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

22 Table 2: Data Collection Summary Method or Activity Purpose Number/Representation Desk review: Review of zonal strategic plans, MOHSW HRH assessments, and partner-led assessments Institutional questionnaire: Structured, self-administered by principal and other staff; mailed in advance of visit Site visits: One-day visits to public preservice nursing schools Interviews with principals: Semi-structured interview with principals, acting principals, and available tutors Interviews with matron- or medical officer-in-charge: Semi-structured interview with matron- and/or medical officer-in-charge at adjoining hospital Student focus groups: Semi-structured FGDs with random sample of students Tour and observation: Facility tour to observe and photograph infrastructure Secondary document review: Review of documents from institutions not provided during visit: financial plans, academic calendars, confirmation of enrollment data especially local students To collect information on institutions plans, priorities, and needs and to provide background to study team members To collect self-reported institutional information on enrollment, fees, infrastructure, finances, and staffing from principals To assess infrastructure and human resources at each institution firsthand, as well as meet with tutors, principals, and students To review information collected in institutional questionnaire and to discuss challenges/opportunities related to scale-up in detail To assess impact of current student enrollment and future scale-up on clinical instruction and care at teaching hospitals To collect information on student life and learning To provide documentation of existing infrastructure at each institution To collect and clarify information collected from visited institutions 8 available zonal strategic plans and other documents 13 visited operating nursing schools 16 eligible, public, pre-service nursing schools 16 visited nursing schools 15 of the 16 hospitals adjoining the visited nursing schools 82 students from 11 nursing schools 16 visited nursing schools 16 visited EN institutions Analysis Qualitative data from interviews, focus groups, and observations were compiled, typed, and reviewed by team members immediately following site visits. Data from institutional questionnaires were entered into a spreadsheet for analysis. Data entry was checked by the two I-TECH team members for each of their institutions to ensure that information from the instruments was captured accurately. Qualitative responses from semi-structured interviews were analyzed and organized by themes and recurring responses to develop overall findings and recommendations. Institution-specific data were reviewed to look for inconsistencies between questionnaires and in-depth interviews. I-TECH sought additional clarification from either faculty at the institution or the MOHSW when necessary 16

23 to address discrepancies. An inventory was developed that includes data collected on all institutions. Team members created individual institutional profiles that present key information for each institution, barriers to enrollment, and opportunities for scaling up enrollment. Written informed consent was obtained from all interview subjects. Written consent (initials only) was obtained from students who participated in the FGDs, and no names or identifiers were recorded, to protect the students identities. An ethics committee at the CDC in Atlanta reviewed and approved the assessment protocol. Limitations The study teams did encounter some limitations during the course of the assessment. The biggest challenge was the lack of a common record-keeping method at the nursing schools as well as between the schools and the MOHSW. As a result, data provided on enrollment was inconsistent. Some of the nursing schools were unable to provide organized, documented records on enrollment statistics for the past five years. In many cases, statistics provided in the institutional questionnaire differed from the official statistics provided by the MOHSW. Some of these discrepancies could be explained by variation in the timing of data collection. For example, data provided to the MOHSW at the beginning of the academic year may not take into account additional students reporting late or students that leave the program mid-year. Other discrepancies could be due to a lack of a consistent format and clear points in time for systematically recording, maintaining, and reporting enrollment data at nursing schools. The student FGDs were most often conducted in Kiswahili by the MOHSW representative, who interpreted the discussion for the I-TECH staff person, who took notes in English. This system provides possible opportunities for misunderstandings or mistranslations. The I-TECH team member reviewed her notes with the MOHSW representative after the FGD to decrease the potential for any misinterpretation. It is also possible that student responses were influenced by the presence of the MOHSW representative, though the study team spent time establishing rapport to minimize the potential for this effect. The team also informed students that their names would not be recorded and that remarks would not be attributed to them individually. At some nursing schools, the students were not available to participate in an FGD because they were in exams or on leave during the assessment visit. As a result, at two institutions, the team was not able to include students perspectives in the report. The reopening institutions did not have students enrolled at the time of the visits. Another limitation was a lack of clarity regarding both the role and the employer of a clinical instructor. The assessment team, the MOHSW representative, the nursing school staff, and the hospital staff, at times, all had different concepts regarding: whether the clinical instructor is an employee of the school or of the hospital; whether the clinical instructor is dedicated full-time to students supervision; whether clinical instructors employed at the nursing school are expected to supervise only skills labs and are dedicated in-class instructors; or whether they are expected to supervise in the hospital wards. This assessment team defines the clinical instructor as a person employed by the nursing school and who is dedicated full-time to the supervision of students in the hospital setting. Recommendations for hiring clinical instructors fall outside of and are in addition to any recommendations to hire nurse tutors for classroom instruction. 17

24 Finally, this assessment focused primarily on assessing enrollment capacity and not the quality of instruction at individual institutions. The assessment team did not observe or evaluate classroom and clinical instruction, or review lesson plans and other training materials used by tutors at visited institutions. Determining the quality and standardization of training is an important area that deserves a rigorous evaluation plan and assessment tools, especially in light of increasing class sizes and the scarcity of tutors. The MOHSW, NACTE, and other partners are currently developing tools and processes for continuous quality improvement at HTIs. FINDINGS The purpose of this assessment was to assess the specific barriers and opportunities for scale-up at the 13 visited schools as well as the three others that reopened in March ) to assist the MOHSW with future planning and 2) to prioritize government and donor interventions in the public nursing schools. As a result, the key findings of this assessment are institution-specific and are covered in the summaries on each institution. The assessment team found six main barriers to increasing enrollment at any specific nursing school: 1) the number of tutors and staff; 2) the 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 opportunities and potential for scale-up, which are 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. These findings are important to understanding the context in which the individual institutions exist and contribute to the final recommendations and conclusions. Summary of Overall Findings Inadequate Infrastructure and Human Resources for Scale-Up To address the MOHSW s request that all HTIs double their enrollment, all but two of the institutions increased their intake of new students in 2008 and And even the two institutions that did not increase their student numbers expect enrollment increases in March Though enrollment has increased by as much as 243% since 2008 many institutions have exceeded their ability to manage it given their current infrastructure and staffing levels. None of the schools stated that their enrollment could increase in this new academic year ( ) without additional infrastructure and/or additional tutors. Several of the nursing schools must now instruct three separate cohorts of students in a two-year program for instance, two second-year classes and one first-year class. Previously, the school may have had only one class during a three-year period. With increased enrollment numbers, many principals have struggled to find additional beds and dormitory spaces and have improvised classroom space in order to teach. Further, the sewage and drainage systems at seven of the 13 visited nursing schools have experienced serious problems due to overcrowding or lack of funds to service and maintain the systems. There is severe overcrowding at many institutions. 18

25 increases are not necessarily commensurate with specific infrastructure developments whether in the planning phase, already budgeted phase, or in the construction phase. Several schools experienced rapid enrollment increases during 2008 and 2009 without additional infrastructure investment while a few others experienced additional infrastructure enhancements without their enrollment numbers increasing significantly. For example, at Mbozi Nursing School, enrollment increased by roughly 60% (70 students) since initiating the two-year program, though classroom space was insufficient for even their original enrollment numbers and the dormitories could not hold any additional students. Mbozi still lacks plans and funding for new infrastructure. In the same way, at Kiomboi Nursing School, enrollment increased dramatically: cohort sizes that were historically near 50 grew to above 90, despite insufficient classroom space and few full-time tutors. Kiomboi s current student tutor ratio is nearly 70:1. In contrast, at Bagamoyo Nursing School, enrollment did not increase, though the school was building a two-story dormitory (although it is stalled in construction) and an additional classroom has architectural plans in place. At Kondoa Nursing School, only small increases in enrollment occurred while additional infrastructure expansion (significant dormitory space and dining space) emerged. It appears that some schools are more successful than others in advocating for limited enrollment numbers and for additional infrastructure improvements. The assessment teams found that enrollment has increased overall by approximately 88% since This estimation is not exact because of incomplete enrollment data and sometimes insufficient data regarding each school s capacity during 2008 when the new two-year curriculum was adopted. Nevertheless, this number demonstrates that enrollment has been significantly scaled-up in the last two years. Table 3: Estimated Scale-up since 2008 Nursing School Estimated Capacity in 2008 as of March 2010 Overall Increase/ Decrease Overall Scale-up Bagamoyo % Geita % Kahama % Kiomboi % Kondoa % Korogwe % Mbozi % Mbulu % Mkomaindo % Njombe % Same % Tarime % Tukuyu % Totals % 19

26 Many nursing schools will not be able to scale up enrollment without additional infrastructure expansion, renovations, more support staff, and full-time tutor hires to come to fruition. Though the MOHSW s goal is to increase enrollment by 100% across all nursing schools, it would have the greatest success increasing enrollment while maintaining uniform instruction and student living standards by focusing on: 1) increasing infrastructure capacity at institutions that are already severely overcrowded; 2) targeting new infrastructure projects where infrastructure is most lacking and not already planned/budgeted; 3) determining where additional enrollment could be achieved with targeted infrastructure expansion; and 4) identifying where the district hospital can support clinical instruction. Many schools already have infrastructure overhaul in progress or budgeted for and needing completion. Other schools are grossly over capacity and in need of immediate infrastructure expansion to train existing students in healthy conditions. In many of the nursing schools, infrastructure expansion has either recently been completed or is already planned and funded. Ten of the 13 open schools currently have infrastructure expansion in progress or have recently completed it (see Table 4). However, at times infrastructure expansion is inconsistent with enrollment trends and consequently still does not meet student needs. For example, at Geita Nursing School, construction of dormitory spaces, a classroom, a library, a skills lab, a dining hall, and tutor offices was completed in Unfortunately, because enrollment has increased dramatically and cohort sizes are larger than ever before, the instructional space is completely inadequate. The skills lab and library have never been used as intended they have been repurposed as classroom space. Tutor offices were repurposed as dormitory space. The institution faces a severe shortage of instructional space (classrooms, skills lab, library, computer lab). Table 4: Infrastructure Expansion Nursing School Construction Completed in the Last 10 Years Construction in Progress as of Visits in March and April 2010 Construction Planned and Budgeted for Bagamoyo N/A Dormitories Classroom and library planned but not budgeted Geita 96 dormitory spaces Classroom Library (since repurposed) Skills lab (since repurposed) None Unknown Kahama 61 dormitory spaces 1 classroom Library Skills lab Administrative space None Unknown Kibondo None, was closed for over 10 years Rehabilitation of existing structures, including dormitory, classroom, systems, and office block In phase II, a new kitchen, classroom, demonstration room, and dormitory block to bring enrollment to a minimum of students Kiomboi None None None Kondoa None 96 dormitory spaces Dining hall/kitchen 2 large 100-person lecture halls 20

27 Korogwe 78 dormitory spaces Kitchen expanded Dining hall being expanded Administration block 2 new classrooms New dining hall Mbozi None None None Mbulu 80 dormitory spaces 1 classroom Dining hall and kitchen Skills lab Library Mkomaindo None None None Nachingwea None, was closed for over 10 years Rehabilitation of existing structures, including dormitory, classroom, systems, and office block, planned for completion in June 2010 In phase II, a new kitchen, classroom, and dormitory block to bring enrollment to a minimum of 200 students Njombe 60 dormitory spaces 1 classroom Dining hall/kitchen 80 dormitory spaces Tutor housing Nzega None, was closed for over 10 years Rehabilitation of existing structures completed in January 2010, including dormitory, classroom, systems, and office block In phase II, a new kitchen, classroom, demonstration room, and dormitory block to bring enrollment to a minimum of 200 students Same Administration building None Multi-story dormitory building of which the first story (44 spaces) is budgeted for 1 classroom budgeted Library Skills lab (sponsored by Tilburg, Holland) Tarime Assembly hall 208 dormitory spaces Skills lab (awaiting furnishing) Dining hall expansion Tukuyu 40 dormitory spaces Dining hall/kitchen/multipurpose room 50 dormitory spaces 1 classroom Severe Shortage of Full-time Faculty The shortage of full-time faculty is the most critical barrier to scale-up for most nursing schools. Of the 16 public nursing schools surveyed, only 7 have adequate tutor-staffing patterns. In the 9 other institutions, 30 more tutors are needed for current enrollment numbers, representing an overall 41% shortage. At target enrollment, that rises to 63 tutors needed (a 61% deficit overall). Principals repeatedly reported that full-time tutors are very difficult to find. They said the teaching profession is unattractive for many health care workers due to the long hours and low pay. One principal stated, The new initiative to hire [registered nurses] (RNs) as tutors is not very successful. RNs at the hospitals are not interested to transfer into teaching because they see the long hours that tutors work. They know that there is no additional pay. At least if they remain as a nurse, their shift is limited. 21

28 Coping with Increased In 2008, when the new EN curriculum was adopted, Mkomaindo NTI rapidly scaled up enrollment. Prior to 2008, 120 students were enrolled. Now, a total student body of 187 divided among three classes has caused severe overcrowding at the institution. Mkomaindo NTI has had very little infrastructure invested in it since it was originally built, so the principal and staff have coped with this drastic rise in enrollment by maximizing every available space on campus. The principal and tutors have even given up their own housing to create more dormitory spaces for students. However, the MOHSW representatives have objected to this and the NTI has been forced to add additional students to all dormitory rooms. Rooms that originally held five beds now hold 12, using double-deckers. In most rooms, desks and cupboards have been removed to make more bed space. Instructional space is not sufficient to accommodate larger cohort sizes; the two classrooms built for 40 students cannot hold any of the cohorts. The skills lab has been sacrificed to create a larger classroom by tearing down its adjoining wall with another classroom. The dining room, with space for only 40, is no longer in use. The library is rarely used because there is no librarian and the space can only fit about 15 students at one time. Tutors report great difficulty teaching to class sizes above 70 students. The library is rarely used because there is no librarian and the space can only fit about 15 students at one time. Another principal stated that the national and local governments do not work well with each other, making it difficult for an employee to transfer from one job to another. A few other principals reported that they can find full-time tutors, but often, one institution s gain results in another institution s loss of a tutor, creating a zero sum game. Full-time Faculty The MOHSW manages training institutions for allied health education and is responsible for setting criteria that facilitate tutor appointments. According to the Assistant Director of Nursing in the MOHSW, new tutors at nursing schools should have good performance in a professional field; be at least one level of training higher than the students in the program; ideally, have completed a nurse tutor-training program, and express interest in training, as demonstrated by a letter submitted to the MOHSW. 22

29 According to NACTE, full-time tutors must meet the minimum educational requirements in the relevant subject area; have successfully acquired instructional techniques and teaching methodologies through a teacher-training course from a recognized, accredited institution; and be registered with NACTE. The discrepancy between these two sets of requirements for full-time tutors has not yet been resolved and currently, institutions generally follow the requirements as dictated by the MOHSW (I-TECH, 2010). The revised MOHSW curriculum and NACTE recommend a tutor-to-student ratio of 1:25 for classroom instruction. Only four of the visited schools met this ratio in the academic year. On average, the nursing schools visited have only 59% of the necessary full-time nurse tutors present and working (see Table 5, below). At the schools visited, 26% of full-time tutors are away from their work, mainly due to attending long-term courses of study. Even if all employed full-time tutors were present and working at their institutions, the deficit would remain at nearly 20% across the board. It should be noted that the Tanzania Nurses and Midwives Council recommends a ratio of 1:8 for clinical instruction (personal communication, May 2010). There are no public nursing schools that come close to meeting this recommendation. More details are presented in Table 6, below. Table 5: Number of Full-time Tutors Needed at Current and Targeted Compared to Existing Staffing Pattern Nursing School Number of FT Tutors Present Current Deficit Given Current Number of FT Tutors Needed, in Total, at Target Bagamoyo Geita Kahama Kibondo Kiomboi Kondoa Korogwe Mbozi Mbulu Mkomaindo Nachingwea Njombe Nzega Same Tarime Tukuyu Deficit at Target Totals (41% overall deficit) (63/103=61% overall deficit) 23

30 Table 6: Ratio of Full-time Tutors Present to Tutors Away Nursing School Present and Working Away Upgrading Skills Away for Any Other Reason Total Number % Away Bagamoyo % Geita % Kahama % Kibondo % Kiomboi % Kondoa % Korogwe % Mbozi % Mbulu % Mkomaindo % Nachingwea % Njombe (sick, not expected to return) 4 75% Nzega % Same % Tarime (sick) 3 33% Tukuyu % Total numbers % Part-time Faculty Part-time tutors are usually qualified health care professionals who work in nearby hospitals. The principal and staff coordinate recruitment. Individual institutions determine the required number of part-time tutors and identify candidates. There are no written education and experience requirements for part-time tutors. They are often hired to teach specific subjects and are given some compensation, usually between TSH 5,000 and 10,000 for each day of teaching (US$3 8). All institutions rely heavily on part-time staff to fill deficits or to cover courses where full-time faculty lack appropriate skills or knowledge. On average, the 13 nursing schools employed nearly seven part-time tutors, in addition to their full-time faculty. Kondoa Nursing School where the student-tofull-time teacher ratio is only 18:1 relies on 10 part-time tutors. Kondoa, compared to many other institutions visited, had more efficient staffing patterns and less overcrowding; yet, with a student body of only 48, 10 part-time tutors were needed to cover the curriculum and provide quality education. In contrast, Kiomboi Nursing School where nearly 270 students are taught by 2 full-time nurse tutors and 2 full-time clinical instructors only employs 3 additional part-time tutors from the adjacent district hospital. 24

31 While part-time tutors help to fill critical staffing gaps at nursing schools, part-time staff have limited training in teaching methodologies and full-time responsibilities at the hospital where they work. Both principals and students emphasized that part-time tutors have limited utility for student and institutional needs. Part-time tutors are employed full time at the district hospital, and consequently have limited time to instruct students in class. Class is often held at times convenient for the part-time tutor but not ideal for students or the school s schedule. Students reported that part-time tutors often teach in the evenings when students would prefer to be studying. Students also reported that part-time tutors are often unavailable for help outside the classroom setting. They reported that parttime tutors are most valuable for specialty subjects in which nurse tutors lack expertise. Principals reiterated the importance of the nurse tutors, as they are generalists with specific training in teaching methodologies. While clinical instructors and part-time tutors (specialists) are needed and valuable, without enough nurse tutors, the quality of teaching is compromised. Clinical Supervision Support Nursing school faculty rely on the supporting district hospitals (or others nearby) to provide clinical training for their students. Trained hospital staff are employees of the hospital and not the school, but the supervision and mentoring they provide to students comprises a critical part of the students education. On the whole, district hospitals are severely understaffed and though efforts are made to supervise students in the wards, there are simply not enough qualified staff to supervise students. It is not uncommon for students to be left in wards without a supervisor. While in most cases the nursing school and the hospital share a positive and beneficial relationship, all principals and matronsin-charge stated that clinical supervision is inadequate. Difficulty in Covering the Compacted, Two-year Curriculum The EN curriculum in Tanzania was originally a four-year in-service program. It was later reduced to a three-year program. And, now it is a two-year program that many principals describe as compacted. Due to the severe shortage of full-time nurse tutors as well as the increase in cohort sizes at many of the nursing schools, teachers are struggling to cover the curriculum given the paucity of human resources (tutors), supervision in the hospital setting, adequate classroom space, and teaching tools (texts and equipment). They experience difficulty in both classroom and clinical instruction. Many principals expressed concern with the length of the two-year program. Several stated their fear that students do not have adequate time to develop competencies that would enable them to work in a rural setting. Many principals believe that because these students are largely admitted straight from Form IV, they do not have the maturity and experience required for future placement in a dispensary or health center. Students also expressed concern about being placed in a dispensary or health center; they said they felt unprepared for rural conditions because of their young age and limited experience. A few institutions reported that some of the program requirements were not feasible within the two-year time period. For example, two nursing school staff said that the requirement to conduct 15 deliveries was unrealistic at their location because the time spent in the hospital setting is limited and sometimes the number of delivery patients is inadequate. In contrast, other institutions reported that their students have ample opportunity to meet the delivery requirement. There are distinct geographical differences with respect to this issue. 25

32 Principals and tutors reported working many overtime hours in an attempt to cover all curriculum modules within two years. Even at fully staffed schools where the recommended NACTE tutor-tostudent ratio exists, principals report that more full-time tutors are necessary. At one fully-staffed school, where the tutors are working significantly overtime, the principal said, It is possible to complete the two-year curriculum on time as long as staffing and resources are truly adequate. She did not think that there was anything inherently wrong with the design of the curriculum, but rather simply described a lack of resources (human and otherwise) to accomplish all of the goals. Teaching in Shifts Is Impractical Teaching classes in shifts is, in practice, unfeasible. There are not enough tutors and those currently employed regularly work overtime to cover the curriculum with large class sizes. While dividing a big cohort into two sections helps mitigate the problems of a large class size, it creates a logistical morass for the tutors. In addition to their regular work, at some nursing schools, tutors are often called upon during instruction to attend to issues that should be dealt with by support staff (secretaries, accountants, guards, cooks), which many schools also lack. Tutors are so busy that they are unable to accompany students on clinical rotations because while one class is in clinical rotation, the tutor is providing classroom instruction to another class. With so few tutors who are already stretched thin, it is impractical to expect them to teach multiple sections of multiple modules they would have no break during the day. To teach classes in sections, many more tutors would be necessary. EN Curriculum Is Weighted toward Clinical Practice, but Institutions Report They Are Least Able to Provide Support in That Area As mentioned previously, district hospitals have difficulty in supporting the clinical supervision of students due to their own staff shortages. Clinical practice is an essential part of the curriculum. Most principals describe the curriculum as weighted toward clinical practice, but that students are unable to achieve those skills not only because of hospital staff shortages but also because: 1) nursing school tutors cannot supervise students in the wards due to staff shortages; 2) most hospitals have a dearth of equipment for students to practice simple procedures such as taking temperatures and reading blood pressure and some hospitals lack enough patients (in particular, deliveries) to support the students practice requirements; and 3) many nursing schools lack a skills lab or proper tools to equip the skills lab. This impacts students ability to develop clinical competencies. Many principals emphasized that fully-equipped skills labs would lessen the burden on hospitals to provide clinical skills. 26

33 Lengthy Process to Validate Students Qualifying Certificates Means That Students Are Dropped Very Late in the Program The MOHSW provisionally admits students into the EN program based on their applications. Once students are selected for a particular institution and report for class, the school is supposed to collect the students qualifying secondary school certificates illustrating each student is fully qualified for the program and submit them to the MOHSW for verification. The certificate verification process is very lengthy. One principal explained that one cohort of students entered the program in September of 2008; certificates were collected by November 2008 and sent to the MOHSW, which relies on the National Examinations Council of Tanzania, under the Ministry of Education and Vocational Training (MOEVT) to verify the certificates. The verification process at this council was delayed and threequarters of a year passed before the MOHSW returned notification for the validity of these certificates. Inevitably, some students are always disqualified from the program because their certificates are found to be forged. Fifty nine percent of all dropped students since 2008 have been dropped from the EN program due to forged certificates more than any other reason. Not only are students dropped from the program, but they are dropped very late in their studies in many cases, after completing a whole year of studies, or half of their program. Some classes have not been checked for forged certificates because the principal decided to forego the process as the request from the MOHSW came very late in the academic year. Once those students graduate and are placed in a dispensary or health center, they will be required to provide original Form IV certificates. At that point, students without the proper certification will be unable to work though they have been trained as ENs and passed their exams. Another principal reported that the MOHSW is asking principals to assist in certificate verification from local students before their applications are forwarded to the MOHSW. This principal thought retention would be improved through this effort. Because pre-service training at public institutions is heavily subsidized, the MOHSW is losing a significant investment when 158 students are dropped due to forged certificates, especially after a year or more of training. The following Table 7 details the losses by institution. 27

34 Table 7: Numbers of Students Lost Due to Forged Secondary School Certificates at Open Institutions Nursing School A Total Number of Students Dropped Due to Forged Certificates B Total Number of Students Dropped for Other Reasons C Total (A+B) D Of Drops, % Dropped (A/C) for Forged Certificates Notes/Special Circumstances Bagamoyo % Geita % Had 6 other not qualified in-service students who went to Distance Learning Kahama % Applies only to 2 nd year cohort; first is still waiting to check Kiomboi % Kondoa 4 Korogwe % First years haven t been checked yet Mbozi 4 Did not submit/check certificates Mbulu % First-year class hasn t finished checking their certificates Mkomaindo % Njombe % Same % No explanation Tarime N/a Certificates not yet checked; 2 fail, 8 repeat, 2 pregnant Tukuyu % These 5 are expected to drop but haven t been dropped yet Totals % 28

35 Discrepancies in Planning and Delayed Infrastructure Completion The ability to scale up enrollment is impeded by inconsistent infrastructure capacity on campus as well as regular delays in the construction process. Nursing schools that have expanded their infrastructure over time have often expanded capacity in one area of student life (e.g., dormitories or dining halls) but not in others (e.g., classroom space). Thus, it can be difficult to determine the proper capacity of the institution as well as realistic scaleup efforts. In real terms, more students are being enrolled and cohort sizes are growing but those students cannot be accommodated throughout all areas of the campus (i.e., dormitories, classrooms, skills lab, dining halls, washing facilities). For example, Kiomboi s infrastructure allows for roughly 200 students in the dormitories, but only 90 total students in the classrooms (capacity of 45 each); and, this school has 270 students with only two full-time nurse tutors. Or, at Njombe, additional dormitory and dining space is nearly completed, but the sanitation systems cannot begin to support use by over 200 students. Classroom space will remain severely overcrowded because they were intended to serve classes in their 40s but now must somehow manage classes in their 80s. While the strategic planning poses its own challenges, the actual construction process itself poses many difficulties as well. It is regularly inefficient. When an institution develops infrastructure plans, the MOHSW must approve them and then allocate the necessary budget. The next step is to tender the project. Several principals explained that, at this point, the Regional Tender Board becomes involved. District authorities may also be involved in the tendering process. After a contractor is selected, construction begins. Generally, principals described that a contractor is paid in three parts. The first payment is due before the contractor breaks ground. The second payment is due halfway through construction and final payment is received upon completion. Principals indicated that construction is often delayed, either at the tendering process or due to contractors not being paid. There are many construction projects stalled. Six of the 16 nursing schools talked of problems with the process. At Kondoa, a new dormitory has sat half-finished since July 2008 due to problems with the Regional Tender Board. At Bagamoyo, another dormitory building has also been stalled since 2008; the principal reported that it was a result of mismanagement of funds. At Kiomboi, there is a severe problem with the water supply. The pump is broken and a new pump has been procured, but the contractor cannot install it until he has received his proper installment payment. At Mbulu, a classroom, dining hall/kitchen, library, and skills lab are either delayed due to contractual problems or awaiting final approvals from the MOHSW. And at Same, the principal has architectural plans drafted for a new multistory dormitory building. The funding for the first story of the building (22 rooms) was allocated from the MOHSW, but there has been very little progress and many delays in the three years that the principal has been at the institution. The current status is that the Tanzania Building Agency has refused to sign-off on the plans unless they are redone because the regional engineer did not check the soil before starting the planning. All of these projects are crucial to these institutions ability to support current and future enrollment. Shortages of Accommodation for Students Almost all of the nursing schools dormitories were built to house two students in a single room, with a proportional number of toilets and washrooms. Currently, however, principals have increased enrollment capacity by adding three and four beds to rooms that were originally designed to hold only two. While there are a few campuses with larger rooms that can hold up to four students comfortably, 29

36 Infrastructure Expansion Planning Geita NTI Dormitory space holds 132 Classroom space is for 76 Current enrollment stands at 109 Many schools experience difficulties in supporting their student body and enrollment scale-up due to infrastructure expansion that is at odds with enrollment trends. For example, since 2006, Geita NTI s campus has been expanding with the addition of 96 dormitory spaces, a library, a skills lab, and a classroom. The NTI has also built an administration block, a kitchen, and four tutor houses. With increased enrollment, cohort sizes have grown from approximately 30 students to nearly 60. The recently-built library and skills lab were never put to use because the principal had to repurpose them as classrooms. Furthermore, some office spaces have been converted into male dormitory rooms. There This room, initially built to be a library, is now used as a classroom to accommodate classes of up to 60 students. is also a severe shortage of furnishings for all of these spaces, making instruction a great struggle. Students remain overcrowded in dormitories because of lack of furnishings in a new dormitory block. Despite the recent infrastructure growth, there remains a serious shortage of facilities, especially in terms of classroom space and dining space, which able to hold only 40 students is severely insufficient. across most institutions enrollment increases have led to severe overcrowding in the dormitories, as shown in Table 8, below. Study and storage spaces have been lost to make room for additional beds. Further, the lack of furnishings at several schools results in unused dormitory spaces and overcrowding in the other furnished rooms. At Mbozi Nursing School, for example, two double-decker beds have been put in rooms and up to six students share those four beds. The study table is rendered useless and cupboard space is non-existent. Students pile their belongings at the ends of beds. Other rooms have six students sharing three beds. At Tarime Nursing School, the original campus classroom has been converted to dormitory space. At Njombe Nursing School, the original dormitory built in 1975, with space for 36 students now holds 62 female students. Up to six females share three beds in a single room. There are cupboards in the rooms but no desks. The ratio is 12 students to one toilet. Mkomaindo Nursing School experiences similar overcrowding and has even had to convert principal and tutor housing to dormitory space. Ten out of 13 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. 30

37 Table 8: Number of total dormitory spaces versus number of total students housed Nursing School Number of Dormitory Spaces (As Designed) Number of Students as of March 2010 % (#) of Students without Rooms Bagamoyo Geita * 38% (46) Kahama *See note Kiomboi % (70) Kondoa % (12) Korogwe Mbozi % (71) Mbulu 120, up to Mkomaindo % (57) Njombe % (74) Same Tarime % (40) Tukuyu % (26) Totals % (325) *While the number of spaces is enough, still there is overcrowding because males and females cannot be in the same block. **Includes 11 distance learners accommodated in the dorms at various times throughout the year. Inability to House Males and Females Together Causes Dormitory Spaces to Be Lost Because most institutions do not house males and females in the same dormitory block, some rooms may go unused while others remain severely overcrowded. At both Kahama and Kiomboi, overcrowding was exacerbated because of this policy. At Korogowe, 11 rooms in the males dormitory lack furnishings. In order to use these 12 rooms, the MOHSW would have to allocate exactly 24 male students to Korogwe, otherwise, there would be more male students than spaces in the male dormitory, or there would be spaces that would go unused. In the upcoming academic year, Bagamoyo and Kondoa will both receive male students for the first time. This poses a significant challenge. Principals are considering short-term solutions such as renting hostel space in the nearby town, partitioning the existing dormitory blocks or converting the washing facility space at the end of a dormitory block. 31

38 Water, Sewage, and Power Systems Are Taxed The increase in dormitory beds was done without parallel improvements in the water supply, power supply, or septic systems. At 7 of the 13 institutions visited, there were problems with either broken equipment, septic tanks that were either too small for the usage or not serviced regularly, and broken drainage systems. Broken showers and sinks were a common occurrence throughout sites. The assessment teams felt the overcrowding at some of the schools was leading to unsanitary conditions that should be addressed before further increases in enrollment take place. At some institutions, such as Mbozi Nursing School, 15 students queue up at one time to use a single toilet. Mbozi and Mkomaindo both suffer from a lack of water supply and that need has been exacerbated with the demand for water as enrollment has increased. At Kiomboi, a broken water pump has gone without replacement because the MOHSW has not paid the contractor; students frequently must purchase water at their own expense. At Tukuyu, the plumbing and electrical systems have not been fully renovated since The electrical circuits commonly trip because they are overloaded. The sewage system, as indicated in Table 9, below, is intended for 36 students and cannot meet the needs of a student body that is over 100. Table 9: Status of Sewage Systems Nursing School Problems with Toilets or Sewage Systems? Comments Bagamoyo Yes Severe septic problems/drainage problems Geita No None reported Kahama Yes Severe overflow problems Kiomboi Yes Severe shortage of toilets Kondoa Yes Drainage problems Korogwe No No problems Mbozi Yes All showers not working; some toilets and sinks not working; too few Mbulu No info No information Mkomaindo Yes Overflow and lack of servicing; too few toilets Njombe Yes Too few; some being constructed Same No Very small school Tarime No Not an issue Tukuyu Yes Some septic tanks are too small Totals 7 of 13 with problems 32

39 The Importance of Infrastructure The need for reliable and adequate septic systems was identified as a key concern at seven of the schools. At three of the seven schools, students also lack a reliable water supply. Unreliable, broken, or irregularly serviced septic or sewage systems leads to unhealthy living conditions for students and staff. At Bagamoyo Nursing School, strong odors emanate from nearby the kitchen where waste drains into the ground rather than into a septic tank. The principal reported that one septic tank collapsed. In Kahama Nursing School s dormitories and dining area, severe blockages in the pipes are a common occurrence and the septic tanks are regularly full. Mkomaindo s toilets cannot support use by nearly 200 students and overflow is common. Mbozi and Mkomaindo have a severe water shortage. At Mbozi, water is available for up to two hours a day. Students often must walk half an hour to a nearby river. In Mkomaindo, district water is unreliable and students regularly purchase water. In Kiomboi, students regularly must purchase water as well because the water pump is broken and the new one cannot be installed until the contractor receives payment from the MOHSW. Overcrowding at nurse training institutions burden septic systems and often leads to unusable facilities, such as this toilet at Kahama NTI. Dining Halls and Kitchens Are Largely Inadequate and Often Unsafe As of April 2010, not a single school had a fully adequate dining and kitchen facility in use (see Table 10, below). In 2010, four nursing schools will have new, adequate dining halls and kitchens. The others are all in need of either renovation or new construction. Many institutions lack proper equipment and storage for cooking (principals report that the cooking stoves are unhealthy and unsafe). For example, at Mbozi Nursing School, the cooking stoves are crumbling and the metal material is finding its way into the food itself. Other nursing schools have dining halls that are not in use as such, having been rededicated as classrooms. Many of the schools dining halls were originally built with a capacity of 40 students; now, with enrollments in the hundreds, the dining halls are useless and the kitchens cannot meet the needs. 33

40 Table 10: Dining Hall and Kitchen Adequacy Nursing School Adequate? Size/Description Bagamoyo No Renovation required for current enrollment; expansion required for scale-up Geita No Dining space inadequate for current enrollment; new kitchen, but stoves broken Kahama No Congested and require expansion Kibondo No Original dining hall built to accommodate 24 students Kiomboi No Dining hall rededicated as a classroom and no longer in use; kitchen too small for enrollment numbers Kondoa Yes (construction near completion) Existing facilities are too small; new ones in process but additional stores needed Korogwe Yes Recently renovated and more expansion happening Mbozi No Worst facilities of all visited institutions: crumbling dining hall, disintegrating kitchen equipment, and no food stores Mbulu No Existing dining hall too small and therefore not in use; new one stalled in construction Mkomaindo No Too-small dining hall used as a serving area; too-small kitchen no longer used due to size so food is prepared in makeshift outdoor kitchen Nachingwea No Original dining hall built to accommodate 24 students Njombe Nzega Yes (within months of completion) Yes (because enrollment limited to 24) Existing dining hall is too small; new dining hall/kitchen will be completed in 2010 Original hall built to accommodate 24 students Same No Small space where students only pick up food; new, larger facilities are needed for scale-up Tarime No Existing facilities are too small; expansion planned Tukuyu Yes (newly constructed building only lacks the new stoves) New, large, adequate facility but lacks new gas stoves that will be added soon Insufficient Classroom and Skills Lab Infrastructure With only a few exceptions, the nursing schools are enrolling between students per class. Classrooms built for 50 or less are often used for cohorts of 70 or even up to 110 students. Nearly all nursing schools have classrooms intended for only 36 students and most can no longer use that space. Overcrowding limits the quality of instruction provided. Nursing Schools have added additional desks and chairs to accommodate students, but many principals reported that they have reached the maximum number of students per classroom. And, at a few institutions, classroom lack desks and chairs altogether. Overcrowded classrooms also impact instructors abilities to fully implement the curriculum tutors are unable to move around the room or help individual students and there is no space for small group activities or discussions. 34

41 Five of the visited schools have new classrooms under construction. In all but one, the classrooms are being built to accommodate about 50 students, despite the fact that cohort sizes regularly exceed those numbers. Only 4 of the 13 schools have rooms that were built as skills labs and are actually being used as skills labs (see Table 11, below). Four other schools have repurposed their skills labs often as classroom space in order to cope with increased enrollment. Many principals report that skills-lab instruction is ideally suited for less than 40 students at a time. They said that the large cohort sizes impacts the quality of education provided. Students cannot comfortably fit in the room and must queue in long lines to practice or view a demonstrated skill. None of the institutions with skills labs report having adequate training equipment; all require additional anatomical charts, models, and equipment. Some principals emphasized the importance of a fully-stocked skills lab to lessen the burden on the district hospitals to provide clinical skills to students. Table 11: Skills Lab Use Nursing School Is There a Dedicated Room for Skills Lab? Yes/No Is the Room Being Used as a Skills Lab? Yes/No Comments Bagamoyo No N/A Uses the only classroom Geita Yes No Kahama Yes Yes Lab doubles as a classroom Kiomboi Yes Yes Well kept Korogwe No N/A One is planned for Kondoa Yes Yes Good condition Mbozi No N/A Used as classroom Mbulu No N/A Uses dining hall Mkomaindo Yes No 2 different labs were taken over for tutor offices and classroom space Njombe Yes Yes Capacity = 43 Same No N/A Tilburg, Holland, sponsoring a new lab Tarime Yes No Waiting to be equipped Tukuyu Yes No Sometimes used a classroom Totals 8 of 13 schools have skills labs 4 of those 8 are being used; only 4 of 13 schools have functional labs Limited Funding Available The funding available for supporting the operations of the HTIs is insufficient to cover all costs and very few institutions have been successful at finding other sources of funding. Institutions were 35

42 asked to provide budget information from the past three years, including the most recent breakdown of funds received through students via cost sharing, MOHSW funds to the institutions (referred to as Other Charges or OC by the institutions), and grants or funds from any other sources. All principals reported that the funds received through cost sharing and the MOHSW are erratic and not sufficient to maintain the institution. Most impacted by the lack of funds are the quality of food, the computer module, and students fieldwork, which is often cut or scaled back. Principals also reported that the MOHSW funds are often very late to arrive, which causes challenges with budgeting and planning. Students frequently complained about how a shortage or delay in funds affected their meals. One principal described the funding flow at her school, saying that the MOHSW warrants of funds arrive not only very late but also are incomplete. For example, the first quarter funds for July through September are supposed to arrive in July. Last year, the funds came in October, three months late. And, not all of the requested money was received. Only some of the line items were included in the warrant of funds. As of March, the second quarter funds, which should have arrived in October, still had not arrived. Only exam, electricity, and water funds arrived for the second quarter. Even the exam funds were not the full amount and the administration had to borrow funds from other areas to cover the cost. In general, principals felt that the students could afford to pay the cost-sharing fees. Principals reported very few cases in which a student experienced great difficulty in paying their fees. Principals explained that in some cases, they withhold final certificates until all cost-sharing fees are paid. Missing Technology The new two-year EN curriculum contains a computer module. But, for students at most NTIs, computers are a luxury. Only two institutions actually had computers that were on campus and that were regularly available for student use: Same NTI had four computers and Internet access and Tarime NTI had five computers, which were bought through cost-sharing fees. Six NTIs taught limited computer skills. For example, at Mkomaindo NTI, the principal rented a single computer and an IT specialist demonstrated skills to them. Students had to go into town and pay to practice their skills. Four of the NTIs did not teach the computer module at all due to lack of computers, funds, and teachers. At Njombe NTC, a large room is available for computer instruction, but the institiution has no computers nor an IT instructor. Here, the principal hired computers and IT specialists from Iringa. Given the dearth of computers and tutors with strong computer skills, the computer module in the new EN curriculum is rarely taught, or at least not thoroughly taught. The lack of computers and Internet means that students are unable to access important resources for research and learning. They also miss the opportunity to learn useful skills for their future posts at health centers and dispensaries, where compiling and managing health data will be a part of their job responsibilities. 36

43 At one institution, the principal reported that three such students received sponsorship for their costsharing fees. The sponsorship came from an NGO in one case and from Catholic nuns in another case. The sponsorship was for girls whose families and tribes discouraged their continuing education. Very few of the schools have regular sources of funding outside of cost-sharing fees and MOHSW funds. Some institutions rent out their recreation halls to outside groups for meetings, weddings, or parties but these sources of funding are extremely limited. The principal of Njombe described renting out space as increasingly difficult because there is much more competition in town nowadays. One school rents accommodation to distance learning students, but this has increased overcrowding at their facility. Another institution raises pigs, selling the piglets for extra revenue. The only case of substantial outside funding was at Same where a town in Holland is a sister city and has raised funds to build a skills lab on campus. Same is awaiting district approval to proceed with the build. Limited Numbers of Local and Rural Students The assessment team looked at the enrollment of local students (detailed in Table 12, below) defined as students from the region where the school is located at each visited institution. The team was unable to gather data that clarified whether a local student was from a more urban or rural setting within the region. As discussed in the background section, studies have shown that growing up in rural areas increases the likelihood of future rural practice. Investing in local recruitment is a potential strategy for addressing the growing gap of health care workers willing to practice in rural areas. Yet, the centralized selection process used by the MOHSW does not prioritize local placement. The numbers of local students are not formally tracked, either centrally or at the institutional level. Further, there is no tracking that distinguishes which or how many students actually come from a rural (traditionally underserved) area versus students who simply come from urban areas within the region where the nursing school is located. Some principals used the second selection process to recommend local students, as a way to increase the proportion of local students at their school. There was a range of local enrollment throughout the institutions visited. At Bagamoyo, there were no local students, but at Same 53% of the student body was from the local Kilimanjaro region. While some principals were interested in increasing the numbers of local students from underserved regions, others reported a desire not to increase local student numbers, believing that local students are more likely to be distracted from their studies due to family obligations or problems. Principals also expressed a belief that a geographically diverse student body enhances the learning process. However, not all staff felt this way. One full-time tutor at Kiomboi said that more local students from her region should be recruited because then they would end up serving in our rural areas and that would help everyone. At Same, the principal explained that in past times, local students were discouraged from applying to the program, but more recently they have been encouraged and applicants come directly to the institution to enquire about the process. Now, Same Nursing School has the highest proportion of local students. Although on the whole, principals did not express an interest in enrolling more local students at their own institution, they did express an interest in recruiting rural students for the EN program overall. Principals recognized the need to increase the number of rural students in the program and would like to see more rural students applying to it. Principals and students thought that more efforts could 37

44 be made to improve outreach and recruitment to rural areas. Some students thought that the information should disseminate from the MOHSW to regional authorities to district authorities to health centers and down to the dispensaries. They also said that secondary schools and churches should all be given information about the EN program and provide it to their constituencies. Some principals, tutors, and students expressed a belief that rural students would be more willing to serve in the rural areas (i.e., the placement goal of this EN program). Many students expressed concern about being placed in a rural setting upon completion of the program, believing they were ill-prepared for rural placement due to their young age and inexperience. They believe students who come from rural areas would be at an advantage in terms of knowledge and abilities, and that rural students would want to serve in the rural setting much more so than their counterparts from urban settings. Table 12: Number of Local Students Enrolled in all Classes in Academic Year Nursing School Number Percentage Total Students Bagamoyo 0 0% 35 Geita 45 41% 109 Kahama 16 15% 104 Kiomboi 5 5% 90* Kondoa 11 23% 48 Korogwe 22 26% 83 Mbozi 67 35% 191 Mbulu 36 34% 107 Mkomaindo 51 27% 187 Njombe 43 20% 218 Same 18 53% 34 Tarime 55 44% 124 Tukuyu 20 20% 102 *Data was only available for the newest class of 90 students; data was not available on the other 128 students Significant Investments Needed for New Programs Along with increasing the number of students studying at existing nursing schools, the MOHSW is also looking for other opportunities to increase enrollment by opening new EN training programs in Tanzania. This can be done either by reopening schools that have closed or by building new schools. To explore these potential strategies, the teams visited three schools that were closed for over 10 years but expected to reopen in 2010: Kibondo, Nachingwea, and Nzega. These institutions were visited in August 2009, and well before any of the centers had received a new intake of students. 38

45 In general, the infrastructure at these institutions had remained untouched since their closure between 1995 and All infrastructure required significant renovation and overhaul. In addition, the original institutions were only built to accommodate 24 maternal and child health-aid students each. Until enough funds are set aside to increase the size of the classrooms, dormitories, and all other infrastructure, the schools will be extremely limited in the numbers of students they can enroll. Also, with the limited number of tutors available, these schools will have to draw tutors from other institutions, which are already short staffed, to begin enrolling students. The MOHSW had planned to reopen each institution in two phases: 1) rehabilitate existing structures, and 2) significantly expand, with new structure to host a student population of students. At the time of the initial visits, Nzega was the only institution that had managed to secure and use allocated funds for renovation. All existing structures were renovated and rehabilitated by January However, because all of the furnishings inside the buildings had been declared unfit for use, Nzega required new beds, desks, chairs, office furniture, kitchen cook stoves and utensils, and dining furniture in order to receive a new intake. I-TECH and the CDC, through PEPFAR, were able to provide over US$60,000 of furnishings to Nzega to allow the institution to reopen for 24 students in March Nzega is now in the process of building additional classrooms and buildings as part of phase II construction. Both Nachingwea Nursing School and Kibondo Nursing School faced significant delays in tendering and receiving the funding designated for rehabilitation. By March of 2010, principals of both schools had found ways to reopen by renting external structures in nearby towns to board and/or train students. Kibondo Nursing School has one cohort of 43 students, and Nachingwea Nursing School has one cohort of 65 students. Neither institution will be able to take a new class until rehabilitation is complete, sometime in If renovations are completed in 2010, both principals intend to accept a new class on campus while keeping the existing class at the rented locations, thus increasing overall intake. Both institutions plan to begin phase II construction in Although adding new programs could have a considerable impact on the number of EN students trained each year in Tanzania, the resources needed to open new nursing schools are significant and the process requires much more time than when existing institutions are expanded. More information on the new sites is available in the institution-specific findings and recommendations section. 39

46 INSTITUTION-SPECIFIC FINDINGS AND RECOMMENDATIONS The institution-specific recommendations aim to support existing enrollment (where scale-up has begun) and, for some institutions, increase enrollment as the planned-for infrastructure and systems are completed. The recommendations aim to increase enrollment without creating or exacerbating overcrowding. The assessment team used the following considerations to determine whether an institution was overcrowded: Dormitory rooms were considered overcrowded if they contained three or more students and did not have room for at least one twin-size bed per student, one small desk as well as at least one cupboard or dresser for the belongings of all the students living in the room. Classrooms were considered overcrowded if they were holding more than 120% of their original capacity (e.g., if a classroom built to comfortably hold 50 students is now holding more than 60 students). Structures, such as tutor housing, dining halls, or skills labs, that had been converted to dormitory or classroom space as emergency measures were not counted as true spaces, unless a new building (i.e., a new, permanent dining hall or skills lab) had also been constructed. To determine the number of tutors needed, the assessment team used the NACTE-recommended ratios for tutors-to-students of 1 tutor per 25 students. The emphasis was placed on full-time nurse tutors, who have general training in teaching methodology and can teach a wide range of subjects. Principals reported that nurse tutors are the core of the teaching faculty. The assessment was conducted at the end of the academic year, so numbers of tutors and students used in graphs and charts are based on the numbers provided by principals in March and April The MOHSW aims to increase enrollment by 100% at nursing schools. 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 found that an additional 100% scale-up from existing enrollment numbers is unrealistic, without drastic and extensive overhaul to the campuses as well as an immense increase in resources, especially human resources. As a result, each institution is reviewed separately. Each institution has its own set of recommendations based on what the assessment team found to be an achievable target enrollment. This school-specific target enrollment comes looking at the current enrollment and capacity, infrastructure expansion in progress or planned for, and capacity to increase enrollment without exacerbating overcrowding and educational quality. If these key factors are considered, then the recommendation is for an overall further scale-up of 41% among the 13 institutions. And, when taking into account the new enrollment of the three additional institutions that will open their doors in 2010, overall enrollment will be scaled up a total of 69% across the 16 schools. This scale-up constitutes a significant increase in enrollment, but is not feasible without a significant investment in full-time tutor hires and infrastructure development. A two-page summary of findings and recommendations for each institution is included in this report. Each summary includes basic background about the school, as well as findings and recommendations regarding dormitories, classrooms, instructional space, and tutors. The full reports from each school are included in Appendix 2. 40

