Health Worker Engagement and Facility Performance in Delivering HIV Care in Tanzania

Introduction: With an increasing number of HIV-patients in treatment, a productive health workforce is essential to provide quality care. Engaged health workers are more productive and provide higher quality care. This study examined latent characteristics of engagement, factors that influence engagement, and the association with health facility performance in providing HIV care in Tanzania. Methods: Engagement data were collected from 1329 health workers; facility-level data were collected from 183 facilities across six Tanzanian regions. We used factor analysis and structural equation modelling to examine latent characteristics of engagement and influencing factors and generalized linear modeling to assess the association between engagement and facility performance. Results: We identified four latent characteristics of engagement (job satisfaction, being accountable, being a team player, and delivering equitable care) and three factors influencing engagement (supportive supervision, human resources and infrastructure, and competencies). All four engagement characteristics were associated with facility performance. Every 10% increase in the proportion of health workers with job satisfaction was associated with 1-percentage point decline in HIV patients lost to follow-up. A 10% increase in those delivering equitable care was associated with 1.8-percentage-point increase in HIV patients lost to follow-up. When more than 40% of health workers were accountable, every 10% increase was associated with 2.8-percentage-point decline in the proportion of HIV-exposed children on co-trimoxazole during their first two months of life. Every 10% increase in the proportion of health workers considered team players was associated with 1-percentage point decrease in the proportion of HIV patients screened for tuberculosis and 3.2-percentage point decrease in HIV patients checking CD4 counts every six months. Facility type and ownership, perceived presence of quality improvement teams, and staffing also influenced facility performance. Conclusions: Engagement is a complex concept affected by health worker and health system factors. Interventions to improve job satisfaction, a characteristic of engagement, can positively impact facility performance. Facility performance cannot be improved through engaged workers alone and should be coupled with approaches to address gaps beyond human resources.