Labour Market Study for the Tanzanian Health Sector: 2006

Draft 4September 2006

Capacity Project, NIMR and Ministry of Health, Tanzania

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Table of contents

List of tables and figures

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List of abbreviations

ADO Assistant Dental Officer

AMO Assistant Medical Officer

ART anti-retroviral treatment

ARV anti-retro virals

CCM Chama Cha Mapinduzi, the ruling political party

CEDHA Centre for Educational Development in Health, Arusha

DMO District Medical Officer

HR Human Resources

HRD human resource development

LATH Liverpool Associates in Tropical Health

MCHA Mother and Child Health Assistant

MUCHS Muhimbili University College of Health Sciences

NGO non-government organisation

NIMR National Institute for Medical Research

PHC primary health care

USAID United States Agency for International Development

WHO World Health Organization

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Executive summary

As the Tanzanian government emerges from a freeze on employment throughout the public sector and the intention is to add to the current workload of the whole health sector by providing free anti-retroviral treatment to all those with clinical indications, this increased workload on an already under-resourced workforce is putting strain on the system. The options available to alleviate this situation are basically a combination of employment of additional people, redistribution of staff between facilities and improved performance by those currently employed.

The decision to hire additional staff to supplement those already present in the selected ART sites has been taken. The Ministry of Health seeks to understand the labour supply market dynamics, both with a view to inform the recruiters regarding the availability of skilled health professionals to respond to the emergency hire programme and to provide an evidence base on which future human resource plans and strategies can be drawn.

A study was carried out in June and July 2006 using a variety of existing data sets to map out the current state of the labour market in the health sector, as no single database can currently provide this information. As would be expected there were some gaps in the data requirements and also some inconsistency. The labour market data was supplemented by interviews with almost all District Medical Officers on their current experience of staff losses and recruitment of replacements. In addition interviews were carried our with a selection of applicants not currently working for the government sector for clinical officers, assistant medical officers and nurses posts in a recent recruitment exercise, to understand the availability and willingness of trained staff to be employment in the health sector.

The picture painted of the state of the labour market in the health sector from the data available was not as gloomy as expected. The supply of applicants for training places for most health professionals is adequate both in terms of quantity and quality with the exception of those entering courses for laboratory and pharmaceutical staff. Data on attrition rates during training was unavailable for all but doctors and this is of some concern with recent losses around a quarter of the entrants.

Whilst training output is increasing, not all health professionals who graduate find jobs. From the most recent data available for clinical officers at least three out of every five clinical officers were unable to find jobs in either the government or the private sector. More doctors who are successful in getting jobs are going into the private sector in the past 10 years.

The impact of the employment freeze has not had quite such a serious impact on the size of the workforce as possibly generally perceived as this was only a constraint on the expansion of posts for which extra funding would be needed.

Overall losses from the government sector are remarkably low and the highest risk of loss is within the first year of employment in approximately during which 10% of people leave for some reason.

The distribution of health professionals working in rural districts as opposed to urban ones is very much in line with the distribution of the population and this balance between care in rural and urban environments is probably one of the most equitable in Africa.

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The age distribution was only analysed for nursing staff. This gives no reason for concern as there is no looming retirement bulge that would lead to a sudden staff shortage.

The general picture from the survey of District Medical Officers is that there is not a serious problem with vacancies and finding people to fill the vacancies – either in rural or urban districts. However the process of actually engaging these people has not seen the numbers required being taken on except for those districts that have been actively advertising vacant posts.

The interviews of recent clinical officer/assistant medical officer and nurse applicants for vacancies were also very encouraging. Most are motivated to serve patients and a surprising number (80% for clinical officers) were prepared to work “out of town” and this was confirmed by the fact that the majority had already recently taken up “out of town” jobs.

In summary, many aspects of the health labour market seem positive. The losses of staff are relatively low compared to some countries in the region and age distributions of cadres analysed do not indicate any problems. Coupled with this relative stability in the existing workforce, there seem to be plenty of people willing to train for most professions and to subsequently work in the health sector and there is a willingness of trained staff currently not working in the health sector to come back many of whom are prepared to work in non-urban areas. The labour market seems well disposed to increasing the number of people required to deliver ART services, though the stated requirement of an extra 28,000 will be challenging. This expansion would require an increase in training output as well as increased ability of the government to employ staff.

The MoH now needs to build on this study so that future information on the labour market will be more easily available and better quality

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1. IntroductionSince independence in 1960 the ruling party, Chama Cha Mapinduzi (CCM) and the government of Tanzania have been committed to fighting the three enemies – illiteracy, poverty and sickness. The government built an infrastructure of regional and district hospitals, health centres and dispensaries with the aim of providing the majority of the population with affordable, accessible and equitable health care. There are currently 5 consultant/specialised hospitals, 17 regional hospitals, 57 district and other hospitals, approximately 400 health centres, and approximately 2400 dispensaries in the government sector. The majority were built in the 1970s and 1980s. Additionally there are over 2300 health facilities run by the private sector, both private for profit and private not-for-profit. A full breakdown is given in Annex 1. Services were provided free at the public facilities until the economic crisis of the 1980s forced the introduction of user fees beginning in 1993.

At about the same time the government had to freeze employment in the whole public sector. Over time this ‘employment freeze’ has resulted in a health system – in particular the publicly-funded section – with a severe shortage of health professionals.

The surge of the HIV/AIDS epidemic has only served to exacerbate the situation. Sero-prevalence rates are now around 7% amongst adults 15-49 years, with about 2 million people infected. It is estimated that 400,000 people will have progressed to a stage where they need anti-retroviral treatment (ART) by 2008.

In 2004 the government decided to provide free anti-retroviral treatment to all those with clinical indications. A care and treatment programme is being implemented country wide. This includes training of health professionals in ART and the supply of all essential components including pharmaceuticals and laboratory equipment and reagents. So far about 20,000 people have been started on anti-retroviral drugs (ARVs) in about 200 health facilities selected for provision of this care and treatment.

A major obstacle to achieving that goal is the shortage of staff key to the provision of ARVs, namely doctors, nurses, pharmacists and laboratory technicians. Due to the toxic nature of the drugs and resulting need of close follow up of the people started on treatment, the National AIDS Control Programme specified standards regarding personnel, equipment, space, etc. that have to be met for the facilities to be allowed to participate. Expansion of new facilities providing ARVs is limited by these essential requirements. Similarly even enrolment of people into the programme by the already enrolled sites is limited because of a lack of fully trained health professionals.

A 2001/2002 survey of health professionals in both private and public health facilities by the Ministry of Health and Social Welfare revealed that about 22,000 additional health professionals were required to fully staff up the government facilities at a level agreed in 1999 between the Ministry of Health, the Public Service Commission and the Treasury. These levels did not consider the additional service loads imposed by the HIV/AIDS epidemic. Kurowski et al (2003) estimated that a further 28,0001 staff would be required for anti-retroviral treatment (ART) and care.

1 Human Resources for Health: Requirements and Availability in the Context of Scaling-Up Priority Interventions in Low-Income Countries Case studies from Tanzania and Chad. Christoph Kurowski, Kaspar Wyss, Salim Abdulla, N’Diekhor Yémadji and Anne Mills, January 2003.

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Options for filling the gaps in order to scale up the provision of ART include employment of additional health professionals, redistribution of staff between facilities and improved performance by those currently employed.

Tanzania is the recipient of Global Funds for HIV/AIDS. The Ministry of Health and Social Welfare intends to use some of these funds from the Global Fund to urgently hire additional staff to supplement those already present in the selected ART sites. In planning the emergency hiring programme the Ministry of Health therefore needs to know more about the:

Availability of health professionals for emergency hire and Their willingness and the conditions required for them to work in the ART

sites

As part of the ground work for the emergency hiring programme, The Capacity Project, together with NIMR, is continuing to provide technical assistance to the MOH to perform an audit to identify barriers and bottlenecks to recruitment. The Capacity Project also together with NIMR, is providing technical assistance to help the MOH to better understand the labour supply market dynamics. A labour supply market analysis will provide information about whether there are adequate numbers of skilled health professional in the labour market to participate in the emergency hire programme. In addition, it will provide an evidence base on which future human resource plans and strategies can be drawn. For example, it was generally assumed that under the employment freeze from 1993-2001 the supply of skilled health workers was greater than the combined public and private sector demand (Dominick and Kurowski, 2004.) However the application of the freeze may not have been as universal as was originally understood. This document presents, within the limitations of available data, a picture of the availability and willingness of the cadres needed to fill the emergency hire plan.

The three main purposes of this study were: 1. To examine recent trends, in the supply of health professionals, so as to

support the MOH in its future planning including for the Emergency Hire Program.

2. To learn from the recent successful rapid recruitment initiative for Clinical Officers.

3. To help the Ministry of Health in Tanzania set up a routine system for tracking the labour market for the health sector.

In practice purpose 2 was extended to become “to understand the perspectives of key staff concerning the work environment, including conditions that will prompt their desire to join the health work force, and preferred incentives for working in rural areas".The study was limited to those health professionals required to scale up the provision of ART services and who would therefore be possible candidates for the emergency hiring programme. These included:

Medical officers and specialists Assistant medical officers (AMOs) Clinical officers Nurses

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Pharmacists and Diagnostic (laboratory) staff.

The full scope of work is given in Annex 2

This report continues with a description of the methods of the study, followed by the results. These results are then reviewed in a discussion section which is followed by a concluding section.

2. Methods

Data collectionThere are two types of data that were collected over a five week period in June and July 2006. Workforce data that are intended to present an overview of the supply of qualified personnel throughout the country. In particular these data present the distribution of the cadres of personnel by whether they are currently in employment, in rural and in urban settings, and by age and sex. The second type of data was obtained through surveys of individuals to obtain insight into the motivation to return to work of potential candidates. Table 1 sets out the data sources and how they relate to these purposes.

Table 1: Data sources and data collected

Purpose Data source(s) Data collected1. To examine

recent trends, in the supply of health professionals, so as to support the MOH in its future planning including for the Emergency Hire Program.

