Health workers have always tended to move in search for greener pastures that include better living and working conditions, improved salaries and opportunities for professional development. These workers have been moving from rural to urban areas, from public to private sector; or from one country to another.
Peter A. Mbago, Programme Manager for Health Workforce Management of the Benjamin Mkapa HIV/AIDS Foundation (BMAF) says the effect of these movements can be devastating in a country like Tanzania where there is an absolute shortage of health personnel.
The number of staff working at the district and regional levels is inadequate and stands at about 35 percent of the manning levels required, according to the Ministry of Health Annual Sector Review, 2006.
The shortage of personnel has been exacerbated, among other things, by the growing population, spread of HIV/AIDS pandemic and other communicable diseases such as malaria and Tuberculosis (TB).
According to Ministry of Health statistics, the current doctor-population ratio stands at 1:100,000 people in rural areas, and sadly, 51 percent of all practicing medical doctors are in Dar es Salaam (commercial city).
This imbalance is noticeable to almost all regions and poses a major challenge to the nationwide provision of health services.
In addition to the personnel crisis, according to studies conducted by both the Clinton Foundation and the Capacity Project in Tanzania, one of the most critical gaps in human resources in Tanzania points to the need for improved performance management at the facility level.
Over-loaded health workers, understaffed facilities, and weak or non-existent performance systems negatively impact worker productivity, and engagement, and contribute to a seeming lack of ownership and empowerment from workers regarding their jobs and responsibilities. Its impact, however, is most severe in the rural areas where quality of health care is seriously affected.
Much is known already about the factors that influence health workers’ choices of location and their decisions to go stay in or leave these areas in rural areas. Often various retention schemes are proposed without strategies to understand factors that influence health workers’ decisions to go to, stay in or leave remote or rural areas. In some other areas, many efforts have not been sustainable, leaving adverse impact in the rural areas.
It is in this context that that the Benjamin Mkapa HIV/AIDS Foundation (BMAF) launched a programme to support rural areas increase access to health workers through improved recruitment and retention. Through a four-year Tanzania Human Resource Capacity Project funded by the United States Agency for International Development (USAID), The BMAF has supported the Ministry of Health and Social Welfare (MOHSW) to improve recruitment through reviewing the information on the advertisement of various vacant posts to give more information on the preference of working stations and more contact information for easy tracking.
Further, the posting letter was reviewed to give more information to Local Government Authorities for easily tracking posted officials and have an opportunity to elaborate opportunities and profiles of the respective working station.
Sometimes health workers refused to report after hearing bad stories or misinformation in the area they had been posted to.
This initiative result to an increase of new health workers posted to local government authorities from 66 percent in 2009/10 to 84 percent in 2010/11 and notable signs have been recorded in the ongoing recruitment for 2011/12.
At district level, BMAF have trained more than 800 Council Health Management Team Members (CHMTs) from more than 70 districts on Human Resource for Health Management based on national policies, regulations, local environment and the WHO global policy recommendations on how to improve retention of rural and remote health workers. Health managers were trained on how to:
lProvide a comprehensive orientation to the newly recruited staff through the developed orientation package. This package sets clear objectives of the induction, individuals responsible for the orientation and a check list of activities to be performed. The package comprehensively introduced new staff to the new environment and kept him/her attractive to the new life in the district;
lProvide a good and safe working environment in order to make the working environment professionally attractive and thereby increase the recruitment and retention in remote and rural areas
Improve living conditions for health workers and their families as these factors have a significant influence on a health worker's decision to locate to and remain in rural areas.
Expose primary and secondary school students on various Regions on various science disciplines as these can have a positive influence on joining health institutions thus attracting and recruiting health workers to specific/local rural areas.
lUse sustainable financial incentives (through the government budget or own source), such as hardship allowances, free housing, paid outreach services, etc., sufficient enough to outweigh the opportunity costs associated with working in rural areas, as perceived by health workers, to improve rural retention.
Ensure that workers receive frequent feedback on their performance according to the expectations defined, and are able to discuss issues and challenges in an open and supportive environment through the Open Performance Review and Appraisal System (OPRAS)
Develop and support career development programmes and provide senior posts in rural areas under Mkapa Fellows Programme and Global Fund Round 9, so that health workers can move up the career path without necessarily leaving rural areas
Mbago further says, “All councils which were able to apply the above BMAF-led innovative methods have an average of retention of reported staff by 85 percent according to the data obtained in October 2011 from the coaching and mentoring visits in the respective Districts’.
Fortunately, success recorded on the earlier programs enabled BMAF to acquire more funding through global fund round 9. Through this program, BMAF in collaboration with Ministry of Health and Social Welfare, intend to realize a 97 percent increase in student intake in the health professions, and to see districts strengthened to attract and retain skilled health workers in 70 hard to reach areas throughout the country by recruiting skilled 460 health workers; and improved staff work environment, especially housing and accommodations through rehabilitation and construction of 700 houses for health workers in these rural areas in Tanzania.
This will lead to reduced percentage of rural-urban health worker disparity, improve equity and access problems in rural areas including those related to HIV, malaria and tuberculosis.
Through implementing these programs, sustainability is another critical element that is being considered, both from a financial and a time perspective. All interventions start with all districts incorporating the initiatives in their respective Comprehensive Council Health Plan and consequently funded by the government budget or the respective LGA’s own source.
“Experience gathered on the implementation of this initiatives shows that most effective interventions do not work in isolation, hence the need for a combined or ‘bundled’ approach that addresses the multiple aspects of management, regulatory (policy), education, and financial incentive as cleared marked by WHO on its global policy recommendations is vital on improving health systems in Tanzania,” Mbago explains.