Action now on the Tanzanian

health workforce crisis

Expanding health worker training – The Twiga Initiative

CNG> +))2
© Touch Foundation 2009

875 Third Avenue

5th Floor
New York, NY 10022

Angus O’Shea
Amanda Rawls
Eliza Golden
Rachel Cecil
Emily Slota
Kasia Biezychudek
Contents
Prologue .................................................................................................................................................................................. 3
The challenge of a molecular system .............................................................................................................................. 4
Acknowledgements .......................................................................................................................................................... 6
Glossary ............................................................................................................................................................................ 6

Executive Summary.............................................................................................................................................................. 7
Increasing training capacity ............................................................................................................................................. 7
Translating policy into action ........................................................................................................................................... 8
Harnessing existing opportunities ................................................................................................................................... 9
Enabling system-wide support....................................................................................................................................... 10
Furthering transformational changes ............................................................................................................................ 10
Capabilities, leadership, and funding are required ......................................................................................................... 11
Implementation starting now .......................................................................................................................................... 11
Meeting the challenge outside Tanzania ....................................................................................................................... 12

Context .................................................................................................................................................................................. 13
A global crisis .................................................................................................................................................................. 13
The state of health and the health workforce in Tanzania ............................................................................................. 16
Policy frameworks .......................................................................................................................................................... 19
The Twiga Initiative ........................................................................................................................................................ 20

THE TWIGA INITIATIVE 1

Methodology ........................................................................................................................................................................ 21
Filling the knowledge gap ............................................................................................................................................... 21
Bottom-up data collection ............................................................................................................................................. 22
The top-down perspective.............................................................................................................................................. 24
Working together ............................................................................................................................................................ 25
The toolkit ....................................................................................................................................................................... 25
A replicable process ....................................................................................................................................................... 25

Findings ................................................................................................................................................................................. 26
Six major constraints ..................................................................................................................................................... 26
Doubling training capacity ............................................................................................................................................. 28
Reducing attrition ............................................................................................................................................................31
Further systemic opportunities ..................................................................................................................................... 32

Beyond Twiga ....................................................................................................................................................................... 34

Financing health worker training ................................................................................................................................... 35
Defining the optimal workforce pyramid ....................................................................................................................... 36
Shortening the pipeline .................................................................................................................................................. 38
Improving faculty access through institutional collaboration....................................................................................... 39
Maximizing limited teaching resources .........................................................................................................................40

Implementation ................................................................................................................................................................... 43
To do now… .................................................................................................................................................................. 43
…to do next… ............................................................................................................................................................. 44
…and to do soon .......................................................................................................................................................... 45
Implementation challenges ........................................................................................................................................... 45
Monitoring and evaluation ............................................................................................................................................. 48

Conclusion ............................................................................................................................................................................ 50
Appendix – List of Interviewees ...................................................................................................................................... 52
Bibliography ........................................................................................................................................................................ 55

2 ACTION NOW

Prologue
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Now to Overcome Tanzania’s Greatest Health
Challenge: Addressing the Gap in Human Resources
for Health!+))-"4Zg]Investing in Tanzanian
Human Resources for Health: An HRH report for the
Touch Foundation!+))/"'
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1
In the Tanzanian health system, the Lake Zone denotes the catchment area of the referral hospital at Bugando in Mwanza. It comprises six regions – Kagera,
Kigoma, Mara, Mwanza, Shinyanga, and Tabora – with a population of around 15 million. Our Lake Zone Initiative focused on priority initiatives to strengthen
the health systems of this catchment area.
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ABOUT THE TOUCH FOUNDATION
The Touch Foundation is a secular, non-profit 501(c)(3)
organization that aims to improve access to basic health
care in sub-Saharan Africa by working with our partners to
overcome two fundamental problems:
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nurses, pharmacists, and lab technicians
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communication, management, medical supplies,
infection control, and data analysis
Touch Foundation’s approach to solving these problems
is unique in that we combine the best of private and public
sector approaches and expertise, leveraged from our
partnerships with governments, corporations, development
partners, and nonprofits. Our model is to engage local leaders
from the beginning in order to help rebuild their existing
healthcare system, rather than building a parallel one.
We have begun our work in Tanzania, an East African
country acutely affected by this workforce shortage.
Since our incorporation in 2004, we have worked with our
Tanzanian partners to expand Weill Bugando’s university and
900-bed teaching hospital in Mwanza, Tanzania, growing it
from an inaugural ten MD students in 2004 to eight hundred
students in eight disciplines in 2008-09.

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Initiative%pab\aik^l^gmlZgnf[^kh_ZiikhZ\a^l
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\k^ZmbhgÇln\amaZmbgo^lmf^gmlbg^bma^kZk^ghmehlm
ho^kma^ehg`m^kf'

THE TWIGA INITIATIVE 5

Acknowledgments Ma^e^Z]Znmahklpah]bk^\m^]ma^phkdp^k^:g`nl
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Zg]ZkkZg`bg`bgm^kob^pl4ma^fbgblmkr&e^]HRH
@he]^g%Zg]KZ\a^e<^\beZk^\hff^g]^]_hkma^bk
MZld_hk\^_hkma^bkmahn`am_ne_^^][Z\dhghnk
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k^\hff^g]Zmbhgl4=k'<aZke^lFZcbg`^%]bk^\mhk&
k^ihkm'
`^g^kZeh_ma^;n`Zg]hF^]b\Ze<^gmk^4Ikh_^llhk
CZ\h[FmZ[Zcb%ikbg\biZeh_ma^P^bee;n`Zg]h The opinions expressed in the report are those of
Ngbo^klbmr<hee^`^h_A^ZemaL\b^g\^l4=k'?k^]^kb\d the authors and may not necessarily represent the
Db`Z]r^%^q^\nmbo^l^\k^mZkrh_a^Zemapbmama^ opinions of McKinsey & Company or the directors or
MZgsZgbZg>ibl\hiZe<hg_^k^g\^Zg]_hkf^k]bk^\mhk employees of, or donors to, the Touch Foundation.
h_ahlibmZel^kob\^l_hkma^MZgsZgbZg`ho^kgf^gm4
Zg]Zeeh_ma^ikbg\biZel%]^Zgl%ahlibmZe]bk^\mhkl%
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]ZmZ\hee^\mbhgZg]ZgZerlbl'

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IabeZ]^eiabZZg]G^pRhkd_hkma^bk]bk^\mlniihkm
Zg]ZllblmZg\^mhma^m^Zf'

GLOSSARY

AHO Accelerated Health Officer HSSP III Health Sector Strategic Plan
AMC Academic Medical Center IAHS Institute of Allied Health Services
AMO Assistant Medical Officer IFC International Finance Corporation
BSP Basic Service Provider JAHSR Joint Annual Health Sector Review
CA Clinical Assistant MDGS Millennium Development Goals
CHAI Clinton HIV/AIDS Initiative MKUKUTA National Strategy for Growth and Reduction of Poverty
CO Clinical Officer MMAM Primary Health Services Development Programme
DALY Disability Adjusted Life Years MO Medical Officer
DFID Department for International Development (UK) MOHSW Ministry of Health & Social Welfare
EN Enrolled Nurses MTEF Medium Term Expenditure Framework
GHWA Global Health Workforce Alliance RN Registered Nurse
HEW Health Extension Worker TSPAS Tanzanian Service Provision Assessment Survey
HRH Human Resources for Health UN United Nations
HRHSP Human Resources for Health Strategic Plan WHO World Health Organization

6 ACTION NOW
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bfikho^^\hghfb\Zg]lh\bZe]^o^ehif^gm':lbfie^
Increasing training capacity
bgm^kvention by a firsm&ebg^phkd^kpbmahnmab`a&^g] Lbg\^ma^in[eb\Zmbhgh_ma^+))/WHOPhke]A^Zema
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]k^llbg`Zphng]\hkk^\mer"\Zgebm^kZeerf^Zgma^ a^Zemaphkd_hk\^]^o^ehif^gmaZl\hgmbgn^]mh
difference bemp^^geb_^Zg]]^Zma' `khp'?hk^qZfie^%ma^Phke];ZgdaZl]^o^ehi^]
Zk^l^Zk\aZk^Z_h\nlbg`^q\enlbo^erhgma^a^Zema
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mk^Zm%ik^l\kb[^%]bli^gl^%k^_^k%Zg]hi^kZm^';nmma^rZk^ !GHWA"\hgvened the firsm@eh[Ze?hknfhgHRHbg
bglahkmlniierbgma^]^o^ehibg`phke]'@ho^kgf^gml DZfiZeZbgFZk\a+))14Zg]ma^;kbmblaf^]b\Ze
Zg]ma^`eh[Ze\hffngbmraZo^[^\hf^bg\k^Zlbg`er chnkgZeThe Lancet ]^ohm^]Zg^gmbk^blln^mhma^
ZpZk^h_ma^lahkmZ`^h_ldbee^]a^Zemaphkd^klÇ \kblblcnlmZfhgma^Zkeb^k'
ËanfZgk^lhnk\^l_hka^ZemaÌ!HRH"ÇZg]bml]bk^a^Zema
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Working Together for Health%aZo^]h\nf^gm^]ma^ bgo^lmf^gmbgik^&l^kob\^mkZbgbg`mh\k^Zm^*-)%)))
fZ`gbmn]^h_ma^\kblblZg]bmlbfieb\Zmbhgl_hka^Zema `^g^kZea^Zema\Zk^phkd^kl]^^f^]^ll^gmbZemh
hnm\hf^lbgma^]^o^ehibg`phke]' Z\ab^o^ln\\^llh_bmlHIV/AIDS-specific objecmbo^l',

Pabe^ma^WHOaZl]^m^kfbg^]maZm+,ldbee^] :\hffhgma^f^bgma^l^ZgZerl^laZl[^^gma^
\ebgb\Zea^Zemaphkd^kli^km^gmahnlZg]i^hie^bl bfihkmZg\^h_l\Zebg`niik^&l^kob\^mkZbgbg`bg
ma^fbgbfnfkZmbhmhikhob]^ma^[Zlb\lmZg]Zk]h_ [nbe]bg`ZlnlmZbgZ[e^a^Zemaphkd_hk\^'-

2
Christoph Kurowski et al., “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” (London School of Hygiene and Tropical Medicine) Jan 2003: 24.
3
See Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008,
Public Law 110-293, 122 Stat 2946 (2008). GPO Access. Web. <http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_cong_public_
laws&docid=f:publ293.110.pdf>.
4
See “Agenda for Global Action,” Global Health Workforce Alliance (GHWA) Mar 2008 <http://www.WHO.int/workforcealliance/forum/1_agenda4GAction_
final.pdf>; see also Nigel Crisp et al., “Training the health workforce: scaling up, saving lives.” The Lancet 23 Feb. 2008: 689-91.

THE TWIGA INITIATIVE 7

Bg+)),%F\Dbgl^r<hfiZgr\hg]n\m^]ZgZgZerlbl Translating policy into action
h_ma^lbmnZmbhgbgMZgsZgbZZg]in[ebla^]Zk^ihkm%
=^libm^bgm^kgZmbhgZebgm^k^lmZg]gZmbhgZeihebmb\Ze
Acting Now to Overcome Tanzania’s Greatest Health
pbee%MZgsZgbZaZlghmr^meZng\a^]Z\hfik^a^glbo^
Challenge: Addressing the Gap in Human Resources
Zg]Z\mbhgZ[e^mkZbgbg`^qiZglbhgikh`kZf'Ma^
for Health%.pab\aln``^lm^]maZmZmak^^&ikhg`^]
MMAM Zg]HRHSP iheb\b^l\Zee^]_hk]hn[ebg`a^Zema
lmkZm^`y is both required and feasible: firsm%\k^Zm^Z
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mZk`^m^]k^\knbmf^gmikh`kZfmh\Zimnk^fhk^h_ma^
\hg\k^m^l^mh_Z\mbobmb^lZg]bgo^lmf^gml_hk]hbg`lh'
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bgm^k]^i^g]^g\b^l[^mp^^g^qiZglbhglbgmkZbgbg`
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ZgZersbg`ma^a^Zemaphkd_hk\^\kblblbgMZgsZgbZ%
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Investing in Tanzanian Human Resources for
Health: An HRH study for the Touch Foundation'/
K^\h`gbsbg`ma^l^blln^l%ma^MZgsZgbZg`ho^kgf^gm
P^\hg\en]^]maZmbgm^ko^gmbhglmZk`^mbg`^qiZglbhg
Zld^]ma^Mhn\a?hng]Zmbhg_hklniihkmbg]^o^ehibg`
h_ik^&l^kob\^mkaining were the essential firsmlm^i
ZgZ\mbhgieZgmaZm\hne]a^eifZd^ma^lmkZm^`rZ
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k^Zebmr'P^_hng]maZmln\\^ll_neer]^o^ehibg`ln\a
\hngmkr%iZkmb\neZker`bo^gma^e^Z]mbf^lk^jnbk^]
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 I
 arlb\Ze%hg&lbm^Zll^llf^gmh_MZgsZgbZÌlmkZbgbg`
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bglmbmnmbhglmh]^m^kfbg^ma^bkihm^gmbZe_hk
pZlab`aer\hlt-effecmbo^%iZkmb\neZkerpa^g\hfiZk^]
^qiZglbhg
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 >
 oZenZmbhgh_lrlm^f&pb]^hiihkmngbmb^lmh
P^k^\h`gbs^Ik^lb]^gmDbdp^m^ÌlZlibkZmbhgmh]hn[e^ bg\k^Zl^mkZbgbg`\ZiZ\bmr%Zg]
ma^\hngmkrÌla^Zemaphkd^kmkZbgbg`\ZiZ\bmrÇeZm^k
 =
 ^o^ehif^gmh_ZgZgZermb\Zefh]^emaZmebgdl
]h\nf^gm^]bgma^CZgnZkr+))1AnfZgK^lhnk\^l
ho^kZeemkZbgbg`\ZiZ\bmy to the effecmh_k^eZm^]
_hkA^ZemaLmkZm^`b\IeZg!HRHSP"0Zg]ma^IkbfZkr
bfikho^f^gmlhgho^kZeea^Zemaphkd^klniier
A^ZemaL^kob\^l=^o^ehif^gmIkh`kZff^!Mpango
Zg]%ma^k^_hk^%mhma^`ho^kgf^gmÌlZ[bebmrmh
wa Maendeleo wa Afya ya MsingiÇMMAM"1ÇZg]
^qiZg]a^Zemal^kob\^lZlhnmebg^]bgma^MMAM'
ikhihl^]ZkZib]^qiZglbhgh_^qblmbg`a^Zemaphkd^k
mkZbgbg`bgltitutions as the firsmlm^imhpZk]Z\ab^obg`
MZgsZgbZga^Zemaiheb\r'

5
Acting Now to Overcome Tanzania’s Greatest Health Challenge: Addressing the Gap in Human Resources for Health (McKinsey & Company, 2004).
6
Lowell Bryan et al., Investing in Tanzanian Human Resources for Health: an HRH study for the Touch Foundation (McKinsey & Company, 2006).
7
Tanzania, Ministry of Health and Social Welfare, Human Resource for Health Strategic Plan 2008-2013 (HRHSP) (Dar es Salaam: MOHSW, Jan. 2008) 11.
8
Tanzania, Ministry of Health and Social Welfare, Primary Health Services Development Programme 2007-2012 (MMAM) (Dar es Salaam: MOHSW, May 2007) 6.

8 ACTION NOW
Bg^Zker+))1%ZchbgmF\Dbgl^rZg]Mhn\a Harnessing existing opportunities
?hng]Zmbhgm^Zfi^k_hkf^]^xtensive field research
Himbfbsbg`\ZiZ\bmrh_^qblmbg`mkZbgbg`bglmbmnmbhgl
Zg]ZgZerlblmhm^lmma^+))/arihma^lblmaZmMZgsZgbZ
through simple, school-specific improvements – such
\hne]]hn[e^bmlmkZbgbg`\ZiZ\bmr[r+)*.Zg]mh
Zl\hglmkn\mbg`g^peZ[hkZmhkb^lhkabkbg`g^pgnkl^
\k^Zm^bfie^f^gmZmbhgieZgl_hkl\Zebg`niMZgsZgbZÌl
mnmhklÇpZl[r_Zkma^fhlmihp^k_nee^o^kmhbg\k^Zl^
mkZbgbg`ikh`kZfl':_m^kZll^llbg`,2h_MZgsZgbZÌl
ma^gnf[^kh_a^Zemaphkd^klmkZbg^]bgMZgsZgbZbg
20a^Zemaphkd^kmkZbgbg`bglmbmnmbhgl%2p^\hg\en]^]
ma^g^Zkm^kf'Bfikho^f^gmlZmma^bg]bob]nZel\ahhe
maZmmZk`^m^]bgm^ko^gmbhglmh^qiZg]mkZbgbg`
e^o^e\ZgZ\\hngm_hklbqmrmh^b`amri^k\^gmh_ma^
\ZiZ\bmrphne]bg\k^Zl^hnminmh_ma^mkZbgbg`
mhmZebg\k^Zl^bgl\ahhebgmZd^\ZiZ\bmr'
lrlm^f[rgbg^mrmhhg^ang]k^]i^k\^gm'Ma^l^
bgm^ko^gmbhglphne]k^jnbk^ZgbgbmbZebgo^lmf^gm
Makhn`abgm^kob^plZg]eh\Ze]ZmZ\hee^\mbhg%p^
h_khn`aer.)fbeebhgZg]Zghg`hbg`ZggnZe\hlm
_hng]maZml\ahhel_Z\^lbq\hffhg\hglmkZbgml
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in scaling up: lack of qualified smn]^gml%lahkmZ`^
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,%1.)'Ahp^o^k%[^\Znl^bmmZdes years from the firsm
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Shg^]bZ`ghlmb\'

9
The reported number of health worker training schools in Tanzania varies widely. According to the 2007 draft HRHSP, based upon the 2005 School Bulletin,
Tanzania has 87 health worker training centers. The MMAM cites 116. The number 97 comes from the 87 in the HRHSP, with some of the institutions listed in
that document subdivided into their component programs, when our field work found them to be functionally independent.

THE TWIGA INITIATIVE 9

Enabling system-wide support
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 >
 g\hnkZ`e and subsidize off-campus housing 
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 >
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pb]^\nkkb\neZk\aZg`^lmaZmpbeeaZo^Z]bk^\mbfiZ\m
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by 25 percent, adding over five hundred additional
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]bli^glZkb^llbmmbg`ngZ[e^mhhi^g%ZpZbmbg`ltaff to
hi^kZm^ma^f'
Furthering transformational change
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a^Zemaphkd_hk\^ltaffing ghZelhkf^^mma^Ziieb\Z[e^
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ho^k11%)))phne]k^fZbg'
No silver bullets
Pabe^bmpZlm^fimbg`mhl^Zk\a_hkZlrlm^f&pb]^
Ëlbeo^k[nee^mÌlhenmbhgmha^eiZee^obZm^ma^k^fZbgbg`
a^Zemaphkd_hk\^`Zi%p^aZo^ghm[^^gZ[e^mh
b]^gmb_rZgy such quick fix in the course of this work
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P^]b]%ahp^o^k%b]^gmb_rZl^mh_mkZgl_hkfZmbhgZe
hiihkmngbmb^lmaZt could significantly narrow the
`Zi'Mhe firsml^mh_himbhglbgoheo^lmkZgl_hkfbg`
ma^mkZbgbg`lrlm^fho^kma^g^qmmphmh_hnkr^Zkl
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 Shorten the training pipeline. MkZbgbg`Za^Zema
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maZgmph'Bmphne][^phkmapabe^mhl^^dg^p

10
Based on the WHO guidelines for health worker density, demand in 2019 will be 140,480 skilled health workers, of which 115,900 must have clinical skills,
indicating that the MMAM policy is aligned with international standards and Tanzania’s needs to meet the MDGs.

