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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

.................................................................................................................................................................. 38 Improving faculty access through institutional collaboration........................... 28 Reducing attrition .............................................................................. 34 Financing health worker training ..................................................................................................................................... 55 2 ACTION NOW ............................................................................................................................................................................................. 39 Maximizing limited teaching resources ......................................... 21 Bottom-up data collection .................................................................................................................................................................................................... 48 Conclusion ... 36 Shortening the pipeline ..................... 25 A replicable process ............ 24 Working together .................................................................... 26 Doubling training capacity .........................................................................................................................................31 Further systemic opportunities ..................................................................................................40 Implementation .......................................................................... 43 …to do next… .................... 52 Bibliography ..................................................................................................................................................................................................................................................... 50 Appendix – List of Interviewees ........................................................................................ 22 The top-down perspective............................................................................... 25 The toolkit ................................................................................................................................................................................................................................................................................ 35 Defining the optimal workforce pyramid ............................................................................................. 32 Beyond Twiga ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... 21 Filling the knowledge gap .............................................................................................................................................Methodology ............................................................................................................................................................................................................................................... 45 Implementation challenges ................................................... 45 Monitoring and evaluation .......................................................................................................................................................................................................................................................................................................................................................... 26 Six major constraints ............................................................................................................................................................................... 44 …and to do soon ................................................................................................................................................................................................................................................................ 25 Findings ........................................................................................................................................................................................................................ 43 To do now… .......................................................

the Lake Zone denotes the catchment area of the referral hospital at Bugando in Mwanza. It comprises six regions – Kagera. Mwanza.n`Zg]h"bgFpZgsZ%ghkmap^lm^kg Field research MZgsZgbZ%Zg][nbe]lnihgik^obhnlphkd[r Ma^[Zl^ebg^]ZmZ\hee^\mbhgZg]ZgZerlbl_hkmabl \hglnemZgmlpbmaF\Dbgl^rÌl@eh[ZeIn[eb\A^Zema k^ihkmpZl\hg]n\m^][rZMhn\a?hng]Zmbhg( IkZ\mb\^%iZkmb\neZkermphik^obhnlk^ihkml3Acting F\Dbgl^rm^Zfho^kZ_hnk&fhgmai^kbh]_khf Now to Overcome Tanzania’s Greatest Health H\mh[^k+))0makhn`aCZgnZkr+))1%pbma_heehp&ni Challenge: Addressing the Gap in Human Resources k^l^Zk\a\hg]n\m^]makhn`a+))1&)2'=nkbg`oblbml for Health!+))-"4Zg]Investing in Tanzanian mh. and Tabora – with a population of around 15 million. ZgZerlblng]^kibggbg`mablk^ihkmpZl\hffbllbhg^] [rma^a^Zemafbgblmkrmha^ei]^m^kfbg^ahpmh produce sufficient numbers of health work^klmhltaff ln\aZg^qiZg]^]a^Zemalrlm^f' Mablk^ihkmlahne][^k^Z]bg\hgcng\mbhgpbma Catalyzing Change: Molecular strengthening of the health system in the Tanzanian Lake Zone!+))2"%* Zelhikh]n\^][rma^Mhn\a?hng]ZmbhgZg][Zl^]hg Prologue phkdng]^kmZd^gZelhpbmama^lniihkmh_F\Dbgl^r' MaZmk^ihkmk^\hff^g]lZgnf[^kh_ikbhkbmr Ma^_heehpbg`k^ihkmpZlpkbmm^g[rma^Mhn\a bgbmbZmbo^lmaZmphne]lmk^g`ma^gma^ng]^kerbg` ?hng]Zmbhg'Bmbl[Zl^]nihgphkdng]^kmZd^g[rma^ a^Zemalrlm^fZg]^gZ[e^Zg^qiZg]^]phkd_hk\^mh Mhn\a?hng]ZmbhgZmma^k^jn^lmh_ma^MZgsZgbZg k^Z\abml_neeihm^gmbZemhbfikho^in[eb\a^Zema' Fbgblm^k_hkA^ZemaZg]Lh\bZeP^e_Zk^%Ikh_^llhk Pabe^mablk^ihkmmZk`^mla^Zemaphkd^kmkZbgbg`bg =Zob]FpZdrnlZ%pbma]bk^\mlniihkm_khfZpro bono MZgsZgbZ%ma^ik^\bibmZmbg`a^Zemaphkd_hk\^lahkmZ`^ lmkZm^`rZg]m^\agb\ZeZllblmZg\^m^Zf_khfF\Dbgl^r blZ`eh[Ze\kblbl'HnkZgZermb\Zeikh\^llblk^ieb\Z[e^ <hfiZgr' Z\khllln[&LZaZkZg:_kb\Z%Zg]p^^qi^\mmaZmfZgr Mablk^ihkm]kZpla^Zoberhgma^Mhn\a?hng]ZmbhgÌl h_ma^k^\hff^g]Zmbhglinm_hkpZk]mhma^MZgsZgbZg phkdmh^qiZg]Zg]lmk^g`ma^gmkZbgbg`h_a^Zema a^ZemafbgblmkrpbeeZiier^jnZeerbghma^k\hngmkb^l' phkd^klZmma^P^bee.2a^Zemaphkd^kmkZbgbg`l\ahhelbg_hnkm^^gh_ Human Resources for Health: An HRH report for the MZgsZgbZÌl+*k^`bhgl%ma^m^Zfbgm^kob^p^]e^Z]^klabi Touch Foundation!+))/"' Zg]ltaff ammkaining schools and affiliam^]\ebgb\lZg] ahlibmZel%mhnk^]_Z\bebmb^l%Zg]lihd^pbmalmn]^gml% Ma^ik^obhnlphkd]h\nf^gm^]ma^l^o^k^lahkmZ`^ `Zma^kbg`]ZmZhgl\ahhe\ZiZ\bmrZg]ma^ikbfZkr h_ldbee^]a^Zemaphkd^klmaZmblabg]^kbg`ikh`k^ll \hglmkZbgmlebfbmbg`^qiZglbhg' bgf^^mbg`ma^Fbee^ggbnf=^o^ehif^gm@hZel Zg]bfikhobg`in[eb\a^ZemabgMZgsZgbZ'L^^dbg` Ma^oblbm^]l\ahhelk^ik^l^gmZ[khZ]\khll&l^\mbhgh_ mh]kZfZmb\Zeerbfikho^mabllbmnZmbhg%MZgsZgbZg ma^mkZbgbg`g^mphkdlbgMZgsZgbZ%bg\en]bg`in[eb\% Ik^lb]^gmCZdZrZF'Dbdp^m^aZl]^\eZk^]maZm ikboZm^%Zg]_Zbma&[Zl^]bglmbmnmbhgl%eh\Zm^]bg[hma ma^\hngmkrpbee\hglmkn\t over five thousand nep knkZeZg]nk[ZgZk^Zl'Ma^rk^flecmma^]bo^klbmrh_ ikbfZkra^Zema\Zk^_Z\bebmb^lmhZme^Zlm]hn[e^Z\\^ll MZgsZgbZÌla^Zemaphkd^kl%\hfikblbg`[hma\ebgb\Ze mhikbfZkr\Zk^Z\khllma^\hngmkr'Ma^k^l^Zk\aZg] phkd^klZg]]bZ`ghlmb\lniihkmltaff%kZg`bg`_khf 1 In the Tanzanian health system. THE TWIGA INITIATIVE 3 . Our Lake Zone Initiative focused on priority initiatives to strengthen the health systems of this catchment area. Mara. Kigoma.n`Zg]hngbo^klbmrZg]m^Z\abg` ahlibmZe!. Shinyanga.

