as well as reasons pregnant women might conceal their pregnancies.

Implementation of free maternal and child healthcare policies: assessment of influence of context and institutional capacity of health facilities in South-east Nigeria

BACKGROUND

Studies examining how the capacity of health facilities affect implementation of free healthcare policies in low and middle-income countries are limited.

OBJECTIVE

This study describes how the context and institutional capacity of health facilities influenced implementation of the free maternal and child health programme (FMCHP) in Enugu state, South-east Nigeria.

METHODS

We conducted a qualitative case study at the state level and in two health districts (Isi-Uzo and Enugu Metropolis) in Enugu State. Data were collected through document review and semi-structured, in-depth interviews with policymakers (n = 16), healthcare providers (n = 16) and health facility committee leaders (n = 12) guided by an existing capacity framework and analysed using a thematic framework approach.

RESULTS

The findings reveal that active health facility committees, changes in provider payment process, supportive supervision, drug revolving fund, availability of medical equipment, electronic data transmission and staff sanction system enhanced the capacity of health facilities to offer free healthcare. However, ineffective decentralisation, irregular supervision and weak citizen participation limited this capacity. Uncertain provider payment, evidence of tax payment policy and a co-existing fee-exempt scheme constrained health facilities in following the FMCHP guidelines. Poor recording and reporting skills and lack of support from district officials constrained providers' adherence to claims' submission timeline. Poor funding, weak drug supply system, inadequate infrastructure and lack of participatory decision-making constrained delivery of free healthcare. Insufficient trained workforce, mission-inconsistent postings and transfers, and weak staff disciplinary system limited the human resource capacity.

CONCLUSIONS

Effectiveness of FMCHP at the health facility level depends on the extent of decentralisation, citizen participation, concurrent and conflictive policies, timely payment of providers, organisation of service delivery and human resources practices. Attention to these contextual and institutional factors will enhance responsiveness of health facilities, sustainability of free healthcare policies and progress towards universal health coverage.

"Doctors ready to be posted are jobless on the street…" the deployment process and shortage of doctors in Tanzania

BACKGROUND

The World Health Organization advocates that health workforce development is a continuum of three stages of entry, available workforce and exit. However, many studies have focused on addressing the shortage of numbers and the retention of doctors in rural and remote areas. The latter has left the contribution of the entry stage in particularly the deployment process on the shortage of health workforce less understood. This study therefore explored the experiences of medical doctors (MDs) on the deployment process after the internship period in Tanzania's health sector.

METHODS

A qualitative case study that adopted chain referral sampling was used to conduct 20 key informant interviews with MDs who graduated between 2003 and 2009 from two Medical Universities in Tanzania between February and April 2016. These MDs were working in hospitals at different levels and Medical Universities in eight regions and five geo-political zones in the country. Information gathered was analysed using a qualitative content analysis approach.

RESULTS

Experiences on the deployment process fall into three categories. First, "uncertainties around the first appointment" attributed to lack of effective strategies for identification of the pool of available MDs, indecision and limited vacancies for employment in the public sector and private sector and non-transparent and lengthy bureaucratic procedures in offering government employment. Second, "failure to respect individuals' preferences of work location" which were based on the influence of family ties, fear of the unknown rural environment among urbanized MDs and concern for career prospects. Third, "feelings of insecurity about being placed at a regional and district level" partly due to local government authorities being unprepared to receive and accommodate MDs and territorial protectionism among assistant medical officers.

CONCLUSIONS

Experiences of MDs on the deployment process in Tanzania reveal many challenges that need to be addressed for the deployment to contribute better in availability of equitably distributed health workforce in the country. Short-term, mid-term and long-term strategies are needed to address these challenges. These strategies should focus on linking of the internship with the first appointment, work place preferences, defining and supporting career paths to health workers working under the local government authorities, improving the working relationships and team building at the work places and fostering rural attachment to medical students during medical training.

Health workers' experiences of collaborative quality improvement for maternal and newborn care in rural Tanzanian health facilities: A process evaluation using the integrated 'Promoting Action on Research Implementation in Health Services' framework

Background

Quality Improvement (QI) approaches are increasingly used to bridge the quality gap in maternal and newborn care (MNC) in Sub Saharan Africa. Health workers typically serve as both recipients and implementers of QI activities; their understanding, motivation, and level of involvement largely determining the potential effect. In support of efforts to harmonise and integrate the various QI approaches implemented in parallel in Tanzanian health facilities, our objective was to investigate how different components of a collaborative QI intervention were understood and experienced by health workers, and therefore contributed positively to its mechanisms of effect.