10 ACTION NOW
 ZiikhZ\a^lmh]^\k^Zlbg`ma^mbf^k^jnbk^]mh
^]n\Zm^g^p%ehp^k&ldbee^]%a^Zema\Zk^phkd^kl'
?hk^qZfie^%\k^Zmbhgh_Z\hg]^gl^]%ldbeel&[Zl^]
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effecmbo^er]^ebo^kikbfZkra^Zema\Zk^l^kob\^l
\hne]ikh]n\^ZgZ]]bmbhgZel^o^gmahnlZg]
a^Zemaphkd^kli^kr^Zk'B_bfie^f^gm^][r+)*,%
mablhiihkmngbmr\hne]^ll^gmbZeer\ehl^ma^`Zi
bga^Zemaphkd^klÇmahn`a\Zk^phne]g^^]mh
[^mZd^gmh^glnk^maZmkZib]mkZbgbg`\hg_^kk^]
sufficient clinical skills to enable the work^klmh[^
effecmbo^bg]^ebo^kbg`ZiikhikbZm^ikbfZkr\Zk^'
 Augment capacity with technology.ObkmnZee^Zkgbg`
m^\agbjn^l%ln\aZlDVDmkZbgbg`ikh`kZfl%\hne]
^qiZg]mkZbgbg`\ZiZ\bmrb_nl^]bg\hgcng\mbhg
pbmabg\k^Zl^]\ebgb\ZekhmZmbhglZm]blmkb\mZg]
k^`bhgZeahlibmZel'Ln\aZiikhZ\a^l\hne]Zelh[^
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bg\k^f^gmZe\hlmh_\hgmbgn^]bgo^lmf^gm_hk
lnlmZbgZ[bebmr'KZblbg`lmn]^gm_^^lZg]himbfbsbg`
ma^`ho^kgf^gmÌlZiikhZ\amh\hlmlaZkbg`%
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^qiZg]bgZf^mah]b\ZepZr%ihm^gmbZeerZmfbgbfZe
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self-financing.
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ma^ik^\bl^bfiZ\mh_^Z\ah_ma^l^bgbmbZmbo^l%Zee
mak^^Zk^l\ZeZ[e^%]^i^g]bg`bgiZkmhgma^e^o^eh_
bgo^lmf^gm'Fhk^ho^k%Zeemak^^h_ma^l^bgbmbZmbo^l
\hfie^f^gm^Z\ahma^k'B_ln\\^ll_neerbfie^f^gm^]%
bg\hf[bgZmbhg%ma^raZo^ma^ihm^gmbZemh^gZ[e^
MZgsZgbZmhZ\ab^o^bmlh[c^\mbo^lZg]]^ebo^k
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funding are required
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and modificambhg'
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bglmbmnmbhgl%shgZee^Z]^klabi%ma^Fbgblmkr%]hghkl%
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MkZgl_hkfZmbhgZeZiikhZ\a^lmha^Zemaphkd^k
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phkd_hk\^maZmf^^mlma^fbgbfnfWHOkZmbh';nm
ln[lmZgmbZeikh`k^llbgphkd_hk\^^qiZglbhg%]kbo^g
[rZ]hn[ebg`h_mkZbgbg`\ZiZ\bmr%\Zg[^Z\ab^o^]
makhn`ahimbfbsbg`ma^^qblmbg`mkZbgbg`lrlm^f%
Zg]k^Zebsbg`ZlfZeel^mh_d^rbgbmbZmbo^lmZk`^mbg`
m^Z\abg`ltaff and smn]^gmahnlbg`Çma^ikbfZkr
\hglmkZbgmlhg\ZiZ\bmr'
?ng]bg`i^kfbmmbg`%mabl_Z\bebmr&e^o^ehimbfbsZmbhg
\Zg[^`bgbff^]bZm^er%Zeehpbg`MZgsZgbZmhfZd^
significant progress while it continues to assess
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]ZmZ\hee^\mbhgf^mah]heh`rZg]ZgZerlblp^k^ghm
k^ohenmbhgZkr%[nmp^[^eb^ve we filled an eq\^^]bg`er
bfihkmZgm`Zimhhh_m^ge^_mngZ]]k^ll^]'HnkZbf
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fZd^ma^e^Zi_khfZf[bmbhnllmkZm^`b^lmh^q^\nmZ[e^
Z\mbhgieZgl'
THE TWIGA INITIATIVE 11
Meeting the challenge outside Tanzania
HnkZll^llf^gmh_\ZiZ\bmrmhl\Ze^nia^Zemaphkd^k
mkaining relies primarily on fieldwork conducm^]
pbmabgMZgsZgbZ%Zg]hnkk^\hff^g]ZmbhglZk^
]^lb`g^]mhZ]]k^llmaZmgZmbhgÌs specific needs. But
p^[^eb^o^maZmZlbfbeZkZiikhZ\a\ZgZg]lahne]
[^Ziieb^]ln\\^ll_neermhhma^k\hngmkb^lZg]a^Zema
lrlm^fl'Ma^d^rblln^lmaZmZkbl^bgMZgsZgbZZk^ghm
so different from those in the resmh_:_kb\Zhk%bg]^^]%
bg^f^k`bg`^\hghfb^lbg:lbZ%Lhnma:f^kb\Z%hk
hma^kiZkmlh_ma^phke]'

Ma^lhenmbhglp^ikhihl^_hkMZgsZgbZ\Zge^o^kZ`^
^qblmbg`bglmbmnmbhglmhZiier_ng]Zf^gmZe%ikho^g
bgm^ko^gmbhglmhbg\k^Zl^ma^a^Zemaphkd_hk\^
Zg]lmZkt improving health outcomes within five
r^Zkl'?nkma^k%[rk^erbg`hg^qblmbg`i^klhgg^eZg]
bg_kZlmkn\mnk^%ma^rikhfhm^eh\Zehpg^klabi[rma^
bglmbmnmbhglÇhg^h_ma^d^rbg`k^]b^gmlg^\^llZkr_hk
ZgrlnlmZbg^]lhenmbhg':g]finally%Z]]bmbhgZe\ZiZ\bmr
pbeelmk^g`ma^ghma^kbgbmbZtives, either disease-specific
hklrlm^f&pb]^%pbmahnmZem^kbg`ma^ng]^kerbg`
lrlm^flmkn\mnk^Zg]ma^k^_hk^kbldbg`ma^\k^Zmbhgh_
ngik^]b\mZ[e^\hgl^jn^g\^l'

12 ACTION NOW

Context
A global crisis
Ma^`eh[Zein[eb\a^ZemaZg]bgm^kgZmbhgZe]^o^ehi&
f^gm\hffngbmb^laZve identified the seo^k^lahkmZ`^
h_ldbee^]a^Zemaphkd^klZlZ\kn\bZeh[lmZ\e^mh
improving health outcomes worldwide. Significant
^ob]^g\^bg]b\Zm^lmaZmma^]^glbmrh_a^Zemaphkd^kl
pbmabgZihineZmbhg]bk^\tly affecmla^Zemahnm\hf^l
_hkma^ihineZmbhg%iZkmb\neZkerhgkZm^lh_fZm^kgZe
fhkmZebmr%bg_ZgmfhkmZebmr, under-five mormZebmr%Zg]
bffngbsZmbhg\ho^kZ`^'**
Ma^Phke]A^ZemaHk`ZgbsZmbhg!WHO"^lmbfZm^lmaZm
ZgZ]]bmbhgZe-',fbeebhga^Zemaphkd^klZk^g^\^llZkr
mh\hf[Zm\nkk^gma^Zema\kbl^lZkhng]ma^`eh[^%pbma
fhk^maZg1))%)))h_ma^l^phkd^klg^^]^]bg:_kb\Z
Zehg^'*+
L^o^kZe_Z\mhklaZo^\hgmkb[nm^]mhmabl\kbmb\Ze
lahkmZ`^'Lmkn\mnkZeZ]cnlmf^gmiheb\b^lbgma^
*21)lZg]*22)lik^llnk^]`ho^kgf^gmlmhk^]n\^
in[eb\l^\mhkphkd_hk\^l%k^lnembg`bgk^]n\^]a^Zema
l^\mhk^fiehrf^gm'BgMZgsZgbZ%_hkbglmZg\^%ma^
`ho^kgf^gmbfie^f^gm^]Zin[eb\l^\mhkabkbg`_k^^s^
bg*22,maZmln[ltantially affecm^]a^Zemaphkd^k
]^fZg]'Bg*221ma^_k^^s^pZliZkmbZeereb_m^]_hk
11
Crisp 689-91.
12
Working Together for Health: The World Health Report 2006 (The World Health Organization (WHO), 2006) 12-13.
13
MMAM 12.
14
Capacity Project et al., Labour Market Study for the Tanzanian Health Sector: Draft 4 (Dar es Salaam: MOHSW, 2006) 19.
15
Sources: World Health Report 2006; Central Intelligence Agency, “Tanzania” World Factbook <https://www.cia.gov/library/publications/the-world-
factbook/geos/tz.html>; team analysis.
ikbhkbmrl^\mhkl%bg\en]bg`a^Zema%[nmbmpZlghm
Z[hebla^]ngmbe+)),'Ma^FbgblmkraZllmZm^]maZm
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k^ihkm^]+,%-0-ltaff produced by the health trZbgbg`
bglmbmnmbhglp^k^^fiehr^][rma^in[eb\l^\mhk'*,
Ma^_k^^s^e^]ghmhgermhk^]n\^]abkbg`[nmZelhmh
]^\k^Zl^]^gkheef^gmbgf^]b\ZemkZbgbg`':+))/
eZ[hkfZkd^mlnko^r\hg]n\m^][rma^Fbgblmkrbg
\hgcng\mbhgpbmama^<ZiZ\bmrIkhc^\mbg]b\Zm^]maZm
in the decade affecm^][rma^_k^^s^!_khf*22/mh
+))."%hger0+*iarlb\bZgl`kZ]nZm^]_khfMZgsZgbZg
f^]b\Zel\ahhel%l^o^k^erebfbmbg`lniier'*-A^Zema
\kbl^lln\aZlHIV/AIDSaZo^ghmhgerbg\k^Zl^]
ma^g^^]_hka^Zemaphkd^klbg]^o^ehibg`gZmbhgl
[nmaZo^Zelh^kh]^]ma^^qblmbg`a^Zemaphkd^k
ihineZmbhgZg]_nkma^k\hfikhfbl^]Zek^Z]rihhk
phkdbg`\hg]bmbhgl'
:mma^lZf^mbf^%ma^`khpmah_Z`bg`ihineZmbhglbg
p^Zemar\hngmkb^laZlbg\k^Zl^]ma^`eh[Ze]^fZg]
_hka^Zemaphkd^kl'Bg[hmakb\aZg]ihhkgZmbhgl%
bgZ]^jnZte planning and insufficient ino^lmf^gmbg
a^Zemaphkd^k^]n\ZmbhgaZle^_m\hngmkb^lngZ[e^mh
f^^ma^Zema\Zk^]^fZg]'P^Zemar\hngmkb^lk^\knbm
_hk^b`ga^Zemaphkd^klmhf^^mma^bkphkd_hk\^g^^]l%
^qZ\^k[Zmbg`ma^a^Zemaphkd^klahkmZ`^bg]^o^ehibg`
\hngmkb^lpa^k^ma^]bl^Zl^[nk]^gbl`k^Zm^lmZg]ma^
Z[bebmrmhikhob]^\hfi^mbmbo^\hfi^glZmbhgblehp^lm'
:_kb\Z[^Zkl+-i^k\^gmh_ma^phke]Ìl]bl^Zl^[nk]^g
pbmahgermak^^i^k\^gmh_ma^phke]Ìla^Zemaphkd^kl
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Ma^+))-Joint Learning InitiativeZg]ma^+))/
WHOPhke]A^ZemaK^ihkm[khn`amma^\kblblh_ma^
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a^Zemaphkders as the linchpin of all efformlmh
ho^k\hf^a^Zema\kbl^lZg]f^^mma^Fbee^ggbnf
THE TWIGA INITIATIVE 13
EXHIBIT 1 EXHIBIT 2
Most disease, fewest doctors Delayed impact
Percent of global disease burden Health worker density Health workers
0 50,000

Eastern Mediterranean
5 45,000

10 Europe 40,000

15 Americas
35,000

20 Western Pacific 30,000

Africa
25
South-East Asia
30 5,000

0
35
2009 2014 2019
0 5 10 15 20 25 30 35
Percent of world population Year of implementation

Health workforce with optimization Student intake with optimization

Regional groupings correspond to WHO regions, as follows: Health workforce steady state Student intake steady state
Americas: North, South, and Central America
Africa: Sub-Saharan Africa and Algeria
Eastern Mediterranean: North Africa including Sudan and Somalia,
the Middle East, Afghanistan and Pakistan
Europe: Eastern and Western Europe including Russia
South-East Asia: South Asia, North Korea, Indonesia, Myanmar, and Thailand
Western Pacific: Oceania, East Asia, Cambodia, Laos, and Vietnam

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]^\eZk^]ma^mZk`^m\ebgb\Zea^Zemaphkd^k]^glbmrh_+,
phkd^kli^km^gmahnlZg]i^hie^'Ma^r]^fhglmkZm^]
maZmpbmahnmbff^]bZm^bgo^lmf^gmbga^Zemaphkd^kl%
mablmZk`^mÇZg]ma^[^mm^ka^Zemabmk^ik^l^gmlÇ
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fZgZ`^f^gmf^\aZgblflmaZm]hghmr^m^qblmbg
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phkd_hk\^bgoheo^l\hfik^a^glbo^fZgZ`^f^gm
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k^m^gmbhg]^i^g]a^Zobernihgi^k\^bo^]]^lbkZ[bebmr
ikh`kZfeZlmbg`mak^^ÇmkZgleZm^lbgmhZlb`gbfi\ZgmeZ`
h_ma^a^Zemaphkd^kikh_^llbhg%]^m^kfbg^]ghmhger
mbf^[^mp^^glmn]^gmlÌ^gmkrbgmhZmkZbgbg`ikh`kZf
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nima^ikh]n\mbhg\ZiZ\bmrh_ma^a^ZemamkZbgbg`
and funding of the workforce require effecmbo^

16
See Joint Learning Initiative (JLI) Human resources for health: overcoming the crisis (Cambridge: Global Equity Initiative, 2004); World Health Report 2006 11.

14 ACTION NOW
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pbee\k^Zm^Zkh[nlmlrlm^f_hkk^mZbgbg`Zg]
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e^o^emh\hngl^e%m^lm%]bZ`ghl^%mk^Zm%Zg]fhgbmhk
HIV&ihlbmbo^iZmb^gml'
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p^^dlmhi^k_hkf\hk^mZldl'?hk^qZfie^%Z\abe]k^glÌ
a^Zemaphkd^k\Zg[^mkZbg^]mhi^k_hkfZiZ\dZ`^
h_mZldlbg\en]bg`[Z[rp^b`abg`%oZ\\bgZmbhgl%Zg]
]blmkb[nmbhgh_k^ar]kZmbhglZemlZg]fhljnbmhg^ml'
;nmpabe^ma^k^Zebmy of the pipeline effecm]^fZg]l
l\Zebg`niikh]n\mbhgZllhhgZlihllb[e^%gZmbhgl
_h\nlbg`ikbfZkberhgma^bff^]bZm^g^^]_hk
\Zee_hkZ\mbhg'>]n\ZmbhgZg]mkZbgbg`ikh`kZfl
bg>mabhibZZg]FZeZpbZk^ibhg^^kbg`bgbmbZmbo^l
mhkZib]erbg\k^Zl^ma^lniierh_a^Zemaphkd^klZm
oZkbhnle^o^el'PbmaZ`ho^kgf^gmikbhkbmrmh^qiZg]
Z\\^llmh[Zlb\a^Zemal^kob\^l%>mabhibZeZng\a^]Z
ikh`kZfmaZmZbflmhmkZbg,)%)))A^Zema>qm^glbhg
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?ng]Zg]ma^Ngbm^]Dbg`]hfÌl=^iZkmf^gm_hk
Bgm^kgZmbhgZe=^o^ehif^gm!DFID)%l^^dlmh]hn[e^
ma^gnf[^kh_gnkl^lZg]mkbie^ma^gnf[^kh_]h\mhkl
bgmkZbgbg`'
;nm]^libm^Zf[bmbhnlmZk`^mlZg]p^ee&bgm^gmbhg^]
ieZgl%fZgr\hngmkb^l_Z\bg`a^Zemaphkd_hk\^
lahkmZ`^llmbeelmkn``e^mhmkZgleZm^lmkZm^`rZg]
Zf[bmbhgbgmhZ\mbhg'Pabe^]hghk`ho^kgf^gmlZg]
NGOlZbfmhlniihkm`ho^kgf^gmikbhkbmb^l%\hfie^q

^qiZg]^]mkZbgbg`\ZiZ\bmrlahne]lbfnemZg^hnler [nk^Zn\kacies and multiple funding flows frequently

]^o^ehiikh`kZflmhZ]]k^llma^hma^kd^rZk^Zlh_ abg]^kieZggbg`Zg]k^lnembgbfie^f^gmZmbhg
a^Zemaphkd_hk\^fZgZ`^f^gm'Ab`a&jnZebmrmkZbgbg`% iZkZerlbl'Ma^l^h[lmZ\e^l\Zg[^_nkma^k\hfieb\Zm^]

17
Sources: 2008 Twiga model [raw sources include: MMAM; HRHSP (draft, Oct. 2007); Tanzania, Ministry of Health and Social Welfare, Staffing
Establishment 2005 (Dar es Salaam); Tanzania, Ministry of Health and Social Welfare, Health Statistics Abstract 2001 (Dar es Salaam); MOHSW monthly
budget allocation to schools (unpublished); WHO Statistical Information System (WHOSIS) < http://www.who.int/whosis/en/index.html>; Tanzania,
Ministry of Health and Social Welfare, HRH Census (Dar es Salaam: 2002); Labor Market Study 2006; Tanzania student focus groups; Tanzania, Ministry
of Health and Social Welfare, School Bulletin Database 2005 (Dar es Salaam); Interviews (see appendix); Tanzania Ministry of Health and Social Welfare
website < http://www.moh.go.tz/>; Tanzania Ministry of Higher Education, Sciences & Technology website <http://www.msthe.go.tz/>; Bryan 2006;
World Bank < www.worldbank.org/tanzania>].
18
See Global Health Workforce Alliance (GHWA) website <http://www.ghwa.org/>; the press release on the launch of the Scaling up Education and Training
taskforce of the Global Health Workforce Alliance is available on the WHO website <http://www.WHO.int/mediacentre/news/releases/2007/pr05/en/
index.html>.

THE TWIGA INITIATIVE 15

EXHIBIT 3
Top ten causes of DALY loss
Africa Tanzania
HIV/AIDS All others HIV/AIDS
Other 12
21 19 18
Cardiovascular
Cardiovascular diseases
diseases 16 TB/Respiratory 4
4 Nutritional 4 13 TB/Respiratory
Nutritional 3 deficiencies
deficiencies 5 5
8 Malaria
9 Neuropsychiatric 6 9
Neuropsychiatric
14 conditions 8 Malaria
conditions 8 Maternal/Perinatal 14
Diarrheal Conditions Diarrheal
diseases diseases
Injuries Maternal/Perinatal
Injuries
Conditions

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a^Zemaphkd^kl%MZgsZgbZlmZg]lhnmZlZieZ\^h_
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MZgsZgbZblbgma^`kbih_Za^Zemaphkd_hk\^\kblbl'Bm
aZlcnlm.'+\ebgb\Zea^Zemaphkd^kli^km^gmahnlZg]
people, one-fifmah_ma^mZk`^mkZmbhikhihl^][rma^
WHO'Ma^]^oZlmZmbg`k^lnemlZk^^ob]^gmbg\hffhg
a^Zemahnm\hf^l%ln\aZlfZm^kgZefhkmZebmrkZm^l%
i^k\^gmh_ehll^lh_=blZ[bebmr:]cnlm^]Eb_^R^Zkl
!DALY"bgMZgsZgbZ'+*Ma^DALY]ZmZf^Zlnk^lghmcnlm
eb_^^qi^\mZg\r[nmZelh]blZ[bebmb^lmaZt effecmbo^er
]^lmkhrr^Zklh_a^Zemareb_^':gnf[^kh_]bl^Zl^&
specific progrZflaZo^^f^k`^]%_ng]^][reZk`^
_hng]ZmbhglZg]fnembeZm^kZe]hghkl%mhikhob]^
]bZ`ghlblZg]mk^Zmf^gmh_ma^l^ieZ`n^l'
Other significant drivers of the health care crisis
bg\en]^fZm^kgZeZg]i^kbgZmZe\hg]bmbhgl%iarlb\Ze

19
For more on challenges of donor funding in the health sector, including fragmentation, unpredictability, short time horizons, and narrow focus, see Jaap
Koot and Rik Peeperkorn, “The Health Sector in the 21st Century; putting health systems strengthening in perspective,” forthcoming: 8-9.
20
As of February 2009, UNICEF reported maternal mortality rates (adjusted for under-reporting and misclassification) to be 950 deaths per 100,000 live
births in Tanzania, and 560 per 100,000 in Kenya <http://www.unicef.com>.
21
Source: WHO “Death & Disability Adjusted Life Years (DALYs) estimates for 2002 by cause for WHO Member States” < http://www.who.int/whosis/
indicators/compendium/2008/1llr/en/>.
22
Source: WHO DALY estimates 2002; team analysis based on extensive qualitative and quantitative field work.

16 ACTION NOW
EXHIBIT 4 EXHIBIT 5
Shrinking fast Current pyramid

Tanzanian population Health workforce

millions thousands Specialists 400
45 70
Health workforce 940
40
60 Medical Officers
35 Assistant
50 Medical Officers 1,400
30
25 Total population 40

20 Registered Nurses 5,500 6,900 Clinical Officers

30
Diagnostic and
15 3,580
20 Support Staff
10 Enrolled 7,070 0* Clinical Assistants
10 Nurses
5
0 0 * Clinical Assistant training began in 2008; staff numbers not yet available.
1994-95 2001-02 2007-08 Diagnostic and support staff includes 1090 laboratory workers, 340 pharmacy
workers, and 2150 other healthcare workers.

mkZnfZ%Zg]]bZkka^Ze]bl^Zl^l%pab\amh`^ma^k
ZfhngmmhZghma^kjnZkm^kh_DALYehll!>qab[bm,"'++
Bndeed, over half the losses suffered by the TZgsZgbZg
i^hie^Zk^ghmik^l^gmerZ]]k^ll^]makhn`a]bl^Zl^&
specific programs and could be significantly reduced
[rbg\k^Zlbg`Z\\^llmh[Zlb\ikbfZkr\Zk^'
Ma^]^oZlmZmbg`bfiZ\mh_fn\ah_MZgsZgbZÌlikbfZkr
]bl^Zl^[nk]^g%ma^k^_hk^%\hne][^]kZfZmb\Zeer
k^]n\^]b_mbf^er]bZ`ghlblZg]ZiikhikbZm^mk^Zmf^gm
p^k^ZoZbeZ[e^'BgMZgsZgbZ%ZlbglhfZgrh_bml
g^b`a[hkbg`\hngmkb^l%ma^d^r[hmme^g^\dik^o^gmbg`
effecmbo^a^Zema\Zk^]^ebo^krblghmg^\^llZkber]kn`l
hk_Z\bebmb^l[nmkZma^kma^gnf[^kh_ldbee^]a^Zema
phkd^klikhob]bg`\Zk^bgmahl^_Z\bebmb^l'
MZgsZgbZÌla^Zemaphkd_hk\^aZl]^\ebg^]^o^gZlbml
ihineZmbhgaZllhZk^]'Bg*22-%Zlma^in[eb\l^\mhk
hiring freeze took effecm%MZgsZgbZaZ]/0%/))a^Zema
phkd^kl_hk+1'1fbeebhgi^hie^';r+))*mablkZmbh
aZ]_Zee^gmh-1%.))a^Zemaphkd^kl_hkZihineZmbhg
h_,-'.fbeebhg%Zg]mh]Zr%ma^\hngmkraZlkhn`aer
+.%)))a^Zemaphkd^kl_hkfhk^maZg_hkmrfbeebhg
i^hie^'+,
Bn less than fifm^^gr^Zkl%ma^ikhihkmbhgh_a^Zema
phkd^klmhmhmZeihineZmbhgaZl_Zee^g[r0.i^k\^gm'
Bg+))-%ma^ChbgmE^Zkgbg`BgbmbZmbo^k^ihkm^]
maZmMZgsZgbZaZ]ma^phke]Ìlehp^lm\ho^kZ`^h_
iarlb\bZgl%pbmahger)'+Fedical Officers (MOl)hk
li^\bZeblmli^km^gmahnlZg]i^hie^'+-;rma^mbf^h_
ma^+))/L^kob\^Ikhoblbhg:ll^llf^gm%maZt figure
aZ]\ebf[^]leb`amermh)'-+. – lmbee]^li^kZm^erehp'
Ho^kZee%ma^mhmZea^Zemaphkd_hk\^aZllahpgZg
Z\\^e^kZm^]]^\ebg^lbg\^+))*&)+!>qab[bm-"'+/
While the figures for phrlb\bZglZk^lah\dbg`%ma^
a^Zemaphkd_hk\^bgMZgsZgbZ_Z\^l^qmk^f^lahkmZ`^l

23
Ottar Maestad Human Resources for Health in Tanzania (Chr. Michelson Institute (CMI Report), 2006); 2008 Twiga model (see note 17); HRH census 2002.
24
CMI Report 4.
25
Tanzania National Bureau of Statistics (NBS) and Macro International, Tanzania Service Provision Assessment Survey 2006 (TSPAS), (Nov. 2007: 22).
26
Source: CMI Report; team analysis based on extensive qualitative and quantitative field work.
27
Staffing Establishment 2005.

