Health Policy and Planning Advance Access originally published online on January 29, 2008
Health Policy and Planning 2008 23(2):137-149; doi:10.1093/heapol/czm049
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The crisis in human resources for health care and the potential of a ‘retired’ workforce: case study of the independent midwifery sector in Tanzania
1 Research and Reproductive Health Specialist, Options Consultancy Services London, UK.
2 Assistant Lecturer, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.
3 Research Associate, Maternity Services Research Team, MUHAS, Dar es Salaam, Tanzania.
4 Reader in International Healthcare, King's College London, UK.
* Corresponding author. King's College London, 5.25 Waterloo Bridge Wing, Franklin Wilkins Building, 150 Stamford Street, London, SE1 9NH, UK. E-mail: susan_fairley.murray{at}kcl.ac.uk
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Abstract |
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The human resource crisis in health care is an important obstacle to attainment of the health-related targets for the Millennium Development Goals. One suggested strategy to alleviate the strain upon government services is to encourage new forms of non-government provision. Detail on implementation and consequences is often lacking, however. This article examines one new element of non-government provision in Tanzania: small-scale independent midwifery practices. A multiple case study analysis over nine districts explored their characteristics, and the drivers and inhibitors acting upon their development since permitted by legislative change.
Private midwifery practices were found concentrated in a ‘new’ workforce of ‘later life entrepreneurs’: retired, or approaching retirement, government-employed nursing officers. Provision was entirely facility-based due to regulatory requirements, with approximately 60 ‘maternity homes’ located mainly in rural or peri-urban areas. Motivational drivers included fear of poverty, desire to maintain professional status, and an ethos of community service. However, inhibitors to success were multiple. Start-up loans were scarce, business training lacking and registration processes bureaucratic. Cost of set-up and maintenance were prohibitively high, registration required levels of construction and equipping similar to government sector dispensaries. Communities were reluctant to pay for services that they expected from government. Thus, despite offering a quality of basic maternity care comparable to that in government facilities, often in poorly-served areas, most private maternity homes were under-utilized and struggling for sustainability.
Because of their location and emphasis on personalized care, small-scale independent practices run by retired midwives could potentially increase rates of skilled attendance at delivery at peripheral level. The model also extends the working life of members of a professional group at a time of shortage. However, the potential remains unrealized. Successful multiplication of this model in resource-poor communities requires more than just deregulation of private ownership. Prohibitive start-up expenses need to be reduced by less emphasis on facility-based provision. On-going financing arrangements such as micro-credit, contracting, vouchers and franchising models require consideration.
Key Words: Human resources, health policy, skilled attendant, retirement, Tanzania, private sector, qualitative, multiple case study
KEY MESSAGES
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Introduction |
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The human resource crisis in health care means that many countries are far from reaching the health-related Millennium Development Goals (MDGs). Factors contributing to this crisis include mal-distribution and low workforce productivity together with an acute shortage of skilled workers in the government health sector. Losses to other health and non-health sectors can be as much as 15–40% per year according to estimates from Zambia, Ghana and Zimbabwe (High Level Forum on the Health MDGs 2004
). In sub-Saharan Africa these problems exacerbate an absolute shortage of health workers. The result is chronic under-provision, impacting disproportionately on vulnerable groups such as women and the rural poor (WHO 2006).
One strategy to alleviate the strain upon government services has been to encourage differing forms of non-government provision (Harding and Preker 2003; Marek et al. 2005), but there are concerns that this may contribute to the further drain of scarce expertise from public services (Van Lerberghe et al. 2002), to inequity of access (Wyss et al. 1996; Benson 2001; Brugha and Pritze-Aliassime 2003), and to difficulties of stewardship in increasingly fragmented systems (Saltman 2000; Sharma 2001). Certainly, careful analysis of both anticipated and unanticipated consequences of shifts in the balance of mixed economies of health care are required (Hanson et al. 2001; Brugha and Zwi 2002; McKee and McPake 2004). Detailed studies of the contextual dynamics and constraints in specific settings can help develop an understanding of what role non-government forms of provision will have within the achievement or frustration of public health goals.
