title: District health manager and mid-level provider perceptions of practice environments in acute obstetric settings in Tanzania: a mixed-method study.
abstract: In sub-Saharan Africa, the capacity of human resources for health (HRH) managers to create positive practice environments that enable motivated, productive, and high-performing HRH is weak. We implemented a unique approach to examining HRH management practices by comparing perspectives offered by mid-level providers (MLPs) of emergency obstetric care (EmOC) in Tanzania to those presented by local health authorities, known as council health management teams (CHMTs).
  
  
  
  This study was guided by the basic strategic human resources management (SHRM) component model. A convergent mixed-method design was utilized to assess qualitative and quantitative data from the Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers project. Survey data was obtained from 837 mid-level providers, 83 of whom participated in a critical incident interview whose aim was to elicit negative events in the practice environment that induced intention to leave their job. HRH management practices were assessed quantitatively in 48 districts with 37 members of CHMTs participating in semi-structured interviews.
  
  
  
  The eight human resources management practices enumerated in the basic SHRM component model were implemented unevenly. On the one hand, members of CHMTs and mid-level providers agreed that there were severe shortages of health workers, deficient salaries, and an overwhelming workload. On the other hand, members of CHMTs and mid-level providers differed in their perspectives on rewards and allocation of opportunities for in-service training. Although written standards of performance and supervision requirements were available in most districts, they did not reflect actual duties. Members of CHMTs reported high levels of autonomy in key HRH management practices, but mid-level providers disputed the degree to which the real situation on the ground was factored into job-related decision-making by CHMTs.
  
  
  
  The incongruence in perspectives offered by members of CHMTs and mid-level providers points to deficient HRH management practices, which contribute to poor practice environments in acute obstetric settings in Tanzania. Our findings indicate that members of CHMTs require additional support to adequately fulfill their HRH management role. Further research conducted in low-income countries is necessary to determine the appropriate package of interventions required to strengthen the capacity of members of CHMTs.
authors: Center for Children & Families, School of Nursing, Columbia University, 617 West 168th Street, Georgian Building Room 346, New York, NY, United States of America. nn2254@columbia.edu.
authors: Njoki
authors: N
authors: Ng'ang'a
authors: Center for Children & Families, School of Nursing, Columbia University, 617 West 168th Street, Georgian Building Room 346, New York, NY, United States of America.
authors: Mary Woods
authors: MW
authors: Byrne
authors: Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY, United States of America.
authors: Margaret E
authors: ME
authors: Kruk
authors: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors: Aloisia
authors: A
authors: Shemdoe
authors: Averting Maternal Death and Disability Program (AMDD), Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, United States of America.
authors: Helen
authors: H
authors: de Pinho
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003906:Developing Countries; D004632:Emergency Medical Services; D004777:Environment; D005260:Female; D006282:Health Personnel; D006801:Humans; D007318:Inservice Training; D007588:Job Satisfaction; D008297:Male; D008427:Maternal Health Services; D008875:Middle Aged; D009774:Obstetrics; D010559:Personnel Management / Q000592:standards*; D012456:Salaries and Fringe Benefits; D013636:Tanzania; D016526:Workload; D017132:Workplace
keywords: Council health management teams; Emergency obstetric care; Human resources management; Mid-level providers; Practice environment; Tanzania