THE TWIGA INITIATIVE 17

 POLICY HEALTH WORKFORCE GOALS PRE-SERVICE TRAINING GOALS

2003-2008/09 ›<jkXYc`j__ldXei\jfliZ\j]fi_\Xck_XjXeXk`feXc ›<ejli\hlXc`kpf]kiX`e`e^

HSSP II priority to improve health services ›;\k\id`e\i`^_kj`q\Xe[jb`ccd`of]nfib]fiZ\kf
›9XcXeZ\XccfZXk`fef]_ldXei\jfliZ\j meet current and future needs
geographically, and across skill levels

2005 Guidelines for ›J\kgifZ\jj\j]fi_ldXei\jfliZ\jdXeX^\d\ek# ›@[\ek`]pkiX`e`e^e\\[j

Reforming Hospitals development, and motivation ›GcXZ\X[\hlXk\jkXún`k_Xggifgi`Xk\jb`ccj`e
›I`^_kj`q\k_\nfib]fiZ\ facilities

2005 MKUKUTA ›Dfk`mXk\_\Xck_j\Zkfikfd\\kD;>j

›<
 ejli\k_Xk/'f]_\Xck_]XZ`c`k`\j_Xm\jb`cc\[
workers in place

2007 JAHSR ›Jki\e^k_\eXe[Zffi[`eXk\\úfikjkf`dgifm\ ›Jki\e^k_\eZXgXZ`kpf]kiX`e`e^`ejk`klk`fej

recruitment and deployment ›@dgifm\kiX`e`e^`e]XjkilZkli\j
›<ejli\k_\-,)e\ncpYl`ck#le$fg\e\[[`jg\ejXi`\j ›9p)''/#`eZi\Xj\gi\$j\im`Z\\eifccd\ek]ifd
are staffed 1,013 to 6,458

2007-2017 MMAM ›I\_XY`c`kXk\Xe[ZfejkilZk/#('.gi`dXipZXi\ ›@dgifm\Xe[\jkXYc`j_dfi\kiX`e`e^`ejk`klk`fejkf

facilities
›Jki\e^k_\e_ldXei\jfliZ\j[XkXYXj\
›Gifm`[\jlgcc`\jkfXccgi`dXipZXi\]XZ`c`k`\j
›<ejli\fg\iXk`feXci\]\iiXcjpjk\d
›@eZi\Xj\ÓeXeZ`XcXccfZXk`fekf(,f]XeelXcYl[^\k
ensure adequate numbers of skilled workers
›<ejli\hlXc`kpf]kiX`e`e^
›=XjkkiXZbZXgXZ`kpYl`c[`e^f]Xcc`\[_\Xck_nfib\ij
to staff primary care facilities

2008-2013 HRH ›Jki\e^k_\ec\X[\ij_`gXe[jk\nXi[j_`g ›;\m\cfgdXjk\ikiX`e`e^gcXe

Strategic Plan ›@dgifm\nfib]fiZ\dXeX^\d\ek ›@eZi\Xj\ZXgXZ`kpf]\o`jk`e^kiX`e`e^`ejk`klk`fej
›@eZi\Xj\Xe[`dgifm\kiX`e`e^ ›JZXc\lg\eifccd\ek
›Gifdfk\i\j\XiZ_Xe[[\m\cfgd\ek ›Jki\e^k_\ehlXc`kpXjjliXeZ\`ekiX`e`e^`ejk`klk`fej
›@eZi\Xj\_ldXei\jfliZ\jÓeXeZ`e^

ZmZeee^o^elh_\Zk^'Ma^phkd_hk\^\Zg[^\Zm^`hkbs^] >lmZ[eblaf^gml^mlZab`almZg]Zk]_hkltaffing leo^el

bgmhmak^^eZk`^l^`f^gml3\ebgb\Zeghg&gnklbg`ltaff%
gnklbg`ltaff%Zg]]bZ`ghlmb\Zg]lniihkmltaff'Ma^
gZtional Staffing EsmZ[eblaf^gml]^m^kfbg^ahp
fZgrh_^Z\a\Z]k^h_phkd^k^Z\a_Z\bebmrmri^g^^]l'
?hk^qZfie^%ma^ehp^lm&e^o^e_Z\bebmr%ma^]bli^glZkr%
bllniihl^]mh[^ltaffed by eight work^kl%h_pahf
five are lower-skilled nurses and tphZk^ehp^k&ldbee^]
\ebgb\Zeltaff'
:mma^hma^k^g]h_ma^li^\mknf%Zk^_^kkZeahlibmZe
bllniihl^]mh[^ltaffed by 1,-+,phkd^kl%h_pahf
*.)!**i^k\^gm"Zk^li^\bZeblmlhkMOl%*%))-!0*
i^k\^gm"Zk^gnklbg`ltaff%Zg]+--!*0i^k\^gm"Zk^
]bZ`ghlmb\hklniihkmltaff'+0 While the official Staffing
bgahlibmZel%a^Zema\^gmk^l%Zg]]bli^glZkb^l%ma^l^
bglmbmnmbhglkhnmbg^erhi^kZm^pbmahgerZ_kZ\mbhgh_
ma^ik^l\kb[^]ltaff'=^i^g]bg`hgma^e^o^eh__Z\bebmr%
Zg:llblmZgmFedical Officer (AMO) hkCO fZrZ\mZl
ma^e^Z]iarlb\bZg'<linical Officers mar^o^gi^k_hkf
[Zlb\lnk`^kb^lln\aZl\Z^lZkbZgl^\mbhglhka^kgbZ
k^iZbkl'+1
Mabl]bl\k^iZg\r[^mween official smZg]Zk]lZg]
k^ZebmrbgikZ\mb\^kZbl^lma^jn^lmbhgh_paZmma^b]^Ze
ldbeefbqbl_hkMZgsZgbZZg]ahpbmphne]mkZgleZm^
bgmhZphkd_hk\^irkZfb]]^lb`g^]_hkma^\hngmkrÌl
g^^]l'P^]b]ghm]bk^\merZ]]k^llma^jn^lmbhgh_
ma^b]^Zephkd_hk\^irkZfb]_hkMZgsZgbZÌla^Zema

28
Interviews with medical staff at Bugando Medical Centre.
29
Source: TSPAS 2007; HRH Census 2002.

18 ACTION NOW
EXHIBIT 6
A long way to go
per 1,000 population

Lower-skilled Mid-level Higher-skilled

United States 8.96 11.79 2.41

South Africa 0.19 4.12 0.72

Sub-Saharan
0.24 0.86 0.12
Africa

Tanzania 0.25 0.53 0.07

Lower-skilled workers: community health workers for SSA and South Africa; clinical assistants, medical attendants, and MCH aides for
Tanzania; medical assistants and nursing aides for the US
Mid-level workers: nurses, laboratory technicians, and pharmacists in all countries; includes clinical officers in Tanzania
Higher skilled workers: physicians in the US; physicians and substitute doctors / AMOs in South Africa, SSA, and Tanzania

l^\mhk%pa^ma^kmhf^^mbgm^kgZmbhgZelmZg]Zk]l%ln\a Policy frameworks

Zlma^MDGl_hka^Zema%hkmhZ\ab^o^]hf^lmb\iheb\r
h[c^\mbo^l%ln\aZlikhob]bg`fhk^^jnbmZ[e^Z\\^llmh
[Zlb\a^Zemal^kob\^l'
Ma^\nkk^gmirkamid seems to be a reasonable profile
_hkma^\hngmkrÌl]bl^Zl^[nk]^g!>qab[bm."%+2Zg]
\nkk^gmerma^`Zi[^mp^^glniierZg]]^fZg]h_
ldbee^]a^Zemaphkd^klbllh`k^ZmmaZmbg\k^Zl^]
ikh]n\mbhgblk^jnbk^]_hkZee\Z]k^lbff^]bZm^er'
Ahp^o^k%bgma^_nmnk^%Zglp^klmhma^l^jn^lmbhgl
Çma^himbfnfiZ\dZ`^h_a^Zemal^kob\^lmh[^
ikhob]^]Zm^Z\a_Z\bebmre^o^e%ma^\Z]k^h_phkd^k
[^lmieZ\^]mh]^ebo^kma^l^l^kob\^l%ma^e^g`maZg]
mri^h_mkZbgbg`g^^]^]mh\hgo^rma^g^\^llZkrldbeel
Çpbee\e^Zkerg^^]mh[^_Z\mhk^]bgmhieZggbg`_hk
a^Zemaphkd^kmkZbgbg`'
Ma^MZgsZgbZg`ho^kgf^gmbl\hffbmm^]mh
bfikhobg`^jnbmrh_Z\\^llmhjnZebmra^Zemal^kob\^l
gZmbhgpb]^[r+)*0%Zg]mhk^Z\abg`a^Zemahnm\hf^
mZk`^mlbgebg^pbmama^MDGl[r+)*.'Ma^l^`hZel
Zk^Z\hffhgmak^Z]knggbg`makhn`ama^k^\^gm
lnbm^h_a^Zemaiheb\b^lZg]lmkZm^`b\ieZgl%bg\en]bg`
ma^+))0MMAM,ma^+))1HRHSP%Zg]ma^fhk^
`^g^kZe+)).GZmbhgZeLmkZm^`r_hk@khpmaZg]
K^]n\mbhgh_Iho^kmr!MKUKUTA"'M^qmbl[^bg`
figZebs^]_hkma^mabk]A^ZemaL^\mhkLmkZm^`b\IeZg
!HSSP III"'Bgebg^pbmama^+))0Chbgm:ggnZeA^Zema
L^\mhkK^ob^p!JAHSR"%ma^]kZ_mm^qmab`aeb`amla^Zema
phkd^kmkZbgbg`ZlZd^r\hfihg^gmh_bfikhobg`
a^Zemahnm\hf^l'

30
MMAM 12.
31
MMAM 12, 15.

THE TWIGA INITIATIVE 19

Ma^^ohenmbhgh_MZgsZgbZgiheb\r_khf+)),mh
ma^ik^l^gmk^flecmlma^bg\k^Zlbg`ZpZk^g^llh_ma^
\kbmb\Zeebgd[^mp^^gma^ZoZbeZ[bebmrh_a^Zemaphkd^kl
Zg]bfikho^]a^Zemahnm\hf^l'
The Twiga Initiative
K^\h`gbsbg`ma^g^^]mh_h\nlhga^Zemaphkd^k
lniierbghk]^kmhZ\ab^o^ikh`k^llhga^Zema
bg]b\Zmhkl%ma^Fbgblmkr]^o^ehi^]ma^Mpb`ZBgbmbZmbo^
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^qiZglbhgh_phkd_hk\^ikh]n\mbhg',*
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m^eelnlmaZmZghma^km^gi^k\^gmpbeee^Zo^pbmabgma^
firsmr^Zk':mma^lZf^mbf^%ma^lrlm^fehl^lZme^Zlm
mabkteen to fifm^^gi^k\^gmh_bmlphkd_hk\^^o^krr^Zk
mhk^mbk^f^gm%]^Zma%Zmmkbmbhgmhghg&a^Zemach[l%
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\hngmkrh_^jnZeihineZmbhglbs^!>qab[bm/"',,

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these, fifm^^gmhmp^gmri^k\^gmg^o^kchbgma^a^Zema

32
In the final draft of the MMAM, targets for new facility construction have been combined with targets for renovation of existing facilities (see policy table
p. 18) We believe the new target still reflects planned construction of 5201 new facilities, and staffing of 652 constructed but currently un-opened and
unstaffed facilities.
33
Source: WHOSIS; World Health Report 2006; US Bureau of Labor Statistics <http://www.bls.gov/>; Bryan 2006; TSPAS 2007; Kurowski 2003: 25; 2004: 10.
34
Average annual attrition rates were calculated based on interviews with school principals, students, independent consultants, and MOHSW officials, as well
as published statistics from the WHO.

20 ACTION NOW
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Methodology
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Filling the knowledge gap
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_h\nl^]hgjnZebmZmbo^Zg]jnZgmbmZmbo^]ZmZmaZm
fb`ambg_hkfln\aZieZg'

Ma^m^ZfZelhng]^kmhhdZg^qaZnlmbo^k^ob^ph_ Our aim was to offer acmbhgpbmabff^]bZm^bfiZ\m%Zl

k^eZm^]a^Zemaphkd_hk\^ikh`kZflZg]lmn]b^l%pahl^ p^eeZlma^Z[bebmrmhe^o^kZ`^^qblmbg`k^lhnk\^l%\k^Zm^
findings helped to cement our assumptions and eh\ZeZ\\hngmZ[bebmr%lniihkmma^`ho^kgf^gmÌl^qblmbg`
ZiikhZ\a',/Mhroughout the fieldwork component  lmkZtegic plan, and balance our efformlZ\khll\Z]k^l'

35
HRHSP; School Bulletins 2005; Tanzania, Ministry of Health and Social Welfare Emergency Recruitment Plan (Dar es Salaam); HRH Census 2002.
36
Some of the most relevant recent studies of this issue include the WHO World Health Report 2006, the Norwegian CMI Report, Kurowski 2003, and
Kurowski’s subsequent work on health workforce in Tanzania including Anna Dominick and Christoph Kurowski, “Human resources for health – an
appraisal of the status quo in Tanzania mainland” July 2004, and Christoph Kurowski, et al., “Scaling up priority health interventions in Tanzania: the
human resources challenge” Health Policy and Planning 20 Feb. 2007.
37
Organizations such as the Capacity Project and I-Tech are doing related system-strengthening work in Tanzania, while the Carter Center’s work in Ethiopia,
the Global AIDS Program in Namibia, and the United Kingdom’s Department for International Development (DFID) work in Malawi provide interesting
comparative examples.

THE TWIGA INITIATIVE 21

EXHIBIT 7A EXHIBIT 7B
Broad training coverage The public/private divide
Number of schools
1-2
Kagera 3-4
Mara
5-6
7-8
Mwanza
Arusha Kilimanjaro Private
Shinyanga
faith-
39%
Kigoma based Government
55%
schools schools
Tabora Tanga
Dodoma Zanzibar
Singida
Dar es
Rukwa Salaam
Iringa 6%
Mbeya Pwani
Private secular
Morogoro schools
Lindi
Rural areas such as
Kigoma, Tabora, and
Ruvuma Mtwara
Ruvuma serve 21% of the
population with 13% of the
training institutions

@bo^gma^bgm^k]^i^g]^g\r[^mween school-specific gnf[^kh_ikh`kams offered, ownership and funding,

Zg]lrlm^f&pb]^bgbmbZmbo^l%ma^m^Zf\hf[bg^]
[hmmhf&niZg]mhi&]hpg]ZmZ\hee^\mbhgmh^glnk^Z
\hfik^a^glbo^%ikZ\mb\Zelhenmbhg'
Bottom-up data collection
Since official damZpZlh_ten insufficient, the team
^f[Zkded on field visits to obtain an accnkZm^ob^ph_
ma^\nkk^gmlbmnZmbhghgma^`khng]%]^m^kfbg^^Z\a
bglmbmnmbhgÌlZ[bebmrmhbg\k^Zl^mkZbgbg`\ZiZ\bmr%Zg]
b]^gmb_rlrlm^f&pb]^^gZ[e^klmhlniie^f^gmeh\Ze
efforml'
MhZ\ab^ve this, the field team was divided into seo^kZe
lfZee`khnilmaZm_Zgg^]hnmZ\khllma^\hngmkr%
li^g]bg`l^o^gp^^dloblbmbg`,2h_MZgsZgbZÌl20
different health work^kmkaining schools and affiliam^]
a^Zema\Zk^_Z\bebmb^l%fZgrfhk^maZghg\^'MkZbgbg`
l\ahhel\Zg[^`khni^]mh`^ma^kZ\\hk]bg`mhgnf^khnl
\kbm^kbZ3`^h`kZiar%lbs^h_lmn]^gm[h]r%mri^Zg]
Zg]lh_hkma'Ma^m^ZfZmm^fim^]mh\ho^kZ[khZ]
\khll&l^\mbhgh_l\ahhel[rZeeh_mahl^f^Zlnk^l'?hk
^qZfie^%p^oblbm^]l\ahhelbg_hnkm^^gh_MZgsZgbZÌl+*
k^`bhgl%\ho^kbg`knkZeZk^Zlpbmahgerhg^hkmph
l\ahhel%Zlp^eeZlnk[Zgl^mmbg`lpbmaZlfZgrZl
^b`ambglmbmnmbhgl!>qab[bm0Z"'
G^ZkeraZe_h_ma^mkZbgbg`l\ahhelZk^ikboZm^er
hpg^]Zg]hi^kZm^]%h_pab\aZln[lmZgmbZefZchkbmr
Zk^_Zbma&[Zl^]!>qab[bm0["',1Mhis has significant
bfieb\Zmbhgl_hk_ng]bg`Zgrikhihl^]^qiZglbhg%Zl
p^eeZl_hkZiieb\Z[bebmrh_lrlm^f&pb]^iheb\r\aZg`^l'
Ma^m^Zfma^k^_hk^fZ]^Zihbgmh_oblbmbg`l\ahhel
h_Zeemri^l'Lbg`e^&ikh`kZfl\ahhelfZd^ni2*
i^k\^gmh_MZgsZgbZÌlmkZbgbg`bglmbmnmbhgl'Mh^glnk^
Ziieb\Z[bebmy of our findings across TZgsZgbZ%p^
visited a significant number of these in addition to all
ma^eZk`^%fnemb&ikh`kZfmkZbgbg`\hfie^q^l'

38
Source: School Bulletin 2005.

22 ACTION NOW
EXHIBIT 8
What it takes

Upgrade from MO Specialist

Internship Medical Officer

Form 6
(12th grade)
Dental Officer

Upgrade from CO Assistant Medical Officer

Clinical Officer

Clinical Assistant

Form 4 Registered Nurse

(10th grade)
Enrolled Nurse

Pharmacy technicians

Laboratory technicians

Educational
prerequisites 0 1 2 3 4 5 6 7 8 9
Years of training

HnkZgZerlbl\ho^k^]fnembie^e^o^elh_a^Zemaphkd^k% Interview guide and data request

_khf[Zlb\]bZ`ghlmb\hklniihkmltaff to specialisml%
?hkma^l^oblbml%ma^m^Zf]^o^ehi^]Z]^mZbe^]
bg\en]bg`mkZbgbg`mbf^ebg^l!>qab[bm1"',2BgZ]]bmbhg
bgm^kob^p`nb]^Zg]]ZmZk^jn^lmmhZllnk^
mhlmn]rbg`ik^&l^kob\^mkZbgbg`Zm^Z\al\ahhe%p^
\hfik^a^glbo^Zg]\hglblm^gm]ZmZ\hee^\mbhg'
`Zma^k^]]ZmZhgbg&l^kob\^ni`kZ]bg`ikh`kZflmaZm
IkbfZkrbgm^kob^plp^k^a^e]pbmama^l\ahhe
Zeehpa^Zemaphkd^klmhk^mnkgmhl\ahhe_hkfhk^&
ikbg\biZe%_heehp^][r]bl\nllbhglpbmahma^k_Z\nemr%
Z]oZg\^]]^`k^^l'Ma^l^ikh`kZflk^ik^l^gmZg
Z]fbgblmkZmhkl%ahlibmZeltaff%Zg]lmn]^gml%pa^g
ZmmkZ\mbo^f^mah]h_kZib]erl\Zebg`nima^ldbeee^o^e
ZoZbeZ[e^%mhmkbZg`neZm^ma^]ZmZZg]bg\k^Zl^
h_ma^^qblmbg`a^Zemaphkd_hk\^%\hgo^kmbg`ehp^k&
confidence in its accnkZ\r'
ldbee^]mhfb]&e^o^eZg]fb]&e^o^emhab`a^k&ldbee^]
phkd^klpbmahnmk^jnbkbg`ma^_neemkZbgbg`mbf^h_ Ma^inkihl^h_ma^\hfie^f^gmZkrbgm^kob^p`nb]^
lmZkmbg`_khfl\kZm\a' Zg]]ZmZk^jn^lt tools was to confirm preobhnler
`Zma^k^]]ZmZ%]^m^kfbg^pa^ma^k^Z\al\ahhepZl
Ho^kZee%p^\ho^k^]g^Zkerlbqmri^k\^gmh_MZgsZgbZÌl
hi^kZmbg`Zm\ZiZ\bmr%Zg]b]^gmb_y specific obsmZ\e^l
ZggnZelmn]^gmbgmZd^h_\hk^\Z]k^l!>qab[bm2"'
bgab[bmbg``khpma'

39
Shortened curricula reducing by one year both registered and enrolled nurse programs, were expected to be implemented in 2008.

THE TWIGA INITIATIVE 23

EXHIBIT 9
Intake by cadre Visited intake capacity

1,913 Total intake capacity

675

542

421
388

239 256 257

225
201 188
174
117 117 124 124

47 47

Specialist Medical Dental Assistant Clinical Nurse Pharmacy Laboratory Other

Officer Officer Medical Officer (RN and EN) skills skills
Officer

Once school-specific bottlenecks were identified,
ma^m^ZfZg]bgm^kob^p^^l\hee^\mbo^erZll^ll^]
paZmk^lhnk\^lphne][^g^^]^]mhZee^obZm^ma^f'
Mabl]nZejnZebmZmbo^(jnZgmbmZmbo^ZiikhZ\aa^ei^]
^glnk^maZmp^k^\h`gbs^]Zee^qblmbg`^qiZglbhg
hiihkmngbmb^lZm^Z\abgltitution, and helped fill and
ni]Zte crucial gaps in official records. W^Zf^g]^]
ma^l^mhhell^o^kZembf^lmakhn`ahnmZlarihma^l^l
Zg]]ZmZmk^g]llab_m^]pbmag^pdghpe^]`^'
Filtering and analysis
:_m^km^lmbg`oZkbhnl]h\nf^gmZmbhgm^fieZm^l%ma^
team designed a school-specific ‘l\hk^\Zk]Ìmhk^\hk]
k^e^oZgm]ZmZ%ZgZers^d^r[hmme^g^\dl%Zg]\hlmhnm
ihm^gmbZelhenmbhgl_hk^Z\abglmbmnmbhg'Bg_hkfZmbhg
\hee^\m^]_khfma^JnZgmbmrLnko^rhkZg]ma^=bk^\mhk
h_Iheb\rZg]IeZggbg`Zmma^Fbgblmkr]^m^kfbg^]
ho^kZee\hlmZllnfimbhgl'
Pe considered it vital for all school-specific
k^\hff^g]ZmbhglmhfZbgmZbghkbfikho^\nkk^gm
mkZbgbg`jnZebmr'Ma^k^_hk^%_hkma^_^pl\ahhelmaZm
aZ]k^\^gmer^qiZg]^]pbmahnmZ]cnlmbg`_hkjnZebmr
\hgmkhe%k^\hff^g]Zmbhglp^k^_h\nl^]hgma^bginml
g^\^llZkrmhkZbl^jnZebmrkZma^kmaZgZ\hgmbgn^]
bg\k^Zl^bglmn]^gmbgmZd^'
The top-down perspective
Ma^m^ZfZelh^qiehk^]`ho^kgf^gmi^kli^\mbo^l
hgbfikhobg`Zg]^qiZg]bg`a^Zemaphkd^k
mkZbgbg`gZmbhgZeer'Mablbgoheo^]bgm^kob^pbg`d^r
lmZd^ahe]^klpbmabgma^FbgblmkrZlp^eeZlma^
ma^gFbgblmkrh_Ab`a^k>]n\Zmbhg%L\b^g\^%Zg]
M^\agheh`r'-)FZgy officials were former highly
m^gnk^]\ebgb\Zeikh_^llbhgZelZg]bglmkn\mhklZg]
p^k^\hglmkn\mbo^mahn`am&iZkmg^klbg]bl\nllbg`

40
At the time of our fieldwork, Tanzania had two ministries overseeing education: the Ministry of Higher Education, Science and Technology, and the Ministry
of Education and Culture. Our team interviewed only officials of the former. These ministries have subsequently been combined, into a single Ministry of
Education and Vocational Training

