title: Maternal and newborn healthcare providers in rural Tanzania: in-depth interviews exploring influences on motivation, performance and job satisfaction.
abstract: BACKGROUND
  Major improvements in maternal and neonatal health (MNH) remain elusive in Tanzania. The causes are closely related to the health system and overall human resource policy. Just 35% of the required workforce is actually in place and 43% of available staff consists of lower-level cadres such as auxiliaries. Staff motivation is also a challenge. In rural areas the problems of recruiting and retaining health staff are most pronounced. Yet, it is here that the majority of the population continues to reside. A detailed understanding of the influences on the motivation, performance and job satisfaction of providers at rural, primary level facilities was sought to inform a research project in its early stages. The providers approached were those found to be delivering MNH care on the ground, and thus include auxiliary staff. Much of the previous work on motivation has focused on defined professional groups such as physicians and nurses. While attention has recently broadened to also include mid-level providers, the views of auxiliary health workers have seldom been explored.
  
  
  METHODS
  In-depth interviews were the methodology of choice. An interview guideline was prepared with the involvement of Tanzanian psychologists, sociologists and health professionals to ensure the instrument was rooted in the socio-cultural setting of its application. Interviews were conducted with 25 MNH providers, 8 facility and district managers, and 2 policy-makers.
  
  
  RESULTS
  Key sources of encouragement for all the types of respondents included community appreciation, perceived government and development partner support for MNH, and on-the-job learning. Discouragements were overwhelmingly financial in nature, but also included facility understaffing and the resulting workload, malfunction of the promotion system as well as health and safety, and security issues. Low-level cadres were found to be particularly discouraged. Difficulties and weaknesses in the management of rural facilities were revealed. Basic steps that could improve performance appeared to be overlooked. Motivation was generally referred to as being fair or low. However, all types of providers derived quite a strong degree of satisfaction, of an intrinsic nature, from their work.
  
  
  CONCLUSIONS
  The influences on MNH provider motivation, performance and satisfaction were shown to be complex and to span different levels. Variations in the use of terms and concepts pertaining to motivation were found, and further clarification is needed. Intrinsic rewards play a role in continued provider willingness to exert an effort at work. In the critical area of MNH and the rural setting many providers, particularly auxiliary staff, felt poorly supported. The causes of discouragement were broadly divided into those requiring renewed policy attention and those which could be addressed by strengthening the skills of rural facility managers, enhancing the status of their role, and increasing the support they receive from higher levels of the health system. Given the increased reliance on staff with lower-levels of training in rural areas, the importance of the latter has never been greater.
authors.affiliation: Institute of Public Health, University of Heidelberg, Heidelberg, Germany. helen.prytherch@yahoo.com
authors.forename: H
authors.initials: H
authors.lastname: Prytherch
authors.forename: D C V
authors.initials: DC
authors.lastname: Kakoko
authors.forename: M T
authors.initials: MT
authors.lastname: Leshabari
authors.forename: R
authors.initials: R
authors.lastname: Sauerborn
authors.forename: M
authors.initials: M
authors.lastname: Marx
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002322:Career Mobility; D002983:Clinical Competence / Q000706:statistics & numerical data; D017598:Efficiency, Organizational; D005260:Female; D006293:Health Promotion / Q000592:standards; D006801:Humans; D007231:Infant, Newborn; D007407:Interviews as Topic; D007588:Job Satisfaction; D008297:Male; D008430:Maternal-Child Health Centers; D008505:Medical Staff, Hospital / Q000193:education / Q000523:psychology* / Q000706:statistics & numerical data; D008875:Middle Aged; D009042:Motivation; D015279:Organizational Culture; D009937:Organizational Objectives; D019035:Rural Health Services / Q000592:standards; D013192:Staff Development / Q000379:methods; D013636:Tanzania; D013647:Task Performance and Analysis; D000078329:Workforce