The consequences for maternity care coverage and outcomes of the general rise in private sector provision are unclear (Brugha and Pritze-Aliassime 2003), but there are areas of concern. In many countries, private obstetrician-led services are associated with inappropriately high levels of technological interventions such as induction of labour and Caesarean section (Price and Broomberg 1990; Murray 2000). There are a handful of studies on the attitudes and motivations of doctors in relation to these rates, principally from Latin America (De Mello e Souza 1994; Murray and Elston 2005).
This article presents findings on the drivers and inhibitors acting upon the development of one new element of non-government provision in Tanzania—the small-scale independent midwifery practice—and considers what contribution this sector may be expected to make to the MDG target of increasing skilled attendance at delivery. Such independent midwifery practices have yet to be the subject of much research or evaluation, although they exist in many African settings (Ghana: McGinn et al. 1990, Obuobo et al. 1999; Uganda: Seiber and Robinson-Miller 2004, Agha 2004; Kenya: Yumkella and Githiori 2000), and Southeast Asia (Philippines: John Snow Inc. 2005; Indonesia: Geefhuysen 1999, Suryanigsih 2005). They have become an explicit element in Safe Motherhood policy to increase coverage of skilled attendance in Indonesia and have attracted some ‘donor’ attention in Uganda, Kenya and elsewhere (see http://www.psp-one.com).
Deregulation to permit private provision in Tanzania
As yet little consideration has been given to the possible positive and negative effects for the workforce, or for public health, of the expanding1 private sector in Tanzania. There has been a long tradition of policy focused on creation of a unified health care system provided by government, voluntary faith-based organizations and parastatals with oversight from the Ministry of Health. Facilities run by voluntary faith-based organizations play an important role as ‘designated district hospitals’, in rural areas. Private for-profit ownership of health facilities was banned in 1977,2 but reinstated in 1991,3 and by 2001 it accounted for just under 20% of health care facilities in Tanzania. The greatest private for-profit activity is at dispensary level, 21% of which were privately owned in 2001 (Ministry of Health 2002). Significant spatial inequalities have emerged with this process, with a tendency for for-profit providers to congregate in the urban areas with existing government provision (Benson 2001). Seventy-eight per cent of the facilities in Dar es Salaam are provided by the for-profit sector (Ministry of Health 2002).
The challenge of delivery care coverage
Sub-Saharan Africa currently accounts for 47% of all maternal deaths (UN Millennium Project 2005). There are ambitions to dramatically increase (to 90%) the proportion of births assisted by a skilled attendant by 2015 in line with targets set for the MDGs. However, the reality is that levels of skilled attendance at delivery increased by only 1% between 1990 and 2003 (UNDP 2005). Increasing rates of skilled attendance at delivery4 in the context of poorly functioning health systems presents an enormous challenge. It is widely recognized that innovative models of service delivery are urgently needed.
In Tanzania, the lifetime risk of maternal death is estimated to be one in ten (WHO 2004). The economic crises of previous decades (Commission for Africa 2005), compounded by some out-migration of skilled staff (McKinsey & Co 2005) and by multiple impacts of HIV/AIDS on the workforce (Beckmann and Rai 2004), are reflected in the deterioration of health care provision. In 2005 the Joint Annual Health Sector Review stated that the health worker crisis in Tanzania had reached emergency proportions. The overall nurse-to-population ratio was estimated to be 160:100 000 and declining. In some rural districts it was just 6:100 000 (High Level Forum on the Health MDGs 2004; Maestad 2006). Accurate data on current workforce composition has been lacking, but the 2001–2 Human Resources for Health (HRH) Census indicated that there were approximately 13 300 active nursing staff across government and non-government sectors in Tanzania. From this, Kurowski et al. (2007) estimate that 8940 fulltime equivalent of nurses and midwives are engaged in Safe Motherhood interventions.
The HRH census also highlighted an ageing health care workforce, with half over the age of 40. Owing to the employment freeze in much of the 1990s, the average age of employed health workers increased significantly and high losses due to retirement are anticipated over the next decade (Kurowski et al. 2004). Recently there has been some increasing momentum around workforce issues, including establishment of a high level Human Resources Working Group in 2003 and plans that include increased zonal training for a range of health cadres, but the challenges are formidable (Dominick 2004; HERA 2006).