24 ACTION NOW
ma^\aZee^g`^lmaZmhg&ma^&`khng]k^Zebmb^lphne]
ihl^mhab`a&e^o^eiheb\b^lZg]Zf[bmbhnllmkZm^`b^l'
P^nl^]^Zkerf^^mbg`lmhb]^gmb_r^qblmbg`
`ho^kgf^gmZebgbmbZmbo^lk^e^oZgmmha^Zemaphkd_hk\^
mkZbgbg`\ZiZ\bmrZg]mh`Zn`e officials’ vieplhg
ahp[^lmmhbg\k^Zl^mkZbgbg`makhn`ainm'?khf
ma^l^\hgo^klZmbhgl%p^]bl\ho^k^]l^o^kZelrlm^f&
pb]^iheb\rhiihkmngbmb^lmaZt could significantly
lniie^f^gmZgy individual school-specific efformlmh
bg\k^Zl^\ZiZ\bmr'
Ma^l^bgbmbZmbo^lp^k^\hgmbgnhnlerk^fined
makhn`ahnmma^ikhc^\m%nembfZm^erZeehpbg`ma^
m^ZfmhgZkkhphnk_h\nlmhZlfZeegnf[^kh_ab`a&
ihm^gmbZeiheb\rikhihlZel':lma^m^Zf]^o^ehi^]
ma^l^k^\hff^g]Ztions for school-specific and
lrltem-wide efforml%eZm^k\hgo^klZmbhgl[^\Zf^
_hknfl_hkm^lmbg`Zg]k^fining our ideas.
Working together
P^]^]b\Zm^]Zln[lmZgmbZeZfhngmh_mbf^mho^mmbg`
final results with k^rlmZd^ahe]^klbgma^`ho^kgf^gm
Zg]Zmma^bg]bob]nZel\ahhel%nlnZeer]nkbg`k^i^Zm
oblbml'MablZiikhZ\a^glnk^]maZme^Z]^klabiZm[hma
gZmbhgZeZg]eh\Zee^o^elhpg^]Zg][^eb^o^]bgma^
ikhihl^]lhenmbhgl'
BmZelha^ei^]^glnk^maZme^Z]^klp^k^fhmboZm^]
mhmZd^ma^g^\^llZkrlm^ilmhpZk]bfie^f^gmZmbhg%
bg\en]bg`\hg]n\mbg`bgm^kgZeg^`hmbZmbhglmhbg\k^Zl^
li^g]bg`hgbg\k^Zlbg`phkd_hk\^ikh]n\mbhg%
bg\hkihkZmbg`l\ahhehimbfbsZmbhgbgmhgZmbhgZe
lmkZm^`b\ieZgl%Zg]nlbg`ma^k^\hff^g]ZmbhglZg]
Z\mbhgieZglmhl^^d^qm^kgZe_ng]bg`'
The toolkit
MhZllblmma^FbgblmkrbgZll^llbg`ma^k^fZbgbg`
.1l\ahhel%ma^m^Zfik^iZk^]Zl\ahheËmhhedbmÌ%
pab\aikhob]^l]^mZbe^]lm^il_hkln\\^ll_nel\ahhe
oblbml%]ZmZ\hee^\mbhg%Zg]ik^iZkZmbhgh_Z\mbhgZ[e^
^qiZglbhgieZgl'BgZ]]bmbhgmhma^bgm^kob^p`nb]^%
]ZmZk^jn^lm%Zg]l\hk^\Zk]%ma^mhhedbmbg\en]^lZ
\hfie^qlik^Z]la^^m&[Zl^]a^Zemaphkd_hk\^ lniier&
Zg]&]^fZg]fh]^emh^lmbfZm^ma^bfiZ\mh_hnk
ln``^lmbhglhgmkZbgbg`makhn`ainmm^gr^Zklbgmhma^
_nmnk^%Zlp^eeZl\Ze\neZm^ma^hg^&mbf^Zg]hg`hbg`
hi^kZmbg`\hlmlh_bfie^f^gmZmbhg'
:\\hfiZgrbg`mableZk`^klniier&Zg]&]^fZg]fh]^e
blZlbfie^kbglmbmnmbhg&e^o^e\hlmfh]^e%pab\a
^gZ[e^l^ZlrZg]\hglblm^gm\hlmikhc^\mbhglh_Zee
possible school-specific intero^gmbhgl'Ma^mhhedbmZelh
bg\en]^lZ]^mZbe^]nl^k`nb]^_hk^Z\a\hfihg^gm
eblm^]Z[ho^'
A replicable process
Ma^ikho^gZ]ZimZ[bebmy of these tools in the field
bg]b\Zm^lmaZmma^rZk^Ziieb\Z[e^Zg]k^ieb\Z[e^bg
hma^kl^mmbg`l'Mablho^kZeef^mah]heh`r^glnk^l
Z\hfik^a^glbo^i^kli^\mbo^`khng]^]bgeh\Zeer
`Zma^k^]_Z\mlZ\khllma^\hngmkr%Zg]bmlk^eZmbo^
lbfieb\bmrfZd^lbm^Zlber^qihkmZ[e^mhhma^kgZmbhgl
_Z\bg`lbfbeZk\aZee^g`^l'
:nl^_neg^qmlm^iphne][^mh]^o^ehima^mhhedbm
_nkma^kbgmhZghgebg^&[Zl^]fh]^e\hfie^m^pbma
bginml[Zl^]hg\Zk^iZmapZrl%\ebgb\Ze`nb]^ebg^l%
Zg]ma^bkanfZgk^lhnk\^k^jnbk^f^gml%Zlp^eeZl
ihineZmbhg]^fh`kZiab\l%^m\'%mhfZd^ma^fh]^e
mknerZiieb\Z[e^mhhma^k\hngmkb^l^qi^kb^g\bg`a^Zema
phkd_hk\^lahkmZ`^l'
Bn the meantime, the school-specific damZ\hee^\mbhg
aZla^ei^]ma^Fbgblmkr`ZbgZ\\^llmheh\Ze
bg_hkfZmbhgmaZmpbeebg_hkf_nmnk^iheb\rbgbmbZmbo^l
Zg]linkhma^ka^Zemaphkd_hk\^bgm^ko^gmbhgl'
Ma^ZgZermb\Zefh]^e%l\ahhemhhedbm%Zg]phkdbg`
k^eZmbhglabil[nbemZmma^eh\ZeZg]gZmbhgZee^o^elpbee
_Z\bebmZm^ma^mkZgl_^kh_bfie^f^gmZmbhgfZgZ`^f^gm
mhma^\hngmkrÌla^Zemae^Z]^klabiZg]^gZ[e^ma^fmh
\hg]n\mln\ak^ob^plbgma^_nmnk^'
THE TWIGA INITIATIVE 25
 Iheb\r&e^o^ebfikho^f^gmlmhbg\k^Zl^_Z\nemr
k^lhnk\^lZg]lahkm^gmkZbgbg`mbf^l_hk\^kmZbg
\Z]k^l\Zg^qiZg]\ZiZ\bmrr^m_nkma^k%Zg]ma^
Z]]bmbhgh_g^pmkZbgbg`ikh`kZfle^o^kZ`bg`^qblmbg`
k^lhnk\^lZm\^kmZbgl\ahhel\Zg\hgmkb[nm^Zg
Z]]bmbhgZe,)mh,.i^k\^gmbg\k^Zl^%k^lnembg`bgZg
ho^kZee]hn[ebg`h_lmn]^gmbgmZd^'

Findings
Ho^kZee%hnkm^Zf_hng]maZmZaZg]_neh_ikbfZkr
\hglmkZbgmlZk^abg]^kbg`ma^`khpmah_ma^MZgsZgbZg
a^Zemaphkd^kmkZbgbg`g^mphkd'Ma^l^\hglmkZbgml
hi^kZm^Zt both school-specific and sysm^f&pb]^
e^o^elZg]\^gm^khgebfbm^]_Z\nemr%bg_kZlmkn\mnk^%
applicant, and financial resources. W^ma^g]^lb`g^]
Zl^mh_ab`a&ikbhkbmrbgm^ko^gmbhglmhmZk`^mma^l^
\hglmkZbgml'
>o^glh%ma^Zgmb\biZm^]bg\k^Zl^bgma^a^Zema
workforce will be insufficient to meem^bma^kma^
`ho^kgf^gmh_MZgsZgbZÌl_Z\bebmrltaffing ghZel%hkma^
bgm^kgZmbhgZe`nb]^ebg^l_hka^Zemaphkd^k]^glbmr'
;kb]`bg`ma^k^fZbgbg`a^Zemaphkd^k`Zipbee
k^jnbk^bgghoZmbo^ZiikhZ\a^lmhanfZgk^lhnk\^
fZgZ`^f^gm%Zlp^eeZlmkZgl_hkfZmbhgZeZiikhZ\a^l
mha^Zemaphkd^kmkZbgbg`Zg]hi^kZmbhgZelmkZm^`b^lmh
Z]]k^llZmmkbmbhg'F^]bnf&Zg]ehg`&m^kfbgbmbZmbo^l
pbeeg^^]mhZ]]k^llma^jn^lmbhgh_Z]]bg`g^p
l\ahhelZg]nl^ma^himbfZea^Zemaphkd^kirkZfb]mh
l^mikbhkbmb^l_hk\Z]k^]^o^ehif^gm'

While the specific consmkZbgmlÇZg]k^\hff^g]^]

bgm^ko^gmbhglÇoZkr_khfl\ahhemhl\ahhe%_hkma^
lrlm^fZlZpahe^%mabll^mh_bgbmbZmbo^l_hkhimbfbsbg`
ma^^qblmbg`mkZbgbg`g^mphkdikhob]^lma^fhlm
ikhfblbg`g^Zk&m^kfZo^gn^mhZ\ab^obg`]kZfZmb\
^qiZglbhgh_ma^a^Zemaphkd_hk\^'
Six major constraints
Makhn`ahnk]^tailed field interob^plZg]]ZmZ
k^jn^lts, we identified six main limitambhglmhl\Zebg`
nia^Zemaphkd^kmkZbgbg`\ZiZ\bmrbgMZgsZgbZ%
affecmbg`[hmagZtional and local efforml'

Ln\ahimbfbsZmbhgZehg^\Zgk^lnembgZ/.mh0) 1. Students: <aZee^g`es include lack of qualified

i^k\^gmbg\k^Zl^bgbgmZd^Z\khll^qblmbg`l\ahhel' lniier%lmn]^gm_^^lmkn\mnk^l%eZ\dh_lmn]^gm

FACULTY SHORTAGE AS AN IMPEDIMENT TO GROWTH

The Sengerema Clinical Officer Training Centre (COTC) is a faith-based institution that currently trains 177 CO students in a three-year
program. The school uses the neighboring Geita District Hospital for clinical training and conducts fieldwork at health centres and
dispensaries throughout the region. As a result, faculty members are constantly away from the school, making it difficult for it to have
more than one or two classes per semester.
Sengerema COTC is currently expanding dormitory and classroom infrastructure with financial aid from CORDAID, a Dutch
development assistance agency. Although these improvements should help expand the school’s capacity, the already over-stretched
faculty cannot handle a student-body increase.
Hiring three additional full-time faculty would fill the current teaching gap and allow Sengerema COTC to grow in capacity by
approximately 35 percent. By investing $6,000 up front and $24,000 per year in faculty salaries, Sengerema COTC could overcome
this one remaining impediment to optimizing capacity, creating 63 places and, within three years, enabling another 30 to 40
dispensaries in Tanzania to be staffed with a qualified health worker.

26 ACTION NOW
 financing arrZg`^f^gml%Zg]ik^&Zg]ihlm&
`kZ]nZmbhgZmmkbmbhg'
2. Non-clinical faculty: Ma^k^blZg^ghkfhnl_Z\nemr
`ZibgMZgsZgbZ'Ma^mkZbgbg`lrlm^f]h^l
ghmikhob]^\hfi^mbmbo^bg\^gmbo^lÇlZeZkb^l%
ieZ\^f^gm%lniihkm%ikh_^llbhgZe`khpma%hkch[
lZmbl_Z\mbhgÇZg]a^Zema\Zk^`kZ]nZm^lZk^h_m^g
ehlmmh^fb`kZmbhgZg]fhk^en\kZmbo^^fiehrf^gm
pbmaNGOlhkbgghg&a^Zema&k^eZted fields.
3. Clinical faculty: Mhere is also a significant gap in
\ebgb\Ze_Z\nemrbgMZgsZgbZ'Phkl^%pbma\ebgb\Ze
khng]lZlma^bkikbfZkrk^lihglb[bebmrZg]pbma
lrlm^fb\]blbg\^gmbo^l!lbfbeZkmhmahl^h_ghg&
\ebgb\Zeltaff "%\ebgb\Ze_Z\nemrZg]ltaff ofm^g
k^`Zk]\ebgb\Zem^Z\abg`k^lihglb[bebmb^lZlZ
[nk]^g'
4. Non-clinical infrastructure: Ma^fhlmikhfbg^gm
bg_kZlmkn\mnk^\aZee^g`e we identified is
the need for more housing, either on or off-
\Zfinl%_heehp^]\ehl^er[reZ\dh_\eZllkhhfl%
eZ[hkZmhkb^l%^jnbif^gm%Zg]mkZglihkmZmbhg'
5. Clinical infrastructure: FZgrh_ma^lfZee^ka^Zema
\Zk^_Z\bebmb^leZ\d^bma^kma^iZmb^gmohenf^hk
iarlb\ZeliZ\^mhZ\\hffh]Zm^ZeZk`^kgnf[^k
h_lmn]^gml%Zllnfbg`ZiikhikbZm^_Z\nemr\Zg[^
_hng]hk\k^Zm^]'
6. Financial resources: FZgrbg]bob]nZel\ahheleZ\d
control over the amount and flow of resources,
\k^Zting difficnemb^lbgieZggbg`_hk_nmnk^
fZbgm^gZg\^Zg]^qiZglbhg'
=nkbg`ma^]ZmZ\hee^\mbhgikh\^ll%p^]bl\ho^k^]maZm
^Z\abgltitution suffers from a unique combinambhg
h_ma^l^h[lmZ\e^l%k^g]^kbg`bmbfihllb[e^mh\k^Zm^

EXHIBIT 10
A sample action plan

Context Year
Year 0 0 Year
Year 1 1 Year
Year 2 2 Year
Year 3 3 Year
Year 4 4 Year
Year 5 5
Description: KCMC is one of the country’s
Total one-time costs ($ thousands) 3100
3100
largest facilities, combining a private
 Purchase buses for clinical rotations 100
100
university (Tumaini) with 7 programs and  Seed capital for loans 3000 Upfront activities
16 programs at the government allied and investments
health school
Description of institution
Total recurring costs ($ thousands) 624
624 985 1363
1363 1707 2068
2068
Key bottlenecks and constraints to program for MO students
 Launch grant 361 722 1100 1444 1805
increasing
Students – Significantly under capacity capacity
 Expand clinical rotations in nearby hospitals
due to successful applicants’ inability – Hire 20 new teachers in nearby hospitals 216 216 216 216 216
– Develop transportation program to facilitate 47 47 47 47 47
to pay (109 students below capacity clinical rotation
now)  Expand loan offer to other programs 398 1157 1916 2657 2657
Non-clinical infrastructure – Would Incremental ongoing
need more dorms/classrooms, but
activities and costs
currently in process of $2m expansion
Clinical faculty – Number of specialists
limits numbers for higher level Total operational costs for
programs, particularly MDs incremental students
 Already covered in loan/grant program above
Overall impact on
Other activities
Total students number of students
Fill unoccupied post-graduate spots
 Complete existing classroom/lab expansion
at school
((already funded by the university) Total students to send
1,400 With to school each year
1,200 Debottlenecking
1,000 Total student intake, by cadre 188 290 290 290 290 290
800  Specialist 22 35 35 35 35 35
600  MO 90 120 120 120 120 120
400
Without  RN 31 50 50 50 50 50
Debottlenecking  Lab skills Change in 27 49 49 49 49 49
200  Other 18 36 36 36 36 36
0 total students
07 08 09 10 11 12 13 14 652 1,129
Year

THE TWIGA INITIATIVE 27


ADDING SCHOOLS AT EXISTING
TRAINING COMPLEXES
Case Example: Mbeya Medical Training Center
Adjacent to one of Tanzania’s four tertiary hospitals, the
Mbeya medical training center has fewer programs and
students than other schools with similar clinical capacity. The
complex currently houses an Assistant Medical Officer school,
a school of dental therapy, and a specialized nursing program
in Operating Theater Management.
With the vast clinical opportunities provided by the Mbeya
Referral Hospital, hospital and academic leadership reported
that the facility is well equipped to offer additional programs
for laboratory technicians, pharmacy technicians, registered
nurses, and clinical officers. Adding new training programs
would allow the training center to expand into a robust
Institute of Allied Health Sciences.
Dental therapists and clinical officers share the same
curriculum for the first year and a half of study, meaning that
students from both programs could be taught simultaneously
with minimal or no additional investment in faculty or
classroom infrastructure. Taking advantage of such synergies
will maximize limited resources in the training system and
result in a greater return on investment for optimizing
Tanzania’s training network.
[eZgd^miheb\b^lmaZt address them sufficiently'Bg
k^lihgl^%p^^fiaZlbs^ma^g^^]mhmZ\de^ma^l^
specific needs on a school-by-school basis, supporm^]
[rma^bfie^f^gmZmbhgh_Fbgblmkr&e^]%lrlm^f&pb]^
^gZ[e^kl'
@bo^gmablg^^]_hkbgltitution-specific intero^gmbhgl%
our final recommendambhglbg\en]^]Z\mbhgieZgl
_hk^Z\al\ahheoblbm^]%\hfie^te with final cosmbg`
Zg]lmn]^gmhnminm^lmbfZm^l[Zl^]hgma^m^g&r^Zk
mbf^ebg^l^m_hkf^^mbg`ma^MMAMmZk`^ml'Ma^l^
]^mZbe^]ieZglikhob]^[hmama^`ho^kgf^gmZg]ma^
l\ahhepbmaZ\hg\bl^]h\nf^gmmaZmebgdll\ahhe&
specific ino^lmf^gmlpbmaik^\bl^bg\k^Zl^lbgmkZbgbg`
hnminm!>qab[bm*)"'
41
Costs were determined through interviews with individual school principals, data collected from the principal Quantity Surveyor at the Ministry, and the
Touch Foundation’s experience overseeing school expansion projects at Bugando’s university.
28 ACTION NOW
Doubling training capacity
Ma^]ZmZ`Zthered in the field shows tham%makhn`aZg
Zf[bmbhnlr^mikZ\mb\ZeZ\mbhgieZg\hf[bgbg`lrlm^f&
wide and school-specific improvements, TZgsZgbZ\Zg
g^Zker]hn[e^ma^bgmZd^h_ma^mkZbgbg`g^mphkd'
=hbg`lhpbeek^jnbk^bfie^f^gmZmbhgh_\hg]^gl^]
\nkkb\neZ_hkgnkl^lZg]COl%Zek^Z]rng]^k]^o^ehif^gm
[rma^Fbgblmkr%Zlp^eeZlhma^klrlm^f&pb]^iheb\r
\aZg`^lmhikhob]^lmn]^gmahnlbg`Zg]bg\k^Zl^
m^Z\a^klniier'Ma^l^iheb\b^lpbee^gZ[e^l\ahhelmh
fZqbfbs^makhn`ainmbgma^bk^qblmbg`ikh`kZflZg]
mhZ]]g^pikh`kZflpa^k^ZiikhikbZm^'Ln\alrlm^f
himbfbsZmbhgpbeebg\k^Zl^lmn]^gmbgmZd^mhho^k0%.))
i^kr^Zkpbmani_khgm\hlmlh_khn`aer.)fbeebhgZg]
hg`hbg`ZggnZe\hlmlh_Zkhng]*)fbeebhg'-*
MhZ\ab^o^ma^_neeihm^gmbZebfiZ\mh_l\ahhe^qiZglbhg%
ma^FbgblmkrZg]bmliZkmg^klfnlm\hfie^m^ma^
ZgZerlblZg]]^obl^Z\mbhgieZgl_hkma^k^fZbgbg`.1
l\ahhelghmZll^ll^]bgmabliaZl^h_ma^]bZ`ghlmb\'
School-specific action plans
=^libm^^Z\al\ahheÌlngbjn^l^mh_\bk\nflmZg\^l%
fhlt schools fit into one of four tri^l3Z\Z]^fb\
f^]b\Ze\^gm^kl!ngbo^klbmb^lpbmaFedical Officer
!MO)Zg]ihlm&`kZ]nZm^ikh`kZfl"%eZk`^mkZbgbg`
\hfie^q^l!fnembie^&\Z]k^ikh`kZfl"%lfZeeikboZm^hk
_Zbma&[Zl^]l\ahhel%Zg]lfZeein[eb\l\ahhel!hg^&hk
mph&\Z]k^ikh`kZfl"'
L\ahhelpbmabg^Z\amri^h_m^glaZk^\hffhg
\hglmkZbgml'B]^gmb_rbg`ma^l^ma^f^lZeehp^]nl
mh^qmkZiheZte our findings to the other 58 health
mkZbgbg`l\ahhelZg]manlmhfh]^ema^ho^kZeebfiZ\m
h_lrltem-wide and school-specific efforml'
Academic medical centers
:\Z]^fb\f^]b\Ze\^gm^kl!AMCl"%pab\abg\en]^Z
ngbo^klbmy and affiliam^]m^Z\abg`ahlibmZe%m^g]mheZ\d
ma^fZgZ`^kbZeZg]Z]fbgblmkZmbo^fZgihp^kg^^]^]
mhhi^kZm^ln\aeZk`^%\hfie^qbglmbmnmbhgl'
Ikh_^llhklZg]]^iZkmf^gma^Z]lZmma^Fnabf[beb
Ngbo^klbmrh_A^ZemaZg]:eeb^]L\b^g\^l!Fnabf[beb"
Zg];n`Zg]hngbo^klbmb^l%_hk^qZfie^%eZ\d
Z]fbgblmkZmbo^lniihkmZg]li^g]ik^\bhnlmbf^
k^\hk]bg``kZ]^lZg]mribg`lreeZ[bkZma^kmaZg
ik^iZkbg`_hke^\mnk^lhkf^^mbg`pbmalmn]^gml'
<ebgb\Ze_Z\nemrf^f[^klZk^Zelhlmk^m\a^]ZmeZk`^
AMCl%mhkg[^mp^^gma^an`^]^fZg]_hkmk^Zmf^gmbg
ma^bkli^\bZemb^lZg]ma^bkmkZbgbg`k^lihglb[bebmb^l'
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:meZk`^mkZbgbg`\hfie^q^l%lmn]^gmZg]_Z\nemr
Z\\hffh]ZmbhglZk^h_m^gma^fhlt significant
[hmme^g^\d'Lmn]^gmlZk^ahnl^]^gmbk^erhg\Zfinl
and no additional space or off-campus housing
blZoZbeZ[e^'Mablblfhlmghmb\^Z[e^Zmma^mak^^
bgm^`kZm^]ikh`kZflbgF[^rZÇAMO%=^gmZeMa^kZir%
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additional dormitories or off-campus housing would
k^lnembff^]bZtely in a fifmri^k\^gmbg\k^Zl^bg
lmn]^gmbgmZd^'
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Z\\hffh]Zm^Z]]bmbhgZeikh`kZfl%ln\aZlZCOl\ahhe
maZm\hne]ib``r[Z\dhgma^AMOikh`kZf':mfhlm
eZk`^mkZbgbg`\hfie^q^l%\nkk^gmltaffing is sufficient
mhaZg]e^mablg^Zk&m^kfbg\k^Zl^'Ma^hg^`eZkbg`
^q\^imbhgblma^FonfbmkZbgbg`\hfie^q%pa^k^
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mhlniihkmma^^qblmbg`EZ[hkZmhkr:llblmZgmikh`kZf'
Small private institutions
FhmboZm^][rmb`amZg]bg_k^jn^gm_ng]bg`%lfZee
ikboZm^bglmbmnmbhglm^g]mh[^ma^fhlt efficiently
kng_Z\bebmb^l'Ma^l^l\ahhelaZo^ZlfZeegnf[^k
h_i^kfZg^gm%]^]b\Zm^]_Z\nemrf^f[^klZek^Z]r
lmk^m\a^]mhma^bkebfbmlmhZ\\hffh]Zm^ma^lmn]^gml'
:]]bg`lmn]^gmlphne]bgfhlm\Zl^lk^jnbk^
Z]]bmbhgZeiZkm&mbf^hk_nee&mbf^ltaff%Zlp^eeZlg^p
]hkfbmhkb^lZg]\eZllkhhfl'
Lbg\^fhlmikboZm^l\ahhelmn]^gmlZk^ghm^eb`b[e^
_hk`ho^kgf^gm\hlm&laZkbg`l\a^f^lhkehZgl%ma^l^
bglmbmnmbhglh\\ZlbhgZeerZeehplmn]^gmlmhk^fZbg
pbmahnmiZying full fees or are unable to fill all
ZoZbeZ[e^lihml%[hmah_pab\a]^ie^m^l\ahhe[n]`^ml'
Small public schools
Ebd^lfZeeikboZte schools, small public schools suffer
_khfho^klmk^m\a^]_Z\nemrZg]bg_kZlmkn\mnk^'
<hgl^jn^gmer%bgo^lmf^gmlbganfZgk^lhnk\^l%
\eZllkhhfl%m^Z\abg`fZm^kbZel%Zg]]hkfbmhkb^lZk^
g^\^llZkrmhl\Ze^nimkZbgbg`\ZiZ\bmr':aZg]_neh_
lfZeein[eb\bglmbmnmbhglaZo^^q\^ll\ZiZ\bmrk^lnembg`
_khfZeZ\dh_bgm^k^lm^]Ziieb\Zgmlhk[^\Znl^ma^r
Zk^mkZglbmbhgbg`_khfhg^mri^h_mkZbgbg`ikh`kZf
mhZghma^k'
?hk^qZfie^%ma^FnlhfZCOMkZbgbg`<^gmk^!COTC"
k^\^gmerlpbm\a^]_khfbg&l^kob\^mhik^&l^kob\^
mkZbgbg`%[nmbgCZgnZkr+))1bmaZ]ghmr^mk^\^bo^]
the 2007 incoming class. Due to the difficnemrh_
\^gmkZeermkZ\dbg`k^`bhgZeieZ\^f^gmlZg]bkk^`neZk
\hffngb\Zmbhg[^mp^^gl\ahheltaff and gho^kgf^gm
officials, the MnlhfZCOTCÌlikbg\biZeaZ]ghb]^Z
pa^gabllmn]^gmlphne]Zkkbo^'
Pabe^ma^l^\hffhgma^f^la^ei^]nlfZqbfbs^
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bg_hkfiheb\rk^\hff^g]Zmbhgl%ma^oZkb^]
lbmnZmbhglbgL^g`^k^fZZg]Fonfb^fiaZlbs^ma^
continued need for the school-specific acmbhgieZgl'
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impedes efficiencrbgma^^qblmbg`lrlm^f'Pabe^Z
lmkZm^`rmhZ]]k^llmablblnk`^gmerg^^]^]%p^_^em
bm[^rhg]ma^bgbmbZel\hi^h_mablphkd'
Bgma^f^Zgmbf^%[r_h\nlbg`Zmma^]^mZbe^]e^o^e%
\e^ZklmkZm^`b\iheb\riZkZf^m^klbgma^mkZbgbg`Zk^Z
can also be addressed. Such school-specific, grZllkhhml
ieZgl\Zg^gZ[e^significant ikh`k^llmhpZk]bg\k^Zl^]
mkZbgbg`\ZiZ\bmr!>qab[bm**"'-+
THE TWIGA INITIATIVE 29
EXHIBIT 11 :]]bmbhgZeer, because official staffing requirements
Doubling output \Zgik^o^gmma^Fbgblmkr_khfhi^gbg`g^pa^Zema
\Zk^_Z\bebmb^l[^_hk^ma^r\Zg[^_neerltaffed, it mar[^
School-specific System-wide nl^_nemh]^obl^bgm^kbfltaffing guidelines to permit
optimization improvements
80-85% 15-20% g^p_Z\bebmb^lmhhi^gikhoblbhgZeerpbmaZk^]n\^]
ltaff'Mablphne]^gZ[e^MZgsZgbZmhfZqbfbs^ma^
600-620 7000-8000 gnf[^kh_g^p]bli^glZkb^lZg]bg\k^Zl^Z\\^llmh
700-800 630
2000-2300 a^Zema\Zk^Z\khllma^\hngmkr%`kZ]nZeerbg\k^Zlbg`
ltaffing am^Z\a_Z\bebmrZlma^lniierh_ldbee^]a^Zema
3500-4000 phkd^kl`khpl'

