Overworked? The relationship between workload and health worker performance in rural Tanzania

The current shortage of health workers in many low-income countries poses a threat to the quality of health services. When the number of patients per health worker grows sufficiently high, there will be insufficient time to diagnose and treat all patients adequately. This paper tests the hypothesis that a high caseload reduces the level of effort per patient in the diagnostic process, using a new data set from rural Tanzania. Tanzania has a severe shortage of health workers, and previous research has pointed at high workload as a main reason for sub-standard clinical performance. We observed and evaluated the level of effort of 159 clinicians in 2,095 outpatient consultations at 126 health facilities with different levels of caseload per clinician. Surprisingly, we find no association between caseload and the level of effort per patient in the diagnostic process. In fact, clinicians appear to have ample amounts of idle time. We conclude that health workers are not overworked and that scaling up the number of health workers in this setting is unlikely to raise the quality of health services. A more promising measure for improved quality is to raise the level of formal clinical training among the clinicians, although training alone seems far from enough to raise quality to adequate levels.