umu.sePublications
Change search
Link to record
Permanent link

Direct link
BETA
Publications (6 of 6) Show all publications
Sirili, N., Frumence, G., Kiwara, A., Mwangu, M., Goicolea, I. & Hurtig, A.-K. (2019). "Doctors ready to be posted are jobless on the street…" the deployment process and shortage of doctors in Tanzania.. Human Resources for Health, 17(1), Article ID 11.
Open this publication in new window or tab >>"Doctors ready to be posted are jobless on the street…" the deployment process and shortage of doctors in Tanzania.
Show others...
2019 (English)In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 17, no 1, article id 11Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The World Health Organization advocates that health workforce development is a continuum of three stages of entry, available workforce and exit. However, many studies have focused on addressing the shortage of numbers and the retention of doctors in rural and remote areas. The latter has left the contribution of the entry stage in particularly the deployment process on the shortage of health workforce less understood. This study therefore explored the experiences of medical doctors (MDs) on the deployment process after the internship period in Tanzania's health sector.

METHODS: A qualitative case study that adopted chain referral sampling was used to conduct 20 key informant interviews with MDs who graduated between 2003 and 2009 from two Medical Universities in Tanzania between February and April 2016. These MDs were working in hospitals at different levels and Medical Universities in eight regions and five geo-political zones in the country. Information gathered was analysed using a qualitative content analysis approach.

RESULTS: Experiences on the deployment process fall into three categories. First, "uncertainties around the first appointment" attributed to lack of effective strategies for identification of the pool of available MDs, indecision and limited vacancies for employment in the public sector and private sector and non-transparent and lengthy bureaucratic procedures in offering government employment. Second, "failure to respect individuals' preferences of work location" which were based on the influence of family ties, fear of the unknown rural environment among urbanized MDs and concern for career prospects. Third, "feelings of insecurity about being placed at a regional and district level" partly due to local government authorities being unprepared to receive and accommodate MDs and territorial protectionism among assistant medical officers.

CONCLUSIONS: Experiences of MDs on the deployment process in Tanzania reveal many challenges that need to be addressed for the deployment to contribute better in availability of equitably distributed health workforce in the country. Short-term, mid-term and long-term strategies are needed to address these challenges. These strategies should focus on linking of the internship with the first appointment, work place preferences, defining and supporting career paths to health workers working under the local government authorities, improving the working relationships and team building at the work places and fostering rural attachment to medical students during medical training.

Keywords
Africa, Deployment, Employment of doctors, Health sector, Health workforce, Internship, Physicians, Rural areas, Shortage of doctors, Tanzania
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-158185 (URN)10.1186/s12960-019-0346-8 (DOI)000457484100001 ()30709401 (PubMedID)2-s2.0-85060945358 (Scopus ID)
Available from: 2019-04-16 Created: 2019-04-16 Last updated: 2019-04-16Bibliographically approved
Sirili, N., Frumence, G., Kiwara, A., Mwangu, M., Goicolea, I. & Hurtig, A.-K. (2019). Public private partnership in training of doctors after the 1990s' health sector reforms: the case of Tanzania. Human Resources for Health, 17, Article ID 33.
Open this publication in new window or tab >>Public private partnership in training of doctors after the 1990s' health sector reforms: the case of Tanzania
Show others...
2019 (English)In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 17, article id 33Article in journal (Refereed) Published
Abstract [en]

Similar to many other low- and middle-income countries, public private partnership (PPP) in the training of the health workforce has been emphasized since the launch of the 1990s’ health sector reforms in Tanzania. PPP in training aims to contribute to addressing the critical shortage of health workforce in these countries. This study aimed to analyse the policy process and experienced outcomes of PPP for the training of doctors in Tanzania two decades after the 1990s’ health sector reforms. We reviewed documents and interviewed key informants to collect data from training institutions and umbrella organizations that train and employ doctors in both the public and private sectors. We adopted a hybrid thematic approach to analyse the data while guided by the policy analysis framework by Gagnon and Labonté. PPP in training has contributed significantly to the increasing number of graduating doctors in Tanzania. In tandem, undermining of universities’ autonomy and the massive enrolment of medical students unfavourably affect the quality of graduating doctors. Although PPP has proven successful in increasing the number of doctors graduating, unemployment of the graduates and lack of database to inform the training needs and capacity to absorb the graduates have left the country with a health workforce shortage and maldistribution at service delivery points, just as before the introduction of the PPP. This study recommends that Tanzania revisit its PPP approach to ensure the health workforce crisis is addressed in its totality. A comprehensive plan is needed to address issues of training within the framework of PPP by engaging all stakeholders in training and deployment starting from the planning of the number of medical students, and when and how they will be trained while taking into account the quality of the training.

