Scaling Up Human Resources for Health

Transcription

1 Scaling Up Human Resources for Health A Situational Analysis of Government Nursing Schools in Tanzania November 2010 THE UNITED REPUBLIC OF TANZANIA Ministry of Health and Social Welfare

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3 TABLE OF CONTENTS EXECUTIVE SUMMARY...1 INTRODUCTION, BACKGROUND, AND METHODS...6 INTRODUCTION...6 BACKGROUND...7 Defining the Health Workforce Crisis...7 Scaling Up at Health Training Institutions...8 Shortages of Clinical Faculty...10 Geographic Maldistribution of Health Care Workers...10 The Nursing Cadre Enrolled Nurse Training Institutions in Tanzania Selection Process for Public Allied Health Students...13 Registration of Allied Health Training Institutions...14 METHODS...14 Data Collection...15 Analysis...16 Limitations FINDINGS...18 SUMMARY OF OVERALL FINDINGS...18 Inadequate Infrastructure and Human Resources for Scale-Up...18 Severe Shortage of Full-time Faculty...21 Difficulty in Covering the Compacted, Two-Year Curriculum...25 Teaching in Shifts is Impractical...26 EN Curriculum is Weighted toward Clinical Practice, but Institutions Report They Are Least Able to Provide Support in That Area...26 Lengthy Process to Validate Students Qualifying Certificates Means That Students Are Dropped Very Late in the Program...27 Discrepancies in Planning and Delayed Infrastructure Completion...29 Shortages of Accommodation for Students...29 Water, Sewage, and Power Systems Are Taxed...32 Dining Halls and Kitchens Are Largely Inadequate and Often Unsafe...33 Insufficient Classroom and Skills Lab Infrastructure...34 Limited Funding Available...35 Limited Numbers of Local and Rural Students...37 Significant Investments Needed for New Programs...38 INSTITUTION-SPECIFIC FINDINGS AND RECOMMENDATIONS...40 Bagamoyo Nursing School Geita Nursing School...43 Kahama Nursing School...45 Kiomboi Nursing School...47 Kondoa Nursing School...49 Korogwe Nursing School...51

4 Mobozi Nursing School...53 Mbulu Nursing School...55 Mkomaindo Nursing School...57 Njombe Nursing School...59 Same Nursing School...61 Tarime Nursing School...63 Tukuyu Nursing School...65 Kibondo School of Nursing...67 Nachingwea Nursing School...69 Nzega Nursing School...71 RECOMMENDATIONS AND CONCLUSIONS...73 Recommendations for Supporting Current Numbers and for Further Scale-up Recommendations for Recruitment and...76 Faculty Development Recommendations...77 CONCLUSIONS...78 REFERENCES...79 APPENDIX 1: SUMMARY OF INSTITUTION-SPECIFIC RECOMMENDATIONS AND FINDINGS...82 APPENDIX 2: FULL INSTITUTION REPORTS...84 Bagamoyo Nursing School...84 Geita Nursing School...92 Kahama Nursing School Kiomboi Nursing School Kondoa Nursing School Korogwe Nursing School Mobozi Nursing School Mbulu Nursing School Mkomaindo Nursing School Njombe Nursing School Same Nursing School Tarime Nursing School Tukuyu Nursing School Kibondo School of Nursing Nachingwea Nursing School Nzega Nursing School APPENDIX 3: DATA COLLECTION TOOLS APPENDIX 4: LIST OF INTERVIEWS APPENDIX 5: CONSENT FORMS...230

5 ACKNOWLEDGMENTS The International Training and Education Center for Health (I-TECH) undertook this assessment with funding from the President s Emergency Plan for AIDS Relief (PEPFAR) through the US Department of Health and Human Services Health Resources and Services Administration (HRSA) Cooperative Agreement No. 6 U91 HA 06801, in collaboration with the US Centers for Disease Control and Prevention s Global AIDS Program (CDC GAP) Tanzania. Sincere appreciation goes to the Ministry of Health and Social Welfare (MOHSW), Directorate of Human Resource Development for its continuous support and collaboration and especially for identifying and allowing its staff to participate in the assessment teams. Special thanks also go to Suzzane McQueen and Angela Makota of CDC GAP for their support and guidance. We would like to acknowledge the contributions of the following individuals, who provided documents, interviews, and/or questionnaires for this report: Ms. Eliaremisa Ayo and Dr. Bumi Mwamasage from Human Resources Development (HRD), MOHSW; the principals and staff at the public health training institutions, schools of nursing and midwifery, as well as the matrons in charge and medical officers in charge at the district hospitals in Bagamoyo, Geita, Kahama, Kibondo, Kiomboi, Kondoa, Mbozi, Mbulu,, Mkomaindo, Nachingwea, Njombe, Nzega, Same, Tarime, and Tukuyu. The authors would also like to sincerely thank Mr. Ndementria Vermund, Mr. Molland Mkamba and Ms. Vumilia Mmari, Nursing Coordinators from the HRD, for taking the time to participate in the assessment teams that collected the data for this report. Their contributions were crucial to the information presented here. Kathryn Karnell, Evance Mori, Emily Bancroft, and Dila Perera led the teams that collected and analyzed all data for this report. Katy Karnell wrote the final report, with additional writing and editing by Dila Perera and Katy Potter. Dr. Flavian Magari, Tumaini Charles, Alyson Shumays, Susan Clark, Martin Kalowela, Ryoko Takahashi, and Sarah Hohl provided additional editing and input. For more information about this report, please contact: Martin Kalowela HRHS Program Manager International Training and Education Center for Health (I-TECH) University of Washington and University of California, San Francisco Ali Hassan Mwinyi/Kilimani Road, Ada Estate, Kinondoni PO Box Dar es Salaam, Tanzania Office: Fax:

