twiga initiative 6xvt2zlh

Action now on the Tanzanian health workforce crisis Expanding health worker training – The Twiga Initiative

© Touch Foundation 2009

875 Third Avenue5th FloorNew York, NY 10022

Angus O’Shea Amanda Rawls Eliza Golden Rachel Cecil Emily Slota Kasia Biezychudek

THE TWIGA INITIATIVE 1

Contents

Prologue .................................................................................................................................................................................. 3

The challenge of a molecular system .............................................................................................................................. 4

Acknowledgements .......................................................................................................................................................... 6 Glossary ............................................................................................................................................................................ 6

Executive Summary .............................................................................................................................................................. 7

Increasing training capacity ............................................................................................................................................. 7 Translating policy into action ........................................................................................................................................... 8 Harnessing existing opportunities ................................................................................................................................... 9 Enabling system-wide support ....................................................................................................................................... 10 Furthering transformational changes ............................................................................................................................ 10 Capabilities, leadership, and funding are required ......................................................................................................... 11 Implementation starting now .......................................................................................................................................... 11 Meeting the challenge outside Tanzania ....................................................................................................................... 12

Context .................................................................................................................................................................................. 13

A global crisis .................................................................................................................................................................. 13 The state of health and the health workforce in Tanzania ............................................................................................. 16 Policy frameworks .......................................................................................................................................................... 19 The Twiga Initiative ........................................................................................................................................................ 20

2 ACTION NOW

Methodology ........................................................................................................................................................................ 21

Filling the knowledge gap ............................................................................................................................................... 21 Bottom-up data collection ............................................................................................................................................. 22 The top-down perspective.............................................................................................................................................. 24 Working together ............................................................................................................................................................ 25 The toolkit ....................................................................................................................................................................... 25 A replicable process ....................................................................................................................................................... 25

Findings ................................................................................................................................................................................. 26

Six major constraints ..................................................................................................................................................... 26

Doubling training capacity ............................................................................................................................................. 28 Reducing attrition ............................................................................................................................................................31 Further systemic opportunities ..................................................................................................................................... 32

Beyond Twiga ....................................................................................................................................................................... 34

Financing health worker training ................................................................................................................................... 35 Defining the optimal workforce pyramid ....................................................................................................................... 36 Shortening the pipeline .................................................................................................................................................. 38

Improving faculty access through institutional collaboration....................................................................................... 39

Maximizing limited teaching resources .........................................................................................................................40

Implementation ................................................................................................................................................................... 43

To do now… .................................................................................................................................................................. 43 …to do next… ............................................................................................................................................................. 44 …and to do soon .......................................................................................................................................................... 45 Implementation challenges ........................................................................................................................................... 45 Monitoring and evaluation ............................................................................................................................................. 48

Conclusion ............................................................................................................................................................................ 50

Appendix – List of Interviewees ...................................................................................................................................... 52

Bibliography ........................................................................................................................................................................ 55


Prologue

pro bono

Acting Now to Overcome Tanzania’s Greatest Health Challenge: Addressing the Gap in Human Resources for Health Investing in Tanzanian Human Resources for Health: An HRH report for the Touch Foundation

t over five thousand ne

produce su!cient numbers of health work ta"

Catalyzing Change: Molecular strengthening of the health system in the Tanzanian Lake Zone

Field research

ta" a aining schools and a!lia

flec

ta"

1 In the Tanzanian health system, the Lake Zone denotes the catchment area of the referral hospital at Bugando in Mwanza. It comprises six regions – Kagera, Kigoma, Mara, Mwanza, Shinyanga, and Tabora – with a population of around 15 million. Our Lake Zone Initiative focused on priority initiatives to strengthen the health systems of this catchment area.

4 ACTION NOW

Government support and consultation

n tandem with field research, the team workclosely with o!cials in the T

edical O!cer

y o!cials consulted include the direc

ta" y o!cials, ta" of the M

tion financing.

Other inputs

e"orts and o!cial

AIDS

MEDICC

tion over the course of five years’

t of such e"or

Despite our e"orta in this field has a

significant impacve significant

weighting toward firs

The challenge of a molecular system

GHWA

su!ciently fle


aining is only the firs

in the absence of

ement, finance, procta" re

ties and e"ec

ficial e"ections or disease-specific

ams outside their field of

Lake Zone Initiative

ABOUT THE TOUCH FOUNDATION

The Touch Foundation is a secular, non-profit 501(c)(3) organization that aims to improve access to basic health care in sub-Saharan Africa by working with our partners to overcome two fundamental problems:

nurses, pharmacists, and lab technicians

communication, management, medical supplies, infection control, and data analysis

Touch Foundation’s approach to solving these problems is unique in that we combine the best of private and public sector approaches and expertise, leveraged from our partnerships with governments, corporations, development partners, and nonprofits. Our model is to engage local leaders from the beginning in order to help rebuild their existing healthcare system, rather than building a parallel one.

We have begun our work in Tanzania, an East African country acutely a!ected by this workforce shortage. Since our incorporation in 2004, we have worked with our Tanzanian partners to expand Weill Bugando’s university and 900-bed teaching hospital in Mwanza, Tanzania, growing it from an inaugural ten MD students in 2004 to eight hundred students in eight disciplines in 2008-09.

6 ACTION NOW

Acknowledgments

HRH

able e"or

The opinions expressed in the report are those of the authors and may not necessarily represent the opinions of McKinsey & Company or the directors or employees of, or donors to, the Touch Foundation.

GLOSSARY

AHO Accelerated Health O"cer

AMC Academic Medical Center

AMO Assistant Medical O"cer

BSP Basic Service Provider

CA Clinical Assistant

CHAI Clinton HIV/AIDS Initiative

CO Clinical O"cer

DALY Disability Adjusted Life Years

DFID Department for International Development (UK)

EN Enrolled Nurses

GHWA Global Health Workforce Alliance

HEW Health Extension Worker

HRH Human Resources for Health

HRHSP Human Resources for Health Strategic Plan

HSSP III Health Sector Strategic Plan

IAHS Institute of Allied Health Services

IFC International Finance Corporation

JAHSR Joint Annual Health Sector Review

MDGS Millennium Development Goals

MKUKUTA National Strategy for Growth and Reduction of Poverty

MMAM Primary Health Services Development Programme

MO Medical O"cer

MOHSW Ministry of Health & Social Welfare

MTEF Medium Term Expenditure Framework

RN Registered Nurse

TSPAS Tanzanian Service Provision Assessment Survey

UN United Nations

WHO World Health Organization


Executive Summary

vention by a firs

di"erence be

HRH

Joint Learning InitiativeWHO

Working Together for Health

WHO

UN)MDG )

tle over five.

t fif

WHO

Increasing training capacityWHO

GHWA vened the firs HRH

The Lancet

AIDS PEPFAR

HIV/AIDS-specific objec

2 Christoph Kurowski et al., “Human Resources for Health: Requirements and Availability in the Context of Scaling-Up Priority Interventions in Low Income Countries – Case studies from Tanzania and Chad” (London School of Hygiene and Tropical Medicine) Jan 2003: 24.