Rates of skilled attendance at birth (those attended by doctors, nurses, midwives, clinical officers and assistant clinical officers) fell in Tanzania during the 1990s from an estimated 46% in 1992 to 36% by 1999 (Bureau of Statistics Planning Commission 1993, and National Bureau of Statistics 1999, respectively). Approximately 84% of health workers are employed in rural areas serving 80% of the population (Dominick and Kurowski 2004) but this statistic hides geographical disparities in service coverage and utilization. According to the most recent official survey, over 80% of urban women but only 35% of rural women reported having a skilled attendant for their delivery (National Bureau of Statistics [Tanzania] and ORC Macro 2005). As rural areas are largely served by low-level cadres (Dominick and Kurowski 2004), many women were probably actually attended by nursing assistants with one year of formal training (Maestad 2006). Delivery care by family members and by traditional birth attendants (TBAs) is widespread at 26% and 11% of births, respectively (National Bureau of Statistics [Tanzania] and ORC Macro 2005).
The specific contribution of non-government provision to maternity care coverage is seldom documented and in Tanzania the information is fragmentary. A 2003 estimate of coverage of births in Ilala municipality, Dar es Salaam, indicates that one in six deliveries there takes place in private facilities ranging from large private for-profit and foundation hospitals to small-scale private and NGO-run clinics (Murray and Nyambo 2003). In 1997 legislation specifically permitted the establishment of private nursing and maternity homes by Nursing Officers (Nurses and Midwives Registration Act 1997). Information drawn from the Nursing Council, Ministry of Health, Regional and District Health Offices, and from the Private Nurses’ and Midwives’ Association (PRINMAT) suggests that there are approximately 60 independent midwifery practices, commonly known as ‘maternity homes’. Below we describe and contextualize this nascent independent midwifery sector, and use these findings to consider its potential within a strategy to increase overall skilled attendance at delivery.
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Methods |
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Research clearance was obtained from the Tanzania Commission for Science and Technology, and from Muhimbili University College of Health Sciences Ethics Committee. An initial national situation analysis included 20 key informant interviews with senior health planners and representatives from relevant professional organizations, plus a review of relevant documentary evidence. From these we generated initial hypotheses about the current social context, organization and delivery of independent midwifery care in Tanzania. From mid-2003 to mid-2004, we tested and extended these hypotheses in a multiple case study. The methodology was chosen for its ability to embrace complexity, and to generate and test hypotheses in real world settings, where boundaries between phenomenon and context are not clearly evident (Yin 2003
). In order to place the midwife-owned practices within their community and health system, we used local Council districts that included maternity homes within the range of health care provision as the contextual ‘cases’.
Nine case districts (see Tables 1–3) were selected, using a purposive sampling strategy. We aimed to include the breadth of geographical, organizational and socio-economic contexts in which private small-scale midwifery practices were thought to be operating. Information from the incomplete national register was supplemented with information from key informants such as PRINMAT. Case districts contained between 1 and 6 maternity homes each. Overall they included 23 such practices, some 40% of those operating in Tanzania at that time. This range was important in order to build confidence that the hypotheses might hold in a variety of contexts and therefore be relevant for informing future policy development for the larger workforce.
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For each case study, health care provision was mapped. Qualitative and quantitative data were collected from the range of sources listed in Box 1. In total 125 in-depth interviews and 58 focus group discussions (FGDs) were conducted, in English or Kiswahili according to respondent preferences. Case studies were conducted consecutively; the iterative research design allowed further hypotheses to be generated and tested as data collection progressed. Tables 1–3
present the key hypotheses relevant to this article within a data matrix and these are cross-referenced in the text. Hypotheses fell into three broad groupings: those concerned with motivations and relationships to the wider health care system; those concerned with location, range and quality of services; and those concerned with demand-side issues of acceptability and utilization. Each hypothesis was tested against the triangulated data for each case derived from the sources listed in Box 1, and supported or modified through pattern replication over the multiple case studies. Hypotheses could thus be supported by literal replication across multiple case studies (in which theoretically predicted replications occur consistently in data, as in hypothesis D in Table 1) or by theoretical replication (in which contrasting results are theoretically predicted, as in hypothesis F in Table 1). | Box 1 Data sources and sampling used in the analysis National and Regional level health management information system data, interviews with senior managers and documentary review. At District level in each of nine case study districts:
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All respondents gave informed consent to be interviewed, consistent with guidelines for interviewing literate and non-literate subjects (Nuffield Council on Bioethics 2002). Consent of local leaders for conduct of the study in each district and village was also obtained. Instruments were drafted in English and translated and adapted for conceptual equivalence in Kiswahili by bilingual members of the research team. A sample was independently back-translated and checked.5 Interviews and FGDs were tape-recorded, transcribed and, where applicable, translated into English by experienced Tanzanian social researchers. In the few interviews where tape recording was not possible6 detailed notes were taken. The 220 primary documents were analysed in English using Atlas Ti 5 by Scientific Software.
