Building leadership and managerial capacity for maternal and newborn health services

Background

Strengthening leadership and management is important for building an effective and efficient health system. This paper presents the findings from a L&M capacity building initiative which was implemented as part of a larger study aimed at improving maternal and newborn outcomes within primary health facilities in the Morogoro, Tanzania.

Methods

The initiative, involving 30 stakeholders from 20 primary health facilities, 4 council health management teams and the regional health management team in the Morogoro region, provided leadership and managerial training through two 5-day in-person workshops, onsite mentoring, and e-learning modules. The initiative was evaluated using a pre-post design. Quantitative instruments included the ‘Big Results Now’ star-rating assessments and a team-developed survey for health providers/managers. The ‘Big Results Now’ star-rating assessments, conducted in 2018 (19 facilities) and 2021 (20 facilities), measured overall facility leadership and management capability, with comparisons of star-ratings from the two time-points providing indication of improvement. The survey was used to measure 3 key leadership indicators - team climate, role clarity/conflict and job satisfaction. The survey was completed by 97 respondents at baseline and 100 at follow up. Paired t-tests were used to examine mean score differences for each indicator. Triangulated findings from focus groups with 99 health providers and health management team members provided support and context for quantitative findings.

Results

Star-ratings increased in 15 (79%) of 19 facilities, with the number of facilities achieving the target of 3 plus stars increasing from 2 (10%) in 2018 to 10 (50%) in 2021, indicating improved organizational performance. From the survey, team climate, job satisfaction and role clarity improved across the facilities over the 3 project years. Focus group discussions related this improvement to the leadership and managerial capacity-building.

Conclusion

Improved leadership and managerial capacity in the participating health facilities and enhanced communication between the health facility, council and regional health management teams created a more supportive workplace environment, leading to enhanced teamwork, job satisfaction, productivity, and improved services for mothers and newborns. Leadership and managerial training at all levels is important for ensuring efficient and effective health service provision.

Factors affecting production of competent health workforce in Tanzanian health training institutions: a cross sectional study

BACKGROUND

In 2008, the government of Tanzania adopted a competency-based education and training (CBET) system to improve medical training. Yet there are still frequent observations of competency deficits among graduates, suggesting that the goal has not sufficiently been met. This study was designed to assess the underlying context of competency deficits in the health workforce in Tanzania and to provide recommendations for improvement.

METHODS

A cross-sectional study using document analysis and focus groups was carried out in 13 training institutions that provided a diploma course in clinical medicine. The research team assessed availability and adequacy of instructors, physical resources and the process and systemic factors that impact curriculum implementation outcomes.

RESULTS

Six (46%) institutions had 75% or more of their teaching staff not trained in curriculum delivery and instructional methods. Seven (54%) institutions had lower instructor-students ratio than recommended (1:25). Overall, the full-time instructors in all institutions constituted only 44% of the teaching staff. Although all institutions had an adequate number of classrooms, the rooms were of small size with dilapidated walls, and had inadequate number of desks/ seats for students. Clinical skills laboratories existed in 11 (85%) institutions, but the majority were of small size, and were not fully equipped as per guidelines and were rarely used. Libraries were available in 12 (92%) institutions but five had seating capacities of 10% or less of the available students. Participants of focus group discussion in the majority of the institutions reported inadequate time allocated for practice and support from the clinical instructors at the practicum sites. Six (46%) institutions had no functioning governing/advisory boards and five (38%) lacked quality assurance policies and implementation plans.

CONCLUSIONS

Currently, health-training institutions in Tanzania are ill-equipped to produce competent clinicians because of major gaps in the structural, process and systemic components. These findings call for major investment to facilitate production of a competent health workforce.

Knowledge acquisition after Helping Babies Survive training in rural Tanzania

BACKGROUND

While the effectiveness of Helping Babies Breathe (HBB) training in Tanzania has been reported, no published studies of Essential Care for Every Baby (ECEB) and Essential Care for Small Babies (ECSB) in this setting have been found. This study compared knowledge before and after HBB, ECEB and ECSB training in Tanzania.

METHODS

Training was provided to future facilitators (n=16) and learners (n=24) in Tanzania. Using standardized multiple-choice questions, knowledge was assessed pre- and post-HBB and ECEB courses for both learners and facilitators, while ECSB assessment was conducted with facilitators only. A >80% score was considered to be a pass. Paired t-tests were used for hypothesis testing.

RESULTS

Knowledge significantly improved for both facilitators and learners on HBB and ECEB (p<0.001) and for facilitators on ECSB (p<0.001). After training, learners had difficulty identifying correct responses on one HBB item (21% incorrect) and three ECEB items (25-29% incorrect). After training, facilitators had difficulty identifying correct responses on five ECSB items (22-44% incorrect).