Number and capacity of training institutions – Schools database

Summary of all health training institutions in Tanzania obtained as word document

Outputs from training institutions for the last 10 years

Excel Worksheet obtained from MOHSW

MOH survey 2001/2002 About 48,000 records in a foxpro database

CEDHA survey 2005 (but also using 2002 data)

Data in Excel sheets one for each region – now combined into one workbook

Nurses Council Registrar Data for about 16,000 nurses in an Access datafile

Medical Council Registrar Data from manual registers and files computerised – about 3,000 records

Pharmacists Registrar Data in excel sheets for about 800 pharmacy staff obtained from the Registrar of Pharmacy professionals

Follow-up of Graduates from Muhimbili University College of Health Sciences

Data on graduands obtained from the College and information about their whereabouts obtained from colleagues

Government Payroll - Health Employees

Data on health professionals obtained from the Treasury through the Public Service Management

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2. To learn from the recent successful rapid recruitment initiative for Clinical Officers.

DMO questionnaire Interviews to 98 DMOQuestionnaire for applicants for jobs at Muhimbili National Hospital and Muhimbili Orthopaedic Institute

Telephone interviews to about 211 job seekers

Questionnaire for applicants for jobs for 8 selected districts

Telephone interviews to about 225 job seekers

Questionnaire to employees in private pharmacies in Dar es Salaam

Face to face Interviews to about 100 employees

3. To help Tanzania set up a routine system for tracking the labour market for the health sector

Activity: Development of a computerised data base of Medical Practitioner registrations

Workforce data

SupplyThe current working stock – or ‘supply’ – of health professionals was obtained from a number of sources in a variety of ways, depending on the cadre of people being examined. There are two main sources that set out to represent the entire workforce, in both the government and faith-based organization (FBO) sectors.

A study commonly referred to as the WHO study which was an audit conducted in 2005. This was conducted by CEDHA. There are some missing components in these data. This study provides numbers of staff in each facility (government and non-government) throughout the country.

The second is a 2001/2002 audit of government and private facilities which lists a lot of detail about every individual employed in the government sector – down to the years of birth of their children. Not all these data items are of value, but the inclusion of facility name and type were extremely useful.

The FBO sector currently has limited data but Capacity Project is co-funding a separate exercise to help with this, in order that in future the whole labour market analyses will be more straightforward.

Attempts to obtain data from the various pension funds in Tanzania were not successful. There are six different funds - there is currently a move to rationalize these – and these indicate who is currently working. However not all the records of the various funds included job titles and therefore this line of enquiry was not pursued.

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Data was also obtained from the government payroll on all health professionals employed in government health facilities. Use of the payroll data was limited due to non-availability of designations (job-titles) for some of these employed after 1999.

PoolDetailed data on the total pool of available health professionals, those working and those not known to be working in Tanzania has been obtained for two significant cadres.

DoctorsThere are several sources of data that were explored in order to understand the labour market dynamics for doctors (including their development to specialists), AMOs, dentists and ADOs.

One is the registration records of the Medical Council of Tanganyika. There are two sorts of record: individual paper files and registers in the form of books. Records were made by extracting data from the registers and entering these onto a spreadsheet. This ensured there were data to work on for this study. The team undertaking this study also arranged to enter the complete paper files onto an Access database. The framework of this was established some time ago by the University in Dar es Salaam, but the data have never been entered. These data from the personnel files are needed for the longer term labour market monitoring we are working towards as described in Purpose 3 above. Both sets of data include all 3,641 doctors, dentists and AMOs who have practiced in Tanzania, including Tanzanian doctors trained in Tanzania, outside Tanzania, for example in the former Soviet Union, Cuba, etc. and some expatriates. There is a separate register specifically for expatriates, which was not included in the study, since they are not considered to be part of the ‘pool’ from which emergency hiring will take place.

A second source of data has been generated from the training registers held by Muhimbili University College of Health Sciences (MUCHS). These registers contain details of all graduates, current students and those who did not complete their courses at MUCHS. Using these records as a starting point and through discussions with a number of doctors, we were able to identify the current whereabouts of their contemporaries. This is a sample, albeit a very large one, of the doctors as it does not include those initially trained outside the country. This approach, known as ‘sisterhood analysis’2, has identified the present status of over 90% of the graduates since the first class graduated in 1968.

Nurses and Midwives

2 For a description of this method see Dovlo, D. and F. Nyonator (1999). "Migration by Graduates of the University of Ghana Medical School: A preliminary rapid appraisal." Human resources for health development journal 3(1).

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The registration records of the Nurses and Midwives council have details of all trained nurses and midwives who elected to register. These records were transferred to a Microsoft Access database in September 2004. This has enabled an analysis of the total supply of those nurses who registered at that time to be carried out. There are nurses who chose to register even though they were not working as nurses at that time.

There should have been an update of this register in September 2006, after the data collection phase of this study, but again this will be valuable for future monitoring needed to achieve purpose 3.

Other Health ProfessionalsThe registration records of the Tanzania Food and Drugs Authority contain details of Pharmacists and pharmacy-related staff (Pharmaceutical Technicians and Pharmaceutical Assistants).

Laboratory professionals are not currently required to register with any professional council or authority.

Annex 3 describes fully the various data sources.

Data from interviews

SupplyIn addition to the workforce data described above, there was a significant exercise to collect data from various individuals on their perspectives about the work environment that will enable the level of recruitment to be increased.

First the Personnel and Administration Section within the Ministry provided an authoritative schedule regarding official government policies regarding recruitment, which do not necessarily coincide with commonly understood rulings. In particular it was apparent that the “unemployment” / recruitment freeze from 1993-2001 was not absolute.

During the initial planning stage of the study there was a meeting with all the 120 District Medical Officers (DMOs) to obtain from them information about each of their districts. This did not seek to obtain precise data as the DMOs were away from their offices, but sought information on recruitment and losses for the four main cadres: clinical staff (medical officers, clinical officers/AMOs), nursing staff (nursing officers, enrolled nurses), pharmacy staff and laboratory staff. For each cadre the DMOs advised whether they had advertised to fill any posts during the precious twelve months, how many people applied, how many posts they succeeded in filling and approximately how many people left and for what reasons.

Applicants to the recent Clinical Officer rapid recruitment initiative and other district level initiatives were surveyed using a combination of face-to-face and telephone interviews.

Face-to-face interviews were conducted in a total of eight districts with at least one from each region of the country. Each DMO within these eight districts directed the interviewers to some of the previous unsuccessful applicants within these districts, or to people he or she knows are qualified in

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a health related field but not working in health. These people were interviewed (face to face or through telephone) to assess their current work status, their views on the best and the worst components about their present or most recent job, their response to having not been taken on as a result of their previous application, their likelihood of re-applying and the incentives they would need to work in some remote parts of the country.

Telephone interviews with recent applicants were conducted by a small team based in Dar es Salaam. The same questions were asked of as many nurses and midwives who could be contacted by telephone and who had applied for work at Muhimbili National Hospital or Muhimbili Orthopaedic Institute in the last one year and were not taken on.

A recent rapid recruitment initiative for clinical officers, which has also been applied to some other cadres of health staff, albeit in smaller numbers, resulted in recruitment of about 600 officers. Plans to interview any clinical officers who may not have taken up posts were not carried out as their details were not available.

A total of 436 health professionals were interviewed - 211 from Muhimbili and 225 from the 8 districts. In all of these the age, sex and location of the individuals interviewed were noted. The main characteristics of the study population are given in Table 2.

Table 2: characteristics of health professionals interviewed in the surveysfemale male total age

rangeAMO 2 2 40, 44clinical officer 23 31 54 24 to 52dental technician 1 1 28health officer 7 7 27 to 39health assistant 1 1 36Intern 1 1 27laboratory assistant 3 8 11 25 to 38laboratory attendant 1 1 32laboratory technician 1 8 9 24 to 37Marketing 1 1 33MCHA 1 1 32medical officer 2 2 34, 38Nurse 208 36 244 23 to 52Paramedic 1 1 28Pharmacy 3 1 4 28 to 35Research 3 3 27 to 32Sales 9 1 10 26 to 34Unknown 65 18 83 21 to 46

319 117 436

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3. Results

Characteristics of the workforceAs this study is focusing on the dynamics of the labour market, the results on the characteristics of the workforce covering all cadres at each stage are reported in a way that reflects the flow through the system:

flows into training, highlighting the adequacy of the number of applicants for available training places

flows through training to identify losses during the training period a comparison between training outputs and entry into employment to identify

potential losses to the system flows through recruitment and deployment, tracking distribution by employer

and how long graduates work in the health sector some characteristics of those currently employed in the health sector include

data on geographical location, age and nationality flows out of the health sector

Flows into trainingThere are a number of sources of data that indicate that there are more than sufficient people recently interested in training to be health professionals of some type or other. With regard to clinical positions, Chart 3 below sets out the various types of clinical staff and the education and training requirements they need to progress through the various levels.

Chart 3: The training and development flows for clinical staff

Medical specialist

Medical officer

3 - 4 years training

5 years trainingForm VI leaver

4 years training

Assistant medical officeradvanced diploma

2 years training for Form VI lvrs

Clinical officercertificate

training to certificate 3 yrs

Forms IV and VI leavers

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The number of training places for medical officers/doctors has been expanding substantially over the last few years and there has been no report of a shortfall of applicants for these places.

However, there is a concern with the ability to attract poorer sections of the population into health professional training, given, for example that doctors pay for their own training for five of six years, except at MUCHS in Dar-es-Salaam. There is some cost sharing, where individuals receive a loan for meals, accommodation and tuition and this is going to extend to private schools. Currently all trainees pay at private institutions and only at the government institutions is there any cost sharing. (The policy announced July 2006 is that the government will provide a loan for the top performers in the Advanced School Leaving Certificate whichever university they are admitted into, whether government or private. All other students, even if they are in government universities, will have to pay for themselves or find sponsors other than government.)

With regard to the applications for clinical officer training, at a selection process for pre-service training last year at Kibaha, 422 people applied for 185 places, and these places were all successfully filled.

