The crisis in human resources for health care and the potential of a 'retired' workforce: case study of the independent midwifery sector in Tanzania
The crisis in human resources for health care and the potential of a 'retired' workforce: case study of the independent midwifery sector in Tanzania
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DOI：
10.1093/heapol/czm049
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发表时间：
2008-03-01
影响因子：
3.2
通讯作者：
Murray, Susan F.
中科院分区：
文献类型：
--
作者：
Rolfe, Ben;Leshabari, Sebalda;Murray, Susan F.
保健领域的人力资源危机是实现千年发展目标中与保健有关的具体目标的一个重要障碍。缓解政府服务压力的一项建议战略是鼓励非政府提供新形式的服务。然而，通常缺乏关于实施和后果的细节。本文考察了坦桑尼亚非政府提供的一个新元素：小规模独立助产实践。通过对九个地区的多案例分析，探讨了它们的特点，以及立法变化允许后对其发展的驱动因素和抑制因素。私人助产实践集中在晚年企业家的新劳动力中：退休或即将退休的政府雇用的护理人员。由于管制要求，经费完全以设施为基础，大约有60个妇产院主要设在农村或城郊地区。动机驱动因素包括对贫困的恐惧，保持专业地位的愿望，以及社区服务的精神。然而，成功的障碍是多方面的。创业贷款很少，商业培训缺乏，注册程序官僚。建立和维护的费用高得令人望而却步，注册所需的建筑和设备水平与政府部门的药房相似。社区不愿意为他们期望政府提供的服务付费。因此，尽管通常在服务条件差的地区提供与政府设施相当质量的基本产妇护理，但大多数私人产妇之家利用不足，难以维持下去。由于他们的位置和强调个性化护理，由退休助产士经营的小规模独立实践可能会增加外围水平分娩的熟练出勤率。这种模式还延长了专业团队成员在人员短缺时的工作寿命。然而，潜力仍未实现。这种模式要在资源贫乏的社区成功推广，需要的不仅仅是放松对私有制的管制。需要通过减少对以设施为基础的供应的强调来减少过高的开办费用。需要考虑小额信贷、承包、代金券和特许经营模式等正在进行的融资安排。
The human resource crisis in health care is an important obstacle to attainment of the health-related targets for the Millennium Development Goals. One suggested strategy to alleviate the strain upon government services is to encourage new forms of non-government provision. Detail on implementation and consequences is often lacking, however. This article examines one new element of non-government provision in Tanzania: small-scale independent midwifery practices. A multiple case study analysis over nine districts explored their characteristics, and the drivers and inhibitors acting upon their development since permitted by legislative change.Private midwifery practices were found concentrated in a new workforce of later life entrepreneurs: retired, or approaching retirement, government-employed nursing officers. Provision was entirely facility-based due to regulatory requirements, with approximately 60 maternity homes located mainly in rural or peri-urban areas. Motivational drivers included fear of poverty, desire to maintain professional status, and an ethos of community service. However, inhibitors to success were multiple. Start-up loans were scarce, business training lacking and registration processes bureaucratic. Cost of set-up and maintenance were prohibitively high, registration required levels of construction and equipping similar to government sector dispensaries. Communities were reluctant to pay for services that they expected from government. Thus, despite offering a quality of basic maternity care comparable to that in government facilities, often in poorly-served areas, most private maternity homes were under-utilized and struggling for sustainability.Because of their location and emphasis on personalized care, small-scale independent practices run by retired midwives could potentially increase rates of skilled attendance at delivery at peripheral level. The model also extends the working life of members of a professional group at a time of shortage. However, the potential remains unrealized. Successful multiplication of this model in resource-poor communities requires more than just deregulation of private ownership. Prohibitive start-up expenses need to be reduced by less emphasis on facility-based provision. On-going financing arrangements such as micro-credit, contracting, vouchers and franchising models require consideration.