Addressing the human resource for health crisis in Tanzania: the lost in transition syndrome

Tanzania is experiencing a serious Human Resource for Health (HRH) crisis. Shortages are 87.5% and 67% in private and public hospitals, respectively.  Mal-distribution and brain drain compound the shortage. The objective of this study was to improve knowledge on the HRH status in Tanzania by analyzing what happens to the number of medical doctors (MD) and doctor of dental surgery (DDS) degree graduates during the transition period from graduation, internship to appointment. We analyzed secondary data to get the number of MDs and DDS; who graduated from 2001 to 2010, the number registered for internship from 2005 to 2010 and the number allowed for recruitment by government permits from 2006 to 2010. Self administered questionnaires were provided to 91 MDs and DDS who were pursuing postgraduate studies at Muhimbili University of Health and Allied Sciences during this study who went through the graduation-internship-appointment (GIA) period to get the insight of the challenges surrounding the MDs and DDS during the GIA period. From 2001 to 2010 a total of 2,248 medical doctors and 198 dental surgeons graduated from five local training institutions and abroad. From 2005 to 2010 a total of 1691 (97.13%) and 186 (126.53%) of all graduates in MD and DDS, respectively, registered for internship. The 2007/2008 recruitment permit allowed only 37.7% (80/218) and 25.0% (7/27) of the MDs and DDS graduated in 2006, respectively. The 2009/2010 recruitment permit allowed 265 MDs (85.48%) out of 310 graduates of 2008. In 2010/2011 permission for MDs was 57.58% (190/ 330) of graduates of 2009 and in 2011/2012 permission for MDs was for 61.03% ((249/408) graduates of 2010. From this analysis the recruitment permits in 2007/2008, 2009/2010, 2010/2011 1nd 2011/2012 could not offer permission for employment of 482 (38.10%) of all MDs graduated in the subsequent years. Major challenges associated with the GIA period included place of accommodation, allowance (for internship) or salary delay (for first appointment), difficulty working environment, limited carrier opportunities and concern for job security. The failure to enforce mandatory registration for internship and failure to absorb all produced MDs and DDS results to loss of a substantial number of these graduates during the graduation-internship-appointment period. To solve this problem, it is recommended to establish better human resource for health management system

Mismatched ambition, execution and outcomes: implementing maternal death surveillance and response system in Mtwara region, Tanzania

BACKGROUND: Since 2015, Tanzania has been implementing the Maternal Death Surveillance and Response (MDSR) system. The system employs interactions of health providers and managers to identify, notify and review maternal deaths and recommend strategies for preventing further deaths. We aimed to analyse perceptions and experiences of health providers and managers in implementing the MDSR system. METHODS: An exploratory qualitative study was carried out with 30 purposively selected health providers and 30 health managers in four councils from the Mtwara region between June and July 2020. Key informant interviews and focus group discussions were used to collect data. Inductive thematic analysis was used to analyse data. RESULTS: Two main themes emerged from this study: 'Accomplishing by ambitions' and 'A flawed system'. The themes suggest that health providers and managers have a strong desire to make the MDSR system work by making deliberate efforts to implement it. They reported working hard to timely notify, review death and implement action plans from meetings. Health providers and managers reported that MDSR has produced changes in care provision such as behavioural changes towards maternal care, increased accountability and policy changes. The system was however flawed by lack of training, organisational problems, poor coordination with other reporting and quality improvements systems, assigning blame and lack of motivation. CONCLUSION: The implementation of the MDSR system in Tanzania faces systemic, contextual and individual challenges. However, our results indicate that health providers and managers are willing and committed to improve service delivery to avoid maternal deaths. Empowering health providers and managers by training and addressing the flaws will improve the system and quality of care

Perceptions of health providers towards the use of standardised trauma form in managing trauma patients: a qualitative study from Tanzania

