Annex 5. Tanzania

Home , Clinical officer, Health in Tanzania, Tanzania Mainland

Background

Tanzania, situated on the eastern side of Africa, is a country faced with major challenges. Internal factors such as poor infrastructure, low education levels, poverty, and diseases exacerbate the extent of these challenges. The bold attempt, in the form of the Millennium Development Goals (MDG) set by the United Nations (UN), to eradicate poverty, mortality, and combat diseases remains important for countries striving to improve the overall state of wellness of their societies. The country has recognized the shortages of health professionals as impacting very negatively on its ability to make progress in achieving health-related MDGs. In an attempt to fill the gap of health professionals, Tanzania has implemented a system of mid-level health workers (MLHWs) in relation to specific health service needs. We review Tanzania’s health statistics and analyze some of the leading health indicators to contextualize a consideration of the impact of MLHWs on health-related MDGs in the country.

An essential part of and what can be considered threshold conditions for any country’s economic and social development is ensuring that its population has access to adequate health care services and facilities. Only half of the population (54%) has access to improved drinking water, while only 24% has access to improved sanitation facilities. As such, maternal mortality, child mortality, HIV/AIDs, pneumonia, and malaria, are major issues that the health system faces, with malaria being the most common. Given the disease profile of this country, it appears that based on the most pressing health challenges (malaria and HIV/AIDS), prevention and health promotion are the greatest health service needs. This clearly supports a more active role for lower level health workers, such as MLHWs, who could assist in carrying the more preventive and health-promoting load of more highly qualified medical practitioners.

The Tanzanian health system is decentralized, and framed most explicitly by its National Health Policy.1 The Tanzanian National Health Policy appears to be driven primarily by the objective to provide access to quality primary health care for all citizens.1 Explicitly linked to the health-related Millennium Development Goals (MDG) is the policy’s identification of and focus on resources towards an essential health care package, which is “an integrated collection of cost effective interventions that address the main diseases, injuries and risk factors” in the country.1 Community health promotion and disease prevention through environmental sanitation and management of occupational health services is recognized as a key component.

Provision of health care, particularly in rural areas and facilities, was adversely affected after the economic recession in the 1970s and 1980s, which resulted in an overall deterioration of health care services. This led to the Tanzanian government introducing Cost-Sharing in 1993 and following that, instituting other financing options such as a National Health Insurance and a Community Health Fund.1

In general, the health services are heavily based on national government financing, with some tax-based funds through local government council tax collection and other earnings.1 The Community Health Fund (CHF) is viewed as an effective “tool for mobilizing voluntary community involvement and participation in supporting their own health,” whereas the Health Insurance Scheme is seen as a “mechanism to ensure medical protection of employees in the formal sector.”1

Regardless of the context within which health care has to occur, fundamental to ensuring the health of the nation is the availability of appropriate numbers and quality of human resources for health. A country such as this, with a decentralized system of health care provision, requiring dispersed access to HRH, coupled with a burden of disease concentrated at the periphery of society, could benefit from the specific health service characteristics that MLHWs can provide.

Situational analysis of MLHW in Tanzania

National HRH strategic plan and policy

The Ministry of Health and Social Welfare is responsible for the governance and leadership of Human Resources for Health (HRH) as well as the human resources needs for the social services sector. The plan considers the status of HRH, the management thereof, and based on these aspects, projects future workforce requirements to suggest strategic interventions. Furthermore, it set out an implementation matrix, which facilitates the structures that need to be in place for the monitoring and evaluation of the plan. Lastly, a budget to support the implementation of the plan is offered.

Tanzania’s most recent policy relating to human resources in the health sector is its Human Resources for Health Strategic Plan 2008 – 2013.2 The plan was developed through a multi-stakeholder process, which was also open to participation from various levels of health and social welfare sector stakeholders. International organizations, such as the WHO, JICA and the Capacity Project, were extensively involved either through consultation or lending financial support. The creation of the plan was coordinated and led through the Human Resource Planning section that resides under the Ministry of Health and Social Welfare. The plan is set to be reviewed every year.

The purpose of the plan is to provide “proper planning, development, management and effective utilization of human resources.”2 The plan is driven by the realities of a high burden of disease accompanied by high level of incidence of non-communicable conditions such as cancer and malnutrition, within the context of extensive human resource shortages. This document sets out the extent of shortages and illustrates that in the public sector, these are most extensive at the lower level health facilities, and in the private sector to be most extensively experienced at the higher level health facilities.

Most importantly is the realization that major disease programs like HIV/AIDS and Malaria programs “impose additional demands on the existing workforce” without a concomitant consideration of the additional support and HRH needed to affect these plans.2

There is no explicit consideration of the role and training of mid-level health workers in the policy. However, in the implementation matrix, which sets out the objectives of the plan and the activities linked to implementing these, there is a strategy to ‘strengthen workforce practices,’ and to ‘scale up enrollment and training of health workers’. Here, there is mention of building a case to accommodate new and emerging health cadres, as well as the re-introduction of community health cadres in line with the primary health care focus.

The HRH information system is not well established.2 Some information is gathered through the health management information system and professional bodies, but these data are very limited for the

12 purposes of informing decision-making and proper planning.2 There are specific difficulties linked to a lack of co-ordination between different units and unreliability in certain instances of the HR data. This is exacerbated by the lack of HR information specifically from the private sector, and the limited ability and skills to analyze demand and supply in order to inform forecasting.