Chart 4 below sets out the various types of nursing staff and the education and training requirements they need to progress through the various levels.

Chart 4: The training and development flows for nursing staff

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With regard to nursing, in the same selection process for pre-service training last year at Kibaha, 333 people applied for 80 places on the diploma course which leads to nursing officer positions. 90 were selected and a further 19 were held in reserve. Although the number of applications for the certificate course was not available, 35 people were selected for the 35 vacancies, and a further 20 were held in reserve.

The situation with regard to applications for some of the other courses for health professionals was not as pleasing. Whilst numerically more people applied than there were training places for the laboratory technician and pharmaceutical technician programmes, in both cases not all the training places were filled. 36 people applied for 25 laboratory technician places but only 13 were selected with 4 held in reserve. For the pharmaceutical technician programme, only 10 people were selected from 24 applicants, even though there were 15 places. Assuming the intention was to run full programmes and there was no organisational constraint, this suggests that the calibre of the applicants was insufficient for these particular courses. It was also learnt that courses for other health professionals not covered by this study, such as physiotherapy and optometry, also lacked sufficiently qualified candidates.

graduate nursing officer

nursing officer(diploma)

3 years

nurse midwife(certificate)

MCHA nursing assistant

nurse (certificate)

form IV leaversstandard 7 leavers

public health nurse B (certificate)

public health nurse A (diploma)

nursing officer specialist(advanced diploma)

form VI leavers

4 years

4 years

1 year

1 year

3 years

3 years

1 year

1 year2 years

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Flows through training

Doctors training outputThe total number of doctors trained at MUCHS since 1968 is 1624. The annual intakes were only in the range 3 to 28 up to 1973; it then increased to somewhere in the region of 50 doctors until 1999. Since then the annual intake has been climbing to an average of 200 a year for the last four years. However, from training institutions records and MOH-HRD Training Department it would appear that, whilst 100% of entrants qualified as doctors a generation ago, on average only about 82% of all intakes complete the course. Most recently, attrition, for whatever reason, of people who entered training in 2000/2001 was 22%, and the losses from the next year’s intake, which is still to finish, is already higher than this at 24%.

As the data on doctors qualifying is disaggregated by sex, it can be seen from Chart 5 that the proportion of female doctors graduating has been steadily increasing from an average of 7% before 1975, to an average of 14% over the next ten years to 1985, 19% from 1986 to 1995, and then to 27% average over the last ten years. Recently women have slightly better course completion rates than men.

Chart 5: Doctors qualifying in Tanzania by sex and by year

Source: Sisterhood analysis.

The number of clinical officers trained in Tanzania over the nine year period from 1996 to 2004 was 4,664 with a further 788 assistant clinical officers finishing their training from 1996 to 1998, after which there have been none produced, see Annex 4. Furthermore 1207 assistant medical officers and 79 assistant medical specialists have been trained over the same period, all without any significant steps changes in annual outputs.

NursingDuring the nine years from 1996 to 2004 between five and fourteen nurses a year have received advanced diplomas in the following specializations, in decreasing

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order of magnitude: teaching; public health; ophthalmology; paediatrics; mental health, theatre management and midwifery. Whilst most of these were spread throughout the period, all forty midwives qualified in 2003.(see Annex 4).

The number of nurses receiving a diploma, after either four years training for form IV leavers or by growing within the service, was 2,789 over the same nine years. These numbers have been increasing from 125 in 1996 to an average of just over 400 a year during the last four years of the period.

The largest numbers of any group of health professionals qualifying is for “enrolled nurse”. This is taken to mean all certificate holding nurse positions, as opposed to diploma holding nursing officers. These too can be trained in a variety of ways, either from form IV school leavers, or standard 7 school leavers, or from nursing assistants who are also standard 7 school leavers, but have also already trained for a year to fulfil that position. This total was 9,363 over the same nine years. These numbers have also been increasing from 673 in 1996 to an average of just over 1167 a year during the last four years of the period.

Comparison of training outputs and appointmentsThe analysis continues with examining the relationship between training output and entry into employment. Data are only currently available for doctors and clinical officers.

Doctors and Clinical OfficersThe national outputs and appointments of the two types of professional in the clinical area of health provision in Tanzania, namely doctors and clinical officers are given in Table 6. Specialists are not included as it is assumed that the vast majority are selected for further training and so their re-appointment is effectively guaranteed. Clinical Officers upgrade to become Assistant Medical Officers. All entrants into the AMO course have to be serving clinical officers and remain employed. The data are confined to the period 1996 to 2001 since the appointment information from the 2002 survey is only up to 2001, and the training output information on the clinical officers is only from 1996.

Table 6: trained and appointed clinical staff for all employers: 1996 to 2001 Level Trained (see

Annex 4)appointed

assuming all the unknown

years of appointment

are in this period

appointedassuming

none of the unknown

years are in this period

Percentage appointed

Doctors but not specialists 242 274 61 25 to 100%Clinical officers 2746 1087 650 27 to 40%

Sources: 2001/2002 survey and from training institutions

This table shows that over this six year period many clinical staff have been trained but not appointed. The large numbers of doctors without a known year of appointment makes drawing conclusions from this particular comparison uncertain, but it is highly unlikely all the “unknown appointment years” are between 1996 and 2001. One extreme is to assume that all the unknown appointment years were in this period, in which case every doctor qualifying would have been appointed. The other

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extreme is that none were in this period, in which only 25% would have been appointed. The actual figure has to be somewhere in this range 25% to 100%. Since 2002 the numbers of medical officers being trained has increased substantially, see Chart 5. Therefore, unless there is going to be a substantial increase in recruitment levels, based on past performance, not all new trained doctors will find posts.

By the same argument, between 1996 and 2001 throughout Tanzania at least three out of every five clinical officers were not appointed to either government or private sector posts on completion of their training. There are many trained clinical staff, particularly clinical officers, trained over this period but who were not appointed at that time. For example, in 2001 528 clinical officers were trained in 2001 but less than 200 were appointed by all the institutions in the country.

The recent recruitment programme has led to the appointment of 528 clinical officers and presumably led to the appointment of some of these three in five, but those selected probably included some trained before 1996 or since 2001 as well.

The following analysis is based on every doctor who has graduated in Tanzania from Muhimbili University College of Health Sciences (MUCHS) and/or been registered within the country. The data includes all students registered at the College since its inception. Students enrolled after 2001 have not yet graduated and are therefore omitted from the analysis. Those who enrolled in 2000 and are supposed to be doing their internship now are included but there may be a few of them still in school if they have to repeat a year or are supplementing a subject. A number of doctors were asked to help provide the information on the current location of their contemporaries using what is known as the ‘sisterhood method’. As a result of this additional data source, the current whereabouts is known of 91% of those who graduated before 1975, 95% between 1976 and 1995 and 91% of those graduating in the last ten years.

Total number of doctorsThe total number of qualified doctors, assumed to be Tanzanian, ever put on the on the register is 2,448. There is a further register of non-nationals that has not been examined. The number of graduates from MUCHS up to and including 2005 is 1546. Of these 36 (1%) are probably not Tanzanian nationals: 3 are listed as Ugandans and 33 have “X” in the nationality column, presumably indicating that they are expatriates. A further 2 have “AT” in the nationality column, but the meaning of this is unknown. There are also many blanks nationality fields, but it is felt that these are very likely to all be Tanzanians. This is a field that would almost certainly be completed if the subject was not a national.

People might no longer work in health for a variety of reasons. People die and retire; they might become incapacitated or they might be dismissed or suspended. These reasons apply to 17% of those known about who graduated before 1975 and reduces to just 2% of those whose whereabouts are known and who have graduated in the last twenty years.

Work locationThose known to be working outside Tanzania also varies according to when they graduated.

Of the 36 or 38 non-Tanzanian doctors only 4 are known to be currently working in Tanzania. Of the earliest Tanzanian graduates, 41% of Tanzanian nationals who

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graduated before 1975 are known to be outside the country. For those graduating over the next twenty years the figure reduces to some 20%. Only 9% of those graduating during the last ten years whose current whereabouts are known (75% of the total) is outside the country.

Those remaining in Tanzania are employed by the government, by the private sector or are seconded into a voluntary agency hospital that serves a government facility. Of the earliest graduates, before 1975, 1 in every 3 is known to be still working, and half of these are working for the government. For graduates from then until 1995 whose whereabouts are known, over 60% of them are working in Tanzania and two thirds of these are in government service. Of those graduating in the last ten years, over half are known to be in government service, a further 15% in private institutions and some 6% as seconded into a voluntary agency hospital, i.e. a designated district or zonal hospital. The whereabouts of the remaining 10% of the medical graduates covered by this study is unknown.

Table 7: current whereabouts of doctors graduating between 1968 and 2005

Year grad

dead out of country

retired govt employ

intern suspended

priv. sector

seconded

unknown

Total

1968-75

17 52 8 25 15 8 10 135

1976-85

26 92 9 167 3 75 25 18 415

1986-95

11 87 161 53 23 18 353

1996 2005

12 111 1 265 138 7 98 27 62 721

total 66 342 18 618 141 7 241 83 108 1624

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Chart 8: whereabouts of doctors by graduation decade

Flows through recruitment and deploymentThe following charts show the distribution of each of the types of people working in this sector, according to the type of owner of the facility at which they work:government, private, voluntary agency, private institution (such as a company providing health care for its staff only) or Muslim organisations. Although religious, they are often not not-for-profit. Voluntary Agency facilities refer to not-for-profit Christian owned. The data is from the 2001/2002 MOH survey. The final column in each case shows the facility for those individuals whose date of appointment is unknown. The first column refers to all those individuals whose year of appointment to their current post is before 1970 – they have been in post for thirty five years. A number of facts are apparent from these charts.

There are certainly reduced numbers of government appointments during the employment freeze period from 1993 to 2001, but there have been always been some appointments every year, even though they are not thought to have replaced all the losses.

The proportion of appointment in the private sector has been increasing in more recent years, but this could be a combination of fresh graduates going straight to such positions and, more likely experienced staff moving to the private sector, as it has expanded. Government practitioners were not allowed to engage in private practice before 1991.