47 BAGAMOYO NURSING SCHOOL Institution at a Glance n This nursing school offers a certificate in enrolled nursing under the MOHSW. n The school is located in the Coast Region of the Eastern Zone, one hour north of Dar es Salaam by road. n In 2010, there was one second-year cohort of 36 students. n There are no students from the local region. n There is a new block of dormitories under construction and several other buildings planned but not yet funded. n Septic and drainage systems are a problem. n This school lacks a skills lab and a library. n There are three full-time tutors, enough for current enrollment numbers. n The target enrollment is 96 students, representing a 165% increase since beginning the two-year program. Dormitory Capacity vs. Dormitory Capacity There is one dormitory block with space for 36 students and operates at capacity. This dormitory block, built in 1974, requires renovation. The wiring, doors, and washing facilities are in poor condition and require rehabilitation. A new two-story dormitory block with spaces for 60 students is currently under construction; however, completion has been stalled since The principal has been following up on this issue to ensure completion and also is working to secure funds to furnish the new block. Recommendations: n Renovate the original dormitory block to ensure the safe and hygienic conditions / / Target 60 spaces needed Current capacity is 36 n Repair existing sinks, toilets, and washing facilities and their underlying sewage/drainage systems. 1st year students 2nd year students n Build more toilets and washing facilities. n Complete and furnish the stalled dormitory block. 41

48 Faculty There are three full-time nurse tutors currently working at Bagamoyo Nursing School. A fourth tutor is away on study leave. The school is supported by six more part-time tutors. Recommendations: n Hire one additional nurse tutor for a target enrollment of 140. n Hire a clinical instructor at the school dedicated to supervising students in the hospital setting. Student to Tutor Ratio additional tutor needed Recommended NACTE student to tutor ratio is 25:1 Classroom Capacity There is one classroom, also built in 1974, intended for 36 students. Architectural plans have been drafted for a new two-story building containing a large classroom on the ground floor, but these plans have not yet been funded. For a target enrollment of 96, the school requires this planned classroom plus one additional classroom with capacity for 50 students. There is no computer lab, skills lab, or library. Textbooks are kept in tutor offices, are mostly outdated, and are too few in number. The planned two-story building contains a library on the top floor. Recommendations: n Fund the planned two-story building containing a classroom and a library, and furnish and equip it with the necessary resources. n Rededicate the small classroom as a computer lab and equip it with computers; hire a computer teacher. n Build a skills lab and equip it with the necessary resources. 0 Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target vs. Classroom Space classrooms needed, each with a capacity for Current capacity is /10 10/11 Target 1st year students 2nd year students Expected Outcomes & Additional Recommendations n With additional infrastructure, one more tutor, and overhaul of the sewage/drainage systems, the Bagamoyo Nursing School could reach a target of 96 students. n Construction of a skills lab is especially important at this school because the district hospital does not have enough cases to support students clinical rotation. n Construct a new dining hall/kitchen to accommodate 96 students. n Construct three more tutor houses that can accommodate families. 42

49 GEITA NURSING SCHOOL Institution at a Glance n This nursing school offers a certificate in enrolled nursing under the MOHSW. n The nursing school sits adjacent to Geita District Hospital in the Mwanza Region, about one and a half hours from Mwanza city by road and about half an hour by ferry. n In 2010, two cohorts of first year students were enrolled in February and October The current body is 109 students. n 13 other distance learners are housed in the nursing school s dormitory spaces. n 41% of current students are from the local region. n There is serious shortage of support staff. n There has been significant infrastructure development in the recent past with the addition of dormitory spaces, but there still is a serious shortage of space for the current student body. This includes classroom and dining space, and administrative issues are causing dormitory space to be unused. n There is a serious shortage of furnishings for classrooms. n This nursing school has four full-time tutors. n The target enrollment is 140 students, representing a 250% increase since beginning the two-year program, and 15% increase over 2010 enrollment. Dormitory Capacity There is physical space for 132 students without overcrowding; however, 56 of those spaces are unused due to a lack of furnishings. And, another new dormitory block with space for 48 sits unoccupied due to delays in handing over of the dormitory buildings to the nursing school. Currently, 122 students are housed in various dormitory blocks and in a converted office space. There is serious overcrowding. Some additional furnishings and shifting of students must occur to maximize dormitory space. Recommendations: n Complete handover procedures for new dormitories to make 48 additional spaces available. n Purchase more beds to fill the remaining places. Shift students to maximize space, returning office space to its original purpose. n Renovate the old dormitory to enhance sanitation and security. n Provide accommodation only to resident students, and discontinue rental of dormitory space for distance learning students. n Add an extra student to 9 rooms to support the target enrollment of 140. vs. Dormitory Capacity / / Target 64 spaces needed 56 spaces will be available if finished rooms are furnished/ opened Current capacity is 76 1st year students 2nd year students 43

50 Faculty There are four full-time nurse tutors currently working and one who is away on study leave but expected to return. The institution is supported by seven more part-time tutors. There are two clinical instructors employed by the district hospital who support the students during clinical rotations. Recommendations: n Hire two additional nurse tutors for a target enrollment of 140. n Build the management skills of the principal and administrative team to improve record keeping of enrollment data. n Hire support staff: warden, accountant, secretary, three cooks, and a watchman. Student to Tutor Ratio additional tutors needed Recommended NACTE student to tutor ratio is 25:1 Classroom Capacity There is a severe shortage of classroom space. Neither of the two classrooms can accommodate the large cohort sizes. The library and skills lab have been rededicated as classrooms, but lack furnishings (there are not even enough furnishings to equip one single room). Two large classrooms with removable partitions are needed to break large cohorts of 70 into two manageable-sized groups for instruction. There is no computer lab and the few computers for tutors are sometimes lent out to conduct limited computer instruction. The library and skills lab equipment and resources are scarce in comparison to other nursing schools. Books are stored in tutor offices. Recommendations: n Construct two new large classrooms with removable partitions for teaching smaller groups and furnish them. n Return the library and skills lab rooms to their original purposes and fully furnish and equip them. n Convert one of the old classrooms into a computer lab and equip it. vs. Classroom Space Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target large classrooms with removable partitions needed Average capacity is /10 10/11 Target 1st year students 2nd year students Expected Outcomes & Additional Recommendations n With management support, additional infrastructure, two more tutors, and the additional dormitory spaces opening/furnished, the target enrollment of 140 can be reached. n Repair/replace kitchen cookstoves and construct a new dining hall. n Identify replacements for the 2011 retiring principal and tutor. n Construct two new tutor family houses. 44

51 KAHAMA NURSING SCHOOL Institution at a Glance n This nursing school offers a certificate in enrolled nursing under the MOHSW. n The nursing school is in the Shinyanga Region of the Lake Zone, about four hours by road from Mwanza city. n As of 2010, there is a student body of 104, divided in two cohorts. n A large number of students dropped out, mainly due to 1) failure to provide qualifying certificates and 2) academic performance. n Though there have been infrastructure expansions and renovations in the recent past, the nursing school needs another classroom, more dining space, and major improvement to plumbing/sewage systems. n There is a large multipurpose assembly hall that holds 250. n The target enrollment is 120, which represents a 240% increase since beginning the two-year program and a 16% increase from current numbers. Dormitory Capacity There are two dormitory blocks with bed spaces for 116 students. Currently, there are 104 students. Due to not wanting males and females housed together, some female rooms are overcrowded while other rooms (17 spaces) were sitting unused. The principal is planning to partition one block so that both sexes can reside there, better maximizing space. This could work well, assuming the MOHSW sends a consistent number of male students to this school. There are serious problems with the sewage, drainage, and water supply systems at this nursing school, forcing students not to use some of the facilities, such as laundry, toilets, and some dormitory washrooms. Even the pit latrine that is located on the outside was filled up, causing unhealthy conditions. The principal indicated that the water table in this area is very high, a concern that must be taken into account in addressing this challenge. n Convert two washrooms in the newer dormitory block to serve as rooms to accommodate four additional students. n Renovate the washrooms in the old dormitory as well as the general sewage, drainage, and water systems. vs. Dormitory Capacity spaces needed Current capacity is 116 Recommendations: n Partition and maximize the existing dormitory space. Coordinate with the MOHSW on the number of male students sent to this institution. 0 09/10 1st year students 10/11 Target 2nd year students 45

52 Faculty Classroom Capacity There are two full-time nurse tutors present and working, though there are actually four employed. The other two are on study leave, which will keep them away for a longer period. There is also a clinical instructor who acts as a warden, but is retiring next year. There is a critical shortage of staff here, so the available tutors are strained, doing other administrative work in addition to teaching. There are five more part-time tutors from the district hospital teaching at the center. Recommendations: n Hire two additional tutors to meet the NACTE ratio for the current 120 target enrollment. n Identify a replacement for the retiring clinical instructor and hire an additional clinical instructor dedicated to supervising students in the hospital setting full-time. Student to Tutor Ratio additional tutors needed There are two typical classrooms, but only one is able to hold the current cohort of 60 students. The other small classroom can hold only 36 students and is no longer used. The skills lab is often used as a second classroom. There is no computer lab nor are there computers available for student use. There are several computers that are kept in tutors offices; they are used during computer training and returned to tutors offices. There is a library with a room capacity of 40 students. There is a large demontration room with a good amount of equipment and tools compared to other institutions visited by the team. Recommendations: n Build another large classrooms that can hold 60 students. n Rededicate the small classrom as a computer lab and procure enough computers for students to use for practice and research. n Procure more teaching aides to enhance demonstrations and more up-to-date books. n Return the skills lab to its original purpose Recommended NACTE student to tutor ratio is 25:1 vs. Classroom Space classroom needed 5 0 Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target Average capacity is /10 10/11 Target 1st year students 2nd year students Expected Outcomes & Additional Recommendations n Hire additional support staff to relieve the burden on the principal and other tutors and to strengthen the overall management of the nursing school. Hires should include: an accountant, a secretary, a full-time warden, cooks, and security guards. n Improve retention by verifying student qualifications before they enter the program. n Expand the dining hall to better accommodate increased enrollment numbers. n Increase library hours so students can use the facility when they are not in class or clinical training. n Procure more teaching aids to enhance demonstrations, as well as more essential textbooks and copies of those texts. 46

53 KIOMBOI NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and offers a certificate in enrolled nursing. n It is located in the Singida Region of the Central Zone, more than an hour north of Singida town. n In 2009, there were 270 students enrolled, divided into three cohorts of 109, 71, and 90, respectively. n The institution is operating greatly over capacity in terms of dormitory and classroom space as well as the student-to-tutor ratio. n Two of the four tutors are new to the institution and have not had any training in teaching methodologies. n There are severe water problems at the institution. n Kiomboi has a target enrollment of 300. Dormitory Capacity vs. Dormitory Capacity Kiomboi was originally built over 60 years ago and since then, has had various additions to its dormitory to expand capacity. Despite its current capacity for about 200 students, there are 270 students being housed, often in rooms that do not have enough beds. Some rooms have 8 students sharing 4 beds. The toilets and washing facilities are inadequate. On average, 15 students share a single toilet or washroom. There is one block of rooms designated for male students that has a few unoccupied rooms. Recommendations: n Add 100 more dormitory spaces. n Until more dormitories can be built, shift the males into a single block so that the females can be provided with a few more spaces, given they are experiencing more extreme overcrowding than the males / / Target Cohort 1 Cohort 2 Cohort 3 There were 3 intakes of students in 18 months between 3/08-9/ spaces needed Current capacity is 200 n Provide more cupboards and study tables to all dormitory rooms. n Build more toilets and washrooms at the existing dormitories and throughout the campus. 47

54 Faculty Classroom Capacity There are four full-time tutors. Two are nurse tutors and the other two are clinical instructors who are new to the institution. These clinical instructors have not had any training in teaching methodologies. The principal has been in her position for over 14 years. Recommendations: n Increase the number of tutors (preferably nurse tutors) by eight, given an enrollment approaching 300. n Hire two additional tutors who are dedicated to supervising students in the hospital setting full-time. Student to Tutor Ratio Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target 8 additional tutors needed Recommended NACTE student to tutor ratio is 25:1 Class sizes have increased significantly in the last two years on average, about 90 students each and Kiomboi Nursing School cannot accommodate them in the existing classrooms nor is it conducive to quality instruction. Only one of the three classrooms is being used as a such because they are too small and tutor shortages mean large class sizes there are fewer tutors teaching more students. Instead, the dining hall is used as a second classroom, though that room is in need of renovation. One of the three classrooms could be expanded on one end to accommodate a larger class size. The institution has a library as well as a skills lab. Both are well-kept up but both are in need of additional resources. Recommendations: n Build two new large classrooms with removable partitions and divide a cohort in two for instruction; alternatively, build 4 new classrooms with space for 50 each. n Renovate one classroom, extending it to hold 50 students. vs. Classroom Space classrooms needed Average capacity is /10 10/11 Target Cohort 1 Cohort 2 Cohort 3 Expected Outcomes & Additional Recommendations n With additional dormitory spaces, larger classrooms, and additional tutors, enrollment could reach 300. n Construct a new multipurpose dining hall and kitchen to serve 300 students. n Hire a warden to oversee student dormitory life, helping to reduce suspensions and increase retention. n Build more pit latrines and washrooms throughout the campus. n Rededicate the smallest classroom as a computer lab and provide computers; hire a tutor to teach computer skills. n Provide additional tutor and administrative space in an unused classroom. n Provide more library textbooks and skills lab equipment; hire a library attendant. 48

55 KONDOA NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and offers a certificate in enrolled nursing. n It is located in the Dodoma Region of the Central Zone, four hours north of Dodoma town on a rough dirt road. n The institution has had only one intake of 48 students since initiating the two-year program. And, with an incoming class of 69 in 2010, the nursing school will experience a 44% increase in enrollment over the past cohort, and a 73% increase overall since beginning the two-year program. n The principal has been in her position for 20 years. n The students have a good relationship with the leadership and engage in decision making, such as meal planning. n There are several buildings in construction and the MOHSW approved plans for additional construction. n Kondoa Nursing School has a target enrollment of 136. Dormitory Capacity Kondoa Nursing School was built in 1977 with dormitory capacity for 40 students. In , there were 48 students and overcrowding in 8 of the 20 rooms, where a third mattress was added to the floor of those rooms. This original dormitory block has never been majorly renovated and it is in need of a major renovation, especially to the plumbing and sewage system. n Provide a temporary increase in other charges funding so the principal can rent temporary hostel space in town until the new dormitory complex is completed. n Hire a warden to oversee the dormitories. vs. Dormitory Capacity 140 A new dormitory complex is half built, but has been stalled since July 2008 due to problems that arose with the Regional Tender Board halfway through construction. It will have spaces for 96 students spaces needed Recommendations: n Renovate the existing dormitory block to ensure a healthy environment and upgrade the sanitation system. n Complete the new dormitory block that has been stalled since July / /11 68 Target Current capacity is 40 1st year students 2nd year students 49

56 Faculty Classroom Capacity There are three full-time nurse tutors and an additional seven part-time tutors from the district hospital. The principal has been at the institution for 20 years. At the time of the visit, this nursing school had a better-than-recommended student-to-teacher ratio of 16 to 1. Yet, the principal and students reported that to cover the intense curriculum, tutors worked evenings, weekends, and holidays. Recommendations: n Hire two to three additional full-time tutors for target enrollment. n Hire a computer tutor, should computer facilities become available. Student to Tutor Ratio Student to Tutor Ratio 09/10 45 Student to Tutor Ratio at Target 2-3 additional tutors needed Recommended NACTE student to tutor ratio is 25:1 There is only one classroom; it is intended for 36 students but currently holds 48. In 2010, there will be 69 incoming students. The institution has development plans that include two new large classrooms to accommodate 100 students each. Those plans have been approved by the MOHSW but are stalled at the Regional Tender Board. The institution has both a library and a skills lab that are well-kept. However, there is no library attendant and therefore students can rarely use the facility. The skills lab is in need of additional equipment, models, and charts, though the ones contained within were well maintained. There is no computer lab or computers available to students. Recommendations: n Build the two large classrooms, as planned. n Rededicate the existing classroom as a computer lab. n Provide more library and skills lab resources. vs. Classroom Space large classrooms needed Average capacity is /10 10/11 Target 1st year students 2nd year students Expected Outcomes & Additional Recommendations n This site can rapidly increase its enrollment once the infrastructure both the buildings in progress as well as those planned/approved but not yet broken ground on is realized. Additional tutors will be very important to maintain the standards at this institution. n Build additional storage space in the new dining hall/kitchen. n Renovate the existing two tutor houses, expanding them to accommodate families. n Build two new tutor houses. 50

57 KOROGWE NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and offers a certificate in enrolled nursing. n It is located in the Tanga Region of the Northern Zone, five or six hours hours from Dar es Salaam, on paved roads. n In 2008, when Korogwe Nursing School moved from training one to two cohorts at a time, the institution went from training 44 to 83 students, almost a 100% increase. n There is a surplus of dormitory space, but the nursing school is still limited by the size of its single classroom. n Students appear to be very content with their living conditions; this could partly be due to the fact that the nursing school has not been strained by overcrowding. n Korogwe Nursing School is expanding its facilities (it has recently renovated, expanded dormitory space, and plans for more construction) so that it can increase enrollment by another 27% to accommodate a target enrollment of 114 total students. Dormitory Capacity Korogwe Nursing School was built in 1976 with dormitory capacity for 36 students. In 2007, a new, expansive dormitory was built to house 76 female students. About 72% of Korogwe s dormitory space has been filled, and there are 32 open spaces that could be available for students. However, 11 rooms lack furnishings and enough male students would have to be allocated by the MOHSW to fill empty spaces in the males dormitory. Though water can be scarce in the dry season, Korogwe s sewage and power systems are relatively strong because they have not been strained by overcrowding. If dormitory space was filled to capacity, more toilets and showers would be needed, as well as a laundry area for male students. Recommendations: n Coordinate with the MOHSW to allocate the correct number of male students to fill the males dormitory. n Purchase furniture for dormitory rooms. n Construct additional showers and toilet facilities once dormitories are filled to capacity to avoid overcrowding and straining systems. n Construct a laundry area for male students. vs. Dormitory Capacity /10 1st year students / Target 2nd year students Current capacity is 114 and 83 spaces are currently used 51

58 Faculty Classroom Capacity There are six full-time tutors, though three are away on study leave. The nursing school relies on an additional nine part-time tutors, including a part-time IT instructor. Two or three additional nurse tutors are needed to meet NACTE s recommended ratio of 25 students per tutor. Recommendations: n Hire two to three additional full-time tutors for target enrollment, as well as two clinical instructors to supervise students during clinical rotations. Student to Tutor Ratio additional tutors needed There is only one classroom here; it is intended for 36 students but currently holds over 50. The institution has broken ground on a new administration block that includes two large classrooms to accommodate 50 students each, as well as a skills lab. There is a small computer lab with four student computers, but no skills lab, and no library. Recommendations: n Build the two large classrooms, as planned. n Plan classes to hold 57 students each but separate the classroom by a partition; in this way, the classroom can hold the target enrollment and act as an assembly hall when the partition is removed. n Use the existing classroom as a library; hire a library attendant. n Provide more library and skills lab resources Recommended NACTE student to tutor ratio is 25:1 vs. Classroom Space Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target large classrooms needed (under construction) Average capacity is /10 10/11 Target 1st year students 2nd year students Expected Outcomes & Additional Recommendations n This site can rapidly meet its target enrollment once the infrastructure especially classroom space is finished. n Expand the dining hall to hold 114 students (in progress). n Build additional tutor houses so that the warden can live on campus. 52

59 MBOZI NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and offers a certificate in enrolled nursing. n It is located in the Mbeya Region of the southwestern highlands zone, about one and a half hours from Mbeya toward the Zambian border. n Mbozi Nursing School is in a rural area, near Moravian Hospital (which is increasingly less able to assist with clinical rotation) and about 20km from the Vwawa District Hospital (which is able to assist with clinical rotation but transportation is a challenge). n There was a total enrollment of 191 students during 2009 with three cohorts of students 56, 58, and 77. n The institution is operating far beyond capacity in terms of dormitory, dining, and classroom space, creating unhealthy conditions for students and staff. n There are severe problems with water supply, electricity, and sewage systems. This is compounded by a large unpaid debt to the electric company. n Mbozi has ample property to expand their infrastructure. n The target enrollment is 120, a decrease from current numbers. Dormitory Capacity Mbozi Nursing School was built in the 1980s as a Rural Medical Aid school for less than 100 students. There are currently 59 rooms, intended for 118 students but now hold 191. These rooms, intended for two students, now hold between three and five, often in only two or three beds. These relatively small rooms are severely overcrowded and have no storage space. In the few rooms that do have study tables, belongings are piled on top of them, rendering the study space useless. On average, 15 students queue up to use the toilets and none of the showers in any of the blocks work. The severe water shortage means that students have access to water only two hours each day. And, there is an outstanding debt to the electric company. Recommendations: n Immediately furnish the rooms with more doubledecker beds. n Scale back enrollment to 120 students total (60 in each class) while undertaking a complete overhaul of all existing structures. n Construct additional dormitories to allow for future scale-up. vs. Dormitory Capacity / /11 Target Cohort 1 Cohort 2 Cohort 3 There were 3 intakes of students in 21 between 1/08-9/ If increased enrollment continues, nearly 80 new spaces are needed Current capacity is

60 Faculty In 2009, there were five full-time tutors. In early 2010, one of the tutors was temporarily out sick and expected to return within months. The principal is new on the job as of February Recommendations: n If enrollment is scaled back to 120, down from 191, then no new tutors are needed. n If enrollment remains near 200, then 3 add more tutors. Student to Tutor Ratio Classroom Capacity There are three classrooms, each built for 30, 30, and 40 students, respectively. Only one classroom is used as a classroom and the others are used as storage. The dilapidated dining hall is used as a second classroom. There is no library, no skills lab, or computer room. Recommendations: n Construct two large classrooms with removable partitions to provide space for large cohorts and to enable groups to be split into smaller sections. n Existing classroom space should be rededicated and renovated to provide a computer lab, library, and a skills lab Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target If enrollment decreases to 120, no new tutors are needed Recommended NACTE student to tutor ratio is 25:1 vs. Classroom Space /10 10/11 Target 2 large classrooms recommended* Average classroom capacity is 33 Cohort 1 Cohort 2 Cohort 3 *Given the special circumstances at Mbozi Nursing School, even if enrollment decreased to dormitory capacity of 120, two new large classrooms are still needed to accommodate large cohort sizes and to free the existing small classrooms to become a library, a computer room, and a skills lab. Total enrollment might be decreased to 120, but with two cohorts of 60 each, rather than three cohorts of 40; larger lecture halls will allow flexibility in class sizes. Expected Outcomes & Additional Recommendations n Provide support for the new principal to resolve outstanding financial issues and develop transparent financial records with the new accountant. Make further auditing and tracing of missing student tuition a high priority to maintain financial solvency, morale, and the institution s reputation. n If enrollment decreases while infrastructure throughout the institution is constructed, then Mbozi Nursing School can strengthen its program and anticipate future scale-up numbers. n Expand tutor housing. n Provide transportation to the district hospital to enable clinical practice. n Seek solutions to the water supply system problems and the outstanding electricity bills immediately. n Renovate all buildings; consider leveling the dining hall/kitchen and replacing it with a new large multipurpose building. n Install covered corridors throughout the campus. n Supply additional textbooks for a library and equipment for a skills lab. 54

61 MBULU NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and offers a certificate in enrolled nursing. n It is located in the Manyara Region of the Northern Zone, about five hours from Arusha. n Since initiating the two-year program, there has been a single cohort intake each year (55 and 50), for a total of 107 students. No new students are expected until September n The school has sufficient office space. n New infrastructure has recently been added and more is planned/budgeted but is delayed. n Water and electricity in the area are generally reliable. n The district hospital needs more clinical instructors to support students clinical rotations. n The target enrollment of 120 can be reached when infrastructure expansion is finished and when four tutors have been hired. Dormitory Capacity vs. Dormitory Capacity Mbulu Nursing School was built in the 1970s, with dormitory capacity for 36. Recently, two new buildings have been constructed and now they have capacity for 120. The new dormitories hold two students per room, in self-contained units. Recommendations: n Renovate the oldest dormitory block to ensure a healthy environment and upgrade the sanitation system Current capacity is 120 and 107 spaces are currently used 0 09/10 Target 1st year students 2nd year students 55

62 Faculty There is only one full-time nurse tutor the principal. One tutor recently retired and is seeking a new contract with the MOHSW; two other tutors are away on long-term study leave. One new nursing officer will begin employment at the school but she does not have any training in teaching methodologies. The school relies on four part-time tutors from the district hospital. Recommendations: n Hire three tutors for the current enrollment of 107. n Plan and hire one additional tutor for scale-up to 120. Student to Tutor Ratio Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target 4 additional tutors needed; 3 needed immediately Recommended NACTE student to tutor ratio is 25:1 Classroom Capacity Originally, there was only one small classroom, but now there are two. Only this second classroom with space for 60 students is used for instruction. The original classroom, which has capacity for 36, cannot hold a cohort; instead, it is used as a temporary computer lab but it is without permanent equipment. There is no library or skills lab. The old dining hall is temporarily being used as a skills lab space. There are plans and funding in place (as of two years ago) for one additional, large classroom; a library; and a skills lab. The Regional Administrative Secretary (RAS) is in charge of the construction and has not yet put out the announcement for tender. The principal is not sure when the construction will be able to move forward. Recommendations: n Move forward on building the classroom, library, and skills lab. n Procure more copies of reference textbooks (titles are largely sufficient for the program). n Procure equipment for the skills lab. vs. Classroom Space classroom needed Average capacity is /10 1st year students Target 2nd year students Expected Outcomes & Additional Recommendations n If infrastructure expansion happens and tutors are secured, then enrollment could reach 120. n Build 2 more staff housing units. n The institution also has budgeted and approved plans for a new dining hall; that should also be pushed forward with the RAS. 56

63 MKOMAINDO NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and offers a certificate in enrolled nursing. n It is located in the town of Masasi in the Mtwara Region of the Southern Zone, about two and a half hours by road from Mtwara. n The institution has had 3 cohort intakes (58, 57, and 72, respectively) and a total enrollment of 187 since initiating the twoyear program. With an incoming class of 71 in 2010, the school will experience a 66% increase in overall enrollment since the two-year program began. n The principal runs a well-organized program and shows her dedication to students by giving up her housing to provide more living space to the students. n The school is in great need of infrastructure development in terms of dormitory space, classroom space, and dining/ kitchen facilities. n The target enrollment is three classes of 93 each (each cohort broken into two groups for instruction) for a total enrollment of 280. Dormitory Capacity vs. Dormitory Capacity Mkomaindo Nursing School was built in 1967, with dormitory capacity for 130 students; no expansion has ever occurred. Between 2008 and 2010, this school experienced severe overcrowding. There are 187 students but only 130 spaces available. The institution has maximized all its space; even the principal s and tutors housing has been rededicated as student living space. Rooms intended to hold five beds now hold 12, using double-deckers. Rooms meant for two to three students now hold five to six. Recommendations: n Renovate the existing dormitory blocks to ensure a healthy environment and upgrade the sanitation system. n Build more toilets and washroom facilities. n Build an additional dormitory block with 57 student spaces to meet current enrollment numbers. n Build another dormitory block with 93 more spaces to meet the scale-up target of 280 students / /11 Target Cohort 1 Cohort 2 Cohort spaces needed now, 150 needed in total Current capacity is

64 Faculty Classroom Capacity There are four full-time nurse tutors and nine additional part-time tutors from the district hospital. There is a shortage of full-time tutors. To meet current enrollment numbers, four tutors are needed now. To meet the target of 280 students, seven more tutors are needed. Recommendations: n Hire four new full-time tutors immediately. n Plan and hire three additional tutors for the scale-up. n Hire a tutor dedicated to supervising students clinical rotations in the hospital. Student to Tutor Ratio additional tutors needed to reach target; 3-4 needed immediately Recommended NACTE student to tutor ratio is 25:1 There were orginally only two small classrooms at this institution, but a wall was torn down to create a larger space out of one of those classrooms and now it can accommodate 70. The other classroom only accommodates 40. Because of the large cohort sizes and three cohort intakes, three large classrooms are necessary both in the short term and to reach the scale-up target of 280. There is a small library that is basically used for storage because there is no librarian and because it can hold few students. There is no skills lab. Equipment is stored around campus. There is no computer lab. Recommendations: n Build three large classrooms with removable partitions to divide cohorts into manageable groups for instruction. n Return the skills lab to its original purpose and provide equipment. n Build a larger library and rededicate the existing library as a second skills lab; provide more texts. n Rededicate existing classroom space as a computer lab and equip it. 0 Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target vs. Classroom Space large classrooms needed Average capacity is /10 10/11 Target Cohort 1 Cohort 2 Cohort 3 Expected Outcomes & Additional Recommendations n If infrastructure expansion occurs, coupled with additional tutor hires, then enrollment could potentially reach 280. n Address the school s water shortage and overflowing sanitation systems. n Return housing to the principal and tutors and build additonal staff housing. n The dining hall/kitchen is inadequate. Build a new multipurpose dining hall/kitchen. n Build an administration block because currrently the school does not have one. 58

65 NJOMBE NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and offers a certificate in enrolled nursing. n The institution sits adjacent to Njombe District Hospital in the Iringa Region of the Southern Highlands Zone, about 12 hours by road from Dar es Salaam. n In 2009, there were three cohorts and a total of 218 students enrolled. n In 2010, Njombe Nursing School expected a new class of 60 students, increasing its overall enrollment to 229 students. n since beginning the new twoyear curriculum has roughly increased by 125% overall, compared to when there was a three-year program. n Njombe Nursing School has a large administration building with space that can be reallocated or renovated to meet future growth. n Target enrollment is 300 students three cohorts broken into smaller groups for instruction. Dormitory Capacity vs. Dormitory Capacity Njombe Nursing School contains four dormitory blocks with a fifth block under construction. The four blocks have spaces for 144 students but currently hold 211 of the 217 total students (the other six are housed in a converted office space). The dormitories lack space for 34% of the student body. At times, six students share three beds in a single room intended for two people. When the new dormitory block is finished in 2010, there will be 80 new spaces, providing for a total student capacity of 224. Capacity will basically meet current enrollment numbers. To further scale-up enrollment from 218 to 300 students (roughly a 50% increase beyond the 125% increase since starting the two-year program) requires a fair amount of infrastructure. Recommendations: n Build 75 additional dormitory spaces. n Add cupboards and tables in existing dormitory rooms. n Upgrade the sewage and water systems to provide for current student needs, as well as increased enrollment numbers / / Target Cohort 1 Cohort 2 Cohort spaces needed: 80 new spaces will come in 2010 with the new dormitory; 76 additional spaces will be needed Current capacity is for up to 144, but is ideally at

66 Faculty There is only one full-time nurse tutor present and working though there are actually three employed. The other two are away on study leave for the long term. There is also a retired volunteer warden/tutor who provides instruction. To support current enrollment, eight full-time tutors are needed immediately; to accommodate the target of 300 students, a total of 11 tutors are needed. Recommendations: n Immediately hire eight additional tutors (one of whom could be an IT specialist.) n Hire an additional three tutors when target enrollment numbers are achieved. Student to Tutor Ratio Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target 11 additional tutors needed 8 tutors urgently needed immediately Recommended NACTE student to tutor ratio is 25:1 Classroom Capacity Though there are three classrooms at Njombe Nursing School, class cohort sizes exceed their average capacity of 50. Only two of the classrooms are currently used for instruction. There is a room available for computer instruction, but there are no computers to furnish it. There is no library, only a storage room for books. Njombe Nursing School has a skills lab meant for 40 students but large cohort sizes make it difficult provide instruction effectively. Recommendations: n Build at least two large classrooms with removeable partitions where a cohort of 100 can be broken into to groups for separate instruction. n Rededicate one of the existing small classrooms or renovate the old dining hall to serve as a library. n Provide additional textbooks and skills equipment, models, and charts, and computers. vs. Classroom Space /10 10/11 Target 3 standard sized or 2 large classrooms needed Average capacity is 50 Cohort 1 Cohort 2 Cohort 3 Expected Outcomes & Additional Recommendations n With 11 additional tutors and additional infrastructure, the institution could support 300 students (a further scale-up of 38%, after already scaling up by 125% since beginning the two-year curriculum.) n Build a large multipurpose room that can serve as a third lecture hall. n Build at least two more side-by-side tutor houses, large enough for families. 60

67 SAME NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and offers a certificate in enrolled nursing. n Same Nursing School is located in the Kilimanjaro Region of the Northern Zone, about one and a half hours by road from Moshi or seven hours from Dar es Salaam. n Since initiating the two-year program, there has been a single intake of 34 students who were taking their exams in March A new class of 50 were expected, representing a 47% enrollment increase. n The principal has been in her position for three years. n The school has the budget and plans for a new dormitory and classroom but, in three years, little progress has been achieved. n There is a new large administration building on campus with ample space. n Water and electricity in the area are generally reliable. n Same Nursing School s target enrollment is 100, with two cohorts of 50 students each a nearly 200% increase since beginning the new two-year program. Dormitory Capacity Same Nursing School was built in 1977 with dormitory capacity for 36. That original dormitory block is very well maintained, but inadequate for an incoming cohort of 50 students. The principal will be forced to remove the rooms tables and chairs to put a third bed in the rooms. There are only three toilets and washrooms in this dormitory building. There is a storeroom off of the kitchen that will also be used for students, though it is a last resort. The institution has architectural plans for a multistory dormitory. The funding for the first story of the building (22 rooms) was allocated from the MOHSW, but there has been very little progress on it in three years. The current status is that the Tanzania Building Agency has refused to sign off on the plans. Recommendations: n Immediately move forward on the new dormitory, both the first and second floors. The first floor will provide 44 spaces. Still, 20 more spaces are needed. n Renovate the existing dormitory blocks to ensure a healthy environment and upgrade the sanitation system. vs. Dormitory Capacity /10 1st year students /11 50 Target 2nd year students 64 spaces needed Current capacity is 36 61

68 Faculty There are currently three full-time tutors. Two are nurse tutors and the third is an RN with training in teaching methodologies. The school is not very reliant upon part-time tutors. Though student-to-tutor ratios are better than NACTE standards, the principal said that two to three more tutors are needed for increased enrollment to maintain instruction quality, given the intensity of the twoyear program. Recommendation: n Hire one additional tutor for the enrollment target of 100. Student to Tutor Ratio additional tutors needed Recommended NACTE student to tutor ratio is 25:1 Classroom Capacity There is only one small classroom, which is intended for 36 students but is crowded even at that capacity. The incoming class of 50 will not fit in this room. The institution has plans for a new classroom that would comfortably hold 50 students. The classroom has been approved by the MOHSW and the budget has been allocated, but the MOHSW has not authorized it yet (no signature). There is no skills lab, library, or computer lab. The school has six computers for students that are usually in storage. The school has plans to build a library that are awaiting sign off by the MOHSW. The people of Tilburg, Holland, have raised money for a skills lab. Recommendations: n Move forward on building the classroom and library. n Add another classroom to fit more than 50 students. n Procure the district council s sign off on the Tilburgsponsored skills lab. n Rededicate the small classroom as a computer lab and fully equip it. n Increase textbooks for the library and equipment for the skills lab. 0 Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target vs. Classroom Space classrooms needed to hold at least 50 Current capacity is 36 in a single classroom 0 09/10 10/11 Target 1st year students 2nd year students Expected Outcomes & Additional Recommendations n If infrastructure expansion happens and tutors are secured, then enrollment could potentially reach 100. n Build a new dining hall/kitchen because the current one is already too small to serve students. n Build two new staff housing units. 62

69 TARIME NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and offers a certificate in enrolled nursing. n It is located in the Mara Region of the Lake Zone, about four hours by road from Mwanza City. n Two cohorts, a total of 124 students, are currently enrolled. n 45.8% of students are from Mara Region, a significant number compared to other institutions. n Though many buildings are under construction or have recently been added to this school, additional classrooms and facilities are needed. n There is a severe shortage of staff, but the principal reports more tutors are on track to join the institution. n Water and electricity are generally reliable. n The target enrollment is 240, breaking large cohorts into manageable size groups for instruction. Dormitory Capacity Currently, there are two dormitories with 84 spaces for 124 students. An additional 48 spaces were created out of a classroom and a tutor house. There are 160 new dormitory spaces expected to be completed in October The old dormitory was refurbished in 2003 but sanitation systems are currently broken. When the new dormitory is complete and spaces that are currently over capacity are adjusted to their original plans, the institution will be able to hold 240 students. Recommendations: n Connect the electricity to the new dormitory used by female students and shift other students to maximize space and decrease overcrowding. n Renovate the old dormitory to enhance sanitation, security, and ventilation. n Complete and furnish the new dormitory in a timely fashion, which will create 160 spaces. n Relocate male students from the tutor s house and the converted classroom, and return those rooms to their original purposes; return desks and cupboards to the oldest dormitory block once overcrowding ceases. vs. Dormitory Capacity /10 1st year students /11 2nd year students 156 spaces needed 160 spaces expected in October 2010 when the new dormitory is completed Current capacity is 84 63

70 Faculty There are two full-time nurse tutors and a registered nurse. There are two more tutors employed, but one is away on study leave and another is on an elongated sick leave. The institution expects to hire four more tutors with the permission from the MOHSW, and one is expected in April The school is also supported by 10 part-time tutors. Recommendations: n Hire two additional tutors to meet the current enrollment of 124 and seven more for the target enrollment of 240. n Hire clinical instructors to supervise students in the hospital setting. Student to Tutor Ratio Student to Tutor Ratio 09/10 80 Student to Tutor Ratio at Target 7 additonal tutors needed; 2 needed immediately Recommended NACTE student to tutor ratio is 25:1 Classroom Capacity There are two classrooms, but only one is able to hold the current 60 students. The other small classroom has been converted into a dormitory for male students. The new assembly hall is being used as a second classroom. For an enrollment target of 240, two large 120-student cohorts must be broken into groups of 60 for instruction. There is a small computer lab with five working computers. The computers no longer have Internet connectivity due to its high cost. There is no library. The institution does have a skills lab, but it has not yet been furnished. Demonstrations are done in classrooms where the materials are brought in and then returned to boxes. Recommendations: n Build three classrooms to enable the school to hold four cohorts of 60 students each. n Furnish the skills lab. Follow up with JHPIEGO on the status of its plans to support the institution. n Rededicate the small classroom (now a dormitory) as a library and equip it with resources. n Build a larger computer room, increase number of computers, and connect them to the Internet. vs. Classroom Space additional classrooms needed Current capacity is /10 1st year students Target 2nd year students Expected Outcomes & Additional Recommendations n Continue efforts to secure more land from the district executive office to be able to construct more buildings; follow up with existing infrastructure plans (dining/kitchen). n Hire additional support staff. A warden will be very important, given the enrollment size. 64

71 TUKUYU NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and offers a certificate in enrolled nursing. n It is based in the Mbeya Region of the Southwestern Highlands Zone and can be reached by road in about 12 hours from Dar es Salaam. n In 2009, Tukuyu Nursing School had two cohorts and a total of 102 students 55 second-year and 47 first-year students. n In 2010, Tukuyu Nursing School will have new infrastructure, including one large dining hall/kitchen/multipurpose building (to hold 120 students), a new dormitory block with 50 student spaces, and one new classroom to hold 50 students. n There is a severe shortage of staff housing at the institution. n Many buildings require renovation to their sewage and electrical systems. n The target enrollment is 120 students, two classes of 60 each. Dormitory Capacity vs. Dormitory Capacity Tukuyu Nursing School has exceeded its dormitory capacity, but a new dormitory block is currently being built that will meet students needs. The existing dormitory blocks have 38 rooms that are supposed to hold 76 students but are now accommodating 102 students. Of the total rooms, 20 hold the proper number of two students. Ten other rooms hold three students each and the last eight rooms hold four students each. The hostel rooms, because they are overcrowded, often lack adequate storage and study space. The oldest dormitory block, built in 1976, is in need of complete renovation to its electrical and plumbing systems. Toilets do not flush and showers do not work / / Target 44 spaces needed; 50 will be available in 2011 in the new dormitory Current capacity is 76 Recommendations: n Complete the dormitory block under construction. n Renovate the original dormitory block, overhauling the electrical, sewage, and plumbing systems. 1st year students 2nd year students 65

72 Faculty There are 3 full-time tutors who are present and working. There is a fourth tutor away in Dodoma, studying for her BSc degree. The institution relies on seven part-time tutors from the district hospital. Recommendations: n Hire two additional tutors to bring the total number of full-time tutors to at least five. n Hire a tutor for computer instruction, should a computer lab be equipped. n Hire a separate full-time tutor to supervise students in the hospital. Student to Tutor Ratio additional tutors needed; 1 needed immediately Recommended NACTE student to tutor ratio is 25:1 Classroom Capacity Only one room (originally the skills lab) is being used as a classroom. This room has space for 50. The original classroom, built for 36 students, can no longer be used as classroom space. A new classroom will be finished in 2010 that can hold 50 students, but another 60-student classroom is needed. The principal reported that the new multipurpose dining room will be used as a classroom due to an insufficient number of classrooms. Currently, there is no permanent skills lab space nor is there a computer room. There is a small library. Recommendations: n Continue to have only one intake per year. n Construct another classroom and return the skills lab to its original purpose. n Send the library attendant for training to create a library that better serves students needs. n Create and equip a computer lab in the original small classroom. n Purchase more library resources and skills lab equipment. vs. Classroom Space 5 0 Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target 60 2 classrooms needed 50 1 coming in 2010, but 1 more with capacity 40 for 60 needed 30 Currently capacity is /10 10/11 Target 1st year students 2nd year students Expected Outcomes & Additional Recommendations n Tukuyu Nursing School can achieve a target enrollment of 120 students if more tutors are hired and additional classroom space is built. n Open the new dining hall/kitchen/multipurpose room by completing its construction with two gas cookers. n Hire additional support staff (cooks) to support the increasing enrollment numbers. n Build additional tutor housing. n Renovate the old dining hall and kitchen to provide an administration block. 66

73 NEWLY REOPENED ENROLLED NURSING SCHOOLS KIBONDO SCHOOL OF NURSING Institution at a Glance n This nursing school is under the MOHSW and will be offering an enrolled nursing certificate; it reopened in March 2010 after over 10 years of closure. n The institution is located in the Western Zone, about three hours by unpaved road from Kigoma town. n The HIV prevalence in this region is 0.9%, far below the national average. n In 2010, there was one first-year cohort of 43 students. n Students are housed and trained off campus in buildings leased from the district council. n Electricity and piped water are highly unreliable in this area. n Renovations to existing structures began in 2010 and once completed will accommodate 24 students. n A second phase of construction to expand facilities should begin in to bring the target enrollment to 120 students. Dormitory Capacity Kibondo Nursing School is currently undergoing renovations. Once completed, the dormitory will have capacity for 24 students and the MOHSW has budgeted furnishings for 24. The current class of 43 students are housed and trained off campus in buildings leased from the district council. Once the renovations are completed ideally in 2010 the principal plans to accept a second class of students who would be housed in these renovated dormitories, while the existing class would continue to be housed in the leased buildings. Recommendations: n Complete the renovation of the dormitory block and fully furnish it. n Expedite the funding for the second phase of construction so that Kibondo Nursing School can enroll 120 students, as planned. 67

74 Faculty There are currently two full-time nurse tutors and six more part-time instructors. Recommendations: n Hire one additional full-time tutor if another intake occurs in n Hire two additional full-time tutors (five tutors, total) for the target capacity of 120 students. Classroom Capacity and Other Instructional Space Currently, students are being instructed in leased space. The single classroom on campus is currently undergoing full renovations and will have capacity for only 24 students. There are plans to construct an additional classroom by 2011 and another in 2012 so that each can hold 60 students. There are no other instructional spaces such as a library or skills lab available. However, a building is under construction for a skills lab and Nuffic will support its functionality. Recommendations: n Complete the renovation of the classroom and fully furnish it. n Expedite the funding for the second phase of construction so that construction can commence and be completed for the two additional classrooms. n Once new classrooms are built, repurpose the small original classroom as a library, computer lab, or administrative space. Expected Outcomes & Additional Recommendations n Provide additional funding for desks, chairs, beds, mattresses, teaching aids, and other essential materials for the existing 43 students, and then again for 120 students in total. n Ensure that building plans include a generator and water storage. Verify that all systems have a capacity for 120 students. Then, expedite the funding process. n Explore using the leased campus permanently as a way to provide off-campus housing to additional students. n Review the second-phase construction plans for inclusion of a library, tutor housing, and administrative space. 68

75 NACHINGWEA NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and will be offering an enrolled nursing certificate; it reopened in March 2010 after 12 years of closure. n The institution is located in the Lindi Region of the Southern Zone, about two hours by unpaved road from Lindi town. n The HIV prevalence in this region is 3.9% below the national average. n In 2010, there was one first-year cohort of 65 students. n Students are housed off campus in buildings leased from the district council but are taught in the one classroom on the nursing school campus. n Electricity and piped water are highly unreliable in this area. n Renovations to existing structures began in 2010 and once completed will accommodate 24 students. n A second phase of construction to expand the facilities should begin in to bring the target enrollment to 120 students. Dormitory Capacity Nachingwea Nursing School is currently undergoing renovations. Once completed, the dormitory will have capacity for 24 students. The two toilets, even after renovation, will be unusable due to lack of water in the region. There are three pit latrines, but only one is currently usable. The current class of 65 students are housed off campus in buildings leased from the district council. Phase II construction plans call for an expansion of facilities to accommodate 120 students. Recommendations: n Complete the renovation of the dormitory block and fully furnish it. n Expedite the funding for the second phase of construction so that Nachingwea can enroll 120 students, as planned. 69

76 Faculty There are currently two full-time nurse tutors and eight part-time instructors. Recommendations: n Hire one additional tutor for current enrollment numbers. n Hire two additional full-time tutors (five tutors, total) for the target capacity of 120 students. Classroom Capacity and Other Instructional Space There is one classroom intended for 24 students at the facility. With one class of 65 students, the principal is struggling to find instructional space. There are plans to construct an additional classroom in the second phase of construction, after renovations are completed. Recommendations: n Review the plans for the phase II of construction and ensure there is enough classroom space for 120 students; consider adding an additional classroom and include furnishings. Expedite the funding for that second phase. n Once new classrooms are built, repurpose the small original classroom as a library, computer lab, or administrative space. Expected Outcomes & Additional Recommendations n Provide additional funding for desks, chairs, beds, mattresses, teaching aids, and other essential materials for the existing 65 students, and then again for 120 students in total. n Review all planned construction to ensure that all buildings and ensuing systems are able to accommodate 120 students. n Provide a generator and cisterns for water storage or a borehole. n Explore using the leased campus permanently as a way to provide off-campus housing to additional students. n Review the second-phase construction plans for inclusion of a library, skills lab, tutor housing, and administrative space. 70

77 NZEGA NURSING SCHOOL Institution at a Glance n This nursing school is under the MOHSW and will be offering an enrolled nursing certificate; it reopened in March 2010 after 13 years of closure. n Renovations to all structures were completed but lack of furnishings hindered the school s opening. n The institution opened through PEPFAR support, which provided furnishings and equipment throughout the facility; a class of 24 entered in March n Nzega Nursing School is located in the Tabora Region of the Western Zone, about three hours by paved road south of Mwanza town. n The HIV prevalence in this region is 6.2%, similar to the national average. n A second phase of construction to expand the facilities should begin in to bring the target enrollment to 200 students. Dormitory Capacity Nzega Nursing School s newly renovated dormitory block has capacity for 24 students. As designed, each room holds two students and contains new mattresses, double-decker bed frames, one desk, two wardrobes, and a chair. Recommendations: n Expedite the funding for the second phase of construction so that Nzega Nursing School can enroll 200 students, as planned. n Ensure that external student toilets and showers have piped water for use, since facilities within the hostel block are insufficient for 24 students. Currently, there are only three toilets, four pit latrines, and three washrooms. These toilets must be connected to piped water before they can be used. There are already blueprints for constructing a new, three-story dormitory complex that will house an additional 176 students. This should be completed in

