Job satisfaction and turnover intentions among health care staff providing services for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania

The number of people living with HIV in Tanzania is currently estimated to be 1 400 000 or 4.7 in every 100 people. About 56% of these are women aged 15 years and older [1]. Tanzania is among the 22 Global Plan priority countries identified by the Inter-Agency Task Team (IATT) on prevention and treatment of HIV infection in pregnant women, mothers and children based on the high number (86000) of pregnant women living with HIV who give birth every year [2]. Six years after the launch of the Global Plan (2009–2015), the proportion of pregnant women living with HIV who received antiretroviral medicines doubled, and a threefold decline in the rate of mother-to-child transmission (MTCT) was observed [2]. Implementation of a new strategy, Option B+, thought to be more effective in preventing both MTCT and partner transmission, and not the least for improving maternal health beyond the breastfeeding period, probably contributed to these global achievements [3‐5]. The Option B+ strategy requires all HIV-positive pregnant and lactating mothers to begin triple antiretroviral therapy (ART) for life regardless of CD4 cell count or disease stage [3]. In the previous prevention of MTCT (PMTCT) strategies, only pregnant women living with HIV with low CD4 count (< 350 cells/μL) or advanced disease stage (WHO stages III and IV) were offered lifelong ART, while those with a high CD4 count (≥ 350 cells/μL) were only offered antiretroviral prophylaxis until the end of the breastfeeding period [6].

Since approximately 40–50% of all HIV-infected pregnant women have CD4 counts ≤ 350 cells/μL [7, 8], Option B+ will almost double the number of women initiating ART for life in PMTCT clinics [9] and multiply the number of mother-infant pairs who require long-term follow-up as compared to previous PMTCT options. Thus, Option B+ has changed PMTCT service delivery model from providing only prophylaxis to providing a full ART care to pregnant and breastfeeding women living with HIV. This adds other responsibilities to PMTCT providers, such as patient’s clinical assessment, laboratory testing and ART prescription and monitoring both during antenatal and postnatal care [3].

For the full benefit of Option B+ to be realized, all pregnant women who test positive for HIV must be initiated on ART, be retained in care, and be supported to adhere to treatment for life [10]. While Option B+ increases the access to ART for more HIV-positive pregnant women, it does require an expansion of the workforce to match the increased workload [9]. The WHO recommends a minimum of 23 health workers for every 10 000 people as a threshold for providing basic health care [11]. In resource-limited countries such as Tanzania, this is very challenging. Even before the implementation of Option B+, there were only 5 skilled health personnel per 10 000 people [11]. Furthermore, in Tanzanian primary health facilities with PMTCT services, the workload is already almost double compared to primary level facilities without such services [12].

Tanzania started to implement Option B+ for PMTCT of HIV in 2013 [13], followed by a 2% drop in MTCT within 2 years of the implementation [2]. Similar to other Global Plan countries, the final MTCT rate (at 18 months) is still twice the 6-week rate, also after Option B+ was scaled up in Tanzania. A possible explanation is that despite high acceptability and initial uptake of Option B+, there are challenges with adherence to ART and retention in care during the postpartum period and beyond [14].

The gaps in achieving adequate adherence and retention in Option B+ care may be exacerbated by high competing demands on the health care system, coupled with existing staff shortages [15]. The understaffing leads to long queues and increased staff workload, which makes it difficult to efficiently counsel the patients and track the defaulters [16]. Higher workload in already overburdened health systems in resource-limited countries have been linked to a negative effect on health care provider job satisfaction [17, 18], especially if the resulting additional tasks and responsibilities are not coupled to incentives [19].

Provider satisfaction is important for PMTCT because satisfied health workers can deliver higher quality services resulting in better health outcomes and higher patient satisfaction [20‐23]. Since patient satisfaction is a determinant of adherence and retention in care [23], improving job satisfaction may play an important role for the implementation of Option B+.

Job satisfaction can reduce work-related stress and thereby employees’ intentions to leave their jobs or to shift workplaces, so-called turnover intentions [24‐28]. Given the prevailing staff shortage in health facilities, which is compounded by an increasing workload through Option B+, identifying factors that could affect job satisfaction may be crucial for improving staff motivation, performance and retention.

This study assessed the level of job satisfaction and intention to leave the current job among health care providers in public health facilities offering PMTCT/ANC services in Dar es Salaam, Tanzania. This is important because the success of Option B+ will depend on the active participation of motivated health care providers.

The response rate was 87% (N = 217 out of 250 distributed questionnaires), but 4 (2%) were incomplete and excluded from the analysis. Among the 213 questionnaires analysed, we found that 54% (N = 115) of the providers in these public PMTCT facilities were dissatisfied with their current job and 35% (N = 74) had thought of leaving their current job.

This study reveals that more than half of all PMTCT health care providers interviewed in the study (the majority of them were working with PMTCT Option B+) were dissatisfied with their current job and one third of them thought about leaving their current job. Dissatisfaction with the current job was strongly associated with being dissatisfied with the level of salary, having inadequate protective gear, having an unclear job description and a feeling of unreasonably long working hours. Actually expressing an intention to leave the current job was associated with other factors such as a sense of poor job stability, poor employee recognition and inadequate feedback on the overall performance of the workplace.

Both dissatisfaction with and intention to leave the current job were independent of age, education or seniority/level of training (health worker cadre) among the PMTCT staff interviewed in Dar es Salaam. Thus, although reasons for job satisfaction and intention to leave one’s job may differ between contexts, work-related factors that can be modified such as offering a reasonable salary, access to personal protection equipment and good leadership and management remain more important than any individual characteristics of the providers [34‐36].