New programs
School-specific in existing Curriculum
optimization complexes changes
2009/2010
output (est.)
New cadres and curricula
Bgk^lihgl^mhma^l^\aZee^g`^l%ma^FbgblmkraZl
eZng\a^]g^pbgbmbZmbo^lmaZmpbeebg\k^Zl^a^Zema
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Mpb`Zikh`kZf'
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:llblmZgml!CAl)%nlbg`Z\hg]^gl^]CO\nkkb\nenf
\hglblmbg`h_hg^r^Zkli^gmbgma^\eZllkhhfZg]Z
second year spent in field internships. Ta^Fbgblmkr
]^lb`g^]mabl\Z]k^mh[^ma^e^Z]bg`\Zk^ikhob]^k
Zmma^]bli^glZkre^o^e%kZgdbg`Z[ho^ma^mphgnkl^l
Zg]hg^eZ[hkZmhkrm^\agb\bZgZelhk^jnbk^]Zm^Z\a
g^p_Z\bebmr'
Ma^l^\hg]blZk^obl^]%fh]neZkbs^]%Zg]
lahkm^g^]gnklbg`\nkkb\nenfmaZmpbeek^]n\^
ma^>gkhee^]Gnkl^!EN)mkZbgbg`_khfmak^^r^Zkl
mhmph%Zg]K^`blm^k^]Gnkl^!RN) mkZbgbg`_khf
_hnkr^Zklmhmak^^'Ma^g^p\nkkb\nenfpZl
bfie^f^gm^]gZmbhgZeerpbmama^+))1bgmZd^'Hg\^
bfie^f^gmZmbhgbl\hfie^m^%ma^\hf[bg^]bfiZ\m
pbee[^Z+.mh,.i^k\^gmbg\k^Zl^bgZggnZebgmZd^'
Ma^l^mphbgbmbZmbo^lZk^\kn\bZemhkZib]erbg\k^Zlbg`
ma^gnf[^kh__khgmebg^phkd^klZoZbeZ[e^mhltaff
ma^g^p]bli^glZkb^lieZgg^]bgma^MMAM'Ma^rpbee
a^ei[khZ]^gZ\\^llmha^Zema\Zk^Z\khllma^\hngmkr
Expanded
output Zg]%Zehg`pbmama^bgm^kbfltaffing requirements,
fZqbfbs^ma^gnf[^kh_g^p_Z\bebmb^lmaZm\Zg[^
\hglmkn\m^]%ltaffed, and opened in the near term.
System-wide policy shifts to enable growth
G^mphkdhimbfbsZmbhgZelh]^i^g]lhg`ho^kgf^gm&
e^]lrlm^f&pb]^bgbmbZmbo^l'Makhn`a\hgo^klZmbhglZm
ma^FbgblmkrZg]bg\hf[bgZmbhgpbma]ZmZZg]mahn`aml
_khfManzanians in the field, the team deo^ehi^]
l^o^kZeiheb\rhiihkmngbmb^lmhZ]]k^llfZchk
\hglmkZbgmlZg]lniie^f^gmma^phkd[^bg`]hg^Zm
ma^eh\Zee^o^e'Mhe team identified four immediam^er
bfie^f^gmZ[e^lrlm^f&pb]^\aZg`^l'
*' >g\hnkZ`e and subsidize off-campus housing.
+' MkZglbmbhg_khfhim&bg\hgmkZ\mnZe^fiehrf^gm
_hkk^mbk^^l!^ll^gmbZeerfZg]Zmhkrk^mbk^f^gm
pbmaZ\nf[^klhf^Zii^Zelikh\^ll"mhhim&hnm
ZnmhfZmb\k^abkbg`'
,' Ikhob]^_nee_ng]bg`_hkln\\^ll_neMD lmn]^gml
mh\hfie^m^fZlm^klikh`kZflbg^q\aZg`^_hkZ
\hffbmf^gmmhm^Z\a'
-' KZbl^\hlml_hk_hk^b`glmn]^gml%^li^\bZeerZm
gnklbg`Zg]COl\ahhelpbmaab`a^klaZk^lh_
_hk^b`glmn]^gml'

42
Source: 2008 Twiga model (see note 17); team analysis.

30 ACTION NOW
EXHIBIT 12 EXHIBIT 13
A better balance Opportunities in improving retention
Percent of highly
skilled workers
Number of health workers
increases from 11%
in 2009 to 15%
in 2019

40,800

40,800 63,500
63,500 Training 52,000
11%
output
Highly skilled
2009-2019
Voluntary 8,000 –
nearly 20%
48,000
25,400
48,000
Health
Health Optimized Attrition Health workforce 25,400
workforce training 2009-2019 workforce 2009
2009 output 2019
2009-2019
Potential 2019 Attrition Health
workforce 2009-2019 workforce 2019
88,900 52,000

B_bfie^f^gmZmbhgh_[hmalrlm^f&pb]^Zg]l\ahhe&
specific initiambo^l[^`bgl[reZm^+)**%ZggnZebgmZd^
pbee^q\^^]0%/))[r+)*.%g^Zker]hn[ebg`\nkk^gm
bgmZd^gnf[^kl';r+)*2mabl^qiZg]^]mkZbgbg`
g^mphkd%bg\en]bg`g^pikh`kZfl%pbeeZ]]ZlfZgr
Zl++%/))g^pa^Zemaphkd^klmhma^lrlm^f'-,
Zmmkbmbhgbg\en]^lphkd^klpah\ahhl^mhe^Zo^ma^bk
ihlmlmhmZd^in[eb\a^ZemaihlbmbhglpbmaNGOlbg
MZgsZgbZ%pah]^\b]^mhphkdbga^Zema\Zk^hnmlb]^
h_MZgsZgbZ%hkpahe^Zve the health care field
Zemh`^ma^k'BgohengmZkrZmmkbmbhgbg\en]^l]^Zmabg
l^kob\^%k^mbk^f^gm%Zg]Ziikho^]Z[l^g\^_hk_nkma^k
^]n\Zmbhg'

Reducing attrition Pe found in our field research thamohengmZkr\Znl^l

:mma^ik^l^gmkZm^lh_ik^&l^kob\^Zg]bg&l^kob\^
Zmmkbmbhg%g^Zkerlbqmri^k\^gmh_bg\k^Zl^]makhn`ainm
pbee[^lhZded up by filling slots vZ\Zm^]makhn`a
Zmmkbmbhg'>o^glh%ma^phkd_hk\^phne]]hn[e^ho^k
m^gr^ZklZg]ma^ho^kZeeldbeee^o^eh_ma^a^Zema
phkd_hk\^phne]bg\k^Zl^!>qab[bm*+"'
account for over one-fifmah_ma^ZggnZephkd_hk\^ehll
Çb'^'%^b`ammahnlZg]h_ma^w-2%)))phkd^kl^qi^\m^]
mh[^ehlm[^mp^^g+))2Zg]+)*2'<nmmbg`ma^
ohengmZkrZmmkbmbhgkZm^bgaZe_phne]k^]n\^maZm
gnf[^kmh_hnkmahnlZg]%bg\k^Zlbg`ma^phkd_hk\^bg
+)*2[rZefhlmm^gi^k\^gmmh.+%)))!>qab[bm*,"'--

Ho^kZeeehll_khfma^phkd_hk\^blZ\hf[bgZmbhg Ahp^o^k%b_ho^kZeeZmmkbmbhgkZm^l\hne][^aZeo^]
h_ohengmZkrZg]bgohengmZkrZmmkbmbhg'OhengmZkr Çghmhgermakhn`a\nk[bg`ohengmZkrZmmkbmbhg[nm

43
Presumes average attrition of approximately five percent of graduates before entering into service (includes emigration and non-clinical work) and annual
workforce loss through attrition, death, and retirement of approximately thirteen percent across all cadres.
44
Source: Ministry of Health Interviews; 2008 Twiga model (see note 17). Calculations based on halving both pre- and in-service attrition due to emigration
and non-clinical work, without altering rates of annual workforce loss due to leave for upgrading coursework, death in service and retirement, across all
cadres.

THE TWIGA INITIATIVE 31

[rik^o^gmbg`]^Zma&bg&l^kob\^makhn`abfikho^]
^fiehr^^a^Zema\Zk^Zg]bg_^\mbhg\hgmkhe%kZblbg`
ma^k^mbk^f^gmZ`^_khf..mh/)%Zg]bgbmbZmbg`hg&
lbm^bg&l^kob\^ni`kZ]bg`\hnkl^lÇ]hn[ebg`bgmZd^
\hne]k^lnembgZmkbiebg`h_ma^phkd_hk\^'
Further systemic opportunities
BgZ]]bmbhgmhma^_hnkd^rlrlm^f&pb]^^gZ[ebg`
bgbmbZmbo^lZg]bfikho^]k^m^gmbhg%p^ghm^]Z
gnf[^kh_ikhfblbg`bgbmbZmbo^lmaZm\hne]_nkma^k
lmk^g`ma^gma^a^Zemaphkd_hk\^bgMZgsZgbZ'FZgr
h_ma^l^b]^Zlhkb`bgZm^]pbmaikbg\biZelZmma^
oblbm^]l\ahhel%Fbgblmky officials, case eqZfie^l
_khflbfbeZker\aZee^g`^]ln[&LZaZkZg\hngmkb^l%hk
makhn`aZgZerlblZg]k^l^Zk\a'
Pabe^fhlmh_ma^l^b]^Zlmhn\ahgmkZbgbg`%ma^r
h_m^gmZk`^mhma^kiaZl^lh_ma^a^Zemaphkd^k
fZgZ`^f^gm\r\e^%_khfk^\knbmf^gmZg]ieZ\^f^gm
mhikh]n\mbobmr%ikhfhmbhg%Zg]k^m^gmbhg'
Optimize student selection and allocation
>gkheebg`lmn]^gmlZml\ahhelbgma^bkahf^k^`bhgl
pa^g^o^kihllb[e^%iZkmb\neZkerbgCOZg]^jnboZe^gm
\Z]k^l%Zg]bgltituting confirmambhg]^Z]ebg^l
_hklmn]^gmlmh\eZbfma^bklihmlZml\ahhelphne]
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32 ACTION NOW
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A^Zema^]n\Ztors are classified and compensam^]
Z\\hk]bg`mhma^bk\ebgb\ZeikZ\mbmbhg^klmZmnl%fZdbg`
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:]]bmbhgZeer%Zlma^EZd^Shg^]bZ`ghlmb\m^Zf
]^m^kfbg^]%Zemahn`afZgrknkZehkk^`bhgZe
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fZgZ`^f^gm\ZiZ\bmrÇ\hf[bg^]pbmaZ\\hngmZ[bebmr
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pbmabg\^gmbo^lln\aZl_k^^Z\\hffh]Zmbhg!pbma
hpg^klabio^lmbg`Z_ter five years of serob\^"Zg]
`nZkZgm^^]^]n\ZmbhgZeehpZg\^l_hkma^bk\abe]k^g'
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A^Zemaphkd^klpblabg`mh\aZg`^ihlmlfnlm
k^lb`g_khfma^bkihlbmbhglmakhn`ama^\^gmkZe
a^ZemafbgblmkrZg]ma^gk^Ziier':s with financial
bg\^gmbo^l%lbfieb_rbg`ma^ikh\^llh_khmZmbhg[^mp^^g
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[hhlmfhkZe^%ikh]n\mbobmr%Zg]k^m^gmbhg%Zlp^eeZl
bg\^gmbobs^bg\k^Zl^]bgm^k^lmbgma^a^Zemaphkd^k
mkZbgbg`lrlm^fZ_m^k`kZ]nZmbhg'
Develop a performance management system
Pa^g\hfi^glZmbhgZg]ikhfhmbhgk^flecm
lmZg]Zk]bs^]Z\ab^o^f^gm&[Zl^]f^mkb\l%bmbl^Zlb^k
mhnl^mahl^mhhelZlbg\^gmbo^lmhbfikho^ltaff
ikh]n\mbobmrZg]i^kformance. Specific memkb\l%
ln\aZlma^i^k\^gmZ`^h_lmn]^gmlln\\^^]bg`hg
lmZg]Zk]bs^]^qZfl%\hne]^g\hnkZ`^ab`a&jnZebmr
m^Z\abg`'
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i^k_hkfZg\^\Zgl^ko^ZlZihp^k_nemhhemh[hhlm
k^m^gmbhgZg]fhkZe^'LbfbeZker%ikhfhmbhgl[Zl^]
hgl^kob\^Zg]ma^jnZebmrh_k^l^Zk\a\hg]n\m^]%
kZma^kmaZghglmZg]Zk]lln\aZlgnf[^kh_in[ebla^]
Zkmb\e^l%a^eimh\k^Zm^bg\^gmbo^lmZk`^mbg`bfikho^]
ikh]n\mbobmrZg]\hffbmf^gm'

Ihlml^e^\mbhgaZlmkZ]bmbhgZeer[^^g\^gmkZebs^]%[Zl^]
ikbfZkberhggZmbhgZeg^^]kZma^kmaZgZiieb\Zgm
ik^_^k^g\^'Ma^FbgblmkraZl[^`ngmhmkZglbmbhgmh
]blmkb\m&[Zl^]k^\knbmf^gmZg]]^iehrf^gmpab\a%b_
[Zl^]bgiZkmhgma^`^h`kZiab\hkb`bglZg]i^klhgZe
ik^_^k^g\^lh_`kZ]nZm^l%phne]bfikho^ma^bk
ebd^ebahh]h_k^ihkmbg`mhZg]k^fZbgbg`Zmma^bkihlm'

Invest in continuing education

<hgmbgnbg`^]n\Zmbhgbl^ll^gmbZemhfZbgmZbg
dghpe^]`^Zg]bfikho^ldbeel%Zg]bm\k^Zm^lZl^gl^
h_Zikh_^llbhgZea^Zemaphkd^k\hffngbmr'MkZbgbg`l
]^lb`g^]mh[nbe]hkk^_k^laldbeellahne][^l\a^]ne^]
]nkbg`[k^Zdlbgma^l\ahhe\Ze^g]Zkmhfbgbfbs^
conflicml[^mp^^gikh_^llbhgZe]^o^ehif^gmZg]
m^Z\abg`k^lihglb[bebmb^l'

:]]bmbhgZeer%_ng]bg`bg]bob]nZemnmhklhk_Z\nemrmh
k^Z\aZab`a^k]biehfZhk]^`k^^e^o^eZlZk^pZk]_hk
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THE TWIGA INITIATIVE 33