Materials and methods

A qualitative process evaluation of a collaborative QI intervention for MNC in rural Tanzania was carried out. Semi-structured interviews were conducted with 16 health workers in 13 purposively sampled health facilities. A deductive theory-driven qualitative content analysis was employed using the integrated Promoting Action on Research Implementation in Health services (i-PARIHS) framework as a lens with its four constructs innovation, recipients, facilitation, and context as guiding themes.

Results

Health workers valued the high degree of fit between QI topics and their everyday practice and appreciated the intervention’s comprehensive approach. The use of run-charts to monitor progress was well understood and experienced as motivating. The importance and positive experience of on-site mentoring and coaching visits to individual health facilities was expressed by the majority of health workers. Many described the parallel implementation of various health programs as a challenge.

Conclusion

Components of QI approaches that are well understood and experienced as supportive by health workers in everyday practice may enhance mechanisms of effect and result in more significant change. A focus on such components may also guide harmonisation, to avoid duplication and the implementation of parallel programs, and country ownership of QI approaches in resource limited settings.

Towards improved health service quality in Tanzania: An approach to increase efficiency and effectiveness of routine supportive supervision

Effective supportive supervision of healthcare services is crucial for improving and maintaining quality of care. However, this process can be challenging in an environment with chronic shortage of qualified human resources, overburdened healthcare providers, multiple roles of district managers, weak supply chains, high donor fragmentation and inefficient allocation of limited financial resources. Operating in this environment, we systematically evaluated an approach developed in Tanzania to strengthen the implementation of routine supportive supervision of primary healthcare providers. The approach included a systematic quality assessment at health facilities using an electronic tool and subsequent result dissemination at council level. Mixed methods were used to compare the new supportive supervision approach with routine supportive supervision. Qualitative data was collected through in-depth interviews in three councils. Observational data and informal communication as well as secondary data complemented the data set. Additionally, an economic costing analysis was carried out in the same councils. Compared to routine supportive supervision, the new approach increased healthcare providers’ knowledge and skills, as well as quality of data collected and acceptance of supportive supervision amongst stakeholders involved. It also ensured better availability of evidence for follow-up actions, including budgeting and planning, and higher stakeholder motivation and ownership of subsequent quality improvement measures. The new approach reduced time and cost spent during supportive supervision. This increased feasibility of supportive supervision and hence the likelihood of its implementation. Thus, the results presented together with previous findings suggested that if used as the standard approach for routine supportive supervision the new approach offers a suitable option to make supportive supervision more efficient and effective and therewith more sustainable. Moreover, the new approach also provides informed guidance to overcome several problems of supportive supervision and healthcare quality assessments in low- and middle income countries.

An account for barriers and strategies in fulfilling women's right to quality maternal health care: a qualitative study from rural Tanzania

Background

Tanzania has ratified and abides to legal treaties indicating the obligation of the state to provide essential maternal health care as a basic human right. Nevertheless, the quality of maternal health care is disproportionately low. The current study sets to understand maternal health services’ delivery from the perspective of rural health workers’, and to understand barriers for and better strategies for realization of the right to quality maternal health care.

Methods

Semi-structured in-depth interviews were conducted, involving 11 health workers mainly; medical attendants, enrolled nurses and Assistant Medical Officers from primary health facilities in rural Tanzania. Structured observation complemented data from interviews. Interview data were analyzed using thematic analysis guided by the conceptual framework of the right to health.

Results

Three themes emerged that reflected health workers’ opinion towards the quality of health care services; “It’s hard to respect women’s preferences”, “Striving to fulfill women’s needs with limited resources”, and “Trying to facilitate women’s access to services at the face of transport and cost barriers”.

Conclusion

Health system has left health workers as frustrated right holders, as well as dis-empowered duty bearers. This was due to the unavailability of adequate material and human resources, lack of motivation and lack of supervision, which are essential for provision of quality maternal health care services. Pregnant women, users of health services, appeared to be also left as frustrated right holders, who incurred out-of-pocket costs to pay for services, which were meant to be provided free.

