Introduction

The retention of the skilled health workforce in primary health care facilities especially in rural areas has continued to be a frustration to many health systems for decades [1, 2]. While the global population is halved between urban and rural, the health workforce is asymmetrically distributed. Only 38% of nurses and 24% of the physicians serve the rural population [3]. Several studies have pointed out poor working conditions, poor remuneration, poor social services, poor supervision from immediate supervisors, salary delays, lack of accommodation, limited opportunities for career growth and limited alternative sources of income as the major perpetuating factors for poor retention of the health workforce in rural areas [4–6].

Tanzania, like many other countries, is struggling with the retention of the skilled health workforce in its primary health care facilities in rural areas [7]. Estimates show that by 2015, Tanzania had less than half the required health workforce with a rural-urban divide favoring urban areas [8]. The shortage of health workers in rural areas jeopardizes accessibility of health care services to rural communities thus contributing to poor health indicators in the country [9]. One of the major efforts in addressing health workforce retention challenges is the 1990s health sector reforms. The health sector reforms aimed at, among other things, increasing health workforce availability through training, absorption and retention [10, 11]. While there have been significant achievements for training, absorption and retention have remained low due to budget limitations [12–14].

Following the adoption of the 1990s health sector reforms, Tanzania operates a decentralized health system. Under the decentralized system, since the mid-1990s districts were made the focal points for health care services planning, provision, and program implementation [15]. As such, they were given the mandate to recruit, deploy and retain health workers which was initially a role of the central government [16]. The administrative reforms also involved the engagement of the community in decision making on matters relating to their health and health care. Therefore, to ensure adequate and systematic community engagement, HFGCs were formed at each health facility. The HFGC is comprised of five members from the community and three appointed members (the health facility in-charge, a member from the village government committee, and a member of the ward development committee). Some of the key roles of the HFGCs are (i) to develop the plans and budget for the facility and (ii) to liaise with Health Facilities Management Teams (HMTs) and other actors to ensure the delivery of quality health services [17]. HFGCs are therefore vital in the retention of health workers at the facilities and districts at large.

In 2006, it was realized that districts were less efficient in the recruitment, deployment, and retention despite the mandate given to them. Therefore, the government revised the decentralization system and formed a partial centralized system, which combined some elements of decentralized and centralized approaches [16]. In the partial centralized system, districts were left with the responsibility of identifying vacancies for employing health workers and retaining the workforce after the vacancies are filled by the central government [16].

In addition to the administrative reforms, the government of Tanzania has tried several other strategies by combining both financial and non-financial incentives to retain the skilled health workforce in rural areas with little or no observable improvements [12]. Financial incentives have often failed to be implemented due to budget limitations while most of the non-financial incentives have ended in budgetary implications and thus also failed to bear the intended results [18]. Even though the central government is responsible for the payment of salaries of health workers employed at the district, other financial and non-financial incentives are the responsibility of the districts. The latter has resulted in a variation in incentives provided to health workers across districts due to the financial capacity of the respective districts and the way priorities are set [19]. Urban districts are economically better positioned and often have better incentives compared to rural districts which have limited opportunities for earning extra income within the professional practice [19].

The popular non-financial incentives across the districts have included among other things; opportunities for continuing education and career development, proactive staff recruitment, compulsory community service, bonding schemes, contracting arrangements and provision of accommodation [15, 20, 21]. However, non-financial incentives like the opportunity for further education is a challenge to the district because for some cadres, providing staff with opportunities for further education is offering them an exit opportunity because the new qualifications that will be acquired are not accommodated in the district staffing level [22]. Furthermore, most of these strategies have been proposed through the central government and mostly without being piloted, and have been imposed on the districts for implementation. Lack of district engagement has often resulted in a mismatch between the devised strategy and the resources needed for its implementation, poor understanding of the strategies and lack of ownership of the strategies [15].

In supporting the implementation of these strategies, some development partners have supported some rural districts in improving the retention of health workers through different measures. In southern Tanzania, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) has been implementing the pro-active staff recruitment programs in six districts. In this system, students are enrolled in training institutions after signing a bond with the council. Another organization, the Benjamin Mkapa HIV/AIDS Foundation, BMAF (a local Non-Governmental Organization), is supporting the construction of houses for health workers in different districts, contractual employment of health workers in rural districts, and contractual employment of tutors in allied health training institutions. The health workers are contracted to work for two years in remote areas, with a relatively better incentive package compared to that provided by the local government. These health workers are supposed to be employed by the local government authorities at the end of their contracts. While construction of houses has not faced many challenges, the contractual employment has often resulted in challenges once the contract expires as the remuneration provided by the government has always been far lower compared to what was offered by BMAF.