Beyond Twiga
>o^gpbmaln\\^ll_nebfie^f^gmZmbhgh_Mpb`ZZg]
ma^k^lnembg`Z]]bmbhgh_++%/))g^pa^Zemaphkd^kl%
MZgsZgbZpbee_Zeelahkmh_bmlZf[bmbhnlmZk`^ml%[^bg`
p^ee[^ehpma^WHOmZk`^mh_+,a^Zemaphkd^kli^k
m^gmahnlZg]i^hie^'Ma^\hngmkrpbeelmbeek^jnbk^
2+%.))Z]]bmbhgZephkd^klmhikhob]^Zfbgbfnf
lmZg]Zk]h_a^Zema\Zk^mhbmli^hie^!>qab[bm*-"%-.
^qi^\m^]bg+)*2mhgnf[^kho^k.)fbeebhg'
Pbmabgma^m^g&r^Zkmbf^ahkbshg%phkd_hk\^
^qiZglbhglmbee_Z\^lmak^^\ab^_h[lmZ\e^l'?bklm%hg\^
school-specific optimizambhgaZl[^^gZ\ab^o^]%ma^
mkZbgbg`g^mphkdpbee[^ZmfZqbfnf\ZiZ\bmr%pbma
gh_nkma^khiihkmngbmb^l_hk^geZk`^f^gm'L^\hg]%
ibi^ebg^blln^llmbee]hfbgZm^Zg]Zk^^qZ\^k[Zm^]%
`bo^gmaZmg^pl\ahhel_Z\^Zfbgbfnfh_mphmh
mak^^r^ZklÌ]^o^ehif^gm[^_hk^ma^r\ZgZ]fbmma^bk
firsmltudent. And finally the cosm%[Zl^]Zlbmphne]
[^hg[kZg]g^pbg_kZlmkn\mnk^%[^\hf^lZefhlm
bglnkfhngmZ[e^'
Mh_nkma^kZ\\^e^kZm^ma^`khpmabgma^a^Zemaphkd^k
lniier[^rhg]Mwiga, the team identified a handful of
Ë`Zf^&\aZg`bg`ÌhkËmkZgl_hkfZmbhgZeÌb]^ZlmaZmfZr
a^eiZee^obZm^ma^l^\hglmkZbgmlZg]iZo^ma^pZrmh
ma^ikh]n\mbhgh_ZeZk`^kZg]fhk^mZk`^m^]a^Zema
phkd_hk\^'FZgraZo^[^^g]bl\nll^]Zmhg^mbf^hk
Zghma^kpbmabgma^Fbgblmkr%[nmghg^aZlk^Z\a^]ma^
Z\mbhg&ieZglmZ`^'
45
Sources: Ministry of Health Interviews; Bryan 2006; HRHSP; 2008 Twiga model (see note 17); World Health Report 2006. Health workforce demand
calculated based on WHO minimum density targets, 2005 staffing establishment for required ratio of diagnostic and support staff, and 2019 population
based on expected annual growth rate of 2.09 percent.
34 ACTION NOW
Lhf^h_ma^fhlmikhfblbg`b]^ZlZk^Zl_heehpl3
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[hmahimbhgl%Zg]Z]]bmbhgZeZgZerlblblk^jnbk^]mh
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EXHIBIT 14
Still not enough
40,789
40,800
63,460 48,000
63,500
25,400
Health Net training Attrition Health
workforce output 2009-2019 workforce
2009 2009-2019 2019
(est.)
Financing health worker training
P^]b]ghmZmtempt to solve for all financial issues
k^lnembg`_khfl\Zebg`niikh`kZfl%[nmbmbl\e^ZkmaZm
financing is seo^k^erebfbm^]ZmgZmbhgZe`ho^kgf^gm
Zg]eh\ZemkZbgbg`_Z\bebmre^o^el'?bgZg\bg`a^Zema
phkd^kmkZbgbg`bgMZgsZgbZieZ\^lZ`k^Zm[nk]^g
hg[hmalmn]^gmlZg]ma^`ho^kgf^gm'Lmn]^gm
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\hlmh_^]n\Zmbhg%Zg]ebfbm^]ln[lb]b^lh_m^ge^Zo^
significant gaps in school resources.
:lln\a%_Z\bebmb^lZk^e^_mpbmahnmk^lhnk\^l_hk
^qiZglbhghkfZbgm^gZg\^':]cnlmbg`lmn]^gm_^^l
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sufficient resources for schools to plan for and finance
ma^bkhpg`khpma'Ahp^o^k%ab`a^k_^^lpbmahnm
lniihkmphne]fZd^Zmtendance difficnem_hkfZgr
lmn]^gml';hma`overnment-provided financial aid
Zg]ikboZm^lmn]^gmehZgikh`kZfl_hkZee\Z]k^l
Zk^g^^]^]mh^glnk^maZma^Zema^]n\Zmbhgk^fZbgl
accessible to all qualified applicants.
Hg^himbhgp^]^lb`g^]mhZ]]k^llmablblln^blma^
]^o^ehif^gmh_ZikboZm^lmn]^gmehZgikh`kZf'
Gap of
92,500
140,500
Health
workers
needed
2019
Private loans
:\hfi^mbmbo^erikb\^]lmn]^gmehZgikh`kZf
phne]bg\k^Zl^ma^ho^kall flow of funds to teaching
bglmbmnmbhgl%fZdbg`l\ahhe^qiZglbhglnlmZbgZ[e^
pbmahnmebfbmbg`Z\\^llmh^]n\Zmbhg'Ln\\^ll_ne
^qZfie^lh_mablZiikhZ\aaZo^[^^gbgbmbZm^]
[rma^Bgm^kgZmbhgZe?bgZg\^<hkihkZmbhg!IFC)
bgiZkmg^klabipbmaikboZm^&l^\mhk[Zgdlbg[hma
Lhnma:f^kb\ZZg]:lbZmakhn`aZ\hfi^eebg`k^mZbe
[nlbg^llfh]^e'
Ma^ihm^gmbZe_hkZlbfbeZklmn]^gmehZgikh`kZflbg
MZgsZgbZ\Zghger[^Zl\^kmZbg^][rZll^llbg`kbld%
]^m^kfbgbg`ihebmb\Zebgm^k^lmZg]in[eb\Z\\^imZg\^%
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[ZgdlZg]fnembeZm^kZehk`ZgbsZmbhgl'
H_\hnkl^%ik^k^jnblbm^l_hkln\aZehZgl\a^f^
bg\en]^%ZmZfbgbfnf%Z\hff^k\bZe[Zgdpbeebg`mh
hi^kZm^bm'Ab`abgm^k^lmkZm^l%ma^ghkfbg:_kb\Z%Zk^
ikhab[bmbo^'Mhe bank will need to be confident of its
financial risks, such as de_ZnemkZm^l%Zg]ma^^qm^gm
mhpab\ama^l^kbldlZk^fZgZ`eable. An efficient
\hee^\mbhgl\a^f^%Ze^`Ze_kZf^phkd%Zg]ZiikhikbZm^
THE TWIGA INITIATIVE 35
EXHIBIT 15
Increasing intake Projected additional 2015 intake
after implementation
Estimated 2009 intake

955

731

82 1,400
96
1,112 351
124
107 250
27 109 538 298 453
238 328 260
148
Specialist Medical Assistant Registered Enrolled Clinical Clinical Pharmacy Laboratory Other
Officer Medical Nurse Nurse Officer Assistant Skills Skills
Officer

bgltitutional and financial manag^f^gmpbeeg^^]mh Ma^k^blZ\e^Zk[n]`^mZkrZ]oZgmZ`^mhma^

[^]^m^kfbg^]'
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a^eiZfhkmbs^ma^kbldl4]hghklaZo^Zek^Z]rlahpg
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k^\hnkl^mh\hfi^mbmbo^erikb\^]ehZgl'MaZm
bglmbmnmbhglpbeemkZgl_^kZ`k^Zm^kikhihkmbhgh_
mkZbgbg`\hlmlmhma^lmn]^gmlblebd^ermh[^Z\\^im^]
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[nmpbmakbldlZiikhikbZm^erlaZk^][rbgm^kgZmbhgZe Defining the optimal workforce pyramid
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phkder gap from the official government Staffing
Applicability >lmZ[eblaf^gm[rgnf[^kZg]mri^h_hi^g_Z\bebmb^l
Lhf^iheb\rZ]ZimZmbhglfZr[^k^jnbk^]mhZiierma^ i^kr^Zk%Zl^goblZ`^]bgma^MMAMiheb\r'
l\a^f^bgMZgsZgbZ'Ahp^o^k%]^libm^ma^ihm^gmbZe
Ma^WHOmZk`^mh_+,phkd^kli^km^gmahnlZg]i^hie^
_hkk^lblmZg\^_khflhf^`ho^kgf^gm%mkZbgbg`
blZ`eh[Zef^Zlnk^[Zl^]hgk^l^Zk\aebgdbg`\ebgb\Ze
bglmbmnmbhg%Zg]lmn]^gme^o^el%ma^k^bl\e^Zkbgm^k^lmbg
a^Zemaphkd^k]^glbmrmhiZmb^gmlZmm^g]^]'Hma^k
Zg]g^^]_hkln\aZikh`kZf'

46
See, for example, Kurowski 2007; Norbert Dreesch, et al., “An approach to estimating human resource requirements to achieve the Millennium
Development Goals” (Oxford U. Press: 2005); Kaspar Wyss “An approach to classifying human resource constraints to attaining health-related Millennium
Development Goals” Human Resources for Health 2004.

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mabkmr]bl\k^m^Zk^ZlmaZm_hkfma^\hk^ikbfZkr\Zk^
g^^]lh_ma^\hngmkr'
:_m^k[k^Zdbg`]hpgma^]ZmZ[r]blmkb\m%ikbfZkber
hg`^h`kZiab\ZeZg]lh\bZeebg^l%ma^g^mk^lnemphne]
b]^gmb_rghmcnlmma^g^^]l_hkMZgsZgbZZlZpahe^
[nmZelhma^hnm^k^]`^lh_Zgr\hgmbgnnfhgpab\a
a^Zema\Zk^phkd^kltaffing decisions are made.
Hg\^mablbg_hkfZmbhgbl^oZenZm^]mh`^ma^kpbmama^
ldbeefbqh_ma^^qblmbg`ihheh_\Z]k^lbgMZgsZgbZ%
Zg]ma^g\hfiZk^]mhma^g^^]^]Z\mbobmb^l_hk^Z\ah_
ma^mabkmr\Zk^iZmapZrl%Z]^mZbe^]hnmebg^h_mkZbgbg`
g^^]lphne]k^lnem'Bmlahne][^Zll^ll^]nlbg`
k^\h`gbs^]WHO`nb]^ebg^lhg\ebgb\Zek^jnbk^f^gml
modified for local interpremZmbhgZg]fnembieb^]_hk
ma^Zfhngmh_mbf^g^^]^]_hk^Z\amk^Zmf^gm'
…to define the task
Ma^k^lnembg`fh]^ephne][^Zkh[nlm]^\eZkZmbhg
h_ma^anfZgk^lhnk\^lg^\^llZkrmhf^^mma^a^Zema
\hg]bmbhglh_ma^\hngmkr%ikhob]bg`ma^gnf[^kh_
_nee&mbf^^jnboZe^gm\ebgb\ZeZllblmZgml%gnkl^l%AMOl%
iarlb\bZgl%Zg]hma^kphkd^klg^\^llZkrmhf^^mma^
ikbfZkr\Zk^\aZee^g`^'
P^k^\hff^g]%ZlZlmZkmbg`ihbgm%ma^Zll^llf^gm
mhhe]^o^ehi^][rDnkhpldbbg+))0%pab\aa^eil
ghmhgermhikhc^\mphkd_hk\^]^fZg]l[nmmhfh]b_r
ma^ng]^kerbg`ldbeel]^o^ehif^gmikh\^llbg_hkfbg`
ablikhc^\mbhgl'-0Ma^k^lneml\hne]ma^g[^nl^]mh
]^o^ehiZgZ\mbhgieZgmhfh]b_rma^mkZbgbg`lrlm^f
Zg]_neerZeb`g\nkkb\neZpbmaiZ\dZ`^lh_g^^]^]
ldbeel%bg\en]bg`ma^ihm^gmbZeZ]]bmbhgh_g^p\Z]k^l
hk\hglmkn\mbhgh_g^pl\ahhel'

47
Kurowski 2007 explores one approach to projecting future human resource needs based on the skill sets and productivity of different cadres of health
workers in Tanzania.

THE TWIGA INITIATIVE 37

At the same time, the findings could be used to
^lmZ[eblainterimltaffing requirements – a minimum
ldbeel^mk^jnbk^]mhhi^gZ\Zk^_Z\bebmr%i^g]bg`ma^
`khpmah_ma^phkd_hk\^mhma^ihbgmZmpab\ak^Ze
ltaffing leo^el\Zg[^f^m'
Bgm^kbfltaffing requirements would affecmma^
kZm^h_g^p_Z\bebmr\hglmkn\mbhg3ng]^kma^\nkk^gm
`nb]^ebg^l%[r+)*2MZgsZgbZpbee[^Z[e^mh[kbg`
^qblmbg`_Z\bebmb^lnimhlmZg]Zk]Zg]ltaff 7-*g^p
_Z\bebmb^l'Ahp^o^k%[rZ]himbg`bgm^kbfltaffing leo^el%
[r+)*2ma^lrlm^f\hne]lniihkm+%,/)g^p_Z\bebmb^l%
each with roughly half the officially required staff
!>qab[bm*/"'
Shortening the pipeline
MkZbgbg`Za^Zemaphkd^kmZd^lZgZo^kZ`^h_mak^^
r^Zkl%Zg]Zmik^l^gmbgMZgsZgbZ%Zfbgbfnfh_
mph'P^ikhc^\m^]maZmbmpbeemZd^khn`aer_hnkr^Zkl
to feel a significant impacmhgMZgsZgbZÌla^Zema
phkd_hk\^_khfmablhimbfbsZmbhgikh\^ll':\\hk]bg`
mhma^FbgblmkrÌl^lmbfZm^]mbf^ebg^_hk[nbe]bg`g^p
]bli^glZkb^l%\hglmkn\mbhgpbee]kZfZmb\ZeerhnmiZ\^
ikh]n\mbhgh_g^pltaff'
BASIC SERVICE PROVIDER PROGRAM OUTLINE
›CfZXc`q\kiX`e`e^`e[`jki`Zk_fjg`kXcjXe[_\Xck_Z\eki\jkf
take advantage of existing capacity.
›;\m\cfgkiX`e$k_\$kiX`e\ijgif^iXdkf\eXYc\iXg`[jZXc\$lg%
›B`Zb$jkXikgif^iXdlj`e^]fi\`^e_\Xck_gif]\jj`feXcjkf
train two hundred top Tanzanian MOs and AMOs in content
of the new curriculum and the most up-to-date training
techniques.
›KiX`eXeX[[`k`feXcj\m\e_le[i\[MOs and AMOs using
newly-trained MOs and AMOs, creating a trainer cadre of nine
hundred, who could then train four Basic Service Providers
(BSPs) every six months.
›<ejli\hlXc`kpf]ZXi\n`k_kiX`e\ijdXb`e^g\i`f[`Zm`j`kjkf
dispensaries to observe the clinical skills of the BSPs
›:ffi[`eXk\n`k_k_\8jj`jkXek;`i\Zkfi]fi8cc`\[?\Xck_kf
create a path for BSPs to upgrade to Clinical Assistant after
completion of a set period of service.
38 ACTION NOW
Primary care providers
Ma^^qblm^g\^h_Zehp^lm&ldbee^]%[nm_hkfZeer
^fiehr^]%\ebgb\Zea^Zemaphkd^k\Zm^`hkrmaZm\Zg
[^kZib]ermkZbg^]mhaZg]e^fhlmikbfZkr\Zl^lZm
ma^]bli^glZkre^o^ephne]k^]n\^ma^]^eZrbga^Zema
phkd^kikh]n\mbhg%^gZ[ebg`g^p_Z\bebmb^lmhhi^g
lhhg^k'
LbfbeZker%Zghma^kmri^h_kZib]ermkZbg^]a^Zemaphkd^k
fb`aml^ko^ZlZgbgm^kf^]bZkr[^mp^^gma^eh\Ze
\hffngbmrZg]]bli^glZkb^lhka^Zema\^gmk^l%a^eibg`
knkZeMZgsZgbZgl]blmbg`nbla[^mp^^g\hg]bmbhgl
maZm\Zg[^mk^Zm^]Zmahf^Zg]mahl^maZmk^jnbk^
ikh_^llbhgZemk^Zmf^gmbgZa^Zema\^gmk^hkahlibmZe'
@bo^g^qi^kb^g\^lbghma^k\hngmkb^l%mkZbgbg`
mbf^_hkma^l^khe^l\hne][^Z_kZ\mbhgh_paZm
\nkk^gm\nkkb\neZk^jnbk^'?hkbglmZg\^%Zldbeel&
[Zl^]\nkkb\nenf_^Zmnkbg`Zlbq&fhgma\eZllkhhf
\hfihg^gm_heehp^][rlbqfhgmalh_lni^koblbhgZg]
mentoring in the field would reduce trZbgbg`mbf^
by fifmri^k\^gmho^kma^\nkk^gmfbgbfnf!hg^r^Zk
bgma^\eZllkhhf_hkZCA)'IeZ\bg`ma^l^phkd^klbg
iZbklbg]bli^glZkr_Z\bebmb^lphne]i^kfbmZeema^g^p
]bli^glZkb^l^goblbhg^]bgma^MMAMiheb\rmhhi^g
pbmabgmak^^r^Zkl%ikhob]bg`Z\\^llmh[Zlb\a^Zema
\Zk^_hkmahnlZg]lh_i^hie^!>qab[bm*0"'
Accelerated AMO training
BgZ]]bmbhgmh\k^Zmbg`Zg^p[Zlb\l^kob\^ikhob]^k%
\nkkb\neZ_hk^qblmbg`\Z]k^l\hne]Zelh[^lahkm^g^]
mhbg\k^Zl^hnminm'CnlmZlma^FbgblmkraZlk^\^gmer
lahkm^g^]ma^mkZbgbg`mbf^h_[hmaRNlZg]ENlZg]
\k^Zm^]ma^g^pCA\Z]k^[Zl^]hgZlahkm^g^]CO
ikh`kZf%bm\ZgZ\\^e^kZm^AMOmkZbgbg`'
<nkk^gmer%ZeeAMO lmn]^gmlZk^ni`kZ]bg`ma^bkldbeel
Z_m^kmak^^r^Zklh_CO mkZbgbg`Zg]Zme^Zlmmphr^Zkl
of clinical work in the field. Hhp^o^k%[rlmZkmbg`
ZiZkZee^eikh`kZfmkZbgbg`AMOlmakhn`ama^bk
COikh`kZf[nm]bk^\merhnmh_l^\hg]Zkrl\ahhe%
Manzania could significantly eqiZg]mabl\Z]k^h_
ln[lmbmnm^]h\mhkl'
EXHIBIT 17
Rapid training provides dramatic increases

53,000 Post-deployment
Output of new 40,800 attrition from new
6-month cadre 42,000 6-month cadre
48,000
15,600
74,500

26,500
Impact of new cadre
63,500 on workforce

25,400
48,000

Health Optimized Impact of Attrition, Health

workforce training rapidly trained 2009-2019 workforce
2009 output cadre 2019
2009-2019 2009-2019

Improving faculty access through l\ahhel%ma^\hngmkr\Zg]^o^ehiZikh`kZfmh

institutional collaboration
Ma^l^o^k^lahkmZ`^h__Z\nemrblma^ikbfZkr_Z\mhk
ebfbmbg`_nkma^ka^Zemaphkd^kmkZbgbg`^qiZglbhgbg
MZgsZgbZ'FZqbfZenl^\Zg[^fZ]^h_ma^^qblmbg`
_Z\nemrk^lhnk\^lmakhn`amphmri^lh_bglmbmnmbhgZe
\heeZ[hkZmbhg3gZmbhgZeZg]bgm^kgZmbhgZe'
Makhn`agZmbhgZe\heeZ[hkZmbhg[^mween the five
MZgsZgbZgngbo^klbmb^lZg]]hs^glh_Zeeb^]a^Zema
laZk^ebfbm^]m^Z\abg`k^lhnk\^l'Ik^l^gmer%laZkbg`
]h^l^qblt but tends to be informal, inefficient, and
mZbehk^]mh_Z\nemrZoZbeZ[bebmrkZma^kmaZg\nkkb\nenf
k^jnbk^f^gml'
:gZmbhgZelrlm^f^gZ[e^l_Z\nemrlaZkbg`%pab\a
\ZgmZd^ieZ\^^bma^kmakhn`aZ_hkfZebs^]lrlm^f
h__Z\nemr\bk\nbm&kb]bg`hkmakhn`alrlm^fZmbsbg`
gZmbhgZe\nkkb\nenf]^o^ehif^gmmh^gZ[e^[khZ]

ETHIOPIA’S PRIMARY CARE PROVIDERS

Health officers in Ethiopia are substitute doctors, with a role very similar to that of AMOs in Tanzania. When Ethiopia launched an
ambitious plan to increase access to health facilities, a dramatic increase in the number of Health Officers to manage these facilities
was called for.
Created with the support of the Carter Center, Ethiopia’s Accelerated Health Officer (AHO) program is furthering this objective
by networking Ethiopia’s universities, developing a targeted curriculum tailored to the country’s disease profile, and making use
of hospitals previously unused for clinical training. To enable the use of the equivalent of regional and district hospitals for clinical
training, the administrators of the AHO program evaluated facilities and made selective upgrades to ensure that each had sufficient
teaching space and an appropriate variety of clinical professionals on staff.
The AHO program is also linked to Ethiopia’s Health Extension Worker (HEW) program, which aims to place 30,000 workers – all
women – in rural villages under the supervision of an AHO. The HEWs are trained for one year in special training sites all over Ethiopia.

