Navigating Scarcity: A Qualitative Study of Healthcare Workers’ Perspectives on Emergency and Critical Care in Tanzanian Primary Health Facilities

Navigating Scarcity: A Qualitative Study of Healthcare Workers’ Perspectives on Emergency and Critical Care in Tanzanian Primary Health Facilities | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Navigating Scarcity: A Qualitative Study of Healthcare Workers’ Perspectives on Emergency and Critical Care in Tanzanian Primary Health Facilities View ORCID Profile Manji N Isack , View ORCID Profile Dickson A Mkoka , View ORCID Profile Beatrice E Mwilike doi: https://doi.org/10.1101/2024.10.09.24315178 Manji N Isack 1 Department of Nursing, Kilimanjaro Christian Medical Centre , Moshi, Tanzania 2 Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences , Dar es Salaam, Tanzania Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Manji N Isack For correspondence: nyaganya2018{at}gmail.com Dickson A Mkoka 2 Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences , Dar es Salaam, Tanzania Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Dickson A Mkoka Beatrice E Mwilike 3 Department of Community Health Nursing, Muhimbili University of Health and Allied Sciences , Dar es Salaam, Tanzania Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Beatrice E Mwilike Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Introduction Emergency and critical care (ECC) services are essential to preventable death, yet they remain poorly developed in primary healthcare (PHC) settings in low-resource countries such as Tanzania. There is a critical gap in understanding the experiences of frontline healthcare workers providing ECC to critically ill patients of all ages in these contexts. This study aimed to: (1) describe the experiences of nurses and doctors in delivering ECC in Tanzania PHC primary facilities; (2) explore systemic and resource challenges; and (3) document their perspectives on essential improvements for service delivery. Methods A qualitative phenomenological study was conducted in 2021 across three PHC facilities in Kilimanjaro, Tanzania. Purposive sampling was used to recruit 12 healthcare workers. Semi-structured, in-depth interviews were conducted, and data were analyzed using thematic analysis. Results The analysis revealed three overarching themes: (1) a constrained ecosystem of care; (2) navigating clinical uncertainty and systemic failure; and (3) the human cost of systemic failure. Participants prescribed a straightforward solution: a multi-level strategy requiring government-led investment in infrastructure, holistic training, and updated policies in a second-order theme (A Frontline Blueprint for Change: Advocacy and Proposed Solutions). Conclusion Tanzanian PHC workers work in resource-scarce settings that hinder care and cause preventable deaths. Their perspectives on ECC can help implement ECC practices aligned with the 2023-2026 national plan. Supporting ECC at the primary level improves patient outcomes and empowers frontline workers. What is already known on this topic Previous studies highlight PHC facing the weakest investment in ECC infrastructure and resources in Tanzania, mainly quantifying material deficits rather than understanding frontliners’ daily experiences of navigating systemic failures. What this study adds This qualitative study provides a deep analysis of the profound human and systemic consequences of ECC resource scarcity, showing how it causes moral distress among providers and preventable patient harm. Significantly, it moves beyond problem identification to offer a participant-derived “Frontline Blueprint for Change,” outlining specific, actionable solutions for strengthening ECC at the PHC level. How this study might affect research, practice or policy The findings offer concrete evidence to support Tanzania’s 2023-2026 National Strategic Plan for Essential ECC. For policymakers and health administrators, this study provides a practical roadmap for targeted investment in infrastructure, equipment, and training, promoting a systemic shift for PHC facilities to deliver effective initial ECC. Introduction Global efforts to reduce preventable mortality rely on timely ECC, but capacity varies widely. [ 1 ] High-income countries have advanced ECC [ 2 , 3 ] , while Sub-Saharan Africa (SSA), with a quarter of the global severe disease burden [ 4 ] , and intensive care unit (ICU) mortality up to 50% [ 5 , 6 ] , has limited critical care capacity (0.53 ICU beds per 100,000 people) and lacks essential epidemiological data. [ 7 ] This crisis is caused by resource shortages; economic constraints in countries like Tanzania limit ECC services to urban tertiary hospitals, leaving PHC facilities— where most rely for initial treatment—severely underdeveloped. [ 8 , 9 ] Consequently, a critically ill patient’s journey often begins in under-equipped PHC facilities, where studies in Tanzania show critical