n`Zg]h%hg^h_MZgsZgbZÌle^Z]bg` closely with officials in the TZgsZgbZgFbgblmkr ahlibmZelZg]f^]b\Zengbo^klbmb^l'Ma^^qi^kb^g\^ h_A^ZemaZg]Lh\bZeP^e_Zk^'Bgm^kob^pl_h\nl^] h_ln\\^ll_nebgo^lmf^gmlbg_Z\nemr%fZgZ`^f^gm% hg\eZkb_rbg`iheb\rikbhkbmb^lZg]\hglmkZbgml4 bg_kZlmkn\mnk^%Zg]hi^kZmbhgZelrlm^flZm. Z\\nkZ\rb_ghmma^Z[lhenm^ik^\blbhgh_ma^]ZmZ' ma^m^Zf\hglnem^]ltaff of the Mbgblmkrh_>]n\Zmbhg Pabe^ln\aZgZiikhZ\ablfhk^mbf^&\hglnfbg`Zg] !pab\a`ho^kglngbo^klbmb^l"Zg]f^f[^klh_ma^ ^qi^glbo^%p^[^eb^o^bm`bo^l`k^Zm^k\k^]b[bebmrmhhnk Ab`a^k>]n\ZmbhgEhZgl.gnkl^lmhf^]b\Zeli^\bZeblml'BgZ]]bmbhgmhik^& AIDSIkh`kZfbgGZfb[bZ%ma^F^]b\Ze>]n\Zmbhg l^kob\^ikh`kZfl%ma^m^Zfk^ob^p^]\hgmbgnbg` <hhi^kZmbhgpbma<n[Z!MEDICC"ikh`kZf%Zg]ma^ ^]n\Zmbhg\hnkl^lmaZm^gZ[e^ehp^k&ldbee^]a^Zema <Zkm^k<^gm^kÌl>mabhibZIn[eb\A^ZemaMkZbgbg` phkd^klmhni`kZ]^mhfhk^Z]oZg\^]ihlbmbhgl' BgbmbZmbo^' P^^qm^glbo^erZiieb^]ma^dghpe^]`^]^o^ehi^][r Government support and consultation ma^Mhn\a?hng]Ztion over the course of five years’ Bn tandem with field research. the team work^] phkdZmP^bee.hZk]%k^`Zk]bg`lmn]^gm ikhihl^]lhenmbhgl' ^]n\Ztion financing.n`Zg]h ]h\nf^gmbg``ho^kgf^gmbgbmbZmbo^lbg\hglb]^kZmbhg% ikhob]^]Zfh]^eh_ln\\^llmaZmhma^kMZgsZgbZg ieZggbg`%hkbfie^f^gmZmbhgiaZl^l4Zg]ikh[bg` mkZbgbg`bglmbmnmbhgl\hne]k^ieb\Zm^'MablphkdZelh ma^ihebmb\Ze_^Zlb[bebmrh_g^pbgbmbZmbo^l'Ma^Mpb`Z a^ei^]b]^gmb_rhiihkmngbmb^l_hkiheb\r\aZg`^maZm BgbmbZmbo^pZlho^kl^^g[rma^<ab^_Fedical Officer% phne]_nkma^k^gaZg\^ma^bfiZ\t of such efforml' =k'=^hFmZlbpZ%Zg]ma^m^Zfphkd^]bgiZkmg^klabi pbmama^=bk^\mhkh_AnfZgK^lhnk\^l=^o^ehif^gm% Despite our efforml%ma^l^o^k^ÇZg]p^ee&dghpg =k'@be[^kmFeb`Z%Zg]abl]^iZkmf^gm' ÇlahkmZ`^h_k^ebZ[e^]Zta in this field has a significant impacmhgZgZgZermb\ZiikhZ\aZg]Zgr Hma^kd^y officials consulted include the direcmhklh_ k^lnembg`\hg\enlbhgl'P^ma^k^_hk^`Zve significant :]fbgblmkZmbhgZg]I^klhgg^e%Iheb\rZg]IeZggbg`% weighting toward firsm&aZg]bg_hkfZmbhg`e^Zg^] Zg]AhlibmZeL^kob\^l%Zg]gnf^khnlfbgblmkr _khfbgm^kob^plhklbm^oblbml%bg\k^Zlbg`]bk^\mbhgZe lniihkmltaff'BgZ]]bmbhgmha^Zemafbgblmky officials. Other inputs The challenge of a molecular system P^ng]^kmhhdZ\hfik^a^glbo^k^ob^ph_^qblmbg` Mablk^ihkmeZrlhnmZgnf[^kh_ikZ\mb\ZepZrlbg efformlmhk^lheo^ma^`eh[Zea^Zemaphkd^klahkmZ`^' pab\aa^Zemaphkd^kmkZbgbg`\ZiZ\bmrbgMZgsZgbZ\Zg Mablbg\en]^]k^ob^pbg`in[ebla^]k^ihkts and official [^^qiZg]^]%k^lnembg`bgZ]hn[ebg`h_a^Zemaphkd^k MZgsZgbZg]ZmZ%Zg]bgm^kob^pbg`in[eb\a^Zema ikh]n\mbhgpbmabgl^o^gr^Zkl'Ma^Z\mbhgieZgl ^qi^kmlZg]k^ik^l^gmZmbo^lh_]hghk`ho^kgf^gml `^g^kZm^]]nkbg`mablk^l^Zk\a\Zg[^bfie^f^gm^] Zg]ghg&`ho^kgf^gmZehk`ZgbsZmbhglphkdbg`hg ghp'IeZglln\aZlma^l^p^k^Zd^r]^fZg]h_ma^ mablblln^' @eh[ZeA^ZemaPhkd_hk\^:eebZg\^!GHWA"\hg_^k^g\^ bgN`Zg]ZbgFZk\a+))1%pab\ae^]mhma^DZfiZeZ BgMZgsZgbZ%ma^m^Zflihd^pbma[hmaeh\ZeZg] =^\eZkZmbhg'BgMZgsZgbZ%ma^ieZglghp^qblmZg] bgm^kgZmbhgZehk`ZgbsZmbhgl%bg\en]bg`Ma^<ZiZ\bmr Zk^iZkmh_`ho^kgf^gmiheb\r%[nmZmma^mbf^h_ Ikhc^\m%B&M^\a%Zg]ma^<ebgmhg?hng]Zmbhg'?hk in[eblabg`%bfie^f^gmZmbhgbllmZee^]]n^mhZeZ\dh_ \hfiZkZmbo^\Zl^lmn]b^l%m^Zff^f[^klbgm^kob^p^] sufficiently fleqb[e^k^lhnk\^lmh\Zkkrma^fhnm' e^Z]^klh_ma^Ngbm^]Dbg`]hfÌl=^iZkmf^gm_hk Bgm^kgZmbhgZe=^o^ehif^gm&lihglhk^]>f^k`^g\r AnfZgK^lhnk\^lIkh`kZfbgFZeZpb%ma^@eh[Ze 4 ACTION NOW .

non-profit 501(c)(3) phkd^klZk^Zee^ll^gmbZemhfZqbfbs^ma^bfiZ\mh_ organization that aims to improve access to basic health ^qiZg]^]mkZbgbg`hgma^ho^kZeelbs^Zg]lmk^g`mah_ care in sub-Saharan Africa by working with our partners to ma^phkd_hk\^'?nkma^k%pabe^a^Zemaphkd^klZk^ma^ overcome two fundamental problems: g^\^llZkrik^k^jnblbm^pbmahnmpab\aa^Zemalrlm^fl ›:i`k`ZXcj_fikX^\f]_\Xck_ZXi\nfib\ijÅ[fZkfij# \Zgghm_ng\mbhg%pa^gma^lrlm^flma^fl^eo^lZk^ nurses. and data analysis Bglahkm%ZlmkZm^`rh_l\Zebg`a^Zemaphkd^kmkZbgbg` Touch Foundation’s approach to solving these problems in the absence of\hfik^a^glbo^a^Zemalrlm^fk^_hkf is unique in that we combine the best of private and public pbeeghm]^ebo^kZlnlmZbg^]bfikho^f^gmbga^Zema sector approaches and expertise. procnk^f^gm%lniier country acutely affected by this workforce shortage. and lab technicians ]rl_ng\mbhgZe%a^Zemaphkd^klZk^l^o^k^eraZfi^k^] ›N\Xbe\jj\jf]\o`jk`e^_\Xck_jpjk\djÅkiXejgfikXk`fe# bgma^bkZ[bebmrmhmk^ZmÇZg]lZo^Çma^bkiZmb^gml' communication. ^o^glmk^g`ma^gbg`Zlbg`e^\hfihg^gmhk\hoZe^gm [hg][^mp^^gmph\hfihg^gml]kZfZmb\ZeerZem^klma^ ikhi^kties and effecmlh_ma^^gmbk^iZkmb\e^4ln\abl Zelhmkn^h_Za^Zemalrlm^f' Pabe^ma^[^g^ficial effecmlh_fZgro^kmb\ZebgbmbZmbo^l ln\aZlbg_ZgmoZ\\bgZtions or disease-specific ikh`kZflZk^ma^k^_hk^\hfi^eebg`%ma^ehg`&m^kf lnlmZbgZ[bebmrh_ma^^qblmbg`a^Zemalrlm^f!hk ma^bfiZ\mh_ln\aikh`kams outside their field of \hg\^gmkZmbhg"Zk^ghmZepZrlZ]^jnZm^erZ]]k^ll^]' P^ma^k^_hk^mZ\de^]mablikh[e^fbgma^Lake Zone Initiative%pab\aik^l^gmlZgnf[^kh_ZiikhZ\a^l ]^lb`g^]mhlmk^g`ma^g^ll^gmbZea^Zemalrlm^f \hfihg^gmlÇbgmZg]^fpbmaa^Zemaphkd_hk\^ \k^ZmbhgÇln\amaZmbgo^lmf^gmlbg^bma^kZk^ghmehlm ho^kma^ehg`m^kf' THE TWIGA INITIATIVE 5 . \aZbgeh`blmb\l%ltaff rem^gmbhgZg]]^o^ehif^gm% Since our incorporation in 2004. pharmacists. leveraged from our hnm\hf^l' partnerships with governments. growing it Zeema^hma^k^e^f^gmlh_Zkh[nlma^Zemalrlm^f'Bg from an inaugural ten MD students in 2004 to eight hundred ma^lmkn\mnk^h_Zfhe^\ne^%k^fhobg`%p^Zd^gbg`%hk students in eight disciplines in 2008-09. f^\aZgblflmh[^]^o^ehi^]lbfnemZg^hnler3a^Zema We have begun our work in Tanzania. we have worked with our bg_kZlmkn\mnk^ieZggbg`Zg]]^o^ehif^gmÇbg]^^]% Tanzanian partners to expand Weill Bugando’s university and 900-bed teaching hospital in Mwanza. finance. Our model is to engage local leaders A^Zemaphkd^kmkZbgbg`\Zgma^k^_hk^[^l^^gmh from the beginning in order to help rebuild their existing [^Zghma^ko^kmb\ZebgbmbZmbo^%k^jnbkbg`^gZ[ebg` healthcare system.:g]mkaining is only the firsmbgZl^kb^lh_lmZ`^lh_ anfZgk^lhnk\^fZgZ`^f^gm'Abkbg`%]^iehrf^gm% ABOUT THE TOUCH FOUNDATION k^m^gmbhg%Zg]ikh_^llbhgZe]^o^ehif^gmh_a^Zema The Touch Foundation is a secular. Tanzania. management. and nonprofits. infection control. rather than building a parallel one. medical supplies. an East African lrlm^ffZgZ`ement. development partners. corporations.