Background Trauma registries (TRs) are essential to informing the quality of trauma care within health systems. Lack of standardised trauma documentation is a major cause of inconsistent and poor availability of trauma data in most low- and middle-income countries (LMICs), hindering the development of TRs in these regions. We explored health providers’ perceptions on the use of a standardised trauma form to record trauma patient information in Tanzania. Methods An exploratory qualitative research using a semi-structured interview guide was carried out to purposefully selected key informants comprising of healthcare providers working in Emergency Units and surgical disciplines in five regional hospitals in Tanzania. Data were analysed using a thematic analysis approach to identify key themes surrounding potential implementation of the standardised trauma form. Results Thirty-three healthcare providers participated, the majority of whom had no experience in the use of standardised charting. Only five respondents had prior experience with trauma forms. Responses fell into three themes: perspectives on the concept of a standardised trauma form, potential benefits of a trauma form, and concerns regarding successful and sustainable implementation. Conclusion Findings of this study revealed wide healthcare provider acceptance of moving towards standardised clinical documentation for trauma patients. Successful implementation likely depends on the perceived benefits of using a trauma form as a tool to guide clinical management, standardise care and standardise data reporting; however, it will be important moving forward to factor concerns brought up in this study. Potential barriers to successful and sustainable implementation of the form, including the need for training and tailoring of form to match existing resources and knowledge of providers, must be considered

Predictors of antiretroviral therapy interruptions and factors influencing return to care at the Nkolndongo Health District, Cameroon

Background: Antiretroviral therapy is a lifelong commitment that requires consistent intake of tablets to optimize health outcomes, attain and maintain viral suppression. Objective: We aimed to elicit predictors of treatment interruption amongst PLHIV and identify motivating factors influencing return to care. Method: We conducted a cross-sectional study using a mixed-method approach in four hospitals in Yaound\ue9. Sociodemographic and clinical data were collected from ART registers. Using purposeful sampling, thirteen participants were enrolled for interviews. Quantitative data were analyzed using Epi-Info and Atlas-TI for qualitative analysis. Ethical clearance approved by CBCHS-IRB. Results: A total of 271 participants records were assessed. The mean age was 33 years (SD\ub111years). Private facilities CASS and CMNB registered respectively 53 (19.6%) and 14 (5.2%) participants while CMA Nkomo and IPC had 114 (42.1%) and 90 (33.2%) participants. Most participants (75.3%) were females [OR 1.14; CI 0.78-1.66] compare with males. 78% had no viral load test results. Transport cost and stigmatization constituted the most prominent predictors of treatment interruption (47.5%) and (10.5%) respectively. Belief in the discovery of an eminent HIV cure and the desire to raise offspring motivated 30% and 61%, respectively to resume treatment. Conclusion: Structural barriers like exposed health facility, and dispensing ARVs in open spaces stigmatizes clients and increases odds of attrition. Attrition of patients on ART will be minimized through implementation of client centered approaches like multiplying proxy ART pick points, devolving stable clients to community ARV model

Health workforce development post-1990s health sector reforms : the case of medical doctors in Tanzania

