emerging evidence from the literature is that the agent can improve recruitment, job
satisfaction, and retention by improving the work environment (Dominic & Kurowski
2004; Kurowski et al. 2007). This would include pragmatically testing some promising
innovations from other countries, which include the provision of well written job de-
scriptions, improved management-employee communication systems and staff realloca-
tion to reduce distributive inequalities (Van Dormael 2008; Munga & Maestad 2009;
Heywood & Harashap 2009). These innovations may not require money. For example,
prompt feedback from local authorities on requests or appeals from dispensaries and
health centres would make a big difference compared to silence or untimely feedback.
This would reduce employee complaints ranging from lack of feedback on requests to
getting money to pay wages to watchmen or to repair a broken chair in the office of the
doctor in charge.
The community health fund is a typical innovation of the central government to de-
centralise decision making over financial resource generation and utilisation at the level
of the health centre and dispensary. Local authorities should see this as an opportunity
to motivate human resources for healthcare rather than a source of revenue for other
expenditure.
Other innovations have been the re-employment of retired staff through contracts.
This initiative has reduced the effect of staff shortages. For example, some nurses and
clinicians were employed in Dodoma, Iringa, and Morogoro through contract and
seemed to be more committed than the other categories of staff although there were re-
portedly cases of a conflict of interests with other staff (Shao et al. 2007).
Lastly, the principal has an obligation to make healthcare service delivery function
despite limitations at the local authority level by increasing the resources allocated
through budgeting. Statistics show that in 2004 budget allocation for the health sector in
Tanzania was by far the lowest in East Africa (World Bank 2008). This trend has to be
reversed if we are to see a better health sector in the country.
Human resource policy implications
The health sector reform strategy to decentralise decision making in a number of key
areas including human resource management for health does not seem to have created
the desired impact when principal-agent-dependency theory is used to inform the under-
standing of human resource for health recruitment and retention in local authorities.
Indeed, a total centralisation of recruitment has the potential to harm staff recruitment
more than decentralisation because employees working in councils have two masters,
one behaving as an agent and another as a principal. This creates bureaucracy and loss
of direction in developing a coherent strategy at the local level for human resource re-
cruitment and retention, which is effectively supported by the central government.
Similarly, the innovation made by the ministry of health and social welfare to intro-
duce a community health fund was a golden opportunity to use the fund to solve some
of the local level problems experienced in health centres and dispensaries. However,
although the fund is inadequate but available it causes more frustration than relief to the
staff and general working environment of health facilities. This is an area where local
authorities need to work on in collaboration with community health fund secretariat.
However, despite these limitations the emerging innovations to use monetary incen-
tives and joint fora for MTUHA reports presentations in council meetings have the po-
tential to improve staff morale and performance through open performance appraisal