resource gaps and the highest burden of critical illness. [ 9 , 10 ] Yet, the human experience navigating these shortages remains largely unexplored. A critical gap exists in understanding the perspectives of nurses and doctors providing ECC amid constraints—what challenges do they face? How do these affect care and outcomes? What are their improvement priorities? The ECC delivery crisis at the primary level hinders universal health coverage in low-resource countries. This first systemic frontline analysis provides a practical solution framework. It explores challenges, approaches, and suggested improvements, offering insights for enhancing the health system. Methods Study Design We employed a qualitative research approach, utilizing a descriptive phenomenological study design. This methodology was selected as the most appropriate to gain an in-depth, nuanced understanding of the lived experiences and shared essence of providing ECC from the perspective of nurses and doctors in PHC facilities. The study was conducted between May and June 2021 in the Moshi Municipal Council, Kilimanjaro Region, Northern Tanzania. Patients or the public were not involved in the design, conduct, reporting, or dissemination plans of our research. Setting and Context The study took place in Moshi Municipal Council, Kilimanjaro. Using the 2022 census with a regional population of 1,861,934 and a 1.3% annual growth rate from 2012-2022, the estimated 2021 population was about 1,838,000. [ 11 ] PHC facilities in Moshi comprise three hospitals, ten health centers (HCs), and forty-five dispensaries, predominantly government-owned. [ 12 ] Purposively, this study occurred in three PHC facilities: St. Joseph Hospital (a council-designated hospital), and two HCs (Pasua and Majengo). These facilities represented a spectrum of PHC capacity, as all provide outpatient and inpatient services and are tasked with initial ECC stabilization. However, their capacity is limited; complex cases must be referred to higher-level facilities—Mawenzi Regional Referral Hospital or Kilimanjaro Christian Medical Centre (KCMC), a tertiary zonal hospital—following the national pyramidal referral system. While St. Joseph manages more complex cases, HCs are more basic and rely more on referral. These facilities are crucial as healthcare workers’ perspectives on ECC at this foundational level, the first contact point for most, have not been previously explored. Eligibility, Inclusion, and Exclusion Criteria The study involved frontline clinical staff (nurses and doctors) from three PHC facilities with at least a year of work, recent ECC experience (within 6 months), and involvement in referrals. They voluntarily consented, excluding those on extended leave or non-clinical roles. Participants from different units (including wards, emergency, theatre, labor ward, and administration) were purposively selected to ensure diverse data with the help of facility/department heads, approached in person, informed about the study, and invited to participate. Determination of Sample Size and Data Saturation Initial sample size for a phenomenological study was 5-25 participants [ 13 ] , but saturation guided ending at 12. [ 14 ] No repeated interviews; data collection and analysis were iterative. After about eight interviews, core themes on challenges in ECC —resource scarcity, referral barriers, emotional burden—became consistent, indicating saturation. The last four interviews confirmed and deepened these themes. Participants from three facilities offered diverse contexts, but universal experiences. No one refused to participate. Saturation was achieved at the phenomenon level, not per facility. Researcher Reflexivity Before the study, the team discussed their backgrounds and assumptions about ECC in Tanzania. The primary researcher, an experienced clinical expert involved at the sites, acknowledged prior understanding of systemic challenges. They consciously set aside these assumptions during data collection and analysis to focus on participants’ perspectives. Trustworthiness was ensured through triangulated coding and the use of SRQR: Standards for Reporting Qualitative Research in drafting the manuscript. [ 15 ] Data Collection and Procedures While data occurred in 2021, the persistent systemic challenges remain relevant to current policy in Tanzania, evidenced by the release of the 2023-2026 National Strategic Plan on Essential Emergency and Critical Care Services. [ 16 ] A refined semi-structured interview guide from facility staff based on ECC challenges in low-resource settings [ 1 , 2 , 4 , 10 , 17 – 20 ] was pilot-tested with two interviews, which were excluded from analysis. All interviews, conducted by the first author in Kiswahili in private hospital rooms, lasted 25-40 minutes and were audio-recorded. No third person was present during interviews. To enhance data familiarity, the researcher also conducted field observations, reviewed