1. Health worker performance in Tanzania - preliminary results from qualitative research Seminar HEB/UoB, 25 October 2006 Aziza Mwisongo (NIMR) and Ottar Mæstad (CMI)

2. Background and purpose Health worker motivation and performance Performance issues –Clinical performance –Patient courtesy –Corruption –Absenteeism Photo: Magnus Hatlebakk

3. Clinical performance and corruption Utilisation Quality of care Health improvement Corruption Clinical performance Other explanations of low performance

4. Methodology 8 focus groups –4 urban, 4 rural –One cadre per group Doctors Clinical Officers Nurses Assistants –One worker per facility in each group –Each facility represented in several groups –Language: Swahili

5. Participant characteristics Number of participants58 Age (mean)42 yrs Female share60 % Level of care Hospital48 % Health centre22 % Dispensary28 % Years in health sector (mean)19 yrs Years in current position (mean)10 yrs Employer Government74 % Private for profit21 % Faith based5 %

6. Corruption is there… Yaah, we ask for the bribes … it’s true that the doctors we take the bribes ” Clinical officer, urban

7. Ways of making money Suppose there’s a queue and there are some patients who do not want to stand on the queue, as a result … they can bribe them in order to let them in before their legal time arrive Medical assistant, urban …they [the medical attendants] just come and say that the patient is a relative while the truth is they have taken a bribe Doctor, rural …they pretend that there are the drugs that are missing… Because the patient wants the service s/he will end up asking “for how much are they sold?” and s/he can say they are sold for 3,000/= or 4,000/= so if you give me this money I can get them. Once s/he get those monies then s/he just take the drugs and send them to the patients … S/he does not buy them, the drugs are there. Nurses, urban When the pregnant women come from the clinic, they come even without some of the very key supplies needed, and if such women go to the maternity ward it becomes the happiest moment to the nurse, because she know that that client is her source of income…It doesn’t mean that the supplies are not there but this is just a strategy of the health workers to gain an income Medical assistants, urban There’s another strategy where the doctor prescribes the drugs that are not in the facility or … sometimes s/he might even use the names that do not exist in order to make sure that the patient does not get that drug anywhere. And when the patient comes back, he … gives them the drugs that are just ordinary drugs Clinical officer, urban One of my young sisters was admitted at Muhimbili Orthopedic and everyday when she wanted the bedpan the nurse demanded Tshs. 1,000 Medical assistant, urban The tendency of postponing the dates of taking the patients to the theatre might be influenced by the goals of the doctors, the goals aimed at inducing the relatives of the patient to start thinking that “for how long should we wait for it,..we are at risk of losing our patient, so it is better to raise the money that will enable us to take our patient to the private hospital of this doctor” Nurses, urban …others might tell you that please write me the most expensive drugs so that my husband can give me the money, I’ll give you 1,000/= Clinical officer, urban Some women have been cheating their husbands that they were pregnant and it was unfortunate that they got miscarriage… That woman might tell you “I am not sick, I don’t have a pregnancy … what I want is to make money from this man… You pretend that you’ve handled my case and it costs 50,000/=, after that you and I take 25,000/= each” Clinical officer, urban In most cases what the patients pays is the kind of an appreciation which in most cases is paid in small amounts Doctor, rural

8. Health workers at all levels are involved …there’re so many people who might be involved in the corruption, those people might be the clinical officer or that person might be the attendant Doctor, urban Normally the doctors are in liaison with the lower cadres [on getting money from patients], though sometimes they may even get into that deal with the nurse Nurses, urban They [nurse assistants] are the main players involved with the corruption and in fact they are responsible for making the health staff been associated with the corruption Nurses, urban They offer bribe, … but it only reaches a few crafty ones, mostly doctors only. Medical assistants, rural When they say that the doctors are better placed to take bribes, that is not true, whoever decides to take the bribe s/he can do anything to win it Doctors, rural

9. Bribes shared only partly – competition in quality? If you will go and ask that doctor that “doctor I have heard that you have received something from the patient and that you have included us on this deal…” then the doctor will tell you “don’t worry I will give you something for soda” Nurse, rural Sometimes patients have relatives who may bring up to 20 oranges to a doctor. … At some incidences the relative may instruct the doctor that the oranges are for him/her and the other staff, but the doctor takes all of it! Medical assistant, rural If s/he gets it, it’s his/hers and if you get it, it’s yours. We don’t distribute amongst ourselves what we get from bribery…That is why we lack companionship Medical assistant, rural you can see a clinical officer … asking women who just got delivery “dear mama, did you give anything to the nurse?” and the mother might say “yes, I just gave her my thanks for properly handling my delivery”…The doctor might call you immediately demanding that you return that money...this is the harassment for us…It’s just their selfishness; they want to be the only people who get those monies Nurse, urban Therefore, the patient will decide to give money to the one who has a good heart and who can help you rather than the one who has a difficult heart Nurse, urban

