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SUMMARYMaternal mortality is very high in Tanzania. Competent hospital care is key to improving maternal outcomes, but there is a crisis of availability and performance of health workers in maternal care. This article uses interviews with managers, nurse-midwives, and women who had given birth in two hospitals providing virtually all the emergency maternal care in one Tanzania city. It contrasts women's experience in the two hospitals, and analyses interconnections with nurse-midwives' and managers' experiences of working conditions. The conceptual literature on nurse empowerment identifies some key explanatory variables for these contrasts. Staff experienced less frustration and constraint in one of the hospitals; had more access to structurally empowering resources; and experienced greater congruence between job commitment and working culture, resulting in better work engagement. Conversely, nurse-midwives in the other hospital were constrained by supply shortages and recurrent lack of support. Contrasting management styles and their impacts demonstrate that even in severely resource-constrained environments, there is room for management to empower staff to improve maternal care. Empowering management practices include participatory management, supportive supervision, better incentives, and clear leadership concerning ward culture. Structural constraints beyond the capacity of health facility managers must however also be addressed.

Health care forms a large economic sector in all countries, and procurement of medicines and other essential commodities necessarily creates economic linkages between a country's health sector and local and international industrial development. These procurement processes may be positive or negative in their effects on populations' access to appropriate treatment and on local industrial development, yet procurement in low and middle income countries (LMICs) remains under-studied: generally analysed, when addressed at all, as a public sector technical and organisational challenge rather than a social and economic element of health system governance shaping its links to the wider economy. This article uses fieldwork in Tanzania and Kenya in 2012-15 to analyse procurement of essential medicines and supplies as a governance process for the health system and its industrial links, drawing on aspects of global value chain theory. We describe procurement work processes as experienced by front line staff in public, faith-based and private sectors, linking these experiences to wholesale funding sources and purchasing practices, and examining their implications for medicines access and for local industrial development within these East African countries. We show that in a context of poor access to reliable medicines, extensive reliance on private medicines purchase, and increasing globalisation of procurement systems, domestic linkages between health and industrial sectors have been weakened, especially in Tanzania. We argue in consequence for a more developmental perspective on health sector procurement design, including closer policy attention to strengthening vertical and horizontal relational working within local health-industry value chains, in the interests of both wider access to treatment and improved industrial development in Africa.

The benefits of local production of pharmaceuticals in Africa for local access to medicines and to effective treatment remain contested. There is scepticism among health systems experts internationally that production of pharmaceuticals in sub-Saharan Africa (SSA) can provide competitive prices, quality and reliability of supply. Meanwhile low-income African populations continue to suffer poor access to a broad range of medicines, despite major international funding efforts. A current wave of pharmaceutical industry investment in SSA is associated with active African government promotion of pharmaceuticals as a key sector in industrialization strategies. We present evidence from interviews in 2013–15 and 2017 in East Africa that health system actors perceive these investments in local production as an opportunity to improve access to medicines and supplies. We then identify key policies that can ensure that local health systems benefit from the investments. We argue for a ‘local health’ policy perspective, framed by concepts of proximity and positionality, which works with local priorities and distinct policy time scales and identifies scope for incentive alignment to generate mutually beneficial health–industry linkages and strengthening of both sectors. We argue that this local health perspective represents a distinctive shift in policy framing: it is not necessarily in conflict with ‘global health’ frameworks but poses a challenge to some of its underlying assumptions.

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