documents, and assessed environments, taking notes. Transcripts were validated by participants via member checking to ensure accuracy before exiting the field. Data Analysis Data were analyzed using an inductive thematic approach based on Braun and Clarke’s (2006) six-phase framework. [ 21 ] All audio-recorded interviews were transcribed verbatim in Kiswahili and translated into English by the first author. The research team reviewed transcripts against recordings to correct errors. The analysis began with a familiarization phase, where all three authors thoroughly read the transcripts. Each independently coded four transcripts manually to identify relevant meaning units. They then compared, discussed, and integrated codes into a unified codebook. The team grouped codes into themes, continuously re-evaluating their coherence and fit. Multiple meetings refined the themes—merging, separating, and redefining— until final themes accurately reflected participants’ perspectives. Results Participants Characteristics Twelve participants were interviewed: five males and seven females. Half (6) were nurses, and half were doctors. Seven were aged between 25 and 35, and five between 35 and 45 years, with 1 to 23 years of work. St. Joseph Hospital contributed five participants, Majengo HC four, and Pasua HC three. Most (n=6) held a Diploma and worked as Assistant Nursing Officers or Clinical Officers; three had degrees (Nursing Officers and Medical Doctors), and three held Certificates (Enrolled Nurses). Interview Findings The analysis revealed a challenging reality for healthcare workers providing ECC in Tanzanian PHC low-resource settings. The thematic analysis revealed three first-order (overarching) themes (A Constrained Ecosystem of Care, Navigating Clinical Uncertainty and Systemic Failure, and The Human Cost of Systemic Failure), and one second-order theme, “A Frontline Blueprint for Change: Advocacy and Proposed Solutions” (see Table 2). Supporting quotations use a hybrid approach, combining prevalence statements (e.g., “A common experience was…”) with participant identifiers (e.g., P05, facility-F1-F3) to demonstrate the universality and detail of findings. View this table: View inline View popup Table 1. Final themes, categories, and codes Theme 1: A Constrained Ecosystem of Care A significant lack of critical resources defined the primary experience of ECC. The resource-limited ecosystem was marked by a shortage of physical infrastructure, medical supplies, human resources, and essential medications, which consistently made it difficult to provide standard care. 1.1 Lack of Space and Infrastructure A collective respondent experience was the lack of a dedicated, fully-resourced space to provide ECC. Participants universally expressed that the space and structures that exist were inadequate, often describing them as small, overcrowded, and not appropriately equipped. An enrolled nurse reported, “Our emergency room is small with three beds, which limits care to many patients and in case of emergencies. This was our biggest challenge during the COVID-19 outbreak.” (P04, F1) A nursing officer noted that they are without the basic units, “First, we don’t have an ED/ICU. Second, we don’t have trained staff in ECC…” (P06, F3) A medical doctor indicated logistical challenges: “Limited space in our overcrowded emergency room makes any rescue procedures very difficult. The staff will have to evacuate other patients first… The delays could result in critical minutes lost…” (P02, F1). 1.2 Significant Shortages of Utilities and Equipment The lack of functioning basic emergency equipment caused frustration and threatened patient safety. Reliance on oxygen concentrators with unstable power supply was a common failure point. The issue of oxygen dependence was illustrated by a nursing officer: “We lack oxygen backup cylinders, and power issues hinder electric concentrator use” (P06, F3). Subsequently, she illustrated what happened as a result: “When I get a patient and electricity is not available, the baby won’t get oxygen on time… I will have to use an empty Ambu bag until it is restored, risking the patient’s survival. Backup cylinders would be extremely helpful.“ A further constraint was the lack of basic monitoring equipment: “We lack a pulse oximeter, which limits oxygen measurement, leaving the reliance on observation“ (P10, F2). 1.3 Absence of Essential Drugs and Supplies Participants detailed the reality of drug stock-outs, and they were frequently faced with decision-making that sent families to purchase drugs at private pharmacies and unnecessary patient referrals. A common frustration was articulated: “…sometimes you are out of salbutamol for nebulization; you have looked everywhere in the hospital and may find nothing, the time is passing by, and I am thinking, come on, how is this patient going to survive?