Learning from the experience of maternity healthcare workers in Malawi: a qualitative study leading to ten low-cost recommendations to improve working lives and quality of care

Background

In Malawi there are too few maternity healthcare workers to enable delivery of high quality care to women. These staff are often overworked and have low job satisfaction. Skilled maternity healthcare workers are essential to improve outcomes for mothers and babies. This study focuses on understanding the working life experience of maternity staff at district hospitals in Malawi with the aim of developing relevant low-cost solutions to improve working life.

Methods

A qualitative study using semi-structured interviews was undertaken in three district hospitals around Malawi’s Capital city. Thirty-one staff formed a convenience sample, purposively selected to cover each cadre. Interviews were recorded, transcribed and then analysed using Interpretative Phenomenological Analysis complemented by Template Analysis to elicit the experience of maternity staff.

Results

Staff describe a system where respect, praise and support is lacking. Many want to develop their skills, however, there are barriers to advancement. Despite this, staff are motivated; they are passionate, committed professionals who endeavor to treat patients well, despite having few resources. Their ‘superdiverse’ background and experience helps them build resilience and strive to provide ‘total care’.

Conclusions

Improving working lives can improve the care women receive. However, this requires appropriate health policy and investment of resources. There are some inter-relational aspects that can be improved with little cost, which form the ten recommendations of this paper. These improvements in working life center around individual staff (respecting each other, appreciating each other, being available when needed, performing systematic clinical assessments and communicating clearly), leadership (supportive supervision and leading by example) and the system (transparent training selection, training being need driven, clinical skills being considered in rotation of staff). To improve working lives in this way will require commitment to change throughout the health system. Thus, it could help address preventable maternal and newborn deaths.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1960-5) contains supplementary material, which is available to authorized users.

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

BACKGROUND

Retention 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.

METHODS

A 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.

RESULTS

None 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.

CONCLUSIONS

Retention 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.

The impact of programs for prevention of mother-to-child transmission of HIV on health care services and systems in sub-Saharan Africa - A review

BACKGROUND

The global scale-up of Prevention of mother-to-child transmission (PMTCT) services is credited for a 52% worldwide decline in new HIV infections among children between 2001 and 2012. However, the epidemic continues to challenge maternal and paediatric HIV control efforts in Sub Saharan Africa (SSA), with repercussions on other health services beyond those directly addressing HIV and AIDS. This systematised narrative review describes the effects of PMTCT programs on other health care services and the implications for improving health systems in SSA as reported in the existing articles and scientific literature. The following objectives framed our review:To describe the effects of PMTCT on health care services and systems in SSA and assess whether the PMTCT has strengthened or weakened health systems in SSATo describe the integration of PMTCT and its extent within broader programs and health systems.

METHODS

Articles published in English and French over the period 1st January 2007 (the year of publication of WHO/UNICEF guidelines on global scale-up of the PMTCT) to 31 November 2016 on PMTCT programs in SSA were sought through searches of electronic databases (Medline and Google Scholar). Articles describing the impact (positive and negative effects) of PMTCT on other health care services and those describing its integration in health systems in SSA were eligible for inclusion. We assessed 6223 potential papers, reviewed 225, and included 57.

RESULTS

The majority of selected articles offered arguments for increased health services utilisation, notably of ante-natal care, and some evidence of beneficial synergies between PMTCT programs and other health services especially maternal health care, STI prevention and early childhood immunisation. Positive and negative impact of PMTCT on other health care services and health systems are suggested in thirty-two studies while twenty-five papers recommend more integration and synergies. However, the empirical evidence of impact of PMTCT integration on broader health systems is scarce. Underlying health system challenges such as weak physical and human resource infrastructure and poor working conditions, as well as social and economic barriers to accessing health services, affect both PMTCT and the health services with which PMTCT interacts.

CONCLUSIONS

PMTCT services increase to some extent the availability, accessibility and utilisation of antenatal care and services beyond HIV care. Vertical PMTCT programs work, when well-funded and well-managed, despite poorly functioning health systems. The beneficial synergies between PMTCT and other services are widely suggested, but there is a lack of large-scale evidence of this.

Continuing professional development for medical, nursing, and midwifery cadres in Malawi, Tanzania and South Africa: A qualitative evaluation

Background

As innovations in the prevention and treatment of HIV and TB advance, continuing professional development (CPD) of health care workers (HCWs) remains a high priority, particularly in sub-Saharan Africa where dual TB/HIV epidemics are compounded by severe HCW shortages. There is further need to examine CPD programs to identify challenges and effective solutions to strengthen HIV/TB-related CPD.