3 See Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008, Public Law 110-293, 122 Stat 2946 (2008). GPO Access. Web. <http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_cong_public_laws&docid=f:publ293.110.pdf>.

4 See “Agenda for Global Action,” Global Health Workforce Alliance (GHWA) Mar 2008 <http://www.WHO.int/workforcealliance/forum/1_agenda4GAction_final.pdf>; see also Nigel Crisp et al., “Training the health workforce: scaling up, saving lives.” The Lancet 23 Feb. 2008: 689-91.

8 ACTION NOW

Acting Now to Overcome Tanzania’s Greatest Health Challenge: Addressing the Gap in Human Resources for Health

y is both required and feasible: firs

allel to the first fif

Investing in Tanzanian Human Resources for Health: An HRH study for the Touch Foundation

aining were the essential firs

t-e"ec

HRHSP

Mpango wa Maendeleo wa Afya ya Msingi MMAM

titutions as the firs

Translating policy into action

MMAM HRHSP

y to the e"ec

MMAM

5 Acting Now to Overcome Tanzania’s Greatest Health Challenge: Addressing the Gap in Human Resources for Health (McKinsey & Company, 2004).6 Lowell Bryan et al., Investing in Tanzanian Human Resources for Health: an HRH study for the Touch Foundation (McKinsey & Company, 2006). 7 Tanzania, Ministry of Health and Social Welfare, Human Resource for Health Strategic Plan 2008-2013 (HRHSP) (Dar es Salaam: MOHSW, Jan. 2008) 11.8 Tanzania, Ministry of Health and Social Welfare, Primary Health Services Development Programme 2007-2012 (MMAM) (Dar es Salaam: MOHSW, May 2007) 6.


xtensive field research

Specifically

es years from the firs

’ e"ec

five to six years af

pipeline e"ec

Harnessing existing opportunities

through simple, school-specific improvements – such

in scaling up: lack of qualified s

ture, and limited financial resources.

tive and e!cient approach than tr

linical O!cer (CO

fi

CO

9 The reported number of health worker training schools in Tanzania varies widely. According to the 2007 draft HRHSP, based upon the 2005 School Bulletin, Tanzania has 87 health worker training centers. The MMAM cites 116. The number 97 comes from the 87 in the HRHSP, with some of the institutions listed in that document subdivided into their component programs, when our field work found them to be functionally independent.

10 ACTION NOW

Enabling system-wide supportSchool-specific optimization e"or

e identified four

e and subsidize o"-campus housing

MD

tifica

CA

t e"ecEN RN

by 25 percent, adding over five hundred additional

adeo"s necessar

ta" them,

ta" to

Furthering transformational change

ta!ng gWHO ficit is now nearly 90,000

WHO

ta!ng demands of the ne MMAM

ta" ne

No silver bullets

y such quick fix in the course of this work

t could significantly narrow the he firs

Shorten the training pipeline.

10 Based on the WHO guidelines for health worker density, demand in 2019 will be 140,480 skilled health workers, of which 115,900 must have clinical skills, indicating that the MMAM policy is aligned with international standards and Tanzania’s needs to meet the MDGs.


e"ec

su!cient clinical skills to enable the worke"ec

Augment capacity with technology.DVD

Ensure financial sustainability.

financial aid, or s

self-financing.

Capabilities, leadership, and funding are required

fining the ne

and modifica

Implementation starting now

WHO

ta" and s

significant progress while it continues to assess

ve we filled an e

12 ACTION NOW

Meeting the challenge outside Tanzania

aining relies primarily on fieldwork conduc

s specific needs. But

so di"erent from those in the res

t improving health outcomes within five

finallytives, either disease-specific


Context

A global crisis

ve identified the se

improving health outcomes worldwide. Significant

tly a"ec

, under-five mor

WHO

tantially a"ec

ta" produced by the health tr

in the decade a"ec

HIV/AIDS

te planning and insu!cient in

Joint Learning InitiativeWHO

ers as the linchpin of all e"or

11 Crisp 689-91.12 Working Together for Health: The World Health Report 2006 (The World Health Organization (WHO), 2006) 12-13.13 MMAM 12.14 Capacity Project et al., Labour Market Study for the Tanzanian Health Sector: Draft 4 (Dar es Salaam: MOHSW, 2006) 19.15 Sources: World Health Report 2006; Central Intelligence Agency, “Tanzania” World Factbook <https://www.cia.gov/library/publications/the-world-

factbook/geos/tz.html>; team analysis.

14 ACTION NOW

MDG

taining a su!cient, produc

fits but also by oppor

ancement. E!cient hiring, deployment, and funding of the workforce require e"ec

The pipeline problem

fifi

"

Delayed impactEXHIBIT 2

Health workers

Year of implementation

45,000

2014

40,000

5,000

50,000

2019

Student intake steady stateStudent intake with optimization

0

30,000

35,000

2009

Health workforce steady stateHealth workforce with optimization

Health worker density

Most disease, fewest doctorsEXHIBIT 1

Regional groupings correspond to WHO regions, as follows:Americas: North, South, and Central AmericaAfrica: Sub-Saharan Africa and AlgeriaEastern Mediterranean: North Africa including Sudan and Somalia, the Middle East, Afghanistan and PakistanEurope: Eastern and Western Europe including RussiaSouth-East Asia: South Asia, North Korea, Indonesia, Myanmar, and ThailandWestern Pacific: Oceania, East Asia, Cambodia, Laos, and Vietnam

Africa

Americas

Europe

Eastern Mediterranean

Western Pacific

South-East Asia

Percent of global disease burden

Percent of world population0 10 15 20 25 305

35

25

20

15

10

5

30

35

0

16 See Joint Learning Initiative (JLI) Human resources for health: overcoming the crisis (Cambridge: Global Equity Initiative, 2004); World Health Report 2006 11.


he pipeline e"ec

ams to address specific diseases ha

HIV

HIV

y of the pipeline e"ec

ta"

More training is needed

GHWA

NGO

HEW)

DFID)

NGO

acies and multiple funding flows frequently

17 Sources: 2008 Twiga model [raw sources include: MMAM; HRHSP (draft, Oct. 2007); Tanzania, Ministry of Health and Social Welfare, Sta!ng Establishment 2005 (Dar es Salaam); Tanzania, Ministry of Health and Social Welfare, Health Statistics Abstract 2001 (Dar es Salaam); MOHSW monthly budget allocation to schools (unpublished); WHO Statistical Information System (WHOSIS) < http://www.who.int/whosis/en/index.html>; Tanzania, Ministry of Health and Social Welfare, HRH Census (Dar es Salaam: 2002); Labor Market Study 2006; Tanzania student focus groups; Tanzania, Ministry of Health and Social Welfare, School Bulletin Database 2005 (Dar es Salaam); Interviews (see appendix); Tanzania Ministry of Health and Social Welfare website < http://www.moh.go.tz/>; Tanzania Ministry of Higher Education, Sciences & Technology website <http://www.msthe.go.tz/>; Bryan 2006; World Bank < www.worldbank.org/tanzania>].

