POOR motivation among health workers is one of the major challenges stifling the reduction of maternal deaths in the country. The problem of women dying while giving birth has been a thorn in the flesh for a long time.
In 2008, Tanzania was one of the 11 countries that made up 65 per cent of all maternal deaths in the world. Government, in 2009, introduced the Pay for Performance (P4P) in Mother, Newborn and Child Health (MNCH), to mitigate the runaway maternal mortality rates and accelerate the attainment of Millennium Development Goals (MDGs) number 4 and 5, addressing mother and child health.
P4P links incentives to performance with the hope that better performance by health workers improves quality of health services and is perceived to have the potential of increasing motivation of health workers, cooperation and teamwork.
A medical attendant at Hembeti Dispensary in Mvomero District, Morogoro, Ms Felista Lupala, said that the fund motivates health workers like her to work hard in the face of difficult working conditions. She said, "In 2009 and 2010 members of staff received 120,000/- each."
She suggests the money from the programme could be added to their salaries to make it easier to access the money on time. Currently, the money is chanelled through the Ministry of Health then to the Regional Medical Officer, before reaching the District Medical Officer.
An enrolled nurse at Wami Dakawa Ward Dispensary, Ms Margreth Yapesa said, "The money motivates us for sure, even if I am not on duty I help expectant mother during the night in case of emergencies."
However, Ms Nelly Mtema (37) of Wami Dakawa village a mother of a two-month-old baby said that health facilities still lack drugs and medical equipment. Dr Frank Godfrey Mrema, Morogoro Regional Medical Officer said that the P4P is a good thing but the issue is who should be paid starting from security guards as all workers at health facilities are involved in one way or another in maternal health.
He said, "As it is, who is entitled to the fund money is very crucial. I cannot say that security guards are not involved as they are the ones to rush and open gates when ambulances come with expectant mothers, they too save lives," he stressed.
The Coordinator of District Health Services, System Strengthening, Policy and Planning Department in the Ministry of Health and Social Welfare, Dr Anna Nswilla said whoever performs his or her best should be awarded no matter what position that person holds as long as the facility is covered under P4P criteria.
However, Dr Mrema said rewarding performance alone will not reduce the rate of maternal deaths without a sufficient number of delivery kits, medical equipment and drugs.
The 2007 Health and Social Welfare Policy states that government in collaboration with other health stakeholders will develop and oversee the implementation on guidelines, strategies and sustainable programmes to reduce maternal deaths and child mortality under the age of five years, especially infants. In collaboration with stakeholders the fund will improve access to drugs, and medical equipment.
Dr Nswilla said that P4P has set indicators that correspond to the level of dispensaries, health centres and hospitals have nine indicators. While the district health operating teams have four indicators and the regional health activities have three.
Taking an example of Coast Region, P4P criteria used according to Dr Nswilla included the rate of contraceptive use, the percentage of expectant mothers who had received the second dose for preventing malaria. She said other indicators include the percentage of expectant mothers with HIV/AIDS infection. These mothers are given medication to prevent infection from mother to child amongst others.
Many developing countries are piloting or scaling up programmes like P4P to meet MDGs and other health indicators. Each country's experience with P4P is different, but by sharing approaches and lessons learned, stakeholders will better understand the processes and challenges involved in programme design, implementation, evaluation, and scale-up.
Despite having a comprehensive service delivery infrastructure from grassroots to tertiary levels, there is significant under-utilisation of the existing capacity for maternal health services, especially due to shortages of qualified staff, and suboptimal performance of providers.
When P4P was introduced in 2009, health centres in Mvomero District qualified for the fund after reaching the minimum required percentages. Mvomero District Medical Officer (DMO), Dr Nicholas Chiduo said that at least every health facility met the standards. Since distribution of the funds depends on the population index, there are 300,312 people, 23 wards and 62 health facilities in the 115 villages whereby in dispensaries 1m/- was awarded, health centres 3m/- and 9m/- to the hospitals.
Dr Chiduo said that initially from the health budget of 2008/09 and other sources like Health Basket Fund, the district set aside some money to pay the bonuses for motivating health workers. "But later, some changes were made and we started to use the council money instead of the money from the development partners," he said. In the 2008/09 budget, the district kept aside 32,900,000/- to motivate health workers.
In 2009/10 it was 58m/-, in 2010/2011 was 57m/-, and 2011/12 was 22,732,000/-. The district has an average of two staff for dispensaries, 15 staff at health centres and about 200 at designated district hospitals. Maternal deaths have declined whereby in 2010, there were 12 deaths, and last year there were only five deaths.
Child mortality for children under the age of five years in the district annually was from 75 per 1 000 in 2010 to 69 per 1 000 in 2012.The percentage of women giving birth at a health centre is currently 70 per cent in the district.
In Rwanda research shows that P4P payments depend on the completion of reports and health providers seem to spend more time on administrative duties and less time ensuring that patients receive quality care.
In the study, researchers assessed that the P4P scheme could increase use and quality of key maternal and child health services. Researchers saw that P4P financial performance incentives can improve both the use and quality of maternal and child health services and could be a useful intervention to accelerate progress towards MDGs for maternal and child health.