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Findings |
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At the time of the data collection the formal independent midwifery sector in Tanzania consisted of about 60 small-scale facility-based practices providing antenatal and childbirth care within a range of primary care services. Private midwifery practices were found concentrated in a ‘new’ workforce: retired, or approaching retirement, government-employed Nursing Officers (Table 1: A) who made the switch’ to self-employment late in life and could be characterized as ‘elder’ or ‘later-life entrepreneurs’ (Spoonley et al. 2002
; Weber and Schaper 2003). The median age of the 23 owners we interviewed was 54 years. Of these the vast majority were business novices, new to self-employment and entrepreneurship (Table 1: B). A small number had a background of ‘serial’ micro-businesses run in parallel with their main government employment. This is not uncommon in Tanzania where nursing salaries are often supplemented with other petty income-generation activities. Here they were used to generate the capital necessary to set up the independent practice:I was shown the Ministry of Health guidelines and saw that they had so many requirements. So I started a small business of keeping pigs, started with one male and two female pigs during the rainy season where it was easy to obtain food to keep them. I got eight piglets from those two females; I sold the first eight piglets and got money to make a local delivery bed; I kept the other eight together with their mothers. Those two females gave birth again, and as the dry season was getting near I decided to sell them all. I went to the mission hospital where I worked before, they sold me some used equipment. (Midwife, Mbeya Region)Some home owners continued to be involved in micro-business activities such as keeping chickens, but their maternity practices, often with pharmacies attached, were their core work activity and represented a significant investment of scarce financial resources (Table 1: C,D). A strong service ethos was also consistently represented in their accounts of their activity, particularly amongst those falling into the ‘later life entrepreneur’ typology (Table 1: E).
Most of the maternity homes were in rural or peri-urban areas, distinguishing them from doctor-run clinics (Benson 2001; and Table 2: M). Most owners of maternity homes in our study had attempted to locate these in previously under-served areas adjacent to key transport corridors. However, as regulations did not permit them to live in the premises, a location close to their residence was required for provision of 24-hour ‘cover’. Some therefore made compromises on the optimal location, with eventual implications for ease of financial sustainability (Table 2: N).
Government regulations stipulate that services provided by nursing and maternity homes must focus around maternal and child health (Table 2: O). All homes provided antenatal care and were equipped at least in basic fashion to attend deliveries, but we found that most practices actually attended only a few births per month (range 0 to 26; median of 3 births/month; Table 3: W). Most practices also provided more remunerative minor curative care; some employed Clinical Officers. A significant part of income came from selling non-prescription drugs for malaria and minor illnesses. Some also provided home-based care for HIV/AIDS, ‘youth-friendly’ reproductive health services, and child growth monitoring.
Determinants of individual engagement in independent midwifery
The motivational aspirations of these independent providers encompassed economic, caring and professional goals. Reported ‘push’ factors without exception centred around financial insecurity: extremely poor government sector salaries, inadequacy of pensions and fear of a decline into poverty after retirement (Table 1: F).
Reported ‘pull’ factors often focused on financial rewards expressed as a stable income source rather than significant profits. Additionally cited were flexible working hours and what Kendall et al. (2002) call ‘mercantile motivation’—the sense of autonomy and achievement to be gained from running one's own small business venture. Motives also included concern for the health and well-being of women in labour and satisfaction in meeting the needs of under-served communities (Table 1: E). Sometimes activity had been initiated in response to a perceived need, other times because of repeated requests for services. Respondents frequently expressed the desire to ‘use one's talents’, not to ‘sit idle’ after retirement from government employment. Linked to this was a desire to maintain social standing through a professional identity (Table 1: G).
Focus groups with soon-to-retire public sector nursing officers and nurse-midwives in all nine districts confirmed the general applicability of these various push and pull factors, and suggested that opening an independent practice may be an attractive idea to many. However, successful multiplication of the small-scale midwifery practice model is dependent also on the dynamics of the social and institutional environment, and here we found there were considerable barriers in spite of the legislated deregulation.