18 See Global Health Workforce Alliance (GHWA) website <http://www.ghwa.org/>; the press release on the launch of the Scaling up Education and Training taskforce of the Global Health Workforce Alliance is available on the WHO website <http://www.WHO.int/mediacentre/news/releases/2007/pr05/en/index.html>.

16 ACTION NOW

The state of health and the health workforce in Tanzania

people, one-fifWHO

WHO HIV/AIDS TB –

DALY DALY

t e"ec

specific progr

Other significant drivers of the health care crisis

Top ten causes of DALY lossEXHIBIT 3

Africa Tanzania

HIV/AIDS

TB/Respiratory

Malaria

Maternal/PerinatalConditions

Injuries

Cardiovasculardiseases

Neuropsychiatric conditions

Other

Diarrhealdiseases

HIV/AIDS

TB/Respiratory

Malaria

Maternal/PerinatalConditions

Injuries

Diarrhealdiseases

Neuropsychiatric conditions

Cardiovasculardiseases

All others18

13

9

1486

544

1912

16

8

1489

534

21

NutritionaldeficienciesNutritional

deficiencies

19 For more on challenges of donor funding in the health sector, including fragmentation, unpredictability, short time horizons, and narrow focus, see Jaap Koot and Rik Peeperkorn, “The Health Sector in the 21st Century; putting health systems strengthening in perspective,” forthcoming: 8-9.

20 As of February 2009, UNICEF reported maternal mortality rates (adjusted for under-reporting and misclassification) to be 950 deaths per 100,000 live births in Tanzania, and 560 per 100,000 in Kenya <http://www.unicef.com>.

21 Source: WHO “Death & Disability Adjusted Life Years (DALYs) estimates for 2002 by cause for WHO Member States” < http://www.who.int/whosis/indicators/compendium/2008/1llr/en/>.

22 Source: WHO DALY estimates 2002; team analysis based on extensive qualitative and quantitative field work.


DALY

ndeed, over half the losses su"ered by the T

specific programs and could be significantly reduced

e"ec

hiring freeze took e"ec

n less than fif

edical O!cers (MO )

t figure –

While the figures for ph

Shrinking fastEXHIBIT 4

0

5

10

15

20

25

30

35

40

45

1994-95 2001-02 2007-080

10

20

30

40

50

60

70

Tanzanian populationmillions thousands

Health workforce

Health workforce

Total population

Current pyramidEXHIBIT 5

940

5,500 6,900

7,070 0*

3,580

400

EnrolledNurses

Clinical Assistants

Clinical O!cers

Diagnostic and Support Sta"

Registered Nurses

Assistant Medical O!cers

Medical O!cers

Specialists

* Clinical Assistant training began in 2008; sta" numbers not yet available.

1,400

workers, and 2150 other healthcare workers.Diagnostic and support sta" includes 1090 laboratory workers, 340 pharmacy

23 Ottar Maestad Human Resources for Health in Tanzania (Chr. Michelson Institute (CMI Report), 2006); 2008 Twiga model (see note 17); HRH census 2002.24 CMI Report 4.25 Tanzania National Bureau of Statistics (NBS) and Macro International, Tanzania Service Provision Assessment Survey 2006 (TSPAS), (Nov. 2007: 22).26 Source: CMI Report; team analysis based on extensive qualitative and quantitative field work.27 Sta!ng Establishment 2005.

18 ACTION NOW

ta"ta" ta"

tional Sta!ng Es

ta"ed by eight workfive are lower-skilled nurses and t

ta"

ta"ed by 1,MO

ta"ta" While the o!cial Sta!ng

ta!ng le

ta"edical O!cer (AMO) CO

linical O!cers ma

ween o!cial s

POLICY HEALTH WORKFORCE GOALS PRE-SERVICE TRAINING GOALS

2003-2008/09 HSSP II priority to improve health services

geographically, and across skill levelsmeet current and future needs

2005 Guidelines for Reforming Hospitals development, and motivation

facilities

2005 MKUKUTA

workers in place

2007 JAHSRrecruitment and deployment

are sta!ed 1,013 to 6,458

2007-2017 MMAMfacilities ensure adequate numbers of skilled workers

to sta! primary care facilities

2008-2013 HRH Strategic Plan

28 Interviews with medical sta! at Bugando Medical Centre.29 Source: TSPAS 2007; HRH Census 2002.


MDG

amid seems to be a reasonable profile

Policy frameworks

MDG

MMAM, HRHSP

MKUKUTA

fiHSSP III

JAHSR

A long way to goEXHIBIT 6

4.12

0.86

0.53 0.07

0.12

0.72

11.79

0.19

0.24

0.25

8.96 2.41

per 1,000 population

Lower-skilled Mid-level Higher-skilled

Lower-skilled workers: community health workers for SSA and South Africa; clinical assistants, medical attendants, and MCH aides for Tanzania; medical assistants and nursing aides for the USMid-level workers: nurses, laboratory technicians, and pharmacists in all countries; includes clinical o!cers in TanzaniaHigher skilled workers: physicians in the US; physicians and substitute doctors / AMOs in South Africa, SSA, and Tanzania

United States

South Africa

Sub-SaharanAfrica

Tanzania

30 MMAM 12.31 MMAM 12, 15.

20 ACTION NOW

flec

The Twiga Initiative

MMAM

MMAM

2007 MMAM

ta!ng

o!cial demand of over 1

these, fif

firsteen to fif

MMAM

32 In the final draft of the MMAM, targets for new facility construction have been combined with targets for renovation of existing facilities (see policy table p. 18) We believe the new target still reflects planned construction of 5201 new facilities, and sta"ng of 652 constructed but currently un-opened and unsta!ed facilities.

33 Source: WHOSIS; World Health Report 2006; US Bureau of Labor Statistics <http://www.bls.gov/>; Bryan 2006; TSPAS 2007; Kurowski 2003: 25; 2004: 10.34 Average annual attrition rates were calculated based on interviews with school principals, students, independent consultants, and MOHSW o"cials, as well

as published statistics from the WHO.