Nonetheless approximately 70% of all these individuals in each cadre are working for the government.

Whilst the appointment of assistant medical officers (and assistant medical specialists) (see Chart 10) remains low, the appointments of clinical officers in the early years of this decade are at similar levels to the 1980s. In fact AMOs

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are not initially appointed as such: they are experienced clinical officers who attend an in-service training to become AMOs and remain employees during the training. It is unclear whether these years of appointment refer to their original appointment as a clinical officer or their upgrading to AMO.

The appointment of the 752 medical officers and specialists for whom data is available has hovered around 10 a year throughout the eighties and nineties (see Chart 11). However the appointment dates for 307 doctors (41% of the total registered) are unknown.

Chart 9: The years of appointment and facility owner for clinical officers

Key:dh = designated district hospital; 16 church or district council owned hospitalsmu = Muslimpi = private institutionpr = privateva = voluntary agencygo = government

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Chart 10: The years of appointment and facility owner for assistant medical officers

Chart 11: The years of appointment and facility owner for medical officers and specialists

When considering the employment freeze on the government sector, there maybe some confusion since employing someone to fill a vacancy depends on how a

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vacancy is defined. It is probably worth clarifying at this stage the various categories of vacancies (see Table 12). If an employee leaves, dies, retires or whatever, then his or her replacement is effectively automatically approved. There are further positions which might be described as funded vacancies, where the annual budget allows for someone to be recruited but the position is not successfully filled. This might be for a variety of reasons. And then there are further vacancies between this budgeted level and an establishment level – a level that has at some time been agreed as the desired number of staff to work in the facility. Vacancy category 1 is in fact the only type of vacancy that was covered by the employment freeze. This applies to all government health facilities and has been described in the introduction. Comparing the 2002 study with the desired staffing levels showed that some 22,000 additional health professionals (not just clinical staff) were required to fully staff up the government facilities at a level agreed in 1999 between the Ministry of Health, the Public Service Commission and the Treasury. These levels did not consider the additional service loads imposed by the HIV/AIDS epidemic.

Table 12: Categories of Vacancy

CategoryApproved staffing level for a facility (agreement between MOH, PSM and Treasury, 1999): includes categories 1, 2, 3, & 4.

1 Vacant: Not Funded in this year’s budget

Can not be filled because not funded

2 Vacant: Funded in this year’s budget

May be filled during this financial year. If not possible this year, it will revert to category 1

3 Vacant: due to death, transfer, dismissal, etc during the financial year

May be filled during this financial year. If not possible this year, it will revert to category 1. Every budget session, these category of vacancies are eliminated to remove ghost workers.

4 Present number of staff

Non-government health facilities on the other hand are required to satisfy minimum levels of staffing laid down by regulations, and are unlikely to exceed these standards significantly.

Distribution of the workforceFurther characteristics of the workforce have been analysed in terms of distribution by geographic location, age and nationality.

Rural and urban districtsThere are draw backs in getting reliable information to understand the flows between rural and urban districts accurately. Without a longitudinal identifier that is used throughout the country for each individual – an employee number – to track movements around the country will prove nearly impossible. One holder of data for example offered the requested data but was unhappy to release them with names included. But we also know it is an important question for assessing supply. However, it is believed that regional disparity is not the issue.

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Before moving into specific cadres, the distribution of all professional staff between rural and urban districts is considered.

The population of Tanzania has 81% described as living in rural areas (28,117,090 / 34,569,232). There are 5.5 million rural households and 1.5 million urban ones, which implies that rural households make up 79% of the total households.

The following is an analysis by location and cadre of 43,803 staff. These data were taken from a file that contains hire and date of birth data on health employees within the Public Sector and includes some voluntary agency employees paid for by the government of Tanzania. These employee records would be held in the treasury database. The location categories are rural district, urban district and regional unit; this unit may be located in an urban setting but is probably serving the more rural parts of the country. 39,844 people were in one of these three categories. Others were specified as working for the Ministry of Health, which is likely to be urban, but not necessarily; for defence; for the Ministry of Natural Resources and Tourism; community development, women and children and for other bodies which could be anywhere. For example this file includes a medical attendant working in the Office of the Speaker at the National Assembly in Dodoma. These 39,844 people were then analysed by the jobs they were doing. The largest group – 15,644 – are medical attendants. These people are excluded, as are guards, cleaners, kitchen staff and the like. Unfortunately 4,160 people were classified as “conversion designation” and could not be categorised below. Annex 5 more details on the urban/rural distribution by job title, though it does not include the regional units.

Table 13 below sets out how the 12,954 professional government and non government staff identified by the 2001/2002 study are broken down by location.

Table 13: Distribution of key health personnel by rural and urban locations or regional unit, for comparison with the population distribution

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As four-fifths of the population is in rural districts, these figures do not suggest a poor or inappropriate distribution of professional staff around the districts of the country, as 79% of these professional staff are either working in rural areas or regional units.To expand on this with regard to nursing staff, the following two charts show the age distribution of nurses in five year bands, with each band further broken down by whether the individual is working in a rural or an urban district.

Chart 14: Age Distribution of Nursing Officers, further spilt by whether they are working in an urban or rural district

Cadre Rural Urban Regional

Principal nurse 80 50 54senior nurse 107 56 55Nurse 1598 434 701Principal nurse midwife PHN-B 24 15 27senior nurse midwife PHN-B 76 54 38nurse midwife & PHN-B 254 172 91asst nurse 2638 699 254

Principal nursing officer 24 8 15senior nursing officer 146 81 153nursing officer 534 347 455

chemical lab technician 1 1senior medical lab technician 2medical lab technician 20 20 7

senior dental surgeon 7 1 7dental surgeon 3 10 11asst dental officer 22 11 17senior dental technicians 1 1dental technician 2 1 1

medical consultant 3 11Principal specialist doctor 1 6 4senior specialist doctor 15 2specialist doctor 4 3Principal med officer 22 21 43medical doctor 38 39 16Principal asst med officer 18 5 20senior asst med officer 36 17 33asst medical officer 174 72 112Principal clinical officer 14 6 1senior clinical officer 157 45 16clinical officer 1877 511 226Total 7874 2707 2373Approximate percentages 61% 21% 18%

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Note: The lower portion of each column represents those working in rural districts.

Chart 15: Age Distribution of Enrolled Nurses, further spilt by whether they are working in an urban or rural district

Note: The lower portion of each column represents those working in rural districts.

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Overall a higher proportion of enrolled nurses are working in rural districts than in urban districts when compared with nursing officers in rural districts. Only 66% of the nursing officers are in rural districts, even though these districts have approximately 80% of the population.

Age and specialisations of nursesThere are 10,044 enrolled nurses in this sample, 7,000 of whom are called midwives; 1,359 are public health nurses and the remaining 1,685 have no additional qualification. The nursing officers consist of 5,118 people. Again the largest occupation group is midwifery with 3,052 of this total. The next largest occupation groups are psychiatric nursing with 945 people and public health with 466.

The nursing officers have a higher proportion of young people than the enrolled nurses, but both age distributions do not suggest any great imbalance. The larger number of nursing officers in the age range 25 to 29 will be the result of the increased emphasis on the use of this cadre and the selection of young people to undergo the training.

Certainly there is no imminent crisis brought on by large numbers of nursing staff approaching retirement.

NationalityThe rationale for examining the distribution of staff by nationality is that non-Tanzanians are not considered to be part of the regular ‘pool’ that can be drawn on. Analysis of the 2001/2002 data indicates that at that time there were very few people identified as non Tanzanians in the workforce. The total number of people in this survey was 47,544. This includes people working in accounts, as dhobis and drivers, as well as medical officers and directors. 44,418 people were identified as Tanzanian. The largest group of non-Tanzanians were 54 Burundians, followed by 12 Indians. Every other nationality had only single figures in the survey.

There remain 2,997 people with no specified nationality. Of these many hold posts such as health attendants and registry assistants, all of whom will almost certainly be Tanzanian. However there are 61 medical specialists, 181 medical officers and 260 nursing officers without an assigned nationality in this survey. Some of these could be expatriates, though about 2000 of these are employees on the MOH payroll working either centrally in Dar es Salaam district, Temeke District in Dar es Salaam or seconded to other facilities throughout the country. Their data were obtained directly from the MOH records. A scan of these uncovered very few if any non-Tanzanians.) Hence, the numbers of non-nationals in the workforce would not appear to be significant for the purposes of this study.

Flows out of the health sectorThe sisterhood analysis of the doctors demonstrated that of those taken on in the last ten years, more than 80% remain working in the health sector, and the majority of these are in the government sector. This percentage reduces to 70% for those initially taken on in the previous twenty years, 1976 to 1995. Only after that does the percentage reduce substantially to more like 40%, as would be expected as people retire and die. Approximately two-thirds of the losses of doctors are due to them dying.

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A survey was carried out earlier in 2006 of the staffing of ART sites throughout the country (4 referral hospitals, 149 regional hospitals, designated hospitals, health centres and even a dispensary). The survey covered all health staff hired into the government sector (regardless of whether they were providing ART services), each year from 1959, and the proportion of each intake that is still working within that sector. This does not distinguish the different types of jobs undertaken, and those leaving could still be working in the health, but for the private sector. This is shown in the Chart 16 below.

This broad sample cohort study provides a useful insight into hiring patterns and survival rates of staff in the public sector. It shows that within the first year of employment in the government sector approximately 10% of people leave for some reason. After this induction loss, the percentage remains incredibly constant for the next fifteen years. Much of this period is one of low hiring numbers as a result of the unemployment freeze. Hence approximately 90% of those hired over the last fifteen years continue to work for the government. Probably most of those who have ceased working for the government did so in their first year. For the next fifteen years intakes, this percentage reduces to more like 85%, but it is only when people have been working in the government sector since 1971 that the percentage reduces to 80%. Thereafter it declines quite dramatically as people retire or die.