The issue that most negatively impacts the sector’s ability to plan, manage, retain and appropriate educate current and future HRH, is primarily the poor system for HR information management, and secondarily, the difficulties current training institutions have in trying to match existing demand. The HRH Strategic Plan acknowledges the lack of retention strategies as one of the main factors negatively impacting on the recruitment and retention of all cadres. The increasingly dire impact of HIV/AIDS on the workforce is acknowledged in the commitment to develop an HIV/AIDS Workplace Program.

MLHWs in Tanzania

Neither the National Health Policy (2003), nor the Human Resources for Health Strategic Plan (2008), details the total numbers of each type of MLHW in Tanzania. The HRH Strategic Plan does offer some consideration of the general HRH supply and demand information, using this to calculate staff shortages across different health facilities in the country. Rather, indications of the spread of MLHWs in Tanzania were found in a recent article by Munga & Maestad (2009), reproduced below. The table shows that the majority of health workers, as well as the main MLHWs (Clinical Officers (COs) and Assistant Medical Officers (AMOs)) are concentrated in the government sector, with the minority found in the private sector. The distribution of different levels of health provider cadres is much more equal in the private sector.

Table 1: Distribution of health workers across cadres and sectors (%), Tanzania (n= 46 896) Cadre Government Private Voluntary Agencies Total Medical Officer 0.8 0.3 0.2 1.3 Assistant Medical Officer 1.0 0.2 0.3 1.5 Clinical Officer 9.0 1.1 1.7 11.7 Nurse/Nurse-Midwife 18.3 2.1 7.4 27.8 Medical Assistant 30.7 1.6 7.9 40.2 Other 10.6 1.5 5.3 17.5 Total 70.3 6.7 22.9 100.0 Source: Munga & Maestad (2009)

Dovlo (2004) estimates the average annual production of MLHWs in Tanzania to be roughly 300 Clinical officers, and 40 Assistant Medical Officers in comparison to roughly 50 Medical Officers/Doctors per year. Mckinsey & Co (2009), through a health workforce pyramid, indicate the Tanzanian health system to have 400 specialists, 940 medical officers, 1400 assistant medical officers, 6900 clinical officers, 5500 registered nurses, 3580 diagnostic and support staff (includes 1090 laboratory workers, 340 pharmacy workers and 2150 other healthcare workers) and 7070 enrolled nurses (at that time the numbers of clinical assistants were not yet available as the training for these cadres only began in 2008).

It is quite a challenge to attempt a situational analysis of MLHWs in Tanzania because, as mentioned, the existing HRH information system is not well coordinated and established.2 An evaluation of the impact of MLHWs in Tanzania has to investigate the role and contribution specifically of COs and AMOs. In Tanzania, COs can provide clinical medicine, and they were the starting cadre, but were upgraded to an "assistant medical officer" with a considerably widened scope of practice. AMOs are trained and able to

13 perform tasks such as medicine, minor surgery, obstetrics, dermatology and anaesthesia.3 These cadres are medical personnel capable of promoting and providing curative as well as preventive health care at a district level.4

Two typologies and brief descriptions are presented below, which illustrates the characteristics of both COs and AMOs in Tanzania.

Brief illustration of COs and AMOs in Tanzania

Whereas a CO is a person with at least 3 years of post-schooling basic and applied medical training, an AMO has an additional 3 years of practical experience and a minimum of 2 years additional education and training. This person is then allowed and regulated to practice general medicine, minor surgery, obstetrics, dermatology and anesthesia.

Development and recruitment of CO and AMO cadre

Due to the extreme shortage of Medical Officers in Tanzania, the government instituted the training of COs to fill the gap in health service needs. Although not an explicit requirement for entry in to the CO training program, many trainees enter as nurses. However, because of the long training and inadequate output of Medical Officers, it was recognized that there is a need for a better trained cadre between the CO and the graduated Medical Officer to provide quality care.4 Thus, once having qualified as a CO, and having at least 3 years of experience, an individual can apply to undergo additional 2 year training program to become a qualified AMO.

AMOs are thus considered an advanced MLHW, trained at the post-basic level, while the CO is a MLHW at the basic level. The Department of Human Resource Development, under the Ministry of Health, sets out the training requirements in the curriculum for AMOs. This recognizes that because of the long and expensive training associated with Medical Officer production, there was a need to have an intermediate, better trained cadre between a CO and a graduated Medical Officers, which the AMO fulfills.5 These cadres are able to work independently, with limited or no supervision from a physician, and within the context of medical practitioner shortages, especially in rural areas.

Tanzania initiated the training of AMOs in the early 1960s, and now has more than 1300 AMOs, along with approximately 5000 COs.6

Roles and responsibilities of COs and AMOs

Individuals that graduate from the CO training program in Tanzania receive a Diploma as COs from the Ministry of Health. These individuals are skilled to manage common medical and reproductive health and simple surgical problems. In contrast to AMOs, they are legally prohibited to perform caesarean sections.

An AMO is a person in possession of an Advanced Diploma in Medicine, and is registered to practice medicine, surgery and midwifery through the auspices of the Tanganyika Medical Council under the Medical Practitioners and Dentists Ordinance of 1968 Cap 409. They can be deployed at District Hospitals and Health Centre Levels, where they can perform the role of Medical Doctors at those levels. The district hospitals are a level below the divisional level, where rural health centers would be found.

Training, accreditation/licensing of COs and AMOs

COs undergo 3 years of post-schooling practical and clinical training. The requirement for entry into these programs is at least a grade 10, although most would enter after successful completion of grade 12. The practical training is typically completed at a district level hospital. After graduation, the individual may apply for licensing through the Medical Council of Tanganyika.