10. Can bargain for higher share of bribe – reduce quality if the nurses know that a certain doctor has already received a bribe then the nurses start to avoid or give less attention to that patient Doctor, rural …when you tell the nurse that this is an emergency case so you should hurry up, you can find the nurse moving from one place to the other and what she is thinking is that you as the doctor you might have got the money from the patient Doctor, urban

11. Unfair bribe allocations create frustration – reduce quality Actually it pains so much especially in case you have noticed that your colleagues might have got something and you are supposed to provide care without getting anything. Nurse, rural …you feel bad because you work and someone else benefits and satisfy her/his personal interests behind your back [by taking the bribe], that affects our work, leads to poor service provision … because you think that you’re just contributing in completing someone’s job Doctor, rural …if I am not with good heart and have seen that a doctor has been bribed but I have not received any share from it, I may, if supposed to give six tablets, give four... if angry I may even give two tablets. Medical assistant, rural

12. Quality care creates suspicion about bribery – reduce quality(?) if you decide to take care of that patient to make sure that you want to get proper diagnosis, then people will start to think that the doctor has got something Clinical officer, rural …when a person like me tries to take care to the patient, others might give such remarks as “are you pretending to be a mother from the church, what do you expect to get from what you’re doing”? Medical assistant, urban …its better to rush than telling them come back tomorrow, they can end up saying that the doctor want something that’s why s/he has asked me to go back tomorrow.. Nurses, rural

13. Bribery and patient’s demand for quality Some don’t believe that they can get good treatment without bribing Medical assistant, rural Now it is very difficult to take money from the people, because they know that once they pay you’ll have to give them the receipt,… unless you meet someone who does not know what is the meaning of the receipt, and it is unfortunate that … they are very likely to be the poor people Nurse, urban It is easy to tell [when there has been a bribe]. The patients will show over-confidence to the level of dictating to you that, “you come and clean here, this is your responsibility” Medical assistant, rural …it happens that the amount of money they gave you is very small say it is 500/=, but the patient will say: “I gave that nurse my money”. S/he will hang on you to the extent that you’ll regret for taking that money. Medical assistant, urban

14. Summary: Bribery and the quality of care Supply of quality care Hold back quality care (e.g. drugs/supplies) in order to grab rents Hold back quality in order to bargain for higher share of bribes Hold back quality in order to avoid accusation about bribery Perceived unfairness of the system creates frustrations that may reduce quality Compete in order to receive “gifts of appreciation” Demand for quality care Higher “price” – lower demand for quality Even small bribes makes patients “over-confident” and “demanding”

15. Clinical performance: some of the issues Doctors rush during consultations –Take brief history –Superficial or no examination –Few lab tests performed Unreliable laboratory testing Deliberate holding back quality care (especially for in-patients) Quality of care depends on individual socio-economic variables Quality of care correlated with facility ownership

16. Clinical performance …once the patient arrives, the doctor will briefly listen to what the patient will have to say, and then … do a quick clinical investigation, and sometimes they don’t even do investigations properly Clinical officer, urban …when a person face a headache they believe it is malaria, so they will prescribe malaria drugs and a patient will take them and leave without any examination Medical assistant, rural Even before the patient finishes explaining his/her illness, the doctor has completed prescribing, Medical assistants, rural …sometimes the doctor think that “if I’ll ask for laboratory test this means that the same patients will have to come back to me, and this will increase my workload, so it is better that I just rush by prescribing without the tests” Clinical officer, rural …I’ve noticed that some of the lab technicians they throw away all the samples, and they fill the results they feel like filling, and as a result they give us the strange results Doctor, urban Yes there is a special treatment, for example if it’s a nurse or a teacher you can not lie to any of them Doctor, rural …in the private the patients are well cared, because they know that when they’ll do what is done in the public facilities, the patients will never go back Medical assistant, urban

17. Short time per patient (outpatient consultations) Source: Own observations 2.5 min

18. Clinical performance - explanations Shortage of staff Pressure from patients Low levels of intrinsic motivation Low salary and difficult living conditions Poor laboratory quality Money making culture Poor human resource management Lack of physical infrastructure / equipment Lack of knowledge and skills

19. You see, we are not doing our job properly because of the shortages of staff Nurse, urban Shortage of staff …if the doctor decide to listen to everyone carefully and concentrate on each patient, at the end of the day that doctor will find her/himself to attended only twenty patients, while on the queue there are hundred patients Nurse, urban …the workload becomes so big and as result the doctors decide to rush in order to catch up with the big number of patients waiting Doctor, urban There’re so many patients, therefore you can find that …in the morning … s/he does the best quality work, but as time goes on you’ll start to see that the person is tired and start to do poor quality work Clinical officer, urban