This is an amalgamation of all jobs. Some jobs are at a higher risk of losing some of their numbers. Doctors are more likely to leave than these overall figures, as seen above. Even so, nurses must make up a substantial proportion of those hired over these years, so their loss rates must conform to this pattern. Overall this is a remarkably low rate of loss

If the initial induction losses could be addressed, then the retention of government health staff would be astounding.

The annual numbers from which this chart was derived are shown in Annex 6

Chart 16: Survival curve of government health staff

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Results from the Interviews

Clinical OfficersThe following is an analysis of responses from 54 clinical officers in face to face interviews. The intention was also to interview by phone the clinical officers who had applied to the Ministry of Health for posting to the districts. This was not possible as the application forms were not traceable at the time. Therefore these 54 are those who had applied directly to the districts and were interviewed by the teams sent to the 8 districts. Those who applied to MOH would probably be ready to work anywhere, whereas these 54 who applied to the districts they have indicated their preference. Complete responses were received from 42 clinical officers with jobs and 10 without. Two responses were insufficiently complete to be included in the analysis. The responses showed similar patterns, whether they were currently working or not.

The only factor that showed a clear spread of responses was where the individual had heard about the possibility of working for the ministry, but with newspapers and notice boards at the top of the list. The number of institutions applied to spread between 1 and 3, with just one individual saying he or she had approached 5. This was one of the few questions for which there was a low response rate.

Over 80% of respondents said that they wanted to serve the patients as the reason they were attracted to apply, The split between whether the reason they wanted to work was being satisfied was evenly split for those who were working, suggesting some dissatisfaction, but fairly obviously the negative response dominated for those who were not working.

37 of the 42 working clinical officers stated that what has actually turned out to be the best thing about the job was the service to patients, as did 7 of the 10 not currently working for government clinical officers. The remainder of ‘best components of the job’ were spread over team work, seminars and good environment. Clinical officers centred their responses to the worst component of the job on remuneration, but with poor leadership and a lack of equipment coming before inadequate housing.

Three quarters of those interviewed replied that they would re-apply if the ministry was to re-advertise. The majority of the remaining respondents stated that they were already employed and they were satisfied. Only two mentioned low salary as a reason not to re-apply

Over 80% of the clinical officers interviewed said they would be available to start working at anytime.

Perhaps most pleasing is that 38 out of 48 clinical officers who responded stated that they would be prepared to work “out of town”; just under 80%.

The detailed breakdown of these responses and of the nurses described below is presented in Annex 7.

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NursesAn analysis of the 244 nurses’ responses to the interviews showed reactions similar to those of the clinical officers, whether they were currently working or not. Complete answers were received from 146 working and 34 non-working people.

Like the clinical officers, nurses showed they had heard about possible employment by the ministry from all the options provided, but almost 80% had either heard through friends or newspapers, rather than radio. This could be a reflection of more effort being put into newspaper campaigns rather than radio campaigns. Nurses had applied to between 1 and 5 institutions with 2 being the most frequent response

Again like the clinical officers, the highest factor that appealed to nurses was service to patients, and here again there is a spread with some responding at every other option, namely salary, status, to gain experience and good environment. Four non-working nurses responded, like their clinical officer colleagues, that they were working where they were because there was no employment opportunity by the government sector.

Only just over a third of the responses say the factor that most attracted them to the job had actually been realised, which is a greater level of disappointment than the clinical officers.

In practice, what has turned out to be the best thing about the job is service to patients, with two thirds of the nurses giving this response. The next most frequent “best things” are team work and seminars.

Again like the clinical officers, nurses centred their responses concerning the worst part of the job on remuneration, but with a spread over the whole range, including the only reference to climate.

119 out of 172 nurses who responded to the question about working “out of town” stated that they would be prepared to do so; just under 70%. Whilst this is a lower percentage than the clinical officers, this is surprisingly high. As the respondents range in age from 23 to 52 and the majority are women, they might be expected to have more commitments keeping them where they currently are.

Here again like the clinical officers, many nurses are ready to start working at any time.

Further responses were obtained from 46 nurses. These were concerned with preferences for specific regions and incentives to accept these posts. These responses are more complex and need individual examination.

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DMO questionnaireAs there was a meeting of District Medical Officers (DMO) taking place at the early stages of data collection, advantage was taken to conduct a quick survey whilst there were a significant number of them together. The questionnaire is shown in Annex 8. The intention was not to obtain precise numbers of staff engaged, lost etc., as the DMOs were away from their posts and we did not wish to hold them accountable for the precision of the information they were providing. The following analyses all refer to numbers of districts, and not, unless specified, to the numbers of staff or posts involved.

Responses were obtained from 84 of the 100 rural districts and 12 of the 19 urban districts.

DoctorsAmongst the rural districts 38 had placed advertisements for doctors during the previous twelve months and 31 had not. 15 did not provide this information.

A quarter of all the rural districts had vacancies (21/84) and a quarter – not precisely the same quarter – had received applications from doctors (20/84.) Even amongst the rural districts, 2 that had not placed advertisements received applications from doctors. As might be expected, the proportion of the rural districts that did not advertise but that also had vacancies for doctors, was much lower (7/31.) Those that placed advertisements were more successful at acquiring new doctors 42% (16/38) compared with those that did not advertise (3/31.)

In contrast only 3 of the 12 urban districts that provided responses had placed advertisements for doctors, perhaps reflecting the greater ease of attracting any staff in urban districts.

Ilala district of Dar es Salaam, had somewhere between 20 and 49 vacancies and between 20 and 49 applications, filling somewhere between 10 and 19 posts. With only two other exceptions, the numbers of doctors involved in all the categories described – posts advertised, applications, vacancies and positions filled – were all less than 5.

Interestingly only 21% of the rural districts had lost any of their doctors during the last twelve months (18/84.) A very similar proportion (bearing in mind the much smaller number of districts involved) is seen amongst the urban districts (3/12.)

Table 17: Number of districts reporting advertising, acquisition and losses of doctors during the last 12 months

Doctorsdistricts responses advertise applications vacancies filled losses

rural 100 84 yes 38 20 21 16 7no 31 2 7 3 9n/a 2 2

urban 19 12 yes 3 1 2 2 1no 6 1n/a 1 1

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Clinical Officers and Assistant Medical OfficersThe proportions of districts placing advertisements, receiving applications etc. for clinical officers / assistant medical officers are slightly higher than enrolled nurses. More districts report at least one loss of a clinical officer / AMO than reporting at least one loss of any other category of staff. The proportion of districts is 60% for rural and 50% for urban districts. Almost every urban district has advertised, received applications and filled vacancies..

Table 18: Number of districts reporting advertising, acquisition and losses of clinical officers and AMOs during the last 12 months

Clinical officer / asst. med. Officerdistricts responses advertise applications vacancies filled losses

rural 100 84 yes 63 48 51 47 43no 14 4 6 6 6n/a 4 2 3 2

urban 19 12 yes 11 10 10 10 6non/a 1

NursesMany more districts placed advertisements for nursing officers than doctors; approximately three out of every four, whether rural districts (66/84) or urban (9/12.) Just over a half of districts had received applications from nursing officers, whether rural districts (45/84) or urban (7/12.) Similarly 58% of all districts, urban and rural had vacancies for nursing officers. As with the doctors, those rural districts that placed advertisements for nursing officers were just as successful at acquiring new nursing (37/84) as the urban districts (5/12) that also placed advertisements.

Interestingly again the proportion of the rural districts that had lost some nursing officers for any reason, including retirement, during the last twelve months (36/84) is almost identical to the proportion in the urban districts (5/12.) Even more significant is that over half the districts did not report have any nursing officer leave during the last twelve months.

Table 19: Number of districts reporting advertising, acquisition and losses of nursing officers during the last 12 months

nursing officersdistricts responses advertise applications vacancies filled losses

rural 100 84 yes 66 45 49 37 32no 12 2 5 1 3n/a 1 1 1

urban 19 12 yes 9 7 7 5 5no 1 0 0 0n/a

As far as districts’ management of enrolled nurses are concerned, the picture is very similar to the districts’ management of nursing officers, with just a few more districts receiving applications, having vacancies and filling positions in rural districts. However considerably more districts lost at least one enrolled nurses than lost at

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least one nursing officers (50 vs. 36.) Further, most districts that did lose people lost less than 5 people in either category of staff, the exceptions being Nzega and Rombo districts where losses are indicated to be much higher.

The actual numbers of nursing officers and enrolled nurses in the various categories are much larger than the doctors in all categories. However the only districts where any category exceeds 50 are amongst nursing officers in Ilala district and amongst enrolled nurses in Temeke – both urban districts in Dar es Salaam.

Table 20: Number of districts reporting advertising, acquisition and losses of enrolled nurses during the last 12 months

enrolled nursesdistricts responses advertise applications vacancies filled losses

rural 100 84 Yes 68 52 52 42 41no 10 4 2 1 6n/a 2 3

urban 19 12 Yes 9 7 7 4 5no 2 1n/a

Pharmaceutical staffFewer rural districts advertised for pharmaceutical assistants and technicians than rural districts advertised for either type of nursing staff, but more than advertised for doctors. The proportion of districts indicating vacancies amongst pharmaceutical staff is half the proportion indicating vacancies amongst either category of nurse. If districts do not have vacancies, they should not need to advertise so much and consequently fewer districts will be filling positions with new staff. The number of districts indicating any losses of pharmacy staff during the last twelve months is much lower than the previous categories. There is only 1 district in 8 having any loss of pharmacy staff: seven out of every eight districts do not seem to have a retention issue.

