Click here to load reader
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
THE TWIGA INITIATIVE 3
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
THE TWIGA INITIATIVE 5
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
THE TWIGA INITIATIVE 7
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.
THE TWIGA INITIATIVE 9
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.
THE TWIGA INITIATIVE 11
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
THE TWIGA INITIATIVE 13
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.
THE TWIGA INITIATIVE 15
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.
THE TWIGA INITIATIVE 17
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.
THE TWIGA INITIATIVE 19
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.
THE TWIGA INITIATIVE 21
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.
THE TWIGA INITIATIVE 23
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
THE TWIGA INITIATIVE 25
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 $24,000 per year in faculty salaries, Sengerema COTC could overcome this one remaining impediment to optimizing capacity, creating 63 places and, within three years, enabling another 30 to 40 dispensaries in Tanzania to be sta!ed with a qualified health worker.
THE TWIGA INITIATIVE 27
financing arr
Non-clinical faculty: 2.
NGO ted fields.
Clinical faculty: 3. here is also a significant gap in
ta" ta" of
Non-clinical infrastructure: 4. e we identified is
the need for more housing, either on or o"-
Clinical infrastructure: 5.
Financial resources: 6. control over the amount and flow of resources,
ting di!c
titution su"ers from a unique combina
A sample action planEXHIBIT 10
Total operational costs for incremental students
Already covered in loan/grant program above
Other activitiesFill unoccupied post-graduate spotsComplete existing classroom/lab expansion (already funded by the university)
31001003000
29035120504936
17071444
21647
2657
Year 4
29035120504936
20681805
21647
2657
Year 5
13631100
21647
1916
985722
21647
1157
624361
21647
398
Total recurring costs
Total one-time costs ($ 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.
THE TWIGA INITIATIVE 29
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.
THE TWIGA INITIATIVE 31
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
THE TWIGA INITIATIVE 33
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.
THE TWIGA INITIATIVE 35
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.
THE TWIGA INITIATIVE 37
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.
THE TWIGA INITIATIVE 39
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)
THE TWIGA INITIATIVE 41
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
THE TWIGA INITIATIVE 43
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.
THE TWIGA INITIATIVE 45
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 TWIGA INITIATIVE 47
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
THE TWIGA INITIATIVE 49
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
THE TWIGA INITIATIVE 51
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"
THE TWIGA INITIATIVE 53
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
THE TWIGA INITIATIVE 55
BibliographyInvesting in Tanzanian Human
Resources for Health: an HRH study for the Touch Foundation
Labour Market Study for the Tanzanian Health Sector: Draft 4.
Strengthening Human Resources Information Systems.
World Factbook
t. “E"ec
The Lancet
The Lancet
Health Policy and Planning
WHO
.WHO
tion_final.pdf>.
Human resources for health: overcoming the crisis
Health Policy and Planning
Human Resources for Health in Tanzania,
Report of a Human Resource Management Assessment of the Tanzania Ministry of Health.
Acting Now to Overcome Tanzania’s Greatest Health Challenge: Addressing the Gap in Human Resources for Health.
Tanzania Service Provision Assessment Survey 2006
Emergency Recruitment Plan
56 ACTION NOW
Health Sector Public Expenditure Review PER update FY 2006
Health Statistics Abstract 2001
HRH Census
Human Resource for Health Strategic Plan 2008-2013
MOHSW monthly budget allocation to schools
Primary Health Services Development Programme 2007-2012 (MMAM) ,
School Bulletin Database 2005
Sta!ng Establishment 2005
Third Health System Strategic Plan
UNICEF.
Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008
WHO
Working Together for Health: The World Health Report 2006
Human Resources for Health
www.touchfoundation.orgwww.mckinsey.com