Methods

Qualitative evaluations in Malawi, Tanzania and South Africa (RSA) were conducted using key informant interviews (KIIs) and focus group discussions (FGDs) in each country to identify barriers and enablers of effective HIV/TB-related CPD. Key stakeholders represented CPD implementers, regulators, and developers. HCWs were purposively sampled from high disease burden districts; each HCW completed brief, semi-structured questionnaires and participated in a FGD. KII and FGD results were combined into key themes spanning across countries using a grounded theory approach.

Results

Fifty-two KIIs were conducted: 17 in Malawi, 19 in Tanzania and 16 in RSA. Eighty-nine HCWs (24 from Malawi, 38 from Tanzania and 27 from RSA) completed questionnaires and participated in FGDs. Primarily, lack of sustainable financial resources and limitations in coordination of CPD result in poor accountability for CPD oversight and reduce CPD quality assurance. Healthcare worker shortages limit CPD opportunities, creating disparities in CPD access. CPD irrelevance and imbalance between HCW-identified CPD needs and current programs reduce enthusiasm for CPD. Facility-level constraints, including poor infrastructure and weak supply chains, restrict implementation of CPD skills and knowledge. Challenges are more severe in rural settings.

Conclusion

To address identified gaps, sustainable funding, strong leadership and collaboration at every level are needed to strengthen CPD regulation and accreditation systems; increase CPD accessibility in the workplace; and create enabling environments for CPD implementation. Together, these improvements may improve TB/HIV CPD quality and patient outcomes.

Saving lives with caring assessments: How Tanzanian nurse-midwives and obstetricians negotiate postpartum practices

AIMS AND OBJECTIVES

To explore the nurse-midwives' and obstetricians' experiences delivering postpartum care assessments and how it was constructed through personal, social and institutional discourses.

INTRODUCTION

The Tanzanian Government has prioritised maternal and child health as an urgent healthcare issue. Nurse-midwives and obstetricians are the two main providers of care throughout the prenatal and postpartum periods.

DESIGN

A qualitative design guided by a feminist poststructuralist methodology.

METHODS

Ten nurse-midwives and three obstetricians from three Regional Hospitals in Dar es Salaam participated in individual semi-structured in-depth interviews.

RESULTS

Assessment emerged as a significant theme with three subthemes. Nurse-midwives shared their beliefs and values about assessments that focused on the safety of mothers and babies. They felt proud working with mothers and babies and shared their frustrations having to deal with inadequate working conditions. Guidelines and practices were part of the institutional discourse that impacted the day-to-day experiences of nurse-midwives and obstetricians. The nurse-midwives held the belief that it was vital to complete a comprehensive assessment to identify danger signs, keep mothers and babies safe and look for any abnormalities. They were concerned that mothers were being sent home too early.

CONCLUSIONS

Nurse-midwives' experiences in the provision of postpartum care portray that these health providers work heartedly to make sure that the mothers and their newborns receive the best care they can provide. The health system is challenged to address the needed supplies and equipment for reproductive health in particular postpartum care services.

RELEVANCE TO CLINICAL PRACTICE

Institutional health discourses significantly affect the practice of nurse-midwives and obstetricians to deliver timely and effective postpartum assessments. Immediate and ongoing postpartum assessments conducted by nurse-midwives and obstetricians can save lives. This study presents the first theme of the study: Caring assessments save lives.

Understanding the factors affecting the attraction and retention of health professionals in rural and remote areas: a mixed-method study in Niger

BACKGROUND

The critical shortage of human resources in health is a critical public health problem affecting most low- and middle-income countries, particularly in sub-Saharan Africa. In addition to the shortage of health professionals, attracting and retaining them in rural areas is a challenge. The objective of the study was to understand the factors that influence the attraction and retention of health professionals working in rural areas in Niger.

METHODS

A mixed-method study was conducted in Tillabery region, Niger. A conceptual framework was used that included five dimensions. Three data collection methods were employed: in-depth interviews, documentary analysis, and concept mapping. In-depth interviews were conducted with three main actor groups: policy-makers and Ministry of Health officials (n = 15), health professionals (n = 102), and local health managers (n = 46). Concept mapping was conducted with midwifery students (n = 29). Multidimensional scaling and cluster analysis were performed to analyse the data from the concept mapping method. A content analysis was conducted for the qualitative data.