Methodology

Filling the knowledge gapfore beginning fieldwork, the teams firs

al specific

findings helped to cement our assumptions and hroughout the fieldwork component

t-e"ec

School-specific improvements to e

t pursuing school-specific

Our aim was to o"er ac

tegic plan, and balance our e"or

35 HRHSP; School Bulletins 2005; Tanzania, Ministry of Health and Social Welfare Emergency Recruitment Plan (Dar es Salaam); HRH Census 2002. 36 Some of the most relevant recent studies of this issue include the WHO World Health Report 2006, the Norwegian CMI Report, Kurowski 2003, and

Kurowski’s subsequent work on health workforce in Tanzania including Anna Dominick and Christoph Kurowski, “Human resources for health – an appraisal of the status quo in Tanzania mainland” July 2004, and Christoph Kurowski, et al., “Scaling up priority health interventions in Tanzania: the human resources challenge” Health Policy and Planning 20 Feb. 2007.

37 Organizations such as the Capacity Project and I-Tech are doing related system-strengthening work in Tanzania, while the Carter Center’s work in Ethiopia, the Global AIDS Program in Namibia, and the United Kingdom’s Department for International Development (DFID) work in Malawi provide interesting comparative examples.

22 ACTION NOW

ween school-specific

Bottom-up data collectionSince o!cial da ten insu!cient, the team

ed on field visits to obtain an acc

e"or

ve this, the field team was divided into se

di"erent health work aining schools and a!lia

ams o"ered, ownership and funding,

his has significant

y of our findings across Tvisited a significant number of these in addition to all

Broad training coverageEXHIBIT 7A

Iringa

Kigoma

Kilimanjaro

Number of schools

Lindi

Mara

Mbeya Pwani

Rukwa

Ruvuma

Shinyanga

Tabora Tanga

Dar esSalaam

1-23-45-67-8

Rural areas such as Kigoma, Tabora, and Ruvuma serve 21% of the population with 13% of the training institutions

Mwanza

Kagera

Arusha

Dodoma

Morogoro

Mtwara

Singida Zanzibar

The public/private divideEXHIBIT 7B

55%39%

6%

Private faith-based schools

Governmentschools

Private secular schools

38 Source: School Bulletin 2005.


ta" to specialisInterview guide and data request

ta"

confidence in its acc

t tools was to confirm pre

y specific obs

What it takesEXHIBIT 8

1 2 3 4 5 6 70 8 9

Upgrade from MO Specialist

Internship Medical O!cer

Dental O!cer

Assistant Medical O!cer

Clinical O!cer

Clinical Assistant

Registered Nurse

Enrolled Nurse

Pharmacy technicians

Laboratory technicians

Upgrade from CO

Educational prerequisites

Years of training

Form 6(12th grade)

Form 4(10th grade)

39 Shortened curricula reducing by one year both registered and enrolled nurse programs, were expected to be implemented in 2008.

24 ACTION NOW

Once school-specific bottlenecks were identified,

titution, and helped fill and te crucial gaps in o!cial records. W

Filtering and analysis

team designed a school-specific ‘

e considered it vital for all school-specific

The top-down perspective

y o!cials were former highly

Intake by cadreEXHIBIT 9

117

421

47

201174

675

124

188

257

117

542

47

239 225

124

256

388

1,913

Visited intake capacity

Total intake capacity

Specialist MedicalO!cer

DentalO!cer

AssistantMedicalO!cer

ClinicalO!cer

Nurse(RN and EN)

Pharmacyskills

Laboratoryskills

Other

40 At the time of our fieldwork, Tanzania had two ministries overseeing education: the Ministry of Higher Education, Science and Technology, and the Ministry of Education and Culture. Our team interviewed only o"cials of the former. These ministries have subsequently been combined, into a single Ministry of Education and Vocational Training


e o!cials’ vie

t could significantly y individual school-specific e"or

fined

tions for school-specific and tem-wide e"or

fining our ideas.

Working together

final results with k

The toolkit

possible school-specific inter

A replicable processy of these tools in the field

n the meantime, the school-specific da

26 ACTION NOW

Findings

t both school-specific and sys

applicant, and financial resources. W

While the specific cons

workforce will be insu!cient to meeta!ng g

Six major constraintstailed field inter

ts, we identified six main limita

a"ec tional and local e"or

Students: 1. es include lack of qualified

FACULTY SHORTAGE AS AN IMPEDIMENT TO GROWTH

The Sengerema Clinical O"cer Training Centre (COTC) is a faith-based institution that currently trains 177 CO students in a three-year program. The school uses the neighboring Geita District Hospital for clinical training and conducts fieldwork at health centres and dispensaries throughout the region. As a result, faculty members are constantly away from the school, making it di"cult for it to have more than one or two classes per semester.

Sengerema COTC is currently expanding dormitory and classroom infrastructure with financial aid from CORDAID, a Dutch development assistance agency. Although these improvements should help expand the school’s capacity, the already over-stretched faculty cannot handle a student-body increase.

Hiring three additional full-time faculty would fill the current teaching gap and allow Sengerema COTC to grow in capacity by approximately 35 percent. By investing $6,000 up front and $24,000 per year in faculty salaries, Sengerema COTC could overcome this one remaining impediment to optimizing capacity, creating 63 places and, within three years, enabling another 30 to 40 dispensaries in Tanzania to be sta!ed with a qualified health worker.


financing arr

Non-clinical faculty: 2.

NGO ted fields.

Clinical faculty: 3. here is also a significant gap in

ta" ta" of

Non-clinical infrastructure: 4. e we identified is

the need for more housing, either on or o"-

Clinical infrastructure: 5.

Financial resources: 6. control over the amount and flow of resources,

ting di!c

titution su"ers from a unique combina

A sample action planEXHIBIT 10

Total operational costs for incremental students

Already covered in loan/grant program above

Other activitiesFill unoccupied post-graduate spotsComplete existing classroom/lab expansion (already funded by the university)

31001003000

29035120504936

17071444

21647

2657

Year 4

29035120504936

20681805

21647

2657

Year 5

13631100

21647

1916

985722

21647

1157

624361

21647

398

Total recurring costs

Total one-time costs ($ thousands)Purchase buses for clinical rotationsSeed capital for loans

($ thousands)Launch grant program for MO studentsExpand clinical rotations in nearby hospitals– Hire 20 new teachers in nearby hospitals– Develop transportation program to facilitate

clinical rotationExpand loan o!er to other programs

29035120504936

Year 3

29035120504936

29035120504936

1882290312718

Total student intake, by cadreSpecialistMORNLab skillsOther

Year 2Year 1Year 0

incremental

(

31001003000

35120504936

17071444

21647

2657

Year 4

35120504936

20681805

21647

2657

Year 5

13631100

21647

1916

985722

21647

1157

624361

21647

398

––

29035120504936

Year 3

29035120504936

29035120504936

1882290312718

Year 2Year 1Year 0

Total students

Without

WithDebottlenecking

Debottlenecking

0

200

400

600

800

1,000

1,200

1,400

07 08 09 10 11 12 13 14

Year

ContextDescription: KCMC is one of the country’s largest facilities, combining a private university (Tumaini) with 7 programs and 16 programs at the government allied health school