Place, publisher, year, edition, pages
BioMed Central, 2019
Keywords
: Health sector reforms, Training of doctors, Policy analysis, Public private partnership, Tanzania, Health workforce shortage
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-150635 (URN)10.1186/s12960-019-0372-6 (DOI)000468753800002 ()31118038 (PubMedID)
Note

Originally included in thesis in manuscript form.

Available from: 2018-08-15 Created: 2018-08-15 Last updated: 2019-06-11Bibliographically approved
Sirili, N. (2018). Health workforce development post-1990s health sector reforms: the case of medical doctors in Tanzania. (Doctoral dissertation). Umeå: Umeå universitet
Open this publication in new window or tab >>Health workforce development post-1990s health sector reforms: the case of medical doctors in Tanzania
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Health systems in many low- and middle-income countries suffer from critical shortages and inequitable geographical distribution of the health workforce. Since the 1940s, many low- and middle-income countries have passed through different regimes of health sector reforms; the most recent one was in the 1990s. Tanzania is a good example of these countries. From the 1990s, Tanzania has been implementing the third generation of health sector reforms. This thesis analysed the health workforce development following the 1990s health sector reforms in Tanzania.

Methods: An exploratory case study employing both quantitative and qualitative research approaches was used to analyse the training, deployment, and retention of medical doctors about two decades following the 1990s healthsector reforms. The quantitative approach involved analysis of graduation books and records from the Medical Council of Tanganyika to document the number of doctors who graduated locally and abroad, a countrywide survey of available doctors as of July 2011, and analysis of staffing levels to document the number of doctors recommended for the health sector as of 2012. The gap between the number of available and required doctors was computed by subtracting available from required in that period. The qualitative approach involved key informant interviews, focus group discussions, and a documents review. Key informants were recruited from districts, regions, government ministries, national hospitals, medical training institutions in both the public and private sectors, Christian Social Services Commission and the Association of Private Health Facilities in Tanzania. Focused group discussion participants were members of Council Health Management Teams in three selected districts. Documents reviewed included country human resources for health profiles, health sector strategic plans, human resources for health strategic plans and published and grey literature on health sector reforms, health workforce training, and deployment and retention documentation. For the training, analysis of data was done thematically with the guide of policy analysis framework. For deployment and retention, qualitative content analysis was adopted.

Results: Re-introduction of the private sector in the form of public-private partnerships has boosted the number of doctors graduating annually sevenfold in 2010 compared to that in 1992. Despite the increase in the number of doctors graduating annually, their training faces some challenges, including the erosion of university autonomies prescribed by the law; coercive admission of many medical students greater than the capacity of the medical schools, thus threatening the quality of the graduates; and lack of coordination between trainers and employers. Tanzania requires a minimum of 3,326 doctors to attain the minimum threshold of 0.1 doctor per 1,000 population, as recommended by the World Health Organization. However, a countrywide survey has revealed the existence of around 1,300 doctors working in the health sector—almost the same as the number before the reforms. Failure to offer employment to all graduating doctors, uncertainties around the first appointment, failure to respect doctors’ preferences for first appointment workplaces, and the feelings of insecurity in going to districts are among the major challenges haunting the deployment of doctors in Tanzania. For those who went to the districts, the issues of unfavourable working conditions, unsupportive environment in the community, and resource scarcity have all challenged their retention.

Conclusions: The development of human resources for health after the 1990s health sector reforms have to some extent been contradictory. On the one hand, Tanzania has succeeded in training more doctors than the minimum it requires, despite some challenges facing the training institutions. On the other hand, failure to deploy and retain an adequate number of doctors in its health system has left the country to continue suffering from a shortage and inequitable distribution of doctors in favour of urban areas. For health sector reforms to bring successes with minimal challenges in health workforce development, a holistic approach that targets doctors’ training, deployment, and retention is recommended.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2018. p. 63
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1974
Keywords
health sector reforms, health workforce, doctors, training, deployment, retention, decentralized health sector, public-private partnership, rural, Tanzania, low- and middle- income countries
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-151721 (URN)978-91-7601-929-0 (ISBN)
Public defence
2018-10-05, Hörsal D, Unod T9, Norrlands universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2018-09-14 Created: 2018-09-11 Last updated: 2018-09-19Bibliographically approved
Sirili, N., Frumence, G., Kiwara, A., Mwangu, M., Anaeli, A., Nyamhanga, T., . . . Hurtig, A.-K. (2018). Retention of medical doctors at the district level: a qualitative study of experiences from Tanzania. BMC Health Services Research, 18, Article ID 260.
Open this publication in new window or tab >>Retention of medical doctors at the district level: a qualitative study of experiences from Tanzania
Show others...
2018 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 260Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Retention of Human Resources for Health (HRH), particularly doctors at district level is a big challenge facing the decentralized health systems in poorly resourced countries. Tanzania, with 75% of its population in rural areas, has only 26% of doctors serving in rural areas. We aimed to analyze the experiences regarding the retention of doctors at district level in Tanzania from doctors' and district health managers' perspectives.