Low levels of demand
The case studies indicate that individual users valued the proximity of the maternity homes. They would trade off the costs of user-fees against the opportunity and financial costs of transport to government services further afield (Table 3: X) and against the unpredictable ‘under the table charges’ (Abel-Smith and Rawal 1992) often encountered there. However, most of the private maternity practices still suffered from chronic under-utilization, in relation to their capacity and to the local need for midwifery and other health care (Table 3: Y). This was due to low interest in professionally attended childbirth in facilities amongst rural communities, and to seasonally variable incomes and scarcity of cash to spend on health care. It also reflected some antagonism on ideological grounds from communities to private sector expansion (Table 3: Z). Community focus groups indicated that notions of citizen rights to health care are still strong. Where local people had contributed to the building of local public dispensaries, for example, they expected to continue to be provided with government services. Even where extended kinship and tribal networks might seem to provide a natural client base for midwives returning home to their village, the reality can be more complex because of expectations that such neighbourly services be provided without charge.
Such demand-side inhibitors caused demoralization and discouragement among the majority of these private midwifery providers, who were unable to actualize their aspirations for their practices. This was compounded by the lack of business skills (Table 1: H) that might have helped them to adapt their approach to accommodate a relatively hostile environment.
Restrictions on ownership
Legislation restricted ownership of these facilities to Nursing Officers who are a key cadre and compose the most senior third of professional nurse-midwives in the country (http://www.nbs.go.tz/health.htm, accessed 6 July 2006). Other less senior midwives who may have many years of recent ‘hands on’ experience of maternity care had no approved route to self-employment within their profession. While probably serving to contain early- to mid-career ‘leakage’ from the government workforce, this limited the size of the post-retirement pool of self-employed midwives.
Bureaucratic constraints
The complex registration procedures for nursing and maternity homes tended to be poorly understood by local health managers whose role was to inspect the facilities (Table 1: I; Table 2: P). They also required coordination and communication between different levels of the system that was unrealistic for a struggling health care bureaucracy. Many practices reported that they had been unable to complete the registration procedure over a number of years. Tanzanian territory covers some 945 000 km2, but to comply with rules for national registration of homes after approval, midwives needed to travel personally to Dar es Salaam to pay the fees, incurring significant travel and opportunity costs. These barriers were compounded by a generally difficult environment for commercial activity. The banking, business licensing and taxation systems all present obstacles to such small-scale entrepreneurs.
Barriers to accessing set-up finance
Shortage of capital and lack of appropriate and unsecured credit represents a major obstacle to the expansion of female enterprises in many settings (Epstein 1993; Mayoux 2001). In Tanzania, women face socio-cultural and institutional barriers, often lacking the ownership title to land and property needed to meet prescribed collateral requirements for commercial loans (Rutashobya 1998; Chijoriga et al. 2002; Stevenson and St-Onge 2005). The midwives consistently reported credit to be expensive and hard to access (Table 1: D). None of those interviewed had the business plan that would normally be required to demonstrate project viability prior to a loan being granted.
Unrealistic specifications
These difficulties were compounded by the high start-up costs of a home (US$5000–10 000), which represented a large financial risk even to those with access to capital. Most maternity home owners in the study had invested their entire savings and pensions into the venture. These high costs were due to infrastructural specifications required by the Ministry of Health which mirrored the physical and human resource criteria specified for public sector dispensaries (an eight-room facility with generator, oxygen and various staff). Such ‘minimum requirements’ were unrealistic for independent providers working at peripheral level and too expensive to be easily sustainable given the prevailing economic conditions in rural areas. None of the owners reported making a profit comparable to the salary that they previously received in the public sector.7 Some homes did provide employment and informal in-service training for nursing staff, but these certainly posed little threat to the government sector with respect to poaching of staff, as such staff were being paid irregularly (Table 1: K).
Further constraints on profitability
Inconsistent and unclear policy relating to charging structures and taxation compounded difficulties for the maternity home owners. Government pronouncements on exemption from user fees for maternal and child health services were widely understood by the population and some district health managers to imply free services in all sectors, although there was no mechanism to reimburse small-scale providers of care such as the maternity homes. Additionally, small health care facilities were charged for tax and business licences in the same way as profitable commercial businesses. In the context of high start-up costs and low demand from poor communities, such institutional behaviours served to further limit the financial viability of the sector (Table 1: L).