Key bottlenecksStudents – Significantly under capacity due to successful applicants’ inability to pay (109 students below capacity now)Non-clinical infrastructure – Would need more dorms/classrooms, but currently in process of $2m expansionClinical faculty – Number of specialists limits numbers for higher level programs, particularly MDs

Change in total students652 1,129

Incremental ongoing activities and costs

Description of institution and constraints to

increasing capacity

Overall impact on number of students

at school

Upfront activities and investments

Total students to send to school each year

28 ACTION NOW

t address them su!ciently

specific needs on a school-by-school basis, suppor

titution-specific interour final recommenda

te with final cos

MMAM

specific in

Doubling training capacitythered in the field shows tha

wide and school-specific improvements, T

CO

School-specific action plans

t schools fit into one of four tedical O!cer

MO)

te our findings to the other 58 health

tem-wide and school-specific e"or

Academic medical centers

AMC

y and a!lia

ADDING SCHOOLS AT EXISTING TRAINING COMPLEXES Case Example: Mbeya Medical Training Center

Adjacent to one of Tanzania’s four tertiary hospitals, the Mbeya medical training center has fewer programs and students than other schools with similar clinical capacity. The complex currently houses an Assistant Medical O"cer school, a school of dental therapy, and a specialized nursing program in Operating Theater Management.

With the vast clinical opportunities provided by the Mbeya Referral Hospital, hospital and academic leadership reported that the facility is well equipped to o!er additional programs for laboratory technicians, pharmacy technicians, registered nurses, and clinical o"cers. Adding new training programs would allow the training center to expand into a robust Institute of Allied Health Sciences.

Dental therapists and clinical o"cers share the same curriculum for the first year and a half of study, meaning that students from both programs could be taught simultaneously with minimal or no additional investment in faculty or classroom infrastructure. Taking advantage of such synergies will maximize limited resources in the training system and result in a greater return on investment for optimizing Tanzania’s training network.

41 Costs were determined through interviews with individual school principals, data collected from the principal Quantity Surveyor at the Ministry, and the Touch Foundation’s experience overseeing school expansion projects at Bugando’s university.


AMC

Large training complexes

t significant

and no additional space or o"-campus housing

AMO

additional dormitories or o"-campus housing would tely in a fif

CO

AMO

ta!ng is su!cient

ta"

Small private institutions

t e!ciently

ta"

ying full fees or are unable to fill all

Small public schools

te schools, small public schools su"er

CO COTC

the 2007 incoming class. Due to the di!c

ta" and go!cials, the M COTC

continued need for the school-specific ac

impedes e!cienc

can also be addressed. Such school-specific, grsignificant

30 ACTION NOW

New cadres and curricula

he firsCA ) CO

second year spent in field internships. T

EN)RN)

, because o!cial sta!ng requirements

ta"ed, it mata!ng guidelines to permit

ta"

ta!ng a

ta" MMAM

ta!ng requirements,

ta"ed, and opened in the near term.

System-wide policy shifts to enable growth

anzanians in the field, the team de

he team identified four immedia

e and subsidize o"-campus housing.

MD

CO

Doubling outputEXHIBIT 11

630

School-specificoptimization

80-85%

2009/2010output (est.)

Expandedoutput

7000-8000600-620700-800

2000-2300

3500-4000

School-specificoptimization

New programsin existingcomplexes

Curriculumchanges

System-wide improvements

15-20%

42 Source: 2008 Twiga model (see note 17); team analysis.


specific initia

Reducing attrition

ed up by filling slots v

NGO

ve the health care field

e found in our field research thaaccount for over one-fif

A better balanceEXHIBIT 12

11% Highly skilled

25,40048,000

63,50040,800

Attrition 2009-2019

Optimizedtraining output

2009-2019

Health workforce

2009

Health workforce

2019

Percent of highly skilled workers

increases from 11%in 2009 to 15%

in 2019

Opportunities in improving retentionEXHIBIT 13

Healthworkforce 2019

52,000

Voluntary 8,000 –nearly 20%

Attrition 2009-2019

Potential 2019 workforce

88,900

Healthworkforce

2009

Trainingoutput

2009-2019

Number of health workers

52,000

25,400

63,500

40,800

48,000

43 Presumes average attrition of approximately five percent of graduates before entering into service (includes emigration and non-clinical work) and annual workforce loss through attrition, death, and retirement of approximately thirteen percent across all cadres.

44 Source: Ministry of Health Interviews; 2008 Twiga model (see note 17). Calculations based on halving both pre- and in-service attrition due to emigration and non-clinical work, without altering rates of annual workforce loss due to leave for upgrading coursework, death in service and retirement, across all cadres.

32 ACTION NOW

Further systemic opportunities

y o!cials, case e

Optimize student selection and allocation

CO

tituting confirma

ts to fill las

Encourage healthy competition

O"ering incentives, such as a $50,000 gr

tion flow be

Invest in workplace improvements and teaching resources

Develop a ‘scheme of service’ for health educators

tors are classified and compensa

it di!cult to design incentive schemes specific to

te classificater fle

ficial to e

Ensure prompt and consistent payment of salaries

y can receive their firs

ers in their firs


Provide incentives for rural placement

aining, with no di"erential for the ves of di"erent pos

ter five years of ser

Permit periodic rotations of health workers

s with financial

ta!ng choices would decrease the risk of accepting a

Place graduates in home regions

Invest in continuing education

conflic

Develop a performance management system

flec

ta" formance. Specific me

ta" e

34 ACTION NOW

Beyond Twiga

WHO

school-specific optimiza

firs tudent. And finally the cos

wiga, the team identified a handful of

tudent financing through crea

fining the ideal composition of the workforce.

AMO

ta"

more fle

y o!cials have given significant thought to

t-e"ec

addition to significant ne

xercised firs

45 Sources: Ministry of Health Interviews; Bryan 2006; HRHSP; 2008 Twiga model (see note 17); World Health Report 2006. Health workforce demand calculated based on WHO minimum density targets, 2005 sta"ng establishment for required ratio of diagnostic and support sta!, and 2019 population based on expected annual growth rate of 2.09 percent.


Financing health worker training tempt to solve for all financial issues

financing is se

flec

significant gaps in school resources.

flecsu!cient resources for schools to plan for and finance

tendance di!covernment-provided financial aid

accessible to all qualified applicants.

Private loans

all flow of funds to teaching

IFC)

he bank will need to be confident of its financial risks, such as de

eable. An e!cient

Still not enoughEXHIBIT 14

Healthworkforce

2009(est.)

