Perceived Impact of Health Sector Reform on Motivation of Health Workers and Quality of Health Care in Tanzania: the Perspectives of Healthcare Workers and District Council Health Managers in Four Districts

Background: Literature on the impact of health sector reform (HSR) on motivation of healthcare workers (HWs) and performance in health service provision in developing countries is still limited. Objective: To describe the impact of HSR on HW motivation and performance in providing quality health care in Tanzania. Methods: Four districts selected from three regions were covered, involving in-depth interviews with HWs in public health facilities (HFs), focus group discussions with district managers and researchers’ observations. Data were analysed using a qualitative content analysis approach. Results: The cost-sharing system in public HFs and national health ‘basket’ funding system introduced in 1990s were the key HSR elements identified by the study participants as impacting on HWs motivation and performance. User-fees for public healthcare services was acknowledged as having supplemented government funds allocated to public HFs, although such facilities still experienced ‘stock-outs’ of essential medicines and other supplies, HF understaffing, low/lack of essential remuneration, shortage of and unrepaired staff houses, meagre office space, lack of transport facilities for emergency cases, minimal recognition of HWs at local primary healthcare committees and the district health service budgeting system being controlled by district and central level authorities, leaving little room for lower level stakeholders to participate. Conclusion: For the national healthcare system to succeed, HSRs will need to involve and motivate HWs who are frontline implementers of the reform strategies.