6 ABBREVIATIONS AND ACRONYMS AIHA AMO CA CATCs CDC CDC GAP CIDA CO COTCs CSSC EN FGD GFATM HRD HRH HRHS HRSA HTI I-TECH JLI Nuffic MAMM MOHSW NACTE NGO PEPFAR PHSDP PO-PSM RN TB WHO ZHRC American International Health Alliance Assistant medical officer Clinical assistants Clinical assistant training centers Centers for Disease Control and Prevention Centers for Disease Control and Prevention Global AIDS Program Canadian International Development Agency Clinical officer Clinical officer training centers Christian Social Services Commission Enrolled nurse Focus group discussion Global Fund for AIDS, Tuberculosis and Malaria Human Resources Development Human Resources for Health Human Resources for Health Scale-up Health Resources and Services Administration Health training institution International Training and Education Center for Health Joint Learning Initiative Netherlands Organization for International Cooperation in Higher Education Mpango wa Maendeleo wa Afya ya Msingi (Primary Health Services Development Programme) Ministry of Health and Social Welfare National Council for Technical Education Non-governmental organization President s Emergency Plan For AIDS Relief Primary Health Services Development Programme President s Office of Public Service Management Registered nurse Tuberculosis World Health Organization Zonal health resource center

7 EXECUTIVE SUMMARY The International Training and Education Center for Health (I-TECH) is providing technical assistance to the Ministry of Health and Social Welfare (MOHSW) of Tanzania and to the US government on strategies to meet the MOHSW s goals to scale up enrollment and increase the output of new health care workers. The MOHSW has asked all health training institutions (HTIs) in Tanzania to increase enrollment by 100%, and mid-level cadres such as clinical officers (CO), clinical assistants (CA), and enrolled nurses (EN) are key target cadres because of their importance to primary health care services. To recommend specific strategies for increasing the enrollment at pre-service HTIs, data are needed on the current barriers and opportunities to scaling up enrollment at existing institutions. The purpose of this assessment is to provide institution-specific data on the 16 public nursing schools to assist the MOHSW to determine the most effective way to increase the output of this cadre of health care workers. This assessment had the following objectives: To document the existing capacity for student enrollment and retention at MOHSW pre-service HTIs for ENs; To identify opportunities to increase both short-term and long-term enrollment and retention capacity at these nursing schools; To document factors limiting short-term and long-term enrollment and retention capacity at visited institutions; and To recommend interventions necessary to overcoming the identified limiting factors. Methods The assessment was conducted during August 2009 (at three reopening institutions) and again in March and April 2010 (at the remaining 13 institutions). Teams comprised of one I-TECH and one MOHSW representative visited all institutions. Prior to the team s visit, an institutional questionnaire was sent to the principal of each institution to collect data on student enrollment trends; utility and physical infrastructure available on campus; finances; and staffing. The teams spent one day at each institution conducting a semi-structured interview with the principal and a focus group discussion (FGD) with students, when possible. The team also toured the facilities to document the infrastructure and visited the local hospital to interview the matron or medical officer in charge. Findings The MOHSW aims to increase enrollment by 100% at EN training institutions. The assessment team found that scale-up efforts have already been initiated at most institutions (since 2008) and all will have increased their enrollment numbers in The assessment team also found that a 100% scale-up from existing enrollment numbers is logistically unrealistic. To be able to accommodate 1