Net trainingoutput

2009-2019

Attrition 2009-2019

Healthworkforce

2019

63,46040,789 140,500

48,000

25,400

63,500

40,800

Gap of 92,500

Healthworkersneeded

2019

36 ACTION NOW

titutional and financial manag

y o"er the mosapidly increasing finance for

Applicability

Defining the optimal workforce pyramid

Our team firser gap from the o!cial government Sta!ng

MMAM

WHO

Increasing intakeEXHIBIT 15

Projected additional 2015 intakeafter implementation

Estimated 2009 intake

Specialist MedicalO!cer

AssistantMedicalO!cer

RegisteredNurse

EnrolledNurse

ClinicalO!cer

ClinicalAssistant

PharmacySkills

LaboratorySkills

Other

538238

1,4001,112

328 148453298

26027

82

124

955

731

351107 250

96

109

46 See, for example, Kurowski 2007; Norbert Dreesch, et al., “An approach to estimating human resource requirements to achieve the Millennium Development Goals” (Oxford U. Press: 2005); Kaspar Wyss “An approach to classifying human resource constraints to attaining health-related Millennium Development Goals” Human Resources for Health 2004.


te decisive figures for

MDG

ta!ng shor

insu!cient for T

flec ta!ng needs or not

Define the pyramid…

y of the disease profile across

HIV/AIDS TB

t result might be the identifica

ta!ng decisions are made.

WHO

modified for local interpre

…to define the task

AMO

EXHIBIT 16

741 fully-sta!ed new facilities by 2019 2,360 partially-sta!ed new facilities by 2019

1,500

1,000

500

2,000

20192011 2013 201720152010

47 Kurowski 2007 explores one approach to projecting future human resource needs based on the skill sets and productivity of di!erent cadres of health workers in Tanzania.

38 ACTION NOW

At the same time, the findings could be used to interim ta!ng requirements – a minimum

ta!ng le

ta!ng requirements would a"ec

ta" 7ta!ng le

each with roughly half the o!cially required sta"

Shortening the pipeline

to feel a significant impac

ta"

Primary care providers

mentoring in the field would reduce trby fif

CA)

MMAM

Accelerated AMO training

RN EN

CA CO

AMO

AMO CO

of clinical work in the field. HAMO

CO

anzania could significantly e

BASIC SERVICE PROVIDER PROGRAM OUTLINE

take advantage of existing capacity.

train two hundred top Tanzanian MOs and AMOs in content of the new curriculum and the most up-to-date training techniques.

MOs and AMOs using newly-trained MOs and AMOs, creating a trainer cadre of nine hundred, who could then train four Basic Service Providers (BSPs) every six months.

dispensaries to observe the clinical skills of the BSPs

create a path for BSPs to upgrade to Clinical Assistant after completion of a set period of service.


Improving faculty access through institutional collaboration

ween the five

t but tends to be informal, ine!cient, and

Rapid training provides dramatic increasesEXHIBIT 17

Health workforce

2009

Impact ofrapidly trained

cadre2009-2019

Attrition,2009-2019

25,400

63,500

48,000

26,500

74,500

53,000

48,000

40,80042,000

15,600

Healthworkforce

2019

Optimizedtrainingoutput

2009-2019

Impact of new cadreon workforce

Output of new 6-month cadre

Post-deployment attrition from new

6-month cadre

ETHIOPIA’S PRIMARY CARE PROVIDERS

Health o"cers in Ethiopia are substitute doctors, with a role very similar to that of AMOs in Tanzania. When Ethiopia launched an ambitious plan to increase access to health facilities, a dramatic increase in the number of Health O"cers to manage these facilities was called for.

Created with the support of the Carter Center, Ethiopia’s Accelerated Health O"cer (AHO) program is furthering this objective by networking Ethiopia’s universities, developing a targeted curriculum tailored to the country’s disease profile, and making use of hospitals previously unused for clinical training. To enable the use of the equivalent of regional and district hospitals for clinical training, the administrators of the AHO program evaluated facilities and made selective upgrades to ensure that each had su"cient teaching space and an appropriate variety of clinical professionals on sta!.

The AHO program is also linked to Ethiopia’s Health Extension Worker (HEW) program, which aims to place 30,000 workers – all women – in rural villages under the supervision of an AHO. The HEWs are trained for one year in special training sites all over Ethiopia.

40 ACTION NOW

ta" r

Maximizing limited teaching resources

ta" aa!lia

Virtual classroom learning

fit from the

t disease-specific courses in Txpansion of those e"or

y findings and recommendaI-TECH

tise in the field and would sign up for a ulum agreed upon by all a"ec

MULTIPLYING CAPACITY

At Muhimbili in Dar es Salaam, a single biochemistry professor is responsible for instructing all MD students (two hundred per incoming class). The number of students he can teach is determined by the size of the lecture theatre and the number of times he can give each lecture.

By recording his lectures and replaying them in another session, as done by Weill Cornell Medical College in Qatar, the university could multiply its capacity to provide biochemistry training while enabling the professor to use his time teaching more specialized courses, conducting research, or meeting individually with students.

48 International Training and Education Center on HIV (I-TECH). Tanzania Distance Learning Assessment: Assessing the Use of Distance Learning To Train Health Care Workers in Tanzania. (I-TECH and MOHSW, 2009). <http://www.go2itech.org/resources/pubications-presentations/> (Accessed 29 Apr. 2009)


y of su!cient technological infr

ICT

Distributed clinical training

ta" and clinical infr

ving significant untapped

EMPLOYING DISTRIBUTED TRAINING AT BUGANDO

Tanzania’s five university-based medical schools would

provide a strong foundation for employing distributed

training. The Weill Bugando university uses the tertiary

referral hospital of the Lake Zone – Bugando Medical Centre

– as its teaching hospital. However, by accessing the medical

o"cers and specialists working in the six regional and 46

district hospitals of the Lake Zone, Bugando could focus

its growth on classroom teaching and building non-clinical

capacity, while dramatically multiplying the number of

students it prepares for clinical practice in the zone.

This approach would have the secondary e!ect of

improving patient care in the utilized hospitals, as well as

increasing the potential that graduates would choose to stay

to practice in those geographic locations.

Accelerating with virtual learningEXHIBIT 18

25,400

63,500

48,000

8,500

56,500

35-40

11,400

40,800

2.52,900

Health workforce

2009

Optimizedtrainingoutput

Additionaltraining output

2009-2019

Attrition2009-2019

Healthworkforce

2019

Impact on workforce

Output of virtuallearning programs

Post-deployment attrition from virtual

learning programs

42 ACTION NOW

ta" a

ta"

MO AMO

CO


Implementation

fined) are necessar

fined and rele

he school-specific ac

tep of each identified recommenda

of maximizing e!ciency) e"or

t been finished, while planning begins on the

To do now...