The training of AMOs in Tanzania takes place in the main at 5 training institutions (those closest to rural areas), with roughly an annual output across all institutions of 240 graduates.4 The training program extends over a period of 2 years and consists of advanced theoretical and practical training and education. Part 1 consists of a theoretical component, including Internal Medicine, Pediatrics and Child Health, Surgery, and Obstetrics and Gynecology. Part 2 consists of the clinical rotations of all the subjects contained in Part 1. Part 3 consists of Community Medicine training and education.

The Tanganyika Medical Training Board is responsible for the accreditation of programs and the awarding of the CO and AMO qualifications. Upon receipt of the qualification, the graduate has to register with the Tanganyika Medical Council, which regulates the practice of the profession. A range of professional associations also exists, but they possess no regulatory power.

Employing institutions for COs and AMOs

The majority of COs and AMOs work in the public sector, with a minority in the private sector. They are trained and prepared to function most effectively in primary health care settings, and would thus be most useful in the ward level and in rural health centers. The AMO is also intended to practice mostly in Primary Health Care settings, although their surgical skills mean that they will be able to provide some care at the secondary level. Dovlo (2004) reports on key information data from Tanzania and Mozambique, estimating that roughly 75% of COs and AMOs served in rural areas.

Supervision and monitoring of CO and AMO programs

Although the Ministry of Health requires that COs and AMOs be supervised by a more senior health care practitioner, where they are deployed (in the main at the district and divisional levels), this is not always the case in reality. Thus, we find that these cadres take on enormous responsibilities, working very often without supervision, and limited opportunities to refer patients to higher levels of care. Although it appears that supervision and monitoring of the training of these cadres are both quite extensive, this does not seem to filter through to the employment situation. This is also supported by Dovlo (2004) when asserting that Tanzania has a board regulating the training of these MLHW cadres, but they do not register and control practitioners.

Performance evaluation of COs and AMOs

There are some studies that evaluated the quality of medical and nursing graduates as well as medical assistants in Tanzania, and found these to be hampered by the particular curriculum design, training methods and quality of training. However, a similar evaluation of quality of emergency obstetric surgery care, in 5 sub-Saharan African countries (including Tanzania), found no significant differences between assistant medical officers and medical officers in terms of outcomes, risk indicators, or quality.6

Salary/ Incentives

Salary information on AMOs and COs in Tanzania is very hard to find. McCoy et al 2008 elaborates on the difficulties in finding salary information in sub-Saharan African by asserting that “data on public- sector pay should be readily available from government databases, but in practice, such data are inaccurate, incomplete, unclear, and out of date.”7 Although Human Resource Financing is discussed in the HRH Strategic Plan, there is no clear indication of the salary packages of different levels of HRH. The plan appears to be more concerned with the financing for training of human resources, than the remuneration needed to retain qualified HRH. However, there is some literature asserting that AMOs are paid lower salaries than certain nurses, lab technicians, and midwives, despite having a qualification that is recognized and supported by their Ministry of Health.8 Recognition of the inadequacy of salary scales is illustrated in the MoHs recent reporting on a special accelerated salary package for health workers in the public sector in Tanzania being instituted.9 Here, salary increases for doctors were put as 37%, 45% for AMOs, 32% for COs, 37% for nursing officers and 31% for pharmacists.

Retention

An essential aspect of retaining the HRH is reducing attrition and increasing training. A recent report by the Touch Foundation (2009: 31) asserted that at current rates of attrition “nearly sixty per cent of increased throughput will be soaked up by filling slots vacated through attrition”. In the National Health Policy, the MoH commits itself in collaboration with the President’s Office, Public Service Management, Regional Administration and Local Government to “set up a clear program for recruitment, deployment, and retention of trained health personnel in appropriate numbers and skills mix.”1 However, it is not clear that the issue of retention of HRH is comprehensively considered in either the National Health Plan or the Human Resources for Health Strategic Plan 2008 – 2013.

Professional advancement

The position of MLHWs in Tanzania is quite particular in that it provides a career progression where the AMO qualification builds on the already qualified CO, with related skills and training. Although there is some evidence to suggest that AMOs do not attract respect and recognition from other medical doctors and administrators, despite fulfilling very similar roles and tasks to a medical doctor.10 Thus, an AMO is an advanced MLHW cadre, and can advance to eventually become a Specialist AMO, which is considered to be equivalent to a Medical Officer (MO). Upon completion of an additional 2 years of training, the individual will then also be called a doctor.