“ (P03, F1). One clinical officer described their dilemma “…when I lack essential drugs or supplies, I prefer to refer my patient early, instead of sending them to private pharmacies, stand there, and then return empty-handed; while delaying care“ (P05, F1). 1.4 Human Resources and Deficits in Training The constraints were both material and human. Participants noted a shortage of healthcare workers and their lack of specialized ECC skills, causing a gap between theoretical guidelines and actual practice. The dual challenge of staffing and knowledge was highlighted: “…apart from lacking equipment…we lack staff. We are few, and largely, we also lack updated knowledge and skills…due to the absence of the on-the-job training“ (P01, F1). The training gap was significant: “ …you could be on shift with someone who does not recognize if a patient is in critical condition…they do not know. People need training to identify critical illness quickly and focus on saving that patient’s life first and foremost ” (P02, F1). As he added, the lack of specialized skills was the main reason for unnecessary referrals: “… if we had staff capable of using ventilators that are rotting inside or providing proper ECC, we wouldn’t need to refer some patients…this is an area where we lack skills” . This theme of a resource-limited ecosystem of care illustrates the impossible context in which healthcare workers are forced to operate. The following themes then detail how they navigate this context, and the consequences that ensue. Theme 2: Navigating Clinical Uncertainty and Systemic Failure Within a constrained ecosystem, healthcare workers improvised (Ad-Hoc) and self-reliant methods to care for critically ill patients, navigating clinical uncertainty without protocols and relying on a systemic referral process that often failed, thereby increasing patient risk. 2.1 Ad-Hoc and Knowledge-Based Patient Assessment In the absence of formalized triage systems, identification of critical illness relied on the individual clinician’s knowledge, experience, and memory of basic training, leading to inconsistent and variable care. A common practice was described: “To identify a critically ill patient, we usually consider vital signs, meaning we look at ABCDE to determine if the patient is in critical condition” (P01, F1). Others reflected this dependence on basic knowledge: “I always consider evaluating levels of consciousness using Glasgow Coma Scale (GCS); it’s based on methods we learned in school and no new” (P02, F1). The lack of objective tools was a major obstacle: “We don’t have a formal system for categorizing patients based on symptoms, but we usually rely on clinical assessment” (P07, F2). 2.2 The Default Response to Refer Due to ongoing constraints in ECC resources, referral was a standard process for critically ill patients. When clinical interventions couldn’t be provided, the default was to refer immediately to a higher level of care. The rationale for an immediate referral was simple: “I refer a patient early when I cannot meet their clinical needs due to either a lack of oxygen, drugs, or equipment” (P01, F1). That reflex was simply a response to an absence of capacity: “We usually refer patients that we feel we cannot handle here…” (P12, F3). One medical officer summarized the sentiment with: “As a primary health facility, we usually have equipment for the ‘initial care’, which are also lacking, so we have to refer regardless of the seriousness of illness” (P07, F2). 2.3 The Ambulance Single Point Bottleneck The referral system was highly problematic due to a severe ambulance shortage. When only one ambulance served all local facilities, transportation to higher care was delayed, often egregiously. The main problem was clear: “The challenge of sharing one ambulance with other HCs and dispensaries in the municipality is awful…” (P10, F2). This participant and others (P08, F2 & P11 & 12, F3) discussed its consequences on patient outcomes: “If you get an emergency, you call an ambulance and you find it is in use… the waiting causes deterioration…some may die or complicate their management in tertiary hospitals” . Similarly, a nursing officer illustrated the peril example: “ It takes over seven kilometers to reach KCMC, sometimes without oxygen. Delivery devices may be unavailable for twins. You tell the driver to hurry, then switch the same nasal cannula if one turns blue… (P06, F3). 2.4 If All Else Fails, Improvise Failure of the referral system limited quick referral options. Healthcare workers demonstrated creativity and resilience, improvising care management with the best available resources and protracted interventions to keep patients alive. A nursing officer described a common workaround for oxygen shortages: “If the electricity isn’t available, the baby won’t get oxygen on time…I use an Ambu-bag until electricity is restored” (P06, F3). This improvisation extended to using family members in cases of equipment and drug scarcity: “We have to direct family to buy in pharmacies. It takes time, and the patient is suffering” (P03, F1). Navigating uncertainty and system failure deeply affected patients and providers. Themes 1 (constraints) and 2 (failed processes) highlight family grief, provider distress, uncertain plans, and system issues, leading to catastrophic outcomes in theme 3. Theme 3: The Human Cost of Systemic Failure The system’s scarcity and failure carried a heavy human burden, resulting in preventable patient harm and moral distress among healthcare workers who felt powerless to provide the standard of care they knew was required. 