RESULTS

The results of the study showed that the local environment, which includes living conditions (no electricity, lack of availability of schools), social factors (isolation, national and local insecurity), working conditions (workload), the lack of financial compensation, and individual factors (marital status, gender), influences the attraction and retention of health professionals to work in rural areas. Human resources policies do not adequately take into account the factors influencing the retention of rural health professionals.

CONCLUSION

Intersectoral policies are needed to improve living conditions and public services in rural areas. The government should also take into account the feminization of the medical profession and the social and cultural norms related to marital status and population mobility when formulating human resources management policies.

Assessing emergency obstetric and newborn care: can performance indicators capture health system weaknesses?

Background

Regular monitoring and assessment of performance indicators for emergency obstetric and newborn care can help to identify priorities to improve health services for women and newborns. The aim of this study was to perform a district wide assessment of emergency obstetric and newborn care performance and identify ways for improvement.

Methods

Facility assessment of 13 dispensaries, four health centers and one district hospital in a rural district in Tanzania was performed in two data collection periods in 2014. Assessment included a facility walk-through to observe facility infrastructure and interviews with facility in-charges to assess available services, staff and supplies. In addition facility statistics were collected for the year 2013. Results were discussed with district representatives.

Results

Approximately 65% of expected births took place in health facilities and 22% of women with complications were treated in facilities expected to provide emergency care. None of the facilities was, however, able to perform at the expected level for emergency obstetric and newborn care since not all required signal functions could be provided. Inadequate availability of essential drugs such as uterotonics, antibiotics and anticonvulsants as well as lack of ability to perform vacuum extraction and blood transfusion limited performance.

Conclusions

Performance of emergency obstetric and newborn care in Magu District was not in accordance with expected guidelines and highly influenced by lack of available resources and an insufficiently functioning health care system. Improving assessment approaches, to look beyond the signal functions, can capture weaknesses in the system and will help to understand poor performance and identify locally applicable ways for improvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1282-z) contains supplementary material, which is available to authorized users.

Unpredictability dictates quality of maternal and newborn care provision in rural Tanzania-A qualitative study of health workers' perspectives

Background

Health workers are the key to realising the potential of improved quality of care for mothers and newborns in the weak health systems of Sub Saharan Africa. Their perspectives are fundamental to understand the effectiveness of existing improvement programs and to identify ways to strengthen future initiatives. The objective of this study was therefore to examine health worker perspectives of the conditions for maternal and newborn care provision and their perceptions of what constitutes good quality of care in rural Tanzanian health facilities.

Methods

In February 2014, we conducted 17 in-depth interviews with different cadres of health workers providing maternal and newborn care in 14 rural health facilities in Tandahimba district, south-eastern Tanzania. These facilities included one district hospital, three health centres and ten dispensaries. Interviews were conducted in Swahili, transcribed verbatim and translated into English. A grounded theory approach was used to guide the analysis, the output of which was one core category, four main categories and several sub-categories.

Results

‘It is like rain’ was identified as the core category, delineating unpredictability as the common denominator for all aspects of maternal and newborn care provision. It implies that conditions such as mothers’ access to and utilisation of health care are unreliable; that availability of resources is uncertain and that health workers have to help and try to balance the situation. Quality of care was perceived to vary as a consequence of these conditions. Health workers stressed the importance of predictability, of ‘things going as intended’, as a sign of good quality care.

Conclusions

Unpredictability emerged as a fundamental condition for maternal and newborn care provision, an important determinant and characteristic of quality in this study. We believe that this finding is also relevant for other areas of care in the same setting and may be an important defining factor of a weak health system. Increasing predictability within health services, and focusing on the experience of health workers within these, should be prioritised in order to achieve better quality of care for mothers and newborns.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1230-y) contains supplementary material, which is available to authorized users.

Subnational variation for care at birth in Tanzania: is this explained by place, people, money or drugs?

BACKGROUND

Tanzania achieved the Millennium Development Goal for child survival, yet made insufficient progress for maternal and neonatal survival and stillbirths, due to low coverage and quality of services for care at birth, with rural women left behind. Our study aimed to evaluate Tanzania's subnational (regional-level) variations for rural care at birth outcomes, i.e., rural women giving birth in a facility and by Caesarean section (C-section), and associations with health systems inputs (financing, health workforce, facilities, and commodities), outputs (readiness and quality of care) and context (education and GDP).