CLINICAL OFFICERS Brief illustration A clinical officer (CO) is a step below an AMO in Tanzania. This person has generally had 3 years of training in basic and applied medicine and is responsible for healthcare of large dispersed rural populations. Development as These are the starting MLHW cadres in Tanzania, where AMOs are now more prominent. a cadre Although these cadres can come from secondary schooling levels, some also enter into the program as qualified nurses. Recruitment The age limit 18-25 years and they have to be medically fit. They are required to have at least a and selection Grade 10, with good credits in science subjects: physics, chemistry, biology and a pass in English. If they are Grade 12 leavers, they need at least 2 principles in Physics, Chemistry or biology. They can also be recruited from already qualified nurses. Roles and General role & responsibilities: Related to maternal health: Related to child responsibilities health: of COs COs are skilled to be able to manage They can manage common, medical, reproductive health reproductive health problems. They can manage and simple surgical problems. They are common, medical legally prohibited to perform caesarean and simple sections. surgical problems. Training (initial Basic training: Hospital or community On-going and on-going) training: training: They undergo three years of post- secondary school practical and clinical The course consists of 14 HRH Strategic Plan training. modules and three practicum recognizes the rotations, typically conducted need and at a district hospital. This importance of facility-based practicum CPD, but the lack portion is overseen by a of a National preceptor. Training Plan is identified as a key challenge towards ensuring this. Accreditation/ The Medical Council of Tanganyika is responsible for the accreditation and licensing of COs. licensing bodies There is also a Clinical Officers Association of Tanzania (COATA), residing under the Muhimbili University of Health and Allied Sciences, offering membership for these cadres to a professional association. Who train The training of COs is the official responsibility of the Ministry of Health, with the Medical them Council of Tanganyika being responsible for accreditation and licensing. The cost of training to the MoHSW for maintaining one distance learning student for 1 year is TSH 172,000 (USD 143), compared with TSH 300,000 (USD 250) for one student for 1 year for the residential course. The majority of COs train at a Clinical Officer Training College. The COTC in Mtwara is an important training hub. It is also the regional administrative center for health training, with responsibility for data collection and strategic planning, as well as offering support to other training institutions. A college for assistant medical officers (a grade more senior than clinical officers) is under construction on the campus (Baraitser et al, 2011) . Where do they The majority of COs work in the government public sector, followed by a much smaller work percentage working in the NGO /voluntary organization and private sectors. They are prepared most specifically to function in primary health care settings. Mckinsey & Co (2006) indicate that in Tanzania COs staff health care facilities across the entire spectrum (tertiary care centers, regional hospitals, district hospitals, health centres and dispensaries). Supervision and Clinical officers take on enormous responsibilities, working without supervision and with monitoring in limited opportunities for referring patients, seeing up to 100 patients a day. As well as treating these programs illness, clinical officers have status as community leaders and health educators, and they need

to know how to manage services, budgets, and human resources (Baraitser et al, 2011).

Performance Who monitors their performances and Outcome of evaluation How many evaluation how frequently evaluations in the last X years Salary/incentive US $500/month, $6,000/year will pay Annual increments etc Any added the salary of a Clinical Officer. incentive different from Cos not working in these primary or secondary care programs Retention What is the retention policy on these Average span of the program? programs? Professional Next level in career growth: advancement Assistant Medical Officer. They can apply to do the STI module to upgrade and extend their diploma training in basic applied medicine and this will elevate them to the level of Assistant Medical Officer (AMO). This assists them in gaining a wider knowledge base in healthcare, and an advanced diploma and licensed practitioner status.

ASSISTANT MEDICAL OFFICERS Brief illustration Assistant Medical Officers in Tanzania, refer to a MLHW that has a minimum of 3 years of the exact type practical experience, with a minimum of 2 years pre-service education, being trained and of NPC regulated to practice general medicine, basic and emergency surgeries, obstetrics, dermatology and anesthesia. They are not recognized internationally, but locally, they are equated to first degree holders. They can be utilized inter-changeably with medical doctors, providing the full range of medical and surgical services in a district hospital. They perform 80% of all caesarian sections in Tanzania, as well as other emergency medical and surgical procedures. Development as AMO are seen as a different cadre of professionals who are substituted to perform tasks a cadre usually performed by medical doctors. They were trained based on the need for more advanced medical skills needs than what was available from COs. The training of these cadres were instituted due to severe shortages of qualified doctors in Tanzania. Recruitment and An applicant must have a Diploma in Clinical Medicine from the Tanganyika Medical Training selection Board. He or she must also have a sponsor to facilitate his/her training. Not only must they have the above diploma, but they must have a minimum of 3 years of working experience in a Health facility with a good recommendation from the employer. To become an AMO, one must first study for three years to become a Clinical officer. After working for three years, one is eligible to join an AMO training school for a two year advanced diploma in Clinical Medicine - which is equivalent to a first degree in medicine. Two more years of study lead to a specialist qualification in anesthesia, pediatrics, radiology, surgery etc. The age of an applicant should not exceed 45 years. Candidates who have been discontinued from MD training programs after four years of training may be considered for admission into the course. Must pass a pre- selection exam set by the Ministry of health except for foreign students. Roles and General Responsibilities: Maternal Health Responsibilities: Child Health responsibilities Responsibilities: of AMO Related to district level An AMO is not only responsible to hospitals: Promoting and take care of all aspects of any Although an AMO providing curative and patients care, but they also have a does not have direct preventive services. Supervise specific responsibility to see to Child Health

implementation of Primary emergency surgery and obstetrics. Responsibilities, they Health Care programs. do impact on Child Participate effectively in the Health in ensuring district health teams. Attend maternal health district planning committee through attending to meetings. Attend any other emergency surgery meetings which promote health and obstetric care care. Supervise peripheral needs. health workers. Arrange and conduct refresher courses for other health workers in order to improve their skills. Oversee the ordering of drugs, equipment and other supplies required by health units. Organise and supervise the running of out - patient departments. Admit patients and perform ward rounds. Manage financial affairs in the district especially when the District Medical Officer is not available. Carry out health system research activities in the district on relevant subjects so as to affect intervention measures against basic problems.

Related to training institutions: Teaching and supervising students. Perform other duties as required by the respective authority.