krZg%l^kobg`bgabl]nZe\ZiZ\bmrZl Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^_hkma^bk Z=bk^\mhkh_F\Dbgl^r<hfiZgrZg]Ik^lb]^gm `^g^khnlZllblmZg\^bg]ZmZ\hee^\mbhg%ZgZerlbl% h_ma^Mhn\a?hng]Zmbhg':fZg]ZKZpel%>ebsZ 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 \hglb]^kable efformlmhpZk]ma^ikh]n\mbhgh_mabl k^\hff^g]Zmbhgl4=k'<aZke^lFZcbg`^%]bk^\mhk& k^ihkm' `^g^kZeh_ma^.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.Acknowledgments Ma^e^Z]Znmahklpah]bk^\m^]ma^phkdp^k^:g`nl HÌLa^Z%Mhn\a?hng]Zmbhg>q^\nmbo^=bk^\mhk% Ma^Znmahkl`kZm^_neerZ\dghpe^]`^ma^MZgsZgbZg Zg]Ehp^ee. or donors to. the Touch Foundation.n`Zg]hF^]b\Ze<^gmk^4Ikh_^llhk CZ\h[FmZ[Zcb%ikbg\biZeh_ma^P^bee. h_ahlibmZel^kob\^l_hkma^MZgsZgbZg`ho^kgf^gm4 Zg]Zeeh_ma^ikbg\biZel%]^Zgl%ahlibmZe]bk^\mhkl% _Z\nemr%Zg]lmn]^gmlpahZllblm^]hnkm^Zfbgma^bk ]ZmZ\hee^\mbhgZg]ZgZerlbl' P^Zelh`kZm^_neerZ\dghpe^]`^ma^ZllblmZg\^h_ \hglnemZgml_khfF\Dbgl^r<hfiZgrÌla^Zema lrlm^flZg]`eh[Zea^ZemaikZ\mb\^lbgEhg]hg% 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 .

<http://frwebgate.cgi?dbname=110_cong_public_ laws&docid=f:publ293. “Training the health workforce: scaling up. Hyde United States Global Leadership Against HIV/AIDS. 2008: 689-91.” The Lancet 23 Feb.gov/cgi-bin/getdoc.i^k*)%)))i^hie^bg+))+%[^_hk^ k^Z\abg`bmlik^l^gmehp'+Mhf^^mma^WHOlmZg]Zk]% Executive Summary MZgsZgbZg^^]ll^o^gmrmh^b`amrmahnlZg]Z]]bmbhgZe \ebgb\Zea^Zemaphkd^klÇghp'=^libm^gnf^khnl bgbmbZmbo^lZg]Z`ho^kgf^gmmaZmp^eek^\h`gbs^lma^ :oZbeZ[bebmrh_mkZbg^]a^Zema\Zk^phkd^klbl blln^ZlZ[lhenm^er\kbmb\Ze%ma^\hngmkraZlghm[^^g ghp_neerZ\\^im^]Zlhg^h_ma^\kbmb\Ze_Z\mhkl Z[e^mhk^o^kl^mablmk^g]' bgbfikhobg`a^Zemahnm\hf^lZg]lZobg`ebo^l' Bgm^eeb`^gmbgo^lmf^gmbga^Zemaphkd^kl\ZgkZib]er 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 ldbeel!^'`'%ik^l\kb[bg`Zmk^Zmf^gm_hk]bZkka^Zhk K^ihkm%bgm^kgZmbhgZebgm^k^lmbgZg]Z]oh\Z\r_hk ]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]. Pabe^ma^WHOaZl]^m^kfbg^]maZm+. Tuberculosis and Malaria Reauthorization Act of 2008. 3 See Tom Lantos and Henry J.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.110.” Global Health Workforce Alliance (GHWA) Mar 2008 <http://www. a^Zema\Zk^g^^]^]mhf^^mma^Ngbm^]GZmbhglÌ!UN) Fbee^ggbnf=^o^ehif^gm@hZel!MDGl)%ma^gnf[^k bgMZgsZgbZblZebmtle over five. 4 See “Agenda for Global Action. “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.WHO. see also Nigel Crisp et al..access.nmma^rZk^ !GHWA"\hgvened the firsm@eh[Ze?hknfhgHRHbg bglahkmlniierbgma^]^o^ehibg`phke]'@ho^kgf^gml DZfiZeZbgFZk\a+))14Zg]ma^.rmablf^Zlnk^%ma^lbmnZmbhgbgMZgsZgbZaZl`khpg ikh`k^llbo^erphkl^bgma^iZlt fifm^^gr^Zkl'Lbg\^ *22-%ma^a^Zemaphkd^k]^glbmraZ]_Zee^g_khf khn`aer+1mh*. 122 Stat 2946 (2008).ZgdaZl]^o^ehi^] Zk^l^Zk\aZk^Z_h\nlbg`^q\enlbo^erhgma^a^Zema A^Zema\Zk^phkd^kl\hngl^e%Zll^ll%]bZ`ghl^%oZ\\bgZm^% phkd_hk\^4ma^@eh[ZeA^ZemaPhkd_hk\^:eebZg\^ mk^Zm%ik^l\kb[^%]bli^gl^%k^_^k%Zg]hi^kZm^'. .int/workforcealliance/forum/1_agenda4GAction_ final.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 bfieb\Zmbhgl_hkang]k^]lh_fbeebhglh_i^hie^'Ma^ Fhlmk^\^gmer%bgCner+))1ma^Ngbm^]LmZm^l +))-Joint Learning InitiativeZg]ma^Phke]A^Zema <hg`k^llk^Znmahkbs^]ma^Ik^lb]^gmÌl>f^k`^g\r Hk`ZgbsZmbhgÌl!WHO"+))/Phke]A^ZemaK^ihkm% IeZg_hkAIDSK^eb^_!PEPFAR"Zg]bglh]hbg`\Zee^]_hk 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'.pdf>. saving lives. GPO Access.gpo.pdf>. Web. Public Law 110-293.. THE TWIGA INITIATIVE 7 .