CONCLUSIONS

Training improved knowledge in Tanzania, but not sufficiently for feeding, especially for low birthweight babies. Targeted training on feeding is warranted both within the Helping Babies Survive program and in preclinical training to improve knowledge and skill to enhance essential newborn care.

Introducing eHealth strategies to enhance maternal and perinatal health care in rural Tanzania

BACKGROUND

Globally, eHealth has attracted considerable attention as a means of supporting maternal and perinatal health care. This article describes best practices, gains and challenges of implementing eHealth for maternal and perinatal health care in extremely remote and rural Tanzania.

METHODS

Teleconsultation for obstetric emergency care, audio teleconferences and online eLearning systems were installed in ten upgraded rural health centres, four rural district hospitals and one regional hospital in Tanzania. Uptake of teleconsultation and teleconference platforms were evaluated retrospectively. A cross sectional descriptive study design was applied to assess performance and adoption of eLearning.

RESULTS

In 2015 a total of 38 teleconsultations were attended by consultant obstetricians and 33 teleconferences were conducted and attended by 40 health care providers from 14 facilities. A total of 240 clinical cases mainly caesarean sections (CS), maternal and perinatal morbidities and mortalities were discussed and recommendations for improvement were provided. Four modules were hosted and 43 care providers were registered on the eLearning system. For a period of 18-21 months total views on the site, weekly conference forum, chatroom and learning resources ranged between 106 and 1,438. Completion of learning modules, acknowledgment of having acquired and utilized new knowledge and skills in clinical practice were reported in 43-89% of 20 interviewed health care providers. Competencies in using the eLearning system were demonstrated in 62% of the targeted users.

CONCLUSIONS

E-Health presents an opportunity for improving maternal health care in underserved remote areas in low-resource settings by broadening knowledge and skills, and by connecting frontline care providers with consultants for emergency teleconsultations.

Increasing the availability and quality of caesarean section in Tanzania

OBJECTIVE

To describe the results of increasing availability and quality of caesarean deliveries and anaesthesia in rural Tanzania.

DESIGN

Before-after intervention study design.

SETTINGS

Rural Tanzania.

METHODS

Ten health centres located in rural areas were upgraded to provide comprehensive emergency obstetric care (CEmOC) and the four related district hospitals were supported. Upgrading entailed constructing and equipping maternity blocks, operation rooms and laboratories; installing solar systems, backup generators and water supply systems. Associate clinicians were trained in anaesthesia and in CEmOC. Mentoring and audit of reasons for caesarean section (CS) and maternal deaths were carried out. Measures of interest were compared using analysis of variance (ANOVA) statistical tests.

MAIN OUTCOME MEASURES

Trends in CS rates, proportion of unjustified CS, use of spinal anaesthesia, and the risk of death from complications related to CS and anaesthesia.

RESULTS

During the audit period (2012-2014), 5868 of 58 751 deliveries were by CS (10%). The proportion of CS considered to be unjustified decreased from 30 to 17% in health centres (P = 0.02) and from 37 to 20% in hospitals (P < 0.001). Practice of spinal anaesthesia for CS increased from 10% to 64% in hospitals (P < 0.001). Of 110 maternal deaths, 18 (16.4%) were associated with complications of CS, giving a risk of 3.1 per 1000 CS; three (2.7%) were judged to be anaesthetic-associated deaths with a risk of 0.5 per 1000 caesarean deliveries.

CONCLUSIONS

Increasing availability and quality of CS by improving infrastructure, training and audit of reasons for CS is feasible, acceptable and required in low resource settings.

TWEETABLE ABSTRACT

Increasing availability and quality of CS in rural Africa is feasible.

Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality in rural Tanzania? The ETATMBA project

OBJECTIVES

During late 2010, 36 trainees including 19 assistant medical officers (AMOs) 1 senior clinical officer (CO) and 16 nurse midwives/nurses were recruited from districts across rural Tanzania and invited to join the Enhancing Human Resources and Use of Appropriate Technologies for Maternal and Perinatal Survival in the sub-Saharan Africa (ETATMBA) training programme. The ETATMBA project was training associate clinicians (ACs) as advanced clinical leaders in emergency obstetric care. The trainees returned to health facilities across the country with the hope of being able to apply their new skills and knowledge. The main aim of this study was to explore the impact of the ETATMBA training on health outcomes including maternal and neonatal morbidity and mortality in their facilities. Secondly, to explore the challenges faced in working in these health facilities.

DESIGN

The study is a pre-examination/postexamination of maternal and neonatal health indicators and a survey of health facilities in rural Tanzania. The facilities surveyed were those in which ETATMBA trainees were placed post-training. The maternal and neonatal indicators were collected for 2011 and 2013 and the survey of the facilities was in early 2014.