The 39 visited schools and system-wide initiatives: execution

ure su!cient funding, engag

research, the team identified se

tion and modifica

44 ACTION NOW

Remaining schools: action planning

While visiting the firs

t of school-specific optimiza

school is di"erent and musvisited and assessed according to its specific

Transformational approaches: diagnostic and conceptual development

fit analysis?

ve as a kick-o" for a

...to do next...

The 39 visited schools: monitoring and evaluation

The remaining schools: execution

48 See note 9 for explanation of number of institutions.


Transformational approaches: action planning

or the five trtudent financing, the workforce pyr

New ideas: diagnostic and conceptual development

...and to do soon

the following series of e"or

All health training schools: monitoring and evaluation

Transformational approaches: execution

learning – would build on the findings and de

Implementation challenges

Capacity constraints

NGO

Decentralization

to each individual school principal. E"ec

significant challeng

49 For a more detailed study on capacity for Human Resources management in the Tanzanian health ministry, see Management Sciences for Health and The Capacity Project, Report of a Human Resource Management Assessment of the Tanzania Ministry of Health Oct. 2006.

50 For more on one initiative to implement a computerized Human Resource Information System in sub-Saharan Africa, see The Capacity Project, Strengthening Human Resources Information Systems Aug. 2007.

46 ACTION NOW

oing e"or

enable more e!cient use of the centr

tional resource flows, and might be more

Information distribution

"

"fl

Cost of system optimization

But these figures do not indica

TSH

51 Source: 2008 Twiga Model (see note 17); team analysis through extensive qualitative and quantitative field work.


The implementation hurdleEXHIBIT 19

0

55

2010 2015 2020

5

10

15

20

25

50

$, millions

TSH

GDP

figures for 2008 confirm thaTSH

TSH

TSH

GDP

TSH

TSH

GDP

GDP

52 Last year for which salary information was available.53 This figure excludes Consolidated Fund Services (CFS) – essentially public debt. All budgetary figures are similarly calculated. See Tanzania,

Ministry of Health and Social Welfare, Health Sector Public Expenditure Review (PER) update FY 2006, <http://siteresources.worldbank.org/healthnutritionandpopulation/Resources/281627-1114107818507/082007DCP2TanzaniaFinalPERReportFY06.doc>.

54 The $71.5m (TSH 89.3bn) was allocated $38.4m (TSH 47.9bn) to Local Government Authorities (LGAs), $7.25m (TSH 9bn) to Regional Administration, $5.1m (TSH 6.4bn) to the ministry HQ, and $20.7m (TSH 25.9bn) to Parastatals, including the largest hospitals.

55 The nominal 2007/08 Medium Term Expenditure Framework (MTEF) allocated TSH 187.4bn to Personnel Emoluments for the Health Sector, including TSH 113.3bn of the Local Government Authorities, TSH 16bn of the central ministry budget, and TSH 58.1bn of grants to parastals. However, nominal allocations exceeded actual expenditure by about ten percent in 2005, 2006, and 2007, suggesting that the total FY2008 MTEF budget of over TSH 682bn is not necessarily indicative of actual allocation and expenditure.

56 Source: 2008 Twiga Model (see note 17); team analysis through extensive qualitative and quantitative field work; CIA World Factbook; 2006 and 2008 MTEF and PER.

57 See Mickey Chopra, et al., “E!ects of policy options for human resources for health: an analysis of systematic reviews” The Lancet Feb. 23, 2008: 668-674.

48 ACTION NOW

Monitoring and evaluationA significant obs

alue of di"erent polic

field of health workforce inter

MMAM

y firs

But improving throughput is not su!cient to improve

Placing and retaining workers

s noted, implementing solutions o"ered by our team

tes a"ectes a"ec

e a di"erence. H

Matching growth to GDPEXHIBIT 20

300 35,000

30,000

25,000

20,000

15,000

10,000

5,000

02006 2008 2010 2012 2014 2016 2018 2020

250

200

150

100

50

0

Salaries$, millions $, millions

GDP

Salaries

GDP


Our team identified some of the t

Measuring impact, modifying initiatives

WHO

overnments and potential funders how significant

50 ACTION NOW

Conclusion

ams and other financing options, could enable a significant increase in supply and help close

his e"or

vel, and ensuring a specific, gr

ely to di"er from countr

work is not su!cient to solve the health workforce

firmly belie

e di!c

us on cadres where there is a specific need? Hta!ng of a handful of

ta!ng


ade-o"s tha

WHO

tion, su!cient facilities, and so for

HIV

52 ACTION NOW

Professor Willbard Abeli Director of Higher Education Ministry of Higher Education

Professor M. About Associate Dean, School of Medicine Muhimbili University of Health and Allied Sciences

Ndosi Aston Director for Distance Learning Kilimanjaro Christian Medical College

Hadija Athumani Principal Bagamoyo Nurse Training Centre

Mama Eliaremisa Ayo Assistant Director, Nurse Training, Human Resources Ministry of Health and Social Welfare

Professor Mohammed Bakari Director of Undergraduate Students, School of Medicine Muhimbili University of Health and Allied Sciences

Rt. Rev. Bishop Aloysius Balina Chairman, Weill Bugando University College of Health Sciences Diocese of Shinyanga

Peter Michael Benderra Acting Principal and Faculty member Mbeya School of Theater Management

Dr. Zacharia Berege Director of Hospital Services Ministry of Health and Social Welfare

Dr. Rene Bonsubre VSO Volunteer, CTC and OPD, Mtwara Regional Hospital; Instructor, Mtwara Clinical O"cer Training Centre

Mama Tabu Chando Director, Administration and Personnel Ministry of Health and Social Welfare

Edwin Chitage Medical Student, Year 3 Muhimbili University of Health and Allied Sciences

Mary J. Chuwa Head, School of Nurse Tutors Muhimbili University of Health and Allied Sciences

Father Angelo Dutto Director, Institute of Medical Health Sciences (DMLS) Ruhua University College (RUCO)

Dabney Evans Executive Director, Institute of Human Rights, Emory University

Dr. Gemba Principal Mbeya Dental School

Matt Gordon Multilateral Policy Advisor Department of International Development (DFID) UK

Professor Ambrose F. Haule Associate Dean, School of Pharmacy Muhimbili University of Health and Allied Sciences

Appendix – List of Interviewees

edical O!cer

ta"


Ghanimu Kajubu Accountant Mvumi Nurse Training Center

Benito Kawala Chief Accountant Weill Bugando University College of Health Sciences

Dr. Thomas Kenyon Deputy Coordinator (Acting) & Cheif of Sta! O"ce of the Global AIDS Coordinator

