Back in dar

After six months in southern Manyara at a faith-based regional referral hospital, I’m back in Dar. The dry, highland landscape of scattered foothills had only just turned to green as I packed up to move back. I have now traded the nightly call-and-response of the hyenas and dogs for the gently rolling waves of the Indian ocean on Dar’s south coast. Instead of working within a single hospital, I now find myself working with Ministry, regional and district health officials, with plans to work with 7 hospitals and many more health centres and dispensaries. As a senior project manager for the Clinton Health Access Initiative, I am working with the Ministry of Health and Social Welfare (MoHSW) to pilot a Pay for Performance (P4P) scheme for the health sector in the Pwani (Coast) region. Modestly, we’re working to reward health workers for quality performance in reproductive and child health services. More ambitiously, we hoping to transform the way that Tanzanian pay structures operate.

As a secondary school teacher in a southern highlands village, I became aware of how difficult it could be to demand quality performance from teachers. Heads of school don’t have the power to hire and fire their teaching staff. They can submit formal complaints regarding teachers who routinely fail to teach, some of whom don’t show up for weeks at a time. I have never known this to produce any tangible result. Pay scales across all sectors are determined by education level and years of experience on the job. Individual institutions have little opportunity to provide incentives for quality performance at work. Individuals may set good examples, they may persuade, but without the force of sanction or reward. In education, the result may be children sitting in unstaffed classrooms for most of the day, either dutifully copying notes passed from one generation of students to the next or else amusing themselves in non-academic pursuits in or out of the classroom. In healthcare, the result may be neglected patients who fail to heal, catch new diseases in the wards or even die.

Both the education and health sectors are overtaxed, with insufficient human resources to fulfill their mandates. There is therefore a natural resistance to firing staff who will likely not be replaced. Energetic, self-motivated staff may be easily discouraged working alongside delinquent colleagues who earn the same or more than they do. Of course there is nothing unique to Tanzania in all of this. When I talk to Tanzanian friends and colleagues in education and health, this seems to be one issue on which people agree. Everyone says that these jobs need to pay more. They also say that paying more for good results will produce the desired effect. “Look at the private schools,” a teacher friend of mine opined, “they pay almost twice what the government schools pay and they hire and fire every year. They only keep teachers who can get their students to pass the national examinations and they succeed where we fail.”

In healthcare, failure can mean death. Inadequate care and attention can lead to misdiagnosis, mistreatment or sepsis. If patients knew their rights and could afford lawyers, our facilities would be bankrupted from malpractice litigation. The situation is dire but is not beyond hope. We have skilled professionals who care about the quality of their work in every facility I have known. These are the individuals that need to be singled out, made as examples, and rewarded for their hard work.

I’m looking out now onto the beach where only 3 nights ago the skies were lit up as bombs exploded and echoed all along the horizon. Our health care workers are still tending to the wounded and displaced and will be for some time. These workers are our first line of response against physical harm in all of its forms. If I can play any part in helping the best of them get recognized for their achievement, the move back to Dar will have been all the more rewarding.

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