78 Faculty There are currently two full-time nurse tutors. Recommendations: n Eight total full-time tutors are needed for target capacity of 200 students. Classroom Capacity and Other Instructional Space There is one classroom intended for 24 students at the facility. There are plans to construct a three-story classroom facility in 2010 to accommodate a total of 200 students. As of March 2010, the external walls had been raised, and the structure will be completed in the same year. Recommendations: n Ensure the completion of the three-story classroom facility. n Once new classrooms are built, repurpose the small original classroom as a library, computer lab, or administrative space. Expected Outcomes & Additional Recommendations n Water storage tanks (which accommodate 200 students) should be installed in existing and new structures. n Ensure that building plans include a generator and water storage, as well as furnishings for 200 students, and verify that all systems have capacity for 120 students. n Resolve challenges to the delays in salary for Nzega Nursing School s founding principal, so she can rejoin the institution as a tutor. n Maintain the steady pace of funding for the second phase of construction, so that Nzega Nursing School can enroll 200 students, as planned. n Review plans for phase II of construction to verify that they include a library, administrative space, and tutor housing. n Explore the possibility of adding another cadre to the institution (CA, lab, or another nursing program). 72

79 RECOMMENDATIONS AND CONCLUSIONS School-specific recommendations that were described in the individual nursing school reports are aggregated and summarized in a table in Appendix 1. Although the recommended investments are substantial, it is important to look forward and plan appropriately for the growth that will be needed over the next three to five years instead of just addressing immediate needs. These findings and recommendations can also help to guide the interventions proposed and funded through Tanzania s GFATM Round 9 proposal. By implementing the recommendations in the school-specific findings, a 41% increase in enrollment could be accomplished across the open nursing schools. Completing the renovation, rehabilitation, and expansion of Kibondo, Nachingwea, and Nzega (enabling them to reach their respective targets of 120, 120, and 200) would increase this overall scale-up to 2,616 total students, representing a 69% increase from enrollment numbers. This is presented in Figure 3, below. Figure 3: Current vs. Target with Scale-up for Nursing Schools /2010 Target with Scale up 2009/ Target % increase In addition to the institution-specific recommendations, there are also some policy-level recommendations for the MOHSW and its development partners that would help to improve the ability of individual Nursing Schools to scale up their enrollment. 73

80 Recommendations for Supporting Current Numbers and Further Scale-up Prioritize and focus efforts on a select number of institutions with the greatest potential. Instead of mandating that all institutions scale up 100%, greater gains may be realized by selectively investing more heavily in those schools with the greatest potential for increased enrollment. Because many of these schools are currently in the process of expanding their infrastructure (where construction is already budgeted for and in process), it is important to complete those projects. At those schools, scale-up efforts are already underway and the potential for increased enrollment is being implemented. New investment from the GFATM Round 9 or other donors might better be directed at nursing schools without significant infrastructure enhancement plans already in place and where: 1) overcrowding already exists; 2) infrastructure expansion would serve the dual purpose of supporting the existing capacity while dramatically expanding capacity for greater enrollment; 3) land is available for building; 4) the leadership is interested in supporting expansion; and 5) the location of the institution supports the MOHSW s overall efforts to increase service in traditionally underserved areas. Focusing on one institution in each zone with the greatest potential for scale-up may yield better results and better quality than pushing each organization to scale up equivalently. In addition to the criteria mentioned above, there are other considerations that could be used for prioritizing, including: Cost/benefit: Determine by calculating the cost and resources required to increase enrollment compared to the number of new students that can be added as a result of those resources. Time required for implementation: Since there is already a two- to three-year window after enrollment before a health worker is placed in the community, prioritize interventions that can be completed quickly. Leadership and management capacity: Ensure strong leadership and management, which are crucial to an institution s long-term ability to scale up and manage higher enrollment numbers. Systems capacity and building capacity: Ensure that existing building infrastructure systems (water, sanitation, electricity) are strong and that there is space to build. Level of need in region: Focus limited resources first on regions with a high need for health care workers, large rural populations, and high HIV prevalence. Complete the infrastructure already in process and initiate infrastructure already budgeted and planned for at several others. The MOHSW is currently supporting infrastructure expansion at many of the nursing schools that were visited. A lot of the projects are nearly complete, while others have been stalled halfway through construction. Still others have been planned and funding has been allocated, but tendering has not taken place. Therefore, any project either in process or planned for should be completed and all development should be coordinated with the necessary parties (e.g., regional tender boards, district authorities) to ensure the smooth and timely completion of structures. For many schools, initiating and completing their planned for construction will allow them to better achieve their target enrollment. 74

81 Support new infrastructure development at the remaining schools where enrollment has increased but for which additional infrastructure has not yet been budgeted. As described above, the United States government, GFTAM, CIDA, and other donors should consider prioritizing support to the other nursing schools that have not expanded their infrastructure in proportion to their increased enrollment numbers (e.g., Mbozi, Mkomaindo, and Kiomboi). These schools are severely overcrowded and are at an important juncture where a major investment could result not only in supporting their current numbers, but could significantly increase their capacities. Mbozi and Mkomaindo are two nursing schools located in traditionally underserved areas of the country. Increase faculty, support staff, and teaching materials to appropriately address current enrollment numbers as well as scale-up numbers The quality of the education provided and therefore the quality of the health care workers produced will decrease if infrastructure development is not coupled with an increase in tutors and support staff. Creating cohorts above 60 students without increasing the number of teaching faculty is not recommended and will in fact be detrimental to the quality of instruction. More tutors are necessary to meet the needs of increased class sizes. Additionally, more support staff such as accountants, wardens, guards, cooks, and librarians are required to help support students learning and institutions functioning. Moreover, with proper support staff, tutors are are not distracted by managerial duties and are able to concentrate on teaching. Lastly, when nursing schools enhance their overarching infrastructure, other teaching materials must be provided as well, including library books, lab equipment, desks, projectors, and so forth. Plan appropriate infrastructure improvements to provide for all the educational and living needs of the student body. When planning for infrastructure improvements on a campus, dining/kitchen, sanitary systems, skills labs, and libraries not just classrooms and dormitories should be considered to provide for all the educational and living needs of the student body. Historically, many schools have experienced infrastructure expansion in an uneven way on their campuses. Main buildings, such as dormitories and classrooms, are prioritized above toilets and libraries, but it is important to consider, holistically, all the elements that provide for students education. Many schools do not have skills labs or adequate libraries. At others, dining halls have lost their utility because enrollment numbers far exceed the physical space. Other schools have increased students per dormitory room, which leads to unhealthy, unsanitary, and unsafe conditions; rooms are overcrowded and poorly ventilated and septic systems are taxed and broken from overuse. For scale-up efforts to be successful, all infrastructure should be built up, not just one area of campus. This should be considered in light of nursing schools that are reopening. When reopening institutions, couple expansion with renovation from the start so that increased enrollment can occur immediately. The strategy for new schools, such as Nachingwea, Nzega, and Kibondo, has been to first secure funds for renovating existing buildings, which have enrollment capacities of about 25 students each. Securing and receiving these funds can take years. Once renovation is complete, the institution must again wait to receive expansion funds through a separate tender process, delaying the enrollment 75

82 of additional students. Therefore, the MOHSW and partners should endeavor to both renovate and expand concurrently so the schools can open and support larger enrollments. Address barriers to prompt and complete disbursement of funds to MOHSW institutions. Many principals identified the limited amount of funds received from the MOHSW as well as the slow disbursement of those funds as critical barriers to implementing improvements. Institutions often do not receive the fully budgeted amount of funds from the MOHSW, forcing them to make difficult choices about how to adjust their costs to cope with the lower budgets and to put expansion plans on hold. Many principals have requested funds for infrastructure projects to increase their enrollment capacity, but the funds even when committed are often delayed, if they arrive at all. If these funds do not arrive before the fiscal year ends, the money is reallocated and lost to that institution. Many of the schools have plans for how to increase enrollment, but these plans are delayed year after year as a result of the inconsistent and limited funds received. Assess the efficacy of content and adequate staffing patterns to support a compressed curriculum. Most principals expressed concerns about the two-year curriculum and are seeking more guidance on how to effectively provide the necessary competencies to their students. The content of the new curriculum should be assessed and appropriate student-to-nurse tutor ratios and student-to-clinical instructor ratios specific to this curriculum should be implemented. Nurse tutors, as generalists, are the core of the in-class instructional needs. Clinical instructors are needed in skills labs and in the hospital setting. Recommendations for Recruitment and Address barriers to the timely verification of qualifying certificates and develop a process to verify certificates prior to enrollment. The greatest barrier to student retention is lack of qualifying certificates. Students are admitted to a school before their qualifications are fully verified. The process to validate certificates is so long that many times, students complete half of the two-year program before being dropped. The MOHSW should investigate ways to validate applicants full qualifications prior to admission. This will significantly reduce attrition. 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. Some principals expressed a desire to limit the number of local students, believing this helps minimize interruptions to the students instruction. Principals also believe that a geographically diverse student body enhances the learning environment. However, research suggests that the best way to increase rural health care worker retention is to train them in their home region. The MOHSW should sensitize principals to the body of research that suggests that educating students locally can benefit their nation as a whole. Once principals are aware of this, the MOHSW could extend the existing program, whereby principals send forward local candidates for second selection. The MOHSW should consider allowing principals to send forward local applicants for the first selection process. Qualified local students could be chosen by a committee rather than by the principal to decrease the possibil- 76

83 ity for individual influence. The central selection process is still necessary to ensure that all students across the country get an equal chance at admission to a nursing school. Overall, principals and students both expressed a belief that a central application is most impartial. However, a hybrid approach could help bolster local enrollment, which might increase the number of graduates willing to stay and work in rural communities. Improve the enrollment data-tracking system at the nursing schools and enhance communication of those data between schools and the MOHSW so to address infrastructure and human resource needs. The lack of a centralized enrollment data-tracking system at nursing schools and the lack of communication of those data to the MOHSW make it difficult to accurately determine the number of students enrolled in nursing schools at any point in time. This is especially important during the selection process, when decisions are being made about how many students to enroll in institutions during first and second selection periods. Tracking male and female data is also crucial to maximizing space at schools. Faculty Development Recommendations Identify principal successors early so that they can be oriented properly and provided leadership training. Most principals do not know who their successors will be prior to retirement, leaving institutions with leadership voids and important missed opportunities for providing mentoring and leadership training to in-coming principals. With significant tutor shortages, the retirement of a principal may leave a significant leadership gap. The assessment team is aware that the following nursing schools expect a changeover in leadership within the next few years: Geita, whose principal will retire in January 2011; Kiomboi, whose principal is nearing retirement but the exact date is unknown; Kondoa, whose principal has been in her position for 20 years and is also nearing retirement; and Tukuyu, whose principal expects to retire in Develop a regular recruitment process for new tutors and increase the capacity of tutor-training institutions. Several full-time tutors are nearing retirement age. Principals repeatedly reported difficulty in finding qualified nurse tutors. They often described hiring nurse tutors as a zero sum game: one institution gains a nurse tutor, but another one loses a tutor. Increasing the capacity of tutor-training institutions can result in producing greater numbers of qualified tutors in the system. Principals also reported that the MOHSW s new effort to recruit RNs as full-time clinical instructors is very challenging. First, they described that many RNs are not attracted to the teaching profession because of the long hours and little remuneration. Also, they said that when an RN is recruited, he/she does not have any training in teaching methodologies. And, they also emphasized that the greater institutional need is for qualified nurse tutors who are generalists and can teach a range of subjects. An ongoing strategy for recruiting medical professionals into the teaching profession and retaining them as tutors is needed to address the growing shortage of full-time tutors at nursing schools. The focus should be on full-time nurse tutors with a minimal level of training in teaching methods. 77

84 Though full-time tutors are preferred for the above-mentioned reasons, nonetheless, part-time tutors remain a crucial component of the educational system. Part-time tutors should be provided with training in teaching methodologies to strengthen their teaching skills and thereby increase the quality of education. Implement programs to train more tutors at the worksite rather than removing them for skills upgrading for long periods of time. A very large proportion (25%) of full-time tutors were away upgrading their skills during the assessment period. Those tutors were not replaced temporarily or permanently by other full-time tutors, significantly contributing to tutor shortages. The MOHSW should consider innovative teacher-training programs that retain full-time tutors at the worksite while providing education or mentoring that allows them to upgrade their skills. 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 the enrollment of students at health training institutions. Although the current nursing schools have scaled-up enrollment to help achieve this scale-up goal, these schools have reached a critical point where significant investments in infrastructure and human resources are needed to ensure quality education and to produce high-quality health care workers who can meet the needs of Tanzania s rural communities. With an estimated gap of 17,000 ENs predicted by 2017, increasing enrollment cannot be the only strategy for addressing health care workforce shortages. The MOHSW also cannot bridge these gaps without both concentrated and coordinated efforts from the schools, development partners, and other public-and privatesector stakeholders. With the new resources from GFATM Round 9, the MOHSW is well positioned to make a significant impact on the health care workforce shortage by scaling up enrollment at nursing schools. The recommendations from this report can help to guide these coordinated efforts. Although the targets outlined in the findings and recommendations of this assessment are bold and the resources needed to reach those targets are substantial, an investment now in school infrastructure will provide benefits for years to come. Investment in the infrastructure of these institutions, coupled with investments in building up the human resources needed to train students effectively, has the potential for the greatest return on investment of any human resource scale-up intervention. 78

85 REFERENCES Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: A review of the literature. Academic Medicine. 2002;77: Burfield WB, Hough DE, Marder WD. Location of medical education and choice of location of practice. Journal of Medical Education. 1986;61: Christian Social Services Commission. Proposal for support to health training institutes for an increased intake of pre-service students. Dar es Salaam: Christian Social Service Commission; de Vries E, Reid S. Do South African medical students of rural origin return to rural practice? South African Medical Journal. 2003; 93, (10): Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Human Resources for Health. 2006; 4: 12. International Training and Education Center on Health (I-TECH). Pre-service site visit report. Dar es Salaam: University of Washington; [unpublished]. International Training and Education Center on Health (I-TECH). Training needs assessment of tutors at clinical assistant and clinical officer schools in Tanzania. Seattle: University of Washington; forthcoming International Training and Education Center on Health (I-TECH). Overview of processes related to recruitment, training, and retention of pre-service tutors at health training institutions in Tanzania. Seattle: University of Washington; forthcoming Joint Learning Initiative. Human resources for health: Overcoming the crisis. Cambridge MA, Global Equity Initiative; Lehmann U, Dieleman M and Martineau T. Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention. BMC Health Services Research. 2008; 8:19: Leon and Riise, Kolstad. Human Resources for Health 2010, 8:3. McKinsey and Company. Investing in Tanzanian human resources for health: An HRH report for the Touch Foundation. New York: McKinsey and Company; [cited 7 Dec 2009]. Available from: Ministry of Health and Social Welfare (MOHSW). Curriculum for clinical officer upgrading students. Dar es Salaam: Government of Tanzania,

86 Ministry of Health and Social Welfare (MOHSW). Mpango wa Maendeleo wa Afya ya Msingi (MMAM) or Primary Health Services Development Programme (PHSDP) Dar es Salaam: Government of Tanzania; Ministry of Health and Social Welfare (MOHSW). Human resource for health strategic plan Dar es Salaam: Government of Tanzania; Ministry of Health and Social Welfare (MOHSW). Report consultancy on rapid assessment of ongoing trends of students in health training institutions in mainland Tanzania for the HRH Working Group. April Mullan F, Frehywot S. Non-physician clinicians in 47 sub-saharan African countries. Lancet. 2007; 370: Rabinowitz HK, Diamond J, Hojat M, Hazelwood CE. Demographic, educational and economic factors related to recruitment and retention of physicians in rural Pennsylvania. Journal of Rural Health. 1999; 15 (2): Rabinowitz HK, Diamond JJ, Markham FW et al. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA. 2001;286(9): Rabinowitz HK, Paynter NP. The role of the medical school in rural graduate medical education: pipeline or control valve? Journal of Rural Health. 2000;16(3): Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG. Which medical schools produce rural physicians? JAMA. 1992; 268 (12): Touch Foundation. Action now on the Tanzanian health workforce crisis: Expanding health worker training The Twiga Initiative. Mwanza: Touch Foundation; [cited 2009 Dec 5]. Available from: World Health Organization. Working together for health: The World Health Report Geneva: World Health Organization; Available from: en.pdf. 80

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88 APPENDIX 1: SUMMARY OF INSTITUTION-SPECIFIC RECOMMENDATIONS AND FINDINGS Nursing School Classrooms to Be Built Dormitories to Be Built Dormitory Room Renovation or Conversion Needed Minimum Full-time Tutors to Hire Other Infrastructure Needed Bagamoyo 1 large classroom for at least 50 Finish 60 spaces* Convert 2 washrooms to male dorm spaces; renovate 18 rooms 1 Renovate dining hall, kitchen, and sewage systems; build library Geita 2 large classrooms for at least 70 each Resolve issues to open new dorms* and furnish them (56 spaces) 2 Repair new cooking stoves; renovate dining hall; build 2 tutor houses Kahama 1 large classroom for at least 60 Renovate original dorm (18 rooms) 2 Repair sewage systems; expand dining hall Kiomboi 4 large classrooms for at least 50 each Add 100 spaces 8 Renovate/expand dining hall/ kitchen; expand classroom; build toilets/washing facilities and tutor houses Kondoa 2 large classrooms for 100 each* Finish 96 spaces* Renovate original dorm (20 rooms) 3 Complete dining hall/kitchen*; increase kitchen storage; expand tutor houses; build 2 tutor houses Korogwe 1 large classroom* for 120 with partitions (modification of existing budgeted building) 2 Complete new admin block with offices and skills lab*; complete dining hall*; renovate tutor houses; build toilets, 3 tutor and 1 warden houses Mbozi 2 large classrooms for at least 90 each with removable partitions Add 80 spaces Renovate all blocks (60 rooms) 0 Mitigate water shortage; pay electricity bills; renovate sewage systems, covered corridors, dining hall/kitchen, and tutor houses Leadership and Management Status/Needs Principal in place; no immediate retirement Principal and 1 tutor will retire in 2011 Support staff needed to relieve management burden Principal nearing retirement Principal in place Principal in place; support needed to resolve financial issues Proposed Increase in Student 61 (35 96) 31 ( ) 16 ( ) 30 ( ) 88 (48 136) 31 (83 114) -71 ( ) 82

89 Nursing School Classrooms to Be Built Dormitories to Be Built Dormitory Room Renovation or Conversion Needed Minimum Full-time Tutors to Hire Mbulu 1 large classroom for 60 students* 4 Mkomaindo 3 large classrooms for 100 each with partitions Add 157 spaces 7 Njombe 2 large classrooms for 100 each with partitions Finish 80 spaces*; add 76 spaces Renovate original block (18 rooms) 11 Same 1 large classroom for 50*; 1 additional large classroom for 50 Add 100 spaces* 1 Tarime 3 large classrooms for 120 each with partitions Finish 160 spaces* Renovate original block (18 rooms) 8 Tukuyu 1 large classroom for 60 Renovate original block (18 rooms) 2 TOTALS 13 open institutions only; doesn t include 3 reopening institutions 13 classrooms with capacity for 100+ and 11 classrooms with capacity for spaces (Not counting already-funded spaces) 170 rooms renovated; 2 rooms converted;56 spaces furnished 51 * MOHSW funding already secured Other Infrastructure Needed Build skills lab*, library*, and 2 tutor houses; resolve blockages in toilets and kitchen* Mitigate water shortage; renovate sewage systems, dining hall/kitchen, staff houses, and admin block; expand library Renovate sewage system; complete dining hall/kitchen*; build multipurpose room, tutor houses, and library Resolve blockages on library*; build skills lab* and 2 tutor houses Mitigate electricity problems in new dorm rooms; furnish dorm rooms; build computer lab Install stoves in kitchen*; renovate sewage and electrical systems and dining room as admin block; build toilets and 3 tutor houses; expand library Leadership and Management Status/Needs Principal in place Principal in place Principal in place Principal in place Principal in place; support staff needed Principal plans to retire in two years 3 retiring in near future Proposed Increase in Student 13 ( ) 93 ( ) 82 ( ) 66 (34 100) 116 ( ) 18 ( )

90 APPENDIX 2: FULL INSTITUTION REPORTS Bagamoyo Nursing School Background Bagamoyo Nursing School was established in 1974 as a maternal child health aides program. In 2004, the program changed to an enrolled nursing (EN) program. In 2008, the EN program adopted the new two-year curriculum mandated by the Ministry of Health and Social Welfare (MOHSW). Bagamoyo School of Nursing is located in the Pwani Region of the Eastern Zone, 72 km north of Dar es Salaam. The institution is adjacent to Bagamoyo District Hospital. It offers a certificate in enrolled nursing under the MOHSW. The institution has provisional registration by the National Council for Technical Education (NACTE). The HIV prevalence in the Pwani Region is 8.9%, which is higher than the national average of approximately 6 7%. Capacity Trends Bagamoyo Nursing School was built to hold 36 students. Since that time, no renovations or expansions have been completed, though there is a dormitory under construction. Because of this limit on space, the institution accepts only one cohort of students at a time. In 2008, 36 of the 39 students (enrolled in academic year) graduated from the three-year pre-service curriculum. In the academic year, there were 35 second-year students. This was the first cohort to use the new two-year curriculum; students finished the program at the end of March There was no intake for , as the institution can accommodate only one class per year, but when the previous cohort graduated in March, there was an intake of 37 students the following month. There are currently no local students at this nursing school, although three are expected in the next academic year. Students have no known external support to pay their institution fees other than their families. Though primarily a pre-service institution for EN students, this nursing school also provides in-service training to nine students through a distance learning program. These students usually only use the institution during exams and clinical/practical trainings. Bagamoyo Nursing School is unable to increase enrollment until infrastructure expands. The target enrollment could be approximately 96 students a 165% increase once the new dormitory is complete and new classroom space is constructed. Retention The current class started as 40 students in the academic year, but four were disqualified soon after beginning the first quarter because they could not provide evidence of re Bagamoyo Nurs- 84

91 ing School quired qualifications. One additional student postponed studies in her second year due to pregnancy. It was not clear how the additional four students were accommodated in the available space at the institution, since it only has beds for 36 students. In the last distance learning class, five students failed their exams and have not yet returned to retake them; the principal continues to encourage them to do so. He expressed his concern that the distance learners perform poorly on exams compared to resident students. Infrastructure The infrastructure currently can only support one intake of approximately 36 students every two years. However, if the dormitory under construction is completed; if the planned classroom and library are funded and constructed; and if a new larger dining hall and kitchen are constructed, then the institution could scale up enrollment by nearly 200%, to 96 students. Systems The institution has a reliable water supply, with a reserve water tank as back-up, which can last for three days, if used carefully. The supply of electricity is generally reliable, though the institution does not have a back-up generator. The wiring systems in the buildings are in a poor condition; they were reported to frequently cause short circuits and need replacement. The septic and drainage systems are a problem at the institution. Some tanks are broken and the kitchen drainage system is exiting into the ground rather than into a tank. Student Accommodation The institution has one dormitory with 18 rooms along one long corridor. Rooms cannot accommodate more than two students each. The institution also has a new two-story block under construction that will have space for 60 students, but it has been stalled for some time. The principal of Bagamoyo Nursing School, near a broken septic tank. In the existing dormitory, the rooms have one double-decker bed on one side, and a built-in desk and cabinet area on the other side. It would be very difficult to fit more than two students in these rooms as they are very small. This block was built in 1974 and since that time, there have been no major renovations, except for a new roof. As such, the bedrooms, washing facilities, and toilets The construction of the dormitory block for 60 students has been stalled, limiting enrollment capacity. are in poor condition, with stained walls and poor ventilation. Some of the doors to the rooms do not close, so students in those rooms cannot keep their belongings secure. The principal and students reported that the wiring was very old so there are frequent short circuits that make the power go out. One washroom is currently used as storage. The principal planned to turn it into dormitory rooms to accommodate four male students in the incoming class. 85

92 A new two-story dormitory has been under construction at Bagamoyo Nursing School since 2007 but was stalled in The construction halted due to problems with the mismanagement of funds. The current principal, new to the position since August 2009, has been following up with the responsible parties (the contractor and district authorities) to uncover the problems and resume construction. The building is close to completion as some rooms are already tiled and electric wiring is partially complete. The ceilings, some other floors, windows, doors, and washrooms await completion. Plans to furnish the dormitory are also underway; the principal has already been given a certain amount (reported to be around nine million TSH) to help furnish the rooms. When finished, the new dormitory will be able to vs. Dormitory Capacity accommodate a minimum of 60 students (two per room). Combined with the existing dormitory, the institution could accommodate a total of 96 students. The principal was not sure if it would be viable to accommodate students locally to address shortage of dormitory space. The institution is located right in Bagamoyo town and the principal thought that a day program could be considered in order to enroll more students. This might work better if students are selected from the local area the school could even be walking distance for them, given the small size of the town. However, a day program will only be successful if classroom space and the number of full-time tutors are increased /10 1st year students 37 10/ Target 2nd year students 60 spaces needed Current capacity is 36 Kitchen and Dining Facilities The very small dining room and kitchen are located adjacent to students dormitories; the space and furniture are barely sufficient for the current students. There is a TV set in the dining room, which is reportedly the only recreational facility available for students. At the time of the visit, the sewage system servicing the kitchen was broken; it discharged a very bad smell around the kitchen and the dormitory areas. The kitchen and food storage areas are also very small, with no cupboards or appropriate facilities to keep utensils and supplies. The whole dining and kitchen area would need to be expanded to accommodate more students. The students washing area, which is adjacent to the kitchen and affected by the broken sewage system, will also need to be renovated and expanded. The dining area is already too small for the current 35 students. It will need to be expanded if enrollment increases. 86

93 Classrooms There is only one small classroom, which has capacity for 36 students; yet, it contained about 40 desks and chairs. The desks and chairs were adequate to hold 35 students and were in relatively good condition. Despite this, the space is at maximum capacity. For a target enrollment of 96 students, two new, furnished classrooms, each with a capacity for 50 students, are needed. The institution has architectural plans drafted to build a twostory building that would have a large classroom on the bottom floor and a library on the top floor, but this has not yet been funded. The principal hopes it will be funded in the next budget year. In the meantime, he plans to teach vs. Classroom Space the incoming class in staggered sessions in the original classroom. But, scale-up requires both 50 additional classroom space and completion of the new dormitory block. Staff Offices and Accommodation The offices for the principal and tutors are very small and cramped. The principal s office accommodates the secretary as well, making it difficult to move around or hold a meeting of even three people. There was an area just outside the principal s office that could be used as a small space for the secretary, but right now it has a cabinet and a photocopier in it. There was one tutor s office with two desks, a table, and the majority of the library materials, which are kept in cabinets because there is no library space. The tutor s office could be adequate for two tutors if the space were better organized, but would be small if more tutors were added. The institution has only two staff houses, one for the principal and another for the warden. The rest of the tutors and institution staff reside outside the campus, with no housing allowances provided /10 Bagamoyo Nursing School s single classroom st year students 10/ Target 2nd year students 2 classrooms needed, each with a capacity for 50 Current capacity is 36 Libraries and Teaching Resources Computers There is no computer lab or computers available for students. The only computer there was in the principal s office, for the secretary s use. Students are currently not taught the curriculum s computer module. The principal had no plans for how students will be trained in the subject. 87

94 Resources in Library There is no library for students to study and the few books available are kept in cabinets in the principal s and tutor s offices. As mentioned above, there are architectural plans for a library building, but the institution has not yet secured funding for the new building, nor funding for additional reference materials. For most subjects, a minimum of four students share a single book. More textbooks are needed both for the current student body and especially for an increased student body. Additionally, tutors and students report that the books are very outdated. As more resources are made available through the Internet, students, tutors, and the acting medical officer in-charge commented that Internet connectivity could help address the need for updated reading/reference materials. Demonstration Rooms and Teaching Aids The institution does not have a skills lab. Tutors move the models in and out of the classroom during demonstration sessions. There are three anatomic charts hanging in the classroom that depict the digestive, nervous, and vascular systems, respectively. Other models are kept in the unused toilets/ bathrooms in the dormitory because there is no other space to store them. Human Resources Leadership and Management The principal recently joined the institution in August He has been actively following up with the MOHSW to facilitate enrollment scale-up and to improve students learning environment. As an example, the principal secured additional funding for furniture from the MOHSW, and continues to follow up with district officials and the MOHSW on the stalled construction of dormitory space. The institution expects to receive male students in the future, and the principal is trying figure out how to accommodate them by modifying the existing facilities. The principal would like to see the library and classroom space construction move forward as well. Tutors There are three full-time nurse tutors teaching at the institution, one of whom is the principal. A fourth tutor, an enrolled nurse, is currently away on study leave in Mtwara. There is also a warden who is a nursing officer who occasionally teaches courses. The principal indicated that at least one additional full-time tutor will be needed if enrollment is to be increased. Besides salaries, no additional compensation is provided to tutors, except for the principal and warden who reside in staff houses located on the institution s campus. The institution also relies on six part-time tutors, all from the district hospital. These include two registered nurses, one assistant medical officer, one clinical officer, and two health officers. The Student to Tutor Ratio Student to Tutor Ratio 09/10 32 Student to Tutor Ratio at Target 1 additional tutor needed Recommended NACTE student to tutor ratio is 25:1 88

95 part-time tutors are paid on an hourly basis and are contracted on the basis of demand. The only subject they have not been able to find a tutor for is the computer module. Clinical Instruction Bagamoyo Nursing School is located adjacent to Bagamoyo District Hospital, which is where students conduct their clinical training. The hospital has 125 beds, but the hospital is rarely filled to capacity; some days, it only has 50 inpatients. The acting matron-in-charge indicated that with so few patients, clinical teaching is sometimes not possible. Students spend three days per week at the hospital and are put in groups of five to six in each ward. There are five wards plus the outpatient department, operating theater, and a reproductive and child health clinic. The mornings are very busy, so they normally have more students on the wards during the morning hours. The former matron-in-charge (who was acting matron during the visit), the acting medical officer-incharge, the principal, and students in the focus group discussion all reported that the hospital and field-visit locations lack proper staffing. Students are heavily relied upon to provide services. The hospital cannot provide adequate clinical training without sufficient numbers of staff. Sometimes medical attendants are the only staff present in a ward and they are unable to provide any instruction to the students because they are untrained personnel. The equipment, supplies, and medication at the hospital are very scarce, which forces the hospital to make many referrals to Muhimbili National Hospital. The operating theater is very small and equipment is scarce. As a result, students are not exposed to more complex medical cases, and may learn to perform only very common procedures. Even in the wards, the facilities are lacking. For example, there is only one blood pressure machine for the wards, so it is rarely available. The acting medical officer-in-charge noted that the absence of resources at Bagomoyo Nursing School and in the hospital (e.g., Internet access, a photocopier, audiovisual equipment, flip charts, and computers) has impacted the clinical instruction that the students receive at the hospital. The acting matron-in-charge felt that two years of study is not enough time for students to learn and become competent ENs. She worried that the short curriculum, combined with the young age of the student body (the students are straight from secondary institution, are younger, and less mature than in-service students), produces less competent health care workers. 89

96 Medical Staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Nursing School Specialists 0 0 Medical officers 3 0 Assistant medical officers 9 0 Clinical officers 11 0 Laboratory 5 0 Nurse tutors 0 3 Registered nurses 18 0 Enrolled nurses 31 0 Pharmacy 4 pharmacists 0 Experience of Current Students Six students spoke with the assessment team. They all indicated that they joined the EN program out of their own will and wished to serve and help people with health problems. The students stated that the MOHSW decided to place them in Bagamoyo Nursing School, and they generally felt that it was okay to study in institutions outside their local areas. One student described that being away from home minimizes distractions that might be caused by being close to home. They also felt that as long as the needed support is provided by the MOHSW, the current selection and placement procedure used by the government is good. When asked about the positive aspects of their learning environment, the students cited the proximity of their institution to the district hospital, the support they receive during the clinical training, and the quality of their diet as factors that help them do well in their training program. When asked about the aspects of their experience that could be improved, students replied that there is a need to increase the quantity and quality of infrastructure, even with the current number of students. The absence of a library and a skills lab in particular was a point of frustration. They also felt the buildings and systems need to be renovated, as many are broken, worn-out, and, at times, endangering their lives (referring to the faulty electrical and broken sewage systems mentioned above). The students indicated the urgent need to increase the number of tutors to five, so that they can provide supportive supervision during the clinical training. Additionally, students asked for computer-skills training and Internet access, as it is part of the curriculum and because it would help address the shortage of books. The students, too, pointed out that the two-year curriculum is difficult to cover in the time allotted. They urged the MOHSW to do a feasibility study on effectiveness of the current curriculum. The students were concerned that the duration of clinical training was shortened in the new curriculum to provide more time for classroom sessions. Students also stated that using English as the language 90

97 of instruction could be a major reason that students fail, especially in the clinical/practical exams. Students were eager to see the institution enroll more than one class at a time, as they felt that the lower classes could learn from their colleagues in upper classes. Some felt there should be a mix of male and female students at the institution. The students also asked that more financial support from the government be provided to students during their field attachments, as the support provided now (food and places to stay) are not adequate to meet their needs. They felt that NTI management needs to give students adequate information regarding time and location of their field attachments prior to their dispatch, so they can prepare accordingly. Future Capacity and Recommendations The institution has plans in place to increase enrollment capacity by nearly 200% and has begun construction of a new dormitory. There are also plans for a classroom and library, but they have not been funded yet. To maintain current enrollment: Resolve the financial issues that have put the construction of the new dormitory building on hold and finalize its construction, creating 60 spaces for students. Procure teaching aids to enhance demonstrations. Renovate the buildings and their sewage and electrical systems (dormitories, including toilets, dining room, and kitchen) to maintain a healthy and safe learning environment for students. Renovate the two toilets and two washrooms that are being used for storage to create temporary space for the incoming male students. To reach a target enrollment of roughly 96 students (165% increase): Construct the planned two-story building, which will include a library and a large classroom that can hold at least 50 students. Construct an additional classroom to hold 50 more students. Build a skills lab and equip it with teaching aids and equipment. This is especially important at Bagamoyo Nursing School, because the hospital does not have enough patients to fully support clinical rotations. Rededicate the existing small classroom as a computer lab and equip it with computers. Hire a part-time computer instructor. Hire one additional tutor to bring the number of full-time tutors to four, for a student body that will near 100. Hire a clinical instructor dedicated to supervising students in the hospital setting. Build three more tutor houses that can accommodate families. Purchase equipment to support increases in enrollment, including computers, an Internet connection, books, and dining room furniture. 91

98 Geita Nursing School Background Geita Nursing School was established with support from the US government in 1977 as a training institution for maternal and child health aides. In 1984, it was transformed into a public health nurse training program. In 2005, it became a three-year program to train enrolled nurses (EN), which turned into a two-year program in Geita Nursing School offers a certificate in enrolled nursing under the Ministry of Health and Social Welfare (MOHSW). It is fully registered by the National Council for Technical Education (NACTE). The institution is located in Mwanza Region in the Lake Zone, in the town of Geita. It is about one and a half hours from Mwanza city by road and another minutes by ferry. The school is adjacent to Geita District Hospital. The HIV prevalence in the region is 5%, which is lower than the 6 7% national average. Capacity Trends Geita Nursing School was originally built to accommodate 36 students. Since that time, additional dormitories have created space for 132 students, but classroom space can only accommodate 76. Currently, there are 109 students. Since the new two-year curriculum was adopted in 2008, Geita Nursing School has had two cohort intakes; the first class of 57 students completed their exams in March 2010 and the second cohort of 52 in July When the first cohort finished, a new class of 70 students arrived, increasing overall enrollment to 122. The target enrollment for Geita is 140 students, with two classes of 70 students broken down into two smaller groups to make instruction manageable. This is roughly a 250% increase in enrollment the since the start of the two-year curriculum, compared to the cohort of 41 students in 2005, and a 15% increase over expected enrollment in This enrollment increase requires a corresponding infrastructure expansion to classrooms, the dining room, tutor offices, and teaching aides as well as more tutors. The institution currently has 45 local students from Mwanza Region, representing 41% of the student body. The principal said that even though local students would prefer to study at Geita, there are many challenges in accepting them. She felt that local students were more often distracted by family issues and more likely to miss classes due to family responsibilities. She also reported that in the past, family members have caused disruptions at the institution by visiting students and demanding medical care and support. 92

99 Retention Geita Nursing School has lost a total of 17 students since beginning the new curriculum. Twelve of these were disqualified six due to forged certificates and another six were mistakenly admitted as in-service students and have since been accepted into an appropriate distance learning program. The other students who dropped out due to pregnancy, poor performance, or disciplinary grounds have been encouraged to retake their exams and rejoin the program in an effort to reduce the attrition rate. The principal attributed the poor academic performance of some of the students to the rigor of the new curriculum, claiming that the amount of material covered is beyond what can be accomplished in the short timeframe. She also said that this year s examiner s report stated that time was insufficient to cover the required elements of the courses, especially in child health and midwifery. Infrastructure Since 2006, Geita s campus has been expanded, with the addition of 96 dormitory spaces, a library, a skills lab, and a classroom. The institution has also built an administrative block, a kitchen, and four tutor houses. However, the original buildings are in need of major renovations. With increased enrollment, many rooms have been repurposed. For example, the library and skills lab are now operating as classrooms and some office spaces have been converted into dormitory rooms for male students. Despite the infrastructure growth, there remains a serious shortage of facilities, especially classroom and dining space. Geita s campus has ample space for further infrastructure development. Systems According to the principal, the water supply from the district is unreliable. The institution has drilled a number of wells for back-up water supply and has additional holding tanks, though these are still inadequate, especially during the dry season when the wells dry out. In critical situations, the school relies on the hospital for water, even though the latter s reserves are also limited. The school s electricity comes from the national grid and is generally reliable. The institution does not have a back-up generator. Student Accommodation Geita Nursing School s dormitory space is intended for 132 students, but 56 of those spaces are unused due to a lack of furnishings. One hundred twenty-two students (109 enrollees plus 13 distance learners who are paying an accommodation) are housed in the remaining spaces, creating serious overcrowding and poor use of space. Above left: The new dormitory rooms for female students are occupied by five students instead of four, as planned. Above right: The room that was initially a library now is used by male students as a dorm. Some reading materials are still stored in the room. 93

100 The institution has four dormitory blocks and an office space that was converted into living space for males. In converting this space, a small library was sacrificed; the old reading materials are still in the room though, along with students belongings. The original dormitory block was built in 1977 and has 18 rooms with space for 36 students. Currently, it holds 54 students; the rooms were modified in (the cupboards and desks were removed) to allow for an increased number of students. vs. Dormitory Capacity spaces needed 56 spaces will be available if finished rooms are furnished/ opened Current capacity is 76 Three more dormitory blocks were constructed between 2007 and 2009 with space for 96 students in 24 rooms. However, only one of these blocks is furnished and able to house students. Fourteen other rooms (56 spaces) sit unused. The principal reported that she has been requesting funds to furnish the rooms from the MOHSW since the fiscal year, but has not yet been successful. The furnishings in the converted office and other crowded dormitory rooms are insufficient to furnish the space. The administration was not clear on why it was choosing to crowd students into occupied rooms, rather than move some of the available furniture into a few of the empty rooms, or why the male students are not moved into one of the new, empty dormitories. Once the dormitory is handed over to the institution, some beds will be moved into it while the school waits for funds from the MOHSW to procure furniture for all the rooms. Once the dormitories are fully furnished and the distance learning students leave the institution, dormitory space will meet current enrollment capacity and allow up to 132 students. For a target enrollment of 140, about 8 student rooms would experience overcrowding. Kitchen and Dining Facilities 09/10 The kitchen was built in 2006 and has two energy-efficient stoves that were out of order during the visit. Currently, a makeshift stove is arranged on the floor. Nearby, the original small dining rooms (and its kitchen) are no longer in use because they cannot accommodate the current student body. For a target enrollment of 140, a new dining hall is needed and the kitchen equipment must be repaired. 0 1st year students 10/11 Target 2nd year students Classrooms Geita Nursing School has two classrooms that are not in use: one was built when the institution opened, and one was constructed in The original room can comfortably hold 36 students. It is used The new kitchen constructed at Geita Nursing School is about 30 meters away from the dining room. The two stoves are out of order. 94

101 informally as an eating or study space. The new classroom can hold 40 students. Because of large cohort sizes, the institution decided to convert the library and skills lab into classrooms. Before being converted, neither of the two rooms were furnished or equipped for their original, intended use. The library room was filled with desks and chairs, and had a flip chart stand instead of a chalkboard. Instruction is compromised because there are insufficient chairs and desks. The principal reported that students must collect all chairs and desks from around the campus (from the dining hall, dormitory rooms, tutor offices, and other places) to have enough to use in one classroom for one cohort. The principal reported that again, she has been requesting funds for furnishings since 2008, but the funding has not yet been allocated. vs. Classroom Space /10 1st year students 10/11 Target 2nd year students 2 large classrooms with removable partitions needed Average capacity is 38 *Large cohorts must be split into two groups for instruction. Two large classrooms with complete furnishings are necessary. They should have removable partitions so that large cohorts can be split into two groups, manageable for instruction. The library and skills lab should return to their original purposes. Staff Offices and Accommodation There is a large, new multipurpose building, constructed in 2007, which is used as both an administrative block and guesthouse. The building contains a large office for the principal and three small offices two for tutors (one of which can be shared by two) and one for the supplies officer. One more tutor office is located in the old building. The principal indicated that more staff office space will be made available when the male students are relocated to the new dormitory. The other side of the administration building contains a space that is used as a guesthouse; it will house a new tutor who is waiting for permanent housing. The space is also used by short-term visitors. The house was empty at the time of the visit. The new classroom is small, with maximum capacity of 40 students. The classroom is too small for the number of current students. The new multipurpose building. One side is for administration and the other side serves as a guesthouse.. The institution has four more houses for tutors one occupied by the principal, two by tutors, and one by the supplies officer. One of the tutors who occupies the houses acts as a warden. 95

102 Libraries and Teaching Resources Computers There are four desktop computers and three laptops, but all are allocated to individual tutors. No computers are available for students to regularly use for practice or research. The principal reported that these computers are moved into the classrooms during the instruction and returned to the tutors offices afterwards. This means that students are not given enough time to practice on the computers or use the Internet. If the computers for students are procured, one of the small classrooms could be rededicated as a computer lab. Resources in Library The institution has a library that is currently used as a classroom. Construction was completed in 2007, but the room had never been furnished or equipped with reading materials. The room already shows signs of wear. The few reference texts that were in good condition are kept in the principal s office; other materials are in the tutors offices. The outdated texts are stored in the converted dormitory rooms where male students are staying. The institution needs more current reading materials. Demonstration Rooms and Teaching Aids Geita has a building that was constructed in 2007 with two rooms, one intended as a small classroom and the other room as a demonstration room. The demonstration room was never furnished or properly equipped with demonstration facilities and materials, and most often serves as a classroom rather than a skills lab. A few desks, chairs, and two tables were the only other pieces of furniture in the room. The assessment team could see very few materials. Those present were mostly broken and were The demonstration room at Geita Nursing placed on the only bed in the room. The principal indicated that School is being used as a classroom. other demonstration materials are kept with students in the dormitories and in some tutors offices and storage facilities, but these were not seen during the tour. Human Resources Leadership and Management Above left: Some reading materials are kept in the cupboard in the principal s office. Above right: This room is meant to be a library but is currently being used as a classroom. The current principal was hired in 2007 during a time of growth some construction was being completed and some initiated. The principal expressed frustration that the increase in enrollment was not met with commensurate infrastructure growth and resources supply (e.g., furnishings and skills lab equipment). She stated that repeated requests have been sent to the MOHSW for the school s specific needs, but that funding has remained minimal. The principal indicated that the institution lacks proper staffing; the few tutors must perform dual or triple roles because the institution lacks a proper 96

103 warden, clinical instructors, an accountant, a secretary, and other support staff (e.g., cooks and security guards), and this puts a great burden on them. Moreover, the principal will retire in January 2011 and another tutor will retire in June 2011, which will exacerbate the staffing shortage if no immediate action is taken. Compared to other EN institutions, Geita is having trouble managing key institutional information. There were a lot of difficulties in determining the exact number of current students. Management capacity to maintain records on enrollment, retention, and other major institutional activities needs to be strengthened. Tutors There are four full-time tutors currently teaching at the institution, which includes the principal. All the tutors are nurse tutors. One other nurse tutor is away on study leave and is expected to return after completing a course. For a target enrollment of 140, two more nurse tutors are necessary, according to the NACTE-recommended standard. Besides salary, tutors are provided with housing. Additional housing would need to be built for new tutor hires. The principal noted that tutors are provided with extra duty allowances. The institution also relies on part-time tutors from the district hospital. This includes two registered nurses, two enrolled nurses, three assistant medical officers, and a computer trainer. The part-time tutors also help students during clinical training at the hospital, as there are only two clinical instructors. Part-time tutors are paid 10,000 TSH for a training that takes two hours or more. There is no additional compensation received by part-time tutors. Clinical Instruction Student to Tutor Ratio Student to Tutor Ratio 09/10 The assessment team interviewed two assistant matrons-in-charge (one for inpatients and another for outpatients) at Geita District Hospital because the hospital matron-in-charge was on annual leave. The hospital holds an average of inpatients per day and the assistant matrons reported that number is sufficient for students clinical training, even if the enrollment is increased by more than 50%. The assistant matrons indicated that the relationship between the hospital and Geita Nursing School is very good, and they appreciate the cooperation that students show when training in the wards. They pointed out that the hospital has a serious shortage of heath care workers at the moment, and having students serves a dual purpose: it helps to relieve the workload of overwhelmed staff; and it is incentive for the health care workers stay up-to-date on the latest knowledge and skills because they must teach and supervise students. First-year students spend approximately 60% of their time in the hospital setting while second-year students spend 80% of their time there. Hospital rotation is organized into morning, afternoon, and Student to Tutor Ratio at Target 2 additional tutors needed Recommended NACTE student to tutor ratio is 25:1 97

104 overnight shifts, so that there is always student coverage. The hospital has two major and one minor operating theater that can hold up to five students at a time, in addition to the other wards where students rotate. The assistant matrons said that there is one more operating theater for obstetric care that is under construction that will provide students with the opportunity to gain exposure to a wider variety of cases. The assistant matrons cited several challenges to supporting students clinical work: insufficient numbers of clinical instructors for the current student body; insufficient equipment and supplies; and inadequate numbers of health care workers to supervise students. The assistant matron also said that more student services are needed at the hospital. Further, the assistant matron felt that the MOHSW should make an effort to increase the number of health care workers at the district hospital to be able to serve the students better while efficiently attending the patients. Medical Staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Geita Nursing School Specialists 0 0 Medical officers 2 0 Assistant medical officers 8 0 Clinical officers 11 0 Laboratory 3 technicians 6 assistants 0 Nurse tutors 0 4 Registered nurses 24 0 Enrolled nurses 40 0 Pharmacy 1 technician 3 assistants 1 pharmacist 0 Experience of Current Students The students were away on clinical training during the time of the assessment team s visit and some had already graduated, so no student focus group discussion was conducted. Future Capacity and Recommendations Geita Nursing School faces several challenges in supporting a target enrollment of 140. The institution needs to strengthen its management capacity, resolve issues hindering the use of the ample dormitory space, and expand infrastructure such as classrooms and the dining hall to support its students educational needs. 98