3.1 Preventable Mortality and Morbidity Participants overwhelmingly believed that system constraints directly led to patient deaths and disabilities that could have been avoided with adequate resources and a functional referral pathway. A medical doctor described this belief: “Many deaths among critically ill patients are preventable, caused by bleeding or lack of oxygen—issues that could be addressed by controlling bleeding or securing airways…” (P02, F1). He also explained the explicit link between delays and long-term disability: “Delays can lead to severe outcomes, like amputation, if care is postponed. Early management can prevent such consequences.” The danger of the referral journey itself was explicit: “Not all referred patients reach their destination; some may die en-route, depending on condition severity and timely care” (P12, F3). 3.2 Moral Distress and Emotional Burden Healthcare workers expressed tremendous emotional distress in relation to the inability to provide appropriate care. The various ways of defining moral distress—all viewed as a moral injury; to know what you should or want to do, but it is not possible—came from all participants and resulted in feelings of guilt, stress, disillusionment, and professional failure. An assistant nursing officer explained how the work situation turned into personal stress: “This affects my ability to work because if it were something I am capable of doing, but now, because of no equipment, I end up referring the patient. This makes me feel uncomfortable or stressed about my work” (P09, F2). The feeling of failing patients was poignant: “… you feel you are failing them because you cannot do anything right…” (P04, F1). The sense of constant burden was overwhelming: “It is challenging to provide adequate, timely care to many patients simultaneously” (P01, F1). 3.3 The Financial and Emotional Burden on Patients and Families The implications of systemic failure extended beyond clinical outcomes, adding a significant financial and emotional burden on many patients and their families, who were often forced to bear the costs and risks of an inefficient system. A medical doctor joined these two burdens as an unjust economic burden to pay for inadequate care: “The need for these services will save the poor, who can’t afford costly care in large hospitals” (P07, F2). An assistant nursing officer summarized families’ experience as being: “Annoying, costly, and stressful” (P08, F2). Systemic failure created a dual burden: patients faced increased risks of death, disability, and financial hardship, while healthcare providers suffered moral injury and distress amid responsibilities and limitations. Participants proposed solutions targeting scarcity, systemic failure, and patient safety, forming the core of the discussion. Discussion This exploratory qualitative study investigated the lived experiences of nurses and doctors delivering ECC in PHC facilities in Tanzania. The study’s findings reveal a consistently strained system where healthcare workers must work through profound scarcity and systemic failure, resulting in significant human costs. The discussion interprets the findings in terms of the literature and highlights key solutions provided by frontline healthcare workers. Summary of Main Findings The analysis identified three main challenges: providers operate in a constrained system lacking infrastructure, equipment, oxygen, staff, and drugs; they navigate clinical uncertainty and systemic failures with ad-hoc assessments, a fragile referral system, and one ambulance serving multiple facilities; these issues cause preventable deaths, disability, and emotional burden on healthcare workers unable to provide standard care. Interpretation in Relation to Existing Literature Our findings align and expand existing literature on ECC in low-resource settings, highlighting systemic and provider gaps in Tanzania and SSA. [ 7 , 9 , 10 , 17 ] The study confirms ongoing shortages of triage spaces, monitoring tools, and oxygen, with a broken referral system causing overburdened hospitals. [ 22 – 24 ] Importantly, it adds the human-centered dimension evidence, showing how shortages force providers’ difficult decisions, creating psychological burden and moral distress, and offering a deeper understanding of system failure from those working of making it work. The