THE TWIGA INITIATIVE 39

bfie^f^gmZmbhgh_^&E^Zkgbg`f^mah]heh`b^l%a^g\^
e^o^kZ`bg`mahl^_Z\nemrmaZm]h^qblm'
Makhn`abgm^kgZmbhgZebglmbmnmbhgZe\heeZ[hkZmbhg
pbmaZg^fiaZlblhgghkma&lhnmaebgdZ`^l%MZgsZgbZ
\hne]]^o^ehiZ`eh[ZeZ\Z]^fb\^q\aZg`^ikh`kZf
maZmphne]Zn`f^gmgZmbhgZem^Z\abg`\ZiZ\bmrZg]
\hgmkb[nm^mhbgghoZmbo^\nkkb\nenf]^o^ehif^gm'
Ln\a^q\aZg`^^qblmlghp[nmm^g]lmh[^ihhker
\hhk]bgZm^]Zg][Zl^]hgma^ZoZbeZ[bebmrZg]]^lbk^
h_bgm^kgZmbhgZeltaff rZma^kmaZghgma^Z\mnZeg^^]l
h_^Z\abglmbmnmbhg':_h\nlhgma^ihm^gmbZe_hk
bg\k^Zl^]bglmbmnmbhgZe\heeZ[hkZmbhglahne]bg\en]^
b]^gmb_rbg`ghmhgerihm^gmbZe\heeZ[hkZmbhgiZkmg^kl%
[nmZelhikhfblbg`ln[lmZgmbo^_h\nlZk^ZlZg]
ihllb[e^Zo^gn^l_hk_ng]bg`'
Maximizing limited teaching resources
BgZghimbfbs^]mkZbgbg`g^mphkd%ma^ZoZbeZ[bebmr
h_mkZbg^klÇmnmhkl%f^gmhkl%_Z\nemr%Zg]\ebgb\Ze
lni^koblhklÇpbee[^ma^fZbg_Z\mhkebfbmbg`
_nkma^k^qiZglbhg'P^ln``^lmmaZmmabl\hglmkZbgm
\Zg[^iZkmerho^k\hf^pbmaobkmnZee^Zkgbg`Zg]
]^\^gmkZebs^]mkZbgbg`m^\agbjn^l!>qab[bm*1"%Zl
Z]him^]bgfZgrhma^k\hngmkb^l'
Ma^l^\hne]bg\en]^[hmaik^k^\hk]^]e^\mnk^lZg]
ma^nl^h_ltaff am\ebgb\Ze\Zk^_Z\bebmb^lghm\nkk^gmer
affiliam^]pbmamkZbgbg`ikh`kZflZllni^koblhkl_hk
\ebgb\ZeikZ\mb\^'
Virtual classroom learning
;nbe]bg`hgma^gZmbhgZeZg]bgm^kgZmbhgZe
\heeZ[hkZmbhgihllb[bebmb^l]^l\kb[^]Z[ho^%ZobkmnZe
e^Zkgbg`ikh`kZf\hne]_nkma^k^qm^g]ma^k^Z\a
h_ebfbm^]m^Z\abg`k^lhnk\^l[r^gZ[ebg`_Z\nemrmh
ikhob]^^e^\mkhgb\o^klbhglh_ma^bke^\mnk^lmhk^fhm^
l\ahhel%pa^k^lmn]^gml\hne]ma^g[^g^fit from the
mkZbgbg`pbmahnm\aZg`bg``^h`kZiab^l'=blmZg\^
48
International Training and Education Center on HIV (I-TECH). Tanzania Distance Learning Assessment: Assessing the Use of Distance Learning To Train Health
Care Workers in Tanzania. (I-TECH and MOHSW, 2009). <http://www.go2itech.org/resources/pubications-presentations/> (Accessed 29 Apr. 2009)
40 ACTION NOW
MULTIPLYING CAPACITY
At Muhimbili in Dar es Salaam, a single biochemistry
professor is responsible for instructing all MD students (two
hundred per incoming class). The number of students he can
teach is determined by the size of the lecture theatre and the
number of times he can give each lecture.
By recording his lectures and replaying them in another
session, as done by Weill Cornell Medical College in Qatar, the
university could multiply its capacity to provide biochemistry
training while enabling the professor to use his time teaching
more specialized courses, conducting research, or meeting
individually with students.
e^Zkgbg`bl\nkk^gmer[^bg`nl^]bglhf^bg&l^kob\^
Zg]lahkt disease-specific courses in TZgsZgbZ%lhZgr
k^ieb\Zmbhghk^xpansion of those efformlphne]g^^]mh
mZd^bgmhZ\\hngmZgy findings and recommendambhgl
_khfZk^\^gmZll^llf^gm[rI-TECHZg]ma^Fbgblmkr'-1
PaZmblg^\^llZkrblZgZll^llf^gmh_ma^ihm^gmbZe
_hkobkmnZee^Zkgbg`bgma^MZgsZgbZg\hgm^qm
!bg\en]bg`m^\agheh`b\ZeZg]bg_kZlmkn\mnk^\aZee^g`^l
Zg]pZrlmhho^k\hf^mahl^\aZee^g`^l"'Ma^
Zll^llf^gmphne]Zelh_h\nlhghiihkmngbmb^lmhebgd
obkmnZee^Zkgbg`mhma^\nkkb\nenf\aZg`^lln``^lm^]
[rma^irkZfb]ZgZerlbl'
E^\mnk^klphne]g^^]mh[^l^e^\m^][Zl^]hgma^bk
^qi^ktise in the field and would sign up for a
\nkkb\ulum agreed upon by all affecm^]mkZbgbg`
bglmbmnmbhglhkk^e^oZgmikh_^llbhgZeZllh\bZmbhgl':
lmZg]Zk]bs^]gZmbhgZe\nkkb\nenfbg[bh\a^fblmkr%_hk
^qZfie^%phne]fZd^bmihllb[e^mhnl^ik^k^\hk]^]
e^\mnk^lZml\ahhelpa^k^ma^k^\nkk^gmerblgh
[bh\a^fblmkrikh_^llhk'MZi^]bglmkn\mbhg\hne]Zelh
^qm^g]m^Z\abg`mhk^fhm^Zk^Zl%^ebfbgZmbg`ma^g^^]
_hklmn]^gmlmh[^\^gmkZeereh\Zm^]g^ZkeZk`^mkZbgbg`
bglmbmnmbhgl'
EXHIBIT 18
Accelerating with virtual learning
Output of virtual
learning programs
11,400
63,500
2.5
Impact on workforce
25,400
Health Optimized Additional
workforce training training output
2009 output 2009-2019
Mh^glnk^maZmlmn]^gmlZ[lhk[ma^fZm^kbZe%mnmhkl
phne]g^^]mh[^ZoZbeZ[e^mhZglp^kjn^lmbhgl%Zg]
p^^derl^e_&Zll^llf^gml\hne][^Z]fbgblm^k^]mh
f^Zlnk^lmn]^gmikh`k^ll'
Ma^ikbfZkrbfie^f^gmZmbhg\aZee^g`^blma^
ZoZbeZ[bebmy of sufficient technological infrZlmkn\mnk^
Zg]lniihkmZ[e^mh]^lb`gZg]kngZk^ebZ[e^
bg_hkfZmbhgZg]\hffngb\Zmbhgm^\agheh`r!ICT"&
[Zl^]mkZbgbg`ikh`kZf'Ln\aZikh`kZf_hkflma^
_hng]Zmbhgh_P^bee<hkg^eeÌlg^pf^]b\Ze\hee^`^bg
=haZ%JZmZk%_hk^qZfie^%Zg]\hne][^nl^]Zlma^
_kZf^phkd_hkln\aZikh`kZfbgMZgsZgbZ'
Distributed clinical training
LbfbeZker%]blmkb[nm^]\ebgb\ZemkZbgbg`phne]
fZd^nl^h_ma^k^`bhgZeZg]]blmkb\mahlibmZel
\nkk^gmer^fiehr^]Zl\Zk^_Z\bebmb^lhgerZg]ghm
ZlmkZbgbg`lbm^l'
<ebgb\Zeltaff and clinical infrZlmkn\mnk^Zk^mphh_
ma^lbq\hglmkZbgmlmhl\Zebg`nimkZbgbg`\ZiZ\bmrZm
l\ahhelZ\khllma^\hngmkr':mik^l^gm%ghmZeeh_ma^
Post-deployment
attrition from virtual
learning programs
35-40
40,800
56,500
2,900 8,500
48,000
Attrition Health
2009-2019 workforce
2019
k^`bhgZeZg]]blmkb\mahlibmZelZk^nl^]Zl\ebgb\Ze
mkZbgbg`_Z\bebmb^l%e^Zving significant untapped
mkZbgbg`\ZiZ\bmrbgma^k^fZbgbg`_Z\bebmb^l'
EMPLOYING DISTRIBUTED TRAINING
AT BUGANDO
Tanzania’s five university-based medical schools would
provide a strong foundation for employing distributed
training. The Weill Bugando university uses the tertiary
referral hospital of the Lake Zone – Bugando Medical Centre
– as its teaching hospital. However, by accessing the medical
officers and specialists working in the six regional and 46
district hospitals of the Lake Zone, Bugando could focus
its growth on classroom teaching and building non-clinical
capacity, while dramatically multiplying the number of
students it prepares for clinical practice in the zone.
This approach would have the secondary effect of
improving patient care in the utilized hospitals, as well as
increasing the potential that graduates would choose to stay
to practice in those geographic locations.
THE TWIGA INITIATIVE 41
<k^Zmbg`hk`Zgbs^]%khmZmbhgZe\ebgb\ZemkZbgbg`
ikh`kZflbgma^l^ng]^knl^]ahlibmZelphne]bg\k^Zl^
ma^gnf[^kh_mkZbgbg`lbm^l%Zeehpbg`l\ahhel_hk
pahf\ebgb\Ze\ZiZ\bmrblZ[hmme^g^\dmh^qiZg]
]kZfZmb\Zeer':]]bmbhgZeer%mablkhmZmbhgZel\a^f^
phne]^qihl^lmn]^gmlmhZ[khZ]^kkZg`^h_ihm^gmbZe
lbm^l_hk_nmnk^^fiehrf^gm'

Bmphne]Zelh[^g^\^llZkrmhZll^lla^Zema\Zk^
_Z\bebmb^lmh]^m^kfbg^pab\aZk^ikhfblbg`\ebgb\Ze
mkZbgbg`lbm^lZg]paZmZ]]bmbhgZebginmlphne][^
g^^]^]!^'`'%mkZbgbg`iarlb\bZglbgm^Z\abg`m^\agbjn^l%
ikhob]bg`lmn]^gmahnlbg`Zg]mkZglihkm%^m\'"mh
^glnk^ln\\^ll_hkZgrbfie^f^gmZmbhgikh`kZf'

Nlbg`\ebgb\Zeltaff amma^l^_Z\bebmb^lmhlni^kobl^Zg]
mkZbglmn]^gmlfb`amk^jnbk^mkZbgbg`bgm^Z\abg`
f^mah]l%Zlp^eeZlni`kZ]bg`ldbeel%]^i^g]bg`hg
ma^\Z]k^[^bg`mZn`am';Zl^]hgma^\nkk^gm
]blmkb[nmbhgh_li^\bZeblmlZg]lni^koblhkrltaff%
k^`bhgZeahlibmZelfb`am[^fhk^ZiikhikbZm^_hk
MOZg]AMOmkZbgbg`%pa^k^Zl]blmkb\mahlibmZelfb`am
[^mm^klnbmgnkl^lZg]COl'

42 ACTION NOW

Implementation
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ikh\^llfhobg`_khfma^lmkZm^`b\h[c^\mbo^h_^qiZg]bg`
a^Zemaphkd^kmkZbgbg`mhma^k^ZebsZmbhgh_maZm`hZe'
Ma^mak^^iaZl^l![khZ]er]^fined) are necessarr_hk
^o^krikhc^\mhkZ\mbobmr`^Zk^]mhpZk]bfikhobg`
a^Zemahnm\hf^lfhk^`^g^kZeer%Zg]Zk^Zl_heehpl3
 <
 hg]n\mZgbgbmbZe]bZ`ghlmb\bgpab\ama^ikh[e^f
bl]^fined and releoZgm]ZmZbl\hee^\m^]'
 =
 ^o^ehiZgZ\mbhgieZgbgpab\ama^\hee^\m^]]ZmZ
blZgZers^]mh\k^Zm^Zgbfie^f^gmZ[e^phkdieZg'
 N
 g]^kmZd^Zg^q^\nmbhgiaZl^%bgpab\ama^
phkdieZgblbfie^f^gm^]Zg]bgbmbZek^lnemlZk^
f^Zlnk^]'
Mhe school-specific acmbhgieZglZg]lrlm^f&pb]^
bgbmbZmbo^lhnmebg^]bgmablk^ihkmZk^k^Z]r_hkma^
mabk]iaZl^'Ahp^o^k%p^p^k^ghmZ[e^mh\hfie^m^
]bZ`ghlmb\lZg]]kZ_mZ\mbhgieZgl_hkZeeh_ma^
ihm^gmbZehiihkmngbmb^lmaZm`k^phnmh_ma^Mpb`Z
]bZ`ghlmb\%lhf^h_pab\ap^hnmebg^]bgma^
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aZlcnlt been finished, while planning begins on the
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THE TWIGA INITIATIVE 43
Remaining schools: action planning
While visiting the firsm,2mkZbgbg`bglmbmnmbhgl%p^
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school is different and musm[^bg]^i^g]^gmer
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development
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mkZgl_hkfZmbhgZeZiikhZ\apbeek^jnbk^kb`hkhnl]ZmZ
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[^g^fit analysis?
48
See note 9 for explanation of number of institutions.
44 ACTION NOW
 :
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 Ahppbeem^Z\abg`jnZebmr[^fZbgmZbg^]8
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the following series of efformlpbeeg^^]mh[^
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learning – would build on the findings and demZbel
]bl\ho^k^]Zg]ieZgg^]_hkbgma^Z[ho^]bZ`ghlmb\
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khee&hnmbghma^kl'
49
For a more detailed study on capacity for Human Resources management in the Tanzanian health ministry, see Management Sciences for Health and
The Capacity Project, Report of a Human Resource Management Assessment of the Tanzania Ministry of Health Oct. 2006.
50
For more on one initiative to implement a computerized Human Resource Information System in sub-Saharan Africa, see The Capacity Project,
Strengthening Human Resources Information Systems Aug. 2007.
Implementation challenges
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\heeZ[hkZmbhg'.)
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THE TWIGA INITIATIVE 45
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51
Source: 2008 Twiga Model (see note 17); team analysis through extensive qualitative and quantitative field work.
46 ACTION NOW
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_ng]lpbee[^lnlmZbgZ[e^Zg]pa^ma^kma^MZgsZgbZg
^\hghfr\ZgfZbgmZbgablmhkb\Ze`khpmakZm^l`bo^g
`eh[Ze^\hghfb\ik^llnk^'
?nkma^k%Zg^qiZg]^]a^Zema\Zk^lrlm^fpbeebg\nk
Z]]bmbhgZe\hlml3\hglmkn\mbhgZg]fZbgm^gZg\^h_
g^p_Z\bebmb^l%^jnbif^gmZg]\hglnfZ[e^lbgmahl^
_Z\bebmb^l%ln[lb]bs^]]kn`lmhlmh\dg^p]bli^glZkb^l%
Zg]lh_hkma'Lhbmbl\e^ZkmaZmk^[nbe]bg`ma^a^Zema
\Zk^mkZbgbg`g^mphkdnlbg``ho^kgf^gmk^lhnk\^l
Zehg^blngebd^ermh[^ihllb[e^'

52
Last year for which salary information was available.
53
This figure excludes Consolidated Fund Services (CFS) – essentially public debt. All budgetary figures are similarly calculated. See Tanzania,
Ministry of Health and Social Welfare, Health Sector Public Expenditure Review (PER) update FY 2006, <http://siteresources.worldbank.org/
healthnutritionandpopulation/Resources/281627-1114107818507/082007DCP2TanzaniaFinalPERReportFY06.doc>.
54
The $71.5m (TSH 89.3bn) was allocated $38.4m (TSH 47.9bn) to Local Government Authorities (LGAs), $7.25m (TSH 9bn) to Regional Administration,
$5.1m (TSH 6.4bn) to the ministry HQ, and $20.7m (TSH 25.9bn) to Parastatals, including the largest hospitals.
55
The nominal 2007/08 Medium Term Expenditure Framework (MTEF) allocated TSH 187.4bn to Personnel Emoluments for the Health Sector, including TSH
113.3bn of the Local Government Authorities, TSH 16bn of the central ministry budget, and TSH 58.1bn of grants to parastals. However, nominal allocations
exceeded actual expenditure by about ten percent in 2005, 2006, and 2007, suggesting that the total FY2008 MTEF budget of over TSH 682bn is not
necessarily indicative of actual allocation and expenditure.
56
Source: 2008 Twiga Model (see note 17); team analysis through extensive qualitative and quantitative field work; CIA World Factbook; 2006 and 2008
MTEF and PER.
57
See Mickey Chopra, et al., “Effects of policy options for human resources for health: an analysis of systematic reviews”The Lancet Feb. 23, 2008: 668-674.

THE TWIGA INITIATIVE 47

EXHIBIT 20 ikh`kZfmakhn`ainm%`khpmah_ma^a^Zemaphkd_hk\^%
Matching growth to GDP a^Zemaphkd^k]^glbmr%Zg]a^Zemahnm\hf^l'

Salaries GDP Ma^MMAMiheb\rblZgZf[bmbhnl\ZeemhZ\mbhgÇmh

$, millions $, millions
Z\ab^o^[^mm^ka^Zemahnm\hf^lZ\khllMZgsZgbZ[r
300 35,000
bg\k^Zlbg`^jnbmrh_Z\\^llmha^Zema\Zk^l^kob\^l
250 30,000 gZmbhgpb]^'Ma^k^\hff^g]ZmbhglbghnkZiikhZ\a
mZd^nimabl\aZk`^%eZrbg`hnmZieZgh_Z\mbhg
Salaries 25,000
200 _hkZ\ab^obg`Zd^y firsmlm^iÇab`a^kmakhn`ainm
20,000 _khfmkZbgbg`_Z\bebmb^l'Mablmakhn`ainmf^mkb\bl
GDP
150 ZiikhikbZm^_hkZgnf[^kh_k^Zlhgl3bmbl^Zlrmh
15,000 bfie^f^gm%^Zlrmh\hlm%Zg]^ZlrmhmkZ\d_khfZ
100 \^gmkZefbgblmkr'
10,000

50 5,000 But improving throughput is not sufficient to improve

0 0
2006 2008 2010 2012 2014 2016 2018
@bo^gma^khe^maZmikboZm^Zg]_Zbma&[Zl^]ikhob]^kl
Zek^Z]rieZrbgMZgsZgbZga^Zema\Zk^]^ebo^kr%Z
in[eb\%ikboZm^%Zg]_Zbma&[Zl^]iZkmg^klabiblma^hger
ebd^er_ng]bg`f^\aZgblf'
Ma^MZgsZgbZg`ho^kgf^gmbl\nkk^gmerl^^dbg`Z
lnlmZbgZ[e^_ng]bg`fh]^e%k^erbg`hgln\a
iZkmg^klabilZlp^eeZlmkZ]bmbhgZe[beZm^kZeZg]
fnembeZm^kZe`ho^kgf^gmZllblmZg\^'Ahp^o^k%lhf^
fhk^kZ]b\ZehimbhglfZr[^g^\^llZkrmhbg\k^Zl^
ikboZm^bgo^lmf^gmbga^Zema\Zk^'P^]bl\nlllhf^
h_ma^l^bghnk\hfiZgbhgk^ihkmhghnkEZd^Shg^
BgbmbZmbo^'
Monitoring and evaluation
A significant obsmZ\e^mh`ho^kgf^gmZ\mbhgmh
Z]]k^lla^Zemaphkd_hk\^blln^lblma^eZ\dh_k^ebZ[e^
bg_hkfZmbhghgma^k^eZmbo^oalue of different policr
ZiikhZ\a^l'.1Hnkk^l^Zk\aaZlrb^e]^]Zl^mh_f^mkb\l
maZmZiierghmhgermhMZgsZgbZ[nmmhma^`khpbg`
field of health workforce intero^gmbhg%^gZ[ebg`
gZmbhglmhmkZ\dma^bfiZ\mh_iheb\rhgmkZbgbg`&
a^Zemahnm\hf^l_hkMZgsZgbZgl4`kZ]nZmbg`a^Zema
phkd^klfnlm[^k^\knbm^]%abk^]%k^mZbg^]%Zg]
2020
]^o^ehi^]%Zg]Zgnf[^kh_lniihkmbg`lrlm^flfnlm
[^fZbgmZbg^]'Bg_hkfZebsbg`Zgbfie^f^gmZmbhg
ieZg%Z\dghpe^]`bg`Zg]Z\\hngmbg`_hkma^l^^jnZeer
bfihkmZgmZg]\aZee^g`bg`^e^f^gmlh_Zkh[nlma^Zema
lrlm^fpbee[^^ll^gmbZe'
Placing and retaining workers
:s noted, implementing solutions offered by our team
lahne]e^Z]mhZ]hn[ebg`h_lmn]^gmbgmZd^pbmabg
_hnkr^Zkl'MkZgleZmbg`mablbg\k^Zl^]bgmZd^bgmhZ
ikhihkmbhgZm^`khpmah_ma^a^Zemaphkd_hk\^]^i^g]l
Zefhlm^gmbk^erhgZmmkbmbhgkZm^l'Mablln``^lmlmaZm
ma^Fbgblmkrpbeeg^^]mh\Zk^_neermkZ\dZg]k^lihg]
mhZmmkbmbhgkZm^lbgk^Zembf^%mh^glnk^maZmma^
bg\k^Zl^]makhn`ainmh_ma^mkZbgbg`lrlm^fblghm
[^bg`ehlmmh`khpbg`Zmmkbmbhg'
CnlmZlZmmkbmbhgkZtes affecmma^bfiZ\mh_bg\k^Zl^]
lmn]^gmbgmZd^%ma^ieZ\^f^gmh_`kZ]nZtes affecml
ahpZg^geZk`^]phkd_hk\^bfikho^lZ\\^llmha^Zema
\Zk^4phkd^klfnlm[^bgma^kb`amch[lZg]bgma^
kb`ameh\ZmbhglmhfZde a difference. H^g\^%]ZmZfnlm
[^\hee^\m^]Zml^o^kZeihbgmlZehg`ma^\aZbgmh^glnk^
maZmma^bginmh_bg\k^Zl^]lmn]^gmbgmZd^k^lnemlbg
ma^^qi^\m^]hnminmh_bg\k^Zl^]Z\\^llmh\Zk^'

48 ACTION NOW
Our team identified some of the tri^lh_]ZmZmaZm Ho^kma^g^qmm^gr^Zkl%ma^MZgsZgbZgihineZmbhg
\hne]l^ko^mablinkihl^3gnf[^kh_phkd^klh_^Z\a bl^qi^\m^]mh`khp_khf-*fbeebhgmh.)'-fbeebhg'
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\ebgb\l%Zg]phkd^kikh]n\mbobmr'BgZgr^o^gm%Z .'+mh1',a^Zemaphkd^kli^km^gmahnlZg]i^hie^'
l^kbhnlZiikhZ\amhieZ\bg`phkd^klZg]^glnkbg` >o^glh%ma^bg\k^Zl^fZraZo^ebfbm^]bfiZ\m
ma^rk^Z\ama^bkihlmlpbee[^\kbmb\Zebg^glnkbg`maZm hga^Zemahnm\hf^lnge^llMZgsZgbZZelh[helm^kl
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bgknkZeZk^Zl%^glnk^lma^k^ebZ[bebmrh_]kn`lniier%
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k^lihglbo^g^llh_ma^k^_^kkZelrlm^f%Zg]Z]]k^ll^l
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a^Zemahnm\hf^l'

LhahppbeeMZgsZgbZZg]bml]hghkldghpb_mabl
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k^eZm^]]^ZmalZg]ma^gnf[^kh_Zmm^g]^][bkmalhg
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mh]^m^kfbg^[hmapa^ma^ka^Zemahnm\hf^lZk^
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f^]b\bg^lhkbfikho^]mkZbgbg`'

GhmhgerpbeemablZiikhZ\aZllblmma^MZgsZgbZg
`ho^kgf^gmbg_nmnk^iheb\rieZggbg`Zg]
ikbhkbmbsZmbhg%bmpbee]^fhglmkZm^mhhma^k
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ma^bfiZ\mh_ik^&l^kob\^mkZbgbg`\Zg[^hgma^
f^mkb\lma^raZo^ie^]`^]mhbfikho^%Zg]Z`Zbglm
pab\ama^rZk^nembfZm^ercn]`^]'

THE TWIGA INITIATIVE 49

 [nbe]bg`Zlmkhg`[nlbg^ll\Zl^_hk^Z\abglmbmnmbhg%
\k^Zmbg`bg]bob]nZeZ\\hngmZ[bebmrZmma^l\ahhe(
bglmbmnmbhge^vel, and ensuring a specific, grZgneZk
bfie^f^gmZmbhgieZgmaZm\Zg[^fZgZ`^]eh\ZeerZg]
fhgbmhk^]gZmbhgZeer':emahn`ama^kZg`^h_ihm^gmbZe
bfiZ\mblebdely to differ from countrrmh\hngmkr%ma^
ikbg\bie^lZg]f^mah]heh`rZk^\hfie^m^erk^ieb\Z[e^'

Bm[^Zklk^i^Zmbg`maZmhimbfbsbg`ma^^qblmbg`mkZbgbg`
g^mwork is not sufficient to solve the health workforce
Conclusion \kblbl'Fbgblmkb^lh_a^Zemabgma^]^o^ehibg`phke]
Zk^ebd^ermh\hgmbgn^_Z\bg`lahkmZ`^lfZgrr^Zkl
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mk^f^g]hnlhiihkmngbmrmhbg\k^Zl^ma^\ZiZ\bmr_hk bfie^f^gmZmbhgh_g^Zk&m^kflhenmbhglln\aZl
a^Zemaphkd^kikh]n\mbhgmakhn`amZ\mb\Ze%hg&ma^& g^mphkdhimbfbsZmbhgpbmaZgZerlblZg]ieZggbg`
`khng]Zll^llf^gmlZg]himbfbsZmbhgh_^qblmbg` _hkehg`^k&m^kfmkZgl_hkfZmbhgZeZiikhZ\a^l'P^
mkZbgbg`bglmbmnmbhgl' firmly belieo^maZm%_hk\hngmkb^lpbma^qblmbg`mkZbgbg`
lrlm^fl%ma^l^ZiikhZ\a^lZk^\hfie^f^gmZkr%ghm
P^]b]ghmb]^gmb_rZgrlbeo^k[nee^mhiihkmngbmb^l Zem^kgZmbo^%_hk\hgmbgn^]]^o^ehif^gm'
mhbff^]bZm^ermkZgl_hkfMZgsZgbZÌla^Zemaphkd^k
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^qiZglbhgk^lnembg`_khfikboZm^l^\mhkbgo^lmf^gm% mkZbgbg`hnminm%ma^k^pbeelmbee[^Z]kZfZmb\\aZlf
ikbfZkber[^\Znl^ma^^gZ[ebg`^gobkhgf^gm_hk [^mp^^glniierZg]]^fZg]h_ma^a^Zemaphkd_hk\^'
ln\abgo^lmf^gm!ln\aZlehZgll\a^f^l"]h^lghm Mabl\aZlf\Zg[^[kb]`^][nmk^jnbk^lbfikho^f^gml
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ehZgikh`kams and other financing options, could ikh]n\mbhg'
enable a significant increase in supply and help close
ma^`Zilhhg^k' Ma^k^Zebmri^klblml%ma^k^_hk^%maZmma^`ho^kgf^gmlh_
]^o^ehibg`\hngmkb^lg^^]mhfZde difficnem]^\blbhgl
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ma^\ZiZ\bmr_hka^Zemaphkd^kmkZbgbg`ho^km^gr^Zkl ahpmh]^iehrZg]fZgZ`^ma^k^eZmbo^er_^pa^Zema
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_ng]bg`%ln\\^ll_nebfie^f^gmZmbhgh_lrlm^f&pb]^ \hngmkb^ll\Ze^niZ[ZeZg\^]irkZfb]h_phkd^klhk
bgbmbZmbo^lmaZmlniie^f^gmeh\Ze\aZg`^%Zg]ho^klb`am _h\us on cadres where there is a specific need? Hhp
h_^g`Z`^]lmZd^ahe]^klZmma^eh\ZeZg]gZmbhgZe lahne]\hngmkb^l[ZeZg\^ma^ltaffing of a handful of
e^o^el' Z]oZg\^]%\^gmkZea^Zema\Zk^_Z\bebmb^lZ`Zbglmltaffing
ZeZk`^gnf[^kh_]bli^glZkb^l8Ahp\Zgma^r[^lm
Pabe^p^\hg]n\m^]hnkZll^llf^gmh_mkZbgbg` ^glnk^maZmma^bg\k^Zl^]ZggnZe\hlmlmhlniihkmZ
\ZiZ\bmr^q\enlbo^erbgMZgsZgbZ%p^[^eb^o^maZmmabl eZk`^kphkd_hk\^Zk^\ho^k^]8
ZiikhZ\amhl\Zebg`nia^Zemaphkd^kmkZbgbg`\ZiZ\bmr
\hne][^^fiehr^][rZgr\hngmkrpbmaZg^qblmbg` Pabe^ma^ZgZerlblp^\hg]n\m^]bgMZgsZgbZ\Zgghm
a^Zemaphkd^kmkZbgbg`lrlm^f'Ma^ZiikhZ\ak^eb^lhg ]bk^\merZglp^kma^l^jn^lmbhgl%ebgdbg`mkZbgbg`