105 Immediate: Provide technical assistance to the administration to develop record-keeping systems to strengthen management and strategic growth at this institution. Identify replacements for the principal and the tutor who are expected to retire in Renovate the oldest dormitory block to provide safe and habitable conditions for students. Hire two additional nurse tutors and one clinical instructor dedicated to supervising students in the hospital. Hire support staff, including a warden, an accountant, a secretary, three cooks, and a watchman. Repair or replace the stoves in the kitchen. To reach a target enrollment of 140 students (15% increase): Ensure that the unoccupied dormitory wing is opened for student accommodation. Fully furnish the units. Furnish the other dormitory wings. Once all dormitories are furnished, the institution will have ample dormitory space. End the accommodation for distance learning students to free up space for students. Return tutor offices to their original purpose once the dormitory spaces are sufficient. Build two large classrooms with removable partitions so that large cohorts can be taught in smaller groups; furnish them with desks, chairs, tables, and cupboards. Construct a new dining room; the expansion of the current room is not possible. Return the library and skills lab to their original purposes, and furnish them with the proper equipment, supplies, and reading materials. Rededicate one of the small classrooms as a computer lab; furnish and equip it with computers and add an Internet connection. Construct two new tutor houses that can accommodate families. 99

106 Kahama Nursing School Background Kahama Nursing School was established in 1975 as a training institution for maternal and child health aides, a cadre that provides reproductive health services including antenatal care, delivery, post delivery care and family planning. In 1994, the institution changed to a nursing program, offering a certificate in public health nursing. Then, in 2005, it began offering a three-year program in enrolled nursing (EN), which was changed to a two-year program in Kahama Nursing School is overseen by the Ministry of Health and Social Welfare (MOHSW) and is fully registered by the National Council for Technical Education (NACTE). Kahama Nursing School is located in Shinyanga Region of the Lake Zone. It sits adjacent to Kahama District Hospital. The HIV prevalence in this region is 7.6%, which is slightly higher than the national 6 7% average. Capacity Trends Kahama Nursing School was originally built to hold 36 students at a time but recent renovations and expansions (completed in 2009) allow it to hold up to 120 students, or two intakes of 60 students each. The institution currently has two classes: 40 students who entered in October 2008 and graduated in March 2010; and 65 students who entered in October 2009 and will graduate in March Total enrollment is currently 104. Target enrollment is 120 students, which represents nearly a 240% increase since the inception of the two-year program, and a 16% increase from current enrollment numbers of 104. There are currently 16 local students (15%) at the institution. The principal pointed out that many students prefer to study away from home to avoid distractions from their family members. Retention Twenty-one students have left before completing their studies since the inception of the two-year program. In the second-year class, 20 of its initial 60 students have left: 13 due to forged or unverifiable certificates; six failed and are repeating their first year (joining the more recent cohort); and one postponed her studies due to pregnancy, but will be allowed to continue after maternity leave. In the first-year class, one student dropped out due to pregnancy, but will be allowed to return after maternity leave as well. More first-year students might be forced to withdraw if they are disqualified when the MOHSW finishes verifying their credentials. The institution allows students who fail to repeat a semester or to retake exams up to two times in an effort to improve retention. 100

107 Infrastructure Kahama has had significant infrastructure development to cope with the increased enrollment demand. In 2003, older buildings were rehabilitated, and five years later, more buildings were added, including dormitories, classrooms, a library, a skills lab, and other administrative space and general facilities. However, some buildings have not been used as intended due to flaws in the sewage and drainage systems. To support a target enrollment of 120 students, one more classroom must be built and the dining room must be expanded. Though the campus does not have large areas to build upon, there is enough room to support this expansion. Systems The piped water supply at Kahama is reliable. There are many large water tanks around the school that serve as back-up supply when water is not available from the district s systems. Although the water supply is reliable, there are serious problems with the sewage and drainage systems, especially in the dormitories and the dining room. The principal attributed this to poor system design, which causes blockage in pipes. In addition, the septic tanks are often full, preventing students from using some of the facilities to avoid overflows and further damage. In the new dormitory, for example, students are allowed to take showers but not to use the toilets. They have to use the pit latrines outside the dormitory, which were also full. The supply of electricity is generally reliable as it is connected to the national electricity network. There is a very small generator for back-up power supply, though it only has enough power to serve the administration block. The district hospital adjacent to Kahama Nursing School has a large back-up generator and plans are in place to link the systems at the two institutions. Student Accommodation The institution has two dormitories one built when the institution began and another that was completed in In total, there are spaces for 116 students. The rooms in the old dormitory have capacity for two students in each room and the new one was designed to hold four students per room. The old dormitory has 18 rooms, each with one doubledecker bed on one side and a built-in desk and cabinet on the other side. It would be very difficult The long corridor along the 18 rooms in the old dormitory. Students felt there should be more exits in case of an emergency. One of the new dormitory rooms that houses five students, with one single and two double-decker beds. to fit more than two students in these rooms, as they are very small. The old dormitory is currently occupied by 19 male students, leaving a total of 17 bed spaces unoccupied. All of the unused rooms have beds except one that is being used as an office for the students union. The dormitories were renovated in 2003 but the doors, toilets, and ventilation windows looked worn and in need of another round of renovation. Students cannot use the washrooms in this dormitory because the water and 101

108 sewage systems are broken. Some of the rooms doors do not lock properly and most students personal property is not well secured. The new dormitory is occupied by female students and has 21 rooms, 19 of which were designed to hold four students each; the other two were designed to house two students each. All the rooms have study tables used by students. The two rooms, which are slightly smaller than the others and are located at the main entrance of the building, were planned as convalescent rooms for students who fall sick and need care. However, due to increased enrollment, they have become standard rooms for students. Some of the rooms in this block are overcrowded, holding five students with two double-decker beds and one single bed. The rooms are big enough to comfortably hold five students, but there is no vs. Dormitory Capacity locker or studying space for the additional student. The principal indicated that the institution plans to allocate the unused spaces in the males dormitory to female students by partitioning the dormitory into separate areas for males and females. This will help to reduce congestion in overcrowded dormitory rooms. The principal considered this to be a viable option because the institution normally receives fewer male students, and expects that trend to continue. The rooms in the dormitory occupied by female students have aluminum doors with transparent glass, and students complained that they are denied their privacy since they can be seen from outside. Some of the students occupying these rooms were using bed sheets or a cloth to shield the doors for privacy. Because the drainage system is not working well, students in the new dormitories are also prohibited from using its indoor toilets, but are allowed to use the showers. All 85 female students use the six pit latrines located just outside. Even though the pit latrines were not connected to the larger sewage system, they were still full. Students complained about this unhealthy situation and the strong odor coming into the dormitory rooms. While the capacity currently is 116, that could be expanded to 120 if two washrooms in the new dormitory were repurposed as dormitory space. They could hold four students in two doubledecker beds. The institution still must determine how to comfortably house male and female students in the same dormitories. One option proposed by the principal is to partition the old dormitory block. This could work well if the principal keeps the number of males received per intake proportional to the available rooms allotted to male students and informs the MOHSW of how many male students to send to the institution. This could help to fill all 36 available spaces in the old dormitory without having to partition the building /10 1st year students / Target 2nd year students 4 spaces needed Current capacity is

109 Next to the new dormitory building is a large washing/laundry space, but it is hardly used due to problems around the water and sewage systems, though the outside clothing lines are used. A recreational space was also constructed as part of the new dormitories, but it was clear that the space is not used often, as it looked more like a storage facility for broken furniture. Kitchen and Dining Facilities The original dining hall is still in use and has been expanded since Kahama was built in 1975; this was done by tearing down the walls and combining what initially were dining, kitchen, and storage rooms. The expansion created a much larger room for more students, but it is still congested, given the population of 104 students. There are 23 tables and 115 chairs. A new kitchen was constructed that contains three big stoves, and more space and storage cabinets for supplies than the original structure. The center has another block with enough rooms to keep food and other equipment, including an office for the storekeeper. Additionally, the assessment team noted that there is a large assembly hall with the capacity to hold between people at a time. There are enough plastic chairs to seat this number of people and the center rents it out for meetings and conferences for approximately 50,000 TSH per day. It is also used by students during examination periods. Classrooms There are two classrooms, but only one is being used. The smaller, older classroom can only accommodate 36 students and neither cohort comfortably fits in the room. The principal has plans to repurpose it as a computer lab once equipment is supplied by the MOHSW. The new, larger classroom can hold 60 students at a time; it has ample furnishings and is regularly used for instruction. vs. Classroom Space classroom needed Average capacity is 48 The skills lab is used as a second classroom. It is big enough to comfortably hold 75 students at a time. It also continues to function as a demonstration room. To support the current and target enrollment numbers, another large classroom is needed. The principal commented that given the limited number of tutors at this institution, it is only possible to teach one session in one large classroom. In some cases it could be possible to teach one session in the morning one in the evening. However, this could only be possible if the number of tutors is increased /10 1st year students 10/11 Target 2nd year students The largest classroom at Kahama NTI, which is able to hold 60 students at a time. 103

110 Staff Offices and Accommodation The institution has ample office space for tutors and other staff, in part because of a shortage of staff. The principal s office is very big and adequate for holding staff meetings. Adjacent to the office is a similar but larger room that is used as a reception area, which is where the yet-to-be-hired secretary will sit. More offices are located in another building. There are four more offices two for tutors, one for a part-time warden, and one used as a computer room. Only one of these offices is now occupied by the school s sole tutor. Other staff members were on study leave. The office for the storekeeper is located in a building where food and equipment are stored, and it is big enough to hold more than two staff. That office space is currently being used as tutors tearoom since the storekeeper has not been recruited yet. There is also a librarian s office located inside the library. The institution has three staff houses that are occupied by the principal and two tutors, one of whom is away on study leave. The warden does not have a house on campus but stays in her own home outside the campus. No housing allowances are provided to the other staff members at Kahama. Libraries and Teaching Resources Computers There is no computer lab or computers available for students. The principal reported that the institution has three desktop and three laptop computers that are used by the tutors. Two of the desktops are in the tutors computer room in the building with tutors offices, and the other one is in principal s office. The tutors also keep the laptops. The assessment team was unable to see inside the office to find out the condition of the computers because it was closed and the keys were with one of the students who was in clinical training at the time of the visit. It was not clear why the keys are kept with one of the students if the computer room is used by tutors only. When asked how the computer module in the curriculum is covered, the principal stated that the tutors are able to teach the subject, and claimed that because the MOHSW had adequately trained them on it, they have adequate skills to teach the students. The principal said that during the training sessions, the tutors computers are moved to the classrooms and then returned after the sessions. This means that students are not given ample time to use the computers for additional practice and research after classroom trainings. The Internet is not available at the institution. The principal indicated that the school will convert the old, small classroom into a computer lab if funds are made available from the MOHSW. The principal claimed that the computers that are in tutors offices will be moved to this room while waiting for others to be added. Resources in Library There is a library that has capacity for more than 40 students at a time, if the room is arranged well. The room is well equipped with large studying tables, chairs, and three big bookshelves. The librarian, whose office is located inside the library, was on leave at the time of the visit and so the library was closed. The books were not sufficient for the large number of students at the school, and most of them were outdated versions. Newer textbooks are kept separately in a small side room; students must register to gain access to these texts. One of the The library has enough space and furniture to hold more than 40 students at once. 104

111 tutors indicated that students regularly use the library, but the assessment team was of the impression that this is not the case, even with the available facilities. In the focus group discussion with students, they indicated that it is difficult for them to use it since its hours are from 7:30 am to 3:00 pm, which is the same time they are either in class or clinical rotation. Demonstration Rooms and Teaching Aids There is a demonstration room at Kahama Nursing School that is big enough to hold more than 60 students for a typical demonstration session. The room is well equipped with demonstration materials and has cupboards and storage spaces to store fragile equipment. Overall, there are many resource materials, including anatomical models and charts, skeletons, examination beds, screens, a wheelchair, trays, and other small equipment for various procedures. Though it is well resourced compared to other nursing schools, the principal still reported that additional equipment is needed, given the large number of students. The demonstration room is also used as a classroom, as indicated above, making it crowded with classroom furniture in addition to demonstration items. The principal noted that, given the large cohort sizes, the room will continue to have a dual purpose until a new, larger classroom or an alternative demonstration room is constructed. The demonstration room and its resource materials. The room is currently used both as a classroom and a demonstration room. Human Resources Leadership and Management The institution is critically understaffed, with only two full-time tutors, a clinical instructor, a librarian, two guards, and a cook to support over a hundred students. Kahama Nursing School is in serious need of a secretary, an accountant, a storekeeper, driver, and a full-time warden. The clinical instructor, who retires next year, also acts as a warden. There are two other staff on study leave, one of whom is the previous principal. The current principal has been in the position since 2008 and plans to continue acting as principal, even when the former one returns. Given the human resource shortage, the principal and the other tutor must serve multiple roles and work many overtime hours to ensure the institution continues to operate smoothly. The students that participated in the focus group discussion sympathized with the burden the two tutors bear, and they were worried that if the situation continues especially with increased enrollment numbers the quality of their education would be further compromised. 105

112 Even with this shortage, the available staff work hard to ensure that classes and clinical training continues according to the curriculum.. Opportunities to attend short courses, housing for some staff, and extra-duty allowances are some incentives provided to staff to reward their hard work. Tutors There are only three full-time tutors: two nurse tutors and one clinical instructor. There are two other full-time tutors who are currently on study leave. The principal felt that they would need to have a total of five tutors plus the clinical instructor, given current enrollment numbers. The institution uses five part-time tutors from the district hospital. These include three registered nurses and two assistant medical officers. The part-time tutors are paid 10,000 TSH per training day. To meet NACTE s recommended student-to-tutor ratio, Kahama will need at least two full-time tutors, apart from clinical instructors. Student to Tutor Ratio Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target 2 additional tutors needed Recommended NACTE student to tutor ratio is 25:1 Clinical Instruction Students conduct their clinical training at Kahama District Hospital, spending three days per week at the hospital, from 7:30 am to 1:30 pm. Only second-year students do night shifts. Students are normally put into groups of five to seven per ward, including the two operating theaters, one minor and one major. The hospital has 242 beds and receives an average of patients per day. The matron-in-charge was interviewed to understand the benefits and challenges the hospital experiences in supporting students clinical rotations. The matron reported that the hospital has enough patients to support students rotation and could even support an increased number of nursing students. There are other private nursing institutions in the district that also use the hospital for clinical training. The equipment at the hospital is very scarce, which the matron felt limits the quality of clinical training. The matron reported that there is a serious shortage of health care workers at the hospital so having students undergoing clinical training there helps to reduce the workload. However, she also explained that the staff shortage makes it difficult to adequately supervise students, even with the current number of them. There is only one clinical instructor who is a full-time employee of Kahama and the matron indicated that at least four more instructors are needed to better support the students. Given the tutor shortage at the Kahama, they are not enough tutors to provide adequate supervision during clinical rounds. 106

113 Medical staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Kahama Nursing School Specialists 0 0 Medical officers 3 0 Assistant medical officers 14 0 Clinical officers 18 0 Laboratory 3 0 Nurse tutors 0 2* Registered nurses 47 1, a clinical instructor Enrolled nurses 48 0 Pharmacy 3 (1 technician and 2 assistants) 0 *Two other tutors are on study leave The matron felt that because the students are fresh from secondary school and lack previous experience working in a hospital, they find the learning environment at the hospital very difficult. Some students tend not to report to the wards during training and some leave before the end of training, which the matron thought was because they lack commitment and interest. Experience of Current Students Four male students and four female students participated in the focus group discussions conducted by the assessment team. All students indicated that nothing compelled them to enroll in the EN program but their own desires to serve in the health care sector. They heard about the program from various media and individual contacts. The students wanted the current selection process to continue as it is. The students thought that the application process could be improved, especially in terms of how the program is advertised and also how applicants learn whether they were accepted. They would like to see the decision-making process happen in a timelier manner. Students also prefer to be placed away from their homes so as not to be distracted but within their zone, to reduce travel and other associated costs. When asked about their learning environment, they stated that the not having enough tutors, managers, and other support staff [overworks and] puts pressure on the staff, which is detrimental to the quality and conditions of teaching and learning. They indicated, for example, that the principal is forced to do work that a secretary, accountant and other operational staff would do, while teach at the same time. Students are also forced to do work that support staff normally do, such as cleaning the grounds and offices, depriving them of the little time they have for studying. There were also complaints about the drainage systems in all the dormitories, as indicated above. Moreover, the males dormitory was regarded as unsafe, especially if a fire breaks out. The corridor is 107

114 very long, with two doors located at either end; the windows have strong iron grills and the outside doors open inwards, which are considered dangerous for exiting quickly during an emergency. The students considered the dining room to be too cramped for all of the students to fit in at once. They also mentioned that the power systems in the buildings are not well made, as they sometimes cause short circuits. Even when the system is retooled, they insisted that the center be linked with the generator at the hospital, because power supply from the national grid system is not always reliable. With regard to clinical training, the students were dissatisfied with the level of support they receive from the clinical instructors. They said that the hospital receives a large number of patients so it becomes very difficult for the limited number of health care workers to adequately support students in addition to their heavy workload. The students remarked that some of the health care workers did not provide the level and quality of support they require, that some of them have forgotten or do not understand some of the procedures that students need to learn. Even with the difficulties, students felt that other things, such as the quality of the food, the commitment of and encouragement from the few tutors they have, as well as the availability of the hospital for them to do clinical training are some of the major factors that help them to do well at Kahama. When asked about the aspects of their experience that could be improved, students felt that there is a need to increase the number of tutors to eight and that other staff should be employed to relieve tutors of their responsibilities outside of teaching. The staff increase should also happen at the hospital so they can receive proper supervision and support during clinical rotations. Students felt that permanent solutions should be sought to address faulty systems and infrastructure. These include completely refurbishing the old dormitory, overhauling the drainage system so it flushes regular fill-up, expanding the dining room, and connecting the electrical system with the hospital generator after the wiring is fixed. Because the library could be used as study space, students would like to see the management extend the hours of the library, so this space can be used when they are not in class or clinical training. The number and type of books should also be increased to reflect the number of students at the nursing school. The students felt that the teaching program is too compact a lot of material packed into the majority of the day, which forces them to study until the evening hours and does not allow time for independent study. This is the regimented schedule throughout the semester, and only leaves them a week or two free to prepare for exams. They felt that the problem is caused by a lack of tutors in the face of the lengthy curriculum that needs to be covered in a relatively short time period. 108

115 Future Capacity and Recommendations To reach the target enrollment of 120 students, human resources and infrastructure need to be expanded. Human resources are at a critical shortage. Sewage systems must be repaired and an additional classroom built. The dining hall requires expansion as well. Immediate and to increase enrollment by 16% (104 students): Hire additional support staff to relieve the burden on the principal and other tutors and to strengthen the overall management of the Kahama Nursing School. Hires should include: an accountant, a secretary, a full-time warden, cooks, and security guards. Renovate the sewage and drainage systems, electrical wiring, and old dormitory so that all toilets and showers can be used and to avoid unhealthy living conditions for students. Hire two more nurse tutors. Identify a replacement for the retiring clinical instructor and hire an additional clinical instructor dedicated to supervising students full-time in the hospital setting. Construct and furnish one large classroom that can accommodate 60 students. Return the skills lab to its original function. Expand the dining hall to better accommodate the increased enrollment numbers. Redistribute students so that dormitory space is maximized, possibly partitioning the oldest dormitory block so that it can accommodate both male and female students. Coordinate with the MOHSW to receive a specific number of male students so that the dormitory space is maximized effectively. Rededicate the smallest classroom as a computer lab and equip it with computers. Increase library hours so students can use the facility when they are not in class or clinical training. Procure more teaching aids to enhance demonstrations, more essential textbooks, and copies of those texts. 109

116 Kiomboi Nursing School Background Before becoming a government nursing institution, Kiomboi Nursing School began in 1952 as a Lutheran missionary training center that offered a program for eight nurses. It was located next to the mission hospital and a Bible school. In 1967, the Ministry of Health and Social Welfare (MOHSW) took over the institution and began a midwifery program for pre-service students. From the institution offered a four-year in-service training program for maternal child health aides, a program that has since been phased out of the national system.. In 2004, Kiomboi Nursing School began offering a three-year program for enrolled nurses (EN), which was condensed to two years in The schooloffers a certificate in enrolled nursing under the MOHSW, with provisional registration by the National Council for Technical Education (NACTE). Kiomboi Nursing School, which is situated next to the Kiomboi District Hospital, is located in the Singida Region in the Central Zone. It is more than an hour north of Singida town and approximately 12.5 hours from Dar es Salaam on a combination of paved and dirt roads..the HIV prevalence in this region is 2.6%, which is significantly lower than the national average of between 6 7%. Capacity Trends Kiomboi has considerably increased its enrollment since beginning the new, two-year curriculum. Whereas the last three-year cohort size was 57, now the institution has class sizes of around 100. The assessment team approximates the target for Kiomboi at 300 total students. The target enrollment capacity is difficult to determine for Kiomboi Nursing School because over the last six decades, infrastructure has been expanded in various areas in an inconsistent or uneven manner, making it challenging to identify the actual capacity. While the school can accommodate roughly 200 students in the dormitories, the classrooms can only accommodate about 90 students (two classes of 45). At the same time, in light of the NATCE-recommended student-to-tutor ratio of 25 to 1, the school s current enrollment capacity should be 100 students, given its four tutors. Regardless of whether one considers classroom, dormitory, or tutor capacity, Kiomboi is operating over capacity, with a current student body of 270. Since beginning the two-year program, the school has had three cohort intakes in a two-year period. The first cohort of 109 students entered in March The second cohort of 67 entered in September 2008 and increased to 71 when four students joined it after being suspended from the first cohort. The last cohort of 90 students began their studies in September The principal was unable to provide data on the number of local students, except for the newest cohort. Five of the 90 first-year students (roughly 5%) come from the local region. The principal and another full-time tutor did not appear to take an active role in recruiting or facilitating local applications. They said that because this is a new program, it is not well known yet, especially in the rural 110

117 areas. They have spoken with the district medical officer and asked her to inform prospective students about the program. They have also put up posters. The tutor and principal would like to see more local students because, as they said, it could ultimately increase the number of health care workers in our own region. Retention In the March and September 2008 cohorts, a total of 25 of 201 students (about 12%) left the program. Thirteen of these were due to forged certificates; this number most likely would have been much larger had the certificates of the first cohort been checked, but they were not. The process of checking the authenticity of certificates is lengthy and often unqualified students dropped very late in the program. The 13 students with forged certificates were not dropped until they were halfway through their two-year program. Seven other students were suspended in their first year of studies, but three have already returned and the others are expected to also re-enter the program. These students were suspended for sleeping outside of the dormitories. This could be due to the lack of a warden at the institution. Four other students left the program without notice very soon after their first clinical exposure. The principal, the tutor, and the other students thought that these students were not inclined to the medical field but had probably joined the program due to family pressure. However, a few students did suggest that if there were psychological counseling for students, it is possible that some of these students would have become comfortable and stayed with the course of study. Infrastructure Kiomboi Nursing School was built more than 60 years ago and has had various aspects of its infrastructure developed and renovated over the years; however, there have not been any major renovations or infrastructure constructed in the last three years. The institution is operating over capacity and is in need of four more classrooms (to fit 50 students each), a new dining hall/kitchen, 100 more dormitory spaces, and additional toilets and washrooms that can accommodate and serve the current enrollment numbers of 270 as well as up to 300 students. Systems Kiomboi has problems with its water, sewage, and electrical systems. Most urgently, the institution is in need of a new water pump. The current pump is broken and works intermittently. When it breaks down, the school buys water at a cost of 50,000 TSH per 20 litres. Students must spend their own money for their washing, cleaning, and drinking needs. When the pump is not working (which is a regular occurrence), students spend on average 3,000 TSH each week for water. A new water pump has been ready for installation since May 2009, but the contractor has been waiting for payments from the MOHSW. The charges were broken into three payments; the first two are required before installation happens and the third is payable upon completion. The MOHSW has only made the first payment. The contractor has already purchased the pump and is ready to install it as soon as the next payment is received. The principal reported that all of the paperwork is in process. Kimboi Nursing School must rely on the water pump because city water is unreliable. The institution 111

118 does not have rain catchment equipment, which could help supplement the school s water supply. There is a huge concrete storage area for water behind the males dormitory block 6 that is intended for rainwater storage, but rain catchment equipment must be reattached to the roof. Though the principal reported that there is not a septic system problem, the student focus group reported overflow problems. Students said that the system is not serviced frequently enough. The site team observed problems in the dormitory blocks toilets and washrooms, which suggest that the septic system needs further examination and servicing. Given the rapid increase in enrollment in the last two years, it is probable that the system is being taxed. Further, the toilets and washrooms are too few in number compared to a student body of 270. There are eighteen toilets and eighteen washrooms, total, in all of the dormitory blocks, which yields a ratio of 15 students sharing one toilet or one washroom. The principal reported that electricity is largely reliable during the dry season, but unreliable during the rainy season. This is due to electric poles falling over during rains because they are not grounded solidly. The assessment team experienced the intermittent electrical power. There is no backup generator. Student Accommodation Kiomboi has 62 rooms that have space for about 200 students; however, 270 students are housed. The student dormitories are grouped into two sets of three blocks each and are located on opposite sides of the road leading into the district hospital and Kiomboi Nursing School grounds. There is overcrowding and, on average, there is only one toilet/washroom per 15 students. One hundred new dormitory spaces are needed to relieve overcrowding and allow for the small (10%) increase in enrollment numbers. It is unclear when the dormitories were built, but all but one of the structures appear relatively sound. The majority of the rooms were designed for four students, but some of them have eight students sharing four beds (two to a bed). Of the 62 rooms, there are three unoccupied rooms in one of the male-occupied blocks. The principal vs. Dormitory Capacity did not want to mix males and females in a block and therefore these rooms went unused. However, the males could potentially be shifted into one block, thus alleviating some of the overcrowding more prevalent in the female blocks. If this shift occurs, the male block would be in urgent need of more toilets and washrooms, as there are only two of each. All four of the female blocks are severely overcrowded. Rooms that are intended to hold four students sometimes hold up to eight, with two students sharing a bed. In most of these rooms, the single cupboard is insufficient and students must pile their belongings on top of the cupboards, under the beds, or in corners of the room / / Target Cohort 1 Cohort 2 Cohort 3 There were 3 intakes of students in 18 months between 3/08-9/ spaces needed Current capacity is

119 Above right: One of the males dormitory rooms that has three beds and three students. Classrooms There are three classrooms at Kiomboi Nursing School. Due to a shortage of tutors, only two cohorts are taught at any one time. vs. Classroom Space 120 The smallest classroom was built for 25 students and cannot hold any of the current cohorts, so it is not used. It also has no furnishings. Sometimes it is used as a makeshift meeting or prayer room. The second classroom was built for 40 students. At times, this room is used as a demonstration room and one end serves as a storage facility. According to the principal, it is rarely used as a classroom for regular instruction. This classroom could be renovated and extended to accommodate a larger class size of 50 students. The third classroom was originally built to hold 45 students, and accordingly has 45 desks and Large cohorts of 100 students should be broken into two groups chairs, but it currently holds 71. The room is overcrowded. There is a podium, but not a table, for and taught in separate classrooms. the teacher and there is a blackboard at the front of the room. The dining hall serves as an additional classroom. It is the largest room for instruction, holding up to 164 students at a time. The largest cohort 109 second-year students are taught in this room. As long as class sizes remain large, additional classroom space is needed. To accommodate the large class sizes, which are now in the 70s, 90s, and 100s, the assessment team recommends splitting a cohort into two groups and teaching them in standard-sized classrooms that hold about 50 students comfortably. Two of the existing classrooms could be used but four more 100 Cohort 1 The second classroom, built for 40 students, has space at the pictured end to expand the building /10 10/11 Cohort 2 Target Cohort 3 4 classrooms needed Average capacity is 43 This is the only classroom out of three that is regularly used for instruction. A cohort of 71 fits into a room meant for

120 classrooms are needed. The existing smallest classroom space could be rededicated as either a computer lab, more administrative offices, a recreation/study room, or a second demonstration room. However, breaking cohorts into two groups is only feasible with both more classroom space and adequate numbers of tutors. Dining Hall and Kitchen Facilities As stated previously, the dining hall has been rededicated as a classroom space, so meals are no longer served in this room. Students carry away their meals from the kitchen. The dining hall can hold 164 students, sitting, at a time. There is a raised stage at one end and a blackboard. The dining hall is in need of renovation, especially the ceiling tiles are falling out of it. There are three half-empty storage facilities behind the dining room that hold various consumables, with an open space between them and the dining area, which would have been where food was served. There is also a fuel storage behind, but attached, to this building. The kitchen facilities are very old, and are inadequate for the current and target enrollment sizes. They are deteriorating and the space is very small. There are only two wood fuelled cooking stoves; two new stoves are needed as well as the ancillary food preparation equipment. The space lacks counters for food preparation and the pantries lack shelves and cupboards. The institution is in desperate need of additional dining and kitchen space for enrollment numbers nearing 300. The existing dining hall could be renovated but its size would still be inadequate, especially given the separate small kitchen area. A bigger dining hall with a larger attached kitchen, plus storage, offices, and washrooms are needed. Staff Offices and Accommodation Kiomboi Nursing School s administration block is relatively small, comprising four offices: the principal s office; the secretary s office; the accounts assistant s office; and a shared tutors office. The structure appeared sound. Internet access is newly provided to the institution by the district hospital, though the tutors reported that it is unreliable and intermittent. The principal s and secretary s offices are small, each containing a desk, a table, a desktop computer, a laptop computer, printer, and fax. The accounts assistant s office has adequate space for a desk and computer; however, he needs an additional shelf and cupboard to properly organize and store all of the files. The shared tutors office holds three tutors and four desks. The tutors laptops are their private property. All four full-time tutors are provided with housing. Above: left: The dining hall is now used as a classroom. At the time of the photo, the room was being cleaned. Center: Tiles are falling from the ceiling. Right: Kitchen facilities are old and inadequate. 114

121 Libraries and Teaching Resources Computers There are no computers available for students use at Kiomboi Nursing School. The computer module of the curriculum has not been taught. Should computers be supplied to the school and additional classroom space constructed, then the smallest unused classroom could be rededicated as a computer lab. Resources in Library The library was built around 2005 and is a well-kept room. There is no librarian, therefore the library does not have regular hours or services. The tutor lends out one reference textbook to a group of 9 or 10 students to share. Books are organized by subject matter on shelves at the back of the room. There is also a space that can be used for book check out or to keep books on reserve. There are six reading tables with 16 chairs. There is one chart on the wall of the male reproductive system. There are approximately 250 holdings. There are a few current textbooks but most of the books are outdated. The tutor reported that they do not have copies of the national guidelines on community-based health care nor the national health policy and its components. Though the library is well ordered, the space is insufficient for a student body of 270. More essential, updated textbooks; more space; and a librarian are all needed to make information services part of the students educational experience. The library has books organized by subject. Demonstration Rooms and Teaching Aids There is a well-organized and well-kept demonstration room. However, the room is too small to accommodate more than 40 students at a time and therefore a single cohort must be taught in shifts. The room contains equipment, charts, and models, stored on shelves and in cabinets both in the main room and in the storage room. Relative to other Nursing Schools, this demonstration lab was better equipped; however, with 270 students, there still is not enough equipment even to teach a class of 50. The room needs beds, chairs, tables, newer charts, and additional models. The models available are used most often for physiology and midwifery. While some of the charts are in good condition, many of them are falling apart. Dishes and gallipots are numerous and used often. There are two blood pressure machines and thermometers. However, the hospital reports that the students took many pieces of the hospital s equipment, In the skills lab, equipment and models are neatly kept on the shelves. Some charts are extremely old and show their age. 115

122 without permission, for their final exams. The hospital and the school seem to disagree on where some of the equipment belongs. The room also needs a sink installed. Human Resources Leadership and Management The principal has been in her position since 1996, yet there seemed to be confusion when it came to quantifying dormitory capacity and other details related to student living. She is now nearing retirement. She manages a staff that includes three other full-time tutors, three part-time tutors, a secretary, an accounts assistant, a driver, three watchmen, and four kitchen attendants. She explained that more watchmen, a warden, and additional cooks are needed. She also stated that seven more fulltime tutors are needed, which is also what the NACTE recommends (to achieve a 25-to-1 student-toteacher ratio). The principal expressed concerns regarding how MOHSW funds impact the nursing program. She explained that not only do the MOHSW warrants of funds arrive very late but they are also incomplete. For example, the first quarter funds for July through September are supposed to arrive in July. Last year, the funds came in October, three months late. In addition, not all of the requested money was received. Only some of the line items were included in the warrant of funds. As of March, the second-quarter funds, which should have arrived in October, still had not arrived. Only funds for exams, electricity, and water arrived for the second quarter. Even the exam funds were not the full amount and the administration had to borrow funds from other areas to cover the cost. Tutors A nurse tutor and the principal in the principal s office. There are four full-time tutors employed at this institution, which includes the principal. The others are one other nurse tutor and two newly-appointed clinical instructors. These new clinical instructors are registered nurses coming from private hospitals who do not have any teaching experience. They are in need of training in teaching methodologies. All of the tutors have been oriented to the new curriculum. The principal and the nurse tutor both expressed concern over the new two-year curriculum, specifically, that the schedule is too short to provide the clinical practice that students require to develop competencies needed for placement alone in a rural dispensary. The time students spend in clinical rotation is both too short and without proper supervision. For example, students are expected to conduct 15 deliveries during their program, but this is not possible compared to the time they spend in the hospital and the availability of delivery patients. Also, tutors must use extra time Saturdays and evenings to cover the curriculum modules because of the lack of staffing. The institution also relies on three part-time tutors from the local hospital. This includes one assistant medical officer and two registered nurses. The principal also expressed concern about the availability of nurse tutors for hire. She said that they 116

123 are very difficult to find and the new registered nurses being hired as clinical instructors do not have any training in teaching methodologies. Seven additional full-time tutors are needed to bring the current student-to-tutor ratio down to 25 to 1. Currently the ratio is nearly 68 to 1. Eight additional tutors will be needed for a target enrollment of 300. Clinical Instruction Student to Tutor Ratio Kiomboi Nursing School sits on the same grounds as the Kiomboi District Hospital, where 0 students serve in the wards and clinics. The Student to Student to Tutor Tutor Ratio Ratio at Target assessment team met with the matron-in-charge 09/10 and the district nursing officer to discuss the benefits and challenges the hospital experiences in its effort to support the students education. The relationship between the hospital staff and the school s tutors and students was described as both mutually beneficial but also challenging. Though students provide much needed assistance in the wards by making beds, bathing patients, and cleaning, the lack of sufficient hospital staff can prove taxing. The matron stated that, at times, students lack the motivation to learn. She said that second-year students are more helpful, experienced, and appreciated. Though there is a newly appointed clinical instructor at the school who has been in the position for five months, the matron reported that she has not seen him supervising students in the hospital setting. The matron said that the students are too numerous for the one hospital clinical supervisor to oversee. The matron and district nursing officer said that there are not enough nurses to supervise students or to demonstrate skills to them. Sometimes there are only attendants on the wards, but having students there under those conditions is still helpful. The matron said that there are problems with students not taking care of the equipment, but attributed this, in part, to students lacking proper instruction and supervision. Another difficulty the hospital experiences is a lack of basic equipment in the wards. The hospital has a bed capacity of 180, though inpatients usually average between 120 and 160. The hospital can accommodate roughly five students in a ward in the morning and five in the evening in the following wards: outpatient department, tuberculosis, labor, female surgical and medical, male surgical and medical, major theater, minor theater, pediatric, postnatal, and dispensing room. Therefore, roughly 100 students can be accommodated in a day. Though the hospital has enough patients for student rotations, there are not enough supervisors. More supervisors are needed, along with more equipment (e.g., gallipots, receivers, blood pressure machines, pulsometers, and stethoscopes). During certain periods of the curriculum, students will spend four out of five work days (80% of their time) in hospital rotation. However, the full-time nurse tutor pointed out that, overall, students do not get enough clinical practice, especially in midwifery. There are not enough deliveries to ensure that each student conducts the required minimum of 15 during their course of studies additional tutors needed Recommended NACTE student to tutor ratio is 25:1 117

124 Medical Staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Specialists 0 0 Medical officers 1 0 Assistant medical officers 4 0 Clinical officers 7 0 Laboratory 3 lab assistants 0 Number of Full-time Tutors at Nursing School Registered nurses 15 2 clinical instructors Nurse tutors 2 Enrolled nurses 27 0 Pharmacy 1 pharmacy assistant 0 Experience of Current Students Three male and four female students who entered the nursing program in September 2008 and are now in their second year of the program met with the assessment team. The students were very engaged in the discussion and vocal, sharing their thoughts and concerns. The students entered the EN program for reasons such as wanting to help the sick and vulnerable. Two students preferred to have specialized skills rather than EN skills; they want to become a doctor or gynocologist, but found themselves in this EN program. Students indicated they were satisfied with the application process. One very satisfied student reported that he submitted the application and then learned of his acceptance on the Internet. There was one person who did not go through the regular application process but said that the principal applied on her behalf. This same student said that she was qualified. Students had a few recommendations for how to improve the process. One recommended that Form Four and Form Six students should be able to put in their application while finishing their school year, rather than waiting for their exam results. In this way, once they pass, they would be able to go straight into the EN program without a time gap. Another would have liked to have been placed in her local region rather than being placed far across the country. Students reported that the tutors were committed; however, they quickly moved to the numerous challenges they face at the school. They agreed that the biggest challenges were the dormitory space, the water supply and sewage system, the shortage of qualified tutors, and the lack of library resources. Dormitories do not have enough space nor enough beds to accommodate all of the students. The toilets are too few in number and students must wait in long queues in the morning. The water supply is completely insufficient. The water pump works intermittently and students are often forced to spend around 3,000 TSH per week of their own money for water for washing, drinking, and cleaning. One student complained that the school is not boiling drinking water for the students. The shortage of full-time tutors results in hardship for the students. The curriculum cannot be covered in time and they finish courses late. In the students opinion, they need seven full-time tutors. Shortage of tutors means that they cannot be supervised on the wards and the available supervisors were described as harsh and too busy to provide any supervision. The tutors cannot supervise because they must be in the classroom, instructing another class of students. One student said of 118

125 the curriculum, Two years would be enough if we had enough teachers. Though there is a library, the holdings are outdated and too few in number, and the students emphasized their need for books. Future Capacity and Recommendations Kiomboi Nursing School is currently operating over capacity and is in need of immediate assistance, especially in terms of classroom space, dormitory space, and full-time tutors. The current student body of 270, which is likely to continue to increase in the short term, does not have the infrastructure, staffing, or clinical instruction needed to support their education. To meet the current needs and plan for the short-term future needs of Kiomboi, the following are recommended: Immediate: Hire eight additional full-time tutors to reduce the teacher-to-student ratio to the NACTE-recommended ratio. Build four additional classrooms that can comfortably hold 50 students each and then break large cohorts into two groups for instruction. Renovate and expand the dining hall and kitchen (or construct new ones) that can serve 300 students. The building should include storage, office space, washrooms, and modern cooking facilities. Renovate the classroom that currently is intended to hold 45 students, extending one end of it so that it can accommodate more than 50 students. Add 100 new dormitory spaces. Hire a warden to oversee all the dormitories. Build new toilets and washrooms in the dormitories and additional pit latrine blocks on campus. Purchase additional desks and chairs for a student body that is now reaching nearly 300. Purchase more library resources, including more copies of more essential books from the curriculum. Hire a library attendant so that the library can be accessible to students. Equip the smallest classroom with approximately 20 computers and hire an IT tutor; alternatively, create more administrative space for the additional tutors. Hire two clinical instructors who are dedicated to supervising students at the hospital full-time, to better support students clinical rotation. Rededicate existing classrooms as a computer lab, a study space, additional tutor offices, and administration space. Build additional tutor housing. 119

126 Kondoa Nursing School Background Kondoa Nursing School was established in 1977 as a training center for maternal and child health aides. With one classroom and one dormitory block, it could accommodate 36 students. In 1988, the institution changed to a four-year program for enrolled nurses (EN), which was condensed into a three-year program a few years later, and further condensed to a two-year program in March The institution has always had a single cohort at a time, graduating one class before beginning another. Kondoa operates under the Ministry of Health and Social Welfare (MOHSW) and is fully registered by the National Council for Technical Education (NACTE). Kondoa is located next to the Kondoa District Hospital in the Dodoma Region of the Central Zone. It is four hours north of Dodoma town on a rough dirt road and approximately 11 hours from Dar es Salaam on a combination of paved and dirt roads. The HIV prevalence in the region is 3.3%, which is much lower than the national average of between 6 7%. Capacity Trends Since the institution adopted the two-year curriculum in March 2008, Kondoa Nursing School has had one intake of 56 students (four of whom left the program). The school, originally built for 36 students, has one small classroom and one dormitory block that can hold 40 students. The cohort of 48 students represents a 20% increase in enrollment compared to past intakes, which averaged 40 students per class. This cohort of 48 students graduated in March The new incoming class was expected to be 69 in total, a scale-up of 44% in total. These enrollment numbers are 73% above dormitory and classroom space, thus the new cohort is having to function in a severely overcrowded environment. This could be mitigated with new infrastructure (which is partially completed) and additional tutors; target enrollment could even reach 136, more than a 250% increase since beginning the two-year curriculum. In the current class, 11 students came from the local region, representing 23% of the student body. The principal prefers not to have local students because she has found that historically, local students are more likely to be distracted from their studies their families are nearby, and illnesses and family problems tend to pull them away from school. Also, community members can become involved if one local student is selected over another. Retention The principal reported that the MOHSW s request for schools to submit students certificates for verification came late in the academic year and therefore, she did not submit them. Out of the 2008 cohort, four students out of 56 have left the program. Two students left due to family problems; one of the two returned to school but transferred to Mkomaindo Nursing School. 120

127 Another student became pregnant and was encouraged to return to school after delivery, but she chose not to return. The fourth student failed. The principal advised her to reapply to the MOHSW so she could attend a school where she could repeat the academic year (since there is only one intake at Kondoa, repeating the year was not an option). The principal did not know whether the student ever attempted to re-enter the program. Infrastructure Kondoa Nursing School was originally built in 1977 with a single classroom, one dormitory block, a small dining hall/kitchen, and a modicum of administration space. Since that time, some infrastructure has been expanded or constructed and more is currently being added. Though Kondoa is beginning to experience severe overcrowding, if the planned infrastructure is completed and other infrastructure is renovated and expanded, this would allow for significant scale-up. Dormitory and classroom space could accommodate approximately 136 students, which would be a nearly 250% increase in enrollment from the current capacity of 40 students. Systems Kondoa Nursing School has a reliable source of piped water and relatively reliable electricity from the national grid. The institution does have a back-up water supply a rain catchment system that is regularly put to use. Not only is rain caught from the roof of the dormitory wing, but the catchment system is sometimes filled with extra piped water so that when there is a disruption in the city supply, the school has ample water. The school does not have a backup generator. There are two urgent problems that need to be addressed. The first is the dormitory plumbing system; the second is the campus rainwater drainage system. The dormitory block was built in 1977 and has never been majorly renovated. The shower pipes drain onto the ground outside of the building. The principal said that the chambers connecting the pipes to and from the showers and toilets to the septic tanks are either blocked or broken. They require immediate repair. With increased numbers of students in the dormitory block, these problems with the toilets and washrooms will only increase. Rainwater erosion is another challenge. A makeshift trench has been dug to try to control land erosion from rainfall. The ditch should be permanently constructed so as to prevent further erosion and ensure that the new dining hall and dormitories under construction are protected. The outside end of the dormitory block where waste is draining out to rather than going to the septic tank. Rain catchment equipment off of the dormitory block. Student Accommodation Kondoa has one dormitory block with 20 rooms, intended to house 40 students. The institution began construction on a new dormitory block in 2007, but construction has been stalled since July That dormitory will have space for 96 students. Once completed, the institution will have spaces for 136 students. 121

128 The original dormitory block has been very well kept and appeared tidy and orderly; however, because it has never had any major renovations, the building is in need of new wiring, painting, ceiling repairs, and renovation to the toilets, washrooms, and plumbing systems. There are currently 48 students housed in 20 rooms. Most rooms contain a double-decker bed on one side, plus two cupboards and a table. Eight of the rooms are overcrowded, with a mattress on the floor for a third student. Construction on a new dormitory complex with 96 spaces commenced in 2007 but was stopped in July 2008 due to problems with the Regional Tender Board. The first two of the three phases of construction were completed as scheduled, but construction was stopped during the third phase when the Regional Tender Board found that the tendering process was faulty. The principal visited the MOHSW procurement offices in February The staff there told her that they would address the issue, and that working with or through the Regional Tender Board caused delays and therefore they will handle the process themselves. The new dormitory complex will be structured so that four rooms surround a communal study area, as well as two toilets/washrooms. There are twelve of these four-bedroom units. There is a reception area at the front of the dormitory, which is also where the warden s office and quarters will be located. In addition, the reception area has a meeting or lounging space. There are toilets and washrooms in this main area as well. This dormitory complex s construction has been halted since July 2008 due to problems with the tendering process. Typical room shared by two students. The room includes a double-decker bed, cupboards, and a table. Overcrowded rooms put a mattress on the floor to accommodate a third student. The dormitory still needs floors, ceiling boards, connection to the water supply, furnishings, outside and inside doors, and paint. Some window finishing appears to be decaying after sitting for two years and there are also a few broken windows. The principal pointed out that the new dormitory was constructed with two classes of 45 students each in mind, meaning that the current dormitory space would not house students any longer. To continue to house students, the original dormitory needs major renovations. The newest class, with 69 students, began in March At the time of the assessment visit, the principal was working out how to house these students. She had planned to ask the MOHSW for emergency funds to rent space in vs. Dormitory Capacity /10 1st year students 69 10/ Target 2nd year students 96 spaces needed Current capacity is

129 town for the male students (the outgoing class was only female students). She was also considering putting a few students in the unused tutor house (a very limited space) as well as having three students share the existing dormitory rooms. Classrooms There is only one classroom at Kondoa Nursing School. It was intended for 36 students but at the time of the visit, held 48 students, and now holds 69. There are 52 desks, 52 chairs, and a blackboard. The roof is leaking and ceiling boards are falling. With increasing student numbers, more classrooms are necessary. The principal reported that the school s strategic plan includes constructing two large lecture halls for class sizes of 100 each. The MOHSW has approved these plans and has allocated the funds, but the tender process was stopped at the Regional Tender Board. The MOHSW has told the principal that they intend to proceed with tendering for the classrooms themselves and will not return the process back to the Regional Tender Board. It is unclear what the problem is. vs. Classroom Space Once two new large classrooms are constructed, there will be more classroom space relative to dormitory space. Potentially, two cohorts could be supported at one time by dividing the large classroom space into two parts. Each cohort of 68 students could be divided into two groups and two groups could be taught at once in each of the large classrooms /10 1st year students 10/11 Target 2nd year students 2 large classrooms needed Average capacity is 40 *Each large classroom would need to be partitioned into two parts for teaching smaller groups. Dining Hall and Kitchen Facilities The dining hall and kitchen facilities were also built in 1977; though the kitchen was expanded in 1989, it is too small. A new dining hall and kitchen were under construction at the time of the visit, and were scheduled to be complete in April The original dining hall has 10 small round tables with chairs. The old cooking area is now a space with unused items awaiting the MOHSW s permission to be discarded. There is one office storage room with a desk, shelves, school supplies, class supplies, and a non-working copier. Once the new dining hall is opened, this old dining facility could be repurposed as a study area. Another possibility would be to renovate the building to create a computer lab or a larger library facility. In the kitchen, there are two wood stoves for cooking, which are not The only classroom at Kondoa Nursing School. It is intended for 36 students but holds 48. New dining (foreground) and kitchen (background with roof) facilities, scheduled to be complete in April