RESULTS

16 of 17 facilities were surveyed. Maternal deaths show a non-significant downward trend over the 2 years (282-232 cases/100,000 live births). There were no significant differences in maternal, neonatal and birth complication variables across the time-points. The survey of facilities revealed shortages in key areas and some are a serious concern.

CONCLUSIONS

This study represents a snapshot of rural health facilities providing maternal and neonatal care in Tanzania. Enhancing knowledge, practical skills, and clinical leadership of ACs may have a positive impact on health outcomes. However, any impact may be confounded by the significant challenges in delivering a service in terms of resources. Thus, training may be beneficial, but it requires an infrastructure that supports it.

A qualitative process evaluation of training for non-physician clinicians/associate clinicians (NPCs/ACs) in emergency maternal, neonatal care and clinical leadership, impact on clinical services improvements in rural Tanzania: the ETATMBA project

OBJECTIVES

The Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival in sub-Saharan Africa (ETATMBA) project is training non-physician clinicians as advanced clinical leaders in emergency maternal and newborn care in Tanzania and Malawi. The main aims of this process evaluation were to explore the implementation of the programme of training in Tanzania, how it was received, how or if the training has been implemented into practice and the challenges faced along the way.

DESIGN

Qualitative interviews with trainees, trainers, district officers and others exploring the application of the training into practice.

PARTICIPANTS

During late 2010 and 2011, 36 trainees including 19 assistant medical officers one senior clinical officer and 16 nurse midwives/nurses (anaesthesia) were recruited from districts across rural Tanzania and invited to join the ETATMBA training programme.

RESULTS

Trainees (n=36) completed the training returning to 17 facilities, two left and one died shortly after training. Of the remaining trainees, 27 were interviewed at their health facility. Training was well received and knowledge and skills were increased. There were a number of challenges faced by trainees, not least that their new skills could not be practised because the facilities they returned to were not upgraded. Nonetheless, there is evidence that the training is having an effect locally on health outcomes, like maternal and neonatal mortality, and the trainees are sharing their new knowledge and skills with others.

CONCLUSIONS

The outcome of this evaluation is encouraging but highlights that there are many ongoing challenges relating to infrastructure (including appropriate facilities, electricity and water) and the availability of basic supplies and drugs. This cadre of workers is a dedicated and valuable resource that can make a difference, which with better support could make a greater contribution to healthcare in the country.

Women's perceptions of the quality of emergency obstetric care in a referral hospital in rural Tanzania

OBJECTIVES

To assess perceptions of the quality of obstetric care of women who delivered in a rural Tanzanian referral hospital.

METHODS

A descriptive-exploratory qualitative study, using semistructured in-depth interviews and participatory observation. Nineteen recently delivered women and 3 health workers were interviewed.

RESULTS

Although most women held positive views about the care they received in hospital, several participants expressed major concerns about negative attitudes of healthcare workers. Lack of medical communication given by care providers constituted a major complaint.

CONCLUSIONS

A more positive attitude by health workers and the provision of adequate medical information may promote a more positive hospital experience of women in need of obstetric care and enhance attendance.

Uptake of guidelines on prevention of mother-to-child transmission of HIV in rural Tanzania: time for change

Guidelines on prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) are inconsistently implemented in low-income countries. Strategies are needed to improve the uptake of these guidelines to prevent avoidable new HIV infections of infants. In 2010 the World Health Organisation presented its new PMTCT guidelines, offering two options for short courses of antiretroviral prophylaxis: Option A and Option B. Option A consists of antenatal prophylaxis with zidovudine followed by intrapartum and postpartum prophylaxis with single-dose nevirapine and zidovudine plus lamivudine. Option B recommends triple antiretroviral prophylaxis until after finishing breastfeeding. Tanzania has adopted Option A, and it is currently implementing it. A new option termed Option B+ has emerged recently, which recommends providing lifelong antiretroviral treatment to all HIV-positive pregnant women. In this article, we discuss the likely impact of this last PMTCT strategy in rural Africa with an example of an observational cross-sectional analysis in a rural referral hospital in Tanzania aiming to assess the uptake of PMTCT recommendations. Gaps were identified at all steps of the PMTCT pathway. Effective uptake of PMTCT guidelines has been shown to be extremely challenging in this setting. The continuously changing recommendations on PMTCT stress the need for a much simpler and effective approach. We argue in favour of implementing Option B+ in Tanzania. Financial challenges need to be faced, but Option B+ would help to overcome many barriers that prevent guidelines to be implemented in order to increase coverage and ultimately achieve the goal of 'virtual elimination' of mother-to-child transmission in sub-Saharan Africa.