8 so many students, campuses would need a drastic and extensive overhaul as well as an immense increase in resources, especially human resources. Moreover, each school faces a distinct set of challenges to further scale-up. The assessment team found six main barriers to increasing enrollment at any specific institution: 1) number of tutors and staff; 2) level of supervision in the clinical setting; 3) classroom capacity; 4) dormitory capacity; 5) other infrastructure issues, which often include sanitation systems, power and water supplies, and dining halls/kitchens; and 6) lack of a process to verify enrollment qualifications. Each institution has its own combination of these barriers to overcome, and therefore its own unique potential for scale-up, which is documented in the section on institution-specific findings and recommendations. The team also documented some key overall findings in ten themes that cut across all institutions: Inadequate infrastructure and human resources for scale-up: Since 2008, the MOHSW has increased enrollment at 11 out of the 13 institutions, at some by more than 200%; however, most have exceeded their ability to accommodate that enrollment. With very few exceptions, infrastructure investment and additional staffing are required adequately supportexisting enrollment numbers as well as for continued scale-up. Severe shortage of full-time faculty: The shortage of full-time faculty is a critical barrier to scaleup for most institutions. In the 16 public nurse training schools assessed, only seven institutions have adequate tutor staffing patterns. In the nine other institutions, 31 more tutors are needed for current enrollment numbers, representing an overall 41% shortage throughout these public nursing schools. Furthermore, at any given time, 26% of full-time tutors are away from their worksites for additional training. If the MOHSW is to increase enrollment by an additional 69% the target set forth in this report then 63 additional tutors are needed. Without the addition of these tutors, a 61% overall tutor shortage will occur. Difficulty in covering the compacted, two-year curriculum: The severe shortage of faculty is exacerbated by the difficulty tutors face in covering the entirety of the curriculum, which was shortened from four to two years. Principals commonly reported that even at fully-staffed institutions defined as those which meet the curriculum-specified tutor-to-student ratio of 1:25 for classroom instruction additional full-time tutors are necessary due to the shorter curriculum, which focuses heavily on clinical practice. At these institutions, principals report that tutors work overtime in the evenings and on weekends to cover the curriculum and students continue to experience a lack of clinical supervision in the hospital setting. Clinical instructors are also in short supply. Lengthy process to validate students qualifying certificates means that unqualified students are dropped very late in the program: More students are dropped from the EN program due to falsified secondary school completion certificates than for any other reason (a total of 93 of 158 students (59% since 2008). The lengthy process involved in submitting and verifying students qualifications leads to unqualified students being dropped very late in their program, often as much as one year into their studies. Discrepancies in planning and delayed construction: Campus infrastructure improvements to key buildings such as dormitories, classrooms, dining halls and kitchens, have often occurred at different paces. As a result, it has been difficult to increase student numbers because the capacities of various buildings are not always equivalent. For instance, the dormitories may be 2

9 able to house 200 students, whereas the classroom space may only hold 100 students, and the dining hall just 40. Frequently, these schools experience long delays in the construction process due to problems with the tendering and payment processes. Two of the three reopening nursing schools have faced significant delays in receiving funding for construction required to rehabilitate their institutions after closures of 10 or more years. Also, because the funding was allocated was for renovation rather than expansion, these reopening schools will initially only be able to host cohorts of 25 students each. Both expansion and renovation need to be funded for new institutions to host larger numbers of students and justify the investment of resources. Shortages of accommodation for students: Many of the nursing schools have increased their enrollment by adding two and even up to four additional students to dormitory rooms that were built for two students. Ten of 13 public nursing schools have overcrowded dormitories, some lacking capacity for as much as 38% of their student body. Severe overcrowding is not a sustainable solution for scaling up enrollment. Furthermore, dormitory spaces are lost because of the policy of segregating male and female students in separate dormitory blocks. Water, sewage, and plumbing systems are also strained by the increased enrollment numbers. Dining halls and kitchens are inadequate and require renovations: As of April 2010, only four operating institutions had an adequate dining and kitchen facility. A few institutions have new dining/kitchen facilities that are scheduled to be available in 2010, but the others are in need of either renovation or new construction. Many institutions lack proper equipment and stores for cooking. (Principals report that the cooking stoves are unhealthy and unsafe). Others have dining halls that are not in use because they have been rededicated as classrooms. Insufficient classroom and skills lab infrastructure: With only a few exceptions, nursing schools are now enrolling between students per class. Classrooms built for 50 or fewer are often used for cohorts of 70 or more students. Overcrowding limits the quality of instruction provided. Skills labs are generally unused, because they have been converted to classrooms or lack models and teaching resources. Limited funding available: All nursing schools reported that the funds received through costsharing and the MOHSW are erratic and not sufficient to maintain the institution. As a result, the quality of food for students is regularly impacted, the computer module is often not taught, and/or the fieldwork component of the curriculum is often cut or scaled back. Institutions lack resources to make major and minor repairs on buildings and to update and expand antiquated water, sewage, and electric systems. Limited numbers of local and rural students: Studies in both low- and high-income countries show that health care professionals recruited from rural areas are more likely to practice in rural areas in the future. Despite these findings, there are limited mechanisms for recruiting and enrolling local students defined as students from the region where the institution is located in the EN program. Further, some school principals report a desire not to increase local student numbers. They assert that local students are more likely to be distracted from their studies due to family obligations or problems and that a geographically diverse student body enhances the learning process. Though some principals discouraged local student attendance, many principals, tutors, and students expressed a strong desire to increase the number of rural students enrolled in nursing programs. They expressed that rural populations were at a disadvantage in 3