130 enough for the current student body. There is also a sink, a desk, one cabinet, and a second storage space for food. Firewood is kept outside under a tin structure. The construction on the new dining hall and kitchen began in November The dining room will have capacity for more than 200 students and can double as an assembly hall or recreation space. The new kitchen area contains a room for cooking that will have two gas stoves; two small rooms with one sink for washing dishes; a room for food preparation and delivery, which will have windows to pass food through to students; and two very small storage rooms. These storerooms are too small and the school will need to build additional food store space. Staff Offices and Accommodation Kondoa s main administration area is located in the same structure as the classroom. These few rooms have never been renovated, though there are leaks in the roof, cracks in the walls, and not enough space for staff needs. There are a total of six spaces for staff in different campus locations. The main administration area holds offices for the principal, the office attendant, tutors, and an accounts assistant. The principal s office is very small. The office attendant s space is outside the principal s room and is large enough for one person. The shared tutors office also includes a meeting table as well as work space for an accounts assistant. Small meetings can be conducted in this space. There are two other tutors offices in the library building. There is also an office in the kitchen area for the storeroom assistant. With increased enrollment numbers, renovated and expanded staff offices will become increasingly important. The principal s accommodation a house on the grounds of the campus is adequate and of an appropriate size. Tutor housing poses a challenge; there are two extremely small houses, each containing a sitting room and two small rooms. But, in one of these houses, five people are sharing the space. The other tutor s house was intended for a single person and was too small for the tutor s family, so he had to move into town to find a house for his family. Both structures require renovation and expansion. Libraries and Teaching Resources Computers There are no computers available to the students at Kondoa. The computer module of the curriculum has not been taught. Should computers be supplied to the school and the planned classrooms be constructed, space on campus could be shifted to create a computer lab. One possibility is to rededicate the existing classroom as a computer lab. Another possibility is to renovate the old dining hall/ kitchen and turn it into a larger library space, then use the existing library for a computer lab. Resources in Library The library was built in 1995; though small (estimated capacity is about 20 students), it appears to be well maintained and organized. The room has three shelves along the back wall that hold about 200 books, which are organized by topic. There are four large reading tables with chairs as well as one king chair. 124

131 There is no librarian and therefore, the library is unavailable to the students. Students are lent books in groups, with four students on average sharing one textbook. The library holds the national guidelines on malaria, HIV, and sexually transmitted infections, as well as manuals on various topics. The institution is in great need of reproductive and child health books as well as family planning books. The library also needs national guidelines on mental health. The library contains demonstration charts handmade by the tutors, who have had to draw them in lieu of having professionally produced ones to use in class. More essential textbooks, more space, and a librarian are all needed to make information services part of the students educational experience. The library provides a pleasant, well-organized environment, but because there is no librarian, the room is largely unavailable to students. Demonstration Rooms and Teaching Aids Kondoa Nursing School has a well-organized demonstration room located in the same building as the library. The space is intended for 40 students and will become overcrowded in 2010 with the institution s increased enrollment numbers. The room contains sinks, two cupboards (which hold models, charts, equipment, and supplies), a blackboard, one hospital bed, one examination table, four study tables, and chairs. Various models of systems are needed as well as pelvic models, dolls, stethoscopes, kidney dishes, gallipots, and forceps. Human Resources Leadership and Management Kondoa has had the same principal for 20 years. In those years, she has never had a single management course; however, her management skills were evident throughout the institution. The buildings and grounds were well kept, strategic plans were regularly developed, and several building and expansion projects are underway. She, the students, and the matron-in-charge at the Tutors and students have taken great care in ensuring that the resources they have remain in good condition. For example, this model is still stored in its original casing. hospital all described mutually respectful, good working relationships. The students in the focus group commended the principal and tutors for volunteering their own evenings, weekends, and even holidays to instruct students so that they could fully cover the curriculum. Unlike many other schools, the students take a more active role in managing some of the daily and budgetary decisions. The principal has involved the students in meal calendars and the students have reported that the food is very good. Like other principals, Kondoa s principal reported that the institution is hard pressed to provide for the educational needs of the students out of the other cost and cost-sharing funds. She said that there are great inconsistencies between what is budgeted and what is actually received. She described the MOHSW s proposal for meal costs as grossly under-budgeted. Given that food is the largest expenditure from the cost-sharing funds, it is the area that is regularly impacted the most. She also said that the MOHSW does not provide funding to supervise the fieldwork of students. Tutors must supervise 125

132 the students at their own expense. At Kondoa, there is no funding for a groundskeeper and therefore students must perform those chores, which take them away from their studies. The only areas of the budget that she regularly has adequate funds for are electricity, communication, and water costs. Tutors There are three full-time nurse tutors employed and present at this institution, one of whom is the principal. All have been oriented to the new curriculum. The institution relies on eight part-time tutors from the district hospital. This includes five registered nurses, two assistant medical officers, and one enrolled nurse, who is a preceptor for clinical supervision. The principal described a shortage of tutors at Kondoa, even though the student-to-tutor ratio is 16 to 1, which is significantly below the NACTE recommendation. The principal reported that there are not enough class hours in the new curriculum and so tutors regularly volunteer their evenings, weekends, and holidays to ensure that the curriculum is covered. Though there are enough clinic hours, supervision is inadequate. The tutors do try to provide some clinical supervision, but they cannot follow all of the students into the clinics. The principal went further to describe some of the challenges of attracting new tutors into the teaching profession. She said that even with the new initiative to hire registered nurses as tutors, those at hospitals are not interested in getting into teaching because they see the long hours that tutors work and know that there is no additional pay. Remaining a nurse means that, at least, their shift is limited. The principal also said that even the mission hospital staff approach her, asking for tutors because they too have a shortage. The principal also said that scheduling changes are not a viable option for making things more efficient at the institution because all tutors work overtime already. But, she did say that it is possible to complete the two-year curriculum on time as long as staffing and resources are truly adequate. She did not think that there was anything inherently wrong with the design of the curriculum, but rather described a lack of resources (human and otherwise) to accomplish all of the goals. Clinical Instruction Student to Tutor Ratio Student to Tutor Ratio 09/10 Kondoa Nursing School sits on the same grounds as the Kondoa District Hospital, where students spend about 60% of their time serving in the wards and clinics. The assessment team met with the matron-in-charge to discuss the benefits and challenges the hospital experiences in supporting the students education. The relationship between the hospital staff and the school s tutors and students appears to be a good one. The matron said that students help a great deal in the wards, picking up the slack that is due to staff shortages Student to Tutor Ratio at Target 2-3 additional tutors needed Recommended NACTE student to tutor ratio is 25:1 126

133 Kondoa District Hospital has an adequate number of patients to support the school s clinical rotations, and would even if the numbers of students increased to as many as 250. However, there are not enough supervisors to mentor and oversee even the current 48 students. There are about 18 different wards and clinics that could receive students and each of those places might be able to accommodate 15 students per day (seven in the morning and eight in the afternoon). One or two trained staff are needed to supervise in each ward or clinic. The two other main challenges the hospital experiences in its effort to support students besides clinical supervision are a lack of tutors to follow up on their own students progress and a lack of basic equipment throughout the hospital (e.g, blood pressure machines, forceps, trays). With regard to the latter, the matron reported that a year may pass before a supply order is filled; moreover, she said that the medical stores department s equipment is often very poor quality. Medical Staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Nursing School Specialists 0 0 Medical officers 2, the district medical officer and a dental surgeon 0 Assistant medical officers 10 0 Clinical officers 6 0 Laboratory 1 lab technician 0 Registered nurses 20 0 Nurse tutors 3 Enrolled nurses 14 0 Pharmacy 0 0 Experience of Current Students Seven female students who had just finished their two-year training program and who were awaiting graduation met with the assessment team. The students ranged in age from 20 to 30 years old and some were employed in other fields before coming to this program. The students described the application process as working fine for them, but they pointed out that they were all from urban areas, whereas they felt that potential candidates from rural areas do not have the same access to information about the program. They recommended that a communication strategy be employed whereby program information travels from the MOHSW to the regional medical officers to the district medical officers to the health centers and then finally reaching the dispensaries, where it can be shared with locals who are seeking care. Announcements should also be sent to secondary schools, churches, and mosques. The students thought that magazine and radio advertisements could also be helpful. 127

134 The students had many positive things to say about their educational experience. They described a relationship between them and the administration as one of cooperation and mutual respect. They felt that the teachers are committed and quick to share their experiences and knowledge with students. The students commended tutors on the many evenings, weekends, and holidays they give up to ensure that the curriculum is covered. The students also reported that they were able to conduct their fieldwork without funding problems. Moreover, between the hospital setting and the fieldwork, they reported having plenty of opportunities to deliver babies. With regard to retention, the students reported that the administration has a strategy to encourage high retention, including providing extra tuition and counseling students. Unlike many other nursing schools, here, the students are actively engaged in running the institution. The students had a committee that participated in making budgetary decisions. The students went so far as to report that the food was very good, and they even had access to fruit sometimes. These students understood the goals of the program and were very willing to enter into rural placements. The assessment team noted that this group of students was older and more experienced, on the whole, compared to other focus groups conducted at other institutions; this could account for their maturity, their good relationships with the staff, and their willingness to accept rural placement upon graduation. While the students were pleased with many aspects of their school, they did cite areas in need of improvement. Overall, they noted needs to improve infrastructure, update teaching resources, and increase staffing levels. With regard to infrastructure, the main difficulties they raised were that the classroom is too small, the dining hall is old, the dormitories are overcrowded, and the toilet/washrooms and their septic systems are overloaded and in disrepair. The students emphasized that a larger septic tank and more toilets/washrooms need to be constructed because there are blockages in the pipes. Students end up using the pit latrines, which are further away, in lieu of the dormitory toilets due to sewage problems; additionally, they said the pit latrines need a water supply for hand washing. The students reported that there is a serious shortage of tutors and other staff. Students felt an additional five tutors were needed to cover the curriculum in full. As for other staff, they indicated a need for a warden at the dormitory, to help manage issues that emerge; a librarian, so that students can use the library (at times, students are locked inside because there is no staff person to oversee it and the administration wants to ensure that no books go missing); a groundskeeper/cleaner, as currently, students must clean and sweep the grounds, which takes away from their study time; and two more watchmen, as well as a fence built around the institution. Students also discussed the various other resources that need to be enhanced. They are in urgent need of library books, as currently, seven or eight students share a single text. They said there are great shortages in midwifery, child health, medical/surgical, anatomy, and general nursing books. There is also a shortage of medical dictionaries. On the wards, students need more basic equipment. The demonstration room needs more models, charts, and an additional examination bed. Finally, students said that more teaching aids, such as projectors, computers, and brochures are needed. 128

135 Future Capacity and Recommendations Kondoa Nursing School is just beginning to significantly scale up enrollment. As of March 2010, the class size is 38% greater than the last class and 65% over dormitory capacity. When the new dormitory block is built and the old block is renovated, the school could accommodate (in terms of housing alone, not classroom space), a total of 136 students a 300% increase in enrollment capacity from its initial 40 students. This drastic increase in enrollment can only be supported if the following recommendations to infrastructure and staffing are achieved; otherwise, the severe overcrowding beginning to be experienced in March 2010 will only be exacerbated: Immediate (to maintain and quickly expand current enrollment at the institution): Complete the construction of the dormitory block, which will have 96 student spaces. This dormitory block, half completed, has been stalled since July 2008 and construction needs to be completed immediately. Complete the dining hall, which is intended for 200 students. Because the building lacks proper storage space, build an additional storage space for food immediately. Commence the planned addition of two large classrooms (to hold 100 students each) adding a removable partition in each room to accommodate increased class sizes and to be able to teach large cohorts in smaller classrooms. Renovate the existing dormitory block (repair ceilings, paint, redo wiring), while renovating the toilet/ washrooms and their sewage systems. This block will allow for 40 student spaces. Provide a temporary increase in other cost funds so that the principal can rent hostel space in town for the incoming class until the dormitories are finished. Hire a warden to oversee the dormitories. Hire a library assistant to create a working library while also increasing the holdings at the library. Rededicate the existing classroom as a computer lab and equip it with approximately 30 computers. Renovate the existing two tutor houses, expanding them to accommodate families. Build two new tutor houses. Hire three additional full-time nurse tutors and one clinical instructor. This ratio is above what is recommended by NACTE but is necessary to maintain educational quality. Increase the equipment and supplies in the skills lab. 129

136 Korogwe Nursing School Background Korogwe Nursing School was established in 1976 as a training center for maternal and child health (MCH) aides, a cadre that has since been phased out of the Tanzanian system. In 1986, it changed to a public health nursing institution, offering a certificate in that field. Nearly a decade later, in 2005, the institution began training MCH aides upgrading to a certificate in nursing; three years later, the institution started offering the two-year enrolled nursing (EN) program. Unlike other institutions, Korogwe never taught the four-year version of the course. In 2010, the first class of EN students will graduate from the institution. Korogwe operates under the Ministry of Health and Social Welfare (MOHSW) and is fully registered by the National Council for Technical Education (NACTE). Korogwe is located next to Magunga District Hospital in the Tanga Region of the Northern Zone. It is approximately eight hours from Dar es Salaam on a paved road. The HIV prevalence in the region is 3.8%, which is much lower than the national average of between 6 7%. Capacity Trends Since the institution adopted the two-year curriculum in March 2008, Korogwe has had three cohort intakes: The first cohort had 51 students, of which 41 remain. The second cohort had 44 students who were upgrading their skills to become ENs. At that point, the total enrollment at the institution reached 95 students (after some first-year students left the program). In 2009, the school received a third intake of 42 EN students, and enrollment reached a total of 83 students. A total of 22 students, or 26% of the student body, are from the Tanga Region. No additional measures were taken to recruit local students; all of them were sent to Korogwe through the central selection process. In 2008, when Korogwe Nursing School moved from training one cohort to two cohorts at a time, the institution went from training 44 to 83 students, nearly a 100% increase. Based on the recent renovations, the expansion of dormitory space, and planned construction, Korogwe is expanding its facilities so that it can increase enrollment by another 27% to accommodate a target enrollment of 114 students. Students and staff appear to be content with their situation; this could partly be due to the fact that the institution has not been strained by overcrowding. Retention In 2008, 51 EN students entered the school, but 10 did not complete the course. Of these 10, two students did not perform well academically, while the eight others were disqualified due to forged secondary school certificates. When noting challenges to retention, the acting principal said primarily poor academic performance, followed by forged secondary school certificates. So far, none of the 42 first-year students who began in 2009 have left the institution. 130

137 Infrastructure Korogwe was originally built in 1976, with a single classroom, one dormitory block for 36 students, a small dining hall/kitchen, and a modicum of administration space that included a half-room intended for a library. Since that time, infrastructure has been renovated, expanded, or constructed, and a number of new projects are underway. Two years ago, a new dormitory was constructed with enough space to comfortably accommodate 78 students. At the time of the visit, some renovations were taking place to expand the dining hall to accommodate at least 20 more students and tables. The dining hall is furnished with tables and chairs purchased in the last two years. The kitchen space was expanded two years ago. The foundation had been laid for a new administrative block that would house two new classrooms with capacity for approximately 50 students each, a skills lab, and offices for tutors and the principal. The structure is expected to be completed in Plans are also being made for building a new dining hall in the next two years. Korogwe has a very large campus and there will still be space to build additional structures. While Korogwe remains in serious need of additional classroom space, the institution should have adequate infrastructure to comfortably accommodate 114 students once planned construction projects are completed. Systems Korogwe has piped water and relatively reliable electricity from the national grid. However, there can be shortages of water during the dry season. The new dormitory also has a new water catchment system and a storage tank with capacity for 60,000 liters, once the piping is complete, which is scheduled to be by the end of The school does not have a back-up generator. No problems with the drainage and septic systems were reported, possibly because the new dormitory has new plumbing and fixtures, and because neither of the dormitories are filled to capacity. In the event the older dormitory was to be filled to capacity, expansion of the sewage system as well as additional toilets and showers would be needed. Construction is just beginning on a new administrative block, which will hold two new classrooms, a skills lab, and tutor offices. Student Accommodation Korogwe has two dormitory blocks the original dormitory with 18 rooms (intended for two students per room) that now is reserved for male students, and a two-year-old dormitory structure with a total of 26 rooms (intended for three female students per room). The original dormitory block has been well-maintained, including the ceilings, and it has newer paint and new screens on the windows. The acting principal reported that only six of the rooms were in use there were not enough beds and furniture to use in the 11 other rooms. One A student in a room designed for two students in the males dormitory. Without double-deckered beds, the rooms have no space for a desk. Twelve rooms are unused because they have no furniture. 131

138 other room was currently being used as storage space. Each occupied room held two students. Because the beds were not double-decked, the rooms were crowded, with little space for a desk. At the time of the visit, the majority of male residents were students who were working at the neighboring hospital as part of their field attachment for clinical officer training. The students pay Korogwe 1,000 TSH per day for four weeks to rent the rooms. The block has two showers and two toilets, and all were in functioning order. There is no dedicated space for male students to wash and dry their clothing. In the event the dormitory was to be filled to capacity, these facilities would be inadequate to support 36 students. vs. Dormitory Capacity / / Target Current capacity is 114 and 83 spaces are currently used An expansive new dormitory structure was opened in 2008, exclusively for female students. Four wings surround an enclosed, grassy courtyard. 1st year students 2nd year students The 26 rooms are spacious and have sufficient space to hold at least three students each, with room to spare for at least two desks and two cupboards. Nineteen of these rooms currently hold three students and seven rooms hold two students. The new complex includes nine showers and eight toilets, as well as a new laundry area with 16 sinks. There is also an office for the warden, who currently lives off-campus because there is inadequate tutor housing. The new females dormitories, left to right: laundry facilities; new sinks for students; the inner courtyard surrounded by four corridors with a water catchment tank; rooms that comfortably fit three students each. About 72% of Korogwe s dormitory space has been filled and there are 32 open dormitory spaces that could be made available for new students. However, barriers remain to filling these spaces. Eleven rooms in the males dormitory lack furnishings and one room would have to stop being used as a storage space. To use these twelve rooms, the MOHSW would also have to allocate exactly 24 male students to Korogwe, otherwise, there would be more male students than dormitory spaces, or there would be spaces that go unused. Even if seven additional female students were added to the females dormitory so that both dormitories were filled to capacity, there is not enough classroom space to train the additional students. 132

139 Classrooms There is only a single classroom at Korogwe. It was intended for 36 students but currently holds up to 44 students at a time. Before 2008, the institution was used to training one cohort at a time and having only one classroom was not a major obstacle. Since starting the EN program and having both first-year and second-year classes enrolled, tutors have continued to use the single classroom by adjusting the academic calendar so that students are taught in four-week blocks in the classroom and then in the clinical setting. This allows, for example, first-year students to complete four weeks of classroom training while the second-year students are training in the wards. Though this is an innovative approach given existing resources, it is not known if this allows for curriculum modules and clinical practicum training to be taught as designed. vs. Classroom Space /10 1st year students 10/11 Target 2nd year students 2 large classrooms needed (under construction) Average capacity is 36 Once the new administrative block is complete, there will be two classrooms built to accommodate 50 students each, as well as a skills lab. Even with the new building, there will still be no space on campus to convene the entire student body at one time, other than the dining hall. If the new classrooms were designed to hold at least 57 students each and built with a removable partition in between, this could create an assembly space for all the students to gather at once, as needed. Dining Hall and Kitchen Facilities The original dining hall and kitchen facilities were built in In 2008, the kitchen was expanded and there is now a large space where more stoves could be added. There is also space for food storage. Though the current dining hall was in the process of being expanded to seat another 30 students, a price quote is being prepared for building a new dining hall, after the administrative block is completed. If both dormitories were filled to capacity, the expansion would be just enough to seat and feed all of the enrolled students in the current dining hall. Additional stoves may also have to be purchased to prepare food for over a hundred students. The single classroom was designed for 36 students but holds over 45. The two cohorts must be taught in rotations. Above left: dining hall under construction with new tables and chairs. Above right: Korogwe Nursing School s kitchen was renovated within the last two years. 133

140 Staff Offices and Accommodation Korogwe s main administration area is located in the same building as the classroom. There have been some modifications to the building, but the original structure holds a principal s office with space for two or three visitors and an office for two tutors. Adjoining these offices is another very small room that holds desktop computers for student use, a photocopy machine, and a printer. The room also includes a small, secure workspace for the institution s accountant. With increased enrollment numbers, more space will be needed for tutors offices. The new administrative block will contain additional office space for at least another two tutors, in addition to offices for the principal and vice principal. The principal s current office could be repurposed as an additional tutors office. There are three tutor houses on the campus one is occupied by the principal, while the other two are occupied by tutors. The principal s accommodation is adequate and of an appropriate size. The other tutor houses share a common wall, are small, and most likely were intended for either single tutors or those with very small families. The institution s warden cannot live on campus because of the lack of tutor housing. Adding housing for the warden would ensure that is she is present on the campus during both the day and evening. If additional tutors are hired, new tutor housing will also be necessary. Libraries and Teaching Resources Computers Korogwe has four desktop computers dedicated for student use. The institution s photocopy machine and printer are also available for students. The computer module is being taught to students using a part-time IT tutor. Students must pay 500 TSH per hour to use the Internet. Visitors can also use the Internet for 1,000 TSH per hour. Students must also pay to photocopy or print from the computers. The computer lab is extremely small, and it would be difficult to add more computers or workspaces for students. There are no plans to build a new computer lab in the new administrative block. Moving the accountant to the new administrative block could allow space for two or three more desktop computers in the existing computer room, but this would not be adequate if Korogwe is training over 114 students at a time. Repurposing the current tutors office as a computer lab would provide space for at least another 20 computers and room to hold computer classes (though students would still have to be divided into smaller groups). Resources in Library Korogwe does not have a dedicated library. While the administration plans to ask the MOHSW for funds to build a library some time in the future, there are no immediate plans to build the structure or to create space in the new administrative block. Any textbooks the institution owns are kept in one locked bookcase in the tutors office, so students can only access books if a tutor is available. When students want to use reference materials, as many as 10 students will borrow a book and use the sole classroom as a reading and study space, when it is available. A dedicated library and librarian are urgently needed for All of Korogwe s library materials are in a bookcase in the tutors office. Students use the classroom for reading and studying, when available. 134

141 this institution. After tutors offices are shifted to the new administration block, the original classroom should be transformed into a permanent library space, with a dedicated librarian. Demonstration Rooms and Teaching Aids Korogwe has neither a demonstration room nor a skills lab. There is no dedicated space for demonstrations, other than in the classroom. A new skills lab is planned for the new administrative block, but the institution will also need adequate charts, reference materials, and models so that the room is fully equipped. The assessment team did not see any charts or anatomical models. The assistant principal did note that the school owned a few, but they were kept in a locked storage room at the back of the classroom. The institution has laptop computers as well as a multimedia projector. Human Resources Leadership and Management The current principal has worked at Korogwe for over five years. The vice principal has also been at the institution for five years and has a strong working knowledge of the institution s history and plans for expansion. In addition to a full-time warden and accountant, there were nine other staff members, including cooks, security guards, and a driver. Korogwe appears to have a good relationship with Magunga Hospital s matron-in-charge. There is an academic timetable posted for both first-year and second-year students, as well as a clear plan to share classroom time between the two cohorts. The institution has undertaken several renovation projects in the past two years, with other major projects planned for the next two years. Though the institution is over twenty years old, care has been taken to maintain buildings and make small renovations and repairs. Students also had high praise for the healthy living conditions and the high quality of food, both of which are common areas of frustration for students at other nursing schools. Unlike most other institutions, which generally find that other cost funds are inadequate to fund all essential activities, Korogwe s administration described having a small surplus of OC funds that they had managed to save. The accountant noted that there were approximately three million TSH that the institution had been able to save and use for minor repairs and improvements, even though they don t reportedly have other significant sources of income and have expenditures that exceeded the amount received from the MOHSW for two of the past three years. Korogwe does have some other modest sources of income that were acknowledged during the course of the visit, such as accommodation fees from students staying as part of a fieldwork assignment; the rental of a small building on campus used as a hospital staff canteen; rental fees for the multimedia projector, laptop, and classroom; as well as fees charged to students and visitors for using computers, the Internet, photocopying, and printing. Though it is not clear if these sources of revenue would be enough to generate the surplus, it is clear that efforts had been made to maintain and improve the institution s infrastructure, as well as student meals and accommodations. Tutors There are six full-time tutors employed by Korogwe, though three are away on study leave for an extended period of time. Three full-time tutors remain at the institution the vice principal, the principal, and a clinical instructor who mostly supervises students in the wards but also does some class- 135

142 room instruction. None of the tutors attended the curriculum orientation held in their area because the vice principal reported that they did not receive an invitation. The institution relies on nine part-time tutors from the district hospital. This includes three registered nurses, two assistant medical officers, an enrolled nurse, a pharmacist, a lab technician, and an IT specialist. The vice principal described a shortage of tutors at Korogwe as one of the most significant barriers to scale-up. Currently, the student-to-tutor ratio (excluding the clinical instructor) is 41 to 1. To reach a target enrollment of 114, Korogwe would need another three full-time tutors to meet the NACTE recommended 25 students per tutor. This does not include clinical instructors, who are expected to be in the clinical setting the majority of the time. If the full-time nurse tutor returned from study leave and was joined by two new full-time tutors (and the two clinical instructors on study leave returned), then the institution would have sufficient tutors to manage and train 114 students. The acting principal felt that the current tutors were able to cover the new curriculum in the time allotted, though there was a concern that condensing the curriculum to two years had diluted it. The tutors were able to cover the curriculum without additional evenings or weekend hours, and this could partially be due to teaching smaller classes, relative to other institutions. Clinical Instruction Student to Tutor Ratio Student to Tutor Ratio 09/10 Korogwe sits adjacent to Magunga District Hospital, where students serve in the wards and clinics in four-week-long rotations. The assessment team met with the matron-in-charge to discuss the benefits and challenges the hospital experiences in its efforts to support students education. The relationship between the hospital staff and the school s tutors and students appeared to be good, with the matron often acting as a part-time tutor and helping to grade clinical examinations. The matron noted that students played an important role in the wards by taking care of patients and acting as auxiliary staff. Students are especially helpful during the transition from the evening- to the day shift, and most students seemed to work at the hospital a total of 24 hours a week in three eighthour shifts. The hospital has an adequate number of patients to support the school s clinical rotations, even if the numbers of students increased to as many as 114. However, there are not enough supervisors to mentor and oversee even the current 83 students. Presently, supervising staff include one clinical instructor employed by the hospital, another clinical instructor employed by the nursing school, as Student to Tutor Ratio at Target 2 additional tutors needed Recommended NACTE student to tutor ratio is 25:1 The school bulletin board with the curriculum schedule for first-year and second-year students. The school year must be carefully planned to make use of the single classroom and allow tutors to support students in the wards. 136

143 well as the nurses in charge of each ward. While the school s vice principal and principal also spend time guiding students through their clinical rotations through a set timetable, the matron was concerned that students are not receiving adequate supervision. There is also a shortage of nurses at the hospital who have advanced training beyond the EN level, so EN students are not always supervised by higher-level nurses, as required. There is also a shortage of basic supplies, including gowns, boots, masks, and kits with supplies for pelvic examinations or for labor and delivery. Medical Staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Nursing School Specialists 0 0 Medical officers 2 0 Assistant medical officers 5 0 Clinical officers 21 0 Laboratory 1 lab technician, 4 lab assistants 0 Registered nurses 240 1* (clinical instructor) Nurse tutors Enrolled nurses 35 0 Pharmacy 1 pharmacy technician 0 *Two other clinical instructors and one other nurse tutor are on study leave for a year or more. Experience of Current Students The assessment team visited Korogwe during the semester break, but two male and six female students who remained at the institution during the holiday met with the team. The majority of the students were in their first year, and lived far away from the institution, so they could not travel home during the break. The students first provided feedback about the application process, saying they found it to be very cumbersome, especially for rural applicants. They suggested increasing recruitment at the secondary schools, using rural dispensaries as collection points for applications, and using dispensary notice boards to alert accepted applicants. The students seemed concerned that rural applicants and those living far from the capitol were disadvantaged by a centralized application process. The students also thought that magazine and radio advertisements in youth-oriented media would be helpful. The participants had many positive things to say about their experience at Korogwe. The tutors and administration had good knowledge, skills, and attitudes, and worked very hard. The students described how the tutors made efforts to unify the student body, even though they came from different regions and backgrounds. The nurses at the hospital were also helpful when guiding them 137

144 through their clinical training. The students commented that the dormitories were comfortable and that they slept well. They were extremely happy about the quality of food, reporting that they have a varied diet that includes meat or fish at least twice a week. One student described the food as better than what they were accustomed to at home. While the students were pleased with many aspects of their SCHOOL, they did cite areas in need of improvement. Overall, the students saw need for improvement of the infrastructure and the teaching resources, as well as for increased staffing levels. With regard to infrastructure, students commented on the difficulties of having only one, crowded classroom that must double as a demonstration area and study room. While they did not report any problems with major systems, some male students commented that the males dormitory rooms felt cramped when there were two double beds that weren t stacked, and that male students didn t have space for washing their clothing. The students said that tthe current computer room was small and difficult for several students to use at a time. They also felt it would be helpful to have a conference or assembly hall, along with some space for recreation, such as a football field or volleyball pitch. The students felt that there is a serious shortage of tutors and other staff, and that the curriculum was a lot to learn in just two years and with a limited number of tutors. Still, they praised the tutors, indicating their willingness to provide extra assistance in the evenings. The group also discussed the various other resources that need to be enhanced at the institution. The lack of a library concerned several students. They shared that they often have to check out a textbook from the tutors office to use in groups of ten, and there was nowhere to study with the book, other than the classroom when it was not in use. The books are few, and it was suggested that some reference materials were out of date. Because there is no demonstration room, students do not have free access to charts or anatomical models, since these resources are kept locked in a storage room. Students in the group reported that they wanted to work in rural communities upon graduation, and were very interested in learning about how to upgrade to a diploma program. Future Capacity and Recommendations In 2008, when Korogwe moved from training one to two cohorts at a time, the institution went from training 44 to 83 students, almost a 100% increase. Based on the recent renovations, the expansion of dormitory space, and planned construction, Korogwe is expanding its facilities so that it can increase enrollment by another 27% to accommodate at least 114 students total. Students and staff appear to be content at the institution, and this could partly be due to the fact that it has not been strained by overcrowding. To fully increase enrollment to 114 without creating overcrowded conditions, the following recommendations to infrastructure and staffing should be implemented: Immediate (to maintain and quickly expand current enrollment at the institution): Revise construction plans for the classrooms accommodating 50 students to build one large classroom that can be divided by a retractable partition. This would allow the room to be used as a large assembly hall when needed. Maximizing space in the design of each classroom could add more room for students, so that students can be seated comfortably in each room. 138

145 Complete construction on the new administrative block that will hold the two new classrooms, offices for tutors, and the skills lab (completion expected in 2010). Construct additional toilets, showers, and a laundry facility for male students. If the males dormitory is filled to capacity, existing facilities will not be adequate. Complete the renovation of the dining hall (underway), to add dining space for an additional 32 students. Additional stoves will need to be purchased to prepare meals for another 30 students. Purchase new furniture for 12 unused rooms in the males dormitory, and reconvert the storage room back to living space, creating a total of 24 additional spaces for male students. Plan enrollment of male students with the MOHSW so that the males dormitory is filled to its 36-student capacity rather than being underused. Hire a library assistant to create a working library out of the current classroom after the new administrative block is complete, while also increasing reference materials. Rededicate the existing tutors office as a computer lab and equip it with approximately 20 additional computers. Renovate the existing two tutor houses, expanding them to accommodate families. Build three new tutor houses and one house for the warden to live on campus. Hire three new full-time nurse tutors and two clinical instructors (if the two instructors on study leave do not return). This ratio is above what is recommended by NACTE but is necessary to maintain educational quality. Purchase equipment and supplies for the skills lab. 139

146 Mbozi Nursing School Background Mbozi Nursing School was established in the 1980s as a rural medical aide training institution. In 1994, the Ministry of Health and Social Welfare (MOHSW) changed it to a nursing and midwives institution, teaching a four-year curriculum and offering a certificate in enrolled nursing (EN). In 2006, the program was condensed into a three-year curriculum; two years later, it was further condensed to a two-year curriculum. The program is fully registered by the National Council for Technical Education (NACTE). Mbozi is located in the Mbeya Region of the Southwestern Highlands Zone. It is in a rural area about one and a half hours from Mbeya, towards the Zambian border, and about 13 hours by road from Dar es Salaam. The institution is near Moravian Hospital, which is a mission hospital. The district hospital, Vwawa, is 20 kilometers away. The HIV prevalence in Mbeya Region is 7.9%, which is higher than the 6 7% national average. Capacity Trends Mbozi began to enroll students in January 2008 for the new two-year program while it phased out the three-year program. has increased over the last two years with this change. Whereas class sizes were in the 30s, they now reach into the 50s and even 70s. The school s infrastructure capacity was at some point intended for approximately 120 students (with 60 dormitory rooms and three classrooms), but currently there are 191 students and only one working classroom. The first two-year cohort 56 students in number entered in January 2008; as of March 2010, they were taking their final exams. The second cohort 58 students began in September The last cohort 77 students began in September In total, there are 191 students enrolled in the program. Mbozi has been assigned a new first selection class of 66 students who will join the program in March 2010 when the second-year class graduates. This new class will increase the overall enrollment at the institution to 201 students. Target enrollment should be scaled back to 120 due to the many problems with infrastructure at this institution. Mbozi has a relatively high number of students from the local region. There are 34 second-year students and 33 first-year students who are local. Local students account for more than 35% of the total enrollment at the institution, far above the other nursing schools. Because the principal was new to his position, he could not offer any specific reasons why local student numbers are high. Retention Since starting the new EN program, Mbozi has lost four students (about 2%). This number is much lower than at other nursing schools. The administration indicated it did not submit students creden- 140

147 tial certificates to the MOHSW for review, and this may be one reason the number is relatively low here. Of the four students who dropped out of the program, one was sick and the other 3 absconded, leaving the school without notice or explanation. Two absconded after annual leave and no followup was conducted to explain their absence. The third returned late after annual leave, only to again abscond without notice soon thereafter. When the institution was a three-year program, they did lose a few students due to academic difficulties. They also had several others abscond. Infrastructure Mbozi was built in the 1980s, with space for 120 students in 15 small dormitory blocks. There were three classrooms that each could hold from 30 to 50 students, but now, only one classroom is used as such. Above: A view of the campus with individual dormitory blocks in background.below: One functioning classroom, able to hold 50 students. There has been very little investment in infrastructure since the school was built. There is no skills lab, nor is there a library. Though renovations to the dining hall, dormitories, staff quarters, and classrooms ostensibly took place in 2005, the site team did not witness any physical evidence of them. All of these buildings are critically in need of repair. A partial perimeter wall was built in 2006 and there is ample space available to construct new buildings. Large portions of the land have been used by staff as farmland; that land can be returned for communal use while still providing staff some gardening space. Systems Increased enrollment, combined with lack of dormitory, classroom, and dining space, has overcrowded the institution, causing it to operate in unhealthy conditions. Though there are several systemic problems, the greatest challenge is the lack of water supply. Currently, the institution s source for water is a spring, which was initiated by the Danish International Development Agency (DANIDA) and is shared with the neighboring village. The supply is inadequate. Even in the rainy season when the supply increases, the institution has water for only two hours a day. In the dry season, students walk 30 minutes to a river to collect water. The principal reported that probably best solution is to dig a deep well (or two wells) on the property. He said that deep Above left: Trench under construction to alleviate the rainwater runoff that is causing structural damage on campus. Above right: View from a dormitory block where the walkway becomes a stream when it rains. 141

148 wells are a common solution in this area. He also said that water catchment is difficult at the institution because the buildings roofs are too small to collect much rain. However, rain is prevalent in this area and a well-designed water catchment system could be very effective. The bottom of a shower stall where putrid water is not draining. None of the showers are in working order. Conversely, because there is a great deal of rain during the rainy season, the campus has experienced difficulties with too much water. Currently, there is a trench under construction on one side of campus to direct rainwater runoff. One piece of the aforementioned perimeter wall was washed away; it was repaired and the trench is being constructed so that other parts of it do not fall down. The principal expressed concern that the trench may not be properly constructed. The rains also significantly impact the institutions walkways. There are no covered corridors throughout the campus and when it rains, even mildly, the walkways become slippery, muddy streams. Covered corridors are essential for safety. Mbozi also has serious electricity problems. The institution owes over six million TSH in back bills to Tanesco (the electric company). The principal (on the job for only a month at the time of the site visit) had to visit Tanesco to plead with the management to keep the electricity on in March because students were entering their exam period. The institution does not have a back-up generator. Sewage systems are another challenge. None of the showers work, many toilets and sinks are broken, and there is standing water in many of the dormitory toilets and washrooms. Given a student body of nearly 200, 15 students queue up at a time to use the toilets and/ or washrooms. Though the principal said there were no problems with the septic tanks, the assessment team observed standing water in the facilities. Investigations are necessary to determine how the septic tanks and piping are coping with the increased enrollment numbers and an unreliable water supply. Student Accommodation Mbozi is using all but one dormitory room for student accommodation. The campus has one house used as a tutor tea room and guest lodging for temporary visitors. When the guesthouse is not being used for visitors, it houses the overflow of students from the dormitories. There are 60 dormitory rooms and 59 provide space for students; the remaining one is used as a prayer room. Because enrollment has expanded considerably since the inception of the two-year program, the dormitory space is extremely insufficient, in terms of physical space, bed availability, washrooms, cupboard space, and study space. Even before enrollment increased, the dormitories were in need of major repairs and renovation. Some of the rooms doors do not close properly, raising security issues. There are 15 separate buildings, all of the same structural model, and each contains four rooms and one washroom with toilets. None of the showers work in any of the buildings. There are two toilets in each building, but often, one or both of them are in disrepair. There is standing water in some of the A room holding two doubledecker beds and 5 females. A typical room holding three students in two beds. Belongings are piled at the heads of the bed and on the table that should be a study table. 142

149 toilet and washrooms. Washrooms are typically used for storing items such as mops, brooms, and buckets. Rooms that were intended for two beds (one double-decker) and two students now often hold between three and five students in two to four beds. There are 33 double-decker beds spread across the dormitory blocks. There are not enough beds, nor is there enough cupboard space. Students belongings are piled at the heads or foots of their beds or on top of study tables that cannot be used for studying due to the overcrowding. The rooms are so small that there is only about a half meter separating the beds and a half meter separating the foot of the bed from the wall. At the time of the site visit, the principal was inquiring about the local availability of double-decker beds to ensure that all students have a bed. Currently, only female students share beds. Even if only two students share a room, these rooms are very small and lack cupboard space. If a double-decker bed was put to one side of the room, as was originally designed, this would provide a little space for a cupboard and a study table on the opposite side of the room. Even before Mbozi considers increasing enrollment further, a major investment in additional dormitory space is needed to mitigate overcrowding. Currently, at least 80 new spaces are needed. Mbozi should consider decreasing enrollment until new dormitory space is built. Classrooms vs. Dormitory Capacity 09/10 There are three classrooms at Mbozi, but only one is currently used as a classroom. All three of the rooms need renovation the ceilings are peeling in all of them. The dining hall is used as a second classroom space. The first (and only working) classroom was built to hold about 30 students, but cohort numbers are 56, 58, and 77, respectively, and all use this classroom. There are 58 desks and old chairs and /11 Target Cohort 1 Cohort 2 Cohort 3 There were 3 intakes of students in 21 between 1/08-9/ If increased enrollment continues, nearly 80 new spaces are needed Current capacity is 120 Above left: Classroom 1 was built for 30, but holds 58 desks and chairs. It is the only classroom being used as a classroom. Above center: Classroom 2 was built for 30, but is currently used for storing equipment used by a contractor who is making repairs on campus. Above right: Classroom 3 was Built for 40, but is currently used for storing consumables, as there is no other free storage in the kitchen. 143

150 a chalkboard. A second classroom originally intended for 30 students is temporarily functioning as a storage space for equipment used by a contractor, who is constructing the trench and possibly a septic tank. It contains two closets at the back as well. The third classroom has been used for food storage since 2003, because the kitchen has no room to store large quantities of goods. It also stores furnishings that need to be thrown away, but the administration must wait for MOHSW approval first. The dining hall is used as a second classroom, but the infrastructure and furnishings are inadequate for teaching. The dining hall can hold 120 students and is used to teach the largest cohort of 77 students. There are 21 tables with attached benches that cannot be moved. Therefore, when the room is used for instruction, the students on the side of the table facing the back of the room must turn around and put their backs to the table, thus giving up a surface to take notes on. To adequately service the existing student body of 191, three new large classrooms with removable partitions are needed. A large classroom could be divided into two teaching spaces and a large cohort could be broken down into two groups for separate instruction. The placement of the existing classrooms, their size and dimensions, would not be practical candidates for renovation. Instead, the existing classrooms could be a skills lab, a library, a computer room, or permanent storage. The third classroom already has a sink along one wall and could be a skills lab, if renovated, as its size already can accommodate a group of more than 40. Dining Hall and Kitchen Facilities vs. Classroom Space Cohort 1 The dining hall and kitchen facilities are in a building that is in need of a complete renovation; both the floor and the ceiling are deteriorating. A tutor reported that the building was renovated in 2005, but as noted above, the assessment team did not see any evidence of this /10 10/11 Cohort 2 Target Cohort 3 2 large classrooms recommended* Average classroom capacity is 33 *Given the special circumstances at Mbozi, even if enrollment decreased to dormitory capacity of 120, two new large classrooms are still needed to accommodate new, large cohort sizes and to free the existing small classrooms to become a library, a computer lab, and a skills lab. Total enrollment might be decreased to 120, but with two cohorts of 60 each rather than three cohorts of 40, larger lecture halls will allow flexibility in class sizes. Above far left: The principal in the dining hall. The room is used as a classroom, among other things. Center left: The floor of the dining hall. Center right: The damage on the ceiling. Far right: The kitchen area lacks proper infrastructure and tools to safely provide food service. 144

151 The dining room space was made to accommodate 120 though it serves 191. In the room, there are 21 tables in reasonable condition that fit about 6 students each. There is also a television connected to a satellite dish that is working. Additionally, there is a large, seemingly empty water tank that appears to be stored in the room. The dining room is used as a dining space, a classroom, an ironing room, a meeting room, an entertainment space, and a study space. It is the largest building on the campus. The kitchen is in disrepair, with worn-out cooking vessels and countertops and no washing area. The principal reported that the cooking pots, utensils, and stoves are deteriorating and pose health hazards, because metal shavings are entering the food. The charcoal for cooking cannot be stored in the kitchen storage due to further health risks. There are two small storage areas that were locked and could not be viewed during the site visit, but clearly were small. As noted above, one of the classrooms is being used for kitchen storage because there is not enough room in the kitchen. There is a small office for the storage manager, but it was also locked. A new kitchen with ample storage is essential, for this institution. Staff Offices and Accommodation There is a very small administration block at Mbozi, containing only four offices. The principal s office has a desk and a couch and can receive about three visitors at one time. The accounts assistant s office is tiny, with just enough room for a desk and a chair; it has a window to receive payments or communication through. The tutor s private office is a small space with room for one person. The shared tutor office/meeting room is an open space, containing two tutor desks, a bit of shelving, and a meeting table. Cracks in the walls indicate that renovations are needed. There are a total of four staff quarters on the grounds of the institution. Two of the houses are of a size that can accommodate a tutor and his/her family; however, the other side-by-side house is very small and most likely was intended for single individuals even though now it is holding tutors with spouses and children. All of these houses are in need of major renovations. The side-by-side house is in need of expansion. Three more tutor houses that can accommodate families will be needed, should three additional tutors be hired to meet current enrollment needs. Libraries and Teaching Resources Computers There are no computers available to the students at Mbozi. The computer module is not covered and there are no funds to hire computers or teachers. It could be possible to convert one of the smaller classrooms into a computer lab if larger classrooms and proper storerooms are constructed. Resources in Library Mbozi does not have a dedicated library. There is a small stock of books in one classroom the only classroom in use along a single bookshelf. There are an estimated 200 books (approximately The library consists of a single shelf about 15 current titles and 200 total books for an institution of 200 students. 145

152 separate titles). The principal remarked that about 10 students share a single textbook. About 15 titles are current ones, but mostly the holdings are outdated. Students must borrow books in groups. Then they use their dormitory room or the dining hall to study. If new, larger classrooms are built, one of the existing classrooms could be turned into a library. A librarian would also be needed as well as more resources in the library. Demonstration Rooms and Teaching Aids One tutor uses this book from 1949 as a reference in his class. There are no demonstration rooms, and there are very few charts (none of them are recent), models, or other teaching aides. The institution only holds one anatomy and physiology model, one pelvic model, one fetal scar and placenta, and two infant models. They have four charts: the reproductive system, the endocrine system, the digestive system, and urinary tract system. These are held in a storeroom. If appropriate storage was built for the kitchen, then the third and largest classroom (currently used for kitchen storage) could be converted to a demonstration lab. That space has room for nearly 50 students and already has a sink albeit a non-working one due to lack of water supply. Human Resources Leadership and Management The principal is new to his position, having just arrived in February At the time of the assessment team s visit, the full financial and historical records were not available because the financial assistant (a tutor who has handled the financial accounts until recently) was out sick. The new accounts assistant was eager to help the assessment team but, being in his position for only about six months, he did not have full access to or knowledge of all the records. With the help of the principal, the accounts assistant, and a full-time nurse tutor, the team gathered enough data to assess the current infrastructure and environment at the school. The principal was eager to assist and explained his initial observations as a new principal at the institution. One of the full-time nurse tutors, who has been working at the school for many years, reported that in 2005, renovations were made to the dormitories and staff quarters. This ostensibly included replacing the water taps, overhauling the electrical system, painting buildings (the dining hall and classrooms), replacing doors, building a fence around the perimeter of the school, and replacing the dining hall floor. The process was supervised by the district engineer and the principal. However, the site team observed that as of March 2010 these structures were in weak condition for buildings that had been renovated within the past five years, with crumbling floors, peeling ceilings, and broken fixtures. Some financial records the current principal shared with the assessment team indicate that receipts were not issued to many students who paid their cost-sharing fees. Also, there is no record of deposit of those fees. The principal indicated that he has been unable to In the principal s office with the principal and a nurse tutor. 146

153 obtain complete financial records to evaluate the cash-flow history, including the cause of the six million TSH electricity bill. Since being in the position, the principal has not received any warrant of funds from the MOHSW. The principal said he intended to visit the MOHSW after the March exams and graduation to discuss the institution s challenges in person with MOHSW leadership. In addition to these issues, Mbozi has a shortage of support staff. The institution needs a secretary, two more cooks, and two more watchmen before enrollment increases any further. Tutors There are currently five full-time tutors: four are nurse tutors and one registered nurse is a clinical instructor. One of the four nurse tutors is on medical leave but is expected to be back at work within months and therefore is counted in this total. With the exception of the newly arrived principal, all of the tutors have been oriented to the new curriculum. The institution also relies on seven part-time tutors, including two assistant medical officers and five registered nurses. At current enrollment numbers, the student-toteacher ratio is 38 to 1. The institution needs 3 more nurse tutors to meet the NATCE standard for current enrollment numbers. The principal stated that there is a significant shortage of nurse tutors and that they are key to instruction because they generalists with training in teaching methodologies. Medical Staff at the Institution Student to Tutor Ratio Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target If enrollment decreases to 120, no new tutors are needed Recommended NACTE student to tutor ratio is 25:1 Medical Staff Registered nurses Number of Full-time Tutors at Nursing School 1 clinical instructor Nurse tutors 4 Specialists 0 Medical officers 0 Assistant medical officers 0 Clinical officers 0 Laboratory 0 Pharmacy 0 147

