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Public private partnership in training of doctors after the 1990s' health sector reforms: the case of Tanzania
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O.BOX 65454, Dar es Salaam, Tanzania.ORCID iD: 0000-0001-5205-624x
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
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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. Vol. 17, article id 33
Keywords [en]
: 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: urn:nbn:se:umu:diva-150635DOI: 10.1186/s12960-019-0372-6ISI: 000468753800002PubMedID: 31118038OAI: oai:DiVA.org:umu-150635DiVA, id: diva2:1239001
Note

Originally included in thesis in manuscript form.

Available from: 2018-08-15 Created: 2018-08-15 Last updated: 2019-06-11Bibliographically approved
In thesis
1. Health workforce development post-1990s health sector reforms: the case of medical doctors in Tanzania
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

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Sirili, NathanaelFrumence, GastoGoicolea, IsabelHurtig, Anna-Karin

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