Frontline Blueprint for Change One significant finding from the study is that participants not only identified challenges but also demonstrated a consistent and clear multi-level blueprint for change. Their suggestions, founded in concrete experience, can be practically applied to enhance ECC. Infrastructure and Resources: A frontline prescription is to ensure primary facilities are equipped with basic provisions for initial care—reliable oxygen sources (including backup cylinders), emergency drugs, and monitoring equipment. Participants noted this would reduce unnecessary referrals, deterioration, and preventable mortalities. Human Resources and Training: Participants stressed the need for inclusive, ongoing universal training for all staff on emergencies and life-saving skills. The curriculum should include basic ECC courses at all levels, especially benefiting lower-educated staff, the majority of whom work at smaller facilities and often lack these skills. This approach is crucial for bridging the gap between theory and practice. Policy and System Structure: Participants urged the government to prioritize ECC at the primary level through policy changes, ensuring qualified staff and adequate infrastructure to improve working conditions and outcomes. Facility-Level Advocacy and Research: Participants emphasized local facility advocacy and research, urging hospital management to assess needs, create strategies, and advocate for resources by highlighting the local burden of critical illness. They also tasked researchers with advocacy, encouraging them to share findings with responsible authorities to promote change, stressing data-driven advocacy. Implications of the Study The insights from this study decipher into clear, actionable recommendations for stakeholders: For Policy and Practice: For the Tanzania Ministry of Health (MoH) and Policymakers: This study provides baseline evidence for the new National Strategic Plan on Essential ECC (2023-2026). [ 16 ] Investment should equip PHC facilities with essential ECC packages (e.g., oxygen, drugs, trained personnel, protocols, and equipment). For Hospital and Facility Administrators: Participants emphasized the importance of local advocacy. Administrators should document ECC cases and referrals to support requests for more resources, using this study’s findings. They could also create a hospital policy prioritizing critical care. For International organizations, NGOs, Researchers, and Experts: Participants highlighted understaffing and skill gaps, emphasizing support for programs that promote mentorship and partnerships—such as between tertiary hospitals like KCMC and primary facilities—to build capacity, develop practical skills, and provide clinical support. Relevance Despite Time Lapsed Timeframe Data Collection: Data for this 2021 study reveal systemic issues like infrastructure deficits, workforce training gaps, and fragile referral systems that are hard to fix quickly. These findings are relevant as Tanzania launched the 2023-2026 National Strategic Plan for Essential ECC Emergency, aiming to expand services. [ 16 ] The plan aligns with the urgent needs and recommendations of frontline healthcare workers, as identified in this study, providing baseline evidence of the challenges the policy must address to succeed. Uniqueness of Findings: The findings are unique, highlighting the severe lack of epidemiological data on ECC in Tanzania’s PHC and the absence of human perspectives. They serve as a benchmark for future research, expanding knowledge of ECC in low-resource SSA settings. Strengths and Limitations This 2021 study faced delays but offers relevant insights into systemic failures for Tanzania’s 2023-2026 National Strategic Plan on Essential ECC. Its strength is detailed lived experiences of PHC workers, enhancing policy relevance. Member checking and multiple analysts increased trustworthiness. As a qualitative study, its findings aren’t statistically generalizable but can be transferred to similar PHC settings with limited resources. Focusing on frontline nurses and doctors provided deep insights, but excluding other roles like pharmacists and radiologists may limit perspectives. Conclusion This study identifies systemic shortages affecting Tanzanian healthcare workers’ well-being and patient outcomes. Workers’ recommendations offer a framework for improving ECC, assessing key gaps in infrastructure, referrals, and staff capacity to establish a baseline. As Tanzania advances its ECC plan, this provides an evidence-based roadmap for a resilient, equitable system that saves lives and supports workers. It helps policymakers make direct investments, prioritize training, and measure their commitment to strengthening care. Data Availability The data supporting the findings of this study are available from the corresponding author upon reasonable request. Declarations Ethical Consideration The Institutional Review Board of