THE sound of the screaming child was becoming irritating to Jacqueline Nyangasa and the other patients in the cold room. As she prescribed medicine to the last patient on the waiting bench, the mother of the wailing child approached her.
Looking at her, she could see that she had been crying also, and all the signs indicated that she was not done crying. “Please help my son, he is in great pain,” she begged her, trying to shove the tiny frame of her son into her arms as the boy increased the volume of his crying.
Jacqueline was exhausted, and as she wondered where the nurse on duty was, the room fell deathly quiet, and it took her several seconds to realise that the young boy had stopped crying. Her attention turned to the mother of the boy, who by now was sobbing quietly, clutching the lifeless body of her son, and in a whisper that wrenched her heart out, she told her that her son was dead.
Unbeknownst to many at the makeshift dispensary, Jacqueline was not a trained doctor or nurse, but a cleaner who has been assisting at the medical centre for six years, and she was prompted to undertake her current role because of lack of a medical doctor.
With a skeleton staff of one medical doctor and a nurse who was supposed to be retired years back, Jacqueline started taking her new role after the old nurse gave her instructions on how to handle patients during her free hours.
The woes at the dispensary have been there for several years, with all the doctors being assigned at the centre quitting soon after their arrival due to the harsh working conditions.
“Worldwide, the geographical distribution of health workers is skewed towards urban and wealthier areas. This pattern is found in nearly every country in the world, regardless of the level of economic development and health system organisation, but the problem is especially acute in developing countries, Tanzania included,” says Dr Abdallah Mtalusito, a Tanzanian health expert based in Burundi.
He says that there are multiple factors influencing a health worker’s decision to relocate, stay or leave a post in rural or remote areas, saying that in Tanzania’s rural areas where the majority of the population continues to reside, problems of recruiting and retaining health staff are most pronounced.
Unsurprisingly then, he says, the health workforce in Tanzania has been documented to be very unevenly distributed between rural and urban districts, adding that a recent country survey (SARA) found that 69 per cent of all health professionals worked on urban facilities.
This, he says, is despite the fact that roughly 70 per cent of the population lives in rural areas. It is noted that the health workforce challenges in the country’s public institutions are significantly related to poor working conditions, lack of resources and equipment.
According to the World Health Organisation (WHO), strong qualified health workforce is essential for countries to be able to make progress towards the goal of Universal Health Coverage (UHC). UHC, defined as people receiving the quality services they need without incurring financial hardship, requires a health workforce that can effectively deliver a wide range of promotive, preventive, curative, rehabilitative, and palliative services to all people.
Currently, there are almost 60 million health workers globally, but they are unevenly distributed across countries and regions. Typically, they are scarcest where they are most needed, especially in the poorest countries.
“In any case, the total number is incapable of meeting the demands of many populations for access to the healthcare they require. Both developed and developing countries are struggling to cope with the huge challenges posed by the imbalance between increasing demand and faltering supply,” says Dr Mtalusito.
According to a report by the Ministry of Health, Community Development, Gender, Elderly and Children, there are indications that Tanzania’s health system is experiencing internal health worker migration not only in terms of rural to urban migration flows, but also between the public and faith-based health sector.
The latter, according to the report, appears to have been triggered by salary and benefits increases introduced for public sector health workers, faith-based organisations were associated with higher salaries as well as better benefit packages, working environments and training opportunities “The reality is, however, that as long as shortages exist across the developed and developing world, there will always be net migration towards areas where wages and salaries are higher, the standard of living is better, and where there are better professional opportunities,” says Dr Mtalusito.
According to Dr Paul Njarabi who opted for private practice after being transferred to rural areas, strengthening health systems, especially at district level is critical to meeting the MDGs and human resources are essential to achieving this.
He says high quality care cannot be provided unless issues of de-motivated staff are comprehensively addressed and more information is clearly needed to strengthen the evidence base for effective human resource strategies and policy decisions.
“Financial incentives, career development and management issues are core factors affecting motivation. It is clear that recognition is highly influential in health worker motivation; furthermore, adequate supplies and appropriate infrastructure are factors that can significantly improve morale,” he says.
Hence, financial incentives by themselves are not the appropriate response. Inconclusive evidence was found as to whether motivational factors are valued differently by different cadres and this needs to be explored further.
Motivational factors are influenced by context and, therefore, it would be productive for future cross country research to use the same, or even standard, data collection tools, allowing more exploration of how context affects motivation, as well as to allow compari