Professor Egbert M. Kessi Provost Kilimanjaro Christian Medical College

Jaockim Kessy Director of Administration Kilimanjaro Christian Medical College

G.M. Kibaya Head of Loans Board Ministry of Higher Education

Stanslaus Kiberiti Principal Kolandoto Nurse Training Centre

Dr. Regina Kikule Director of Policy and Planning Ministry of Health and Social Welfare

Deodata J. Kilumile Nurse Tutor Bagamoyo Nurse Training Centre

Dr. Daniel T. Kisimbo Director, Distance Education Program Morogoro Health Training Institute

Dr. Arndt Koebler Anethesia and ICU Bugando Medical Centre

Theela W. Kohi Dean, School of Nursing Muhimbili University of Health and Allied Sciences

Rapton Kunchela Tanga School of Environmental Health

Professor Gideon Kwesigabo Dean, School of Public Health and Social Sciences Muhimbili University of Health and Allied Sciences

Professor B.S. Lembariti Deputy-Vice Chancellor, Planning, Finance and Administration Muhimbili University of Health and Allied Sciences

Mike Magere Head, School of Laboratory Weil Bugando University of Health and Allied Sciences

Mary S. Magomi Principal, Morogoro Nurse Training Centre Coordinator, Morogoro Zonal Training Centre

Professor Cassian Magori Head, Department of Anatomy Weill Bugando University College of Health Sciences

Professor William Mahalu Head, Department of Surgery Weill Bugando University College of Health Sciences

Dr. Moses Malaba Principal Musoma Clinical O"cer Training Centre

Catherine E.L. Malika Head, School of Radiology, Institute of Allied Health Sciences Muhimbili University of Health and Allied Sciences

Anna Mangula Principal Mirembe Nurse Training Centre

Dr. Martin Director Centre for Educational Development in Health (CEDHA)

Professor Zablon Masesa Head, Department of Physiology Weill Bugando University College of Health Sciences

Dr. Joshua A. Masikini Medical O"cer In Charge Bukumbi District Hospital

Mr. Mavunde Statistician, Planning, Human Resources Ministry of Health and Social Welfare

Dr. Meshack M.Z. Massi Regional Medical O"cer Morogoro Regional Hospital

Dr. Josiah Mekere Principal Lugalo University

Dr. Nicodemus E. Mgalula Principal Tanga Dental Therapist School

Professor Charles A. Mkony Dean, School of Medicine Muhimbili University of Health and Allied Sciences

Fadhila Mkony Administrator, Human Resources Ministry of Health and Social Welfare

Richard Mkumbo Health Economist Ministry of Health and Social Welfare

Scola Mlaui Deputy Director, Administration and Personnel Ministry of Health and Social Welfare

Dr. Gilbert Mliga Director, Human Resources Development Ministry of Health and Social Welfare

Dr. Frederick Mongi Principal, Mbeya Assist. Medical O"cer Training Centre Director, Mbeya Zonal Training Centre

Gustav Moyo Registrar Tanzanian Nurses and Midwives Council

Veronica M. Mpazi Nurse Tutor, School of Nurse Tutors Muhimbili University of Health and Allied Sciences

Rocky R. Mpungwe Principal Mvumi Nurse Training Centre

54 ACTION NOW

Professor Jacob Mtabaji Principal Weill Bugando University College of Health Sciences

Dr. L.B. Mtani Principal Sengerema Clinical O"cer Training Centre

Dr. Deo Mtasiwa Chief Medical O"cer Ministry of Health and Social Welfare

Dr. Mteta Dean, Faculty of Medicine Kilimanjaro Christian Medical College

Dr. Elifuraha G.S. Mumghamba Senior Lecturer, School of Dentistry Muhimbili University of Health and Allied Sciences

Pheby Murusuri Principal Bukumbi School of Nursing and Midwifery

Dr. Amos Mwakilasa Assistant Director, Continuing Ed, Human Resources Ministry of Health and Social Welfare

Mama E. Mwakalukwa Assistant Director, Planning, Human Resources Ministry of Health and Social Welfare

Bumi Mwamasage Assistant Director, Allied Health Training, Human Resources Ministry of Health and Social Welfare

Dr. Emmanuel Mwandu Chief Medical O"cer Kolandoto Nurse Training Centre

Osiah Mwasulama Laboratory Director Mbeya Referral Hospital

Zainab S. Nanyaro Principal Tanga Nurse Training Centre

Dr. Sydney Ndeki Consultant, Zonal Training Centres Ministry of Health and Social Welfare

Vernand Ndemetria Training Coordinator – Nurse Training Ministry of Health and Social Welfare

Dr. B. Ndawi Director, Iringa Primary Healthcare Institute & Iringa Zonal Training Centre

Dr. Matthew Ndomondo Acting Principal Sengerema Nursing School

Edward Ngowi Engineer, O"ce of the Director of Policy and Planning Ministry of Health and Social Welfare

Dr. Emmanuel N’gwamkai Acting Principal Tanga Assist. Medical O"cer Training Centre

Dr. William Nyagwa Chief of Party, Tanzania The Capacity Project

Emily Nyakiha Head, School of Nursing, Institute of Allied Health Sciences Weill Bugando University College of Health Sciences

Mfungo Nyandigira Head, School of Radiology, Institute of Allied Health Sciences Weill Bugando University College of Health Sciences

Dr. Robert Peck Clinical Instructor, Internal Medicine and Pediatrics Weill Cornell Medical Centre at Weill Bugando University College of Health Sciences

Professor Abdulla Rajab Senior Education O"cer Ministry of Higher Education

Dr. Eleuter R. Samky Director-General Mbeya Referral Hospital

Dr. Christian Schmidt Pediatrics Bugando Medical Centre

S.S. Senya Director, Institute for Allied Health Sciences Muhimbili University of Health and Allied Sciences

Mama Shamu Principal Mtwara Nurse Training Centre

H.G. Shangali Head, Allied Health Sciences School Kilimanjaro Christian Medical College

Dr. Shayo Admistrative Director & Faculty Member Mtwara Clinical O"cer Training Centre

Dr. Edward Silayo Instructor, School of Advanced Dental O"cers Muhimbili University of Health and Allied Sciences

Dr. Mark E. Swai Pediatrician, Director of Hospital Services Kilimanjaro Christian Medical Centre

Rwezaura Tibaijuka Head, School of Pharmacy, Institute of Allied Health Sciences Weill Bugando University College of Health Sciences

Leka Tingitana Business Manager Ifakara Health Training and Research Centre

Masiah Veneranda Nurse Tutor Bagamoyo Nurse Training Centre

Karin Anne Wiedenmayere Senior Specialist, Pharamcy Swiss Tropical Institute, Ifakara Health Training and Research Centre

Mavis L. Yengo Academic Head, Advanced Nursing Studies Program The Aga Khan University – Tanzanian Institute of Higher Education


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