Background: Health systems in many low- and middle-income countries suffer from critical shortages and inequitable geographical distribution of the health workforce. Since the 1940s, many low- and middle-income countries have passed through different regimes of health sector reforms; the most recent one was in the 1990s. Tanzania is a good example of these countries. From the 1990s, Tanzania has been implementing the third generation of health sector reforms. This thesis analysed the health workforce development following the 1990s health sector reforms in Tanzania. Methods: An exploratory case study employing both quantitative and qualitative research approaches was used to analyse the training, deployment, and retention of medical doctors about two decades following the 1990s healthsector reforms. The quantitative approach involved analysis of graduation books and records from the Medical Council of Tanganyika to document the number of doctors who graduated locally and abroad, a countrywide survey of available doctors as of July 2011, and analysis of staffing levels to document the number of doctors recommended for the health sector as of 2012. The gap between the number of available and required doctors was computed by subtracting available from required in that period. The qualitative approach involved key informant interviews, focus group discussions, and a documents review. Key informants were recruited from districts, regions, government ministries, national hospitals, medical training institutions in both the public and private sectors, Christian Social Services Commission and the Association of Private Health Facilities in Tanzania. Focused group discussion participants were members of Council Health Management Teams in three selected districts. Documents reviewed included country human resources for health profiles, health sector strategic plans, human resources for health strategic plans and published and grey literature on health sector reforms, health workforce training, and deployment and retention documentation. For the training, analysis of data was done thematically with the guide of policy analysis framework. For deployment and retention, qualitative content analysis was adopted. Results: Re-introduction of the private sector in the form of public-private partnerships has boosted the number of doctors graduating annually sevenfold in 2010 compared to that in 1992. Despite the increase in the number of doctors graduating annually, their training faces some challenges, including the erosion of university autonomies prescribed by the law; coercive admission of many medical students greater than the capacity of the medical schools, thus threatening the quality of the graduates; and lack of coordination between trainers and employers. Tanzania requires a minimum of 3,326 doctors to attain the minimum threshold of 0.1 doctor per 1,000 population, as recommended by the World Health Organization. However, a countrywide survey has revealed the existence of around 1,300 doctors working in the health sector—almost the same as the number before the reforms. Failure to offer employment to all graduating doctors, uncertainties around the first appointment, failure to respect doctors’ preferences for first appointment workplaces, and the feelings of insecurity in going to districts are among the major challenges haunting the deployment of doctors in Tanzania. For those who went to the districts, the issues of unfavourable working conditions, unsupportive environment in the community, and resource scarcity have all challenged their retention. Conclusions: The development of human resources for health after the 1990s health sector reforms have to some extent been contradictory. On the one hand, Tanzania has succeeded in training more doctors than the minimum it requires, despite some challenges facing the training institutions. On the other hand, failure to deploy and retain an adequate number of doctors in its health system has left the country to continue suffering from a shortage and inequitable distribution of doctors in favour of urban areas. For health sector reforms to bring successes with minimal challenges in health workforce development, a holistic approach that targets doctors’ training, deployment, and retention is recommended

Health workforce development post-1990s health sector reforms : the case of medical doctors in Tanzania

Background: Health systems in many low- and middle-income countries suffer from critical shortages and inequitable geographical distribution of the health workforce. Since the 1940s, many low- and middle-income countries have passed through different regimes of health sector reforms; the most recent one was in the 1990s. Tanzania is a good example of these countries. From the 1990s, Tanzania has been implementing the third generation of health sector reforms. This thesis analysed the health workforce development following the 1990s health sector reforms in Tanzania. Methods: An exploratory case study employing both quantitative and qualitative research approaches was used to analyse the training, deployment, and retention of medical doctors about two decades following the 1990s healthsector reforms. The quantitative approach involved analysis of graduation books and records from the Medical Council of Tanganyika to document the number of doctors who graduated locally and abroad, a countrywide survey of available doctors as of July 2011, and analysis of staffing levels to document the number of doctors recommended for the health sector as of 2012. The gap between the number of available and required doctors was computed by subtracting available from required in that period. The qualitative approach involved key informant interviews, focus group discussions, and a documents review. Key informants were recruited from districts, regions, government ministries, national hospitals, medical training institutions in both the public and private sectors, Christian Social Services Commission and the Association of Private Health Facilities in Tanzania. Focused group discussion participants were members of Council Health Management Teams in three selected districts. Documents reviewed included country human resources for health profiles, health sector strategic plans, human resources for health strategic plans and published and grey literature on health sector reforms, health workforce training, and deployment and retention documentation. For the training, analysis of data was done thematically with the guide of policy analysis framework. For deployment and retention, qualitative content analysis was adopted. Results: Re-introduction of the private sector in the form of public-private partnerships has boosted the number of doctors graduating annually sevenfold in 2010 compared to that in 1992. Despite the increase in the number of doctors graduating annually, their training faces some challenges, including the erosion of university autonomies prescribed by the law; coercive admission of many medical students greater than the capacity of the medical schools, thus threatening the quality of the graduates; and lack of coordination between trainers and employers. Tanzania requires a minimum of 3,326 doctors to attain the minimum threshold of 0.1 doctor per 1,000 population, as recommended by the World Health Organization. However, a countrywide survey has revealed the existence of around 1,300 doctors working in the health sector—almost the same as the number before the reforms. Failure to offer employment to all graduating doctors, uncertainties around the first appointment, failure to respect doctors’ preferences for first appointment workplaces, and the feelings of insecurity in going to districts are among the major challenges haunting the deployment of doctors in Tanzania. For those who went to the districts, the issues of unfavourable working conditions, unsupportive environment in the community, and resource scarcity have all challenged their retention. Conclusions: The development of human resources for health after the 1990s health sector reforms have to some extent been contradictory. On the one hand, Tanzania has succeeded in training more doctors than the minimum it requires, despite some challenges facing the training institutions. On the other hand, failure to deploy and retain an adequate number of doctors in its health system has left the country to continue suffering from a shortage and inequitable distribution of doctors in favour of urban areas. For health sector reforms to bring successes with minimal challenges in health workforce development, a holistic approach that targets doctors’ training, deployment, and retention is recommended