Weak integration in the local health system
Management systems for the regulation of private facilities were extremely weak at all levels. These private practices were less well integrated into referral and administrative networks than equivalent level public facilities (Table 1: J). This was reflected in generally poorer access to on-going training, supplies and supervision. Regulation and support of private facilities was highly dependent on the inclinations of individual District and Regional Medical Officers. Some maternity homes were actively supported and given vaccines, drug fridges and delivery registers from district stores, but many received no support. District supervision of private facilities existed in theory, but it was limited, as it is in the public sector, by lack of vehicles or fuel (Table 2: Q). Reports of experiences from countries such as Ghana (Obuobo et al. 1999) had led to an initial hypothesis of resistance from government health workers to receiving such referrals from private care. This was not supported in our case studies, often because the maternity home owners could draw upon their long government sector careers for credibility.
Using an independent midwifery practice—what quality of care?
Concerns about obstacles to the maternity homes’ sustainability rest upon an implicit assumption that they can, under current or more favourable circumstances, offer women a good quality service. We used an equipment and services checklist to assess quality of care in the maternity homes, and triangulated the findings with narratives from users. Quality was similarly assessed at the nearest comparable government facility.
Quality of personal care was reported by community members and by providers to be far superior in these private practices to that in government facilities. As a ‘relational good’ (Kendall et al. 2002), personal interactions have important implications for quality of care in pregnancy and particularly in childbirth, but these are often neglected in government facilities. Verbal and sometimes physical abuse by midwives in the public sector featured frequently and consistently in women's accounts of their care from all the case districts, and it was reported in user focus groups to be a major deterrent to seeking care at the government facilities (Table 2: R).
One study of antenatal care in Dar es Salaam (Boller et al. 2003) highlighted that technical quality of care is related to the cadre of staff providing the care, and found that 80% of antenatal care in their sample of public facilities was provided by MCH Aides, with only a two-year basic training. This can be compounded in rural areas by high vacancy rates and low motivation in staff. We found that some of the private maternity homes also were staffed by lower cadres of staff such as MCH Aides when the owner was absent. Such situations tended to occur in the cases where the owner-manager had other professional commitments elsewhere. The technical quality of care was basic at the maternity homes, but it was similar to that offered by equivalent government facilities (Table 2: S). Shortages of basic drugs and equipment were common to both. In the public sector, these were caused by irregular supplies from medical stores, in the private sector by insufficient capital to pre-purchase from commercial sources and lack of access to discounted supplies from government medical stores.
On-going professional development was extremely limited amongst independent sector midwives, the exception being clinical updates offered by PRINMAT as part of their annual conference events (Table 2: T). Private sector midwives reported that they were almost never invited to update-training arranged by the government sector. However, such resources are in short supply and many public sector midwives also receive little in-service training. At the time of data collection, for example, none of the practising midwives interviewed in either sector in the study districts had received any specialized in-service training in managing obstetric emergencies, and we found only erratic use of the partograph to monitor well-being in labour in both sectors.
Limited skills in the early detection of obstetric complications are compounded when facilities are geographically isolated. The median distance from the maternity home to the nearest district referral hospital was 9 km. The furthest in the case study districts was 65 km. Half were over 30 km away and on very poor roads. Communication and transportation in an obstetric emergency was therefore an important issue. Recent advances in communications technology have been important in reducing some of the isolation of small clinics and most practices surveyed did have telephone communication, usually a cellphone (Table 2: U). None of the maternity homes had a formal emergency transport plan (Table 2: V), but all facilities reported some established method for emergency referral. Transport was much more readily available for those in peri-urban settings—in most cases using public transport (taxi or bus)—and far more limited in rural conditions. The costs of referral were significant and in all cases borne by the client, although some maternity homes reported lending money in emergency cases. Whilst referral for complications was often difficult to accomplish quickly, it was just as difficult for equivalent local government facilities which also lacked their own motor transport, and expected the referred patient to bear the costs of transfer.
Public health implications—what does the independent midwifery sector offer for increasing coverage of skilled attendance for childbirth in countries like Tanzania?
