Health worker motivation in a low-income context. The case of rural health services in Tanzania

Background: The optimism from the early post-colonial period in sub-Saharan Africa, with the effort to provide good health services was in many countries challenged by severe economic problems a few decades later. The focus in the health sector has largely been on health workers in sufficient numbers and with adequate training, combined with infrastructure and supplies at the health facilities. In Tanzania, and in many other countries in sub-Saharan Africa, the number of health workers and their training has been a continuous challenge, not the least in rural areas, for decades. In addition to addressing this challenge, there is a growing focus on the importance of health workers’ motivation for their work as a particularly important dimension. Objective: Poor health worker motivation has been documented to have serious implications for the quality of health services, and has been coined a major challenge in many lowincome country. The main objective is to generate knowledge on health workers’ motivation with a particular focus on rural Tanzania. An overarching objective is to produce knowledge that can feed into debates on how to meet the complex challenges related to motivation in the health services in resource constrained rural settings. Health workers’ experiences with working conditions have been located at the core of debates on motivation. Paper I explores public sector health workers’ experiences with their working conditions and discusses the study findings within the context of post-colonial and post-socialist Tanzanian history. Paper II explores health workers’ preferences for workplace with a particular focus on reasons for movements between health facilities with different types of ownership, in particular the public and churchrun health system - the two central sectors in health service delivery in rural Tanzania. Paper III aims to address public sector health workers’ experiences with a performance appraisal system and their expectations towards a planned results-based payment system in the health sector in Tanzania. Methods and data: The study has chosen a qualitative study design to elicit detailed information on the study topic. The data comprise in-depth interviews (IDIs) and focus group discussions (FGDs). The bulk of the data was collected at public health facilities in Mbulu District, Manyara Region in northern Tanzania with additional data collected in a church-run hospital in the same district. In addition, national and local documents and informal discussions with health workers and local community residents have been central sources of information. The study draws on knowledge of culture and language gained through earlier work related- and ethnographic experience in the same area in Tanzania. Results: This study provides insights into health workers' understanding and assessment of their working conditions and the relation to motivation at the workplace. The study has found that public sector health workers claim there is a considerable degree of unfairness in the working conditions, not the least in terms of the financial conditions. A serious lack of transparency in human resource management is also reported. Despite the considerable degree of dissatisfaction, the public sector health workers nonetheless seem to prefer to continue to work in the public health sector. The main reason for this preference is the good pension scheme in the public sector social security fund. Health workers in the church-run sector express great dissatisfaction with their pension scheme, which offers much lower retirement benefits than in the public sector. These health workers do however praise the workplace for the good resources and health facility infrastructure. The study revealed severe challenges in the implementation of the performance appraisal system in the public sector and questions its applicability. The performance appraisal system does not seem to function according to its intentions, as it neither facilitates a proper identification of work related aims nor does it ensure proper evaluation or follow up of the stated goals. The system is perceived as neither feasible nor acceptable to the study participants. Health workers expressed great expectations towards the results-based payment system that is to be implemented. Conclusions: The overall study findings emphasise the importance of the financial dimension of working conditions for work related motivation. In a rural setting with limited access to formal employment, the income from salaried work plays a very important role in supporting the family. This explains the concerns about the salary level and not the least the concerns about access to any additions on top of the salary. The study has moreover revealed that recognition of performance seems to carry substantial potential in increasing work related motivation. It is vital that the human resource management in the health sector in Tanzania addresses the serious shortcomings in working conditions in terms of salary level and resources in public health facilities, as well as enhancing transparency at the workplace. The study calls for a wider historical, political, socio-economic and cultural contextualisation of the study findings in order to identify why the findings emerge in the way they do