7 Tanzania. 2006).i^k\^gm4 Ma^eZ\dh_]ZmZhgpab\amh[Zl^[nlbg^ll\Zl^l Zg]mabk]Zg]bgiZkallel to the firsmZg]l^\hg]% Zg]\hlm^]bfie^f^gmZmbhgieZglbgab[bm^]ma^ bg\k^Zl^mkZbgbg`\ZiZ\bmr[rZme^Zlt fifmri^k\^gm_hk a^ZemafbgblmkrÌlZ[bebmrmhl^^d_ng]bg`':g]ma^ ma^lrlm^fmhk^fZbgZm\nkk^gm\ZiZ\bmrk^eZmbo^mh bgm^k]^i^g]^g\b^l[^mp^^g^qiZglbhglbgmkZbgbg` ma^ihineZmbhg' \ZiZ\bmr%ho^kZeelniier(]^fZg]mk^g]l_hka^Zema phkd^kl%Zg]ieZgg^]\hglmkn\mbhgh_g^pa^Zema Bg+))/%Mhn\aZg]F\Dbgl^rin[ebla^]Zchbgmlmn]r \Zk^_Z\bebmb^lp^k^ghm_neer]h\nf^gm^]_hknl^bg ZgZersbg`ma^a^Zemaphkd_hk\^\kblblbgMZgsZgbZ% phkd_hk\^ieZggbg`' 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 mhpZk]`khpbg`Zkh[nlma^Zemaphkd_hk\^bgma^ k^Zebmr'P^_hng]maZmln\\^ll_neer]^o^ehibg`ln\a \hngmkr%iZkmb\neZker`bo^gma^e^Z]mbf^lk^jnbk^] ZgZ\mbhgieZgk^jnbk^]mak^^\hfihg^gml3 _hka^Zemaphkd_hk\^\k^Zmbhg'?nkma^k%p^]bl\ho^k^]  I  arlb\Ze%hg&lbm^Zll^llf^gmh_MZgsZgbZÌlmkZbgbg` maZmbgo^lmbg`bgbg]b`^ghnla^Zemaphkd^kmkZbgbg` bglmbmnmbhglmh]^m^kfbg^ma^bkihm^gmbZe_hk pZlab`aer\hlt-effecmbo^%iZkmb\neZkerpa^g\hfiZk^] ^qiZglbhg pbmabfihkmbg`a^Zemaphkd^kl_khfZ[khZ]'  >  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. Investing in Tanzanian Human Resources for Health: an HRH study for the Touch Foundation (McKinsey & Company. 6 Lowell Bryan et al. Ministry of Health and Social Welfare. 2008) 11. 2004). Ministry of Health and Social Welfare. 8 Tanzania. Human Resource for Health Strategic Plan 2008-2013 (HRHSP) (Dar es Salaam: MOHSW.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 phkd^kmkZbgbg`[nm]b]ghm\hgg^\mmablpbmaZ mZk`^m^]k^\knbmf^gmikh`kZfmh\Zimnk^fhk^h_ma^ \hg\k^m^l^mh_Z\mbobmb^lZg]bgo^lmf^gml_hk]hbg`lh' \nkk^gmmkZbgbg`hnminm4l^\hg]%bg\k^Zl^ikh]n\mbobmr i^k^qblmbg`a^Zemaphkd^k[rZlfn\aZl0. 8 ACTION NOW .%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%.Bg+)). May 2007) 6.. Jan. Primary Health Services Development Programme 2007-2012 (MMAM) (Dar es Salaam: MOHSW.

+%)))[r R^ZkM^g%hkfhk^maZg]hn[e^bml\nkk^gmlbs^'P^ ^qZfbg^]mabl\kbmb\Zeblln^h_k^m^gmbhgbghnkEZd^ Shg^]bZ`ghlmb\' 9 The reported number of health worker training schools in Tanzania varies widely. The MMAM cites 116. based upon the 2005 School Bulletin. THE TWIGA INITIATIVE 9 .%1.))a^Zema Pabe^^Z\ah_ma^. Tanzania has 87 health worker training centers. MZgsZgbZphne][^`kZ]nZmbg`Z[hnm0%.2l\ahhelp^oblbm^]_Z\^]Zngbjn^ \Zk^phkd^kli^kr^Zko^klnlma^+))2kZm^h_Z[hnm \hf[bgZmbhgh_ma^l^\hglmkZbgml%p^p^k^^g\hnkZ`^] .)'Ahp^o^k%[^\Znl^bmmZdes years from the firsm mhe^ZkgmaZm_^p_Z\^]Zeelbq'>Z\abglmbmnmbhgaZ] bg\k^Zl^bglmn]^gmbgmZd^ngmbemahl^lmn]^gml^gm^k \ZiZ\bmrmhliZk^hgZme^Zlmhg^]bf^glbhg%fZdbg` ma^phkd_hk\^!ma^Ëibi^ebg^’ effecm"%ma^_neebfiZ\mh_ himbfbsZmbhgh_ma^\nkk^gmmkZbgbg`g^mphkdZfhk^ bg\k^Zl^]mkZbgbg`\ZiZ\bmrpbeeghm[^^ob]^gmngmbe ZmmkZ\tive and efficient approach than trrbg`mh\k^Zm^ five to six years afm^kma^g^pikh`kZfblbgbmbZm^]' g^pbglmbmnmbhglbff^]bZm^er' ?nkma^k%\nkk^gmZmmkbmbhgkZm^lbgma^a^Zema\Zk^ BgZ]]bmbhg%Zgnf[^kh_l\ahhel\hne]`^g^kZm^ phkd_hk\^!Zo^kZ`bg`Z[hnmmabkm^^gi^k\^gmh_mahl^ ^\hghfb^lh_l\Ze^pbmafbgbfZebgo^lmf^gm[rZ]]bg` bgl^kob\^ZggnZeer"f^ZgmaZmZ[hnm0.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.%-))mh-1%)))b_bfie^f^gmZmbhg [^`bglbg+)*)"'B_ohengmZkrZmmkbmbhg\hne][^aZeo^]% ma^a^Zema\Zk^phkd_hk\^\hne]`khpmh.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`. and limited financial resources. school-specific improvements – such \hne]]hn[e^bmlmkZbgbg`\ZiZ\bmr[r+)*.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.i^k\^gmh_ g^pikh`kZfl'BgMZg`Z%_hk^qZfie^%ma^^qblmbg` ma^phkd^kl`kZ]nZmbg`Zk^[^bg`nl^]mhk^ieZ\^ ]^gmZel\ahheikh`kZf\hne][^e^o^kZ`^]mh\k^Zm^Z ^qblmbg`phkd^klkZma^kmaZgZ]]bg`mhma^a^Zema g^p<linical Officer (CO"mkZbgbg`ikh`kZf%Zlma^mph \Zk^ihineZmbhg'Bg\hf[bgZmbhg%ma^k^_hk^%[hmama^ ikh`kZflaZo^ma^lZf^\nkkb\nenf_hkma^fiklmr^Zk pipeline effecmZg]ab`aZmmkbmbhgkZm^lebfbmma^g^Zk& Zg]ZaZe_'Ln\a^qiZglbhgphne]k^jnbk^\hglmkn\mbhg m^kfbfiZ\mmaZmbg\k^Zl^]mkZbgbg`\ZiZ\bmr\ZgaZo^' h_ZeZk`^k\eZllkhhfZg]^qiZg]^]lmn]^gmahnlbg`% =^libm^mabl%p^_hng]maZmZ]himbhgh_mablieZg [nm\hne]Z\ab^o^Zgbg\k^Zl^h_nimh_hkmrCOlmn]^gml \hne]g^Zker]hn[e^ma^a^Zema\Zk^phkd_hk\^[rma^ pbmahnmma^g^^]_hkZ]]bmbhgZe_Z\nemr' m^gmar^Zk!_khf+. The number 97 comes from the 87 in the HRHSP.)fbeebhgZg]Zghg`hbg`ZggnZe\hlm _hng]maZml\ahhel_Z\^lbq\hffhg\hglmkZbgml h_Zkhng]*)fbeebhg' in scaling up: lack of qualified smn]^gml%lahkmZ`^ h_ghg&\ebgb\Ze_Z\nemr%lahkmZ`^h_\ebgb\Ze_Z\nemr% Specifically%mablf^ZglmaZmbgma^m^gmar^Zk bgZ]^jnZm^ghg&\ebgb\Zebg_kZlmkn\mnk^%ln[&l\Ze^ _heehpbg`ma^bfie^f^gmZmbhgh_mablikh`kZf% \ebgb\Zebg_kZlmkn\ture. when our field work found them to be functionally independent. According to the 2007 draft HRHSP. with some of the institutions listed in that document subdivided into their component programs.