The findings presented here suggest that small-scale independent midwifery practices may have potential to contribute to rates of ‘skilled attendance’8 for delivery at peripheral level. These ‘nursing homes’ or ‘maternity homes’ do not possess some of the negative attributes associated with doctor-owned private for-profit services, such as concentration in better-off urban areas and over-intervention (Mackintosh and Tibandebage 2002). Doctors owning dispensaries often practice multiple job-holding or ‘dual practice’ in public and private sectors (Van Lerberghe et al. 2002; Harrington 2003), but we found little dual practice among these independent sector midwives. Independent practice is currently seen primarily as a post-retirement option,9 so there is little drain on, and more complementarity with, the government sector maternity workforce.
However, this form of provision has yet to make any significant contribution to rates of skilled attendance at delivery. To make a contribution of 1% to national coverage of deliveries,10 for example, all the existing independent midwifery practices would each need to be providing, every week of the year, delivery care to 4–5 women who would not otherwise have obtained professional care from the health care system, and this level of activity is not currently being met. The average volume of deliveries attended in the maternity homes is not high or sustained, for all the reasons already outlined. Furthermore, some of those women using private maternity homes are individuals who are substituting delivery care in the public sector for private sector treatment, representing little net gain in overall rates of skilled attendance.
Structural changes in the health sector labour market, including a public sector employment freeze in 1993 and an increase in the retirement age from 55 to 60 in 1999 (Kyejo 2001), contributed to an ageing health care workforce (Kurowski et al. 2004). There will be a large cohort of retiring midwives over the next few years, and our data, derived from case studies in a variety of districts, suggests that returning to home villages may be quite a common practice at retirement. However, to harness this resource, and indeed for any significant expansion of this sector, reduction of the legal and institutional barriers will be needed.
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Discussion |
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Brugha and Zwi (2002
), in their review on the evidence for global approaches to private sector provision, end with a strong plea for caution in implementation of policies to enhance the private sector's role in delivering health care, and a call for more detailed research to inform this. Health systems need to be understood within their local social and political contexts, and such case studies using multiple sources and methods of data collection are labour intensive, but as Keen and Packwood (2000) argue, they prove valuable in situations where policy change is occurring in ‘messy real world settings’.
One advantage of the approach is its ability to start with generic questions and to become more focused and specific as knowledge of the subject matter increases. We did not know when we set out to map this sector that we would find the post-retirement model of maternity home ownership to be so predominant in Tanzania at the current time. When we then conducted a search for documentation on the mobilization of ‘mature’ or ‘retired’ workforces to compensate for shortages in health care resources, we found recent reference to ‘flexible retirement’ and ‘retire and return’ policies in industrialized countries such as the UK (DoH 2006; Nursing Research Unit 2007) and Australia (NSW DADHC 2000). We did not, however, identify any research studies on the implementation of such strategies in low-income countries. The potential of the untapped pool of skilled health workers represented by retired workers is beginning to be recognized in Africa as one within a series of measures to increase inflows of human resources (High-Level Forum on the Health MDGs 2004; Maslin 2005; Global Health Workforce Alliance 2006). Our findings do suggest that there may be scope, in this Tanzanian context at least, for encouraging retired nurse-midwives to develop independent practices in under-served areas within a network of coordinated and supported health services, although it is necessary to be cautious about extrapolations from a small group of early adopters to the wider workforce. What does seem clear is that for any such scenario to function optimally, changes are needed at several levels and that supply and demand-side barriers need to be taken into consideration.
Moving forward
Our study demonstrates the real life complexity of enactment of a policy ‘good idea’. The proprietors of the private practices we studied aspired to combine financial, caring and professional aims, but despite the legislative change, they faced institutional barriers that systematically failed to support these aspirations and prevented other interested midwives from engaging in such activity.
As a result of this research a special working group of the Nursing Council, including private practitioners, drafted new guidelines in late 2004. These are based on the intended care rather than the current blueprint facility-based specification. They will reduce start-up costs and should allow private practitioners to tailor their services according to their skills and local needs, and open up a future possibility of domiciliary midwifery care. The Registrar's office is also considering revising legislation to allow Enrolled Nurse-Midwives and Nursing Officers to set up these practices, thus expanding the potential private midwifery workforce.
