Background
Retention of medical doctors (MDs) in Tanzania
Methods
Study design
Study setting
Data collection
District | No. of KIIs | No. of FGD participants |
---|---|---|
A | 7 (5 MDs and 2 Health Managers) | 7 |
B | 4 (2 MDs and 2 Health Managers) | 9 |
C | 4 (2 MDs and 2 Health Managers) | 6 |
Total | 15 | 22 |
Data analysis
Ethical considerations
Results
Unfavourable working conditions
‘When I reported here I was told I would be provided with a housing allowance of Tshs 80,000/ month… I am staying in a house where the rent is Tshs 200,000/month…but since I came here more than a year ago I have not received that 80,000 even for a single month…. If I get another position where I will be valued, I will leave this place…’ [medical doctor-District B]
District | Forms and amount of allowances |
---|---|
A | On call (20,000 TZS per call), Housing (150,000 TZS per month), Uniform allowance (varies), and Responsibility allowance for head of sections (varies) |
B | On call (20,000 TZS per call), Housing (80,000 TZS per month) |
C | On call (20,000 TZS per call) |
‘As a trained doctor, I really need to practise what I was trained for… Here I am utilizing a very small portion of my knowledge... Imagine I rely on very basic laboratory investigations and X-ray to come to the conclusion of a complicated diagnosis… The chance of false diagnosis is great… Even when you have the right diagnosis, again, the lack of medicine challenges you… I wish to be in a place where I can utilize at least 50% of my knowledge…’ [medical doctor-District C]
‘You give a referral to a patient but they cannot afford the transport costs… Normally it is required that when you refer a patient you must provide a vehicle and an escort nurse… How can we do that in this case? ...The cost of a flight is very high…it is really discouraging… Most of the time we end up witnessing and certifying the death of patients who we referred before but who failed to go...’ [medical doctor-District C]
Unsupportive environment in the community
The presence of private facilities that offered opportunities for part-time (after work in the public sector) practice for earning extra income on top of their salaries was stated to be an important retention factor. The existence of the private health facilities that offer part-time jobs varied from many in District A, a few in District B to none in District C.‘Life is very difficult here... If you can imagine, the indigenous treat us as foreigners who are here for our own interests… It is very difficult to rent a house here, until you have stayed here for a long period… Just as others that were here before, I am also on my way of leaving…’ [health manager-District C]
‘I work here and at two other private places [he mentions them] after my normal working hours…. I earn more than twice my salary from the private practice…. Where else should I go?’ [medical doctor-District A]
‘You tell the relatives that we currently do not have the medicine [he mentions some] needed for the treatment of your patient. We advise them to go and buy it…. While you are sitting waiting for the medicine, they come back with the political leader…. You are embarrassed, but in the end, the leaders are the ones who set low budgets for you…. I am only here because an opportunity to leave has not yet arisen.’ [medical doctor-District C]
‘Education is not a priority here… There are no good private schools where you can take your children… The good hospital is this one, which, as I told you, lacks so many things … I will have to leave for another place where my children will have the assurance of good education, health care, and the likes…’ [medical doctor-District B]
‘My friend, we are very close to Dar, only 25 minutes, but yet we are very far from it. You need to be very rich to go there regularly… This adds to my reasons for not staying here anymore…’ [medical doctor-District C]
Strategies used by managers to retain doctors in situations of resource scarcity
The establishment of a minimum financial incentive package was another strategy revealed by the managers in their effort to retain the MDs in the three districts. The common form of allowance that was found in all minimum financial packages of the three districts was the on-call allowance. In District B, on top of the on-call allowance there was the housing allowance, and in District A the minimum financial incentive package was comprised of an on-call allowance, a housing allowance, a uniform allowance and a responsibility allowance for head of sections (Table 2).‘You know, MDs are a very fluid cadre…. If you do not show them their career path, be sure they will leave immediately; knowing this, we have the career development plan in the incentive package plan…. This has helped us to retain most of our MDs…’ [FGD member-District A]
In order to create opportunities for the MDs to earn extra income but still be retained at the district hospitals, we found that District A was in an arrangement to open an intra-mural private practice within all its hospitals; there were no such similar plans in Districts B and C.‘You know we have so many plans… We are planning to build a hostel for the intern doctors at our plot in [mentions the name of a neighbourhood place]. We will put everything there …they will pay less rent compared to if one is renting as an individual in the community… We will also provide reliable transport to travel to and from the hospital … We are sure this will solve the accommodation issue, motivate our interns and also generate income for the hospital…’ [FGD member-District A]
‘We are planning to create a window for a fast-track clinic (private practice) at our hospitals in [mention of two hospitals]… This will generate income for our hospitals, but at the same time raise incentives for our health workers and hence retain them…’ [health manager-District A]
‘We would like to pay all allowances on time…but we lack funds… If it were you, and you do not have drugs at the hospital and you get some amount of funds, what will you place high up in your priorities? Will you pay for allowances or purchase drugs?’ [health manager-District B]