The issue of Human Resources for Health is today acknowledged as one of the
main detriments to the success of health sector reform in the United Republic
of Tanzania. The challenges to meet the health related Millennium Development
Goals and keep on track with the implementation of Global Fund proposals are
also being increasingly traced back to the scarcity of this most precious of
all resources. Whilst the topic has recently been catapulted into the limelight
the problem has not suddenly appeared but has been developing over many years.
With the default upon the national debt in the early 1990s the country was left
with no other choice but to freeze employment in the public sector. This served
to reduce health worker supply considerably and created a demographic gap in
the age of health care workers.
According to a recent review by McKinsey & Company Tanzania is estimated
to have 25,000 skilled health workers in the public, private as well as faith-based
sector, of which only 1,900 are higher skilled medical staff. In Kenya and South
Africa with similar population sizes the figure is 80,000 and 255,000 respectively.
Shortages are highest among clinical officers and laboratory technicians (60%),
followed by nursing cadres (50%) and doctors (40%). Furthermore, the distribution
of staff between urban and rural areas is highly unequal. Whilst the rate of
assistant medical officers per million people in cities totals 43, in less populated
areas it is only 19. It should, at this point, be recalled that approximately
70% of Tanzania’s population live in rural areas.
Coordination of diverging efforts in the area of Human Resources for Health
remains a challenge for the Ministry of Health even within a well functioning
SWAp mechanism. This can in part be explained by the large number of stakeholders
working in Tanzania in the areas of health and HIV/AIDS, but also by the vertical
approach used to address the three big killer diseases most particularly HIV.
When it comes to Human Resources for Health the World Bank, WHO, CDC (funded
by PEPFAR, President Bush’s “President’s Emergency Plan for AIDS Relief), USAID,
the Global Fund, GTZ/InWEnt and JICA are just some of the key players at policy
level, with the Clinton and Bill and Melinda Gates Foundations gaining increasing
importance as well.
The Second Health Sector Strategic Plan July 2003 - June 2008 addresses Human
Resources Development both as a priority area and as one of the nine key strategies
making up the overall health sector reform. Added political weight was provided
as the issues importance is mentioned in the Poverty Reduction Strategy Paper
and was raised in the 2006 General Budget Support Review. The unique contribution
the health sector has to make to the implementation of the National Multisectoral
Strategic Framework for HIV has caused the challenges that result when staff
are not available in the right places lower down the system to become a topic
of national debate.
In recent years moves towards greater efficiency and a clearer division of
roles within the health sector have been made. Whilst responsibility for training
has remained at central level with the Ministry, local governments were made
responsible for the provision of health services, including recruitment and
hiring of health staff as part of the process of decentralisation. Heralded
as an important step to devolve authority to a level closer to the populations
being served, limited capacity at the newly formed local government level –
and the call for new skills such as lobbying, amongst the more technical council
health management teams have in fact hindered the implementation of rapid and
flexible employment of staff in the short term. In 2005 the HRH situation was
officially declared a crisis and the Ministry of Health passed a moratorium
that for the next three years urgent measures need to be taken. An example here
was the decision to assign 600 clinical officers graduating in 2005 to work
across the country, bypassing the district recruitment process.
This reflects the way that human resources as a whole often finds itself at
a difficult juncture between parallel reform processes. Decentralisation and
health sector reform are both ongoing as too is a comprehensive reform of the
public service whilst the training institutions for human resources are being
affected by the reform process in higher education. Human resources for health
needs also to take into consideration the fact that a substantial proportion
of health service delivery and training is provided by non-state actors. In
particular we refer here to voluntary associations such as the church but also
to private practitioners. Together with the state these are the employers of
health staff and dynamics of competition are increasingly seen to be at play.
Brain drain is not only a problem across international borders, but within countries.
In Tanzania a drain of health staff into non-governmental organisations in the
context of Global Health Initiatives can also be discerned.
In January 2006 the Government of Tanzania increased wages in the public sector
– including for health staff. Faith-based institutions found themselves unable
to match the salary rise and now report losing their staff to public service.