10 the application process because rural people were less aware of the EN program, its requirements, and its application process. Principals, tutors, and students believe that rural students will be more likely to serve in rural areas upon completion of the EN program and they would like to see more rural students recruited. Recommendations Based on the findings of this assessment, the MOHSW can support the current enrollment at many of these institutions and increase enrollment at the other public nursing schools with targeted investment in tutors, classrooms, dormitories, dining, and sanitation systems. The assessment team has provided a set of recommendations for each institution based on an achievable target enrollment. If the recommended infrastructure and human resources are provided, an overall further scale-up of 41% among the 13 institutions can occur. Additionally, including the new enrollment at the three additional nursing schools that were opened in 2010, overall enrollment will be scaled up a total of 69% across the 16 public nursing schools. Along with the institution-specific recommendations that are located in each institution report, this report describes a number of additional recommendations to the MOHSW and other stakeholders involved in building the capacity of HTIs. Recommendations for Supporting Current Numbers and for Further Scale-Up: Complete infrastructure improvements already in process at many of the nursing schools and initiate infrastructure already budgeted and planned for at several other institutions. Support new infrastructure development at the remaining institutions where enrollment numbers have increased but for which additional infrastructure has not yet been budgeted. Increase faculty, support staff, and teaching materials to appropriately address current enrollment numbers as well as scale-up numbers. Plan appropriate infrastructure improvements to provide for all the educational and living needs of the student body:.1) Consider classroom and dormitory space as well as necessary dining/ kitchen, sanitary systems, skills labs, and libraries; 2) Fund immediate expansion at reopening institutions rather than renovation with expansion to follow at a later date. Address barriers to prompt and complete disbursement of funds to MOHSW institutions. Assess the efficacy of content and adequate staffing patterns to support a compressed twoyear curriculum. Recommendations for Recruitment and : Address barriers to the timely verification of qualifying certificates; develop a process to verify certificates prior to enrollment. Sensitize principals to the need for greater local and rural recruitment; increase principals involvement in the selection process; and develop strategies to increase local enrollment, with an emphasis on rural areas. Improve the enrollment data-tracking system at nursing schools; enhance communication of those data between schools and the MOHSW so to address infrastructure and human resource needs. 4

11 Faculty Development Recommendations: Identify principal successors early so that they can be oriented properly and provided with leadership training. Develop a regular recruitment process for new tutors and increase capacity of tutor-training institutions. Implement programs to train more tutors at the worksite rather than removing them for skills upgrading for long periods of time. Conclusions The immense need for health care workers in Tanzania has led to an incredible effort by the MOHSW and other government authorities to prioritize scaling up student enrollment at HTIs. Although the current public nursing schools have largely scaled up enrollment to assist the MOHSW in meeting its goals, the institutions have reached a critical point where significant investments in infrastructure and human capacity are needed to ensure quality education and produce high quality health care workers who can meet the needs of Tanzania s rural communities. With the new resources from Global Fund for AIDS, Tuberculosis and Malaria (GFATM) Round 9, the MOHSW is well positioned to make a significant impact on the health care workforce shortage by providing the necessary infrastructure, staffing, and teaching aids that can create a high quality educational environment. The recommendations from this report can help to guide these coordinated efforts. 5

12 INTRODUCTION, BACKGROUND, AND METHODS INTRODUCTION From August 2009 through March 2010, the International Training and Education Center for Health (I-TECH) conducted an assessment of the barriers to and opportunities for scale-up at 16 public health training institutions (HTIs) for enrolled nurses (ENs) in Tanzania. Conducted as part of I-TECH s Human Resources for Health Scale-Up (HRHS) program, the purpose of this assessment was to help Tanzania s Ministry of Health and Social Welfare (MOHSW) prioritize the resources available for scaling up enrollment at HTIs. I-TECH was established in 2002 by the Health Resources and Services Administration (HRSA) in collaboration with the US Centers for Disease Control and Prevention (CDC). I-TECH is a collaboration between the University of Washington and the University of California, San Francisco, and has offices in Africa, Asia, and the Caribbean. I-TECH works in partnership with local ministries of health, universities, non-governmental organizations (NGOs), medical facilities, and other organizations to support the development of a skilled health work force and well-organized national health delivery systems. The MOHSW and the CDC requested I-TECH s technical assistance to integrate components on HIV and tuberculosis (TB)/HIV into the curriculum for clinical assistants training centers (CATCs) and clinical officers training centers (COTCs). Beginning in 2007, I-TECH added these items to the curriculum and developed teaching materials for three semesters. The ultimate goal is to enable the graduates of the training centers to provide quality care and management of HIV and TB/HIV. In 2007, The American International Health Alliance (AIHA) provided a similar program of support to the MOHSW and assisted with the revision of the enrolled nurse and registered nurse curricula to include HIV content. In complement to the curriculum development work, I-TECH supports a number of interventions to strengthen the capacity of pre-service tutors in 16 HTIs in teaching and facilitation skills and knowledge of fundamentals of HIV and TB/HIV. Additionally, I-TECH has worked with Zonal Health Resource Centers (ZHRCs) to increase the training capacity of in-service training faculty. The HRHS program builds on the work of these two programs as well as that of AIHA, with the goal of supporting the MOHSW to address Tanzania s human resources crisis by increasing the number of qualified health care workers. This program works closely with tutors, principals, and students at public pre-service institutions that train ENs, clinical assistants, clinical officers, and laboratory assistants to increase their capacity to train more new health care workers. The HRHS program will support the MOHSW in its efforts to increase enrollment at HTIs through assessments and specific interventions aimed at addressing barriers to scale-up. As part of this project, selected HTIs will receive a package of interventions, which may include infrastructure development, hiring additional tutors, leadership development, scholarships for students, and the purchase of teaching aids. I-TECH s efforts will focus on HTIs in the public sector under the authority of the MOHSW, recognizing that other partners will be supporting similar efforts in the private sector, including faith-based training institutions. 6