Enabling system-wide support ]bli^glZkb^llbmmbg`ngZ[e^mhhi^g%ZpZbmbg`ltaff to hi^kZm^ma^f' School-specific optimization efforml%ahp^o^k%\Zgghm ln\\^^]pbmahnmlbfnemZg^hnllrlm^f&pb]^\aZg`^l mhlniihkmmahl^bfikho^f^gml'Pe identified four Furthering transformational change ln\abgbmbZmbo^l3 >qiZg]bg`\ZiZ\bmrbl^ll^gmbZe%[nm[rbml^e_bmpbee  >  g\hnkZ`e and subsidize off-campus housing  ghm^gZ[e^MZgsZgbZmhZ\ab^o^bmlhpgZf[bmbhnl _hklmn]^gml' a^Zemaphkd_hk\^ltaffing ghZelhkf^^mma^Ziieb\Z[e^ WHOlmZg]Zk]l'Ma^]^ficit is now nearly 90. MkZbgbg`Za^Zema fbkkhklma^ZoZbeZ[e^lniierh_phkd^klmhltaff them. phkd^kmZd^lZgZo^kZ`^h_mak^^r^ZklZg]ghe^ll fbgbfbsbg`ma^pZlm^Zg]ihebmb\Zekbldh_[kZg]&g^p maZgmph'Bmphne][^phkmapabe^mhl^^dg^p 10 Based on the WHO guidelines for health worker density.000  >  g\hnkZ`^_Z\nemrf^f[^klmh\hgmbgn^m^Z\abg` a^Zemaphkd^kl%Z\\hk]bg`mhWHO`nb]^ebg^l'Mabl [^rhg]ma^gZmbhgZek^mbk^f^gmZ`^h_/)' \hkk^lihg]l\ehl^ermhma^oZ\Zg\b^lmaZmpbee[^  I  khob]^bg\^gmbo^l_hkln\\^ll_neMDlmn]^gml \k^Zm^]pbmama^ltaffing demands of the nepMMAM mhm^Z\abg^q\aZg`^_hkikbhkbmr^gmkrmhZ iheb\r%pab\a\Zeel_hkfhk^maZg*-)%)))phkd^kl ihlm&`kZ]nZm^li^\bZebsZmbhg' [r+)*0 *)mhltaff nep_Z\bebmb^lZlp^eeZlma^^qblmbg`  K  ZmbhgZebs^mnbmbhgmh^glnk^maZmbg\hf^i^k ]bli^glZkb^l%a^Zema\^gmk^l%Zg]ahlibmZel' lmn]^gm\ho^klma^_nee\hlmh_lmn]^gmlÌ^]n\Zmbhg' >o^gpbmama^bfie^f^gmZmbhgh_Mpb`Z%ma^\hngmkr Ma^Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^!ma^ pbeeaZo^cnlm-1%)))phkd^klbg+)*2%e^Zobg`Z`Zi Fbgblmkr"aZlZek^Z]rng]^kmZd^gl^o^kZelrlm^f& h_ho^k2+%)))pa^gihineZmbhg`khpmablmZd^g pb]^\nkkb\neZk\aZg`^lmaZmpbeeaZo^Z]bk^\mbfiZ\m bgmhZ\\hngm'<nmmbg`ZmmkbmbhgkZm^lbgaZe_\hne]Z]] hgmkZbgbg`makhn`ainm'Ma^l^k^oblbhglbg\en]^ i^kaZil_hnkmahnlZg]mhma^phkd_hk\^'R^mZ`Zih_ lahkm^gbg`ma^gnklbg`\^ktificam^Zg]]biehfZ ho^k11%)))phne]k^fZbg' ikh`kZfl!_khfmak^^mhmphr^ZklZg]_khf_hnkmh mak^^r^Zkl%k^li^\mbo^er"%Zg]Z]]bg`Zg^p<ebgb\Ze No silver bullets :llblmZgm!CA"\Z]k^%pbmamphr^ZklÌmkZbgbg`'Ma^ Pabe^bmpZlm^fimbg`mhl^Zk\a_hkZlrlm^f&pb]^ g^t effecmpbee[^mhbg\k^Zl^makhn`ainmh_>gkhee^] Ëlbeo^k[nee^mÌlhenmbhgmha^eiZee^obZm^ma^k^fZbgbg` Gnkl^l!EN"[r.480 skilled health workers.i^k\^gmZg]K^`blm^k^]Gnkl^l!RN" a^Zemaphkd_hk\^`Zi%p^aZo^ghm[^^gZ[e^mh by 25 percent. of which 115. demand in 2019 will be 140. indicating that the MMAM policy is aligned with international standards and Tanzania’s needs to meet the MDGs.900 must have clinical skills. adding over five hundred additional b]^gmb_rZgy such quick fix in the course of this work a^Zemaphkd^klZmma^ikbfZkr\Zk^e^o^ei^kr^Zk' hkbgma^^qi^kb^g\^h_^bma^kF\Dbgl^rhkma^Mhn\a Nlbg`ma^]ZmZZgZerlblmhhep^]^o^ehi^]%ma^ ?hng]ZmbhgbgMZgsZgbZho^kma^iZlmlbqr^Zkl' MZgsZgbZg`ho^kgf^gmpbee[^Z[e^mhfhgbmhkma^ P^]b]%ahp^o^k%b]^gmb_rZl^mh_mkZgl_hkfZmbhgZe bfiZ\mh_ma^mkZbgbg`bfikho^f^gmlhgZr^Zk&[r& hiihkmngbmb^lmaZt could significantly narrow the r^Zk[Zlbl%ebgdbg`mkZbgbg`lrlm^fbfikho^f^gmlpbma `Zi'Mhe firsml^mh_himbhglbgoheo^lmkZgl_hkfbg` ma^ZoZbeZ[e^lniierh_a^Zemaphkd^klbg^Z\a\Z]k^' ma^mkZbgbg`lrlm^fho^kma^g^qmmphmh_hnkr^Zkl Ma^mhhe\Zg^gZ[e^]^\blbhgfZd^klmhb]^gmb_rma^ [rk^eb^obg`_ng]Zf^gmZe\hglmkZbgmlhgma^\nkk^gm mkadeoffs necessarr_hkma^MZgsZgbZg`ho^kgf^gmmh lrlm^f%Zl_heehpl3 Z\ab^o^bml`hZel'Mabl_kZf^phkdpbeeZeehpMZgsZgbZ mhl^mZiZ\^_hkma^^qiZglbhgh_\Zk^_Z\bebmb^lmaZm  Shorten the training pipeline. 10 ACTION NOW ..