METHODS: A qualitative study was carried out in three districts from June to September 2013. We reviewed selected HRH documents and then conducted 15 key informant interviews with members of the District Health Management teams and medical doctors working at the district hospitals. In addition, we conducted three focus group discussions with Council Health Management Team members in the three districts. Incentive package plans, HRH establishment, and health sector development plans from the three districts were reviewed. Data analysis was performed using qualitative content analysis.

RESULTS: None of the districts in this study has the number of doctors recommended. Retention of doctors in the districts faced the following challenges: unfavourable working conditions including poor working environment, lack of assurance of career progression, and a non-uniform financial incentive system across districts; unsupportive environment in the community, characterized by: difficulty in securing houses for rent, lack of opportunities to earn extra income, lack of appreciation from the community and poor social services. Health managers across districts endeavour to retain their doctors through different retention strategies, including: career development plans, minimum financial incentive packages and avenues for private practices in the district hospitals. However, managers face constrained financial resources, with many competing priorities at district level.

CONCLUSIONS: Retention of doctors at district level faces numerous challenges. Assurance of career growth, provision of uniform minimum financial incentives and ensuring availability of good social services and economic opportunities within the community are among important retention strategies.

Place, publisher, year, edition, pages
BioMed Central, 2018
Keywords
Africa, Decentralization, Health systems, Health workforce, Human resources, Medical doctors, Physicians, Retention, Rural, Tanzania
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-150436 (URN)10.1186/s12913-018-3059-0 (DOI)000450979400001 ()29631589 (PubMedID)2-s2.0-85045188033 (Scopus ID)
Funder
Sida - Swedish International Development Cooperation Agency
Available from: 2018-08-08 Created: 2018-08-08 Last updated: 2019-04-16Bibliographically approved
Sirili, N., Kiwara, A., Gasto, F., Goicolea, I. & Hurtig, A.-K. (2017). Training and deployment of medical doctors in Tanzania post-1990s health sector reforms: assessing the achievements. Human Resources for Health, 15, Article ID 27.
Open this publication in new window or tab >>Training and deployment of medical doctors in Tanzania post-1990s health sector reforms: assessing the achievements
Show others...
2017 (English)In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 15, article id 27Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The shortage of a skilled health workforce is a global crisis. International efforts to combat the crisis have shown few benefits; therefore, more country-specific efforts are required. Tanzania adopted health sector reforms in the 1990s to ensure, among other things, availability of an adequate skilled health workforce. Little is documented on how the post-reform training and deployment of medical doctors (MDs) have contributed to resolving Tanzania's shortage of doctors. The study aims to assess achievements in training and deployment of MDs in Tanzania about 20 years since the 1990s health sector reforms.

METHODS: We developed a human resource for health (HRH) conceptual model to study achievements in the training and deployment of MDs by using the concepts of supply and demand. We analysed secondary data to document the number of MDs trained in Tanzania and abroad, and the number of MDs recommended for the health sector from 1992 to 2011. A cross-sectional survey conducted in all regions of the country established the number of MDs available by 2011.

RESULTS: By 1992, Tanzania had 1265 MDs working in the country. From 1992 to 2010, 2622 MDs graduated both locally and abroad. This translates into 3887 MDs by 2011. Tanzania needs between 3326 and 5535 MDs. Our survey captured 1299 MDs working throughout the country. This number is less than 40% of all MDs trained in and needed for Tanzania by 2011. Maldistribution favouring big cities was evident; the eastern zone with less than 30% of the population hosts more than 50% of all MDs. No information was available on the more than 60% of MDs uncaptured by our survey.

CONCLUSIONS: Two decades after the reforms, the number of MDs trained in Tanzania has increased sevenfold per year. Yet, the number and geographical distribution of MDs practicing in the country has remained the same as before the reforms. HRH planning should consider the three stages of health workforce development conceptualized under the demand and supply model. Auditing and improvement of the HRH database is highly recommended in dealing with Tanzania's MD crisis.

Keywords
Health sector reforms, Human resource for health model, Medical doctors, Planning, Shortage of doctors, Training and deployment
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-138467 (URN)10.1186/s12960-017-0202-7 (DOI)000411104500001 ()28376823 (PubMedID)
Available from: 2017-08-23 Created: 2017-08-23 Last updated: 2018-09-11Bibliographically approved
Sirili, N., Frumence, G., Kiwara, A., Mwangu, M., Goicolea, I. & Hurtig, A.-K. "Doctors ready to be posted are jobless on the street..." the deploymnet process and shortage of doctors in Tanzania.
Open this publication in new window or tab >>"Doctors ready to be posted are jobless on the street..." the deploymnet process and shortage of doctors in Tanzania
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-150636 (URN)
Available from: 2018-08-15 Created: 2018-08-15 Last updated: 2018-09-13
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0001-5205-624x

Search in DiVA

Show all publications