13 Before recommendations can be made for specific strategies to increase enrollment at pre-service HTIs, data are needed on the current barriers to and opportunities for scaling up enrollment at existing institutions. The purpose of this report is to provide institution-specific data on the 16 public nursing schools that offer a two-year EN certification to assist the MOHSW in determining the most effective way to increase the output of this cadre of health care workers. This assessment had the following objectives: To document the existing capacity for student enrollment and retention at MOHSW pre-service HTIs for ENs; To identify opportunities to increase both short-term and long-term enrollment and retention capacity at these schools; To document factors limiting short-term and long-term enrollment and retention capacity at visited institutions; and To recommend interventions necessary to overcoming the identified limiting factors. BACKGROUND Defining the Health Care Workforce Crisis The global shortage of health care workers is threatening the success of key health and development goals in low-income countries throughout the world. The magnitude of the global crisis is well documented. In 2006, the World Health Organization (WHO) identified 57 countries with critical shortages of doctors, nurses, and midwives, 36 of which are located in Africa (WHO, 2006). The Joint Learning Initiative (JLI) estimates that more than one million new health care workers are needed in sub-saharan Africa alone, which is almost triple the number of workers already in place (JLI, 2004). The health care workforce crisis is defined by more than just the absolute numbers of health care workers trained, deployed, and retained. The skills mix of existing health care professionals and the misdistribution of health care workers between urban and rural areas are both major contributors to the scope of the crisis in many countries (WHO, 2006; JLI, 2004). In Tanzania, the health care workforce crisis has hampered the government s ability to meet its goals for improving the social and economic well being of its population. Quality health care services are a key component of comprehensive social services, yet the shortage of qualified health care personnel consistently restricts the efforts of the government to increase the quantity and quality of health care services available throughout the country (MOHSW, 2006). In 2007, the MOHSW launched the Primary Health Services Development Programme (PHSDP) (PHSDP, ) to address performance issues of the health sector. The PHSDP, or Mpango wa Maendeleo wa Afya ya Msingi (MAMM), as it is known in Kiswahili, set a goal of establishing a dispensary in each village and a health center in each ward an area comprised of 5-7 villages by Meeting this goal will require a rapid increase in the number of health care workers to fill the existing staffing gaps within the health care sector and appropriately staff these additional health care facilities. The government of Tanzania estimates that in 2006 there was a shortage of over 90,000 health care professionals in the public and private sectors combined. This accounts for almost three-quarters of 7

14 the health care workforce (MOHSW, 2008). Through MAMM, the government plans to build 3,088 dispensaries, 19 district hospitals, 95 maternity waiting homes, and 2,074 health centers to address the unmet need for primary health care services. The number of new professional health care workers required to staff these additional facilities is estimated to be almost 90,000, bringing the total new health care workers needed for the public sector alone to 144,704 by 2017 (MOHSW, 2008). The efforts to scale up training, recruitment, and retention of health care workers must be ambitious and comprehensive in order for the MOHSW to meet MAMM s objectives. In the 1990s, an employment freeze and budget ceilings led to a glut of newly trained health care professionals with no opportunities for public sector employment. Many trained health care workers were forced to leave the sector for other employment opportunities (MOHSW, 2008). Between 2005 and 2008, the President s Minister s Office of Public Service Management (PO-PSM) approved 12,004 new positions within the health care sector as a way to help absorb unemployed health care professionals. As this pool of unemployed health care workers is absorbed back into the system, the MOHSW must increase the production of new health care workers to fill the new positions created by PO-PSM. Scaling Up at Health Training Institutions One of the most effective long-term strategies for increasing the number of qualified health care workers to fill the vacancies in the health care sector is to increase the number of students enrolled in HTIs. This strategy is also one of the most time-consuming; experts estimate that it will take at least a decade to achieve meaningful increases in training capacity in Tanzania (McKinsey, 2006). Tanzania has 116 HTIs that train future health care professionals in both degree and non-degree programs. Tanzania s current training capacity cannot keep up with population growth and attrition in the health care sector. Without significant interventions to increase the number of health care workers trained, Tanzania will actually experience a decline in human resources for health (HRH) on a per capita basis (McKinsey, 2006). In 2007, Tanzania s HTIs had produced a total of 23,474 graduates in all cadres over a 10-year period, only 16% of which were employed in the public sector (MOHSW, 2008). The MOHSW s objectives under MAMM call for an increase in HTI enrollment over a 10-year period, going from 1,013 students to 10,499 (MOHSW, 2007). The MOHSW s HRH strategic plan projected that new enrollment in pre-service institutions would reach more than 6,000 students by the middle of 2008 (MOHSW, 2008). However, the rapid assessment of enrollment trends conducted for the HRH Working Group in 2009 showed that in September 2008, the new enrollment rate was only 3,831 students, instead of the targeted 6,450 students (MOHSW, 2009). Although the growth from 1,013 students to 3,831 students was substantial, the planned building of dispensaries and health centers through MAMM require that the MOHSW and its partners keep expanding training capacity in order to fully address the human resource crisis in the health sector. As Figure 1 below indicates, if the enrollment trend continues at only 60% of the MAMM targets (as it did in ), the gap between actual HTI enrollment and projected enrollment needed will continue to increase. Swift action is needed to correct the course of the current enrollment trend. To meet MAMM s targets, Tanzania must continue to aggressively increase enrollments as well as facility capacity at the HTIs. Therefore, a significant investment of resources and a clear strategy for addressing priorities are required. 8