% bfie^f^gmZmbhgieZgmhlniihkmhg`hbg`^oZenZmbhg mablhiihkmngbmr\hne]^ll^gmbZeer\ehl^ma^`Zi and modificambhg' bga^Zemaphkd^klÇmahn`a\Zk^phne]g^^]mh [^mZd^gmh^glnk^maZmkZib]mkZbgbg`\hg_^kk^] Ma^Fbgblmkr\Zgghm]hmablbg]^i^g]^gmer%ahp^o^k% sufficient clinical skills to enable the work^klmh[^ `bo^gbmlZek^Z]rlmk^m\a^]k^lhnk\^l'<heeZ[hkZmbhg effecmbo^bg]^ebo^kbg`ZiikhikbZm^ikbfZkr\Zk^' bg[hma_ng]bg`Zg]^q^\nmbhgbl\kbmb\Ze'MkZbgbg`  Augment capacity with technology. leadership. ZiikhZ\a^lmh]^\k^Zlbg`ma^mbf^k^jnbk^]mh Capabilities. significant progress while it continues to assess Zg]]^lb`gfhk^mkZgl_hkfZmbhgZebgbmbZmbo^l'Hnk Pabe^Z]]bmbhgZeZgZerlblblk^jnbk^]mh]^m^kfbg^ ]ZmZ\hee^\mbhgf^mah]heh`rZg]ZgZerlblp^k^ghm ma^ik^\bl^bfiZ\mh_^Z\ah_ma^l^bgbmbZmbo^l%Zee k^ohenmbhgZkr%[nmp^[^eb^ve we filled an eq\^^]bg`er mak^^Zk^l\ZeZ[e^%]^i^g]bg`bgiZkmhgma^e^o^eh_ bfihkmZgm`Zimhhh_m^ge^_mngZ]]k^ll^]'HnkZbf bgo^lmf^gm'Fhk^ho^k%Zeemak^^h_ma^l^bgbmbZmbo^l pZlmhikhob]^ma^g^\^llZkrm^\agb\ZeZllblmZg\^mh \hfie^f^gm^Z\ahma^k'B_ln\\^ll_neerbfie^f^gm^]% fZd^ma^e^Zi_khfZf[bmbhnllmkZm^`b^lmh^q^\nmZ[e^ bg\hf[bgZmbhg%ma^raZo^ma^ihm^gmbZemh^gZ[e^ Z\mbhgieZgl' MZgsZgbZmhZ\ab^o^bmlh[c^\mbo^lZg]]^ebo^k bg\k^Zl^]l^kob\^lmhbmli^hie^' THE TWIGA INITIATIVE 11 .ObkmnZee^Zkgbg` bglmbmnmbhgl%shgZee^Z]^klabi%ma^Fbgblmkr%]hghkl% m^\agbjn^l%ln\aZlDVDmkZbgbg`ikh`kZfl%\hne] Zg]Z]oblhklfnlmphkdlrlm^fZmb\ZeermhpZk]Z ^qiZg]mkZbgbg`\ZiZ\bmrb_nl^]bg\hgcng\mbhg \hffhg`hZeZg]pbmabgZ\hffhg_kZf^phkd' pbmabg\k^Zl^]\ebgb\ZekhmZmbhglZm]blmkb\mZg] k^`bhgZeahlibmZel'Ln\aZiikhZ\a^l\hne]Zelh[^ Implementation starting now nl^]mh\hgmbgn^bg&l^kob\^mkZbgbg`_hkphkd^kl MkZgl_hkfZmbhgZeZiikhZ\a^lmha^Zemaphkd^k mkZbg^]hgZ\\^e^kZm^]l\a^]ne^l' mkZbgbg`pbee[^g^\^llZkrmh`^g^kZm^Za^Zema  Ensure financial sustainability. or smn]^gmehZgl\hne]a^eil\ahhel \hglmkZbgmlhg\ZiZ\bmr' ^qiZg]bgZf^mah]b\ZepZr%ihm^gmbZeerZmfbgbfZe Z]]bmbhgZe\hlmmhma^`ho^kgf^gm%Zg]^gZ[e^ma^ ?ng]bg`i^kfbmmbg`%mabl_Z\bebmr&e^o^ehimbfbsZmbhg ^qiZglbhgh_mkZbgbg`\ZiZ\bmrmh[^bg\k^Zlbg`er \Zg[^`bgbff^]bZm^er%Zeehpbg`MZgsZgbZmhfZd^ self-financing. and ^]n\Zm^g^p%ehp^k&ldbee^]%a^Zema\Zk^phkd^kl' funding are required ?hk^qZfie^%\k^Zmbhgh_Z\hg]^gl^]%ldbeel&[Zl^] Himbfbsbg`ma^^qblmbg`mkZbgbg`lrlm^fZg] \nkkb\nenf_hkZehp^lm&ldbee^]\ebgb\Ze\Z]k^mh k^fining the nepmkZbgbg`ZiikhZ\a^lpbeek^jnbk^ effecmbo^er]^ebo^kikbfZkra^Zema\Zk^l^kob\^l ldbee^]ikhc^\mfZgZ`^f^gm%Z\ab^oZ[e^ZggnZe \hne]ikh]n\^ZgZ]]bmbhgZel^o^gmahnlZg] mZk`^ml_hkbfikho^]makhn`ainm%Zg]Zmahn`am_ne a^Zemaphkd^kli^kr^Zk'B_bfie^f^gm^][r+)*. Lmn]^gm_^^lZm phkd_hk\^maZmf^^mlma^fbgbfnfWHOkZmbh'.nm fhlmikboZm^Zg]Zee`ho^kgf^gml\ahhel]hghm ln[lmZgmbZeikh`k^llbgphkd_hk\^^qiZglbhg%]kbo^g \ho^kma^_nee\hlmh_^]n\Zmbhg%e^mZehg^ma^ [rZ]hn[ebg`h_mkZbgbg`\ZiZ\bmr%\Zg[^Z\ab^o^] bg\k^f^gmZe\hlmh_\hgmbgn^]bgo^lmf^gm_hk makhn`ahimbfbsbg`ma^^qblmbg`mkZbgbg`lrlm^f% lnlmZbgZ[bebmr'KZblbg`lmn]^gm_^^lZg]himbfbsbg` Zg]k^Zebsbg`ZlfZeel^mh_d^rbgbmbZmbo^lmZk`^mbg` ma^`ho^kgf^gmÌlZiikhZ\amh\hlmlaZkbg`% m^Z\abg`ltaff and smn]^gmahnlbg`Çma^ikbfZkr financial aid.

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 .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.

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

Cambodia.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. and Thailand Western Pacific: Oceania. North Korea.000 10 Europe 40. South. 2004).EXHIBIT 1 EXHIBIT 2 Most disease. Myanmar. fZgr\hngmkb^l' phkd^kli^km^gmahnlZg]i^hie^'Ma^r]^fhglmkZm^] maZmpbmahnmbff^]bZm^bgo^lmf^gmbga^Zemaphkd^kl% :grln\\^ll_nelmkZm^`r_hkk^lheobg`ma^a^Zema mablmZk`^mÇZg]ma^[^mm^ka^Zemabmk^ik^l^gmlÇ phkd_hk\^\kblblfnlm\hglb]^kZeeh_ma^l^lmZ`^l \Zgghm[^Z\ab^o^]'*/ Zehg`lb]^ma^bg\k^Zl^]ikh]n\mbhgh_a^Zemaphkd^kl' <k^Zmbg`Zg]k^taining a sufficient. producmbo^a^Zema The pipeline problem phkd_hk\^bgoheo^l\hfik^a^glbo^fZgZ`^f^gm Ma^e^g`mah_a^Zemaphkd^kmkZbgbg`ikh`kZflÇ Z\khllZ\hgmbgnnfh_Z\mbobmb^l'K^\knbmf^gmZg] kZg`bg`_khfmphmhfio^r^Zkl%pbmama^Zo^kZ`^ 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 [rlZeZkrZg][^g^fits but also by oppormngbmb^l_hk Zg]ma^bk^gmkrbgmhma^a^Zemaphkd_hk\^'Mabl \hgmbgn^]i^klhgZe]^o^ehif^gmZg]ikh_^llbhgZe Ëibi^ebg^Ì^ff^\mZ\\^gmnZm^lma^bfihkmZg\^h_l\Zebg` Z]oancement. Afghanistan and Pakistan Europe: Eastern and Western Europe including Russia South-East Asia: South Asia. Efficient hiring.000 Eastern Mediterranean 5 45. 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. and Central America Africa: Sub-Saharan Africa and Algeria Eastern Mediterranean: North Africa including Sudan and Somalia. Indonesia. as follows: Health workforce steady state Student intake steady state Americas: North. Laos. and Vietnam =^o^ehif^gm@hZel!MDGl"_hka^Zema%ma^l^k^ihkml fZgZ`^f^gmf^\aZgblflmaZm]hghmr^m^qblmbg ]^\eZk^]ma^mZk`^m\ebgb\Zea^Zemaphkd^k]^glbmrh_+.000 Africa 25 South-East Asia 30 5. World Health Report 2006 11.000 15 Americas 35. fewest doctors Delayed impact Percent of global disease burden Health worker density Health workers 0 50. the Middle East. deployment.000 20 Western Pacific 30. 14 ACTION NOW . East Asia.