Related to community health: Conduct health education to the community. Monitor communicable diseases. Design preventive measures. Promote PHC programs. Training (initial Pre-service: Initial: On-going: and on-going) AMO foundation has already Rotations of 14 weeks each with An AMO should be been laid in the Clinical Officer the exception of the Community able to continuously training course. This entry level medicine rotation which has 13 update his/her cadre has working experience of weeks. Introduction to clinical knowledge and skills a minimum of three years in the medicine takes a block of 8 weeks by interacting with peripheral health units or and involves the teaching of the his colleagues, District Hospitals. whole class at beginning of the reading Medical course. Part 1 consists of a Journals, attending theoretical part in the following refresher courses subjects: Internal Medicine, and seminars and Pediatrics and Child Health, teaching subordinate

Surgery, Obstetrics and staff. Gynecology. Part II covers the Clinical rotations in the above subjects. The aim of the Clinical rotations is to enable the AMO to acquire sufficient practical professional skills in the management of all the Medical conditions common in the tropics. Part III is Community medicine. The aim of community medicine course is to enable the Assistant Medical Officer to manage both effectively and efficiently the PHC programs under his/her jurisdiction. The last four weeks are then spent on survey methods as follows: 1st week survey protocol design at the school, 2nd week data collection in the field, 3rd week data analysis and report writing while at school, 4th week report presentation in class plenary where there could be invited guests. Accreditation/ AN AMO is a holder of an Advanced Diploma in Medicine that is awarded by the Tanganyika licensing bodies Medical Training Board. Upon this they can apply to the Medical Council for licensing. AMOs are registered to practice medicine, minor surgery, obstetrics, dermatology and anesthesia, and midwifery by the Tanganyika Medical Council under the Medical Practitioners and Dentists Ordinance of 1968 Cap 409. No information is available in terms of whether this licensing is for life-time or if re-licensure is required on a specified basis. Their role is to support adherence of high standard of medical ethics in clinical and public health practice by its members through the dissemination of the MAT booklet, Guiding Principles on Medical Ethics and Human Rights in Tanzania. Who train There five training institutions: KCMC, Bugando, Mbeya, Tanga and TTCIH-Ifakara acting in them conjunction with Consultant/ Referral Hospitals or equivalent venue with adequate facilities and resources for theory and clinical teaching. In addition, the hospital must have an active Community Health department which facilitates training and supervision of peripheral health units as well as Primary Health Care. The training institution should have tutors trained in a recognized University or equivalent at Master’s Degree level. Where do they Primary care setup: They work in the main in district hospitals, although they are envisioned work to serve a rural constituency more than what a Medical Officer would do. Secondary care setup: They are able to provide secondary care, although the focus of increasing the training of AMOs is to better serve rural areas and the primary and emergency health care needs. Mckinsey & Co (2006) indicate that they primarily staff district hospitals, regional hospitals and national tertiary care centers. Supervision and Supervision and monitoring of training is well established: Courses are normally conducted in monitoring Consultant/Referral Hospitals. Clinical Tutors are responsible for supervision and monitoring. They are trained in a recognized University or equivalent at Masters Degree level. Clinical skills are evaluated by several clinical tutors, over a 24 month period, on the basis of repeated real life experience in many varying clinical situations. Clinical examinations consist of one long case examined for 40 minutes followed by an oral examination of 20 minutes. The written

examination consists of mainly objective and essay type questions. Composed of multiple choice, matching and true-false questions and carries 50% of the overall mark. The remaining 50% is comprised of a clinical, problem solving essay question.

Performance Who monitors their performances and how Outcome of How many over evaluation frequently? evaluation? last X years? Salary/incentives Accurate AMO salary information not yet had Annual increments etc Added incentive been found. However, UNDP Tanzania, different from through their recently initiated Millennium cadres not Villages Project offered the following package, working in as an example of what an AMO could earn in primary/ Tanzania. Type of Contract: Service Contract. secondary care Duration: One year initially. Salary: SB 3 programs Minimum. Retention What is the retention policy on these Average span of the programs? program Professional Next level in career growth: advancement After completing the AMO program, they can apply to become an AMO at specialist level. However, after working at AMO level for five or more years, mostly in rural health centers or district hospitals, they are eligible for two more years of training in one of the referral hospitals. Upon graduation, they obtain the title of "Doctor," and are licensed to practice medicine like MDs.

Appendix 5.1 Country Context

Tanzania, situated on the eastern side of Africa, is a country faced with major challenges. Internal factors such poor infrastructure, low education levels, poverty, and diseases exacerbate the extent of these challenges. The bold attempt, in the form of the Millennium Development Goals (MDG) set by the United Nations (UN), to eradicate poverty, reduce mortality, and combat diseases remains important for countries striving to improve the overall state of wellness of their societies. The country has recognized the shortages of health professionals as impacting very negatively on their ability to make progress in achieving health related MDGs. In an attempt to fill the gap in health professionals, Tanzania has implemented a system of mid-level health workers (MLHWs) in relation to specific health service needs. We review Tanzania’s health statistics and analyze some of the leading health indicators to contextualize a consideration of the impact of MLHWs on health related MDGs in this country.

Country profile

Tanzania has a population of over 43 million people with a majority under the age of 18. There has been a steady slowdown in the population growth rate from 7.5% (in 1970 – 2009) to 4% (2000 – 2009). Socio-economic factors such as poverty and increasing cost of living and education levels are assumed to have contributed to the decline in population rates. The population continues to be overwhelmingly rural, with only 26% of its populace residing in urban areas.

Table 2: Selected demographic information for Tanzania, 2009 Demographic indicators 2009 Population (thousands) 43,739 Population (thousands) under 18 22,416 Population (thousands) under 5 7,792 Annual no. of births (thousands) 1,812 Annual no. of under-5 deaths (thousands) 188 % of population urbanized 26 Source: WHO (2011)

The country’s land area is 945 km², and is very arable and mountainous in the North east where the World Heritage site Mount Kilamanjaro is situated. There are great lakes known for their unique fish species. Tanzania, Mozambique, and Zambia share water resources in terms of lakes. Lake Victoria is shared to the north with Uganda and Kenya, Lake Tanganyika with Zambia, Burundi, and the Democratic Republic of Congo, and Lake Nyasa is shared with Malawi and Mozambique. Tanzania is divided into 26 regions - 21 on the mainland (for instance, Dar es Salaam, Kigoma, Kilimanjaro, and Mwanza) and 5 in Zanzibar (Zanzibar North, Zanzibar Urban/West, Tanga, etc). Tanzania has a tropical climate, where in the highlands, temperatures range between 10 and 20 degrees Celsius while the rest of the country remains hot and humid with temperatures rarely falling below 20 degrees. There are 2 major rainfall periods between October to December and March to May. This climate of course, impacts the specific disease profile in the country, and presents the ideal environment for the high prevalence of malaria.