15 Figure 1: MAMM Target, 2009 Study Findings and Projections (MOHSW, 2006; MOHSW, 2009) Although some steps have been taken to meet the objectives laid out in the MAMM program, the resources have not been available to fully implement the MOHSW s plans for increasing enrollment in HTIs. Though the MOHSW increased the training capacity of existing pre-service institutions with very limited additional resources, most pre-service institutions have not been able to double the size of the student body with their current infrastructure. Institutions report that they are strained by trying to train large groups of students without sufficient clinical faculty, administrative staff, classrooms, dormitories, library and resource materials, or computers (I-TECH, 2008; I-TECH, 2010). An assessment of 39 institutions by the Touch Foundation found that there were some common constraints to scale-up, including faculty shortage, inadequate non-clinical and clinical infrastructure, and limited financial resources (Touch Foundation, 2009). To address the lack of resources for meeting scale-up targets, the government of Tanzania successfully solicited significant resources from the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) Round 9. A portion of these funds will be used to support health system strengthening activities and goals. One of the key objectives of this funding is to increase production of midlevel- and highlyskilled health care workers in Tanzania s existing public, private, and faith-based training facilities. With the funds received from the GFATM, the MOHSW plans to increase student intake at HTIs from 3,501 to 6,885 over five years. Demand by potential students does not seem to be a barrier to scale-up, at least for many of the training institutions. According to the Director of Nursing at the MOHSW, over 8,000 individuals applied for acceptance to pre-service nursing programs and more than 5,800 of these applicants were qualified. However, currently, the nursing schools have capacity for at most 2,200 students (personal communication, 19 May 2010). 9

16 Shortages of Clinical Faculty The shortage of full-time clinical faculty referred to as tutors in Tanzania is consistently identified as a critical barrier to scaling up enrollment at HTIs. Existing institutions are requested to double their intake and formerly closed training institutions have reopened to meet MMAM s objectives. However, the number of tutors has not seen a corresponding increase. Rather, the production of new, permanent tutors is declining and the current pool of practicing tutors continues to decrease in size (MOHSW, 2008). The HRH crisis also affects the HTIs themselves. According to the HRH strategic plan, public HTIs had the highest percentage of unfilled positions among all health facilities. In 2006, 1,711 health professionals were required to staff the 72 public HTIs, but 26% of those positions were unfilled. In comparison, the vacancy rates at dispensaries, health centers, and district hospitals were 69, 59, and 67% respectively (MOHSW, 2008). The MOHSW enrollment study also shows significant staffing gaps with very few new full-time tutors posted to HTIs in the last two years. The staff deficit at the 56 institutions that provided selfreported data was 190 full-time faculty an estimated gap of 45% in the overall teaching faculty at HTIs (MOHSW, 2009). Despite this gap, only 32 new full-time faculty had been posted to these 56 institutions over the past two years (MOHSW, 2009). One of the factors contributing to the low number of new faculty posted to HTIs is the lack of clinical health care professionals choosing to enter the teaching profession. at the three faculty training centers that provide training in teaching methodology decreased to 52% capacity in 2009, with a total of only 47 new clinical faculty currently enrolled in faculty-training programs (personal communication with training institutions, November 2009). Assessments by I-TECH found that the shortage of clinical faculty further compounds low morale among existing faculty by increasing the workload of individuals, who are concurrently discouraged by existing salary levels and limited opportunities for promotion and further training (I-TECH, 2009). When 129 tutors at training institutions for clinical officers (COs) and clinical assistants (CAs) were asked about training opportunities they had received, respondents said that, on average, they had attended only two courses, trainings, or workshops during their entire teaching career. Most of the trainings were provided by the MOHSW or I-TECH in the past two years. Exactly 50% of these tutors had been teaching for six to eleven years, or more (I-TECH, 2009). Geographic Maldistribution of Health Care Workers Maldistribution of health care workers between rural and urban areas is another key contributor to the HRH crisis in Tanzania. Although the majority of the population is found in rural areas, greater numbers of the most highly skilled health care workers are found in urban areas. There are 53 physicians and 43 assistant medical officers (AMOs) per million people in urban areas, and only 17 physicians and 16 AMOs per million people in rural areas (McKinsey, 2006). Creating more HTIs in rural areas and increasing enrollment of students from the region could increase the number of trained health care workers in rural areas. A considerable body of research from both high- and low-income countries shows that growing up in rural areas increases the likelihood of future rural practice (Rabinowitz, 1999; Rabinowitz, 2001; Dussault, 2006; de Vries, 2003; Lehmann, 2008). Other studies show that training in a rural location and exposure to rural health 10