Understanding the Rural–Rural Migration of Health Workers in Two Selected Districts of Tanzania

Globally, rural–urban migration has been the focus in addressing the question of availability of health workers in rural areas. Often, the rural–rural migration of health workers, another important dimension is neglected. This study aimed to analyze the magnitude and the underlying factors for rural–rural migration of health workers in two rural districts of Tanzania. An exploratory comparative cross-sectional study adopting both quantitative and qualitative approaches was carried out in two districts of Kilwa in Lindi region, southern Tanzania, and Rombo in Kilimanjaro region, northern Tanzania. In a quantitative approach, 174 health workers (both clinicians and nonclinicians) filled in a self-administered questionnaire between August 2015 and September 2016. For the qualitative sub-study, 14 key informants that included health facilities in-charges and district health managers from the two districts were interviewed. In addition, three focus group discussions were conducted with members of the health facilities committee, in the two districts. Over 40% of health workers migrated from one workstation to another between 2011 and 2015. Close to 70% of the migrated health workers, migrated within the same districts. The proportion of health workers migrated was higher in Kilwa compared to Rombo. However, the difference was not statistically significant. The major underlying factors for migration in both districts were: Caring for the family and Unfavorable working and living conditions. In Kilwa, unlike Rombo, rejection by the community, superstitious beliefs, and lack of social services, were the other major factors underlying migration of the health workers. While addressing rural–urban migration, attention should be paid also to the rural–rural migration of health workers. Lastly, addressing the migration of health workers is a multi-dimensional issue that needs the engagement of all stakeholders within and beyond the health sector

Exodus of Clinicians from Public Sector to Non-Clinical Practice in Private Sector in Dar es Salaam Tanzania; Exploring the Drivers

Background: Globally, shortage of clinicians health workforce is among the major challenges facing the health systems of many countries including Tanzania. Migration of medical doctors from clinical practice to non-clinical practice partly contributes to this challenge. This study aimed to explore factors influencing Medical Doctors’ decision to migrate from clinical practice in the public sector to non-clinical practice in the private sector in Dar es Salaam Tanzania.Methods: An exploratory qualitative study was conducted using 12 in-depth interviews with medical doctors working in the private sector but formerly worked in the public health sector. Interviews were digitally recorded, transcribed verbatim and thematically analyzed.Results: Three main themes emerged; health system-level drivers that has three sub-themes, namely poor work environment, heavy workload due to shortage of clinicians and underfunded public health sector; individual-level drivers, which include four sub-themes: Age, area of specialization, marital status and empathy to patients; and external environment drivers consisting of two sub-themes: peer pressure and community culture.Conclusion: Improving the work environment through increased funding will partly address the main health system drivers underlying migration from the clinical practice. Furthermore, nurturing junior doctors to be enthusiastic and adapting to cultural shocks can partly help to address the individual and external drivers. Keywords: Shortage, Medical Doctors, Clinicians, Physicians, migration, health workforce, Tanzania Clinical Practice, Non-Clinical Practice

Extended data

Interview guides for strengths and limitations of electronic Research Ethics Information Management System in a health training institutio