Table 21: Number of districts reporting advertising, acquisition and losses of pharmaceutical staff during the last 12 months

pharmacy asst and techdistricts responses advertise applications vacancies filled losses

Rural 100 84 yes 51 24 13 10 4no 22 1 6 2 5n/a 1 3 0 3

Urban 19 12 yes 8 4 5 3 3no 2 1n/a

Laboratory staffThe laboratory assistants and technicians staff seem to require less recruitment with only 10 of the 96 districts reporting any losses from this category of staff during the last twelve months. Fewer districts have succeeded in filling vacancies amongst this category of staff, consistent with few people leaving. This suggests these people are a very stable element of the workforce. Only Nzega district indicates more than 5 people leaving for any reason during the previous twelve months

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Table 22: Number of districts reporting advertising, acquisition and losses of laboratory staff during the last 12 months

Laboratory asst and techdistricts responses advertise applications vacancies filled losses

Rural 100 84 yes 49 21 37 8 6no 21 3 4 1 2n/a 1 2 4 1

Urban 19 12 yes 9 5 7 3 1no

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4. Discussion

Limitations and lessons for future labour market studies

The study above has endeavoured to distil data from a variety of sources covering different time periods and present an overview of the availability and deployment of trained health professional staff throughout Tanzania. The sources of data themselves are independent and complete consistency between them would not be expected. Even if an individual is on the records at a specific location, that is not a guarantee that they are working there. Further, within the individual sources there are missing data. Any human resource information source is continuously out of date as people are always changing their job status, location and circumstances; the question is only the degree to which the data are current.

A major purpose of the study to assist the MoH in setting up a routine system for tracking the labour market. This study has revealed some areas that need to be strengthened. As has been described data were obtained from a number of different sources and these have been detailed within this document. In endeavouring to obtain information about the national supply of professional staff, information was sought from the Registrars for both nursing and doctors, and assistance was given to the registrar of doctors with entry of his records onto a database. The doctors register gave a current reflection of that profession. The nursing register should very recently have gone through an update. However there is no consistent way of obtaining the current status of health professionals throughout the country, or even with in the government sector. The WHO survey of 2005 was a snapshot taken at a specific time; if we had been able to obtain data about positions held within pension records, then this would have been a more current snapshot picture for more health professionals. The sisterhood analysis, for one profession, is a more up-to-date snapshot. What is needed is a moving picture that starts from a survey and then captures changes in status on a regular basis, whether that is people recruiting, leaving, being upgraded, transferring location or whatever. This moving picture can be stopped at any time to present a new snapshot and replayed to summarise the changes that have taken place over a specified period. Thereby there would, for government service at least, be one consistent source to enable all management (at all levels) and other concerned individuals to better understand the availability of professional health staff to satisfy the service they are responsible for delivering.

The continuous updating of the information gathered by this survey would need a substantial investment of time to achieve, not least in deciding who is responsible for maintaining it and its accuracy, but it would enable the decision makers as to how to move forward rather than try to understand where they are.

Notwithstanding the limitations of this study, useful information about the labour market has been revealed.

Flows into and completion of training

The supply of people interested in pursuing sometimes lengthy pre-service training before becoming qualified health professionals appears to be sufficient to fill the training places available. The significant increase of women training to be doctors indicate a more inclusive recruitment process which is important for a number of

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reasons including ensuring an adequate supply of applicants for training places. The educational level, at least as far as being acceptable to enter training for nursing and medical officer courses is also sufficient, but not for those entering courses for laboratory and pharmaceutical staff.

Attrition during medical training has been increasing and recent rates of around a quarter must clearly be of concern to those investing in the expansion of the health sector. The cause of this high rate of attrition needs to be investigated. Since academic ability on entry seems to meet the requirements, there may be other factors leading to students leaving. Analyses of attrition rates for other cadres were not possible due to the unavailability of data. However, given the concern about the lack of adequate staff for the health service, such data should be regularly collected and analysed to ensure that there appropriate strategies in place to ensure minimal wastage at this crucial point in the careers of health professionals..

From training to employment

Whilst training output is increasing, not all health professionals who graduate find jobs. From the most recent data available for clinical officers at least three out of every five clinical officers were unable to find jobs in either the government or the private sector.

The proportion of doctors successfully finding job is falling compared to the 1970s and early1980s. At that time, most doctors went into government jobs. This is changing and a higher proportion have been going into are now working in the private sector. This is likely to increase with the expansion of the private sector.

The impact of the employment freeze has not had quite such a serious impact on the size of the workforce as possibly generally perceived. This is partly because this was not a comprehensive freeze – only on the expansion of posts for which extra funding would be needed. As the ban did not affect non-government health facilities, they continued to increase their staff numbers in order to satisfy minimum levels of staffing laid down by regulations.

Losses from the health sector

Overall losses from the government sector are remarkably low. The highest risk of loss is within the first year of employment in approximately during which 10% of people leave for some reason. After this induction loss, the percentage remains incredibly constant for the next fifteen years and it takes more than thirty years to lose the next 10%. After this number of years of service people are retiring or may succumb to long-term sickness or even die which explains why the percentage remaining declines quite dramatically.

The distribution of the existing workforce

The distribution of health professionals working in rural districts as opposed to urban ones is very much in line with the distribution of the population. 79% of the combined numbers of assistant nurses and more senior nurses, nursing officers, laboratory technicians, dental technicians and more senior people in dentistry and clinical officer

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and more senior clinical staff work either in rural districts or in regional units. Although the population of Tanzania has 81% described as living in rural areas, households in rural areas make up 79% of the total households. There are some imbalances: higher proportions of nursing officers in urban districts and certificate nurses in the rural districts but these could relate to the type of health care provided. This balance between care in rural and urban environments is probably one of the most equitable in Africa.

The age distribution of all nursing staff gives no reason for concern. There is no looming retirement bulge; nor is there a shortage of middle aged people with experience to pass on to the young new recruits, who are also present.

There are very few non-Tanzanians working in the health sector, either in the more professional positions or in the more unskilled positions, even though this latter group is not relevant to this study.

Experiences of filling vacancies as district level

The general picture from the survey of District Medical Officers is that there is not a serious problem with vacancies and finding people to fill the vacancies – either in rural or urban districts. However the process of actually engaging these people has not seen the numbers required being taken on. There is certainly a problem is with pharmacists, laboratory staff and for some reason enrolled ‘certificate’ nurses.

The districts have mostly been active in recruiting staff. Those that are proactive and advertise vacancies are much more likely to be able to fill the vacancies. Advertising vacancies is necessary now that, as part of decentralisation, the practice of centralised posting has disappeared. Help with improving the practice or recruitment through advertisement would help here.

Views of recent applicants

The interviews of recent clinical officer/assistant medical officer and nurse applicants for vacancies wereas very encouraging. Most are motivated to serve patients and a surprising number (80% for clinical officers) were prepared to work “out of town” and this was confirmed by the fact that the majority had already recently taken up “out of town” jobs. Most said they would be available to start work immediately. Nonetheless, they had realistic concerns about the jobs and though these concerns were not only about the remuneration package. Clinical officers were quite concerned about poor leadership and the lack of equipment. Nurses were also concerned about poor leadership and some were concerned about housing.

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5. Conclusion

This study has made inventive use of a number of existing human resource data sets and supplemented them with small surveys in order to describe the current state of the labour market in the health sector. Unsurprisingly from this modest exercise it has not been able to paint a comprehensive or totally accurate picture of the labour market. Nevertheless, the experience has produced useful lessons for future endeavours and some important and perhaps slightly surprising findings that will be useful both to the health sector in general and more particularly for the emergency hire programme.

Many aspects of the health labour market seem positive. The losses of staff are relatively low compared to some countries in the region. Age distributions analysed do not indicate any problems, like large numbers due to retire. Coupled with this relative stability in the existing workforce, there seem to be plenty of people willing to train for most professions and to subsequently work in the health sector and there is a willingness of trained staff currently not working in the health sector to come back. Furthermore, many of these people are prepared to work in non-urban areas which would help to improve the equitable access to health services. The labour market seems well disposed to increasing the number of people required to deliver ART services, though the stated requirement of an extra 28,000 will be challenging. Training output will need to increase. Also a major impediment to expansion is the government’s ability to employ staff. This is partly the ability to pay (though additional funds are being made available in the short term) and partly the ability to recruit staff effectively and efficiently so that potential candidates are not lost due to lack of administrative responsiveness.

The MoH now needs to build on this study so that future information on the labour market will be more easily available and better quality..

Finally, it goes without saying that getting staff into post is only half the battle. Managing staff performance to ensure that staff are willing and able to contribute effectively is just as important to the challenge of providing effective ART and other health services.

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Annexes

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Annex 1: Facilities

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Annex 2: Scope of WorkCapacity Project/NIMRI

Assistance to MOH Tanzania (Mainland)Scope of Work – For a labour supply market analysis

Dates- June 12- July 29, 2006 (Seven weeks)

Team Members

1 – Capacity/International Consultant- Technical Lead

1- Capacity In-Country Consultant

1- MOH

1- NIMRE Staff or consultant

A. Context and Background

As the momentum for tackling the HRH crises builds-up, MOH Tanzania is showing strong interest to initiate an emergency hiring program. The emergency program will seek to expand the number of skilled workers through an expedited hiring process targeting districts in rural underserved areas with the highest vacancy rates. As part of the ground work for the hiring program, The Capacity Project is offering technical assistance to the MOH to perform an audit to identify barriers and bottlenecks to recruitment. The MOH also seeks to understand the labour supply market dynamics. A labour supply market analysis will provide information about whether there are adequate numbers of skilled health professional in the labour market to participate in the emergency hire program. Currently, the level of unemployment among health workers and the absorption rate of critical cadres in the health sector is unknown. It was generally assumed that under the unemployment freeze from 1993-2001, the supply of skilled health workers was greater than the demand ( Dominick and Kurowski, 2004) The Capacity Project proposes to work with other in-country partners (MOH and NIMR) to meet the technical assistance needs for conducting a labour supply market analysis.

B. Purpose of labour supply market analysis 1. To examine recent trends, in the supply of health professionals, so as

to support the MOH in its future planning including for the Emergency Hire Program. ( consider at least last 5 years following lifting of unemployment freeze ).

2. To learn from the recent successful rapid recruitment initiative for Clinical Officers.

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3. To help Tanzania set up a routine system for tracking the labour market for the health sector.