20. Pressure from patients those patients who are waiting outside they feel like you’re wasting their time or there’s something that you’re discussing with this patient in order to get something from her/him. Doctor, urban It reaches a time you just rush due to limited time available because you will hear patients outside complaining that you stay with patients for too long. Clinical officer, rural …the clinician may not be interested to quarrel with villagers so he/she has to comply with their request...In some cases he/she assists them even if it is professionally unethical Medical assistant, rural …you might think that by doing such things like asking them a number of questions, you’re doing the right thing for them, but they might perceive it as wastage of their time. … therefore, some of the doctors decide to rush into diagnosis Nurse, urban

21. Low intrinsic motivation …the situation is really not … good, we just work for the sake of working but the concentration is really low Doctor, rural …there’re people who are just practicing this work in order to gain an income but they don’t have a call for the work, for people who have a call are ready to go to the patient touching her/him while those who have just joined in the field for the purpose of earning an income are not ready to touch the patient Medical assistant, urban …I think it is because some people have just joined this profession because they could not find a job but in fact they don’t have a call. These must have joined the profession because they had no alternative Medical assistant, urban Honestly speaking, … the nursing discipline does no longer exist. What was long held to be the call … does no longer exist because there’s no longer love to the patients Medical assistant, urban …employment of people who does not have any interest with the field of medicine, this is common in the government Doctor, urban

22. Low salary and difficult living conditions …due to small amount of salary that they get.. the doctors have been rushing in order to finish quickly… so that s/he can leave early to reach at her/his part time office Nurse, urban Sometimes you leave home without even taking tea due to hardship of life, so you lack concentration Doctors, rural...you may come to work while you’re thinking about your financial problems. You will not have the time to sit and listen to a patient, at the end of the day you request the wrong investigation. Doctor, rural I think people are working under the silent boycotting, … although they go to work … they don’t want to toil …because of the small amount of salaries they get Clinical officer, urban You get tired but you have to force yourself to do the job as a result you end up underperforming, because you will be thinking of your problems at home, you don’t even have time to cultivate a vegetable garden, but yet the government does not even think of paying you for working overtime, this discourages us. Nurses, rural

23. Poor laboratory quality …we have a shortage of staff.. at the beginning the [laboratory] technician might be accurate, but as time goes on s/he might start seeing the things that are not existing. Nurse, urban …there’re so many patients, and that [laboratory] person wants to go out and do some other activities somewhere else in order to increase her/his income Doctor, urban

24. Money making culture

25. Poor human resource management In the government there’s no such culture of people to make follow up of staff performance because if you decide to warn somebody, it is possible that that person might have some relatives at the ministry level. Doctor, urban …for example when I go for further studies I have my own expectations that when I get back I will be someone else and my income will increase. So if that will not happen my performance will be poor. Doctor, rural It happens that the same doctor … is just rushing when you meet her/him in the public facilities, but later when you meet her/him in the private facility you’ll be surprised to see that s/he is taking a very good care of the patients. Clinical officer, urban

26. Physical infrastructure / equipment you’ll find out that in one room there’re three doctors, and as a result the doctors are not in a good environments to examine the patient. So once the patient come the doctor take a brief history, make diagnosis and decide to let the patient to go. Doctor, urban …you may need to examine a patient but you may find that you have no gloves, so you go to look for them, and it takes time to get them, you get tired of waiting and decide to take a tea break… Doctor, rural The other thing is about equipments, because you will see that we just have one BP machine that is kept on the nursing officer’s office which is located a bit far from where you are Doctor, urban

27. Knowledge and skills They [the trained healthworkers] have been leaving the [training] institutions with the eye catching certificates, but with a low capacity to deliver/perform. Medical assistant, urban I think what hinders our performance is the issue of education. Education especially for us the nurse assistants. Medical assistant, rural For doctors this is not a problem, knowledge is not a factor. They just decide to malpractice and they are selfish. Consider why a mere nurse, with low education level, does much work and does it very well, while those with higher education mess-up. Medical assistant, rural...at the beginning when the doctor just begin the work, s/he will adhere to the agreed principles [on patient treatment], but as you get along, you start to change. Clinical officer, urban

28. One possible story Doctors know what to do (know-do gap) Intrinsic motivation when leaving school is not lower than in other countries Meets a long queue of patients, demanding short waiting time Lack of effective performance management implies that patient pressure becomes a dominating force This works together with –low salaries: have to earn income from other sources; not willing to work long days –physical infrastructure: lack of privacy But why such a big pressure from patients for quick diagnosis? –Don’t trust doctors; come with their own diagnosis and use the doctors as a ”dispensing machine” –Excessive expectations to modern medicine: ”Just give me a pill” –????

29. Few health workers Source: JLI report 2004