BackgroundIn the United Republic of Tanzania, as in many regions of Sub-Saharan Africa, staff shortages in the healthcare system are a persistent problem, particularly in rural areas. To explore staff shortages and ways of keeping workers in post, we ask, (a) Which cadres are most problematic to recruit and keep in post? (b) How and for what related reasons do health workers leave? (c) What critical incidents do those who stay face? (d) And why do they stay and cope?MethodsThis is a multi-method paper based on analysis of data collected as part of a cross-sectional health facility study supporting maternal and reproductive health services in the United Republic of Tanzania. Qualitative data were generated through semi-structured interviews with Council Health Management Teams, and Critical Incident Technique interviews with mid-level cadres. Complementary quantitative survey data were collected from district health officials, which are used to support the qualitative themes.ResultsMid-level cadres were problematic to retain and caused significant disruptions to continuity of care when they left. Shortage of highly skilled workers is not only a rural issue but also a national one. Staff were categorised into a clear typology. Staff who left soon after arrival and are described by ‘Look, See and Go’; ‘Movers On’ were those who left due to family commitments or because they were pushed to go. The remaining staff were ‘Stayers’. Reasons for wanting to leave included perceptions of personal safety, feeling patient outcomes were compromised by poor care or as a result of perceived failed promises. Staying and coping with unsatisfactory conditions was often about being settled into a community, rather than into the post.ConclusionsThe Human Resources for Health system in the United Republic of Tanzania appears to lack transparency. A centralised monitoring system could help to avoid early departures, misallocation of training, and other incentives. The system should match workers’ profiles to the most suitable post for them and track their progress and rewards; training managers and holding them accountable. In addition, priority should be given to workplace safety, late night staff transport, modernised and secure compound housing, and involving the community in reforming health services culture and practices.

ObjectivesDuring 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.DesignThe 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.Results16 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.ConclusionsThis 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.

ObjectivesThe 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.DesignQualitative interviews with trainees, trainers, district officers and others exploring the application of the training into practice.ParticipantsDuring 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.ResultsTrainees (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.ConclusionsThe 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.

High prevalence of EBF suggests that it is an attainable behavior, whereas low prevalence of daily ASF provision suggests that adequate diets are difficult to achieve after breastfeeding cessation. These findings support current recommendations for HIV-infected mothers in resource-poor regions to continue breastfeeding for at least 1 year and suggest the need for greater support with complementary feeding. Associations between HIV disclosure and infant feeding merit further exploration, and correlations between enrollment facility and infant feeding highlight the potential influence of clinics on achieving infant feeding recommendations.

Respectful maternity care research in Tanzania continues to increase. This is an overview of the literature summarizing research based on the domains which comprise this quality of care indicator, ranging from exploratory and descriptive to quantitative measurements of birth perinatal outcomes when respectful interventions are made. The domains of respectful care are reflected in the seven Universal Rights of Childbearing Women but go further to implicate facility administrators and policy makers to provide supportive infrastructure to allay disrespect and abuse.The research methodologies continue to be problematic and several ethical cautions restrict how much control is possible. Similarly, the barriers to collecting accurate accounts in qualitative studies of disrespect require astute interviewing and observation techniques. The participatory community-based and the critical sociology and human rights frameworks appear to provide a good basis for both researcher and participants to identify problems and determine possible solutions to the multiple factors that contribute to disrespect and abuse. The work-life conditions of midwives in the Global South are plagued with poor infrastructure and significantly low resources which deters respectful care while decreasing retention of workers. Researchers and policy-makers have addressed disrespectful care by building human resource capacity, by strengthening professional organizations and by educating midwives in low-resource countries. Furthermore, researchers encourage midwives not only to acquire attitudinal change and to adopt respectful maternity care skills, but also to emerge as leaders and change agents.Safe methods for conducting care while addressing low resources, skilled management of conflict and creative innovations to engage the community are all interventions that are being considered for quality improvement research. Tanzania is poised to evaluate the outcomes of education workshops that address all seven domains of respectful care.