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e^o^emh\hngl^e%m^lm%]bZ`ghl^%mk^Zm%Zg]fhgbmhk Z\\^llmh[Zlb\a^Zemal^kob\^l%>mabhibZeZng\a^]Z
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hma^k]bl^Zl^Zg]]blZ[bebmrZk^ZlZlp^ee%mkZbgbg` ?ng]Zg]ma^Ngbm^]Dbg`]hfÌl=^iZkmf^gm_hk
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l\Zebg`niikh]n\mbhgZllhhgZlihllb[e^%gZmbhgl Zf[bmbhgbgmhZ\mbhg'Pabe^]hghk`ho^kgf^gmlZg]
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^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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MZgsZgbZblbgma^`kbih_Za^Zemaphkd_hk\^\kblbl'Bm ]^lmkhrr^Zklh_a^Zemareb_^':gnf[^kh_]bl^Zl^&
aZlcnlm.'+\ebgb\Zea^Zemaphkd^kli^km^gmahnlZg] specific progrZflaZo^^f^k`^]%_ng]^][reZk`^
people, one-fifmah_ma^mZk`^mkZmbhikhihl^][rma^ _hng]ZmbhglZg]fnembeZm^kZe]hghkl%mhikhob]^
WHO'Ma^]^oZlmZmbg`k^lnemlZk^^ob]^gmbg\hffhg ]bZ`ghlblZg]mk^Zmf^gmh_ma^l^ieZ`n^l'
a^Zemahnm\hf^l%ln\aZlfZm^kgZefhkmZebmrkZm^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 phkd^kl_hk+1'1fbeebhgi^hie^';r+))*mablkZmbh
ZfhngmmhZghma^kjnZkm^kh_DALYehll!>qab[bm,"'++ aZ]_Zee^gmh-1%.))a^Zemaphkd^kl_hkZihineZmbhg
Bndeed, over half the losses suffered by the TZgsZgbZg h_,-'.fbeebhg%Zg]mh]Zr%ma^\hngmkraZlkhn`aer
i^hie^Zk^ghmik^l^gmerZ]]k^ll^]makhn`a]bl^Zl^& +.%)))a^Zemaphkd^kl_hkfhk^maZg_hkmrfbeebhg
specific programs and could be significantly reduced i^hie^'+,
[rbg\k^Zlbg`Z\\^llmh[Zlb\ikbfZkr\Zk^'
Bn less than fifm^^gr^Zkl%ma^ikhihkmbhgh_a^Zema
Ma^]^oZlmZmbg`bfiZ\mh_fn\ah_MZgsZgbZÌlikbfZkr phkd^klmhmhmZeihineZmbhgaZl_Zee^g[r0.i^k\^gm'
]bl^Zl^[nk]^g%ma^k^_hk^%\hne][^]kZfZmb\Zeer Bg+))-%ma^ChbgmE^Zkgbg`BgbmbZmbo^k^ihkm^]
k^]n\^]b_mbf^er]bZ`ghlblZg]ZiikhikbZm^mk^Zmf^gm maZmMZgsZgbZaZ]ma^phke]Ìlehp^lm\ho^kZ`^h_
p^k^ZoZbeZ[e^'BgMZgsZgbZ%ZlbglhfZgrh_bml iarlb\bZgl%pbmahger)'+Fedical Officers (MOl)hk
g^b`a[hkbg`\hngmkb^l%ma^d^r[hmme^g^\dik^o^gmbg` li^\bZeblmli^km^gmahnlZg]i^hie^'+-;rma^mbf^h_
effecmbo^a^Zema\Zk^]^ebo^krblghmg^\^llZkber]kn`l ma^+))/L^kob\^Ikhoblbhg:ll^llf^gm%maZt figure
hk_Z\bebmb^l[nmkZma^kma^gnf[^kh_ldbee^]a^Zema aZ]\ebf[^]leb`amermh)'-+. – lmbee]^li^kZm^erehp'
phkd^klikhob]bg`\Zk^bgmahl^_Z\bebmb^l' Ho^kZee%ma^mhmZea^Zemaphkd_hk\^aZllahpgZg
Z\\^e^kZm^]]^\ebg^lbg\^+))*&)+!>qab[bm-"'+/
MZgsZgbZÌla^Zemaphkd_hk\^aZl]^\ebg^]^o^gZlbml
ihineZmbhgaZllhZk^]'Bg*22-%Zlma^in[eb\l^\mhk While the figures for phrlb\bZglZk^lah\dbg`%ma^
hiring freeze took effecm%MZgsZgbZaZ]/0%/))a^Zema 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

>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_\-.013 to 6. 29 Source: TSPAS 2007.)e\ncpYl`ck#le$fg\e\[[`jg\ejXi`\j ›9p)''/#`eZi\Xj\gi\$j\im`Z\\eifccd\ek]ifd are staffed 1.gi`dXipZXi\ ›@dgifm\Xe[\jkXYc`j_dfi\kiX`e`e^`ejk`klk`fejkf facilities ensure adequate numbers of skilled workers ›Jki\e^k_\e_ldXei\jfliZ\j[XkXYXj\ ›<ejli\hlXc`kpf]kiX`e`e^ ›Gifm`[\jlgcc`\jkfXccgi`dXipZXi\]XZ`c`k`\j ›=XjkkiXZbZXgXZ`kpYl`c[`e^f]Xcc`\[_\Xck_nfib\ij ›<ejli\fg\iXk`feXci\]\iiXcjpjk\d to staff primary care facilities ›@eZi\Xj\ÓeXeZ`XcXccfZXk`fekf(. 18 ACTION NOW .-+. HRH Census 2002.)!**i^k\^gm"Zk^li^\bZeblmlhkMOl%*%))-!0* bgmhZphkd_hk\^irkZfb]]^lb`g^]_hkma^\hngmkrÌl i^k\^gm"Zk^gnklbg`ltaff%Zg]+--!*0i^k\^gm"Zk^ g^^]l'P^]b]ghm]bk^\merZ]]k^llma^jn^lmbhgh_ ]bZ`ghlmb\hklniihkmltaff'+0 While the official Staffing ma^b]^Zephkd_hk\^irkZfb]_hkMZgsZgbZÌla^Zema 28 Interviews with medical staff at Bugando Medical Centre.458 2007-2017 MMAM ›I\_XY`c`kXk\Xe[ZfejkilZk/#('. 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 ›. 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.f]XeelXcYl[^\k 2008-2013 HRH ›Jki\e^k_\ec\X[\ij_`gXe[jk\nXi[j_`g ›.phkd^kl%h_pahf ldbeefbqbl_hkMZgsZgbZZg]ahpbmphne]mkZgleZm^ *. 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.\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.\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% bgahlibmZel%a^Zema\^gmk^l%Zg]]bli^glZkb^l%ma^l^ gnklbg`ltaff%Zg]]bZ`ghlmb\Zg]lniihkmltaff'Ma^ bglmbmnmbhglkhnmbg^erhi^kZm^pbmahgerZ_kZ\mbhgh_ gZtional Staffing EsmZ[eblaf^gml]^m^kfbg^ahp ma^ik^l\kb[^]ltaff'=^i^g]bg`hgma^e^o^eh__Z\bebmr% fZgrh_^Z\a\Z]k^h_phkd^k^Z\a_Z\bebmrmri^g^^]l' Zg:llblmZgmFedical Officer (AMO) hkCO fZrZ\mZl ?hk^qZfie^%ma^ehp^lm&e^o^e_Z\bebmr%ma^]bli^glZkr% ma^e^Z]iarlb\bZg'<linical Officers mar^o^gi^k_hkf bllniihl^]mh[^ltaffed by eight work^kl%h_pahf [Zlb\lnk`^kb^lln\aZl\Z^lZkbZgl^\mbhglhka^kgbZ five are lower-skilled nurses and tphZk^ehp^k&ldbee^] k^iZbkl'+1 \ebgb\Zeltaff' Mabl]bl\k^iZg\r[^mween official smZg]Zk]lZg] :mma^hma^k^g]h_ma^li^\mknf%Zk^_^kkZeahlibmZe k^ZebmrbgikZ\mb\^kZbl^lma^jn^lmbhgh_paZmma^b]^Ze bllniihl^]mh[^ltaffed by 1.

physicians and substitute doctors / AMOs in South Africa. and MCH aides for Tanzania.25 0.96 11. laboratory technicians. SSA."%+2Zg] Zk^Z\hffhgmak^Z]knggbg`makhn`ama^k^\^gm \nkk^gmerma^`Zi[^mp^^glniierZg]]^fZg]h_ lnbm^h_a^Zemaiheb\b^lZg]lmkZm^`b\ieZgl%bg\en]bg` ldbee^]a^Zemaphkd^klbllh`k^ZmmaZmbg\k^Zl^] ma^+))0MMAM.53 0. THE TWIGA INITIATIVE 19 .86 0.EXHIBIT 6 A long way to go per 1. medical attendants.12 0. 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 Ma^MZgsZgbZg`ho^kgf^gmbl\hffbmm^]mh h[c^\mbo^l%ln\aZlikhob]bg`fhk^^jnbmZ[e^Z\\^llmh bfikhobg`^jnbmrh_Z\\^llmhjnZebmra^Zemal^kob\^l [Zlb\a^Zemal^kob\^l' gZmbhgpb]^[r+)*0%Zg]mhk^Z\abg`a^Zemahnm\hf^ Ma^\nkk^gmirkamid seems to be a reasonable profile mZk`^mlbgebg^pbmama^MDGl[r+)*. 31 MMAM 12.07 Lower-skilled workers: community health workers for SSA and South Africa. clinical assistants.ma^+))1HRHSP%Zg]ma^fhk^ ikh]n\mbhgblk^jnbk^]_hkZee\Z]k^lbff^]bZm^er' `^g^kZe+)).'Ma^l^`hZel _hkma^\hngmkrÌl]bl^Zl^[nk]^g!>qab[bm. and pharmacists in all countries.24 0.19 4. includes clinical officers in Tanzania Higher skilled workers: physicians in the US.000 population Lower-skilled Mid-level Higher-skilled United States 8. medical assistants and nursing aides for the US Mid-level workers: nurses.72 Sub-Saharan 0.41 South Africa 0.GZmbhgZeLmkZm^`r_hk@khpmaZg] Ahp^o^k%bgma^_nmnk^%Zglp^klmhma^l^jn^lmbhgl K^]n\mbhgh_Iho^kmr!MKUKUTA"'M^qmbl[^bg` Çma^himbfnfiZ\dZ`^h_a^Zemal^kob\^lmh[^ figZebs^]_hkma^mabk]A^ZemaL^\mhkLmkZm^`b\IeZg ikhob]^]Zm^Z\a_Z\bebmre^o^e%ma^\Z]k^h_phkd^k !HSSP III"'Bgebg^pbmama^+))0Chbgm:ggnZeA^Zema [^lmieZ\^]mh]^ebo^kma^l^l^kob\^l%ma^e^g`maZg] L^\mhkK^ob^p!JAHSR"%ma^]kZ_mm^qmab`aeb`amla^Zema mri^h_mkZbgbg`g^^]^]mh\hgo^rma^g^\^llZkrldbeel phkd^kmkZbgbg`ZlZd^r\hfihg^gmh_bfikhobg` Çpbee\e^Zkerg^^]mh[^_Z\mhk^]bgmhieZggbg`_hk a^Zemahnm\hf^l' a^Zemaphkd^kmkZbgbg`' 30 MMAM 12.79 2. 15.12 Africa Tanzania 0.