Figure 1: Map of Tanzania

Source: www.wordtravels.com Within these regions, there are 98 districts, each with at least one council, created to increase local authority. There are 114 councils with the majority of these operating in rural and only 22 in the urban areas. Dares Salaam is the largest city and is the commercial capital. Dodoma, located in the center of Tanzania is the new capital and houses the unions and parliament.

There have been multi-party elections since 1995, although there is only one dominant political party - Chama Cha Mapinduzi. The president and the national assembly are elected concurrently by direct popular vote for a 5 year period. The president selects cabinet ministers and the constitution allows the president to nominate non-elected members to the national assembly. They have passed laws that ensure that women hold positions in the national assembly. The judicial system has 5 levels combining tribal, Islamic, and British common law. Judges are appointed by the Chief Justice of Tanzania, except those for the Court of Appeals and the High Court who are appointed by the President. Under the leadership of Julius Nyerere, the socialist government focused heavily on achieving social equity through the development of strong health and education sectors. These policies were, however, unsustainable, given the realities of an economic crisis and negligible growth.

The country’s colonial legacy has had an impact on the extent of inequality still experienced by the majority of Tanzanians today. For instance, while some peasants were connected to the cash crop export economy, others were not, resulting in some of the populace living relatively comfortably in urban areas in comparison to the vast majority in rural areas, which does not.

After years of borrowing from the International Monetary Fund (IMF), the country went through reforms to change the structure of their economy and has grown and reduced poverty. After President Nyerere stepped down in 1985, his successor adopted a gradual process of economic liberalization and democratic reform. At present, social policy is guided by the Tanzania Development Vision 2025, which identifies three principal objectives: “achieving quality and good life for all; good governance and the rule of law; and building a strong resilient economy that can effectively withstand global competition.”

The population of Tanzania consists of people of African, Arab, Indian and Pakistani origin and a small Chinese constituency, with the majority on the mainland and some in Zanzibar. There are over 120 African ethnic groups, of which the Sukuna and Nyamwezi have over a million members, and their origins include the nomadic Maasai and Luo groups. These 120 ethnic groups have their own languages but the Sandawe groups speak languages of the Khoisan family.

Although Swahili is the official national language, after gaining independence, it is commonplace for English to be used alongside it. English is not conventionally used in administration or parliament, but in the court of law, it is still the de facto official language. The primary schools mostly teach in Swahili, whereas English is the language of choice for universities where people exclusively use it to communicate with each other. Other spoken languages are Gujarati, Portuguese, and to a lesser extent, French, from the neighboring country of the Democratic Republic of Congo (DRC).

It is estimated that roughly one third each of the population is Muslim, Christian and have indigenous religious beliefs. The Christian believers mostly consist of Roman Catholics, Protestants (Lutheran), Pentecostals and Seven Day Adventists. The Christians are mainly found inland, while almost all Muslim communities are concentrated in the coastal areas of Zanzibar. Other religious groups, such as Buddhists and Hindus can also be found.

It is clear that Tanzania’s complex social and political dynamics contain specific implications for the success of health interventions, and the human resources needed to implement them.

Economy and poverty

Tanzania’s economy has been performing better in recent years but the majority of people continue to live below the poverty line, and it is thus not surprising for it to be classified as a low-income country. The economy is mostly based on agriculture, accounting for over half of the Gross Domestic Product (GDP), and the sector employs almost half of the working population. Cultivated land is approximately 4% of the land area. The country is abundantly supplied with natural resources such as commodities and natural gas.

There is a small percentage of the population that has secure employment, and thus a relatively stable and high standard of living, but the vast majority of Tanzanians live in poverty. In 2011, the United Nations Development Program's (UNDP) human development index (HDI), ranked Tanzania 156th out of a total of 174 nations. The country is thus seen as one of the least developed and poorest in the world.

There is a sustained economic division between the general peasantry and those with higher-paying jobs in the urban centers. According to the CIA World Fact book, the poorest 10% of the Tanzanian population consume a marginal 2.9% of total national consumption, while the richest 10% consume 30.2%. Table 3 provides an illustration of the extent of poverty. While some positive progress has been made in reducing most poverty rates, the inequality between the rich and the poor continues to widen (for instance the GINI index has risen from 35 in 2000 to 38 in 2007). Table 3: Selected poverty rates in Tanzania Poverty rates 2000 2007 GINI index 35 38 Income share held by highest 10% 27 30 Income share held by highest 20% 42 45 Income share held by lowest 10% 3 3 Income share held by lowest 20% 7 7 Poverty gap at $1.25 a day (PPP) (%) 47 28 Poverty gap at $2 a day (PPP) (%) 64 48 Poverty gap at national poverty line (%) 11 10 Poverty headcount ratio at $1.25 a day (PPP) (% of population) 89 68 Poverty headcount ratio at $2 a day (PPP) (% of population) 97 88 Poverty headcount ratio at national poverty line (% of population) 36 33 Sources: World Bank (2007), Global Poverty Working Group (2009), Development Research Group (2008)

Overview of the Tanzanian health system

Table 4: Selected health system indicators, Tanzania (2008) Health system indicator Country % of population using improved drinking water sources Total 54 Urban 80 Rural 45 % of population using improved sanitation facilities Total 24 Urban 32 Rural 21 Source: WHO (2011)

The population’s access to water and sanitation is an indication of the extent to which the populace might be exposed to unsanitary and disease-prone instances, and can be used to assess the baseline state of health. It is clear that access to clean, drinkable water and sanitation prevents to a large extent the exposure to common diseases.