METHODS

We undertook correlation analyses of subnational-level associations between health system inputs, outputs, context, and rural care at birth outcomes; and constructed implementation readiness barometers using benchmarks for each health system input indicator. We used geographical information system (GIS) mapping to visualise subnational variations in care at birth for rural women, with a focus on service availability and readiness, and collected qualitative data to investigate financial flows from national to council level to understand variation in financing inputs.

RESULTS

We found wide subnational variation for rural care at birth outcomes, health systems inputs, and contextual indicators. There was a positive association between rural women giving birth in a facility and by C-section; maternal education; workforce and facility density; and quality of care. There was a negative association between these outcomes and proportion of all births to rural women, total fertility rate, and availability of essential commodities at facilities. Per capita recurrent expenditure was positively associated with facility births (correlation coefficient = 0.43; p = 0.05) but not with C-section. Qualitative results showed that the health financing system is complex and insufficient for providing care at birth services. Bottlenecks for care at birth included low density of health workers, poor availability of essential commodities, and low health financing in Lake and Western Zones.

CONCLUSIONS

No region meets the benchmarks for the four health systems building blocks including health finance, health workforce, health facilities, and commodities. Strategies for addressing health system inequities, including overall increases in health expenditure, are needed in rural populations and areas of highest unmet need for family planning to improve coverage of care at birth for rural women in Tanzania.

Situational analysis of facilitators and barriers to availability and utilization of magnesium sulfate for eclampsia and severe preeclampsia in the public health system in Brazil

BACKGROUND

Eclampsia is the main cause of maternal death in Brazil. Magnesium sulfate is the drug of choice for seizure prevention and control in the management of severe preeclampsia and eclampsia. Despite scientific evidence demonstrating its effectiveness and safety, there have been delays in managing hypertensive disorders, including timely access to magnesium sulfate. To conduct a general situational analysis on availability and use of magnesium sulfate for severe preeclampsia and eclampsia in the public health system.

METHOD

A situational analysis was conducted with two components: a documental analysis on information available at the official websites on the policy, regulation and availability of the medication, plus a cross sectional study with field analysis and interviews with local managers of public obstetric health services in Campinas, in the southeast of Brazil. We used the fishbone cause and effect diagram to organize study components. Interviews with managers were held during field observations using specific questionnaires.

RESULTS

There was no access to magnesium sulfate in primary care facilities, obstetric care was excluded from urgency services and clinical protocols for professional guidance on the adequate use of magnesium sulfate were lacking in the emergency mobile care service. Magnesium sulfate is currently only administered in referral maternity hospitals.

CONCLUSION

The lack of processes that promote the integration between urgency/emergency care and specialized obstetric care possibly favors the untimely use of magnesium sulfate and contributes to the high maternal morbidity/mortality rates.

Women's perceptions of antenatal, delivery, and postpartum services in rural Tanzania

Background

Maternal health care provision remains a major challenge in developing countries. There is agreement that the provision of quality clinical services is essential if high rates of maternal death are to be reduced. However, despite efforts to improve access to these services, a high number of women in Tanzania do not access them. The aim of this study is to explore women's views about the maternal health services (pregnancy, delivery, and postpartum period) that they received at health facilities in order to identify gaps in service provision that may lead to low-quality maternal care and increased risks associated with maternal morbidity and mortality in rural Tanzania.

Design

We gathered qualitative data from 15 focus group discussions with women attending a health facility after child birth and transcribed it verbatim. Qualitative content analysis was used for analysis.

Results

‘Three categories emerged that reflected women's perceptions of maternal health care services: “mothers perceive that maternal health services are beneficial,” “barriers to accessing maternal health services” such as availability and use of traditional birth attendants (TBAs) and the long distances between some villages, and “ambivalence regarding the quality of maternal health services” reflecting that women had both positive and negative perceptions in relation to quality of health care services offered’.

Conclusions

Mothers perceived that maternal health care services are beneficial during pregnancy and delivery, but their awareness of postpartum complications and the role of medical services during that stage were poor. The study revealed an ambivalence regarding the perceived quality of health care services offered, partly due to shortages of material resources. Barriers to accessing maternal health care services, such as the cost of transport and the use of TBAs, were also shown. These findings call for improvement on the services provided. Improvements should address, accessibility of services, professionals' attitudes and stronger promotion of the importance of postpartum check-ups, both among health care professionals and women.