title: "Once the government employs you, it forgets you": Health workers' and managers' perspectives on factors influencing working conditions for provision of maternal health care services in a rural district of Tanzania.
abstract: BACKGROUND
  In many developing countries, health workforce crisis is one of the predominant challenges affecting the health care systems' function of providing quality services, including maternal care. The challenge is related to how these countries establish conducive working conditions that attract and retain health workers into the health care sector and enable them to perform effectively and efficiently to improve health services particularly in rural settings. This study explored the perspectives of health workers and managers on factors influencing working conditions for providing maternal health care services in rural Tanzania. The researchers took a broad approach to understand the status of the current working conditions through a governance lens and brought into context the role of government and its decentralized organs in handling health workers in order to improve their performance and retention.
  
  
  METHODS
  In-depth interviews were conducted with 22 informants (15 health workers, 5 members of Council Health Management Team and 2 informants from the District Executive Director's office). An interview guide was used with questions pertaining to informants' perspective on provision of maternal health care service, working environment, living conditions, handling of staff's financial claims, avenue for sharing concerns, opportunities for training and career progression. Probing questions on how these issues affect the health workers' role of providing maternal health care were employed. Document reviews and observations of health facilities were conducted to supplement the data. The interviews were analysed using a qualitative content analysis approach.
  
  
  RESULTS
  Overall, health workers felt abandoned and lost within an unsupportive system they serve. Difficult working and living environments that affect health workers' role of providing maternal health care services were dominant concerns raised from interviews with both health workers and managers. Existence of a bureaucratic and irresponsible administrative system was reported to result in the delay in responding to the health workers' claims timely and that there is no transparency and fairness in dealing with health workers' financial claims. Informants also reported on the non-existence of a formal motivation scheme and a free avenue for voicing and sharing health workers' concerns. Other challenges reported were lack of a clear strategic plan for staff career advancement and continuous professional development to improve health workers' knowledge and skills necessary for providing quality maternal health care.
  
  
  CONCLUSIONS
  Health workers working in rural areas are facing a number of challenges that affect their working conditions and hence their overall performance. The government and its decentralized organs should be accountable to create conducive working and living environments, respond to health workers' financial claims fairly and equitably, plan for their career advancement and create a free avenue for voicing and sharing concerns with the management. To achieve this, efforts should be directed towards improving the governance of the human resource management system that will take into account the stewardship role of the government in handling human resource carefully and responsibly.
authors.affiliation: Department of Clinical Nursing, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. mkokamalinga@yahoo.co.uk.
authors.forename: Dickson Ally
authors.initials: DA
authors.lastname: Mkoka
authors.affiliation: Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. gmahiti2011@gmail.com.
authors.forename: Gladys Reuben
authors.initials: GR
authors.lastname: Mahiti
authors.affiliation: Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. angwarakiwara@yahoo.com.
authors.forename: Angwara
authors.initials: A
authors.lastname: Kiwara
authors.affiliation: Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. mmwangu@yahoo.com.
authors.forename: Mughwira
authors.initials: M
authors.lastname: Mwangu
authors.affiliation: Department of Public Health and Clinical Medicine, Unit of Epidemiology and Global Health, Umeå University, 901 85, Umeå, Sweden. isagoiko@yahoo.es.
authors.forename: Isabel
authors.initials: I
authors.lastname: Goicolea
authors.affiliation: Department of Public Health and Clinical Medicine, Unit of Epidemiology and Global Health, Umeå University, 901 85, Umeå, Sweden. anna-karin.hurtig@epiph.umu.se.
authors.forename: Anna-Karin
authors.initials: AK
authors.lastname: Hurtig
mesh_terms: D001291:Attitude of Health Personnel; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000458:organization & administration* / Q000523:psychology*; D006801:Humans; D007318:Inservice Training; D007407:Interviews as Topic; D008427:Maternal Health Services / Q000458:organization & administration*; D017150:Public Sector; D012424:Rural Population; D013636:Tanzania; D035502:Trust