17 issues during training also increase the probability of future rural practice (Burfield, 1986; Rosenblatt, 1992). Establishing additional training institutions in rural areas, investing in expanding those already in rural areas, or increasing the amount of fieldwork for health professional students could help address maldistribution of the health care workforce. Efforts to increase rural retention and recruitment should ideally focus both on selecting appropriate candidates and providing students with sufficient opportunities to explore rural practice experiences during their training (Rabinowitz, 2000; Brooks, 2002). The Nursing Cadre Institutionalized nursing and midwifery training in Africa started with the provision of supplementary assistance in church- and mission-related health care services. Most formal nurse training programs started in the 20th century and then intensified during the colonial period when most hospitals ran nurse training programs. In the 1970s, this trend changed. Nurse training programs became associated with college and university training. This initial training created a lower level of nursing cadre, commonly referred to as enrolled or auxiliary nurses. Individuals with primary and middle school education were qualified for such programs. Professional nurse or registered nurse training required completion of high school and three years professional training, encompassing a higher professional level with more depth of theory and science (Manjanja, 2005). All of the nursing schools assessed in this report train this enrolled nurse cadre. The EN cadre in Tanzania is a two-year curriculum that results in a certificate. Whereas previously the training involved an in-service program that took four years, the program has been revised to take pre-service students and train them over a two-year period. Secondary students who have finished Form IV (equivalent to grade 11) with certain marks in sciences are eligible to apply for this training. ENs can later upgrade to a diploma level registered nurse. A nurse is considered to be a skilled worker occupying the lowest position in the health care worker hierarchy. While the training of a nurse focuses more on patient care, due to the human resource crisis in the health sector, nurses find themselves doing multiple tasks, including those for which they were not trained (Meena, 2009). Despite the incomplete data on the actual size of the nursing cadre in Tanzania, it is clear that there is a severe shortage of nurses. Data compiled by the Tanzania Nurses and Midwives Council suggests that as of July 2007, the country had a total of 20,115 nurses, out of whom 7,254 had diploma and higher levels, and 12,861 were certificate holders. The WHO Country Health System Fact Sheet 2006 for Tanzania records that the nursing density per 1,000 population was 0.37 (WHO, 2006, Training for nurses of all levels severely lags behind the needs. From 2002 to 2007, the number of nurses graduating annually increased from 910 to 4,000 for diploma holders and from 469 to 13,791 for certificate holders; yet, this increase has not bridged the resource gaps within the nursing cadre. Given that Tanzania, like many other countries in sub-saharan Africa, has a small and inequitably distributed health workforce, increasing the number of ENs placed in rural areas dispensaries and health centers represents one of the important ways the MOHSW is working to combat the geographical imbalance of health care workers. An assessment of HTIs in Tanzania found that training tends to lead toward specialization; however, general services are needed in the rural dispensaries and health centers and the EN curriculum supports those needs (Leon and Koelstad, 2010). 11

18 There is a critical shortage of COs, nursing officers, ENs, and laboratory assistants in Tanzania as shown in Table 1 below. These four cadres make up almost 85% of the current adjusted deficit of health care workers in Tanzania. With 2008 enrollment numbers, Tanzania can expect to have vacancy rates of 74 90% by 2018 in these cadres. Any efforts to address the health care workforce crisis in Tanzania should consider these crucial cadres for maximum impact. Table 1: Projections of Health Care Workers Needed for Regional Hospitals and Lower Facilities by Selected Cadres (MOHSW, 2009) Adjusted Deficit* Production Estimate (2007/ /18) from current HTIs Estimated Vacancy Rates by 2018 at Current Production Clinical Officers 33,120 5,495 83% Nursing Officers 21,263 2,170 90% Enrolled Nurses 17,033 4,480 74% Laboratory Assistants 14,932 2,960 80% * Adjusted deficit takes into account attrition and output to the private sector. However, it does not consider the planned building of new health centers and dispensaries throughout Tanzania, which will further increase the deficit. Enrolled Nurse Training Institutions in Tanzania Of the 116 HTIs in Tanzania, there are 63 institutions public, private, and faith-based that train nurses. Of those, 31 train ENs (certificate level training). There are 13 public nursing schools in Tanzania. There are also three nursing schools that opened in March 2010 in Nzega, Kibondo, and Nachingwea. Public nursing schools are largely located throughout Tanzania (as shown in Figure 2, below) at the district level and adjacent to the district hospital where students conduct their clinical training; however, a few are further away from a district hospital. According to Strategic Objective 3.1 of the HRH strategic plan, the MOHSW introduced the CA cadre and scaled up the production of ENs as a way to increase the number of health care professionals serving at the community health level (MOHSW, 2008). The EN curriculum was also shortened from four to two years, with the aim of producing more nurses in a shorter period of time. 12

