THE HIGH BURDEN COUNTRY INITIATIVE (HBCI): MEETING THE DEMAND FOR FULLY COMPETENT RCH PROVIDERS IN THE

UNITED REPUBLIC OF TANZANIA

Dr. Neema Rusibamayila Assistant Director, Preventive Health Services RCH Tanzania Ministry of Health and Social Welfare

Background on the HBCI

September 2010: launch of Global Strategy for

Womens and Childrens Health by the UN Secretary General

September 2011: Greentree meeting to discuss

strengthening implementation of critical MNH interventions

HBCI initiative proposed for the 8 countries making up

nearly 60% of the global maternal and newborn mortality burden

First step: comprehensive national needs assessment to

review availability and status of human resources with midwifery capabilities at the community level

HBCI technical working group

UNFPA, WHO, UNICEF, UNAIDS, Global

Health Workforce Alliance (GHWA), ICM, FIGO, ICS Integrare, Jhpiego, Royal Tropical Institute (KIT) and University of Southampton

Secretariat: ICS Integrare

What is the appropriate midwifery workforce, and how is it to be deployed, to equitably deliver MNH interventions at scale and quality, and what (including costs) needs to be in place to achieve universal access?

Tanzania HBCI Effort

Assessment conducted between April and September 2012
Desk review Technical mission Identification of information

gaps Collection of data to fill the gaps Analysis of data Stakeholder verification workshops

Areas assessed
Essential interventions for MNH and utilization.

Access, equity, quality, efficiency and utilization of MNH services. Midwifery workforce. Production and performance of the midwifery workforce. Work environment. Enabling working environment to maximise and sustain the midwifery workforces contribution to MNH. Management and policies. Management system and policies, leadership and partnerships to maximise and sustain the midwifery workforce Financing. Financial resources for providing adequate financial incentives and developing costed plans to maximise and sustain the midwifery workforce

Key findings
Essential MNH interventions and utilization
11 categories of health workers comprise the midwifery

workforce each with specific competencies, though some overlap

No one specific cadre competent in the full set of

midwifery competencies and dedicated to frontline care

Though the scope of the nurse/midwife and clinical officer

allows them to provide at the least the 7 basic EmOC signal functions, their working environment and/or practical training is insufficient to allow them to do so

Key findings
Midwifery workforce
Equitable distribution of

workforce in recent years

Recruitment and

The RCH workforce in Tanzania

deployment processes are still issues in ensuring RCH services are equitably delivered vacancy rates estimated between 40% to 86%
Lack of full midwifery

skills in at least one of the cadres challenges equitable coverage

Key findings
Work environment
Distribution of facilities

seems to align with areas where most pregnancies expected, though not conclusive

Health facilities by expected pregnancies

However, insufficient staffing

with appropriate balance of RCH competencies

Need for strengthening

referral, commodity and equipment systems, and to find ways to improve staff motivation

Key findings
Management and policies
Targets, policies,
45000

Staffing needs for the RCH units in Tanzania according to the DPSG.
Staffing needs according to the 2012 draft staffing guidelines - Total number of EN, ANO, CO, AMO and MO ]working in the RCH units Number of EN currently available in the RCH units (48% of EN is working in the RCH units)

strategies, standards, guidelines, information systems, donors and implementing partners are in place and aligned
Implementation of these

40000

35000

30000

25000

20000

15000

is needed to improve availability of staff, equipment and commodities

Number of ANO currently available in the RCH units (34% of ANO is working in the RCH units)

10000

5000

Number of CO currently available in the RCH units (11% of CO is working in the RCH units)

0 2010 - current number 2017 - total number of of facilities facilities required under MMAM

Key findings
Financing
Fragmented health financing system

government now working interministerially on Health Financing Strategy

Government health expenditure is roughly

7% of the total health expenditure (THE), with THE for RH estimated at 18% of THE
Health insurance initiatives expanding

Projected staffing needs and supply

18000

16000 Supply of EN 14000 Supply of ANO Supply of CO Supply of AMO 12000 Supply of MO Total staffing needs 10000

8000 2015 2020 2025

Projected supply as proportion of projected need

Rural vs. urban
BASELINE SCENARIO Coverage of staff requirements RURAL RCH units EN ANO CO AMO MO Coverage of staff requirements URBAN RCH units EN ANO CO AMO MO

2015 39% 407% 42% 66% 46% 2015 143% 1474% 118% 207% 1170%

2020 40% 423% 42% 73% 66% 2020 130% 1380% 104% 207% 1504%

2025 39% 416% 40% 77% 81% 2025 113% 1215% 90% 195% 1651%

Suggested solutions
Eight policy options identified for costing comprising issues

related to production, deployment and equipment availability

Scenario: application of the eight policy options

Coverage of staff requirements RURAL RCH units EN ANO CO AMO MO Coverage of staff requirements URBAN RCH units EN ANO CO AMO MO 2015 77% 97% 88% 78% 54% 2015 128% 162% 110% 108% 543% 2020 86% 107% 92% 92% 80% 2020 129% 161% 104% 115% 719% 2025 96% 111% 98% 101% 99% 2025 129% 149% 99% 113% 800%

Projected cost and impact

Total amount required from 2014 through

2025 is an estimated USD $2,057,760,586

This estimate excludes relocation/transfer

allowances for newly posted workers This estimate does not take into account annual inflation
Using LiST, estimated that up to 259,000

lives could be saved by 2025

Assessment conclusions
Total number of projected pregnancies 2015-2025 is

42,898,166
If the 8 policy options are implemented from 2013, this

will save 2,000-6,400 maternal lives and 11,800-30,000 newborn lives; and prevent 900-2,900 stillbirths
Total cost between 2014 and 2025 is USD

$2,057,760,586
By 2025, 129,000-259,000 lives could be saved at the

cost of USD $48 per pregnancy

Next steps for Tanzania

Finalize draft report Call for stakeholder meeting to review report

findings and proposed solutions and make recommendations for discussion with the Minister of Health and Social Welfare Develop a joint action plan (departments within the Ministry of Health and Social Welfare, as well as other relevant Ministries) for roll-out of proposed solutions

Acknowledgements
Authors: Neema Rusibamayila, Maryjane Lacoste, Dunstan Bishanga, Petra ten Hoope-Bender, Christel Janssen, Kathy Herschderfer, Mariam Khan, Rutasha Dadi.

Institutions: The Ministry of Health and Social Welfare, ICS Integrare, Royal Tropical Institute (KIT), UNFPA/Tanzania, UNICEF/Tanzania, WHO/Tanzania, USAID/Tanzania, AMCA and Jhpiego/Tanzania

Asanteni sana