154 Clinical Instruction Mbozi is experiencing great difficulty in meeting students clinical rotation needs. The principal reported that this situation could get worse if enrollment increases. The assessment team was unable to visit the nearby mission hospital or the district hospital to interview their matrons-in-charge, but the principal explained the challenges the institution is facing. The school is near Moravian Hospital, which is a mission hospital. According to the principal, there are not enough patients to fully support clinical rotations, especially in the maternity ward. As a result, students many not have adequate opportunities to practice midwifery skills. The hospital is also building a new nurse training center, which may be completed by At that point, the mission hospital s own student body will have first priority in clinical rotations, making it even more difficult for the Mbozi students to gain clinical skills. The Vwawa District Hospital is 20 kilometers from Mbozi. Students do serve at this hospital and the principal reported a good relationship with the facility. The MOHSW representative on the site visit also emphasized that part of the mandate of the district hospital is to support the training of health care workers and therefore the hospital should continue to be of assistance in this way. Because Mbozi cannot support the transportation costs of their students, it can be difficult to conduct clinical rotations at the district hospital. The training center has one vehicle with a very limited budget for fuel. The vehicle must transport students in groups to the hospital, which takes a great deal of time and does not allow for daily or even weekly visits and rotations to occur. Rather, students must go to the district hospital for the period of a full month for a practicum. They are not supervised by nursing school tutors and it is difficult to ensure their safety or know the adequacy of their accommodation. Students go in groups of 15 at a time for a one-month period. This means that while at clinical practicum, those students are missing classroom instruction. When they return, the tutor must re-teach parts of the curriculum, which affects the overall quality and efficiency of training. Further, this one-month rotation is only for their midwifery skill set. Mbozi is in urgent need of additional funding to support the clinical rotation of their students so that students graduate with sufficient midwifery training and experience. Experience of Current Students Three male and three female students who entered the nursing program in September 2009 met with the assessment team. Reasons the students entered the EN program included the desire to educate communities on health issues and promote good health as well as to control diseases, especially through education. When asked about the application process, all of the students were relatively satisfied and believed that the process was fair. They prefer the centralized application process and thought that a local application system implied favoritism, which should be avoided. When asked about the overall environment at the school and what was working well, the students said that their teachers were committed. One said that they appreciated having a television in the dining hall. Students discussed some of the infrastructure and human resource challenges at their institution. 148

155 They first pointed out the extreme water supply problem, indicating that even during rainy season, they only have two hours a day when water is flowing in the pipes. The students said that there are not enough classrooms and that the one classroom plus the dining hall were inadequate. They would like four classrooms as well as desks, tables, and chairs to furnish them. They described the dormitories as overcrowded, with too many people in each room and 15 people queuing up to use a toilet or washroom in the morning, despite there not being a single shower that works. The students said that many new dormitory buildings are needed. They also said that some students do not have mattresses and bed frames. Their dormitory and ablution blocks also lack basic cleaning supplies. In addition to this infrastructure, the students said that they would like to have a library and a skills lab fully equipped with all the necessary books, models, tools, supplies, and teaching aids to make them functional spaces for learning. They mentioned that they also need computers. Students offered input on the human resource challenges, saying that there is a shortage of teachers and five more full-time teachers are needed. They also spoke of their clinical rotation at Moravian Hospital, saying that while there are enough patients on the wards, there are not enough supplies and equipment. There are not enough women delivering babies to meet their midwifery practicum requirements either. Further, they remarked that the hospital staff are overworked and cannot provide the oversight needed. Students were unhappy with their diet, describing that they can go more than two or three months at a time without any meat in their diet. They may be served beans for an entire month at a time. When asked about their relationship with the administration and their student government s role in running some of the school s affairs, the students offered that they were quiet about their concerns for fear of administrative repercussions. They described that in 2009, the former principal had punished two students after they raised issues with the principal. (The current principal had thought that the students were suspended for fighting.) Finally, students were aware that this EN program is intended to place graduating students in rural areas, but they were all hoping that they would be placed in a city instead. They were not enthusiastic, but said they were willing to accept rural jobs. Future Capacity and Recommendations Mbozi is currently over capacity and in need of immediate assistance to address the lack of beds and the overcrowding of the current facilities, as well as to develop financial transparency. Given the comprehensive work necessary to bring the infrastructure in line with current needs, a decision needs to be made between scaling back enrollment in the immediate future to 120 (while addressing the most salient system, classroom, and dining hall problems) or to continue with the target enrollment of 200 students (while addressing those most salient problems and investing in significant new infrastructure immediately). To increase its enrollment by an additional 50% to 90 or 100 students per class would entail a complete overhaul of the campus. Multiple classrooms, a new administration block, over 150 new dormitory spaces, new large dining and kitchen facilities, and additional tutors and staffing would all be required. 149

156 To meet the current needs and plan for the short-term future needs of Mbozi, the following is recommended: Immediate: Provide support for the new principal to resolve outstanding financial issues and develop transparent financial records with the new accountant. Further auditing and tracing of missing student tuition is a high priority to maintain financial solvency, morale, and the institution s reputation. Address the severe shortage of water at the institution, possibly through building two wells and creating a water catchment system. Pay the outstanding electricity bill of TSH 6,000,000 to Tanesco. Provide additional funding to support the transportation costs for students to conduct clinical rotation at Vwawa District Hospital. Do not send a third cohort later in the year when the two-year cohort graduates to scale down enrollment numbers until better infrastructure is built on campus. Address the overflowing and broken sanitation systems to create a sanitary and safe environment for the current students by repairing and/or replacing toilets and washrooms in all areas of the institution, as well as building new toilets and washrooms to service more than 200 students. Purchase beds and mattresses (double-decker structure) to accommodate the current student body of over 191. If enrollment is not scaled back immediately, build and furnish dormitory space for at least 80 students to address the severe overcrowding. Once additional dormitory space is built, rearrange the old dormitory rooms so one double-decker bed is on one side of the room and furnish the opposite side of the rooms with cupboards and a study table. Build covered corridors throughout the campus to create a more habitable, safe, and clean environment. Build a new dining hall and kitchen with modern facilities and adequate storage, similar to the structure at Tukuyu Nursing School, which will serve a large student body and can also double as an assembly hall. Renovate the four existing tutor houses, expanding the two smaller units so that the space can accommodate a tutor s family. Build two more tutor houses to accommodate additional tutor hires, if enrollment is scaled up. Build two additional large classrooms with removable partitions to accommodate 90 students each and then repurpose existing classrooms for storage, a library, a skills lab, and/or a computer lab. As long as enrollment remains near 200, hire two nurse tutors to bring the student-to-tutor ratio to 25 to

157 Mbulu Nursing School Background Mbulu Nursing School was established in the 1970s as training center for maternal and child health (MCH) aides, a cadre that has since been phased out of the Tanzanian system. In 1999, the program changed to an in-service public health nursing program for students who were upgrading their skills. Ten years later, in 2009, the program again changed to become a three-year in-service program for nurse midwives. Additionally, that year, the institution adopted the new two-year, pre-service enrolled nursing (EN) curriculum, offering a certificate in that field under the Ministry of Health and Social Welfare (MOHSW). The school is fully registered by the National Council for Technical Education (NACTE). The institution is located adjacent to Mbulu District Hospital, in the town of Mbulu, which is in the Manyara Region of the Northern Zone, about 5 hours from the town of Arusha by road. The HIV prevalence in Manyara Region is 1.7%, which is much lower than the national average of 6 7%. Capacity Trends Mbulu was originally built to hold 36 students, but a number of new buildings have been constructed and now dormitory capacity is at 120. Prior to adopting the new EN curriculum, Mbulu only enrolled one class of 40 students every three years, so enrollment has been vastly increased in the past year, though now there are no in-service or distance learning students at Mbulu. During the academic year, there were 107 students: 57 first-years and 50 second-years. The academic year at Mbulu runs from September to August, so no new students were expected until September Since beginning the two-year program, enrollment has increased by 150%. The target enrollment is 120 students, representing a 235% overall increase since the two-year program began. The institution currently has 36 local students (34% of the student body). According to the principal, until recently, it was not acceptable for local students to enroll in the institution, but the MOHSW policy has changed and now more local students are admitted through second selection. Ten local students are in the second-year class and 26 are in the first-year class. Retention Last year, four students were forced to leave due to problems verifying the authenticity of their credentials. The principal expects there to be two or three students who will leave the first-year cohort for the same reason, but they have not yet finished collecting and verifying their certificates. The principal feels that the problems with certificates are temporary and will reduce over the next few years, because the MOHSW is asking principals to assist with this process for local students before their applications are forwarded to the MOHSW. 151

158 In the current second-year class, three additional students did not pass their exams and chose not to come back to retake them. The principal believes this was more because these students were not qualified to begin with, rather than because the classes were too difficult. The principal feels that if appropriate candidates who have passed their science subjects are selected, all students should be able to pass the EN program with no problems. In general, all students are able to pay their cost-sharing fees. No students are sent home for failing to pay, and all the students have always paid the fees without having to have their certificates withheld. There is one first-year student that the principal is concerned about because she is from a very poor family that has no resources. The principal is not sure how this student will come up with the money, but she is an exception, as most students are able afford the fees. Infrastructure Mbulu has recently expanded and more is in process. New dormitories, a classroom, and staff offices have been built and another classroom, dining hall/kitchen, library, and skills lab are either delayed due to contractual problems or awaiting final approval from the MOHSW. Some of the existing buildings need to be renovated and repurposed because they can no longer accommodate the new, larger cohort sizes. With the completion of this infrastructure, a target enrollment of 120 students is realistic. But because the institution lacks ample land, careful planning is necessary for future infrastructure enhancements. Systems The water supply at the school is generally reliable, although the principal stated that water is very expensive here, compared to other regions, and that the money for it provided by the MOHSW is never enough. The institution does have reserve tanks where it can hold water. Electricity is relatively stable in the region, but the institution has a generator for emergencies. Student Accommodation There are three dormitory blocks: one original building from the 70s and two new buildings that opened in The original dormitory has 18 rooms along a long corridor like the other institutions that were built for training MCH aides. This building has not been renovated but it is extremely clean and well maintained; it appears to be in better condition than the dormitories at many other schools that were constructed around the same time. One of the dormitory rooms held three beds, but the rest of the rooms held two. There were two cupboards in each room, as well as a small table. vs. Dormitory Capacity / Target Current capacity is 120 and 107 spaces are currently used In February 2010, the institution opened two other dormitories with an additional 40 rooms, 1st year students 2nd year students 152

159 total. The rooms are large and each is self-contained, with its own toilet and washroom. Each room currently holds two students, but because of the extra facilities, these rooms could hold three or four students if the institution s enrollment grows. Mbulu could increase its capacity to 140 students just by adding a third student to the new dormitory rooms. Kitchen and Dining Facilities The institution currently uses a small kitchen and very small dining area that were originally built to support 36 students; however, there are 107 now and this room cannot accommodate them all. The institution started to build a new kitchen and large dining area, but the contractor abandoned the project before it was finished because he was not receiving payments. The dining area is finished, but the kitchen is not. As a result, the new dining area is not being used because the current kitchen is on the other side of the institution, and is not convenient to carry food back and forth. The new dining area is being used as a demonstration room while the principal works to address the issue with contractor s payments so that the new kitchen can be completed. Classrooms There are two classrooms one is the original classroom that was built for 36 students, and the second is a new, larger classroom that holds about 60 students. Only the new classroom is being used for classes, and the first-year and the second-year students use it in shifts. The small classroom is used as a computer lab or a meeting room. Mbulu plans to build one additional large classroom. Funds for it, and a library and skills lab, were budgeted two years ago but the regional administrative secretary is in charge of construction and has not yet put out the announcement for tender. The principal is not sure when construction will be able to move forward. Staff Offices and Accommodation There is sufficient office space at the institution. There is an office for the principal in the old administration building, as well as another room that is used as a staff work area, a library, and a tearoom. In the new classroom building, there are two offices one for tutors and one for the accountant. The accountant s office is large enough to accommodate two staff and the tutors office holds three desks. There are three staff houses at the institution. There is also a new house for the principal that is under construction and it is almost complete. vs. Classroom Space One of the two new dormitory buildings at Mbulu. The new classroom holds about 60 students /10 1st year students Target 2nd year students 1 classroom needed Average capacity is

160 Libraries and Teaching Resources Computers The institution does not own computers for the students. To provide them access to computers for the computer module in the new curriculum, the institution rented 10 computers and placed them in the smaller classroom. It is unclear where the rental funds are coming from and it seems that students may be paying extra fees to have computer access, as there is no funding for this in the budget. The principal reported that it has been difficult to find tutors to teach the computer module. The institution has hired someone from the town to assist, but this person demands more than the typical part-time tutor fee of 10,000 TSH per day. Mbulu rented 10 computers, which are kept in the old classroom to use for the computer module. Resources in Library There is no library; students sign out textbooks from one of the tutors. According to the principal and students, the institution has all the books needed for the curriculum but only enough copies for about one book per 10 students. Funding for a library has been allocated by the MOHSW, but construction has been delayed by the tendering process, which is being managed by the regional administrative secretary. Demonstration Rooms and Teaching Aids There is no demonstration room or skills lab, but the institution is using the new dining hall for this purpose. The MOHSW has allocated funds for a new skills lab, but again, construction has been delayed by the tendering process. Human Resources Leadership and Management Mbulu is highly organized, clean, and well structured, which is a testament to its leadership and management. It is clear that the tutors on study leave and the tutors that have retired are still very dedicated to the institution, as they assist the principal with instruction or exam preparation in their free time. The leadership does set very strict rules about students movement during their free time. This was not encountered at other visited institutions. While this may contribute to the school s discipline and structure, it also creates some discontent among students. Tutors Currently, there is only one full-time tutor the principal. There is also a warden who does not teach, but does sometimes help with clinical instruction. In 2009, there were four tutors at Mbulu, but since then, one tutor retired (though hopes to get a contract with the MOHSW to continue teaching at the school); and two others are taking a study leave this year. During the assessment team s visit, the two tutors on study leave returned during their school break to help prepare exams. The principal 154

161 was very grateful for this assistance, because without their support, she would not have been able to properly prepare the exams. Student to Tutor Ratio 120 The principal found a young nursing officer who is interested in becoming a tutor, and she will be reporting to the institution soon. She does not have any training in teaching methodologies. The principal said that it has been very difficult to find registered nurses who are interested in becoming teachers. The nurses are concerned that teaching is too taxing, and that you have to take your work home with you. Mbulu is a large institution, and it is untenable to have only one full-time tutor. At least four additional tutors will be needed if it is to meet its target enrollment of 60 students per class Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target 4 additional tutors needed; 3 needed immediately Recommended NACTE student to tutor ratio is 25:1 The institution also uses three registered nurses and one assistant medical officer from the local hospital as part-time tutors. The principal reported that it is difficult to find nurses at the hospital who are willing to teach, even as part-time tutors. Clinical Instruction Mbulu is adjacent to Mbulu District Hospital, which is where students receive their clinical training. The hospital has about 135 beds and receives about 100 patients each day. The assessment team met with one of the more senior assistant medical officers Former tutors return to Mbulu Nursing School during their study breaks to help prepare exams. at the hospital, as well as the acting matron-in-charge. The matron and the medical officer-in- charge were both at a budget retreat during the week of the assessment team s visit. The assistant medical officer stated that the relationship between the hospital and the institution is very good, and that the students are able to help on wards with insufficient staff. The acting matron also added that sometimes the nurses are even able to learn from the students. At first, the assistant medical officer stated that there were no challenges, but with probing, both he and the acting matron admitted that the shortage of hospital staff can be challenging for clinical teaching, which is why they ask the tutors to come to the hospital with the students, to support them. But, with only one tutor at the institution this year, that has been difficult. If the institution is to scale-up enrollment, the assistant medical officer and acting matron felt that more clinical instructors are definitely needed, to support the hospital and the students. They felt that there was enough equipment to support more students and enough patients for students to see a number of cases. According to the principal, there are a lot of challenges with clinical training. The principal has tried to allocate people at the hospital to be in charge of clinical instruction, but with the staffing shortage, 155

162 they are not available when the students rotate in the wards. The principal also said that there are only small surgeries done in the hospital s operating theater, which makes it hard for students to see a full range of procedures. But, the hospital is upgrading its operating theater, so the principal hopes that will help to increase the number and types of surgeries done. Medical Staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Nursing School Specialists 0 0 Medical officers 1 0 Assistant medical officers 5 0 Clinical officers 6 0 Laboratory 0 technicians 3 assistants 0 Nurse tutors 0 1 Registered nurses 6 0 Enrolled nurses 43 0 Pharmacy 0 technician 3 assistants 0 Experience of Current Students Five female students and three male students met with the assessment team to discuss their experiences at Mbulu. The students decided to become nurses for a variety of reasons. Some were impressed by the good services nurses provide to the community. Others had been impacted by nurses who provided care to sick family members. One student really wanted to be a doctor, and sees nursing as just one step on the path to upgrading skills and education. When asked about the application process, the students said that the first selection is done by the MOHSW, but the principal is very involved in choosing students for second selection, which contributes to the higher number of local students at the institution. When asked if they liked studying close to home, one student said that studying outside of one s area provides more diverse experiences. The students did say that the beginning of the academic year was delayed by almost two months because of the second selection process and the time spent verifying certificates. They suggested that the verification of certificates should happen before students are placed, to avoid these delays and disruptions. When asked about the positive aspects of the institution, one student said that the availability of models helps them learn, as the models represent almost a true example of the human body they will be treating. Another student was pleased that there is a hospital next door for their clinical practice. Other students cited the challenges, such as the poor facilities at the hospital that deprive them of 156

163 opportunities to effectively practice clinical training. However, other students did say that the clinicians there try support them as best as they can, even though they are few in number. They also stated that there have never been enough clinical instructors to support them in the wards. The students said that the institution was stronger, educationally, when there were four tutors, and that having only one tutor is creating difficulties with their studies. The students were also concerned about the school s infrastructure. They would like to have a library where they can study, especially for the first-year students because they have no desks in their rooms. The students also felt that the institution needs another classroom because they are forced to be instructed in one classroom in shifts. One student also said that the institution needs to improve toilets and bathrooms in the old dormitory, as two are broken, forcing them to use only three toilets for 36 students. The students expressed the need for a skills lab, as they are currently using the dining room as a demonstration room. They also asked for recreational facilities and a canteen for purchasing supplies because they are not allowed to leave campus without specific permission from the warden or the principal. The students requested that the MOHSW make it easier for them to complete the computer module by providing funds for computers and a part-time tutor for it. Currently, students are incurring extra costs to study this module, yet it is a part of the core curriculum mandated by the MOHSW. Future Capacity and Recommendations Mbulu has already scaled up its enrollment considerably, supported in part through the addition of a new classroom and two new dormitory buildings. The lack of tutors is of extreme concern, as there is just one full-time tutor for over 100 students. With a few small investments and the completion of the new library, skills lab, classroom, and kitchen, Mbulu could even add a few more students to have two classes of 60 students each, if more tutors are placed there. Immediate (and to scale-up to a 120 enrollment target): Resolve blockages with the regional administrative secretary to complete the tendering process for the classroom, skills lab, and library buildings. Finish the kitchen and toilets that have been stalled by the contractor s work stoppage and pay him for his work. Immediately hire at least three additional tutors to meet current enrollment needs; and hire four full-time tutors when enrollment numbers increase to 120. Resolve computer training issues to alleviate the costs to students. Procure more essential textbooks and demonstration materials. Hire a clinical instructor (separate from other full-time tutor hiring) who will supervise students hospital rotations on a full-time basis. Construct two additional tutor houses to accommodate newly hired tutors. 157

164 Mkomaindo School of Nursing Background Mkomaindo Nursing School was built in 1967 by the Anglican Church as a training program for nurse midwives for pre-service students. In late 1970, the center was taken over by the Ministry of Health and Social Welfare (MOHSW); it continued to offer a certificate in nurse midwifery, adding in-service students. This program continued until 2005, when it changed to a three-year program for enrolled nurses (EN), which was condensed to a two-year curriculum in This nursing school is fully registered by the National Council for Technical Education (NACTE). Mkomaindo is located next to Mkomaindo Hospital in the town of Masasi, which is in the Mtwara Region of the Southern Zone. It is about one and a half hours from Lindi and two and a half hours from Mtwara town by road, in a relatively underserved area. The HIV prevalence in this region is 3%, which is much lower than the national average of 6 7%. Capacity Trends Mkomaindo was originally built for three classes of 40 students each, but there are currently 187 students enrolled, in three cohorts. There are three cohorts because there were two enrollments in Fifty-eight second-year students finished in March 2010, 52 second-year students finished in September 2010, and 72 first-year students who will finish in September There are also five inservice students who have been retaking their final term since they did not pass their exams in A new class of 71 students joined the program in March 2010 when the aforementioned second-year classes graduates. This new class increased overall enrollment to 200 students, including those five students repeating their coursework. The target enrollment is 280 students, which is an increase of 40% over its 2010 enrollment, with large cohorts being divided into smaller groups for instruction. Mkomaindo has a relatively high number of students from the region. There are 28 second-year students and 23 first-year students who are local. Local students account for more than a quarter of the enrollment at the institution. Retention Since starting the new two-year curriculum, Mkomaindo has lost about 20% of students from each of the first two classes due to problems verifying their secondary school certificates. For the two classes that started in 2008, 14 students in each class were asked to leave for this same reason. It takes a several months to very certificates, a process that often doesn t begin until students are enrolled. The principal submitted certificates for the September 2009 cohort in November 2009, but was still waiting for the results as of March None of the EN students have left the institution for any reason other than certificates. When the institution was a three-year in-service program, they did lose students due to academic issues, preg- 158

165 nancy, transferring to other schools, or poor behavior. In the final class of the three-year in-service program, there were five students who did not pass their exams. These students returned to the institution to retake their exams in March of Infrastructure Mkomaindo was built in 1967 for a maximum of 120 students. Very has been done to the infrastructure since it was originally built, and as a result, there is severe overcrowding, as buildings are too small to accommodate the almost 200 students. The institution is strained, using every available space to hold students, which has resulted in several rooms being used for purposes other than what they were originally intended for. Systems generally do not work properly and are in serious need of rehabilitation/replacement. Systems The water supply in Masasi District is extremely unreliable, which impacts the institution. There are two back-up water tanks, but they were only built to support 90 students. The students often purchase their own water. Electricity has historically been unreliable in the region as well, but the principal reported that it was supposed to be improving soon due to the use of natural gas as an energy source. The institution does not have a generator. According to the students and the principal, the septic tanks at the school are full but it is very expensive to hire a company to empty it. The students requested that new toilets be built to address this issue. Student Accommodation Mkomaindo is using all available space 58 rooms on the property for student accommodation. Because enrollment has expanded considerably without commensurate expansion to buildings, the institution has been forced to maximize space by adding additional beds to all possible rooms and by taking over tutor and principal housing for students. What was originally the warden s house now accommodates six female students. Twelve male students stay in what was supposed to be the principal s house. The principal lives in a single dormitory room in another part of the school and share her sitting room with a group of female students who are in the dormitory room next to her. Rooms that originally held five beds now hold 12, using double-deckers. Rooms that were meant for two to three students now hold five or six. Because of the number of students in each room, there is not enough space for desks or cupboards for most of the students. Personal vs. Dormitory Capacity / /11 Target Cohort 1 Cohort 2 Cohort spaces needed now, 150 needed in total Current capacity is 130 *Mkomaindo had three intakes in 18 months from

166 belongings are kept in suitcases, under beds, or in the few cupboards that are left in the rooms. There are no desks in the rooms for students to study. And, due to overcrowding on campus, there are very few places for students to study, outside of their rooms. For Mkomaindo to significantly increase enrollment, a major investment in additional dormitory space needs to be made Above lefr: A room in one of the female dormitories that now holds 12 students. Above right: A males dormitory room now holds six beds with space for only two small tables and no cupboards for belongings. to decrease overcrowding, return staff housing to its original purpose, and make room for additional students. Classrooms There are two classrooms, both of which were built to hold about 40 students too small for the number of students currently attending the institution. One of the classrooms was expanded by removing the dividing wall between the classroom and a demonstration room, creating one long classroom. As a result, that classroom can hold 50 students more comfortably; however, the other classroom cannot accommodate any of the other cohorts. The principal stated that students have to share chairs to fit into the classroom. There is also a small recreation room, smaller than both the classrooms, that is sometimes used as a classroom space. This is necessary since there are times when all three groups of students need classroom space. If the institution is to meet its current enrollment needs as well as scale up to 280, then three large classrooms that can be partitioned into two parts are needed. Large cohorts can be broken down into smaller groups for instruction. As long as Mkomaindo continues to have three different intakes of students at once, it will be important to have at least three large classrooms. Right now, there is only one classroom suitable for a large class and, as stated before, the old skills lab had to be sacrificed for its expansion. vs. Classroom Space /10 10/11 Target Cohort 1 Cohort 2 Cohort 3 3 large classrooms needed Average capacity is 40 These large classrooms should be partitioned into two parts so that large cohorts are taught in more manageable groups of about 50 each. The smaller classroom has furniture to hold about 44 students but must hold classes of students. 160

167 Kitchen and Dining Facilities The dining hall was built for about 40 students, so given the number of students, it is only used as a serving area. Students use any place they find suitable to sit and eat, such as in the dormitory rooms, under the trees, in the recreational rooms, and the like. Since there are no places to store students plates, cups, and utensils, students keep these items with their other belongings in the dormitory rooms. It is notable that the assessment team saw some kerosene cooking stoves in dormitory rooms; students said they sometimes do their own cooking in the rooms. The old kitchen is also no longer used due to its small size, and two external kitchens have been set up to create enough space to cook for all the students. The institution needs expanded dining and kitchen facilities that include adequate space for students to eat and store their eating utensils. Staff Offices and Accommodation There is no administration block, so the four staff offices are spread out across campus. The principal uses a former dormitory room as her office, with a space outside it for a secretary. The tutors office is in the old midwifery demonstration room, next to the library. The accountant s office is downstairs from the principal s office. As mentioned, there is no staff housing because it has all been converted to student housing. The principal stays in one single dormitory room, but the warden and other staff rent houses in town. Libraries and Teaching Resources Computers There are no computers available to the students at Mkomaindo. For the computer module in the new curriculum, the principal hired someone from the town to provide instruction. That instructor demonstrated the activities from the curriculum on a single computer and then students were asked to go into town to use computers at an Internet cafe to practice what they had just learned. There was one computer in the tutors office and one computer in the principal s office, but there is no Internet access at the institution. Resources in Library There is a small library, but it is not used by students because there is no librarian. The space for about 15 students at a time is clearly insufficient in light of the large student body. One of the tutors is in charge of lending the books to students. According to the principal and the tutors, there are not enough books for students, and the books that are available do not cover all aspects of the new curriculum. The principal would like additional copies of updated books. The books available in the library are not sufficient for the number of students. Mkomaindo is a distance learning site for Aga Khan University, so there is one shelf of books owned by Aga Khan for its students. The Mkomaindo tutors and students can use these books when they are not in use by Aga Kahn students. 161

168 The principal would like to build a large library, more suitable to the size of the institution. If this happens, they would turn the current library into a demonstration room. Demonstration Rooms and Teaching Aids There are no demonstration rooms; when the school was built, there were two, but they have been rededicated for other purposes. The former midwifery demonstration room has become the tutors office and currently holds five tutors. The second demonstration room was overtaken to expand the classroom next door to hold larger classes of students. There are some models and teaching aids scattered around the classrooms and tutors office, but according to the principal, there are not enough of them. The ones that the assessment team observed during the visit were very old and in poor condition. Human Resources Leadership and Management The principal has been at the institution for about one and half years. The institution despite the large number of students, the staggered enrollment, and the extremely limited facilities was very organized. Class schedules, clinical rotations, and academic calendars were color-coded, laminated, and displayed clearly on the boards at the entrance of the school. The principal shows incredible dedication to the students, evidenced by her giving up her housing to create more space for students. This dedication and that of the tutors were called out by the students during the focus group discussion. Tutors There are four full-time tutors as well as one warden who is a public health nurse with training in teaching methodologies who teaches part-time. The principal and one other tutor are nurse tutors. Another full-time tutor is a registered nurse who has been seconded from the hospital to assist the institution. The principal has sent this nurse to a short course in teaching methodologies. The remaining full-time tutor is a registered nurse who recently finished her nursing training and arrived at the institution in March She does not yet have any training in teaching methodologies, but the principal recruited her as a clinical instructor. The principal is currently looking for a short-course in teaching methodologies for this new tutor to attend. Student to Tutor Ratio Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target 7 additional tutors needed to reach target; 3-4 needed immediately Recommended NACTE student to tutor ratio is 25:1 All of the tutors, with the exception of the newest tutor who just arrived, were oriented on the new curriculum. The principal expressed concern that two years is not enough time to prepare students to work by themselves in periphery units. She felt it would be better if the qualified students could work 162

169 under someone for some time before going out on their own, for more support and supervision. She also stated that supporting 72 students in a single class is very difficult for tutors. The institution also relies on nine part-time tutors from the local hospital, including five registered nurses and four assistant medical officers. Each tutor oversees specific subjects from the curriculum, but they may ask staff at the hospital to teach topics within that subject. That way, each subject has the oversight of one of the full-time tutors, but they can draw on the expertise of the part-time tutors from the hospital as well. The principal and tutors in the tutor office. The principal reported that it has been difficult to find a teacher for the computer module. The institution has hired someone from town for this purpose, but he is asking for more money than the usual 10,000 TSH per day that is provided to part-time tutors. They have also had difficulty implementing the section on Integrated Management of Childhood Illness, due to inadequate funding. Clinical Instruction None of the leadership of Mkomaindo Hospital was available to meet with the assessment team on the day of the visit. Members of the team had met with the medical officer- and the matron-incharge of the hospital in August 2009 while visiting Masasi Clinical Assistant Training Centre, and they had the following information about the hospital s human resources. Medical Staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Nursing School Specialists 0 0 Medical officers 2 0 Assistant medical officers 7 0 Clinical officers 13 0 Laboratory 2 technicians 0 Registered nurses 18 5 Enrolled nurses 32 0 Pharmacy 1 pharmacist 0 Experience of Current Students Four female and four male students met with the assessment team to discuss their experiences as students. When asked why they decided to become nurses, one student spoke about the desire to receive the sort of respect given to nurses in the community for their noble services. Another student was inspired by having family members in the medical profession, while others spoke of nursing as their calling. 163

170 The students felt that it was important to be placed at a school outside of your local community because studying far from home provides students with more exposure to new environments and cultures. This exposure will help students provide health care services in diverse conditions and to diverse groups. When asked about the positive aspects of their experience at Mkomaindo, the students first complimented the tutors for their incredible dedication to the institution. They felt that the tutors work very hard despite their limited numbers and that the commitment they show to the students is overwhelming. The tutors also keep the students disciplined by providing close supervision and punishment to deviants. The students requested more tutors to be posted to the intuition so that there would be a total of 10 tutors, plus a librarian and a computer-skills trainer. When asked what aspects of the school could be improved, the students wanted a library, more dormitories (to decrease overcrowding), and larger classrooms. They also stated that all the buildings were in need of repair, and that the tutors and the principal deserved larger and more appropriate office spaces. They also felt that with the shortage of tutors, it was difficult to cover the whole curriculum in just two years. The students said that the food is very bad and that they only receive rice, ugali, and beans every day due to lack of funds allocated for food. They also requested improved mattresses, beds, desks, and chairs, because furnishings are very old. In terms of clinical teaching, the students complimented the tutors on trying to pass by the clinical areas every day to make sure that students have some guidance. The shortage of hospital staff means that rarely is there qualified staff to assist students with their clinical training. The students also said that the school and the hospital do not have all the equipment needed for clinical training, and they recommended that the school purchase more equipment for procedures, which could be reserved specifically for the students. Future Capacity and Recommendations Mkomaindo is operating far over its capacity and it is in need of immediate assistance to address the overcrowding of the current facilities and infrastructure as well as the lack of tutors. Because nearly all aspects of the institution require attention, meeting the current students needs can be addressed within the scope of further, immediate scale-up. Additional dormitories, classrooms, instructional aids, and tutors are all needed. Immediate: Address the shortage of water at the institution and the overflowing sanitation systems to create a sanitary and safe environment for students, as well as plan for a future usage by 280 students. Build dormitory space for at least 57 students to address the severe overcrowding and to return housing to staff. Hire four additional nurse tutors. Build a new dining hall/kitchen/multipurpose room that can serve 280 students. The existing one can only hold 40 and is no longer used. Build two additional large classrooms that can be partitioned to teach two groups at once. 164

171 Build a larger library and rededicate the existing library space as a skills lab. Rededicate the smallest classroom as a computer lab and equip it with computers. Hire a librarian. To reach a target enrollment of 280 students: Build an additional 100 dormitory spaces for additional students. Build another large classroom with a removable partition. Even if there are enough tutors to split the classes into smaller groups, Mkomaindo will still need a total of three large classrooms to accommodate three enrollments of students, as both first- and second-year students need classroom space. Hire four additional tutors to support an institution with three large classes of 93 students each. Build additional staff housing and an administration block. Assuming the district hospital experiences the same staffing challenges that all other visited hospitals face, hire a full-time clinical instructor at the school to supervise students during clinical rotations. 165

172 Njombe Nursing School Background Njombe Nursing School was established in 1975 as a nine-month training program for maternal and child health (MCH) aides, a cadre that has since been phased out of the Tanzanian health care system. Soon after, it was extended to a one and a half-year program; then, it evolved into a nursing program, offering a public health nursing certificate, followed by a three-year nurse and midwifery program. Of late, Mpango wa Maendeleo wa Afya ya Msingi (MAMM)(also known as the Primary Health Services Development Programme) condensed the nursing program to a two-year course of study, offering a certificate in enrolled nursing (EN) under the Ministry of Health and Social Welfare (MOHSW). Njombe is fully registered by the National Council for Technical Education (NACTE). Njombe is located in the Iringa Region of the Southern Highlands Zone, in the town of Njombe. It is about 4 hours from Iringa and 12 hours from Dar es Salaam by road. Njombe District Hospital sits adjacent to the school. The HIV prevalence in this region is 14.7%, which is more than double the 6 7% than the national average. Capacity Trends When Njombe was originally built, it had one classroom and one dormitory block to serve a cohort of 36 students. Today, there are three classrooms and 218 students. Now that the school offers the two-year EN certificate, there are two cohort intakes per year (March and September) and three total cohorts being taught at any one time. There are 55 enrollees in the January 2008 cohort, 83 in the March 2009 cohort, and 80 in the September 2009 cohort. The 55-student second-year cohort took their final exams, in March After March exams finish and that cohort leaves, a new class of 60 students entered the program, increasing overall enrollment to approximately 229 students. The target enrollment is 300, a 31% increase. About 20% (43 of the 218 [as of March 2010]) students come from the local region of Iringa. The principal considers this number to be a good proportion of local to non-local students. There are 26 second-year students and 17 first-year students who are local. Retention The most common reason that students leave the EN program is forged certificates. More than 11% (7 out of 63) of students in the January 2008 cohort and roughly 6% (5 out of 83) of students in the March 2009 cohort were forced to leave due to forged certificates. Of the 63 students who began in March 2008, 7 students failed their exams (11%) and are repeating their first year of studies. Only two students dropped out of the program: one due to illness and the 166

173 other due to pregnancy. One student has transferred to Mkomaindo School of Nursing and Midwifery and the principal believes that student remains enrolled there. Infrastructure Njombe was built in 1975, with 18 rooms to accommodate a maximum of 36 students. In 2005, new infrastructure was added and currently more is being constructed, including a large dining hall with a kitchen, a dormitory, and tutor housing. When completed, the institution will be better able to serve the current student body. For further scale-up, larger classrooms and more tutors will be necessary. This campus has a very large administration block with a plethora of rooms and space, which could be renovated or reallocated to meet specific needs, such as a library or a meeting space. The administration block at Njombe contains an abundance of space. Systems The water and sewage systems are overloaded are a considerable health threat to this school. They cannot support use by over 200 students. The sewage system has not been significantly upgraded since the school had only 36 students. The septic tanks are overflowing. They are serviced every three months but are already full before two months pass. The original dormitory block, intended to house 36 students, there are now 62 students, causing extreme taxing of the sewage and shower facilities. Further, the city water supply is unreliable, so rain catchment equipment and tanks are needed to supplement the city water. The principal reported that the electricity is largely reliable at the school; however, the school is located in an area where electrical storms are prevalent, with lightening storms that destroy power lines. This has affected internet reliability through TTCL (the parastatal telephony company which provides connectivity through above-the-ground wire connections). At the time of the site visit, the school s internet had been down for two months. Student Accommodation Njombe has spaces for approximately 144 students, but currently holds 211. There is one additional office room that has been converted to a living space for six students who are retaking their exams. There is severe overcrowding in the dormitory blocks. The institution has been forced to maximize their space by putting three and four beds (double-deckers) in a room intended for only two students. There are four dormitory blocks (one for males and three for females). There is another dormitory under construction, scheduled to be completed during The original dormitory, meant for 36, now holds 62 female students. Each room should hold two, but some hold up to six with three beds between them. There are cupboards in the rooms but no desks. 167

174 There are two toilets and washrooms at one end of the hall and three toilets and washrooms at the other end. There are 12 students to one toilet. There is no laundry area in this dormitory. The males dormitory has 12 rooms with four beds (two double-deckers) in each room. The block can hold 48, but the principal could not say how many actually occupy it. Each room has two desks but no cupboards, though they are being purchased with available funds. At the end of the hall are three toilets and washrooms as well as a laundry area. More toilets and washrooms are needed. Pit latrines are being built on campus. The other two dormitories, both for females, were built in 2006 and are connected by a toilet/ shower area between them. There are a total of 30 rooms; though each room was intended to vs. Dormitory Capacity hold two students, sometimes there are five or more in a room. The wing between the dorms has four toilets and nine washing facilities. There is space used for outdoor laundry on both sides of the dormitories. The dormitory under construction has 17 large, self-contained rooms and is intended to accommodate 80 students. It has an covered outdoor laundry area, a sitting/living room for students, and an additional block of pit latrines nearby. It is expected that this building will be completed later in When the new dormitory block is finished, the school will have a total of 224 spaces available, assuming the male dormitory block continues to hold up to four students in a single room. To scale up enrollment further from 218 to 300 students (roughly a 38% increase) would perpetuate the severely overcrowded conditions. Scale up is not practical unless and until an additional 76 spaces are created / / Target Cohort 1 Cohort 2 Cohort spaces needed: 80 new spaces will come in 2010 with the new dormitory; 76 additional spaces will be needed Current capacity is for up to 144, but is ideally at 120 Above left: The dormitory under construction is scheduled to be finished in 2010, with 80 spaces for students. Above center: One of the many male dormitory rooms where four males share the space. Above right: One of many female dormitory rooms where three beds hold six students. There are no cupboards for belongings or study tables. 168

175 Classrooms There are three classrooms, but only two are being used as such. The third sits unused because there is only one full-time tutor and one volunteer warden/full-time tutor. When the school was built in 1975, there was only one classroom for 36 students; the classroom was later expanded to fit 60 students, now making it the largest classroom at the school. It holds 89 desks and chairs as well as a teaching table and a blackboard. The second and third classrooms were built less than three years ago, each intended to hold 40 students, though could accommodate 50. While there are 77 chairs and desks in the second classroom, if all were occupied, it would be very crowded. The third classroom was empty, but there were extra desks and chairs in the other classrooms and elsewhere that could furnish this third classroom. As long as class sizes remain large, additional classroom space is needed. To accommodate the large class sizes which are now in the 80s and potentially growing, with a target enrollment reaching 100 in addition to the three existing classrooms, the school either needs three more classrooms that each accommodate 50 students, or two large 100-student classrooms with a removable partition. With the latter, a removable partition could divide a large cohort into two separate, manageable groups of 50 each for instruction. Dining Hall and Kitchen Facilities vs. Classroom Space The current dining facility and kitchen are very old, small, and in disrepair. Students must eat there in shifts. There is a new dining hall being constructed; once complete, the old dining area could be renovated and repurposed as a student recreation space or a library /10 10/11 Target Cohort 1 Cohort 2 Cohort 3 3 standard sized or 2 large classrooms needed Average capacity is 50 *Due to large their large size, cohorts should be broken into two groups and taught in manageable sections of 50 each, either by partitioning large classrooms or by providing standard 50-student classrooms. The new dining hall will seat up to 250 students and should be completed in the first half of The new building will house a kitchen, food storage, a cook s office, and toilets and washrooms for the kitchen staff. Given the increased student numbers, two additional cooking staff are necessary. The old kitchen at Njombe. 169

176 Staff Offices and Accommodation Njombe s administration block is one of the greatest infrastructure strengths of the school. There is a generous amount of administrative space 16 rooms in total more than enough to accommodate tutor offices. There are so many rooms that extra offices can be rented out. The principal s office is large, with space for receiving visitors. The secretary s space is adequate, with a computer, printer, and photocopier in working order. There are offices for tutors, the cleaner, a volunteer, a retired-but-working warden/tutor, and even a tailor. Other rooms are used as storage for supplies, textbooks, and chairs (which are rented out as a revenuegenerating activity); and there is a tutor tearoom, a meeting room, and a room for the workers union. The office space is adequate, should there be an increase of more than 8 more tutors. The rooms in the administration block compose a space that is highly flexible (some smaller and some larger rooms) that can be switched around to deal with growth (e.g., the current tearoom could move to a larger room should more staff come on board, or minor renovations could be made to create a small library). With regard to staff housing, the quarters would not be sufficient, should additional tutors be hired. The principal has a house and the servants quarters of that house were turned into a home for the secretary who will soon be sharing it with the newly-hired clinical instructor. The kitchen and dining hall under construction, expected to be complete in Njombe s administration block has extra space. Here, even the tailor has an office for his work. Libraries and Teaching Resources Computers There are no computers available for students use. There is a large room on campus that could be used as a computer lab. For the computer module in the new curriculum, the principal hired an IT person from Primary Health Care Institute-Iringa to teach part of it and rented several computers for two weeks, but this is very costly. The instructor (present at the time of the site visit) reported that the two-week course does not cover the entire module, only a basic introduction to computers. Resources in Library While there is not an official library or a librarian, there is a large storage room used for books in the administration block. The space cannot accommodate the entire student body, but it is large enough to hold a growing collection of books. The books are arranged by subject matter and students can borrow materials. There are many shelves, three tables, and two chairs that could be used as a reading space. There are no cupboards. The store for library books has shelving and a few tables. 170

177 Given that the third classroom is currently not used, and if two large new classrooms are built, then the library resources could be moved to that small classroom to make it an official library. However, without a librarian, it would continue to function simply as book storage. The books are largely outdated and are few in number. The principal estimates that 25 students share a single, essential reference book. Current titles in multiple copies are needed to support the curriculum. Demonstration Rooms and Teaching Aids There is a skills lab with some equipment in it. The room is intended to hold 43 students at a time, though class sizes are now in the 80s. According to the principal and students participating in a focus group, even if the room were larger, it would not be appropriate to try to demonstrate skills to such a large number of students. As it is now, students must wait in long queues to view or practice a technical skill in the lab. Compared to many other sites, this skills lab was relatively more resourced. The room holds four screens, two hospital beds, a baby s crib, bed sheets, blankets, forceps, trays, one ZOE model for antenatal exams, one internal organs torso and head model, one steamer, one sterilizer, and one breast exam model. However, the principal and students reported that there were not enough models or charts. Human Resources Leadership and Management The principal has been at the institution for about five years. She was very knowledgeable about the history and the needs of the school as well as its expenditures and revenue-generating activities. She is currently overseeing numerous construction projects. The principal actively searches for revenuegenerating opportunities. For example, chairs are rented out to the community for events. There are also pigs bred on the property and the piglets sold to raise funds for the school. Tutors There is a severe shortage of full-time tutors at this institution. Though there are three full-time tutors employed, only one is present and currently working: the principal. A retired nurse tutor volunteers as both a warden and a full-time tutor; she receives a small payment for her work. One tutor is out sick with heart problems and is not expected to return to work. One clinical instructor is expected to join the staff this year. Student to Tutor Ratio additional tutors needed 8 tutors urgently needed immediately All of the tutors have been oriented to the new curriculum. The principal expressed concern that two years is not enough time to prepare students to work by themselves in rural dispensaries and health centers Student to Tutor Ratio 09/10 Student to Tutor Ratio at Target Recommended NACTE student to tutor ratio is 25:1 171

178 She also worried that students do not receive the necessary instruction or supervision, especially with only two tutors actually teaching, though even if all employed tutors were teaching, it wouldn t be enough. Tutors are unable to accompany students on clinical rotations while one class is in clinical rotation, the tutor is teaching another class. Further, with so few tutors, mitigating strategies like breaking down a large cohort into two sections for instruction would not be possible because then a tutor would be constantly teaching and have no break. To teach classes in sections, many more tutors would be necessary. The principal reported that at least eight more full-time tutors are needed, in addition to the new clinical instructor. The institution relies on five part-time tutors from the local hospital. This includes three assistant medical officers, one medical officer, and one registered nurse. At the hospital, the principal said that more preceptors and mentors who can support clinical supervision are needed. Clinical Instruction The Njombe district nursing officer met with the assessment team to discuss the benefits and challenges that Njombe District Hospital experiences in its effort to support students clinical rotations. The relationship between the district hospital and the school is a positive one. The district nursing officer explained that because there is a shortage of trained staff at the hospital, students are helpful changing beds, cleaning, delivering specimens to the laboratory, and taking temperatures. On average, students spend about 40% of their time in the wards on clinical rotation versus 60% spent on classroom instruction time. There are two main challenges the hospital experiences in its effort to support student learning. First, there is a shortage of EN or registered nurses to supervise and follow up with students. As a result, students are sometimes left alone in a ward. Second, there is a shortage of vital equipment and supplies, such as blood pressure machines, suction machines, sterilizers, thermometers, and catheters. These challenges, combined with the fact that the school does not have enough tutors to supervise students at the hospital, further highlight the need for more human resources to provide student support. While there are plenty of patients to support clinical rotation, there are not enough supervisors to support the more than 60 students at a time in the hospital. The district nursing officer recommended that there be three or four student supervisors per hospital ward to support so many students. Currently, there is only about one supervisor per ward. The district nursing officer reported that when a particular ward is fully staffed, the supervision goes well. 172

179 Medical Staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Nursing School Present and Working Specialists 0 0 Medical officers 3 0 Assistant medical officers 12 0 Clinical officers 4 0 Laboratory 1 lab technicians 3 lab assistants 0 Registered nurses 93 0 Nurse tutors 1* Enrolled nurses 22 0 Pharmacy 1 pharmacist 1 pharmacist technician 0 * The volunteer warden/tutor, in practical terms, is functioning as a second tutor at Njombe. Experience of Current Students Four male and four female first- and second-year students met with the assessment team. The students offered magnanimous reasons for entering the nursing program, including the desire to improve the health of people in their home areas, to help patients, to reduce mother and child deaths, and to educate others. When asked about the application process, many students described being assisted or encouraged by relatives or authorities (such as a zonal coordinator) to submit an application. Another saw a notice on a hospital board. One student traveled to the offices of the MOHSW to obtain information about the program and to submit an application. Students had differing ideas about whether the application process should be centralized or decentralized. Some wanted to apply to the MOHSW, while others wanted to submit applications through a hospital, a principal, or even a church. When asked about the overall environment at the school, some students thought the situation was comfortable while others were uncomfortable with their surroundings. Overall, they were satisfied with the quantity and quality of food. Students desire more books and models (they only have a pelvic and fetal scar model). They also emphasized that there is a shortage of tutors. When asked about what in their program of study could be improved, they brought up the difficulties with clinical rotations. There is a shortage of equipment in the hospital to practice common procedures, from blood pressure machines to gallipots to dressings and other tools. Overall, though, they were satisfied with the supervision they were receiving in the hospital setting. The students understood that the intention of the EN program was to post new graduates to rural areas and they expressed a willingness to go to villages; however, they were also concerned about 173