Increasing the size of the maternity workforce can only be part of the solution. ‘Skilled attendance’ requires at least two key components: a skilled attendant and an enabling environment that includes equipment, supplies, drugs and transport for referral, and backup emergency obstetric care (EmOC) (Bell et al. 2003). This requires lifting of current restrictions that prohibit midwives from dispensing the full list of drugs suggested for routine delivery and basic EmOC (WHO 2003). Health services in Tanzania are currently undergoing a process of decentralization and the responsibility to ensure facilities have affordable access to essential drugs and equipment falls to district managers. Whilst providing free or discounted supplies to facilities operating on a market model may seem generally counter-intuitive, the supply of basic equipment to self-employed midwives operating on a subsistence basis in under-served areas may keep their practice afloat and affordable.
If retiring nurse-midwives take up the possibility now theoretically open to them, and devise more tailored low cost services that do not simply attempt to replicate government facilities, then their potential to create ‘something new and different’ (Drucker 1985; Faugier 2005) and be more truly ‘entrepreneurial’ may be realized. For example, developing new services and extending into domiciliary clinical practice may be a greater possibility. It remains to be seen whether this is attractive to the midwives themselves. Despite the problems faced, many of the owners we met were immensely proud of their clinics, which represented personal achievement and social standing. It may be that ownership of one's own clinic will remain a powerful motivator.
If sustainability and the needs of poor communities are to be properly addressed then on-going financing needs to be considered. There would seem to be some real benefits in combining public finance with private provision in this scenario because of the potential to draw in a ‘new’ workforce, rather than simply to replace public with private provision. Other countries offer some examples of targeted micro financing: micro-credit lending to users increased the use of trained TBAs in Bangladesh; micro-loans to private midwives in Uganda contributed to improved quality of services (Walker et al. 2001); and targeted performance-based contracts have been combined with vouchers distributed to potential users in Indonesia (Institute for Health Sector Development 2004). Franchising models piloted in the Philippines (John Snow Inc. 2005) may be possible via a private midwives’ association such as PRINMAT. Such approaches would merit pilot studies in Tanzania.
Because of their location and emphasis on personalized care, small-scale independent practices run by retired midwives could potentially—with the right support—increase rates of skilled attendance at peripheral-level delivery. They cannot be seen as more than one strand in the human resources strategy required to bring skilled attendance at delivery to the majority of Tanzanian mothers, but this model may represent an opportunity to harness currently under-utilized human resources in the push towards Safe Motherhood and the MDGs.
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Acknowledgements |
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This research was funded with a grant from the Health Foundation (Ref 1824/1506). The authors thank M Joyce Safe, Mr Godfrey Mohamella (GM) and Mr Gustaf Moyo, Ministry of Health, United Republic of Tanzania; Dr Thecla Kohi and Dr Helen Lugina, Muhimbili University College of Health Sciences, Tanzania; and Ms Pauline Khng, King's College London, for their assistance, and the communities, practitioners and managers who took part.
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1 Estimated to account for 6% in 1995, rising to 14% in 2002 (Dominick 2004
). 
2 Private Hospital (Regulation) Act 1977.
3 Private Hospitals (Regulation) (Amendment) Act 1991.
4 A ‘skilled attendant’ is defined by the World Health Organization and the professional confederations (WHO, ICM, FIGO 2004) as ‘an accredited health professional ... who has been educated and trained to proficiency in the skills necessary to manage normal pregnancy, childbirth and the immediate post partum period, and in the identification and management and referral of complications in women and newborns’.
5 English and Kiswahili versions of the research tools are available online at http://www.kcl.ac.uk/teares/nmvc/research/project/moreinfo.php?id=76&the_group=1.
6 A small number of interviews and FGDs were not recorded, usually where a respondent expressed such a preference due to excessive background noise or technical failure.
7 For Nursing Officer grade, the salary is about US$80 a month
8 The broader question of ensuring skilled attendance requires a well-functioning health system overall. This will require improving training, drugs and equipment supplies, and transportation networks not only for the maternity homes but also across the public sector as already indicated.
9 The age profile of employed midwives has changed in recent years partly due to a public employment freeze in 1993 and partly due to mortality in younger age groups. Fifty per cent of health staff are estimated to be over 40 years old (Kurowski et al. 2004).
10 Figure based upon 2004 population estimate of 36 588 225 and 39 births per 1000 population, from http://www.odci.gov/cia/publications/factbook/geos/tz.html, accessed 3 February 2005.
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Accepted for publication 27 November 2007.
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