Muhimbili University of Health and Allied Sciences (MUHAS) approved the study on April 9, 2021 (Ref. No. DA.282/298/01.C/). The Director of Moshi Municipal Council (No. MMC/A.40/13/1/VOL.VI/152) and hospitals granted permission. Written consent was obtained from all participants before interviews. To ensure complete confidentiality of both participants and the specific facilities involved in this study, all identifying information has been omitted. Participants are referred to by pseudonyms (P01-P12). The three study facilities are referred to by the neutral codes F1-F3. While the facilities were of different types (e.g., HCs, a council-designated hospital), this specific information is omitted from the participant quotes to prevent deductive disclosure of their identities, given the small number of sites studied, and the presence of only one council-level hospital, which could direct the precise location. This enables the analysis of themes by facility type/level while protecting their specific identities. Consent for publication Not applicable Author contributions MNI: Conceptualization, Methodology, Resources, Investigation, Data curation, Formal analysis, Validation, & Writing – original draft. DAM: Conceptualization, Methodology, Formal analysis, Validation, Writing – review & editing, & Supervision & Project administration. BEM: Conceptualization, Methodology, Formal analysis, Validation, Writing – review & editing, & Supervision. However, all authors approved the final manuscript. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. Declaration of competing interests The authors declare no competing interests exist with respect to the research, authorship, and/or publication of this article. Availability of data and materials The data supporting the findings of this study are available from the corresponding author upon reasonable request. Acknowledgements We thank all participants for their time, regardless of responsibilities. The authors used [Grammarly Premium, V1.2.195.1755] for editing, but ideas, data analysis, and writing are entirely our own. Footnotes mkokamalinga{at}yahoo.co.uk , beatricemwilike{at}yahoo.com Summary of Significant Revisions This revised manuscript represents a substantial evolution from the previous version, strengthened significantly by incorporating feedback from a previous journal's peer review process. The key enhancements are: 1. Methodological Rigor and Transparency: The data analysis section has been completely revised to explicitly follow the six-phase framework for thematic analysis by Braun & Clarke (2006), providing a clear step-by-step explanation from familiarization to theme development. Added a detailed subsection on "Ethical approval and consent to participate" as required, including the date of ethical approval. Included the full semi-structured interview guide as a table to demonstrate the validity and focus of the data collection method. 2. Deeper Analytical Narrative in Results: The Results section has shifted from mainly describing to delivering a strong analytical story. We have greatly cut down the number of quotes, keeping only the most meaningful examples. Importantly, we now offer detailed interpretation and in-depth analysis after each quote, clarifying the meaning, motivations, and significance of the participants' statements, going beyond just listing themes. 3. Reframed and Impact-Focused Discussion: The Discussion has been completely reorganized to address the "so what?" question. It now goes beyond simply restating results by interpreting findings within the context of existing literature. It synthesizes participant solutions into a "Frontline Blueprint for Change.' Additionally, it introduces a new subsection titled "Implications for Policy and Practice, Time Lapsed, and Uniqueness of Findings" that offers actionable recommendations for specific stakeholders, such as the Ministry of Health and hospital administrators. 4. Clarifications and Enhancements: Setting: Clarified the use of 2022 census data by calculating and using an estimated 2021 population figure for the study period. Scope: Explicitly stated that the study encompasses care for patients of all ages throughout the abstract and manuscript. Justification: Enhanced justification for the qualitative sample size (n=12) with a reference to the concept of data saturation. These revisions have profoundly strengthened the manuscript's theoretical foundation, analytical depth, and practical utility for policymakers, ultimately enhancing its contribution to the fields of global health and health systems research. Abbreviations ECC Emergency and Critical Care ED Emergency Department HC Health Center ICU Intensive Care Unit KCMC Kilimanjaro Christian Medical Centre PHC Primary Healthcare SSA Sub-Saharan Africa References 1. ↵ Schell CO , Gerdin Wärnberg M , Hvarfner A , Höög A , Baker U , Castegren M , et al. 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