180 what their living conditions would be. They were worried that the MOHSW was not necessarily providing housing for those assignments. Students were curious about the process of upgrading from an EN to a diploma-level nurse. Future Capacity and Recommendations Njombe is currently operating over its capacity and is in need of immediate assistance, especially in terms of human resources. It is not possible to further increase enrollment (as of March 2010, there are nearly 230 students with an average cohort size of 75) without significant investment in the school s infrastructure. Instead, by finishing the construction in progress especially the new dormitory and the dining hall the institution can provide an adequate physical infrastructure for the existing student body. But, without additional full-time tutors, improvements to the physical space are not enough to improve conditions at this school. Immediate (to maintain current enrollment at the institution): Complete the construction of the dormitory, dining hall, kitchen, toilets, and washrooms to create a more adequate and a healthy living space for students. For the health of the student body and staff, overhaul the existing sewage system, expanding it to serve not only the current population but future enrollment increases (300 students). Build two large lecture halls with removable partitions that can each accommodate up to 100 students; or, build three more classrooms that can accommodate 50 students each. Hire eight additional full-time tutors to reduce the teacher-to-student ratio. One of those tutors could be an IT specialist. Build two more side-by-side houses for new tutor hires. Purchase more library resources, including more essential books from the curriculum. Equip the computer room with approximately 40 computers. Increase staffing levels at Njombe District Hospital to have better clinical supervision for students on clinical rotation. Rededicate one of the smaller classrooms as a library and the other as a library study space. Alternatively, renovate the old dining hall and kitchen to create a library space. To reach target enrollment of 300: Add 76 additional dormitory spaces to accommodate additional students. Build a large multipurpose room that can serve as a meeting room and recreation hall, and possibly as a rentable space to bolster school revenue. Build an additional room that could serve as a library and hire a librarian. Build additional tutor housing. 174

181 Same School of Nursing Background Same School of Nursing was established in 1977 with support from the US government as a training center for maternal and child health (MCH) aides, a cadre that has since been phased out of the Tanzanian health care system. In 1996, the institution changed, offering a two-year in-service public health program. In 2004, the program again changed to become a three-year in-service nursing and midwifery program. Four years later, in 2008, the institution began the two-year pre-service program for enrolled nurses (EN). Same offers a certificate in that field under the Ministry of Health and Social Welfare (MOHSW) and is fully registered by the National Council for Technical Education (NACTE). The nursing school is located in the Kilimanjaro Region of the Northern Zone in the town of Same, adjacent to Same District Hospital. Same is about one and a half hours from the town of Moshi by road, and about seven hours from Dar es Salaam by road. The HIV prevalence in Kilimanjaro Region is 1.9%, which is much lower than the 6 7% national average. Capacity Trends Same was originally built to hold 36 students. Though it has plans for infrastructure expansion, none have yet manifested and therefore the institution still only accepts one intake of students at a time. At the time of the site visit, Same had a total of 34 second-year students. These students were scheduled to take their exams and graduate in March numbers have remained steady since the adoption of the two-year program. Prior to the adoption of the new curriculum, Same had about students at a time. At the end of March 2010, the institution received a new class of 50 students this 40% increase in enrollment is straining the school s current infrastructure and capacity. At the time of the visit, the principal felt that the number of students who will actually report to the institution will likely be fewer than 50, given past trends. In previous years, the institution only received students during first selection and increased that number during the process of second selection. The target enrollment for this institution is 100 students, representing an increase of 175% from its initial capacity. The EN students in this institution are all pre-service students. There are also nine in-service distance learning students who are assigned to take their exams at Same. The institution currently has 18 local students (53%). The principal said that the MOHSW used to discourage local students from applying to their local institutions, and therefore many locals did not do so; however, in the past few years, more local students have come to the institution to enquire about the program and to seek enrollment. Retention The current class started as 40 students in the academic year. Five students dropped out during their first year due to poor academic performance and an additional student left during the 175

182 second year for the same reason. According to the principal, Same has not had to disqualify any students due to forged certificates. The principal did not feel that the institution does anything differently from other institutions, so she was not sure why Same has not experienced the same problems with certificates as other institutions. Infrastructure Systems According to the principal, the water and electricity in Same are generally reliable and do not cause many problems for the institution. The water is available every other day, and the institution has water tanks to hold reserve water. The power supply has also been reliable, and the institution does not have a generator. Student Accommodation The institution has one dormitory with 18 rooms along one long corridor. These rooms are a bit wider than those at some of the other former MCH aides institutions, but they are not set up to take more than two students in each room. The rooms have double-decker beds on one side and built-in desks and cabinets on the other side. It would be very difficult to fit more than two students in the rooms as they are configured. If the full 50 students report to the institution in the next academic year, the principal said she would be forced to remove the desk/table in each room to add a third bed. There are only three toilets and washing facilities for the students, so any increase in students will also require an increase in those facilities. vs. Dormitory Capacity There is one additional room with four beds in it that is located directly off the kitchen. Formerly a storeroom, it was converted last year when 40 first-year students reported to the institution, which had no extra space in the dormitory. When the institution lost five first-year students, they stopped using this room for students. It is currently used for the distance learning students when they are at the institution for exams. Because of its proximity to the kitchen, this room is not ideal for housing students /10 1st year students 10/ Target 2nd year students 64 spaces needed Current capacity is 36 The principal has architectural plans drafted for a new multistory dormitory. The funding for the first story of the building (22 rooms) was allocated by the MOHSW, but there has been very little progress and many delays in the three years that the principal has been at the institution. The current status is that the Tanzania Building Agency has refused Same s dormitory rooms have double-decker beds on one side of the room and a built-in desk on the other side. 176

183 to sign off on the plans unless they are redone because the regional engineer did not check the soil before creating them. It is unclear when construction will start, but this building is crucial to Same s ability to scale up enrollment and accept two classes of students at one time. With this additional infrastructure, the institution will have the ability to meet a target enrollment of 100 students two classes of 50 each. Kitchen and Dining Facilities The very small dining room and original kitchen are adjacent to the dormitories. There were no chairs in the dining hall; it is used as a space for picking up meals but not eating. The institution added a large area for food preparation and cooking. The kitchen and dining areas are all very clean, orderly, and well maintained. The principal did state that ideally, she would like to have a larger dining hall for the students, especially if the institution is to increase enrollment. Classrooms There is only one small classroom at Same with desks and chairs for 36 students. The room was completely full with this amount of furniture, so it would The one small classroom at Same be difficult for the is full with 36 desks and chairs. institution to hold a class of 50 students with its current layout. The institution also has plans for a new classroom that would hold 50 students comfortably. 0 While these plans have been approved and funded by the MOHSW, the MOHSW has not yet authorized the school to move forward with them. The principal is waiting for the signature from the MOHSW that will allow construction to commence. vs. Classroom Space /10 1st year students 10/11 Target 2nd year students 2 classrooms needed to hold at least 50 Current capacity is 36 in a single classroom In addition to this classroom, one other classroom is needed to accommodate a target enrollment of 100 students. The existing small classroom could be rededicated as a computer lab, a study space, or a recreational area. Staff Offices and Accommodation A new administration building at Same was built in There is a large office for the principal, a conference room for the staff, a private office for the accountant, and five additional offices for tutors and staff. There is a surplus of tutor offices. The administration building is the only new construction on campus. New administration building at Same. 177

184 There are three houses for tutors; the principal lives in one and the warden and one other tutor live in the others. The third tutor, who arrived in 2007, has to rent her own accommodation in town. Libraries and Teaching Resources Computers There are six old computers available for the students, which are stored in the principal s former office when not in use. This room, combined with the adjacent former secretary s office, could be a computer lab if the wall between them was knocked down and minor renovations made. There is no Internet access at the institution for staff or students. When teaching the computer module in the curriculum, they move all the computers into one room. A Japanese volunteer who was placed in Same helped to teach the computer module last year. This volunteer s contract is now finished, but the principal has recruited a teacher from a nearby community development college who is helping to teach it. Resources in Library Same does not have a library building, although the principal plans to build a library once the MOHSW authorizes it. There is a small room in the old administration building where they keep the books, and students go there to sign out books from one of the tutors. Same has an adequate number of books for 36 students in most subjects. According to the principal, they are short on supplementary books for the mental health and leadership and management modules. If the institution scaled up enrollment, more copies would be needed. The principal has been looking to hire a library assistant, but has had trouble finding people in Same who meet the MOHSW s qualifications for this position. Library books are kept in a room in the old administration building because there is no dedicated library building. Demonstration Rooms and Teaching Aids Same does not have a demonstration room or skills lab. There is a well-organized closet in the back of the classroom where the principal stores the equipment for demonstrations. Although the equipment is well maintained and organized, there was not enough of it to support all the students. For example, there were only three pelvic models, which is not enough for 36 students during the midwifery courses. The town of Same has a sister town in the Netherlands called Tilburg, which provides support to the district council, the hospital, and the nursing school. The people of Tilburg have raised funds to build a skills lab at Same, and the district will manage the construction process. The Equipment for demonstrations at Same. principal is waiting for the district to sign off on the plans. She expects this will happen soon and that construction will commence in

185 Human Resources Leadership and Management The principal has been at Same for about three years. During that time, the institution has received funding for a new classroom and building, although those plans have not yet been realized due to delays in the planning process. The principal seems committed to the institution and is interested in increasing enrollment so that the school can accommodate two classes of students at one time. The institution was very clean and orderly, and the buildings were well maintained, despite their age. Tutors There are three full-time tutors currently teaching at the institution. There is also a warden who teaches part-time, in addition to her warden Student to Tutor Ratio 35 duties. Two of the tutors, including the principal, are qualified nurse tutors. The third tutor and the warden are registered nurses who have been trained in teaching methodologies. The principal indicated that she would need at least three 20 additional full-time tutors to increase enrollment while maintaining educational quality. This number is greater than the NACTE ratio of 25 students to 1 tutor. According to the NACTE ratio, Same would need one additional full-time tutor if enrollment were scaled up to two classes of 50 0 Student to Student to Tutor students each. But, her argument for additional Tutor Ratio Ratio at Target 09/10 full-time tutors was reiterated by other nursing school principals who also felt that despite meeting the NACTE-recommended ratio, in reality, more tutors are needed to maintain quality. 1 additional tutors needed Recommended NACTE student to tutor ratio is 25:1 The principal said that the institution is not heavily reliant on part-time tutors, as it has enough full-time tutors to cover most of the subjects for the one class of students at the institution. The school does sometimes use two registered nurses (including the patron at the hospital), one medical officer, one assistant medical officer, and one health officer as part-time tutors and to help with clinical examinations. Clinical Instruction The assessment team met with the medical officer-in-charge at Same Hospital, a district hospital with 120 beds and about 70 admissions per day. The patron of the hospital conducts students clinical examinations, so was not available to meet with the team. The medical officer was at the HIV care and treatment clinic, which was extremely busy with patients at the time of the visit. The medical officer stated that the collaboration between the hospital and the nursing school is strong, as they have been working together for many years to train and upgrade MCH aide students. The medical officer felt that there is ample time for students to practice clinical skills and that they 179

186 learn a lot working at the hospital. He also felt that the fact that some of the staff are part-time instructors helps with collaboration between the institution and the hospital. According to the medical officer, the shortage of staff is the biggest challenge to providing effective clinical training to students. The students often do not find trained personnel in the wards to teach them, and they end up working with medical attendants. Sometimes the tutors come to the hospital to assist, but generally the students learn from the staff at the hospital and there are not enough of them. The medical officer also felt that new equipment was needed to better train students. He felt it is important to have all the necessary equipment so that the clinicians can give proper instruction to the students. He was concerned that there are many things the students only learn about in books but never see because equipment is so limited. The medical officer did not feel that it would be difficult for the hospital to handle an increase in students. Since first- and second-year students learn different procedures, the hospital could spread them out accordingly. The institution and the hospital currently put about four to five students on each ward per shift. The principal also felt that this number could be increased since there are many patients. Medical staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Nursing School Specialists 0 0 Medical officers 0 (1 is on study leave at Kilimajaro Christian Medical Center) 0 Assistant medical officers 6 0 Clinical officers 9 0 Laboratory 2 lab technicians 2 lab assistants 0 Nurse tutors 0 2 Registered nurses 27 2 Enrolled nurses 29 0 Pharmacy 1 pharmacy technician 2 pharmacy assistants 0 180

187 Experience of Current Students The students were taking their final clinical exams during the time of the visit, so no student focus group discussion was conducted. Future Capacity and Recommendations The institution already has plans in place that would allow it to enroll a second class and increase enrollment by more than 175%, compared to its original capacity of 36 students. If the blockages that are keeping these plans from moving forward can be overcome, Same could have enrolled a second class, potentially by March Realistic and immediate to meet a target of 100 students: Resolve the planning issues that have put the construction of a new dormitory on hold and commence construction immediately. The first story of the new dormitory plan calls for 22 rooms, which would immediately allow Same to double its enrollment by adding a second class of 40 students. Completing both stories will allow for more than 100 total spaces on campus. Resolve the blockages hindering the approval of plans for the library and large classroom. Build a new dining hall and kitchen to accommodate 100 students. Build an additional classroom to comfortably accommodate 50 students. Move forward on the planned skills lab sponsored by the town of Tilburg, Holland. Hire one additional tutor to meet the NACTE-recommended ratio once target enrollment is achieved. Hire an additional clinical tutor to supervise students during clinical rotation full time. Renovate the old administration space to create a computer lab for students and equip it with new computers; invest in an Internet connection. Procure additional, essential textbooks, manuals, and equipment for the library and skills lab. Build two more tutor houses. Rededicate the original classroom as a recreational or study space. 181

188 Tarime School of Nursing Background Tarime School of Nursing was established in 1979 as a training institution for maternal and child health aides, a cadre that has since been phased out of the Tanzanian health care system. In 2005, the institution began offering a three-year certificate program for enrolled nurses (ENs), adopting the condensed, two-year version in Tarime School of Nursing is under the Ministry of Health and Social Welfare (MOHSW) and is fully registered by the National Council for Technical Education (NACTE). The institution is located adjacent to Tarime District Hospital in the Tarime District of the Mara Region, which is in the Lake Zone. The HIV prevalence in this region is 5.3%, which is lower than the national average of 6 7%. Capacity Trends Tarime was originally built to hold 36 students, but has expanded its dormitory and classroom spaces. While there are now 84 dormitory spaces, there is only classroom space for 60, though enrollment far exceeds that. There a total of 124 students divided in two cohorts 68 first-year students and 56 second-year students, the latter of whom were scheduled to graduate in July This total represents nearly a 250% increase from original capacity. There is additional dormitory infrastructure expansion scheduled, but classroom space is still lacking. The target enrollment for this institution is 240 students, but this is dependent upon significant investments in infrastructure and human resources. Land is limited at Tarime and therefore strategic infrastructure expansion is crucial to further scale-up. If target enrollment is achieved, the institution will experience a more than 100% increase over current enrollment. The institution currently has 55 local students (44%). The principal said that the local communities are very eager to enroll students locally. During the application periods, for example, local community members tend to come to the institution to persuade the principal to enroll their children at Tarime. Though the selection process and procedures are centrally determined by the MOHSW, the institution normally provides guidance and support before sending in its applications to the MOHSW. In addition, local students are given priority during second selection. All 36 students admitted in second selection in the last two academic years were from Mara Region. The principal explained that Tarime gets more local students than other nursing schools because of the appealing environment of the institution. The principal cited the good working relationships between it and the community as well as the physical environment as factors in attracting local students. Students involved in the focus group also indicated that they prefer to study in schools that are located at least within the zones of their homes, which might also explain why they prefer this institution. 182

189 The principal indicated that normally, the MOHSW sends more students than the institution can hold, but this has been balanced with those who drop out or fail to take the offers. Retention Compared to other institutions visited, Tarime appears to have more students struggling academically who, in turn, are forced to drop out or repeat coursework. Ten students in the first cohort of the twoyear program failed, though only two of them fully dropped the program; the other eight repeated coursework and joined the newer cohort of students. All 60 students from the first-year cohort who entered the program in July 2009 remain. This cohort now has 68 students, in light of the eight repeating their first year. This cohort might have been larger, but none of the 14 second-selection students reported for class; the principal could not explain the reason for this. To date, none of the students have been dropped due to forged certificates or inadequate qualifications but this is because the process to verify their data has not been completed by the MOHSW. The principal suspects that at least two first-year students will be asked to leave once verification is completed. Infrastructure Tarime has expanded its facilities since first opening in Recently, a large assembly hall was added and additional infrastructure is under construction, including dormitories, a classroom, offices, and a skills lab, as well as expansion being done to the dining hall). Unlike many other institutions, the power and water supply systems generally work well. Tarime has very limited land space for structure growth and has requested land from the adjacent district hospital to build more dormitory space, which is actually under construction. The principal indicated that they are negotiating with the district executive office to acquire a 20-acre plot of land from the conservation area adjacent to the school. The principal stated that the situation looked promising and she showed determination to keep pushing for this. Systems The principal indicated that the supply of water and electricity from the district s systems is largely reliable. However, there was no running water during the time of the visit, even though the school has large water reserve tanks to hold more than 10,000 cubic liters of water. The principal reported that the water supply systems were not working well ever since the new dormitory was completed, which blocks some areas from receiving piped water. The institution has no back-up power supply and depends entirely on the supply from the national grid. Student Accommodation Tarime has three dormitories with a total of 34 rooms, making 84 spaces. An additional 48 spaces have been created by converting a classroom into dormitory space, which, all together, accommodate 124 students. There are 63 double-decker beds dispersed throughout the rooms. Some spaces were not occupied. 183

190 The oldest dormitory has 18 rooms for 36 students, but one of the rooms is used for storage. The rooms are overcrowded with three or four students in each room. The desks and cupboards have been removed. This dormitory has never been refurbished and the doors, toilets, painting, and ventilation are not in good condition. The second dormitory is located on the ground floor of a new two-story building. It has 12 rooms for four students each, for a total of 48 spaces. The building also holds a skills lab, a classroom, and office space for tutors on the upper floor. One of the dormitory rooms is used for food storage. The principal reported that there are some empty beds. This building does not yet have electricity, though it is wired for it. The principal noted that the current electrical voltage supply vs. Dormitory Capacity at the school is very low, to the extent that it will not work properly if the new building is supplied from the same source. The institution was advised to apply for a completely new transformer from the TANESCO (the national power supply company), which they have already done. They were in the final stage of the process at the time of assessment team s visit /10 1st year students /11 2nd year students 156 spaces needed 160 spaces expected in October 2010 when the new dormitory is completed Current capacity is 84 Other dormitory spaces have been fashioned out of the original small classroom meant for 36 students. The classroom was partitioned into rooms, three of which hold male students and one large one can hold six female students. Thirty male and 18 female students live in this classroom/dormitory. Students use one toilet located on one hall of the classroom/dormitory, and it also serves as a bathing area. The students said that they also use other pit latrines and showers located outside the building. The other dormitory space is a former tutor house where 12 male students live. Construction has commenced on a new two-story dormitory that will have 40 rooms with capacity for a total of 160 students. There will be ample washrooms and laundry facilities. At the time of the visit, slightly less than half of the building had been completed. The project engineer, in agreement with the principal, stated that the building would be completed and furnished by October Once completed, and once the electricity is secured in the second dormitory, the institution will have space for 244 students. Further, the tutor house can return to its original purpose and the classroom be rededicated as a small library, as the space is not designed to accommodate students. The old dormitory: The cupboards and reading tables were removed to make room for two double-decker beds. A new dormitory that is under construction at Tarime. It will have 40 rooms to house 160 students. The classroom at Tarime holds 60 students at a time. 184

191 Kitchen and Dining Facilities Kahama Nursing School has a very small dining room and a small kitchen intended to service 36 students. The principal reported that plans for expansion are in the final stages, but the assessment team had the impression that only the staff and visitors use the space for their meals, rather than students. The funds for expansion were already provided and the institution is waiting for the MOHSW to finalize the tendering procedures for the work to begin. Classrooms Though there are two classrooms but, only one is used for instruction. It has enough space as well as desks and chairs to comfortably hold 60 students at a time. At the time of the visit, the institution was using the large assembly hall as a second classroom because it has the capacity to hold 80 students at a time. There is enough furniture in this hall and at the moment, it is being used by the second-year class of 56 students. To reach a target of 240 students, the institution would have to accept two very large cohorts: 120 first-year students and 120 second-year students. These large groups would have to be broken down into groups of 60 for instruction. To accommodate them, the institution would need three vs. Classroom Space new classrooms, each with capacity for 60. Other facilities and human resources would be needed as well /10 1st year students Target 2nd year students 3 additional classrooms needed Current capacity is 60 Staff Offices and Accommodation There are enough staff offices and office equipment, such as computers, printers, a photocopier, and shelves, and all are in good condition. The principal s office is large, with space and furniture enough to hold a small meeting. There is another large office space for the academic officer that is big enough to hold two more tutors. The new building has another office that can hold two more tutors but is not yet occupied. There is a small room for the secretary adjacent to the principal s office and one for the storekeeper located in the same building. The offices will be sufficient even when there are more tutors. Principal s office at Tarime. Other tutors and staff have adequate office space. The institution has six housing spaces for tutors, including the one that accommodates 12 male students. This is a large number of tutor spaces, in comparison to other institutions. The other houses are occupied by the principal, two tutors, an accountant, and a storekeeper. The principal has made an agreement with the other staff occupying the houses that they will vacate them once new tutors arrive. The other staff will have to find their own accommodation and no allowances will be provided. 185

192 Libraries and Teaching Resources Computers There is a computer room with six computers one is broken and the other five are regularly used by students. The principal reported that the computers were bought using the savings from the costsharing money, and some income generated from renting out the assembly hall. Students take their computer lessons in this very small room that only holds 10 students at a time. A part-time computer training specialist teaches the students and also trains other clients from outside the school, who pay 20,000 TSH for the services. The generated funds are used for computer maintenance, to buy accessories, and to pay the Internet bill. The funds also help to pay the trainer, who is available full-time at the institution and is treated as one of the full-time staff. The principal said that efforts to employ the trainer on a permanent basis are promising. The Internet was not working at the time of the visit and the principal said it was disconnected due to cost. However, even when there is a connection, only tutors have access and students are not allowed to use it. The principal stated that they would not be able to pay for the services if students were allowed to use the Internet. Resources in Library There is no library building; rather, books are kept in a small room in the old administration block, along with the demonstration materials. Students must sign books out. When the new dormitory building is complete, the old classroom now partitioned as dormitory space will be reconverted to a library. Additional and current versions of reading materials, including books, reference materials, and new furniture will be needed. Students reported that groups of eight or more must share a single textbook. Tarime library is a small room at the old administration building. Reading materials are kept along with demonstration materials, which are kept in boxes. Demonstration Rooms and Teaching Aids The institution has a new room in the recently-completed building that is designed to be a demonstration room. The room however, is completely unfurnished and empty because the institution is waiting for allocated funds from the MOHSW this financial year. The principal said since last year, Jhpiego expressed interest in supporting the institution to furnish and equip the skills lab, but nothing had happened as of the visit. At the moment, all the demonstration materials are kept in boxes in a small room along with the library materials, as mentioned previously. Demonstration materials are brought into the classroom for demonstration sessions and returned to the library area for storage. Human Resources Leadership and Management The institution has a current total of 11 full-time employees. This includes three tutors and nine other staff members, including an accountant, a storekeeper, a secretary, two cooks, two security guards, 186

193 and office attendants. There is another cook that is paid for by the principal to support the other kitchen staff. The secretary and office attendants will retire in December. There are also two more teaching staff employed, but one is on study leave and another is no longer teaching due to illness. The institution expected to replace the tutor who left due to illness in April There are many recent developments at Tarime that could be directly attributed to the current management and leadership. The principal has demonstrated initiative and commitment towards increasing the capacity of the institution to hold more students while maintaining the quality of teaching. She continues to send more proposals to the MOHSW for further expansion of the existing facilities. The new, large dormitory block under construction and efforts to secure land from the hospital demonstrate the principal s motivation to improve the institution and its surroundings. The partitioning of unused classroom space into a dormitory to create more bed spaces also shows creative problemsolving. Perhaps as an indication of the institution s reputation, the principal noted that there are more tutors who are expected to come on board, some of whom requested to be transferred to Tarime. The institution maintains a good relationship with the local community and district hospital management. The principal thinks that staff should be motivated through regular visits from the MOHSW and the President s Office of Public Service Management, as well as opportunities for staff development and skills upgrading. The principal shared her vision of the institution offering a diploma and other higher degrees. Tutors Currently there are three nurse tutors present and working, including the principal two of these are nurse tutors, while the third is a registered nurse. They have all been oriented to the new curriculum and trained in teaching methodologies. There is one more tutor who is a public health nurse (PHN) but has not been able to teach since 2005, due to health problems. The principal indicated that there are four more tutors on track to join the institution, one of whom was expected at the beginning of April According to the principals, finding tutors for any specialty is not a problem, as there are many tutors at other nursing schools that request transfers to Tarime. Student to Tutor Ratio Student to Tutor Ratio 09/10 Besides salary, the principal indicated that the tutors receive additional compensation from the MOHSW, such as housing, extra-duty allowances, leave allowances, and examination expenses. Some of these allowances, especially extra-duty and examination, are not sent to the institution very often. The assessment team could not verify whether the allowances were provided from the resources sent by the MOHSW with the institutions operational budget, or from other sources. The institution relies on ten part-time tutors, including six registered nurses, two medical officers, one pharmacist, and a computer training specialist. All except the computer training specialist work Student to Tutor Ratio at Target 7 additonal tutors needed; 2 needed immediately Recommended NACTE student to tutor ratio is 25:1 187

194 at the district hospital and are paid 10,000 TSH per training day. The part-time tutors have also been trained in teaching methods, as organized by the MOHSW. No additional compensation is given to part-time tutors apart from opportunities to attend orientation and training workshops. Clinical Instruction The assessment team met with the assistant matron-in-charge at Tarime District Hospital because the matron-in-charge was on leave. The hospital contains 176 beds and on average, has a daily admission of between 70 to 100 inpatients. The assistant matron indicated that having students doing their clinical practice at the hospital benefits both parties, especially because the hospital has a shortage of health care workers. The assistant matron indicated that the hospital needs 56 more registered nurses and 113 more ENs. Students spend seven hours (7:30 am to 2:30 pm) in the wards, in groups of eight to 10 students per ward. They are supervised by a nurse and an attendant as there are no clinical instructors at the school to supervise students. The principal indicated that they contract interested nurses on a parttime basis to provide clinical instruction, and are planning to request that the hospital to make them full-time instructors. Even so, the number of students that a nurse has to instruct is overwhelmingly high and the assistant matron felt that five students is the maximum a nurse can effectively supervise. The matron indicated that the current number of patients is adequate for the training of EN students. Also, there are a variety of cases to support a range of training, even if enrollment numbers increased. However, the matron felt that there should be one clinical instructor in each ward to instruct students. The matron also stressed that it was important to increase the number of health care workers in all the cadres, as well as provide additional necessary equipment. Medical Staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Nursing School Specialists 0 0 Medical officers 0 0 Assistant medical officers 6 0 Clinical officers 15 0 Laboratory 3 technicians 3 assistants 0 Nurse tutors 0 2 Registered nurses 24 (only 10 in bed-set care) 1 Enrolled nurses 34 0 Pharmacy 2 assistants 0 188

195 Experience of Current Students A total of eight students with a balanced male and female representation participated in the focus group discussion to give their opinion on the enrollment process and their experience as students at Tarime. There was a general consensus that joining the EN program was the students own career choice, rather than their being forced by family members or other circumstances. Students heard about the EN program through various national media, notice boards in different public institutions including the MOHSW and schools as well as from individual contacts. Students claimed that the current advertising mechanisms by which they get information on enrollment openings are not working as desired, since many received the information haphazardly and, in most cases, at a very late stage. It was proposed that the information on application dates and procedures be provided in secondary schools, as is done with other opportunities. One student proposed the use of village and ward executive officials to disseminate the information, as it could reach many more potential students. Even though the students were not keen on attending an institution to close to their home, they would prefer to stay within their zone to reduce travel costs. When asked about their environment, students said they appreciated their tutors efforts to ensure that they successfully complete their training. They also recognized the support the district hospital offers them, despite the challenges with regard to supervision. Students emphasized the need for more tutors, including clinical instructors, in the wards. When asked the number of tutors they would like to see added, the consensus was that five more would be suitable; this would also help reduce the workload on the principal. Students indicated that supervision was lacking in the wards and that sometimes there are no supervisors at all. Students felt they were missing out on learning opportunities. They reported that there is only one clinical instructor dedicated to second-year students and none for first-year students. Students reported that the old dormitory is congested and the new dormitory lacks electricity. When asked if the current structures would be sufficient if enrollment increases by 50%, the reply was that chaos would ensue. They indicated that the big classroom could only comfortably hold the current number of students per class. The dining room is so small that they have to eat outside, and the dormitory spaces are already too congested. They also indicated concerns about the lack of library space, the outdated library materials, and the small amount of materials, given the large number of students. As there is no skills lab, they are forced to do all the procedures in the classrooms. Students expressed concern that the time allotted for completing the curriculum is not sufficient. One student remarked that the field training stint of four to six weeks duration is not adequate either. Students mentioned that they would like to have playing grounds for football, netball, volleyball, and facilities for table tennis. Currently there are no recreational facilities at the institution apart from the television set located in the small dining room. Future Capacity and Recommendations Tarime has a very motivated principal who would like to see the program continue to expand. To support current enrollment numbers and to increase enrollment to 240 in the near future, significant infrastructure expansion and additional human resources are necessary. Even to support the current enrollment numbers, dormitory and classroom space must be enhanced and three more tutors are needed. 189

196 Recommendations Immediate: Connect electricity to the new building and remove students housed in the classroom/dormitory to maximize the dormitory s capacity of 48 students. Complete construction and furnish the new dormitory, as planned, by October 2010 to be able to fully use the space. Then, in total, 244 dormitory spaces will be available. Renovate the old dormitory building to enhance sanitation, security of the rooms, and ventilation. Hire at least three new full-time tutors to meet recommended student-to-teacher ratios. According to the principal, four tutor hires are already in process. To increase enrollment to 240 (100% increase): Construct three classrooms to enroll large cohorts of 120 students per year. Those cohorts should be broken into two groups of 60 each for more manageable instruction. Resolve any blockages to completing the tendering procedures for the expansion of the new dining hall, and start construction, ensuring capacity is for 240 students. Hire eight additional full-time nurse tutors in total. According to the principal, four of those hires are already in process. Hire at least two additional clinical instructors dedicated supervising students in the hospital. After the dormitory is complete in October 2010, rededicate the small classroom as a library and equip it with furniture and textbooks necessary for such a large program. Hire additional support staff, particularly a librarian and other clerical staff (e.g., a secretary, office attendant, and driver) as some of the current staff are retiring at the end of the year. A dedicated warden will be important, given such a large enrollment. Also hire for those positions that are inadequately staffed, such as cooks and guards. Continue efforts to secure more land from the hospital or from the district council at the conservation area bordering the institution. Equip the skills lab room with the necessary tools. Follow up with Jhpiego on its plans to support this effort. Build a larger computer room to hold more students at one time, add more computers, and invest in an Internet connection. 190

197 Tukuyu Nursing School Background Tukuyu Nursing School was established in 1976 as a two-year training program for maternal and child health aides, a cadre that has since been phased out of the Tanzanian health care system. In 1996, it changed to a public health nursing institution, offering a certificate in that field. In 2004, the program changed again to become a three-year training program for enrolled nurses (ENs), condensing to a two-year in Tukuyu Nursing School offers an EN certificate under the Ministry of Health and Social Welfare (MOHSW) and it is fully registered by the National Council for Technical Education (NACTE). Tukuyu, which is adjacent to Tukuyu District Hospital, is in the Mbeya Region of the Southwestern Highlands Zone. It is located about an hour and a half by paved road from Mbeya town and about 12 hours by paved road from Dar es Salaam. The HIV prevalence in the region is 7.9%, which is higher than the 6 7% national average. Capacity Trends When Tukuyu was originally built, it had one classroom and one dormitory block to serve a cohort of 36 students. Today, there are two cohorts with a total of 102 students. Under the new curriculum, the first class, which has 55 students, entered the school in January 2008 and will graduate March The second class, which has 47 students, entered in September 2009 and will graduate in September There are also 12 distance learning students employed at the adjacent district hospital who require regular assistance from this institution. Tukuyu has been assigned a new class of 52 (first selection) students who will join the program when the first class graduates in March The target enrollment for the institution is 120, representing an increase of 235% from its original capacity and an 18% increase from current enrollment numbers. About 20% of Tukuyu s 102 students come from Mbeya Region. The principal considered this proportion close to ideal she said it was important to have a geographically diverse student body to provide a richness of experience and perspective to the students. She reported that the MOHSW allows her institution to put forward ten local students to fill a class and that it ensures another ten slots are provided to other students from the region. Retention While the program has retained most students only one student dropped out due to academic difficulties forged certificates have posed a problem for the institution. The principal reported that five students may be forced to leave because of forged certificates, but that they have not yet been dropped. The process to submit and then verify certificates through the MOHSW is lengthy, resulting in students completing a year of coursework before the process can be completed. 191

198 The institution has several measures to increase retention. Struggling students counseled and mentored. They are also continual assessed so as to identify their needs early and then respond to them. Infrastructure Tukuyu has had little improvement made to the infrastructure since it was originally built. The infrastructure is operating over capacity, especially in terms of dormitory space, classroom space, toilets, washrooms, and the sewage system. Presently, there are three buildings under construction: a multipurpose room that can fit up to 120 students seated or 500 students standing; a new dormitory that will hold 50 students; and one classroom that will hold 50 students. When the new infrastructure is complete, these buildings can accommodate an enrollment of 120 students. Systems While the principal reported that the water and electricity supply from the local area and national grid are largely reliable, at the school, the sewage system is insufficient and electrical wiring faulty. The plumbing and electrical systems have never been fully renovated. The electrical circuits commonly trip because they are overloaded. The sewage system is intended for 36 students and cannot meet the needs of a student body that is over 100. Moreover, it has not been serviced in the last two years. While the principal did not report any overflow A toilet area with standing water in the original dormitory block. Many sinks, toilets and showers do not work. The building has never been majorly renovated. problems, the principal and students did report that the plumbing was broken in many areas of the dormitory s washrooms, toilets, and sinks. Student Accommodation Tukuyu has 38 rooms with spaces for 76, but actually accommodate 102. Rooms were intended to hold two students each, but many hold three or four. Out of all the rooms, 20 hold the proper number of two students; ten other rooms hold three students each; and the last eight hold four students each. The oldest dormitory block, built in 1976, has 18 rooms that house 39 students. The conditions in the building are unsafe, with old electrical and plumbing systems. The structure needs major renovations to make conditions habitable. Rooms that contain two beds also contain one reading table and one cupboard for storage. Rooms with three beds have only one cupboard and no reading table. At the end of the hall are washrooms. The toilets do not flush and the showers do not work; however, there was no reported sewage overflow. vs. Dormitory Capacity /10 1st year students / Target 2nd year students 44 spaces needed; 50 will be available in 2011 in the new dormitory Current capacity is

199 The second dormitory block was built in and contains 20 rooms distributed among three wings and houses 63 students both females and males. Among the three wings, the most severe overcrowding occurs in the males rooms where two double-decker beds and two cupboards furnish the room. There are beds and cupboards in all of the rooms but no reading tables. There are three toilets and three washrooms per wing, but the sinks do not work. The septic system for this building is inadequate because the tank is not large enough. Above left: The new dormitory block under construction. Expected to be completed in 2011, it will have space for 50 students and three guests. Pictured are new laundry sinks with clotheslines in foreground. Above right: Dormitory room in the co-ed building. The males rooms hold four beds and four students. There is no room for a study table. There is another dormitory block currently under construction, which started in 2009 and is scheduled to be complete in It will house 50 students in rooms that will have beds, cupboards, and reading tables. There will be a communal sitting room and a guest wing that can hold three guests at any time. When the new dormitory block is finished, the school will have space for 126 students. Classrooms The institution was originally built with one classroom that held 36 students. Later, a skills lab that held 50 students was built. As enrollment increased, the administration has tried to shuffle space to accommodate instructional needs. Currently, the original classroom is used as a tearoom for staff or, at times, as a skills lab, while the regular skills lab is being used as a classroom. There is a new classroom under construction that will hold 50 students. It was scheduled to be completed in April 2010 and at the time of the visit, only needed minor finishing touches and paint. The building has storage for charts and teaching aids, as well as an office. vs. Classroom Space 60 2 classrooms needed 50 1 coming in 2010, but 1 more with capacity 40 for 60 needed Currently 30 capacity is /10 10/11 Target 1st year students 2nd year students The classroom is not yet furnished; the institution budgeted for them for and the principal is waiting for and expects approval from the MOHSW. Once the new classroom is completed, the institution will have one proper classroom. A second classroom that can comfortably accommodate 60 students is needed so that the skills lab can be returned to its original purpose. Until a second, 60-student classroom is planned and constructed, the institution will most likely 193

200 use the new multipurpose dining hall/kitchen for instruction. This room can hold 120 students, sitting. The principal reported that it will be used for instruction and exam taking, as well as a rentable space for revenue-generating activities. Dining Hall and Kitchen Facilities The current dining facility and kitchen are very old and small, and are in disrepair. There is no ventilation and storage is inadequate for example, there is no space for firewood). The dining space is so small, students must eat in shifts. The building could be renovated to provide more administrative space, a small computer lab, or study space for students. The new multipurpose dining hall and kitchen building is nearly complete. It will accommodate 120 students sitting or up to 500 people standing. It has a large kitchen area, but the institution is waiting for two gas stoves before the kitchen is functional. Once the stoves are installed, students will be able to eat meals in the dining hall. The new kitchen facilities include separate areas for cooking, washing, and food preparation. There are two small storage rooms that will house consumables, but are presently used as temporary housing for visiting guests. Adjoining the building are two toilets and one washroom for the cooking staff. The principal reported that the multipurpose room will be used as a classroom because of the large cohort sizes and limited classroom space. Staff Offices and Accommodation Above left: The original classroom, built for 36, now serves as a staff tearoom or sometimes as a demonstration room. Above right: This new classroom, built for 50 students, was scheduled to be completed in April, Above left: The new multipurpose room is waiting for gas stoves before being able to serve students. Above right: The room where the gas stoves will be. The room in back is where washing/food preparation will occur. One of the tutor houses. Tutor housing is too small to hold families. Tukuyu does not have a dedicated administration block, just two offices one for the principal and one for the secretary, with a receiving area separating the two offices. The principal s office contains a desk with a computer and two couches, with a coffee table between them. About four guests can be received at the same time. There is also one small tutors office opposite the library. Another tutors office will be available in the new classroom building. The institution needs a new and expanded administration block with ample offices and meeting spaces. As mentioned above, the old dining hall and kitchen could be renovated, providing administrative offices. The institution has internet access through Tanzania Telecommunications Company, but this can become unreliable during electrical storms. 194

201 The institution has three houses available for staff. One is used by a single male tutor, another is used by the warden, and the third is used by one female tutor (but was shared with the fourth tutor, who has since left for studies but will return). The principal stays outside the institution to free up space for the other staff. Tutor housing is very small and cannot accommodate families. At least three more tutor houses are needed for scale-up (for the principal and two additional tutors). The existing housing should be renovated and expanded to accommodate families. There is ample space on the grounds to construct new housing. Libraries and Teaching Resources Computers There are no computers available for students use, nor is there a computer lab. For the computer module in the new curriculum, the principal hired an IT staff person and computers from Tukuyu town. These were paid for through the cost-sharing fees from students. The instruction is for 30 hours and the principal reported that the module can be covered in that time. The original small classroom that now serves as a tearoom could potentially be a computer lab, if computers were supplied. Resources in Library The library is in a small room that is the same size as the original classroom; it has the potential to accommodate around 30 students. There is just one shelf of books and only two chairs; there are no desks. There is an enclosed counter space for a librarian to check out or hold materials for reference only. The demonstration bed for the skills lab is stored in this room because, at times, the library doubles as a demonstration room. There are also two computers in this room, but they are for staff use only. There is a library attendant to oversee the library, but the person is not a trained librarian. Though the person was accepted to the Bagamoyo School for library studies, he had no sponsorship to attend. There are about 400, mostly outdated, books on the shelf. There are some essential reference books, but there are major gaps and shortages of books on basic nursing, community health nursing, and anatomy, as well as medical dictionaries. There are two models in the library: the anatomical structure of the human body and a female pelvis. There are also many types of national guidelines found on the shelf, which are reportedly used by staff. Demonstration Rooms and Teaching Aids Though Tukuyu at one time contained a skills lab, that room now serves as a classroom. Tutors sometimes conduct skills lab sessions in the original classroom or in the library. The equipment that previously was part of the skills lab is now stored in the classroom or in the general storage facility. The principal and students reported that teaching aids, charts, models, and equipment are all greatly lacking. They also noted that if the skills lab were enhanced, this would lessen the burden on the hospital to provide all practical instruction. The institution does have a few teaching aids, including one overhead projector, one LCD projector, two laptops, flip charts and a flip chart stand, and one white board. 195

202 Human Resources Leadership and Management The principal of Tukuyu has been at the institution for 12 years. She plans to retire in two years and expects that the current deputy will become the principal. The principal manages an institution with 102 students and two other full-time tutors. In addition, she is currently overseeing the construction of the classrooms, dormitories, and the new multipurpose room. The principal discussed the challenges of meeting the educational needs of the students with the MOHSW funds and the cost-sharing funds. She pointed out that the MOHSW mandates how the cost-sharing fees are allocated. They must be spent on specific things, like electricity, water, telephone, food, diesel, allowances for part-time tutors, medical costs for students, exam expenses, and travel expenses. The lack of funding most impacts the quality and quantity of food available to students. The principal spoke of how the MOHSW may approve their proposed budget but then, due to scarcity of funds, only give the school 20% of that. Regularly, the school receives less than half of its proposed budget. Despite these financial challenges, the principal did manage to cover the computer module in the curriculum (unlike most schools). The principal said that there are a few revenue-generating activities at the institution. Chairs are rented to the community for events and they will also rent out the new multipurpose room. However, there is a lot of competition in town for rental space and the principal does not expect that venture to produce much income. Tutors There are three full-time tutors employed and present at Tukuyu, one of whom is the principal. The fourth tutor is away in Dodoma, studying for her BSc degree in nursing. All of the tutors have been oriented to the new curriculum. The institution relies on seven part-time tutors from the local hospital, which includes two registered nurses, two medical officers, one assistant medical officer, one pharmacist, and one lab technician. At the hospital, the principal said that more preceptors and mentors who can support clinical supervision are needed. The principal felt that with only three full-time tutors and a two year term of study, students do not receive enough instruction or supervision Student to Tutor Ratio Student to Tutor Ratio 09/10 necessary to become fully competent practitioners. She described the then current graduating class (leaving the program in March 2010) as not having sufficient practical skills. She also reported that MOHSW funding is not enough to support the cost of transporting students to their fieldwork sites Student to Tutor Ratio at Target 2 additional tutors needed; 1 needed immediately Recommended NACTE student to tutor ratio is 25:1 196

203 The principal reported needing two more full-time nurse tutors and one IT instructor at the school, as well as a registered nurse at the hospital to serve as a clinical supervisor. According to the NACTErecommended ratio of 25 students to one tutor, Tukuyu needs one more tutor immediately and eventually two more tutors for a target enrollment of 120. The principal said that the MOHSW has budgeted for additional tutors, but that finding and hiring tutors is difficult. She described that the local and national governments do not work with each other and therefore it can be difficult for an employee to transfer from one part of the government to the other. With regard to in-service training for tutors, the principal described younger tutors as especially eager to learn new skills. The principal would like to see more opportunities for training available. To improve staff morale, she recommended sending tutors for short courses in teaching methodologies, as well as current health-related topics. Clinical Instruction The medical officer-in-charge met with the assessment team to discuss the benefits and challenges that Tukuyu District Hospital experiences in its effort to support students in their clinical rotations. The relationship between the hospital and the nursing school is one of mutual benefit. The medical officer described the students as proud to serve in the hospital. Moreover, he said that the hospital staff appreciate the students help. Students spend about 60% of their time in the hospital and 40% in the classroom. The hospital s greatest challenge in supporting students is the lack of qualified supervisory staff. There are only about 17 staff members qualified to supervise students. The nursing school tutors are not able to supervise students in the wards and the hospital does not have enough qualified persons to put in charge of students. The hospital needs a clinical instructor dedicated to overseeing student rotations. Currently, the ratio of students to supervisor is about ten to one. The medical officer said, ideally, that ratio should be five to one. At Tukuyu District Hospital, there will soon be seven wards and 20 other clinics/departments where students could rotate. The hospital can accommodate about 150 students each week; however, though there are adequate numbers of patients (estimated 90 inpatients and 250 outpatients each day), there are not adequate staff to supervise and mentor. Greater quantities of basic equipment (e.g., carts, trays, medical supplies) are needed as well. The comprehensive district plan aims to secure more equipment, but the medical officer did not know when or how much the hospital would receive. 197

204 Medical Staff at the Health Care Facility and Institution Medical Staff Number Employed and Working in Facility Number of Full-time Tutors at Nursing School Specialists 0 0 Medical officers 2 0 Assistant medical officers 12 0 Clinical officers 15 0 Laboratory 2 lab technicians 2 lab assistants 0 Registered nurses 22 Nurse tutors 3 (who are registered nurses) Enrolled nurses 65 0 Pharmacy 1 pharmacy technician 0 Experience of Current Students Four male and four female students met with the assessment team, half of whom were in their first year of study and half in their second year. All of the students participating in the discussion stated that they entered this program because they wanted to help others. One spoke of how being a health care worker is a respectable profession. Another spoke of his desire to keep his good health and assist others in maintaining or achieving good health. Several said that from a young age, they wanted to be a nurse. One student stated that he wanted to improve his own socioeconomic living conditions. When asked about the application process, one student was very pleased with the process and said that it was rapid and smooth. Several students were advised by relatives to apply or saw a notice about the program at a hospital and then applied. But another said that the process was unclear and that if a person at the MOHSW had not guided him through it, he would not have been informed of the opportunity. He thought that the application process could be improved if the MOHSW advertised the application notice more widely, through outlets such as television and radio. One student pointed out that a local application process is problematic for people who do not live near a training institution. She thought that the centralized application process was more impartial. Two students offered ways to improve the application process. One offered a possible explanation for why some accepted applicants do not show up for first selection at a school. He said that in the year he applied, the MOHSW informed applicants that they would receive notice in November. When November passed without notification, he thought that he did not get into school and knew of other applicants who thought the same. As a result, some friends he knew moved on to explore or find other opportunities, not realizing that their letters of acceptance were delayed. He received notice a month later in December and reported to school the following January. He believed that because the MOHSW created the expectation that notice would be provided by a certain date, some applicants dropped out of the process when they did not hear by that date. He recommended that the MOHSW 198

205 more carefully approach its outreach communication. Another issue with the application process raised by another participant was that he had difficulty understanding the acceptance letter because it listed private school fees as well as public school fees. He recommended separating the acceptance letters so that an applicant sees only the correct cost-sharing fee associated with his institution. When asked about the overall environment at the school, students said that they lacked full-time tutors necessary for their courses. Because there are so few full-time tutors (only three for 102 students), sometimes students find themselves without a tutor, sitting in class with no instruction because the tutor is assisting as a cashier or in the kitchen. Sometimes, when there are not enough tutors to instruct, a class of students is forced into the hospital wards to do rotations, though they prefer to be in the classroom. The students jointly agreed that a clinical instructor is needed at the hospital to oversee students clinical rotations. They also stated that they are in need of tutors who are specialists, rather than having one tutor teaching three different topics. They thought eight to 10 full-time tutors would more adequately meet their educational needs. They also said they need a computer instructor. Students also discussed some of the limitations of being taught by part-time tutors. They pointed out that those part-time tutors have full-time jobs and many responsibilities, and therefore cannot dedicate the time students need to be supported in their education. The part-time tutors often teach in the evenings, which can be a difficult time for students. They did think that specialty subjects, such as surgery, would be best suited for a part-time tutor. Students diets were reported as adequate. They pointed out the issue of cash-flow at the school as causing interruptions to the supply and quality of the food. They were not happy with the cook s abilities. Students would like the dormitories to be improved, as they are overcrowded and without proper ventilation. The water and sewage systems were reported to be inadequate. Students would like to see improvements made to the library holdings and teaching aids. There are not enough current titles or numbers of books. Currently, three to four students share one book from the curriculum s recommended-reading list. As for teaching aids, the school has only one pelvis model and one fetal scar model for 56 students to use in a skills lab session. Students believed that upon completion of the program, they could be assigned to any level of health care facility. When the facilitator explained the aim of the program, the students expressed concern about how they would survive in a rural area, especially as their experience has been only in school settings (they have only lived in supervised settings i.e., home and school). The students had many ideas for how the MOHSW could provide incentives to encourage rural postings, including increased salaries, housing, a motorcycle, phones, and supplies. Future Capacity and Recommendations Tukuyu is operating over capacity and is in need of immediate assistance to address the overcrowding of the facilities and infrastructure. When the multipurpose building, classroom, and new dormitory are finished; when at least one additional nurse tutor is employed; and when computers and additional books are available, then Tukuyu will begin to better serve the needs of its current enrollment 199