While water resources are deemed abundant, there is great variation in water availability throughout the country. It is worrying to note that only half of the population (54%) has access to improved drinking water, while only 24% have access to improved sanitation facilities. The extent of inequality is starkly illustrated by the great disparities between these indicators for urban and rural populations. While there has been an improvement in recent years, at present, over 80% of urban areas receive clean drinking water compared to only 45% of rural areas. In terms of having sustainable access to improved sanitation, this is true for just over 30% of urban dwellers, in comparison to about 20% of their rural counterparts (in 2008).

Main health problems according to the burden of disease

To assess the major problems in a country’s health system, the typical starting point is the indicators associated with life and death. The rates of mortality and fertility are also used as proxies to indicate the degree of development in a country, in comparison to others. In Tanzania, the general fertility rate (total births per woman) in 2009 was 5.5%. Positively, the general life expectancy has risen from 51 years in 1990 to 55 years in 2009, but this is still substantially lower than the global average (68 years).

Table 5: Selected health, mortality and burden of disease indicators for Tanzania (2009) Health indicators Country Regional average Global average Life expectancy at birth 55 54 68 Neonatal mortality rate (under 28 days of life) 33 Infant mortality rate (1 year and > per 1000 births) 68 Adult mortality rate (per 1000 adults 15 – 59 years) 385 383 176 Under-5 mortality rate (per 1000 live births) 108 127 60 Maternal mortality ratio* (per 100 000 live births) 790 620 260 HIV prevalence (per 1000 adults 15 – 49 years) 56 47 8 TB prevalence (per 100 000 population) 170 475 201 TB death rate (per 100 000 people) 11 Sources: Tanzanian HRH Strategic Plan, UNICEF 2008

Vast numbers of women die (the majority of which are preventable deaths) every year, related to complications during or resulting from pregnancy and birth. Maternal mortality, closely related to the right to the highest attainable standard of health, is the outcome generally used to assess progress

25 towards improving maternal health. Tanzania’s 2008 maternal mortality rate (790 per 100 000 live births) is shocking in that it represents almost 3 times the global average, and is roughly 1/4 more than that experienced in the region.

Further related is the issue of child mortality. Although the child mortality rate is almost double that of the global average, it is positive that there has been a decline between 1990 and 2009 (162 to 108), as well as for the infant (99 to 68) mortality rate during the same period. The leading cause of child deaths, of those children who survive the neonatal period, continues to be the consequences of preventable diseases, including malaria, pneumonia, diarrhea, malnutrition, complications arising from low birth weight, and HIV/AIDS. More than 70% of a staggering almost 11 million child deaths every year are attributable to the following highly preventable causes: diarrhea, malaria, neonatal infection, pneumonia, pre-term delivery, or lack of oxygen at birth.11 When we examine the distribution of causes of death in children under the age of 5 in Tanzania (2008), malaria and pneumonia (both 16% of deaths) are ranked a combined first, followed by diarrhea (13% of deaths) as the second most common. It is encouraging that over half (close to 57%) of children under the age of 5 are receiving anti-malaria drugs (2008) but there are still too many who remain untreated.

For adults, HIV/AIDS continues to be the leading cause of death. Between 2005 and 2009, the percentage rate of prevention among young people who have comprehensive knowledge of HIV illustrates the extent of inequalities still evident between men and women, with the rate for men (42%) being higher than that for women (39%). Anti-retroviral treatment coverage for people with advanced HIV infection in 2008 was a very low 14%.12 Most recently, the Iringa recorded the highest rate of HIV/AIDS prevalence at 14.7% (previously 13.4%) followed by Dar es Salaam at 8.9% (previously 10.9%), Mbeya at 7.9% (previously 13.5%) and Shinyanga at 7.6% (previously 6.5%). Zanzibar had the lowest prevalence rate at 0.6%. In terms of age, the highest prevalence is amongst the 35-39 age group (10%) (Tanzania Affairs, 2009). Table 5 indicates that the HIV prevalence of Tanzania is substantially higher (7 times) than the global average.

It is encouraging that the country’s TB prevalence is 15% lower than that of the global average, and also represents a decline from the 2006 figure (187). Perhaps more importantly, the death rate from TB has declined since 2006 (13); and the 2009 figure represents 6.5% of 2009 TB prevalence, while the treatment success rate recorded in 2008 is at 88%.

As the health policy describes, the major challenge that “the people of Tanzania suffer most from [is] acute febrile illness caused by malaria, [while] the groups most vulnerable… are young children and pregnant women.” The overall prevalence of malaria in young children in Tanzania is at 18%. The great inequalities in the country are again illustrated in a big disparity between this rate in the rural and urban areas. In rural areas, 20% of children carried the malaria parasite compared to 7% in urban areas. Kagera had the highest prevalence of malaria among young children (42%), while Arusha had the lowest with less than 1% (Tanzania Affairs, 2009). Thus, although HIV and TB are important, malaria is acknowledged as the biggest health problem in Tanzania and it is concerning that its prevalence has remained virtually static between 2002/3 and 2004/5 (decreasing only from 40.9% to 40.1%).

Given the disease profile of this country, it appears that based on the most pressing health challenges (malaria and HIV/AIDS), prevention and health promotion are the greatest health service needs. This clearly supports a more active role for lower level health workers, such as MLHWs, who could assist in carrying the more preventive and health promoting load of more highly qualified medical practitioners.