Therefore, despite the reforms, the revision of the administrative system and the different strategies adopted for the retention of health workforce, most of the rural districts have failed to retain an adequate number of skilled health workforce [7, 12, 16]. Furthermore, like in many other parts of the world, the majority of studies on the health workforce issues conducted in Tanzania have focused on documenting shortage in terms of numbers, geographical imbalance and the associated factors in general [6, 7, 12, 23]. Previous studies conducted in rural districts of Tanzania have shown that the retention of health workers is influenced by other factors including family ties, socio-cultural factors and availability of social services [10, 22, 24]. They have also shown that little attention has been paid to retention strategies coming from the rural districts to inform the national level. Thus, this study sought to explore bottom-up health workers’ retention strategies by analyzing experiences from two rural districts of Rombo and Kilwa.

Materials and methods

Study setting and selection of study site

The two regions of Lindi and Kilimanjaro respectively were selected for the following reasons; Lindi is one of the two regions forming the southern zone where proactive staff recruitment, a form of bottom-up approach retention strategy is being implemented. This is among the zones that have a critical shortage of health workers [14]. Kilimanjaro is one of the three regions forming the northern zone, and is among the zones that have a relatively better health worker density compared to other zones, despite that the zone is still below the recommended World Health Organization (WHO) standard of doctors to population ratio of 1: 10,000> [14]. The two zones (Table 1) were purposefully selected to explore the influence of the different cultural practices, economic activities, and the availability of social services. In terms of districts, Kilwa District, one of the six districts forming Lindi region was randomly selected from among five districts of the southern zone where proactive staff recruitment is implemented. Other districts where proactive staff recruitment is implemented are Nachingwea, Tandahimba, Masasi and Nanyumbu in Mtwara region. Administratively, Kilwa is subdivided into 20 wards. Kivinje district hospital plus three randomly selected health facilities from three villages in two randomly selected wards with health facilities were involved in this study.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Geopolitical zones of Tanzania.

https://doi.org/10.1371/journal.pone.0246262.t001

Rombo district on the other hand, was randomly selected from among five rural districts of Kilimanjaro region and Huruma hospital (District Designated Hospital) plus three other health facilities from three villages in two randomly selected wards with health facilities were involved in this study.

Data collection

Using a semi-structured interview guide and focus group discussion guide written in Kiswahili language, we conducted 19 key informant interviews and three focus group discussions with 19 members of HFGCs (Table 2). A trained research assistant with a background in social science and more than ten years’ experience in conducting qualitative research was taking notes during the interviews and discussions as they were being conducted by the researcher. All KIIs and FGDs were audio-recorded using a digital voice recorder. The audio recorder was kept in a secure place by the researcher. The KIIs lasted between 30 and 60 minutes while the FGDs lasted between 60 and 90 minutes. The interviews were carried out in the informants’ offices or designated rooms at the health facilities. Each FGD comprised 6 to 7 members of the HFGCs and were conducted at one of the designated rooms at the health facility or classroom in a nearby school as identified and arranged by the village leader.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Participants for KIIs and FGDs.

https://doi.org/10.1371/journal.pone.0246262.t002

Results

From 19 KIIs and 3 FGDs with 19 participants, two categories of retention strategies emerged, the health-facility level and the district-level health workers retention strategies (Table 3).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Summary of retention strategies by level.

https://doi.org/10.1371/journal.pone.0246262.t003

Discussion

We aimed to explore bottom-up strategies for the retention of health workers at the primary health care system by conducting our study in two rural districts of Rombo in the northern zone and Kilwa in the southern zone of Tanzania. In this study, we report two major categories of bottom-up health worker retention strategies; (i) Health facility-level health worker retention strategies which are the promotion of good community reception to newly employed health workers, promoting a good working relationship with local government leaders and good cooperation and trust amongst health workers, and the rewarding of best performers of the year; and (ii) District level health worker retention strategies which include limiting migration of health workers within regions, working in collaboration with Non-Governmental Organizations in housing construction, active headhunting at training institutions, and the provision of education advancement and career opportunities through financial support. From the two categories, we feel that health worker retention strategies go beyond remuneration. Despite some of the strategies having some overlapping elements, in this section, we start by discussing the health facility level strategies and end-up with district level strategies. We discuss them distinctly as the two involve different levels of players.

The affiliation of new-comers to the community and work environment as revealed by our study brings a sense of belonging and acceptance of health workers by the community. Sirili et al. 2018 reported that poor working relationships amongst health workers and between health workers and the community through their local government leaders contributes to poor retention of health workers in rural areas [19, 22]. According to Maslow’s hierarchy of needs, a sense of belonging and acceptance create a sense of satisfaction [26]. Several studies from different contexts have shown that job satisfaction is linked with the retention of workers [27–29]. Therefore, having strategies that impact on the satisfaction of health workers is important, however, care must be exercised in the so-called ‘good community reception’ as different ethnic groups may have a different interpretation of what is good or bad especially when the receiving community and the workers are from different ethnic groups.