50 ACTION NOW
\ZiZ\bmrho^kmbf^pbmama^ikhc^\m^]lniierZg]
]^fZg]h_a^Zemaphkd^klbl\kbmb\Zebg_kZfbg`ma^
mkade-offs tham\hngmkb^lg^^]mh\hglb]^k%Zeehpbg`
ma^fmhfZd^bg_hkf^]]^\blbhglhgahpmh[^lm
fZgZ`^ma^\aZee^g`^lZehg`ma^khZ]_khfma^bk
\nkk^gmlmZm^mhf^^mbg`ma^WHOmZk`^mh_+,a^Zema
phkd^kli^km^gmahnlZg]i^hie^'

:ldbee^]phkd_hk\^bl[nmhg^\hfihg^gmh_ma^
\hfie^qa^Zemalrlm^ffhe^\ne^%Zehg`pbmaZ\\^ll
mhf^]b\bg^%]bZ`ghlmb\^jnbif^gm%in[eb\a^Zema
^]n\Ztion, sufficient facilities, and so forma';nmbmbl
Zg^ll^gmbZeib^\^ÇZ\hkg^klmhg^maZm\hne]fZd^
Z\ab^obg``eh[Zea^ZemamZk`^ml_hkk^]n\bg`fZm^kgZe
]^Zma%\abe]ahh]fZeZkbZ%Zg]HIVbg_^\mbhgZk^Zebmr'

THE TWIGA INITIATIVE 51

Appendix – List of
Interviewees
;rma^^g]h_ma^]bZ`ghlmb\%p^aZ]\hg]n\m^] :mma^Fbgblmkrh_Ab`a^k>]n\Zmbhg%pa^k^
bgm^kob^plpbmaZeZk`^gnf[^kh_i^hie^Z\khll ngbo^klbmb^lZk^`ho^kg^]%p^bgm^kob^p^]ma^=bk^\mhk
MZgsZgbZ[hmabg`ho^kgf^gmZg]bgma^a^Zema h_Ab`a^k>]n\ZmbhgZg]f^f[^klh_ma^Ab`a^k
mkZbgbg`l^\mhk'Pbmabgma^MZgsZgbZg`ho^kgf^gm% >]n\ZmbhgEhZgl;hZk]'Mahl^bgm^kob^p^]p^k^ghm
bgm^kob^p^^lbg\en]^]ma^<ab^_Fedical Officer%fZgr ebfbm^]mh[nmbg\en]^ma^_heehpbg`'
]^iZkmf^gm]bk^\mhkl%ZllblmZgm]bk^\mhklng]^kma^
]^iZkmf^gmh_AnfZgK^lhnk\^lZg]=^o^ehif^gm%
Zg]gnf^khnllniihkmltaff'

Professor Willbard Abeli
Director of Higher Education
Ministry of Higher Education
Professor M. About
Associate Dean, School of Medicine
Muhimbili University of Health and
Allied Sciences
Ndosi Aston
Director for Distance Learning
Kilimanjaro Christian Medical College
Hadija Athumani
Principal
Bagamoyo Nurse Training Centre
Mama Eliaremisa Ayo
Assistant Director, Nurse Training, Human
Resources
Ministry of Health and Social Welfare
Professor Mohammed Bakari
Director of Undergraduate Students,
School of Medicine
Muhimbili University of Health and
Allied Sciences
Rt. Rev. Bishop Aloysius Balina Mary J. Chuwa
Chairman, Weill Bugando University College Head, School of Nurse Tutors
of Health Sciences Muhimbili University of Health and
Diocese of Shinyanga Allied Sciences
Peter Michael Benderra Father Angelo Dutto
Acting Principal and Faculty member Director, Institute of Medical Health
Mbeya School of Theater Management Sciences (DMLS)
Ruhua University College (RUCO)
Dr. Zacharia Berege
Director of Hospital Services Dabney Evans
Ministry of Health and Social Welfare Executive Director, Institute of Human
Rights, Emory University
Dr. Rene Bonsubre
VSO Volunteer, CTC and OPD, Mtwara Dr. Gemba
Regional Hospital; Instructor, Mtwara Principal
Clinical Officer Training Centre Mbeya Dental School
Mama Tabu Chando Matt Gordon
Director, Administration and Personnel Multilateral Policy Advisor
Ministry of Health and Social Welfare Department of International Development
(DFID) UK
Edwin Chitage
Medical Student, Year 3 Professor Ambrose F. Haule
Muhimbili University of Health and Allied Associate Dean, School of Pharmacy
Sciences Muhimbili University of Health and
Allied Sciences

52 ACTION NOW
Ghanimu Kajubu Professor B.S. Lembariti Mr. Mavunde
Accountant Deputy-Vice Chancellor, Planning, Statistician, Planning, Human Resources
Mvumi Nurse Training Center Finance and Administration Ministry of Health and Social Welfare
Muhimbili University of Health and
Benito Kawala Dr. Meshack M.Z. Massi
Allied Sciences
Chief Accountant Regional Medical Officer
Weill Bugando University College of Mike Magere Morogoro Regional Hospital
Health Sciences Head, School of Laboratory
Dr. Josiah Mekere
Weil Bugando University of Health and
Dr. Thomas Kenyon Principal
Allied Sciences
Deputy Coordinator (Acting) & Cheif of Staff Lugalo University
Office of the Global AIDS Coordinator Mary S. Magomi
Dr. Nicodemus E. Mgalula
Principal, Morogoro Nurse
Professor Egbert M. Kessi Principal
Training Centre
Provost Tanga Dental Therapist School
Coordinator, Morogoro Zonal
Kilimanjaro Christian Medical College
Training Centre Professor Charles A. Mkony
Jaockim Kessy Dean, School of Medicine
Professor Cassian Magori
Director of Administration Muhimbili University of Health and
Head, Department of Anatomy
Kilimanjaro Christian Medical College Allied Sciences
Weill Bugando University College of Health
G.M. Kibaya Sciences Fadhila Mkony
Head of Loans Board Administrator, Human Resources
Professor William Mahalu
Ministry of Higher Education Ministry of Health and Social Welfare
Head, Department of Surgery
Stanslaus Kiberiti Weill Bugando University College of Health Richard Mkumbo
Principal Sciences Health Economist
Kolandoto Nurse Training Centre Ministry of Health and Social Welfare
Dr. Moses Malaba
Dr. Regina Kikule Principal Scola Mlaui
Director of Policy and Planning Musoma Clinical Officer Training Centre Deputy Director, Administration and
Ministry of Health and Social Welfare Personnel
Catherine E.L. Malika
Ministry of Health and Social Welfare
Deodata J. Kilumile Head, School of Radiology, Institute of
Nurse Tutor Allied Health Sciences Dr. Gilbert Mliga
Bagamoyo Nurse Training Centre Muhimbili University of Health and Director, Human Resources Development
Allied Sciences Ministry of Health and Social Welfare
Dr. Daniel T. Kisimbo
Director, Distance Education Program Anna Mangula Dr. Frederick Mongi
Morogoro Health Training Institute Principal Principal, Mbeya Assist. Medical Officer
Mirembe Nurse Training Centre Training Centre
Dr. Arndt Koebler
Director, Mbeya Zonal Training Centre
Anethesia and ICU Dr. Martin
Bugando Medical Centre Director Gustav Moyo
Centre for Educational Development in Registrar
Theela W. Kohi
Health (CEDHA) Tanzanian Nurses and Midwives Council
Dean, School of Nursing
Muhimbili University of Health and Professor Zablon Masesa Veronica M. Mpazi
Allied Sciences Head, Department of Physiology Nurse Tutor, School of Nurse Tutors
Weill Bugando University College of Muhimbili University of Health and Allied
Rapton Kunchela
Health Sciences Sciences
Tanga School of Environmental Health
Dr. Joshua A. Masikini Rocky R. Mpungwe
Professor Gideon Kwesigabo
Medical Officer In Charge Principal
Dean, School of Public Health and
Bukumbi District Hospital Mvumi Nurse Training Centre
Social Sciences
Muhimbili University of Health and
Allied Sciences

THE TWIGA INITIATIVE 53

Professor Jacob Mtabaji Vernand Ndemetria S.S. Senya
Principal Training Coordinator – Nurse Training Director, Institute for Allied Health Sciences
Weill Bugando University College of Ministry of Health and Social Welfare Muhimbili University of Health and
Health Sciences Allied Sciences
Dr. B. Ndawi
Dr. L.B. Mtani Director, Iringa Primary Healthcare Institute Mama Shamu
Principal & Iringa Zonal Training Centre Principal
Sengerema Clinical Officer Training Centre Mtwara Nurse Training Centre
Dr. Matthew Ndomondo
Dr. Deo Mtasiwa Acting Principal H.G. Shangali
Chief Medical Officer Sengerema Nursing School Head, Allied Health Sciences School
Ministry of Health and Social Welfare Kilimanjaro Christian Medical College
Edward Ngowi
Dr. Mteta Engineer, Office of the Director of Policy Dr. Shayo
Dean, Faculty of Medicine and Planning Admistrative Director & Faculty Member
Kilimanjaro Christian Medical College Ministry of Health and Social Welfare Mtwara Clinical Officer Training Centre

Dr. Elifuraha G.S. Mumghamba Dr. Emmanuel N’gwamkai Dr. Edward Silayo
Senior Lecturer, School of Dentistry Acting Principal Instructor, School of Advanced
Muhimbili University of Health and Tanga Assist. Medical Officer Training Centre Dental Officers
Allied Sciences Muhimbili University of Health and
Dr. William Nyagwa
Allied Sciences
Pheby Murusuri Chief of Party, Tanzania
Principal The Capacity Project Dr. Mark E. Swai
Bukumbi School of Nursing and Midwifery Pediatrician, Director of Hospital Services
Emily Nyakiha
Kilimanjaro Christian Medical Centre
Dr. Amos Mwakilasa Head, School of Nursing, Institute of
Assistant Director, Continuing Ed, Allied Health Sciences Rwezaura Tibaijuka
Human Resources Weill Bugando University College of Head, School of Pharmacy, Institute of
Ministry of Health and Social Welfare Health Sciences Allied Health Sciences
Weill Bugando University College of
Mama E. Mwakalukwa Mfungo Nyandigira
Health Sciences
Assistant Director, Planning, Human Head, School of Radiology, Institute of
Resources Allied Health Sciences Leka Tingitana
Ministry of Health and Social Welfare Weill Bugando University College of Business Manager
Health Sciences Ifakara Health Training and Research Centre
Bumi Mwamasage
Assistant Director, Allied Health Training, Dr. Robert Peck Masiah Veneranda
Human Resources Clinical Instructor, Internal Medicine Nurse Tutor
Ministry of Health and Social Welfare and Pediatrics Bagamoyo Nurse Training Centre
Weill Cornell Medical Centre at
Dr. Emmanuel Mwandu Karin Anne Wiedenmayere
Weill Bugando University College of
Chief Medical Officer Senior Specialist, Pharamcy
Health Sciences
Kolandoto Nurse Training Centre Swiss Tropical Institute, Ifakara Health
Professor Abdulla Rajab Training and Research Centre
Osiah Mwasulama
Senior Education Officer
Laboratory Director Mavis L. Yengo
Ministry of Higher Education
Mbeya Referral Hospital Academic Head, Advanced Nursing Studies
Dr. Eleuter R. Samky Program
Zainab S. Nanyaro
Director-General The Aga Khan University – Tanzanian
Principal
Mbeya Referral Hospital Institute of Higher Education
Tanga Nurse Training Centre
Dr. Christian Schmidt
Dr. Sydney Ndeki
Pediatrics
Consultant, Zonal Training Centres
Bugando Medical Centre
Ministry of Health and Social Welfare

54 ACTION NOW

Bibliography
;krZg%Ehp^ee%^mZe'Investing in Tanzanian Human
Resources for Health: an HRH study for the Touch
Foundation!G^pRhkd3F\Dbgl^r<hfiZgr%+))/"'
<ZiZ\bmrIkhc^\m%GZmbhgZeBglmbmnm^h_F^]b\ZeK^l^Zk\a
Zg]MZgsZgbZFbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'
Labour Market Study for the Tanzanian Health Sector:
Draft 4.!=Zk^lLZeZZf%+))/"'
<ZiZ\bmrIkhc^\m'Strengthening Human Resources
Information Systems.:n`'+))0'
<^gmkZeBgm^eeb`^g\^:`^g\r'ÉMZgsZgbZ'ÊWorld Factbook
+))1%ammil3((ppp'\bZ'`ho(eb[kZkr(in[eb\Zmbhgl(ma^&
phke]&_Z\m[hhd(`^hl(ms'amfe'
<ahikZ%Fb\d^r%LZeeZFngkh%ChagG'EZobl%@nggOblmZg]
LZkZ;^gg^mt. “Effecmlh_iheb\rhimbhgl_hkanfZg
k^lhnk\^l_hka^Zema3ZgZgZerlblh_lrlm^fZmb\k^ob^pl'
The Lancet,0*%bll'2/*,!?^['+,%+))1"3//1'
<kbli%Gb`^e%;b^g\^@ZpZgZlZg]Bfh`^gLaZki'ÉMkZbgbg`
ma^a^Zemaphkd_hk\^3l\Zebg`ni%lZobg`ebo^l'ÊThe
Lancet,0*%bll'2/*,!?^['+,%+))1"3/12'
=hfbgb\d%:ggZZg]<akblmhiaDnkhpldb'ÉAnfZg
k^lhnk\^l_hka^ZemaÇZgZiikZblZeh_ma^lmZmnljnhbg
MZgsZgbZfZbgeZg]'ÊCner+))-'
=k^^l\a%Ghk[^km%<Zkf^g=he^Z%FZkbhK
=ZeIhs%:e^qZg]k^@hn[Zk^o%Hkobee
:]Zfl%FZkn:k^`Zpb%DZkbg;^k`lmkhf%A^e`Z
?h`lmZ]%=^eeZLa^kZmm%C^ggb_^kEbgdbgl%Kh[^km
L\a^ki[b^kZg]FZrZ]ZRhnll^_&?hq'É:gZiikhZ\amh
^lmbfZmbg`anfZgk^lhnk\^k^jnbk^f^gmlmhZ\ab^o^
ma^Fbee^ggbnf=^o^ehif^gm@hZelÊHealth Policy
and Planning+)!."!+))."3+/0'
@eh[ZeA^ZemaPhkd_hk\^:eebZg\^ik^llk^e^Zl^hg
eZng\ah_ma^L\Zebg`ni>]n\ZmbhgZg]MkZbgbg`
mZld_hk\^%ammi3((ppp'WHO'bgm(f^]bZ\^gmk^(g^pl(
k^e^Zl^l(+))0(ik).(^g(bg]^q'amfe'
@eh[ZeA^ZemaPhkd_hk\^:eebZg\^%5ammi3((ppp'`apZ'hk`(7'
@eh[ZeA^ZemaPhkd_hk\^:eebZg\^.É:`^g]Z_hk@eh[Ze:\mbhgÊ
FZk'+))15ammi3((ppp'WHO'bgm(phkd_hk\^ZeebZg\^(
_hknf(*XZ`^g]Z-@:\tion_final.pdf>.
ChbgmE^Zkgbg`BgbmbZmbo^'Human resources for health:
overcoming the crisis!<Zf[kb]`^3@eh[Ze>jnbmr
BgbmbZmbo^%+))-"'
Dhhm%CZZiZg]KbdI^^i^kdhkg'ÉMa^A^ZemaL^\mhkbgma^
+*lm<^gmnkr4inmmbg`a^Zemalrlm^fllmk^g`ma^gbg`bg
i^kli^\mbo^Ê!_hkma\hfbg`"'
Dnkhpldb%<akblmhia%DZliZkPrll%LZebf:[]neeZZg]:gg^
Fbeel'ÉL\Zebg`niikbhkbmra^Zemabgm^ko^gmbhglbg
MZgsZgbZ3ma^anfZgk^lhnk\^l\aZee^g`^ÊHealth
Policy and Planning ++!,"!?^['+)+))0"3**,'
Dnkhpldb%<akblmhia%DZliZkPrll%LZebf:[]neeZ%
GÌ=b^dahkR†fZ]cbZg]:gg^Fbeel'ÉAnfZg
K^lhnk\^l_hkA^Zema3K^jnbk^f^gmlZg]:oZbeZ[bebmr
bgma^<hgm^qmh_L\Zebg`&NiIkbhkbmrBgm^ko^gmbhglbg
Ehp&Bg\hf^<hngmkb^lÇ<Zl^lmn]b^l_khfMZgsZgbZ
Zg]<aZ]Ê!Ehg]hg3Ehg]hgL\ahheh_Ar`b^g^Zg]
Mkhib\ZeF^]b\bg^%CZg'+)),"'
FZ^lmZ]%HmmZkHuman Resources for Health in Tanzania
!<ak'Fb\a^elhgBglmbmnm^,+))/"'
FZgZ`^f^gmL\b^g\^l_hkA^Zema<ZiZ\bmrIkhc^\m%Report
of a Human Resource Management Assessment of the
Tanzania Ministry of Health.H\m'+))/'
F\Dbgl^r<hfiZgr' Acting Now to Overcome Tanzania’s
Greatest Health Challenge: Addressing the Gap in
Human Resources for Health.+))-'
MZgsZgbZFbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^%ammi3((
ppp'fha'`h'ms('
MZgsZgbZFbgblmkrh_Ab`a^k>]n\Zmbhg%L\b^g\^l
M^\agheh`r%ammi3((ppp'flma^'`h'ms('
MZgsZgbZGZmbhgZe;nk^Znh_LmZmblmb\lZg]FZ\kh
Bgm^kgZmbhgZe%Tanzania Service Provision Assessment
Survey 2006%Gho'+))0'
MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'Emergency
Recruitment Plan !=Zk^lLZeZZf"'
THE TWIGA INITIATIVE 55
MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'Health Phke]A^ZemaHk`ZgbsZmbhg LmZmblmb\ZeBg_hkfZmbhgLrlm^f%
Sector Public Expenditure Review!PER"update ammi3((ppp'pah'bgm(pahlbl(^g(bg]^q'amfe'
FY 2006%ammi3((lbm^k^lhnk\^l'phke][Zgd'hk`(
Prll%DZliZkÉ:gZiikhZ\amh\eZllb_rbg`anfZgk^lhnk\^
A>:EMAGNMKBMBHG:G=IHINE:MBHG(
\hglmkZbgmlmhZmmZbgbg`a^Zema&k^eZm^]Fbee^ggbnf
K^lhnk\^l(+1*/+0&***-*)01*1.)0()1+))0=<I+&
=^o^ehif^gm@hZel'ÊHuman Resources for Health +3**
MZgsZgbZ?bgZeI>KK^ihkm?R)/']h\'
!+))-"%ammi3((ppp'anfZg&k^lhnk\^l&a^Zema'\hf(
MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'Health \hgm^gm(+(*(**'
Statistics Abstract 2001 !=Zk^lLZeZZf%+))*"'
MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'HRH
Census!=Zk^lLZeZZf%+))+"'
MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'Human
Resource for Health Strategic Plan2008-2013!=Zk^l
LZeZZf%CZg'+))1"'
MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^' MOHSW
monthly budget allocation to schools!ngin[ebla^]"'
MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'Primary
Health Services Development Programme 2007-2012
(MMAM)!=Zk^lLZeZZf,FZr+))0"'
MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'School
Bulletin Database2005!=Zk^lLZeZZf%+))."'
MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'Staffing
Establishment2005!=Zk^lLZeZZf%+))."'
MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'Third
Health System Strategic Plan!L^im'+))1]kZ_m"'
UNICEF.ÉD^grZÊZg]ÉMZgsZgbZÊfZm^kgZefhkmZebmrkZm^l
!Z]cnlm^]"'?^['+))2%ammi3((ppp'ngb\^_'\hf'
Ngbm^]LmZm^l%Tom Lantos and Henry J. Hyde United
States Global Leadership Against HIV/AIDS,
Tuberculosis and Malaria Reauthorization Act of
2008%In[eb\EZp**)&+2,%*++LmZm+2-/!+))1"'
@IH:\\^ll'5ammi3((_kp^[`Zm^'Z\\^ll'`ih'`ho(
\`b&[bg(`^m]h\'\`b8][gZf^6**)X\hg`Xin[eb\X
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Ngbm^]LmZm^l;nk^Znh_EZ[hkLmZmblmb\l'ÉGnklbg`%
Ilr\abZmkb\%Zg]Ahf^A^Zema:b]^lÊZg]ÉF^]b\Ze
:llblmZgmlÊ?^['+))2%ammi3((ppp'[el'`ho('
Phke];Zgd%ÉMZgsZgbZ%Êppp'phke][Zgd'hk`(mZgsZgbZ'
Phke]A^ZemaHk`ZgbsZmbhg'É=^Zma=blZ[bebmr:]cnlm^]
Eb_^R^Zkl^lmbfZm^l_hk+))+[r\Znl^_hkWHO
F^f[^kLmZm^l%Êammi3((ppp'pah'bgm(pahlbl(
bg]b\Zmhkl(\hfi^g]bnf(+))1(*eek(^g('
Phke]A^ZemaHk`ZgbsZmbhg'Working Together for Health:
The World Health Report 2006!+))/"'

56 ACTION NOW
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