Given the trend that the faith-based sector generally delivers health care in
some of the remotest areas of the country it is ultimately the poor populations
in such regions who are suffering as a result.
It must also be stated that despite the increase, salary levels are still considered
to be insufficient to assure a minimal living standard and supplementary income
sources continue to be sought by health workers. This can take the form of “under
the table payments” for services rendered, of moonlighting in private practice
whilst being on the public payroll or looking for continuous education and on
the job trainings which reimburse travel costs and provide per diems at a level
that stand in total disproportion to an average salary. It has been estimated
that the costs for per diems and other hidden benefits could translate into
a 13% rise in salaries for all health staff. Complex reality dictates that to
tackle the issue of salaries the entire public sector has to be looked at. The
difficulties of securing predictable funding for system running costs and of
bringing “hidden additions” to staff salaries out into the open in a move to
overall “good governance” stand in the way of a comprehensive approach being
taken.
Vertical programmes feed into this unfavourable scenario. On the job training
offers remains rather uncoordinated with development partners and NGOs funding
certain priority areas and thus inducing an inequitable availability of training
opportunities. Additionally, sometimes such large numbers of health staff are
called to attend trainings that health centres and district hospitals are left
without key staff to attend to the patients.
The way that non-comprehensive efforts can serve to magnify such imbalances
is shown clearly by the Mkapa Fellowship programme. The objective of this programme
is to increase the number of health staff in rural areas by providing additional
salaries to people willing to relocate and work there. This includes incentives
such as housing allowances and participation at international conferences. On
paper it makes perfect sense. However, the result has been increased frustration
on the part of health staff already working in such difficult areas. The process
of selecting the new staff and their working stations has not been seen as transparent.
Furthermore, it has resulted in those selected for the privileged conditions
working side by side with similarly qualified Tanzanians earning the standard
salaries.
Despite the odds however, both the Government as a whole and the Ministry of
Health in particular are taking steps. A HRH taskforce has been established
which includes representatives of several ministries (Health, Finance, Regional
and Local Government (PMO-RALG), Public Service Management (PO-PSM)), WHO, World
Bank, bilateral agencies and research institutions (National Institute of Medical
Research). Furthermore, a new system to evaluate and appraise civil servants
across the entire public sector has been launched. It includes the formation
of measurable objectives for envisaged results, six monthly feedback, annual
performance reports in cooperation with employees, etc. (OPRAS, Open Performance
and Review Appraisal System). Though this is considered as a step in the right
direction, rapid and visible improvements are considered unlikely given the
relatively underdeveloped performance-orientated organisational culture. For
example technical supervision, which is supposed to be a tool to monitor professional
performance, has remained checklist driven and at times also serves as a way
to generate additional income via the travel allowances. Complaints of health
staff regarding supervision include that mistakes are criticised at once - even
in front of patients- but then there is little positive discussion about how
changes could be made and sometimes no further feedback is received at all.
The Ministry of Health is addressing the skills mix of health staff by promoting
the upgrading of lower cadres such as rural medical aides, medical attendants,
maternal and child health aids and nurse assistants. The intention is to phase
these cadres out over time as better skilled HRH become available. Concurrently
the Ministry is continuing to train all cadres instead of falling into the temptation
of only focusing on lower cadres, which are quicker and less expensive to train.
Health Training Institutions have been encouraged to increase their student
intake for pre-service training with some colleges that have hitherto trained
clinical officers being considered for upgrading to assistant medical officers
colleges. It is increasingly being recognised that assistant medical officers
now form the backbone of the Tanzanian health system.
There is still much to be done to combine a strategic planning for the entire
sector, within a comprehensive civil service wide approach. There are also calls
for increased flexibility to overcome bureaucratic hurdles and consider how
staff can be managed and used more efficiently – putting willing retired staff
back to work or using part time options spread between working stations. Above
all the realisation is there that just as the problem has not arisen overnight,
its effects will continue to be felt for many years to come and achieving a
solution will take a long term, enduring approach and an incredibly high level
of political will from the Government and its development partners alike.
*Both authors work at the Swiss Centre for International Health, a department
of the Swiss Tropical Institute. Contact: Ricarda.merkle@unibas.ch