C. Elements of Supply to be considered, and suggested data sources

Current stockElement of supply to be considered

Suggested data sources

Data gathering method

What is the current stock of health professionals working in health service jobs in Tanzania (by cadre, employer, institution type, sex, age and/or length of service, nationality, level in health care system distribution)? [changes in last 5 years]

WHO Audit 2005 survey data Existing HR data Sources 2001/2002 HR surveyPayroll Data FBO data sourcesPersonnel service enrollment

What is the total pool of qualified health professionals (working in health service jobs? Working in other jobs? Not working?)

o What % of Tanzanian residents have education as a health professional?

o What was the registered and/or practicing membership in 2005?

Professional Councils’ records 2002 census dataPension schemes data setsNSSFPPFPSPF

Increment Element of supply to be considered Suggested data

sources Data Gathering Method

How many qualified applicants apply to Training Institutions for Nurses, Clinical Officers, Lab Technicians, Pharmacists? (notable increases or decreases in past 5 years)

o By sexo By Age o nationality

Training institutions Records MOH-HRD Training Department

What proportion of applicants is enrolled? What proportion of applicants graduates (By sex, age, Institution, trainee district of origin, cadre)? (notable increases or decreases in past 5 years)

o By Sex o By Age o nationality

Training institutions RecordsMOH-HRD Training Department

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Of those offered a place, what proportion accept?

How many new graduates are hired and deployed (by sex, age, geographical distribution, cadre, employer, nationality ? (notable increases or decreases in past 10 years)

Pension funds new enrolleesMOH, PORALG FBO data sources

For selected professionals to track

How many Tanzanians have been hired, were trained outside, e.g. Soviet Union, Cuba, by sex etc. This applies only to doctors.

Professional councils

For doctors/ specialists, set up Access data-base also for future tracking

What are the vacancy levels by employer, geographical zone (region and by urban/rural split), institutional type? (notable increases or decreases in past 10 years)

MOH. Recommended manning levels

2001/2 HR survey data

Approved manning standards by facility type – for MOH. Andrew has agreed authorized FBO levels.

Qualitative Why do funded posts continue to

be vacant? Govt policies ( MOH Personnel and admin, public service) Interview with applicants for muhimbiliDMOs for rural

How can we be sure health professionals would be interested?

Interview with DMOs

What are the characteristics of people who have applied and recruited?

Application formsInterview with applicants

Losses Element of supply to be considered

Suggested data sources

Data Gathering Method

What is the level of retirement and pre-retirement attrition into non health professions or entirely out of the labour force? (notable increases or decreases in past 5 years)

Pension funds - not censusNursing council for non active nurses. Retirement and death for all providers.

Request and analysis of available pension data.

What is the flow across In Country-regional borders?

Recognize that there will be draw backs in getting reliable information to answer this question. But also know it is an important question for assessing supply

Note: Doctors pay for own training for five of six years, except Univ. of Dar. Now cost sharing, receive loan fro meals, accommodation and tuition. Extending to private schools. 109 nursing schools -68 govt rest private – all trainees pay at private institutions - at govt there is a coat sharing -

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Note_ it is believed regional disparity is not the issue. Greater concern is the ability to attract poorer sectors of the population into health professional training.

Activity Breakdown

Phase 1: June 12- 24 (Planning – 12 days)

Phase 2: June 26- July 15 (Data collection – 3 weeks)

Phase 3: July 18-29 (Analysis and preparation of report – 12 days)

Deliverables

End of Phase 1: More detailed study protocol, including guidelines for data collection; Deadline: 24 June

End of Phase 3: A supply labour market analysis report, analyzing trends in:

Supply of health professionals (including basic counts) Graduation Qualified persons Inter-regional migration (to the extent possible) Retirement (To the extent possible)

Deadline: 29 July

The report should clearly stated data sources used successfully. It should also identify what data was not available and the reason, and provide appropriate recommendations for information systems to provide data for future labor market analysis.

Key Stakeholders/Contacts

Capacity projecto Tanzania country point person: Fatu Yumkellao Tanzania country coordinator-Dr Fatma Kabole

Ministry of Health: Mrs Mwakalukwa NIMR: Aziza Mwizingo USAID/Tz: Susan Monaghan CDC: Justine Treadwell

Key References

a) Tanzania WHO HRH study files

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b) Dominick A, Kurowski C (2004)- HRH- An Appraisal of The Status in Mainland Tanzania

c) Kurowski C, et al. (2004)- HRH Requirement and Availability in the Context of Scaling Up Priority Interventions in low income countries. Case Studies from Tanzania and Chad

d) Martineau T( 2004)- Report of a study on HRH Governance in Tanzania for the MOH / World Bank

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Annex 3 Data Sources Census Data

o Data source(s): DMO Questionaire.xlso 2002 Census population by region & districto Males, Females, Total, Household Sizeo Rural, Urban

Health Units Data / Staffing Requirementso Data Source(s):

1. Fanoc.xls By District/Facility Summarized by Region, District, Grouped Facility

(Designation)2. Health Units Staff requirements June 2006.xls (proxy for

projected changes??) Summarized by Designation

3. CEDHA HRH FINAL.xls Staffing Health units required/approved 1999

4. MATRIX.xls Number of Filled/non-filled vacancies for 2005 By Region & District Employer

Training Data – Medical Doctorso Data Source(s):

1. MD.DBF – 1963-2005 Date entering program, Date Graduated, Gender

2. MD INTAKE.xls – 2000/1 – 2005/6 – Summary Data Cross-Sectional counts of intake #s by programme yr

and programme level Summarized by Male/ Female, by programme yr and

programme level Attrition is NOT possible because each subsequent

year is a mixture of repeat students and continuing students/new students.

3. OUTPUTS.xls – 1994-2006 Health Training Institutes By Cadres & Specialties. Year OUTPUTS ALLIED HEALTH 95-05.xls Assistant Medial Officers. These individuals will be sent

to more remote areas to perform procedures versus a medical officer/ doctor who remain in the more urban area (ie., DSM). Some few clinical officers upgrade to AMO in the special fields of Ophthalmology, Anaesthesia, or Radiology. The majority upgrade to general AMO without specialization.

Time Datao Data Source(s):

1. HEALTH.DBF – 1945-2006 Hire and DOB data on health employees of Tz. within the Public Sector

(some voluntary agency employees are paid by the government of Tanzania. Thus, these employee records would be held in the same treasury database)

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Employment Designation Region/District

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Annex 4: Outputs from Training Institutions in Tanzania HEALTH TRAINING INSTITUTES OUTPUTS

CADRE 1996 1997 1998 1999 2000 2001 2002 2003 2004 TOTALMedical Officers 28 31 30 42 50 61 67 103 122Medical Officer Specialists                   Physician 9 7 6 9 7 8 8 11 9 Obstetric/Gynacology 9 8 7 5 3 5 6 6 8 Internal Medicine 14 6 6 10 8 10 9 5 4 Surgery 6 5 3 3 6 5 4 4 3 Psychiatry 3 2 0 0 0 0 0 0 0 Paediatric 5 3 3 4 2 1 3 2 3 Orthopaedic/Traumatology 0 0 0 0 0 2 1 2 0 Microbiology/Immunology 0 0 0 0 0 0 0 2 4 Haematology 0 0 0 0 0 0 0 0 1 Anatomy & Pathology 0 0 0 0 0 0 0 1 2 Dermatology & Venereology 0 0 0 0 0 0 0 3 3 Radiology 0 0 0 0 0 0 0 3 3 Tropical Medicine 1 1 2 2 2 0 0 0 0 Orth/T 0 0 0 0 0 1 1 0 0 Public Health 0 3 0 0 12 16 17 25 9 Health Planning and Policy 0 0 0 0 0 0 0 2 2 Medical Education 0 0 0 0 0 0 0 3 3 Health Promotion 0 0 0 0 0 0 0 0 9 Physiotherapy 0 0 0 0 0 0 0 0 1 Primary Health Care 0 0 0 0 0 0 0 3 1 Mother and Child 0 0 0 0 0 0 0 0 1 Environmental Health 0 0 0 0 0 0 0 0 3 Human Resource Development 0 0 0 0 0 0 0 2 2 Community Disability 0 0 0 0 0 0 0 0 1Medical Officer Specialists Subtotal 47 35 27 33 40 48 49 74 72Medical Officers and MD Specialist Subtotal 75 66 57 75 90 109 116 177 194Dentists 4 7 4 8 16 11 8 13 13Pharmacists 19 18 14 17 19 14 21 32 49Advance Diploma in Paediatric Nursing 11 0 12 0 12 0 8 3 15Advance Diploma in Nurse Teachers 24 0 25 0 25 0 25 0 25Assist. Dental officers 0 12 7 14 12 8 9 11 12Assist. Medical officers 110 74 108 103 118 165 248 152 129 1,207Assist. Medical officers, Opthalmology. 4 4 6 0 5 0 5 0 4Assist. Medical officers Radiology 4 0 4 0 0 0 5 0 5Assist. Medical officers Anaesthesia   16 0 11 0 2 0 4 0Anaesthetic officers         11 2 0 4 5Advance Diploma in Ophthalmic Nursing 13 0 13 0 14 0 9 5 14Advanced diploma public health Nursing   21 0 21 0 20 5 21 0Advanced diploma mental health Nursing - 20 0 0 0 0 4 0 31 0Adv. Diploma theatre Mgt. Nursing 12 0 8 0 10 0 9 0 12Clinical officers 249 434 486 495 554 528 640 643 635 4,664Assistant Clinical Officer * 340 215 233 0 0 0 0 0 0Dental technicians         4 4 4 4 4Dental therapy 24 22 21 27 21 16 19 21 26Health officers 59 81 83 56 77 86 95 76 72

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Health officers vector control 7 0 9 0 10 0 10 0 10Health Medical records 17 18 20 15 16 15 13 18 16Centre for Educational Development-CEDHA                  Laboratory assistants 79 78 103 99 113 108 115 110 66Diploma in medical laboratory         26 33 25 30 49Advanced diploma medical laboratory         9 6 10 8 9Diploma in nursing 125 219 204 345 288 403 360 454 391 2,789Diploma in optometry 11 7 7 9 11 11 12 10 12Diploma Physiotherapy Technician 9 8 7 5 13 9 13 12 12Certificate Physiotherapy Technician         - 3 10 3 3Health technician         - 28 42 44 60Pharmaceutical assistants 19 14 14 13 25 18 16 20 18Primary health care institute         7 19 9 9 0Pharmaceutical technicians         14 12 14 14 8Diploma in physiotherapy         13 10 13 12 13Radiographic assistants 11 14 12 11 18 18 16 20 18Dermatology 8 11 7 7 9 11 5 5 4Diploma in radiography 7 8 10 13 7 9 11 12 9Advanced diploma in midwifery 0 0 0 0 0 0 0 40 0Enrolled Nurses 673 990 831 1033 1168 1127 1206 1173 1162 9,363TOTAL 1906 2306 2275 2335 2685 2748 3059 3032 2881 23,536

In the country there are 109 training schools, 68 are government funded, the rest are private.

