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CHAPTER ONE 1.0 INTRODUCTION The human resources crisis coupled with poor performance of health workers in the health sector in low and middle-income countries (LMICs) like Tanzania, is receiving increased global attention [1]. This has resulted into policymakers and planners realizing that it is simply not possible to achieve the Millennium Development Goals (MDGs) if health workers’ availability and performances are not addressed more effectively [1]. Poor performance leads to inappropriate care, which contributes to reduced health outcomes, as people do not use services or are mistreated when they do. In the process of improving healthcare system, Tanzania faces challenges such as shortage of health workers, increased case loads for health workers due to migration of skilled health personnel, double burden of disease and the HIV/AIDS scourge that affect both the general population and health personnel hence it is vital for Tanzania to have a well function health system with a well motivated staff that carries out their work according to standard set by the system [3], within the existing organizational structure. The working environment in health care comprises of two major components, namely, physical and psycho-social. During early days of development of health organization psychology only physical environment in work place was given importance and was considered as a predominant determinant of employees‟ performance. Earlier studies examined the effect of illumination, temperature, noise, and atmospheric conditions on performance of the workers [5]. However, no consistent relationship could be noted between these components of physical work environment and performance. Studies in health care psychologists have further examined social and psychological environment and its effects on employees‟ performance [5]. The recognition of the significant role of psycho-social environment led to the emergence of organizational psychology, and furthers the concept of „quality of work life‟. The importance of physical work environment has now been realized. Therefore, the modern health care industries are making all possible efforts to make work environment more comfortable, safe and healthy. In Tanzania, the government through the Ministry of Health and Social Welfare (MoHSW) has the same concern as other Africans countries which are to ensure health and social welfare services are of high quality, effective, accessible and affordable, delivered by a well performing and sustainable national health and welfare system that encourages responsiveness to the needs of the people [6].One of the strategy used was the introduction of a Result Based Management (RBM) using a home grown rubric referred to as Performance Improvement Model (PIM). This is an integrated approach to performance management. This approach, among other things, requires all public service institutions to plan, implement, monitor, evaluate, and report on performance, and finally carry out performance reviews. From the year 2000 to 2006 performance improvement model was installed in all Ministries, independent Departments, Executive Agencies and Regional Secretariats [4]. Also the public service introduced a number of processes, tools and mechanisms in order to facilitate the institutionalization of a performance management system. The specific tools for performance management include strategic and operational planning, client service charters, service delivery surveys, self assessment programmes, performance budgets, the introduction of Open Performance Review and Appraisal System (OPRAS) and comprehensive Monitoring and Evaluation (M&E) system. Furthermore the Performance Improvement Fund (PIF) was established and implemented to support changes identified in Strategic Plans however all these seem to be failing into improving health workers performance [4]. Taking this fact into consideration this study focused on working environment factors which have positive or negative effect on health care performance in Reproductive and child health services the question which the researcher was trying to answer was, what is the effect of working environment on performance level of Reproductive and child health care provider in Tarime District? This dissertation is therefore organized as follows: It starts with the introduction, review of available literature concerning the study, study methodology, results, and discussion of results and finally it ends with conclusion and recommendation. 1.1 Statement of the Problem Poor health-worker performance in low and middle income countries is particularly exacerbated by human resources (HR) shortages that reached critical levels in many resource-poor settings, especially in rural areas like Tarime and has been a major concerned in these countries health sector. Since the start of the Joint Learning Initiative (JLI), in 2003, the human resources crisis in low-income countries (LICs) has received global attention, particularly the crisis in sub-Saharan Africa. In Tanzania less than 50% of the required staff is available to serve rural populations; while at times health care is provided by non-qualified staff [7, 8]. This situation seriously compromises the health status of the communities. The poor performance has been attributed to poor diagnosis and even death of the sick people. Although there is no conclusive evidence concerning the relationship between health outcomes and the number of human resources (HR) available for health care, it is clear that qualified and motivated human resources are essential for adequate health service provision[9]. Low performance can be determined by poor knowledge to perform a given work, poor working condition and poor communication between employer and employee and employee themselves. Determinants of poor performance can be influenced in a variety of ways, The 2006 World health report describes three levels to influence workforce performance this include job-related interventions that focus on individual occupations, support-system related interventions and interventions that create an enabling environment and focus on managerial culture and organizational