19 Figure 2: Location of Public Nursing Schools in Tanzania (Indicated by Purple Stars) Selection Process for Public Allied Health Students The selection process for allied health professional students at public institutions is managed by the Directorate of Human Resource Development (HRD) at the MOHSW. All interested candidates apply directly to the central MOHSW where their applications are reviewed and their credentials verified. The MOHSW produces the list of students accepted to each institution and notifies candidates. This process is called first selection. More students are assigned to each institution than it can hold because, each year, between 15 and 30% of accepted students from the first selection decide not to attend. About two to three weeks after the reporting date for EN students, the HTIs report the number of students that arrived at the institution during first selection and the number of spaces remaining to be filled. The MOHSW reviews the list of qualified candidates and selects another set of students to be placed at the institutions during second selection and notifies those students who then report to the institution, if they still want a space. The time between when the first students report to the institution and when the second selection candidates arrive can take between one to two months. It is also during this second-selection process that principals may send forward names of local students qualified for the program and thereby increase local representation at the institution. Many institutions end up being filled above their actual capacities, depending on the numbers of students that actually arrive during first selection, the number of spaces remaining that individual principals report, and the additional number that arrive through second selection. 13

20 Registration of Allied Health Training Institutions The quality of technical training institutions is coordinated and monitored by the National Council for Technical Education (NACTE). All training institutions that fall under NACTE s jurisdiction must be registered by NACTE before they can begin enrolling students. NACTE s registration process considers the adequacy of infrastructure, faculty, funding, curricula, governance, support services, and long-term planning, among other factors. Each training institution is scored based on the registration criteria using the data in their application form and physical verification through a site visit from a NACTE authority. To commence training, an institution must receive at least a provisional registration from NACTE by scoring a minimum of 3.5 out of 5.0 on the registration criteria. A score of 4.3 or above will provide full registration. All of the visited, operating nursing schools currently enrolling students are registered by NACTE. METHODS While the MOHSW has detailed plans for meeting the nation s demand for more health care workers, there are few data illustrating the barriers and opportunities to scaling up enrollment at specific HTIs. Most schools report that they have increased enrollment as much as possible with current infrastructure (I-TECH, 2008). Clear, institution-specific action plans are needed to galvanize resources and address significant bottlenecks so that the MOHSW s bold scale-up plan will reach its targets. In response to the need for data to inform the MOHSW s efforts, several partner organizations are studying enrollment trends and possible ways to scale up enrollment. In 2009, the Christian Social Services Coalition (CSSC) and the Canadian International Development Agency (CIDA) conducted assessments of strategies for increasing enrollment capacity at private, faith-based pre-service institutions. In 2008 and 2009, the Touch Foundation conducted a detailed assessment of 39 HTIs throughout 14 regions of Tanzania. Both assessments found that specific interventions, such as tutor hires or construction of new facilities, could increase HTI output, but that the specific needs of each institution varied. The Touch Foundation s assessment also recommended programmatic changes, such as staggering classes of students as a way to increase enrollment (Touch Foundation, 2009). Only three of the institutions assessed by the Touch Foundation were public CO, CA, or EN institutions under the authority of the MOHSW, leaving a gap in the data available on public institutions. Using modified versions of the tools developed by the Touch Foundation as well as additional tools, I-TECH conducted a focused assessment of all public nursing schools in order to develop institutionspecific action plans. The primary focus of this assessment is these public nursing schools. 14

21 Data Collection The assessment was conducted between August 2009 and March Teams comprised of one I-TECH representative and one MOHSW representative visited a total of 16 schools: 13 public nursing schools and three new schools that have reopened in Prior to the team s visit, a questionnaire adapted and augmented from the Touch Foundation s tool, with permission was sent to the principals of all public nursing schools in operation during the academic year. The questionnaire was not sent in advance to institutions that had not yet started to enroll students. This self-administered questionnaire collected data on student enrollment trends over the past four years, infrastructure available on campus, finances, and staffing. (See Appendix 2.) The teams also reviewed institution and zonal plans, where available, as well as any prior site visit or assessment reports conducted by I-TECH or other institutions. The teams spent one day at each school. During the site visits, the teams conducted a semi-structured interview with the principal to collect data on the institution s ability to enroll additional students while maintaining a quality experience for them. In some cases, additional full-time faculty members joined the interview to provide input on certain subjects. The teams also toured the facilities, documenting the available infrastructure through photographs and notes. Where possible, the teams also conducted focus group discussions (FGDs) with six to twelve students at the institution to learn about their experience as students. (See Appendix 2.) In most cases, students were selected at random, but where classes were not in session or exams were taking place, the principal identified one or two students to recruit participants. Faculty and staff were not present during these discussions. In some cases, students were unavailable for an FGD due to exams or a break in the academic calendar. During site visits, study teams collected copies of financial reports, business plans, academic calendars, and other supporting documents regarding operation of the institution. Because the hospital plays an important role in clinical training of students, the teams visited the hospital to interview the matron- or medical officer-in-charge to gather data about the ability of the hospital to provide effective clinical training to students. In some cases, the district medical officer or district nursing officer also met with the teams and provided his/her perspective on scaling up enrollment. I-TECH was represented at all site visits by either Dila Perera, HRH Scale-Up Manager; Katy Karnell, Consultant; or Evance Mori, HRH Scale-up Coordinator. The MOHSW was represented by Mr. Ndementria Vermund, Mr. Molland Mkamba, and Ms. Vumilia Mmari, Nursing Coordinators. 15