This means that in order to retain existing staff and to attract new health care providers to work with antenatal care and PMTCT in particular, it is also necessary to invest in management and leadership skills in the health care sector. In addition to ensuring a sense of security through higher job stability, interventions aimed at improving the workplace atmosphere such as higher transparency in terms of decision-making and more positive feedback on an individual provider’s work as well as on the overall performance of the clinic are very important. This is especially important today since Option B+ has changed the PMTCT service delivery model from providing short-term MTCT prophylaxis to full ART care aimed to continue medications for life. Thus, the new PMTCT strategy has not only increased the patient load but also resulted in additional tasks at the antenatal care level such as clinical monitoring of the HIV infection, drawing blood samples (for CD4 and viral load tests) and prescribing ART, tasks that previously were carried out in ART clinics. However, despite such an inevitable increase in workload, Option B+ was the preferred option among the majority of health personnel in our study. Most thought Option B+ had a higher potential for effective prevention of MTCT than previous strategies [4, 37, 38], to improve the long-term health of women and children and eliminate MTCT if implemented efficiently.

To effectively implement Option B+, satisfied and motivated providers is key, since they must be highly committed to spend adequate time with the clients to inform them about the PMTCT program and also to provide individual counselling, emphasizing the importance of adherence to medication (for both mothers and their infants) and retention in ART care [16].

Previous studies from African countries have cited dissatisfaction with remuneration as the most important factor to enhance staff motivation and retention [39‐42]. Also in the current study, most providers reported that they were dissatisfied with their salaries in turn increasing their level of overall job dissatisfaction almost sixfold. However, in addition to the remuneration, which is highly resource-constrained, other factors that should be easier to improve such as unclear job descriptions, inadequate availability of the protective materials such as gloves, and long working hours also independently contributed to job dissatisfaction.

The availability of adequate and functional personal protective materials is particularly essential in HIV service delivery where both providers and patients must feel that the providers are adequately protected [43] alleviating stress and their fear of HIV transmission [44, 45].

Furthermore, we found that providers who were dissatisfied with their workload were three times more likely to be dissatisfied with their current job. A heavy workload, most often due to the shortage of health workers (the majority being women), cuts the time that would otherwise be available for family duties and recreation, in turn increasing their risk of stress-related morbidity, absenteeism and burnout [17]. Thus, apart from inadequate salary and supplies [43, 46], a heavy workload [46, 47] and an unfavourable working environment [48, 49] are important reasons for job dissatisfaction and attrition of health personnel.

Our findings add to the current evidence that illustrates the multidimensional nature of job satisfaction and dissatisfaction and the variation between different contexts [50, 51], but it also further underlines the importance of the work environment [46, 47, 52].

Our study did not find a significant impact of inadequate training and supervision on overall job dissatisfaction as reported previously by others [47, 53]. The high rates of salary dissatisfaction could have overshadowed this factor, but perhaps the training and active supervision provided to all PMTCT providers in preparation for the implementation of Option B+ made them feel more ready for the task. The fact that providers who thought that their clients would prefer Option B+ were less likely to be dissatisfied with their current job probably reflects the importance of moral gratification in relation to patient satisfaction. It could also reflect the health providers’ hopes and expectations that Option B+ could result in less effort invested into enhancing adherence and tracking defaulters in the long term, consequences that are yet to be evaluated.

The intention to leave the current job in our study was largely influenced by job instability and the fear of losing one’s job. This finding was unexpected since public-sector employment is permanent and pensionable in Tanzania. We speculate that this could be a reflection of either poor communication between employers and employees and/or the routine practice in Tanzania to rotate staff between different public health facilities. Staff rotation is done with the intention to reduce work-related stress and burnout and improve satisfaction among the providers [54] but can obviously also affect health workers’ motivation especially when it poses regular re-training challenges and constant re-adaption to new work environments [55]. In the present study, other factors for the intention to leave one’s current job include dissatisfaction with the way superiors value or recognize the work one performed and poor feedback regarding the overall performance of the clinic. Health care managers need to be made more aware and educated on the importance of good leadership and management that recognize employees’ work and provide timely feedback on both individual performance and the performance of the unit as a whole in order to encourage workplace retention and to improve health service delivery [56‐58].

Thus, we conclude that optimal implementation of Option B+ and desired MTCT outcomes will require more supportive leaders, improved working conditions and staff communication in parallel with increased remuneration.

A possible limitation was the fact that our results may have been influenced by the fairly short work experience providers had of Option B+ since the study was conducted during the transition from Option A to Option B+. Their positive views on Option B+ could also have been biased by recently having received the on-the-job trainings related to Option B+ implementation. This could have influenced their level of satisfaction with trainings and their positive expectations of Option B+; however, it is unlikely to have had any influence on other aspects of job satisfaction. Additionally, the study used a cross-sectional design, which does not allow conclusions about causal relationships. However, we believe that our findings contribute to the existing knowledge on a crucial area for the public sector in Tanzania and similar contexts in East Africa where optimizing the conditions for successful implementation of PMTCT Option B+ is of high importance for millions of women and children.

We found that although remuneration is crucial for job satisfaction, there are also other important factors that influence both job satisfaction and intention to leave the job.

Thus, in order to recruit and retain satisfied PMTCT providers to sustain Option B+ in Tanzania, deliberate efforts should be directed to making public clinics more attractive workplaces by ensuring reasonable salaries and working hours, clearer job descriptions, appropriate safety measures and job stability as well as ensuring adequate management skills.