Voices from the Capacity Project

In countries where available human resources for health (HRH) are insufficient to meet the needs, it is increasingly vital that health workers are supported to do their jobs effectively and efficiently.

“First of all, if you want to improve health then you have to look at what is existing [in terms of HRH] and identify if, for example, the health workers have the skills needed,” says Khamis Khamis, Head of the Human Resource Division at the Zanzibar Ministry of Health and Social Welfare in Tanzania. “Do they have the appropriate equipment and environment, and are they working as they’re supposed to, in terms of productivity?”

Health care worker productivity is a key ingredient of quality health services. The benefits of addressing productivity include greater efficiency, reduced workload intensity, increased worker satisfaction and a higher quality of care. In Zanzibar, the Ministry of Health and Social Welfare is committed to developing interventions that improve productivity and address the major health challenges. In partnership with the Ministry, the Capacity Project is carrying out an initiative to investigate productivity in the health sector and select, implement and evaluate interventions to improve efficiency.

The Project completed a baseline study in 2006, followed by a stakeholder workshop to analyze the most significant gaps and select interventions. The study observed more than 65 health care providers across 30 facilities to understand how they use their time on the job, and what challenges and obstacles decrease their productivity. On average, health workers spent three-fifths of their observed time doing productive activities, primarily providing direct care for patients. More than one-fourth of the observed time was spent doing unproductive activities, mostly waiting for patients.

“The study showed that the districts are, as we say, the cornerstone, because it is there where they deal with the problems,” says Khamis. Therefore, he adds, regarding health workers at district-level facilities, “knowing—although they are few—how they are working” is crucial. “Is it according to the needs or not?”

Zanzibar’s health infrastructure relies on a network of Primary Health Care Units (PHCUs), which are the foundation of Zanzibar’s public health system. In addition to providing the first tier of direct care, PHCUs are expected to deliver community outreach and education programs, and gather and report community health data back to higher levels of the system. When PHCUs experience problems with efficiency and quality of care, these problems ripple up through other levels, undermining the entire system.

The study revealed several gaps in the system, says Khamis, including issues of “coordination, teamwork, transparency and proper supervision.” The area of supervision needs attention, he acknowledges, because health workers “are doing tremendous work but there are still some problems.” Motivation is another challenge; some workers “say that they are doing [important tasks] but no one recognizes what they do.”

Analyzing the study findings, stakeholders perceived the problem of low productivity at the PHCUs to be the most immediate. In June, the Project facilitated a follow-up workshop to select targeted interventions and inform an implementation plan. Stakeholders considered strategies that were evidence-based, inexpensive and within their power to implement in the short term. Next steps include prioritizing the interventions, confirming pilot sites and writing an implementation plan.

Stakeholder leadership groups are key to the Project’s approach. Reflecting on the successful progress of the productivity initiative, Khamis remarks, “There is this aspect of involving everyone responsible in an activity, so that people feel it is our thing, like this workshop.” He explains that “people have more to share, they just need support and guidance on how to do this.”

“They’ve appreciated the opportunity to be invited to share their ideas,” comments Paul Ruwoldt, the Project’s Workforce Support Advisor, “and one of the challenges for us is to continue their involvement and provide feedback to them as we all move forward.”

Khamis adds, “Sometimes we seem to slow down but the Capacity Project keeps pushing us to continue. We very much appreciate that.”

The productivity improvement interventions will be tested and refined in Zanzibar, and from this experience the Project will develop a set of productivity approaches intended to be applicable across countries.

[July 2007. Print a PDF version. Read an interview with Khamis Khamis on the HRH Global Resource Center.]

The Capacity Project, funded by the United States Agency for International Development (USAID) and implemented by IntraHealth International and partners, helps developing countries strengthen human resources for health to better respond to the challenges of implementing and sustaining quality health programs.

The Voices from the Capacity Project series is made possible by the support of the American people through USAID. The contents are the responsibility of IntraHealth International and do not necessarily reflect the views of USAID or the United States Government.