Structure of the health system

Administratively, it is important to understand that Tanzania is the union between Tanganyika (Tanzania Mainland) and Zanzibar, and the Tanzanian National Health Policy prescribes the health services provision for Tanzania Mainland only. Tanzania Mainland is divided into 21 administrative regions, with a further subdivision into 106 Districts with 121 Council Authorities. Under this structure, the provision of health services is divided into 3 levels: National, Regional and District. Each district is furthermore divided into divisions, wards, villages and ‘vitongoji/mitaa.’

The ministry of health, through the regional secretariat, supports and facilitates the implementation of health services at the council level. It works according to a pyramidal referral system operating upward from the lowest (village) level. The types of services provided at each level, arranged from the bottom upwards, are as follows:  Village level: Village health posts  Ward level: Community dispensaries  Divisional level: Rural health centers  District level: District/District designated hospitals  Regional level: Regional hospitals  Zonal level: Referral/Consultant hospitals  National level: National and specialized hospitals

Beneath the health system of Tanzania is a socialist regime, which prescribes certain roles, values and functions to the government with regard to services it renders to its society. The Tanzanian health system views government as the major provider and financier of health services, with a particular emphasis on the provision of primary health care services.

The Tanzanian health system is decentralized, and framed most explicitly by its National Health Policy.1 The Tanzanian National Health Policy appears to be driven most explicitly by the objective of providing access to quality primary health care for all its citizens. As stated, “since its adoption by the government, primary health care has been the cornerstone of the Tanzanian national health policy”.1 Most explicitly linked to the health related Millennium Development Goals (MDG) is the policy’s identification and focus of resources towards an essential health care package, which is “an integrated collection of cost effective interventions that address the main diseases, injuries and risk factors” in the country, consisting of:

 Reproductive and child health  Control of communicable and non-communicable diseases, and  Treatment of common conditions of local prevalence within the district.1

Community health promotion and disease prevention through environmental sanitation and management of occupational health services are also recognized as key components.

The role of the public and private health sector is set out in the National Health Policy, and described and envisioned as a public/private partnership, where the common goal of health should be realized by combining efforts in some instances. Although there is this vision for sharing and jointly mobilizing resources, it is the responsibility of the Ministry of Health to regulate and co-ordinate the establishment of health facilities and the delivery of health services by the private sector.1

Provision of health care, particularly in the rural areas and facilities, was adversely affected after the economic recession in the 1970s and 1980s, which resulted in an overall deterioration of health care services. This led to the Tanzanian government introducing Cost-Sharing in 1993 and following that, instituting other financing options such as a National Health Insurance and a Community Health Fund .1 User fees accompanied the introduction of cost-sharing.

Although there are provisions for health insurance in some form, the “scope of commercial health insurance is very limited and there is a growing experience of community-based pre-payment schemes”.13 Thus, Tanzania is known more for its Community Health Fund (CHF) schemes, with the introduction of a mandatory health insurance being initiated in the early 2000s, which “made it compulsory for all public servants to become a member of the National Health Insurance Fund (NHIF)”.13 The next phase envisions the extension of this health insurance to formal sector employees in the private sector via health insurance contributions to the National Social Security Fund (NSSF). The objectives of these policies are, in the first instance, to establish a reliable method of enabling employees to contribute towards their own health, while also improving accessibility and the quality of health services in both the private and public sectors.

In general, the health services are heavily based on national government financing, with some tax-based funds through local government council tax collection and other earnings. Although the central government remains the main financier of health services in Tanzania, the financing of health is supported by local government and service provision, voluntary agencies and faith based organizations, executive agencies, community contributions and development partners. There is an aspect of out-of- pocket financing under community contributions, where communities might be “encouraged to contribute through user-fees in health facilities to complement the government financing”.1 The Community Health Fund (CHF) is viewed as an effective “tool for mobilizing voluntary community involvement and participation in supporting their own health,” whereas the Health Insurance Scheme is seen as a “mechanism to ensure medical protection of employees in the formal sector.”1

When we consider the state of the health system in comparison to other countries, Table 6 indicates that health expenditure per capita has declined since 2006, although it is quite positive that health expenditure as a percentage of government expenditure has risen from 14% in 2006 to 18% in 2009. This implies a shift of health expenditure away from the population to the infrastructure and resources needed to provide health. Government has thus stayed in line with their commitment in 2003 for the health sector allocation to reach 14% of budget share. It is interesting that out-of-pocket expenditure on health has increased as a percentage of private expenditure on health, whereas it has declined in total.

Table 6: Financing the health system, Tanzania Selected health system indicators 2006 2007 2008 2009 Health expenditure per capita, PPP (constant 2005 international $) 72 57 57 68 Health expenditure, total (% of GDP) 7 5 5 5 Health expenditure, public (% of GDP) 4 4 3 4 Health expenditure, private (% of GDP) 3 1 1 1 Health expenditure, public (% of government expenditure) 14 18 18 18 Out-of-pocket health expenditure (% of private health expenditure) 54 65 65 65 Out-of-pocket health expenditure (% of total expenditure on health) 22 18 18 17 Sources: World Bank (2007), Global Poverty Working Group (2009), Development Research Group (2008)

Regardless of the context within which health care has to occur, a baseline to ensuring the health of the nation is the availability of appropriate numbers and quality of health human resources. A country such as this, with a decentralized system of health care provision, requiring dispersed access to HRH, coupled with a burden of disease concentrated at the periphery of society, could benefit from the specific health service characteristics that MLHWs can provide.