arrangements [7]. To improve the performance of health care, supportive working environment is needed. This encompasses more than just having sufficient equipment and supplies. It also includes systems issues, such as decision-making and information-exchange processes, and capacity issues such as workload, support services and infrastructure [10]. Although it is logical to link poor performance to poor working conditions, there is limited documentation showing how poor working conditions influence health provider productivity, competence and responsiveness. While some of the reviewed studies done in the country have looked at health worker performance and working environment factors, most of these studies focus on how motivation, supervision, skills to perform the given work, and availability of working tools affect performance [11,12,13],and rarely into the role of working environment and performance of health workers especially focusing on how working environment affect the availability, competence, productivity and responsiveness combined as they affect elements of performance of health workers in reproductive and child health care. This study tried to examine whether there is a relationship between working environment and performance level of the health care provider or otherwise. Therefore, specifically, this study investigated the effect of working environment on performance level of health care providers in Tarime district. The study examined how working environment affects workers performance and evaluated the extent to which working environment would contribute to encouraging or discouraging health care provider to perform well. 1.2 Rationale of the Study This study has produced information on the relationship between working environment and health worker performance that might be used to understand how performance of 5 health workers in the Reproductive and Child Health care is affected by working environment that need special attention in the reduction of maternal and infant mortality on health care provider‟s area. Furthermore, the research findings could be used to inform the district on working environmental factors influencing performance of health care provider. It also serves as background information for promoting and advocating good environment for improved performance of health care worker in Tarime district. More over it serves as background information for future research of the same topic. 1.3 Conceptual Framework This conceptual framework tries to explain how working environment influences health workers performance. It assumes that working environment consists of two components that are physical environment and behavior component. Physical environment comprises the comfort level (presence of office building and working tools) which influences health provider‟s availability, productivity and competence. Also there is an office layout (presence of privacy) which influences health workers productivity and competence. The behavior component of environment (how workers interact with each other and absence of noise) tends to influence productivity and responsiveness, and in totality they may improve or decrease health workers performance. (See illustration in figure 1) 6 Figure 1: Conceptual Framework: Effects of Working Environment on RCH Health Workers Performance WORKING ENVIRONMENT FACTORS a) PHYSICAL COMPONENT OF WORK ENVIRONMENT. 1. COMFORT LEVEL • Office building space and Infrastructures (water and electricity). • Presence of working tools and medical supplies. 2. OFFICE LAYOUT • Presence of Privacy b) BEHAVIOUR COMPONENT OF WORK ENVIRONMENT 1. LEVEL OF INTERACTION. • Work interaction 2. DISTRUCTION • Absence of noise 2. PRODUCTIVITY  Health worker workload 3. COMPETENCE • Adherence to standard operating procedures • Communication with patients 4. RESPONSIVENESS • Clients‟ and health workers‟ satisfaction Improve/ decrease health workers performance in Reproductive and Child Health Clinic. PERFORMANCE INDICATORS 1. AVAILABILITY  Drugs availability.  Health worker availability 7 1.4 Research Question What is the effect of working environment on performance level of the health care providers? Specifically the research aims at answering the following questions: 1. What is the effect of office building space on health providers‟ availability performance in Tarime district? 2. How does health provider interaction with fellow worker affect health workers‟ productivity performance in Tarime district? 3. How availability of drugs affect the competence performance of reproductive and child health care providers in Tarime district? 4. How availability of equipment (BP – machine) affect the competence performance of reproductive and child health care provider in Tarime district? 5. What is the effect of presence of privacy on health workers‟ competence performance in Tarime district? 6. What is the effect of noise on health workers‟ responsiveness performance in Tarime district? 7. What are the Clients‟ perceptions on elements of performance (availability, competence, productivity and responsiveness)? 1.5 Objectives This study focused on the following broad and specific objectives. 1.5.1 Broad Objective To explore the relationship between working environment and performance level of health care provider working in reproductive and child health unit (RCH) in Tarime district. 8 1.5.2 Specific Objectives 1. To explore the effect of office building space on availability performance of reproductive and child health care provider. 2. To assess how health provider interaction with fellow worker affects health workers‟ productivity performance. 3. To explore availability of drugs in relation to competence performance of reproductive and child health care provider. 4. To explore availability of equipment (BP- machine) in relation to competence performance of reproductive and child health care provider. 5. To assess presence of privacy in relation to health provider competence performance. 6. To find out how noise affects health workers‟ responsiveness performance. 7. To explore Clients‟ perception on elements of performance (availability, competence, productivity and responsiveness)

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