HRH Planning and Policy Development Planning

Overall human resources policies and the conditions of service for all public servants are determined and regulated by the Public Service Commission. The Human Resources Development department in the MOHSW is responsible for specific policy development in the health sector, as well as HRH planning and pre-service and in-service training. The main achievements over the evaluation period in this area are that a HRH planning unit was established in the MOHSW in 1999 and in the same year national HF staffing

standards were set. On the negative side, the national HRH plan 1996-2001 has not been implemented, reportedly due to lack of funding.

The problem descriptions in sector strategy documents clearly demonstrate an under- standing that HRH was an important limiting factor in achieving sector objectives. Indeed, the JAHSR report for 2004 uses the term crisis in relation to human resources. On the other hand, a review of JAHSR reports shows that well-known problems and potential solutions were repeatedly identified, with very little reported progress in imple- menting agreed activities.

Even in 2006, HRH planning is hampered by the weaknesses in the HRH information system. It is neither comprehensive nor reliable enough to guide planning and decision- making. Even information from the GoT payroll is not easily available to planners. Currently information is collected from multiple sources with associated difficulties in coordination and reliability. One aspect of this is the limited collection and sharing of HRH information from the private sector. Finally, there is limited technical capacity in the MOHSW for analyzing HRH demand and forecasting future needs.

As efforts were made to decentralize HRH functions during the evaluation period, a lim- ited form of HRH planning was devolved to councils and carried out mainly through the staff strength analysis done annually in the CCHP. In the CCHPs, council planners compile available resources and compare them to the facilities staffing standards devel- oped in 1999. Council health managers and workers regard these standards as seriously out-dated in that they do not reflect the present workload and disease burden. Moreover, staffing level norms are identical for each HF of the same type (hospital, health centre or dispensary), irrespective of utilization levels, resulting in very uneven workloads between HFs as observed during district case studies.

Policy Development

In the area of policy development, Gilson et al. (2005) in Supporting retention of HRH:

SADC policy context45 _{mention that HRH problems are influenced by the broader govern-}

ance context of the country, because they require coordinated action between several min- istries as well as LGAs. (p. 53) The paper brings up the possibility that slow implementa- tion could be due to “the immense complexities of the Tanzanian governance structures”, a reason why the MOH (initially) might have emphasised continuous education through the ZTCs as a key response to the crisis. At least training is in their hands and does not need to be coordinated with other parts of government (p. 57-58). In contrast, other key policies to address the HRH problems, such as financial and non-financial incentive pack- ages and changes in recruitment, require intensive and difficult negotiations with other ministries, one possible reason why it has taken so long to address them.

A key policy issue yet to be effectively addressed is the need for including FBO and pri- vate sector workforce in planning exercises. In the 1990s many public health workers moved to FBO and private facilities attracted by higher salaries, better benefit packages, working environments and training opportunities. However, in recent years a reverse movement has occurred, largely due to the same factors, with the GoT now offering

45) Gilson L, Erasmus E. Supporting retention of HRH: SADC policy context; Annex 4: The Tanzanian experience. Centre for Health Policy, School of Public Health, University of Witwatersrand, September 2005.

better employment conditions. The loss of trained personnel by FBOs and the private sector to the public health services is so significant that efforts to strengthen human resources in public health facilities may result in a weakening of those resources in the 40% of health facilities operated outside government.

Another area in which a policy is lacking is the fact that an unknown number of profes- sional staff leave the country to find work in other African countries, in particular in Botswana and South Africa. Gilson and Erasmus (2005) suggest that the post-independ- ence policy of developing allied health professions has served the country well, as their qualifications are not transferable internationally and such cadres are therefore much less likely to migrate (page 48). On the other hand, a policy to retain more highly qualified staff as MOs and registered nurses in Tanzania is now urgently needed.

Although during the JAHSR 2001 all partners agreed that HRH should be given higher priority, it was not until the end of the evaluation period that MOHSW was able to draft a new HRH plan (2007-2012). The new policy does attempt to address the main prob- lems and recognizes both the political and economic context and was developed in a par- ticipatory manner. On the other hand key informants noted that it lacks adequate supply and demand projections.

Assessing Staff Shortages

Seven out of 16 district self-assessments indicate that the number of health staff has improved somewhat since 1999, but 12 out also reported that staff shortages are (still) a significant challenge. The self-assessments rated this constraint to improving service quality of highest significance among those they identified. District assessments by the external evaluation team also confirmed that staff shortages are still severe. Without exception, key informants mentioned lack of human resources as a serious constraint in the health sector.

The Human Resource Crisis Continues

The health sector in Tanzania is facing a serious human resources crisis that is negatively affecting its ability to deliver quality health services. Although qualifications of staff have improved and their numbers have increased, there are severe shortages at all levels,

exacerbated by the expanded population, increased disease burden and the increased demand for staff for the large HIV/AIDS, malaria and TBL programmes. Although many people have been trained, few have been recruited and even less stay in post. Salaries have increased, but an incentive package to motivate staff to work in remote or hardship areas is not yet in place.

Data from the World Development Indicators 2003, quoted by Gilson and Erasmus (2005), show that Tanzania’s nurse to population ratio was 8.5/10,000 between 1995- 2000, while Kenya had 9, Botswana 22 and South Africa 47/10,000. The situation is even worse for MOs. Bryan, Garg et al. reported in 200646 _{that of the approximately}

46) Investing in Tanzanian Human Resources for Health. Bryan, Garge et.al. MiKinsey and Company for TOUCH Foundation Inc. July 2006. p. 16.

25,000 skilled HRH in Tanzania, fewer than 1000 were physicians (another survey esti- mated 1,339). Using even the higher estimate, this is equivalent to one doctor per 25,000 persons, far below the WHO recommended ratio (1:10,000). Considering the fact that 300 doctors work in the Muhimbili National Hospital in Dar Es Salaam (website 2007), and that many MOs work in administrative positions as DMO, RMO or in the central MOHSW, the situation outside the capital becomes even more difficult with very few doctors in clinical practice.

Bryan and Garg (2006) combined the numbers for MO and AMO positions in an effort to estimate the size of the higher skilled cadre in Tanzania and compare that to Kenya and South Africa. They found that Tanzania and Kenya were comparable in terms of the percentage of all health staff who were higher skilled (seven%) but that the ratio of higher skilled staff to population was much lower in Tanzania (1.5:1000 in Tanzania, compared to 5.7:1000 in Kenya). On both measures, Kenya and Tanzania were very far behind South Africa.