206 numbers. To increase numbers to the target enrollment of 120 students, additional infrastructure investment and human resources are necessary. Immediate (to maintain current enrollment at the institution): Complete construction on the multipurpose room (and installation of stoves), the dormitory, and classroom. Completely overhaul the plumbing and electrical systems in the original buildings, including toilets, washrooms, the dormitory, classrooms, and the administration area). Renovate the existing dormitories and provide proper furnishings when the rooms return to normal occupancy numbers. Return the demonstration room to its original purpose. Hire an additional nurse tutor and a full-time clinical instructor who supervises students at the hospital full time. Rededicate the smallest classroom as a computer lab and equip it with computers. Hire a computer teacher. Hire two more cooking staff. Provide additional training on library management for the library attendant. Purchase more library resources, including more essential books from the curriculum. Build three additional tutor houses to accommodate tutors and their families. Renovate the old dining hall/kitchen and turn it into an administrative block. To reach a target enrollment of 120 students (an 18% increase): Build a classroom that can comfortably accommodate 60 students. Hire an additional nurse tutor to keep the student-to-tutor ratio at 25 to 1. Build additional toilets and washrooms that can serve more than 120 students. Purchase additional books, computers, and teaching aids. Build and furnish a new, larger library that can accommodate at least 60 students at a time. 200

207 NEWLY REOPENED ENROLLED NURSING SCHOOLS Kibondo School of Nursing Background Kibondo School of Nursing was formerly a training institution for maternal and child health (MCH) aides, a cadre that has since been phased out of the Tanzanian health care system. The school accommodated a total of 24 students, with an intake every two years, before it was closed in 1997 due to a shortage of funds at the Ministry of Health and Social Welfare (MOHSW) level. Kibondo reopened in March 2010 as an MOHSW training institution for enrolled nurses. The school is not yet registered with the National Council for Technical Education (NACTE). Kibondo is a district located in the Western Zone, three hours by unpaved road from Kigoma town. The road is under construction, so travel time can vary greatly in the rainy season. The school is adjacent to the only hospital in the district. The HIV prevalence in this region is.9%, far below the national average. Current Capacity Trends In March 2010, the new principal succeeded in reopening the institution after over 10 years of closure, despite significant delays in funding. This was accomplished by leasing buildings from the district council that formerly housed offices for a displaced persons camp (the Kigoma region formerly hosted several camps for refugees from Burundi and the Democratic Republic of Congo). As of June 2010, training was occurring at the leased facilities rather than at the school itself. The principal was able to take a new cohort of 43 students, though she felt that the borrowed campus could have held a total of 45 students. If renovations to the actual school are completed before September 2010, she will request that a second class of 24 students from the MOHSW be housed and trained at the original institution. If renovations are not completed in time, she plans to train the 43 current students and wait until 2011 to accept a second intake. After the second phase of construction is complete, Kibondo is expected to have a target enrollment of 120 students two classes of 60 students each. Retention Because the first cohort in over 10 years entered the institution in March 2010, retention data is not yet available. Infrastructure At the time of the visit (August 2009), Kibondo had not started its extensive rehabilitation due to a serious delay in tendering the funds allocated for a complete overhaul of existing structures. Renovations were initiated in early 2010 and they are expected to be complete around September The institution is adjacent to the district hospital and there is a large amount of land on which to build. The second phase of construction which is to be funded in 2010 and completed in 2011 or 2012 will add new buildings that will bring the enrollment capacity to

208 The best way to maximize enrollment capacity would have been to increase classroom and dormitory capacity immediately, rather than prioritizing the rehabilitation of existing structures that could only accommodate 24 students. Even though eventually the MOHSW plans to expand Kibondo to accommodate up to 120 students, it should seriously consider permanently leasing the temporary campus that the principal has developed as a way of expanding classroom space and housing, until all new structures are complete. Essentially, the principal has successfully established a satellite campus, which could be used as a permanent source of off-campus housing and/or training. This secondary campus was not in existence and therefore not assessed during the site visit; it would be important to visit this site to see its actual potential and capacity. Original pit latrines for students. All sewage systems at Kibondo must be replaced or renovated. Systems All major systems at the institution require rehabilitation and expansion, and renovations are in progress. Previously, Kibondo only had toilets and showers for 24 students, as well as three additional latrines. Because Kibondo town is not on the national grid, electricity is highly unreliable, as is piped water. It will be necessary to have a generator and cisterns for water storage at this institution. The hospital staff noted that the generator is used almost daily and fuel is an ongoing, major expense. The institution should expect substantial additional costs for generator fuel. There is no Internet connection or fax machine at the school. Once existing systems are renovated, it will be important to assess whether there is sufficient capacity for 120 students. Student Accommodation All of the school s bedding, beds, chairs, desks, cupboards, tables, and other furnishings were stored for over 10 years, and many items are no longer fit for use. The MOHSW did provide funding for new furnishings, but only for 24 students. The institution already needs more beds, desks, chairs, and other basic components for its 43 current students. The single dormitory block at Kibondo was built and designed to accommodate 24 students, with two students per room. Each room includes two built-in cabinets and a small desk. While most institutions were built to hold two students per room, Kibondo, similar in design to Nachingwea and Nzegas (described below), has rooms that are extremely narrow. Three beds per room would leave very little space between beds placed vertically in the rooms, and enough space for a cupboard or small desk, but not both. More importantly, currently there are only two toilets, two pit latrines, and two showers that all must be renovated. Adding more than 24 students would overwhelm these facilities. Even after renovation, the dormitory block will only hold 24 students. As part of the second phase of construction, a dormitory will be built so that there is capacity for a total of 120 students. 202

209 Classrooms There is a single classroom at Kibondo, built to accommodate 24 students. Even with crowding, the classroom could accommodate a maximum of 35 students. To train more students, additional classrooms would have be constructed. There are plans to construct an additional classroom facility by 2011, and another classroom by 2012, so that eventually there will be two classrooms that can each hold 60 students. The current classroom could then be converted to a library or administrative space. Dining Hall and Kitchen Facilities Kibondo s original dining hall was built for 24 students. The institution still needs furniture for its current 43 students and the 120 students it expects to hold in the future. Renovation for the kitchen facilities, which required a total overhaul, began in Staff Offices and Accommodation The Kibondo complex includes two houses for tutors and their families. One has been inhabited by a former tutor (who is now the warden) since the school was closed. It still requires extensive renovations. The second house is not habitable without renovations. The principal currently rents accommodation in the town. Kibondo has one office that tutors share, along with a small room that was originally a library. The institution will need more administrative space after enrollment expands. The dining hall, built for 24 students, must be renovated. Most furnishings at Kibondo likely have to be replaced. The warden, at home in tutor housing, where she has lived since the school was closed. All housing needs extensive renovation. Libraries and Teaching Resources Computers At the time of the visit, the principal was borrowing a computer from the Kibondo District Hospital. Otherwise, there are no computers at the school. Space for student computers will need to be set up once enrollment is maximized. Resources in Library There is currently one bookshelf that holds all of Kibondo s books. The institution was placed on a list to receive books from the MOHSW and only received a small number of them insufficient for one class of 43 students. The room originally used as a library is no longer adequate. Kibondo will need a new library space once enrollment is maximized. Demonstration Rooms and Teaching Aids The school has no overhead- or multimedia projectors, anatomical models, charts (or even flip charts), usable desks, chairs, or chalk boards. The school will receive a skills lab from the Netherlands Organization for International Cooperation in Higher Education (Nuffic) once the building to house it has 203

210 been completed. As of June 2010, the new skills lab structure was being constructed, and was expected to be complete by the end of the year. Human Resources Leadership and Management The current principal was recruited to lead the rehabilitation and reopening of the institution. She is motivated, positive, and dynamic, and holds regular meetings with her existing staff members. Her cooperation with the district council and the resulting temporary campus is an indication of her ingenuity and commitment when faced with serious delays in completing the renovation. Tutors In addition to the principal, the former principal remained on campus and stayed in one of the tutor houses. She continues to work at the district hospital. She will now be both a warden and tutor. According to the principal, the MOHSW has indicated it will place a third full-time tutor at the institution. The principal has six part-time tutors from the district hospital. The principal and warden held weekly staff meetings to maintain their morale, as they waited for construction funds to be released. In the background are the original textbooks, dating from before the institution s closure in Clinical Instruction The Kibondo District Hospital is adjacent to the school, and has an inpatient capacity of 60, with approximately 200 outpatients at a given time. The acting district medical officer talked at length about the human resource crisis in Kibondo and the region, and the challenge of recruiting hospital staff. In response, the hospital has started an innovative program, sponsoring 43 hospital workers for continuing education. These workers are bonded to the district and will return to work there after completing their courses. He has noticed that this has helped bring clinicians to work in the area, motivated by the opportunity for further studies. As an example, the hospital had only two assistant medical officers in 2002, but now has 12. Currently, apart from a small number of environmental health students and medical officer interns on field attachment, there were no other students who received their clinical training at the hospital prior to Kibondo s reopening. The district medical officer would like to have more students, but is limited by the lack of available housing in Kibondo town. The shortage of health care workers in the region can be seen in the number of health care workers at Kibondo District Hospital, when compared to other district hospitals. 204

211 Medical Staff at the Health Care Facility and the Nursing School Medical Staff Specialists Number Employed and Working in Facility None (uses assistant medical officers trained in surgery and as anesthetists) Number of Full-time Tutors at Nursing School Medical officers 1 Assistant medical officers 12 Clinical officers 6 Laboratory 1 technician 4 assistants Registered nurses 43 Nurse tutors 2 Enrolled nurses 16 Pharmacy No pharmacist 1 technician (from Mkapa Foundation) 2 assistants Experience of Current Students There were no students enrolled at the institution at the time of the site visit. Future Capacity and Recommendations The MOHSW has already articulated plans to expand Kibondo to train a total of 120 students. If the plans for the second phase of construction include all structures and resources that are needed for 120 students, this goal will be met. The MOHSW might be able to exceed this goal (or even train a second cadre, such as clinical assistants, for this high-need area) by continuing to use the second campus for off-campus housing and instruction, if tutors are adequate. However, the second campus capacity should be thoroughly assessed and documented. Immediate (to maintain current enrollment at the institution): Provide additional funding for desks, chairs, beds, mattresses, teaching aids, and other essential materials for the existing 43 students, and then again for 120 students in total. Ensure that building plans include a generator and water storage (because of scarcity of water and power in region), and verify that all systems have capacity for 120 students. If there are 24 new students in 2010, another tutor will be required. 205

212 To meet the MOHSW s goal of a total of 120 students at the institution: Expedite funding for the second phase of construction so that Kibondo can enroll 120 students, as planned. Continue to lease the secondary campus until phase II construction is complete, or explore using the campus permanently as a way to provide off-campus housing to additional students. Ensure that there are five full-time tutors are at the institution. Review plans for the second phase of construction and verify that plans include: A library Adequate administrative space for at least five tutors (for the target enrollment of 120) Additional tutor housing, given scarcity of housing in the town Intended uses for the existing classroom space 206

213 Nachingwea Nursing School Background Nachingwea Nursing School was formerly a training institution for maternal and child health (MCH) aides with classes sizes of 24 students before it was closed in 1998 due to a shortage of funds from the Ministry of Health and Social Welfare (MOHSW). In March 2010, Nachingwea reopened as a MOHSW training institution for enrolled nurses, but has not yet registered with the National Council for Technical Education (NACTE). This school is located in a very underserved area in the Lindi Region of the Southern Zone, about a two-hour drive from Lindi on an unpaved road. The HIV prevalence in this region is 3.9 percent, which is below the national average. Current Capacity Trends Nachingwea was constructed for a total enrollment of 24 students. Because of major delays in receiving funds for rehabilitation, the principal made an agreement with the district council to lease the former administrative block of the district s social development program for use as student housing. Nachingwea now trains 65 students; they stay near campus in the leased structure and use the school s only classroom for instruction. After the second phase of construction is complete, Nachingwea will have a target enrollment of 120 students, or two classes of 60 students each. Retention Because the first cohort in over 10 years entered the institution in March 2010, retention data is not yet available. Infrastructure At the time of the visit (August 2009), Nachingwea had not started its extensive rehabilitation because of a long delay in tendering the funds allocated for overhauling existing structures. Renovations started in 2010 and were expected to be complete by the end of The institution is adjacent to the district hospital and there is a large amount of land on which to build. The second phase of construction which is to be funded in 2010 and completed in 2011 or 2012 will add new buildings that will bring the enrollment capacity to 120. The best way to maximize enrollment capacity Above left: Old beds and mattresses in one of the dormitory rooms. Above right: The toilets at Nachingwea have not been used in a decade due to lack of water. 207

214 would have been to increase classroom and dormitory capacity immediately, rather than rehabilitating existing structures that could only accommodate 24 students. Even though the MOHSW plans to eventually expand Nachingwea to accommodate up to 120 students, it should seriously consider permanently leasing the temporary campus that the principal has developed as a way to expand classroom and housing space until all new structures are complete. The principal has effectively established a satellite dormitory, which could be used as a permanent source of off-campus housing. This secondary campus was not in existence and therefore not assessed during the site visit; it would be important to visit this site to see its actual potential and capacity. Systems Nachingwea started extensive rehabilitation in 2010, after finally receiving the allocated funding. All major systems at the institution require renovation and expansion. Because Nachingwea is an extremely underserved area, water and electricity are both unreliable. Sources of water are particularly scarce in this area. It will be a necessity to have a generator and cisterns for water storage or a borehole at this institution. Once systems are renovated, it will important to assess whether they have capacity for a 120 students. Student Accommodation All of the bedding, beds, chairs, desks, cupboards, tables, and other furnishings were stored for over 10 years and many items are no longer fit for use. The MOHSW did provide funding for additional furnishings, but only for 50 students. The principal managed to provide for the current 65 students by economizing. The single dormitory block at Nachingwea was designed and built to accommodate 24 students, with two students per room. The rooms have a built-in cupboard and desk on one side of the room and a double-decker bed on the other side, making it impossible to add a third bed without removing the cupboard and desk. There are two showers and two toilets in the dormitory block, but they are in need of renovation. Because of the area s lack of water, the toilets are not usable and three pit latrines (only one of which is usable) are outside. Adding more than 24 students would overwhelm these facilities. Classrooms There is one classroom at Nachingwea, built to accommodate 24 students. Even with crowding, the classroom could only accommodate a maximum of 35 students. To train more students, additional classrooms would have to be constructed. Even with one class of 65 students, the principal is struggling to find instructional space. There are plans to build an additional classroom in the second phase of construction. Dining Hall and Kitchen Facilities The dining hall and kitchen date from when the school was first constructed. Both structures and their contents needed to be rehabilitated to be usable. The dining hall is in the process of being Classroom, originally built for 24 students, with the original furniture. 208

215 renovated, with completion expected in The current kitchen will be renovated during the second phase of construction. Staff Offices and Accommodation Nachingwea has three houses on the hospital property for tutors and their families. These houses are extremely small two of them only have two rooms and the third has three rooms and all are in need of extensive renovation. The larger one is completely uninhabitable due to neglect; it lacks a kitchen and a clean toilet, and there is extensive damage to the walls, windows, and ceiling. The staff offices are currently housed in original structures that are extremely small. A new administrative block may be needed once enrollment is expanded. Libraries and Teaching Resources Computers There is no computer available at Nachingwea. When the principal needs a computer, she must rent one in town or see if there is one she can use at the hospital. The institution will need space for student computers once enrollment is maximized. Resources in Library None of the books or learning materials are in usable condition, in addition to being out of date they are left from the MCH aides program. The institution did receive some new books from the MOHSW, but there are not enough for 65 students. Nachingwea will need a new dedicated library structure. Demonstration Rooms and Teaching Aids The institution has no overhead or multimedia projectors, anatomical models, charts, or flip charts, nor usable desks, chairs, or chalkboards. The school does not have a skills lab; it is crucial to build a skills lab for this institution to effectively train nurses. Human Resources Library materials remaining from the MCH aides program. Leadership and Management The current principal joined the school in January She created the plan for the institution, solicited cost estimates, and is leading the rehabilitation and reopening of the institution once the funds are received. She is extremely motivated and enthusiastic about the school reopening and is very committed to making it a strong institution. However, progress on construction has been hampered because of delays in funding for the initial rehabilitation. Her use of district facilities for off-campus housing is an example of her willingness to seek other solutions in the face of obstacles. Tutors The principal had a plan that calls for seven full-time tutors, but there is only one other tutor besides her to teach 65 students. There is a kitchen attendant who is still employed at the institution. He is 209

216 currently acting as the store manager and general assistant since there is no kitchen in service. Eight part-time tutors from the hospital are used to supplement instructors. Clinical Instruction Nachingwea is on the same property as the Nachingwea District Hospital. The medical officer in charge is very supportive of the new school, and felt very positive that the new nurses being trained at the institution would help to fill the gaps in the district. He was very concerned about the shortage of human resources in his district and welcomed any initiative that would help to address this issue. He did express concern that there would not be enough clinicians at the hospital to support the needs of the students. There are no other students being trained at the hospital, so he was very pleased to have the institution close by. Nachingwea District Hospital has an extreme shortage of health care workers, especially in the medical officer and assistant medical officer cadres, as illustrated in the table below. Medical Staff at the Health Care Facility Medical Staff Specialists Number Employed and Working in Facility None Number of Full-time Tutors at Nursing School Medical officers 1 Assistant medical officers 5 Clinical officers 14 Laboratory 4 technicians Registered nurses 15 Nurse tutors 2 Enrolled nurses 43 Pharmacy 1 technician Experience of Current Students There were no students enrolled at the institution at the time of the site visit. Future Capacity and Recommendations The MOHSW has already articulated plans to expand Nachingwea to train a total of 120 students. If the plans for the second phase of construction include all structures and resources that are needed for 120 students, this goal will be achievable. The MOHSW might be able to exceed this (or even train a second cadre, such as clinical assistants, for this high-need area) by continuing to use the second campus for off-campus housing and instruction, provided tutors are adequate in number. The second campus capacity should be thoroughly assessed and documented. 210

217 Immediate (to maintain current enrollment at the institution): Provide additional funding for desks, chairs, beds, mattresses, teaching aids, and other essential materials required for the existing 65 students, and then again for 120 students in total. Add one more tutor to bring the student to tutor ratio to recommended levels. Ensure that building plans include a generator and water storage, because of scarcity of water and power in region, and verify that all systems can accommodate 120 students. To meet the MOHSW s goal of a total of 120 students at the institution: Expedite funding for the second phase of construction so that Nachingwea can enroll 120 students, as planned. Continue to lease the secondary campus until phase II construction is complete, or explore using the campus permanently as a way to provide off-campus housing to additional students. Ensure that there are five full-time tutors are at the institution. Review plans for the second phase of construction and verify that plans include: A skills lab. A library structure. Adequate administrative space for at least five tutors (for target enrollment of 120). Additional tutor housing, given scarcity of housing in the town. Intended uses for the existing classroom space. 211

218 Nzega Nursing School Background Nzega Nursing School was formerly a training institution for maternal and child (MCH) aides. The institution trained and accommodated 24 students before it was closed in 1997 due to a shortage of funds from the Minisry of Health and Social Welfare (MOHSW). Nzega reopened in March The institution is not yet registered with the National Council for Technical Education (NACTE). The school is located near the center of town, next to the district hospital, approximately three hours by paved road from the town of Mwanza and two hours from Singida. Nzega is located in the Tabora Region of the Western Zone, and borders the Shinyanga and Singida regions. The HIV prevalence in Tabora is 6.2%, which is in line with the national average. Current Capacity Trends Nzega was constructed for a total enrollment of 24 MCH aid students. The institution has not had an intake of students in over 10 years. In 2010, Nzega completed the first phase of construction the renovation of all existing structures but lacked furnishings and equipment. Based on the original visit to the institution in 2009, it was determined that Nzega could open immediately, without further development, if the essential items were purchased to furnish all facilities, including offices, the classroom, the dining hall, and dormitories. In March 2010, the institution received these essential furnishings from I-TECH and the Centers for Disease Control and Prevention (CDC) through funds from the US President s Emergency Plan for AIDS Relief (PEPFAR). Nzega s current infrastructure capacity is 24 students, so enrollment was capped at the recommended number. If the second phase of expansion continues as planned, a second intake of students may enter the institution in The target enrollment is 200 students. Retention Because the first cohort in over 10 years entered the institution in March 2010, retention data is not yet available. Infrastructure Nzega was able to access funding for rehabilitation in a timely manner. This is partially due to direct intervention by the assistant director of nursing and others within the MOHSW Human Resources Department and a strong working relationship between the principal and local engineers and authorities. As a result, Nzega completed renovating all existing structures by The second phase of construction began in early 2010, beginning with a new classroom block that will All Nzega s chairs, desks, and beds were stored for 12 years, declared unfit for use, then auctioned 212

219 hold new classrooms, a library, and a skills lab. This second phase is expected to be complete by the end of All of the stored bedding, beds, chairs, desks, cupboards, tables, and other furnishings were formally examined by an auditor from the government and were condemned for use. All the materials were disposed of through public auction. Only a single office desk and chair remained in the institution. As described above, the institution received support from I-TECH and the CDC through PEPFAR funds for essential furnishings for the tutor offices, the classroom, dormitories, and the dining hall. Systems The sanitation systems were renovated, and all latrines, toilets, and showers have been replaced. There are also new piped sinks for laundry. The school does not have a generator, though power in the area is generally reliable. Five back-up water tanks, sufficient for a total enrollment of 200 students, were purchased for the institution with PEPFAR support. Renovations to the institution were well planned, and three new toilets were added for students. However, these toilets must be connected to piped water before they can be used. The MOHSW is also responsible for making sure that the water storage tanks are installed into new structures. It will be important to verify that systems are adequate to support a final enrollment of 200 total students. Student Accommodation Each room now accommodates two students, as designed, and contains: new mattresses, doubledecker bed frames, one desk, two wardrobes, and one chair. Currently, there are only three toilets, four pit latrines, and three washrooms. To avoid overwhelming the newly rehabilitated facilities, the MOHSW agreed to not add more than 24 students. There are already blueprints for constructing a new, three-story dormitory complex that will house an additional 176 students. This is expected to be completed in Classrooms There is one classroom at Nzega, built to accommodate 24 students. Even with crowding, the classroom could accommodate a maximum of 35 students. To train more students, additional classrooms will have to be constructed. There are plans to construct a three-story classroom facility in 2010 to accommodate a total of 200 students. As of March 2010, the external walls had been raised, and the structure will be completed in the same year. The current classroom has space for only 24 students; pictured here with new furniture. Dining Hall and Kitchen Facilities The original dining hall was built for 24 students. The kitchen and dining hall were recently renovated by the MOHSW, and new furnishings, cooking instruments, and equipment (for 200 students) were purchased. It will be important to make sure that the second phase of construction expands the dining facilities to serve over 200 individuals. 213

220 Left: Dining hall under renovation at the time of the visit in Center: Dining hall with new furniture, March Right: New high-efficiency, high-capacity cook stoves. Staff Offices and Accommodation The Nzega complex includes two houses for tutors that have been renovated and are ready for a tutor to inhabit with his/her family. A house for the principal was being constructed on land outside the school and should be complete by the end of Libraries and Teaching Resources Computers With the recent funding from the MOHSW, two laptops were purchased for the principal and tutor, as well as a desktop computer for the secretary and two desktop computers for students. More computers will be necessary when more than 24 students are enrolled. The new classroom block should also allocate adequate space for a large computer lab, given that there will eventually be 200 students. One of two renovated houses ready for tutors. The principal has a new, separate house located off campus. Two computers for students. More are needed when enrollment increases. Library Resources There were no books from the former institution in usable condition. The school received a shipment of books from the MOHSW, but they are barely sufficient for 24 students. More textbooks and reference materials are needed. Demonstration Rooms and Teaching Aids The school had no overhead or multimedia projectors, anatomical models, charts, or flip charts, nor usable desks, chairs, or chalkboards. The PEPFAR funds provided a multimedia projector, a flip chart stand and pads, as well as white boards for the classroom. Jhpiego provided a laptop and multimedia projector. A skills lab will be built in the new classroom block and the Netherlands Organization for International Cooperation in Higher Education (Nuffic) will provide all of the furnishings, teaching aids, and models. 214

221 Human Resources Leadership and Management A retiring principal from a faith-based nursing school was recruited to serve as acting principal and to lead the rehabilitation and reopening of the institution. In comparison to other reopening nursing schools, the most progress has taken place at Nzega. This is due to the incredible initiative on part of the principal, as well as close collaboration with engineers and local government leaders at the district level, and also because the institution was able to receive and tender funding for the initial rehabilitation. The principal worked without pay for over a year, due to delays in receiving her salary through the MOHSW system. Though she still lives in Nzega, a new principal has been assigned to Nzega and he assumed his post in January The former and new principals work closely together. Both played important roles in the collaboration with I-TECH, identifying necessary furnishings to purchase and setting up the new furniture in the school. Tutors Even before the school was officially open, one additional full-time tutor had been identified and transferred from another nursing school. Currently, there are two full-time tutors the principal and the newly transferred tutor. The former principal works at the neighboring hospital and plans to return to teach at the school part-time. Additionally, there are two other clinicians at the hospital who have formal training in health education who would like to teach at the institution. MOHSW Human Resource Department staff have noted a lot of interest from other nurse tutors in relocating to Nzega because they have heard that the institution has newly renovated and available tutor housing. Clinical Instruction The Nzega District Hospital is adjacent to the nursing school; it has an inpatient capacity of 170, and approximately outpatients at a given time. Dr. Ndwagile, the medical officer-in-charge, was extremely eager to see Nzega reopen and to have students at the hospital. Currently, apart from registered nurse students from Kolondoto who are on field attachment, no other students receive clinical training at the hospital. Compared to other district hospitals, Nzega District Hospital has a large ratio of nurses to patients. Though it lacks specialists, including surgeons, the hospital has two pharmacists and a newly renovated Care and Treatment Center operated in partnership with Elizabeth Glaser Pediatric AIDS Foundation. 215

222 Medical Staff at the Health Care Facility and Training Institution Medical Staff Specialists Number Employed and Working in Facility None (all come in through a rotation program with Kilimanjaro Christian Medical College) Number of Full-time Tutors at Nursing School Medical officers 3 Assistant medical officers 4 with 2 more by end of year Clinical officers 11 Laboratory 1 technician 4 assistants Registered nurses 19 Nurse tutors 2 (one is the former principal) 2 Enrolled nurses 37 Pharmacy 2 pharmacists 2 technicians Experience of Current Students There were no students enrolled at the institution at the time of the site visit in August Future Capacity and Recommendations After the initial site visit to Nzega in August 2009, the initial recommendation was that resources should be directed towards buying essential materials to train 24 students. Unlike other reopening institutions, funding had been received at Nzega and the school has been able to nearly complete the process of renovation, though it had not budgeted for essential furniture. The purchase of these materials allowed the institution to enroll an initial 24-person class of students in March With two full-time tutors, new systems, and new furniture and resources, the principal reported that instruction at the institution is proceeding smoothly. For the long-term, the MOHSW already has concrete plans, construction blueprints, and cost estimates to build a three-story classroom and an additional three-story dormitory complex so that the institution can train 200 students by Because Nzega is a new institution, the MOHSW is fully taking advantage of available resources to build new structures to meet the target capacity, rather than only adapting the existing structures. Given its future dormitory capacity and Nuffic-equipped skills lab, Nzega would also be an excellent site for adding another cadre, such as clinical assistants or lab students, or even a nursing diploma program. As always, tutors would have to be sufficient. 216

223 Immediate (to maintain current enrollment at the institution): Ensure that external student toilets and showers have piped water for use, since facilities within the dormitory block are insufficient for 24 students. Install water storage tanks in existing and new structures. Ensure that building plans include a generator and water storage, as well as a budget for furnishings for 200 students, and verify that all systems have capacity for 120 students. Resolve challenges to the delays in salary for Nzega s founding principal, so that she can rejoin the institution as a tutor. To meet the MOHSW s goal of a total of 200 students at the institution: Maintain the steady pace of funding for the second phase of construction, so that Nzega can enroll 200 students, as planned. Ensure that there are eight full-time tutors at the institution. Review plans for the second phase of construction and verify that plans include: A library. Adequate administrative space for at least eight tutors (for target enrollment of 200). Additional tutor housing, so all tutors have accommodation. Intended uses for the existing classroom space. Explore the possibility of adding another cadre to the institution (clinical assistants, lab students, or another nursing program). 217

224 APPENDIX 3: DATA COLLECTION TOOLS STUDENT ADMISSIONS/ACADEMIC PROGRAMMES Name of Institution: Zone and Region: Name of Principal or Respondent: Title of Academic Programme: Type of degree(s) offered: (certificate, ordinary diploma, advanced diploma) Academic year: Start date:_ End date: # In academic year st year students who arrived for 1st selection Additional 1st year students taken in 2nd selection Total number of students from local area (region) in 1st year class Total attending students (in all years of study in the programme) 1st year: 2nd year: 3rd Year: (if applicable) 1st year: 2nd year: 3rd Year: (if applicable) 1st year: 2nd year: 3rd Year: (if applicable) Current Year ( ) 1st year: 2nd year: 3rd Year: (if applicable) 5. Number of graduates 6. How many students did not complete the programme (dropped out before graduation) per class? 1st year: 2nd year: 3rd Year: (if applicable) 1st year: 2nd year: 3rd Year: (if applicable) 1st year: 2nd year: 3rd Year: (if applicable) 1st year: 2nd year: 3rd Year: (if applicable) 218

225 7. 8. What are some possible reasons students did not complete the programme? In your current facility and at current staffing levels, would you be able to accept more new, entering students in the current academic year? If yes, how many more? YES NO If yes, number of additional students: Student Fees 9. How much do students pay in cost-sharing fees each academic year? What number of your current student body are local students, coming from the region where the school is located? What number of these local students board outside of the school at their homes or with family (day students)? What number of your current student body is made up of foreign students from outside of Tanzania? 13. What annual fees do foreign students pay? a. 15. What number of your current students are subsidized partially or fully by their employers? What portion of student fees do employers typically fund or provide loans for? What number of students are subsidized partially or fully by other sources (e.g., churches, other non-government organizations)? 15a. What portion of student fees do these other sources typically fund or provide loans for? 219

226 Budget/Expenditures The following information is requested to have an accurate understanding of what monetary resources are available at your institution, as well as the expenses at your institution. Any information that you provide will only be used for the purposes of this situational analysis. Please provide a copy of your institution s last financial report. What were your total school expenditures (all expenditures) in each of the following academic years? What is your budget for the academic year? 18. How much funding/income is provided directly to the school (not to students) by each of these sources? (Use current school year data if available; if not, use the previous year s data. Please note which you are using.) 18a. Income from student fees: Year of data: 18b. Funding from government: Year of data: 18c. Funding from non-government organizations: Year of data: 18d. Income or funding from other sources (please specify): Year of data: Infrastructure 19. How reliable is the water supply in the area? 20. Does the institution have a back-up supply of water? YES NO 21. How reliable is electricity in the area? 22. Does the institution have a generator for electricity? YES NO 220

227 Classrooms and Teaching Resources 23. How many classrooms/lecture halls do you have? Of the total number of classrooms you have listed above, how many were not built to be used as classrooms (e.g., a meeting hall being used as a classroom)? How many students can be taught in a typical classroom/ lecture hall? How many students can be taught in the largest classroom/lecture hall? 27. Do you have a skills lab at the institution? 28. Are library materials and textbooks sufficient for current students? Please explain How many computers are available at the school for students to use for studying, research, or computer modules in the curriculum? Do you have a computer lab with more than 5 computers in one room? 31. If yes, is the computer lab regularly used by students? Student and Tutor Accommodation 33. How many total hostel rooms are there at the school? How many total beds do you have in your hostels (i.e., how many students can you accommodate)? How many of the hostel rooms have three or more students sharing the room? How many of the hostel rooms are not being used because they need repairs? How many of the hostel rooms are being used for purposes other than student housing (e.g., staff offices, storage, staff housing)? Are there ways for students to board locally (e.g, in a neighboring town or private houses)? 221

228 What would you estimate as the monthly cost for a student to board locally? How many tutor/staff houses do you have at the institution? Other Infrastructure 41. Are other facilities for students such as the canteen, cooking areas, washrooms, and meeting halls adequate for the current number of students? YES Please explain: NO Would they be adequate if enrollment was increased by 50% more students? YES NO 42. Please explain: 43. Have you made any investments in infrastructure (i.e., classrooms, dormitories, libraries) in the last 3 years? If so, what changes/additions were made and what were the associated costs? 44. How many students are able to use the new facilities or infrastructure that were invested as compared to before the investment? Tutors And Staff Full-Time Tutors Cadre Number of Full-time Tutors Registered nurses: Enrolled nurses: 45. Nurse tutors: Other nurses (specify): Medical officers: Assistant medical officers: Clinical officers: Other cadres (specify): 222

229 46. Are there any full-time tutors are not teaching this academic year? If so, what are the reasons? 47. Besides salary, what additional compensation, accommodations, allowances, and benefits (e.g., transportation, housing) do full-time tutors receive? Part-Time Tutors Cadre Number of Part-time Tutors Registered nurses: Enrolled nurses: 48. Nurse tutors: Other nurses (specify): Medical officers: Assistant medical officers: Clinical officers: Other cadres (specify): What is the hourly salary of a typical part-time faculty member? In addition, what additional compensation, accommodations, allowances, and benefits (e.g., transportation, housing) do part-time tutors receive? Non-Teaching Staff 51. Administrative/clerical staff: 52. Other (please explain): Please provide a copy of your class schedule, weekly timetable, or yearly academic calendar, if available, to help understand the schedule used to plan activities at your institution. Please also provide a copy of your latest financial report. You may send it by to [email protected], or provide it during the visit to your institution. Thank you very much for taking the time to complete this questionnaire. This questionnaire will be collected from you when I-TECH and the MOHSW jointly visit your institution. If you have any questions feel free to contact Dila Perera, HRH Scale-up Manager: or [email protected] 223

230 SEMI-STRUCTURED INTERVIEW FOR PRINCIPALS AT ENROLLED NURSING TRAINING INSTITUTIONS HRH Situational Analysis Name of Institution: Zone and Region: Name of Principal or Respondent: Title of Academic Programme: Type of degree(s) offered: (certificate, ordinary diploma, advanced diploma) Academic year: Start date:_ End date: Note to interviewer: Review consent form with principal before proceeding. Please be sure to have the institutional questionnaire completed by the principal available when conducting the interview, in order to complete any missing information, clarify questions, and refer to during this interview. Please be sure to receive a copy of the institution s financial report, as well as latest academic calendar. Current 1. Have you increased the intake of students in 2009 compared to 2008? What was the intake in 2008 and what was the intake in 2009? 2. Are there in-service (upgrading) students also being trained at this institution? If so, how many are there? 3. Are all available student spaces currently filled? a. If yes or no, what are some of the reasons for this? b. If yes, how well equipped is your facility to support the current number of students? 4. How many students are from the local area (neighboring towns and villages within the region)? What things may limit the number of students that come from the local area? Budget and Costs 5. Are you able to cover the costs of running the institution from cost-sharing fees and the over head cost funds from the MOHSW? Yes or no? If not, why not? 6. Are you able to reserve funds for other school investments (e.g., hiring of additional tutors and improving infrastructure) from the cost-sharing fees? 7. Do you have other sources of funding for students? If so, what are they? 224

231 Instruction 8. Are you implementing the new curriculum at this institution? a. If yes, have staff and students all been oriented on the new curriculum? 9. What, if any, challenges do you face in ensuring that students receive the education needed to be able to work in a health facility upon completing the program? Ways to Increase 10. What would it take to increase the size of the student body by at least 50% in the next two years? 11. What would you concentrate on first in order to move toward the goal of greatly increasing student enrollment? Tutors and Staff 12. Are you able to find tutors with the appropriate qualifications to teach all of the subjects? Are there specific specialties where it is more difficult to find qualified tutors? 13. What would you do to improve the capacity of existing tutors and staff (clinical and non-clinical) in order to enroll more students? a. Probe: Could any program, scheduling, or management changes be made to help support a much higher capacity of students at this institution? (e.g., staggering timing of academic year, having a morning group and afternoon group?) 14. If new tutors need to be hired in order to increase enrollment, how many additional tutors would need to be hired? What about other additional staff? (Probe for numbers.) The following questions ask about what actions you would take (or areas you would concentrate on) in order to be able to accept a 50% increase in students, if you had additional budgetary resources. Infrastructure 15. If you had additional resources, what would you do to improve infrastructure used for teaching in order to increase enrollment (clinical and non-clinical, can be classrooms, laboratories, libraries)? (If answered, no need to repeat question.) 16. What could be done to use existing facilities to support a much larger capacity of students (e.g., increasing number of students per dormitory room, rearranging classroom seating)? 17. If you had additional resources, what would you do to improve student living infrastructure in order to increase enrollment (e.g., canteen, washrooms, kitchen, dormitories, study areas, meeting halls)? (If answered, no need to repeat question.) 225

232 Student Recruitment and Retention 18. Do some students drop out before completing their program? What might be some causes? 19. What are the measures already in place/to be taken in order to overcome the student drop out/failure to complete the program? 20. Do some students take longer than expected to graduate? What might be some causes? (If answered, no need to repeat question.) 21. How do the costs to students of studying affecting their ability to complete their studies? Additional Comments 22. Are there any additional issues/topics we did not cover today that you would like to mention? HRH STUDENT FEEDBACK GROUP INTERVIEW GUIDE Institution Date Interviewer Note taker Others present (apart from students) Total # students # Female students # Male students Welcome students and introduce yourself and any other members of the team. All attendees should have copy of the consent form to review and sign before the discussion group begins. 1. Tell us about your decision to become a nurse. What attracted you to this profession? 2. What was the application process like? Probe: If you could improve it what would you do? 3. I would like to ask you about your environment here at the school. That includes the tutors, the buildings, the dormitories, where you live, the places where you study, and even the canteen where you eat. What are some things that help you to do well in school here? 4. What are things that could be improved? Probe for learning environment, curriculum, infrastructure (e.g., dorms, classrooms, labs, recreation areas), tutors, clinical experience at the hospital, food, etc.) 5. Do you personally know students who leave the school before completing the program? Probe: What are the causes? 6. Do you personally know students who take longer to graduate? Probe: What are the causes? 226

233 7. Have you heard where former students have been employed once they completed the nursing course? Probe: Are there students who are not working, not placed, if working outside MOHSW, where? 8. Is there anything else you d like to say to help us to learn more about your experience as students here? BRIEF SEMI-STRUCTURED INTERVIEW FOR MEDICAL OFFICER- AND MATRON-IN-CHARGE HRH Situational Analysis Name of health facility: Zone and region: Name of respondent: Title of academic programme: Because your healthcare facility is located near a training institution, your hospital plays an important role in training future health care workers. Thank you for taking the time to speak with us. Review consent document before proceeding. Questions for Medical Officer- or Matron-in-Charge: 1. What has worked well in the clinical training of enrolled nursing students at the hospital? 2. Have you faced any challenges integrating enrolled nursing students into the daily work of the hospital? 3. What portion of their time do students in the enrolled nurse training program spend working in the hospital? 4. What is the maximum number of students that can comfortably receive clinical training at the local health care facility? 5. If the school were to scale up enrollment, what would be needed to enable the health care facility to provide the clinical nursing training needed? 227

234 In your facility, are the following sufficient for training enrolled nursing students? 1. Patients Is this amount sufficient for the clinical training of current students? Would this amount be sufficient if student capacity were increased (by more than 50%)? Please tick: YES NO Comments: 2. Hospital staff who act as instructors to nursing students during clinical rotations 3. Operating theaters Please tick: YES NO Comments: Please tick: YES NO Comments: Medical Staff at the Healthcare Facility 4. Specialist (please specify type): Number Employed and Actually Currently Working in the Health Care Facility 5. MO: 6. AMO: 7. CO: 8. Lab technician/assistant: 9. Registered nurses (diploma and above): 10. Enrolled nurses (certificate only): 11. Pharmacy technician/assistants: 228

235 APPENDIX 4: LIST OF INTERVIEWS Principals: Bagamoyo Nursing School Geita Nursing School Kahama Nursing School Kibondo Nursing School Kiomboi Nursing School Kondoa Nursing School Korogwe NTI Mbozi Nursing School Mbulu Nursing School Mkomaindo Nursing School Nachingwea Nursing School Njombe Nursing School Nzega Nursing School Same Nursing School Tarime Nursing School Tukuyu Nursing School Medical Officers- or Matrons-in-Charge at the Following Hospitals: Bagamoyo District Hospital Geita District Hospital Kahama District Hospital Kibondo District Hospital Kiomboi District Hospital Kondoa District Hospital Korogwe District Hospital Mkomaindo District Hospital Nachingwea District Hospital Njombe District Hospital Nzega District Hospital Same District Hospital Tarime District Hospital Tukuyu District Hospital Mbulu District Hospital 229

236 APPENDIX 5: CONSENT FORMS MEDICAL OFFICER OR MATRON-IN-CHARGE INTERVIEWS The Ministry of Health and Social Welfare (MOHSW) wants to increase the number of students trained at health training institutions. I-TECH, with support from the Centers for Disease Control and Prevention Tanzania (CDC), is conducting this assessment to collect information for the MOHSW on opportunities and barriers to increasing enrolment at health training institutions. We are asking you to participate in this assessment as the Medical Officer-in-Charge or another key health professional participating in the clinical training of students, since an increase in students could have an impact on your hospital. Purpose The purpose of this short interview is to collect information about the clinical training of students at the hospital. We are also interviewing the principals of the health training institutions, and we will write an assessment report for the MOHSW. The MOHSW may use this report for future planning. Participation is voluntary, and the purpose of this consent form is to give you the information you will need to decide whether or not to participate in the assessment. Procedures This interview will take about 15 minutes of your time. We will ask you questions about what has worked well in the clinical training of students and what challenges you face while training students. We will also ask you about facilities available at the hospital for training students, including about the cadres and number of staff at the hospital. Risks If you choose to participate, there is a risk you may feel uncomfortable discussing difficulties or challenges at the hospital. Because the names of the institutions will often be used in the report, we cannot guarantee the information you give us will remain confidential. However, the information you provide will not be linked to your name and we will not give your name in any part of the report. Benefits You will not personally benefit from participating in this assessment. Health training institutions in Tanzania may benefit in the future from additional support provided as a result of this assessment. Alternatives If you choose not to take part in this assessment, I will not interview you. Confidentiality Original data from the interviews will be stored in a locked cabinet in I-TECH s office, and will be destroyed within two years after use. Person to Contact If you have any questions about this assessment, please contact Dila Perera, HRH Scale-up Manager at or [email protected]. 230

237 Voluntary Participation, Refusal, and Withdrawal Your participation in this interview is voluntary. You do not have to answer any questions, and you are free to stop this interview at any time. Subject s Statement: This assessment has been explained to me. I volunteer to take part in this assessment. I have had a chance to ask questions. If I have questions later on about the assessment, I can ask the I-TECH contacts listed above. Signature of subject Printed name Date MOHSW STAFF AND PRINCIPAL INTERVIEWS The Ministry of Health and Social Welfare (MOHSW) wants to increase the number of students trained at health training institutions. I-TECH, with support from the Centers for Disease Control and Prevention Tanzania (CDC), is conducting this assessment to collect information for the MOHSW on opportunities and barriers to increasing enrolment. We are asking you to participate in this assessment as the leader of a health training institution operating under the MOHSW. Purpose The purpose of this interview and our visit to your institution is to collect information about the enrolment and training capacity of this institution. We will use this information to write an assessment report for the MOHSW. The MOHSW may use this report to make future planning decisions. Participation is voluntary, and the purpose of this consent form is to give you the information you will need to decide whether or not to participate in the assessment. Procedures This interview will take about two hours of your time. We will also ask you to provide a tour of key facilities at your school, which may take another hour. We will ask you questions about the current enrolment at the institution and the infrastructure at the institution. We will also ask you questions about the number of staff at the institution, and the budget of your institution. Lastly, we will ask you about barriers and challenges to increasing enrolment at the institution and your ideas for how to overcome those barriers. Risks If you choose to participate, there is a risk you may feel uncomfortable discussing difficulties or challenges of your institution. Because the names of the institutions will often be used in the report, we cannot guarantee the information you give us will remain confidential. However the information you provide will not be linked to your name and we will not give your name in any part of the report. The MOHSW may use the information collected by this assessment for planning purposes, however the assessment will take into account information from many sources and not just interviews with principals or other staff. Benefits You will not personally benefit from participating in this assessment. Some health training institutions in Tanzania may benefit in the future from additional support provided as a result of this assessment. 231

238 Alternatives If you choose not to take part in this assessment, I will not interview you. Confidentiality Original data from the interviews will be stored in a locked cabinet in I-TECH s office, and will be destroyed within two years after use. Because the assessment report will identify specific institutions by name, it will be possible to identify the information and responses that you provided in the assessment report. However the information you provide will not be linked to your name and we will not give your name in any part of the report. Person to Contact If you have any questions about this assessment, please contact Dila Perera, HRH Scale-up Manager at or [email protected]. Voluntary Participation, Refusal, and Withdrawal Your participation in this interview is voluntary. You do not have to answer any questions, and you are free to stop this interview at any time. Subject s Statement: This assessment has been explained to me. I volunteer to take part in this assessment. I have had a chance to ask questions. If I have questions later on about the assessment, I can ask the I-TECH contacts listed above. Signature of subject Printed name Date STUDENT DISCUSSION GROUPS Introduction The Ministry of Health and Social Welfare (MOHSW) wants to increase the number of students trained at health training institutions. I-TECH, with support from the Centers for Disease Control and Prevention Tanzania (CDC), is conducting this assessment to collect information for the MOHSW on things that could help or prevent adding more students at health training institutions. We are asking you to take part in this assessment as a student at a health training institution. Purpose The purpose of this group discussion is to ask you a few questions about your experience studying at this training institution. As students, you have valuable information to provide about the experiences you have had here. Participation is voluntary, and the purpose of this consent form is to give you the information you will need to decide whether or not to take part in the assessment. Procedures This group discussion will take about one hour of your time. We will ask you questions about your experience applying for school, the things you like about being a student here, and the things you do not like about being 232

239 a student here. We will also ask you about what other students do for work after completing their studies and about any reasons students do not complete their studies at this institution. Risks If you choose to participate, there is a risk you may feel less at ease discussing difficulties or challenges at the school. Some people also are less at ease discussing their personal opinions about the school. Benefits You will not personally benefit from participating in this assessment. Health training institutions in Tanzania may benefit in the future if more resources are provided as a result of this assessment. Alternatives If you choose not to take part in this assessment, I will not interview you. Confidentiality Original data from this focus group will be stored in a locked cabinet in I-TECH s office, and will be destroyed within two years after use. We will not report the names of the students who participated in the focus group anywhere in the report or in our notes. Your responses and comments will not be linked to your name in any way in the report or in our notes. However, because this is a group discussion and other students are participating, we cannot guarantee confidentiality. If you feel less at ease having any of your statements shared with others in or outside the group, please do not share them during the discussion. Person to Contact If you have any questions about this assessment, please contact Dila Perera, HRH Scale-up Manager at or [email protected]. Voluntary Participation, Refusal, and Withdrawal Your participation in this interview is voluntary. You do not have to answer any questions, and you are free to leave the discussion group at any time. Subject s Statement: This assessment has been explained to me. I volunteer to take part in this assessment. I have had a chance to ask questions. If I have questions later on about the assessment, I can ask the I-TECH contacts listed above. Initials of subject 233