The provision of prizes to best performers of the year as devised by some of the facilities is perhaps a less costly strategy and can be improved by institutionalizing it such that the incentives come from health facility resources rather than from individual contributions. It is strongly advised that district authorities adopt this strategy and scale it up. By scaling up the strategy to the district level, district authorities can set harmonized packages for different levels of facilities for both facility and individual-level performance. We feel that the latter will ensure the sustainability of this strategy. The WHO in its global policy recommendations, states that appropriate financial incentives are an important retention strategy [3], however, to implement financial incentive strategies sustainably, health facilities must devise innovative approaches for income generation. One way practiced by some urban health facilities is the opening of a window for intramural private practice services after the normal working hours for selected services [19]. This may help health facilities to generate some income for providing certain financial incentives like extra-duty allowances, responsibility allowances and even rewarding performance at the end of the year. However, its practicability may be challenged in some facilities especially those in rural areas.

At the district level, the study unveiled limiting migration of health workers within regions, working in collaboration with Non-Governmental Organizations in housing construction, active headhunting at training institutions, and the provision of career opportunities and career support as the most prominent strategies. Limiting the migration of health workers to facilities within the district or to other districts within the region as found in this study is a managerial decision and perhaps a less costly strategy in comparison to most of the other identified strategies. This strategy is crucial as it taps into political will and enhances the understanding that health worker retention goes beyond the health sector. The latter is pointed out by several other studies in different places [30–33]. However, the working environment within the district varies from one facility to another and thus without careful measures to regulate movement within the district, some facilities will continue to be more affected than others. Furthermore, migration of health workers from one place to another is a product of many drivers including family ties [19, 22], which may limit a person from moving out of the district or region as it may have both social and economic consequences and thus result in dissatisfaction. Studies have shown that job satisfaction is directly linked to workers’ retention, as such, coercively limiting migration would only have short term results [34]. Therefore, there is a need to develop long term strategies to apply multi-sectoral stakeholder engagement to address issues around family union, social services, and the working environment at remote areas of the districts in question [35].

Working in collaboration with Non-Governmental Organizations in housing construction as revealed in this study is not different from what other studies have documented [3, 36, 37]. This strategy is in line with both Tanzania’s public-private partnership (PPP) policy and the WHO advocacy on the role of collaborative work between the public and private sectors for improved results [38, 39]. The revealed efforts by heads of facilities and community members in building houses for health workers call for joint efforts by all stakeholders to lessen the burden that the government must carry against other competing priorities and limited resources. This strategy not only reduces the resource burden but also creates a sense of ownership by the community of their own health. In places where NGOs can work with facilities and communities to construct houses, such efforts and engagement should be promoted and sustained.

Active head hunting for graduating students in health training institutions as revealed in this study was a strategy used previously in Tanzania when districts had the mandate of employing health workers [40]. Among the weaknesses of this strategy was the failure of some poor districts to attract health workers, however, the strategy has the advantage that those who agreed to go to said districts were more likely to stay [12, 41]. This strategy might work better in this era where there are many graduates competing for limited employment opportunities in the health labour market [14]. To make this strategy more attractive and effective, once these graduates have joined the respective districts, deliberate efforts should be made to employ them immediately recruitment slots are made available by the government.

The enhancement and support of career opportunities by granting permission and the provision of financial support for further education as used in the two districts is widely recognized by many authors as a good strategy for the retention of the health workforce in underserved areas [33, 36, 37, 42]. Even though the providing of educational advancement and career opportunities and financial support, is termed as a non-financial incentive, its implementation needs financing. The provision of education and career opportunities is widely reported as one of the retention strategies for health workers used in rural areas in many places [30, 32, 33]. However, a study by Sirili et al. [22] in 2018, reported that the provision of career opportunities in rural Tanzania was challenged because the organization of health services at district hospitals and the human resources for health manning levels do not provide room for a specialist to be employed at the district level [10]. In this regard, offering the opportunity for specialization as a retention strategy may promote migration from the district and defeat the purpose. Based on these findings, the authors feel that policymakers need to re-examine the use of developing career opportunities as a non-financial incentive for the retention of health workers in rural Tanzania. The re-examination should consider both the policy landscape such as schemes of service available and the resources to implement this strategy sustainably.

In general, the findings of this study like in other previous studies in Tanzania and other places [6, 30, 43–46], underscore the fact that retention of health workers is a complex phenomenon that requires multiple strategies at different levels. We feel that with the growing population and increased burden of non-communicable diseases amidst communicable diseases, the failure to retain health workers in rural areas may lead to worse health indicators than the current status.

Conclusion

The findings of this study underscore that retention of health workers at the primary health care level requires not only central (national) level strategies but rather a combination of strategies from the national to the facility level, financial and non-financial, and strategies that target the individual health worker as well as the general community where they work. Bottom-up retention strategies have an element of community, health worker and community participation in governing health facilities and thus are easily understood by stakeholders at the primary health care level. The latter is crucial for ownership thus making the strategies more likely to be sustainable. Finally, the retention of health workers in rural districts calls for multiple strategies beyond financial incentives. Further studies are needed on a large scale to uncover more bottom-up retention strategies and test the few that were identified by our study.

Supporting information

Acknowledgments

The authors sincerely acknowledge the support from the Ministry of Health, Community Development, Gender, Elderly and Children and the local government authorities and all research participants.