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Annex 5: Rural/Urban split of professional personnel for public and private facilities

DATA FROM THE 2001/2002 SURVEY

FOR STAFF OUTSIDE CONSULTANT/SPECIALISED, AND REGIONAL HOSPITALS

OC DESIGNATION RURAL URBAN UNKNOWN TOTALADO Assistant Dental Officer 36 22 0 58AMO Assistant Medical Officer 368 138 1 507AMS Assistant Medical Officer, Specialist 39 4 0 43AO Others 2712 812 5 3529BMT Technician, Hospital Maintenance 3 1 0 4CO Clinical Officer 4251 1064 3 5318DO Dental Officer 4 13 0 17DS Dental Specialist 0 3 0 3DTE Dental Technician 1 4 0 5DTH Dental Therapist 55 30 0 85HA Health Assistant 787 197 3 987HO Health Officer 480 160 0 640LAA Health Laboratory Assistant 507 251 0 758LNI Health Laboratory Technician 110 128 1 239LNO Health Laboratory Technologist 1 10 0 11MA Health Attendant 11727 2142 9 13878MO Medical Officer 104 160 0 264MR Medical Records 157 49 0 206MS Medical Specialist 32 79 0 111NB Maternal & Child Health Aid 1981 510 2 2493NM Nurse/Nurse Midwife 3769 1063 4 4836NO Nursing Officer 2070 725 11 2806OP Optician 12 10 0 22OTE Orthopaedic Technician 7 10 0 17OTH Occupational Therapist 1 0 0 1PA Pharmaceutical Assistant 102 25 0 127PH Pharmacist 8 17 0 25PHY Physiotherapist 11 12 0 23PT Pharmaceutical Technician 48 17 0 65RA Radiographic Assistant 64 4 0 68RD Radiographer 24 21 0 45RT Radiographic Technician 1 2 0 3TU Tutor 0 2 0 2UN Unknown 198 38 0 236

Total 29670 7723 39 37432

FOR STAFF IN CONSULTANT/SPECIALISED, AND REGIONAL HOSPITALS

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OC DES RURAL* URBAN UNKNOWN ** TOTALADO Assistant Dental Officer 0 18 3 21AMO Assistant Medical Officer 0 129 36 165AMS Assistant Medical Officer, Specialist 0 36 0 36AO Others 30 1489 482 2001AUD Audiometrist 0 2 0 2BDO Blood Donor Organiser 0 1 0 1BMT Technician, Electro Medical 0 2 0 2CO Assistant Clinical Officer 4 184 137 325DO Dental Officer 0 26 14 40DS Dental Specialist 0 4 2 6DTE Dental Technician 0 14 1 15DTH Dental Therapist 0 8 6 14HA Health Assistant 0 40 0 40HO Health Officer 0 58 83 141LAA Health Laboratory Assistant 1 110 0 111LNI Health Laboratory Technician 1 95 49 145LNO Health Laboratory Scientific Officer 0 59 0 59MA Health Attendant 109 3440 282 3831MO Medical Officer 0 122 119 241MR Medical Records 1 120 1 122MS Medical Specialist 1 167 34 202NB Maternal & Child Health Aid 0 62 0 62NM Nurse/Nurse Midwife 20 1570 49 1639NO Nursing Officer 10 1243 136 1389OP Optician 0 31 2 33OTE Orthopaedic Technician 0 13 1 14OTH Occupational Therapist 0 2 0 2PA Pharmaceutical Assistant 1 27 0 28PH Pharmacist 0 56 29 85PHY Physiotherapist 0 35 3 38PT Pharmaceutical Technician 1 37 3 41RA Radiographic Assistant 0 22 0 22RD Radiographer 0 52 2 54RT Radiographic Technician 0 1 0 1TU Tutor 0 10 0 10UN Unknown 0 13 0 13

Total 179 9298 1474 10951

* Kibongoto Hospital is rural but specialised for resistant TB.** Many of these are in MOHSW payroll list but are attached to health unitsoutside the Ministry and outside Dar es Salaam

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Annex 6: Numbers of government health staff hired and terminated, by year

hired current terminated2006 321 302 192005 243 213 302004 194 178 162003 780 729 512002 1487 1313 1742001 671 597 742000 432 383 491999 3846 3367 4791998 105 89 161997 32 29 31996 344 308 361995 296 266 301994 557 512 451993 680 609 711992 922 819 1031991 2009 1718 2911990 2167 1875 2921989 1702 1474 2281988 2222 1930 2921987 1837 1563 2741986 1835 1588 2471985 1242 1066 1761984 1800 1554 2461983 1508 1329 1791982 2147 1861 2861981 1626 1420 2061980 1929 1687 2421979 1443 1205 2381978 1219 1048 1711977 1244 1078 1661976 696 599 971975 771 671 1001974 1040 862 1781973 802 662 1401972 817 668 1491971 849 678 1711970 657 504 1531969 341 250 911968 219 158 611967 187 128 591966 192 129 631965 115 73 421964 120 62 581963 44 21 231962 35 12 231961 28 11 171960 14 6 81959 22 13 9

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Annex 7: Responses of Clinical Officers and Nurses to the Questionnaire

The question “would you be prepared to work out of town?” was preceded by the statement “the greatest need the country has for your skills is in the rural areas.” 

Clinical Officers

When you applied to us, how did you hear about the job?

10friends

4radio

18newspaper

15notice boards

2transfer

3own initiative

how many institutions did you apply to for a job?

91

112

103 4

15 6

Before you started, what appealed to you about the job?

44service to patients

2salary

1Fame

1to gain experience

3good environ-ment

1None

has this happened? 22

yes30No

what has turned out to be the best thing about the job you are doing?

44service to patients

3team work good

perform-ance

none4seminars

1good environ-ment

and what is the worst thing? 9

leadership24remune-ration

8working tools

4housing

5rumour mongering/ laziness

2None

If we are placing more advertisements, would you apply again?

39yes

13no

if not, why not?

4currently satisfied

too long in one place

5already employed

services still needed

2low salary

1

would you be prepared to work out of town?

38yes

10No

when would you be ready to start working? 36

anytime3satisfied

2August

1September October

3year end

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Nursing staff

When you applied to us, how did you hear about the job?

70friends

9radio

71newspaper

18notice boards

1transfer

11own initiative

how many institutions did you apply to for a job?

421

672

383

104

25 6

Before you started, what appealed to you about the job?

156service to patients

10salary

6Fame

1to gain experience

2good environ-ment

5None

has this happened? 64

yes116No

what has turned out to be the best thing about the job you are doing?

130service to patients

21team work

6good perform-ance

5none

5seminars

13good environ-ment

and what is the worst thing? 33

leadership89remune-ration

30working tools

11housing

10rumour mongering/ laziness

10None

If we are placing more advertisements, would you apply again?

160Yes

20no

if not, why not?

9currently satisfied

1too long in one place

5already employed

2services still needed

1low salary

Would you be prepared to work out of town?

119yes

53no

when would you be ready to start working? 115

anytime2satisfied

22August

15September

5October

7year end

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Annex 8: Questionnaire for District Medical Officers

District………………..Name…………………Phone number………………

We are currently undertaking a study to assess the availability of trained professional health personnel who are either currently not working at all, or possibly working in non-health jobs. You will know more about this in your district than the centre, so if you would kindly complete the following brief questionnaire for the government and designated facilities in your district, it will help the Ministry work out the feasibility of implementing an emergency hiring scheme. It should take no more than a few minutes of your time. Each row in each question only needs one tick – you just decide which column is most appropriate.

1 Did the district place any advertisements for any of the following groups of health professionals during the period July 05 to June 06?

yes NoDoctorsNursing OfficersEnrolled NursesAMO/Clinical OfficersPharmacy Asst/TechLaboratory Asst/Tech

2 During the same period, July 05 to June 06, approximately how many suitably qualified individuals from these same groups applied to join your district, either to an advertisement or independently?

0 1-4 5-9 10-19 20-49 50+DoctorsNursing OfficersEnrolled NursesAMO/Clinical OfficersPharmacy Asst/TechLaboratory Asst/Tech

3 During the period July 05 to June 06, approximately how many vacant positions throughout the district did you have funding to fill, irrespective of whether the vacancy was a replacement for someone who has left or an unfilled position in the approved establishment?

0 1-4 5-9 10-19 20-49 50+DoctorsNursing OfficersEnrolled NursesAMO/Clinical OfficersPharmacy Asst/TechLaboratory Asst/Tech

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4 Approximately how many positions did you succeed in filling, including postings from MoH?

0 1-4 5-9 10-19 20-49 50+DoctorsNursing OfficersEnrolled NursesAMO/Clinical OfficersPharmacy Asst/TechLaboratory Asst/Tech

5 Approximately how many people left for each of the following reasons from each professional group? In this case please put a number in each column: for example 0, 1-4, 5-9, 10-19, 20-49 or 50+

reason death or ill health

emigration Working elsewhere in Tz

retirement other

DoctorsNursing OfficersEnrolled NursesAMO/Clinical OfficersPharmacy Asst/TechLaboratory Asst/Tech

Please check you have written your district and your phone number on the other side at the top. If you have time and are inclined to help us understand even more, please put any comments below. Asante

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