- K^\h`gbsbg`ma^g^^]mh_h\nlhga^Zemaphkd^k lniierbghk]^kmhZ\ab^o^ikh`k^llhga^Zema :lZk^lnem%lbqmri^k\^gmh_^Z\ar^ZkÌlg^p^gmkZgml bg]b\Zmhkl%ma^Fbgblmkr]^o^ehi^]ma^Mpb`ZBgbmbZmbo^ Zk^lbfierk^ieZ\bg`]^iZkm^]phkd^klkZma^kmaZg bg+))/Émhlmk^g`ma^gma^Ta^Zemaphkd_hk\^V Zn`f^gmbg`ma^phkd_hk\^'Ma^MMAMiheb\rma^k^_hk^ ikh]n\mbhg\ZiZ\bmrbgMZgsZgbZÊZg]`khpma^a^Zema \Zeel_hkZ\hfik^a^glbo^Zll^llf^gmh_MZgsZgbZÌl phkd_hk\^'BmaZlghp[^^gbg\hkihkZm^]bgmhma^ \nkk^gma^Zemaphkd^kmkZbgbg`\ZiZ\bmr%_heehp^][r MMAMiheb\r%. fifm^^gmhmp^gmri^k\^gmg^o^kchbgma^a^Zema 32 In the final draft of the MMAM. as well as published statistics from the WHO. Ma^\nkk^gmlrlm^fbgMZgsZgbZmkZbglkhn`aer_hnk mahnlZg]a^Zemaphkd^kli^kr^ZkZ\khllZee\Z]k^l'H_ these. Bryan 2006. students.gov/>.. targets for new facility construction have been combined with targets for renovation of existing facilities (see policy table p.g^pa^Zema\Zk^_Z\bebmb^l!]bli^glZkb^l%a^Zema \^gmk^l%Zg]]blmkb\mahlibmZel". TSPAS 2007. and MOHSW officials..%1. 34 Average annual attrition rates were calculated based on interviews with school principals.)pab\almZm^lZlZlmkZm^`b\h[c^\mbo^ma^ ma^]^o^ehif^gmh_Z``k^llbo^ieZglmh]kZfZmb\Zeer ^qiZglbhgh_phkd_hk\^ikh]n\mbhg'. 2004: 10. US Bureau of Labor Statistics <http://www.+Zg]^qiZg]^]ltaffing k^jnbk^f^gmlbgZee_Z\bebmb^l'Mablpbeek^lnembgZg official demand of over 1-)%)))a^Zema\Zk^phkd^kl [r+)*0Çlbqmbf^l\nkk^gmZoZbeZ[bebmr%[nmlmbeee^ll maZgaZe_ma^^qblmbg`phkd_hk\^bgLhnma:_kb\Z%Z \hngmkrh_^jnZeihineZmbhglbs^!>qab[bm/"'. 18) We believe the new target still reflects planned construction of 5201 new facilities. Kurowski 2003: 25.* l\Ze^nimkZbgbg`\ZiZ\bmrZ\khllZee\Z]k^l' :g^qZfbgZmbhgh_ma^iheb\rbfi^mnl_hkma^Mpb`Z Ma^Mpb`ZBgbmbZmbo^pZl]^lb`g^]mhZ\ab^o^ BgbmbZmbo^k^o^Zellhnk\^lh_\nkk^gmfhf^gmnf_hk ^qZ\mermaZm' bg\k^Zl^]\ZiZ\bmr'Ma^MMAMaZll^m_hkmam^g&r^Zk mZk`^mlbgmak^^Zk^Zl3a^Zemalrlm^flmk^g`ma^gbg`% bg\k^Zlbg`anfZgk^lhnk\^l_hka^Zema%Zg]bfikhobg` a^Zemahnm\hf^l'Ma^FZr 2007 o^klbhgh_ma^ MMAMlmZm^]mZk`^mlbg\en]bg`ma^\hglmkn\mbhgh_ .bls.Ma^^ohenmbhgh_MZgsZgbZgiheb\r_khf+)). World Health Report 2006. 33 Source: WHOSIS.mh \Zk^lrlm^f%Zg]ma^EZd^Shg^]bZ`ghlmb\m^Zf ma^ik^l^gmk^flecmlma^bg\k^Zlbg`ZpZk^g^llh_ma^ m^eelnlmaZmZghma^km^gi^k\^gmpbeee^Zo^pbmabgma^ \kbmb\Zeebgd[^mp^^gma^ZoZbeZ[bebmrh_a^Zemaphkd^kl firsmr^Zk':mma^lZf^mbf^%ma^lrlm^fehl^lZme^Zlm Zg]bfikho^]a^Zemahnm\hf^l' mabkteen to fifm^^gi^k\^gmh_bmlphkd_hk\^^o^krr^Zk mhk^mbk^f^gm%]^Zma%Zmmkbmbhgmhghg&a^Zemach[l% Zg]m^fihkZkr]^iZkmnk^mh_Z\bebmZm^ni`kZ]^mhZ The Twiga Initiative ab`a^k\Z]k^'. 20 ACTION NOW . independent consultants. and staffing of 652 constructed but currently un-opened and unstaffed facilities.

Zl^]hgma^bk\hlt-effecmbo^g^ll% _^Zlb[bebmr%Zg]mbfbg`%ihllb[e^lhenmbhgl^oheo^]bgmh =^o^ehibg`ZgZ\mbhgieZgk^jnbk^l[nbe]bg`nihgma^ mak^^]blmbg\mZ\mbhg`khnil3 ^qblmbg`anfZgk^lhnk\^l_Z\m[Zl^%\hee^\mbg`g^p  School-specific improvements to eqiZg]mkZbgbg` jnZgmbmZmbo^Zg]jnZebmZmbo^]ZmZ%Zg]nlbg`[hmamh \ZiZ\bmr ]^o^ehiZikZ\mb\Zeikh`kZfmaZm\Zg[^bfie^f^gm^] pbmabgma^^qblmbg`a^Zema\Zk^mkZbgbg`lrlm^f'Mhmabl  Lrlm^f&pb]^^gZ[e^kl!gZmbhgZeiheb\r\aZg`^l ^g]%ma^m^Zf]^lb`g^]Zkb`hkhnl%^ob]^g\^&[Zl^] Zg]bg\^gmbo^ikh`kZfl" f^mah]heh`r%pab\ap^nl^]mh^oZenZm^ma^a^Zema  MkZgl_hkfZmbhgZek^_hkflh_ma^gZmbhgZe phkd_hk\^lbmnZmbhgZm[hmaeh\ZeZg]gZmbhgZee^o^el' ZiikhZ\amha^Zemaphkd^kmkZbgbg`!ikbfZkber [rbglmbmnmbg`Z[khZ]&[Zl^]obkmnZee^Zkgbg` Filling the knowledge gap ikh`kZf" .. “Human resources for health – an appraisal of the status quo in Tanzania mainland” July 2004. and the United Kingdom’s Department for International Development (DFID) work in Malawi provide interesting comparative examples. HRH Census 2002.n`Zg]hÌlngbo^klbmrahlibmZe bgFpZgsZ' Ma^l^lhnk\^likhob]^]Z[khZ]ng]^klmZg]bg` h_^qblmbg`h[lmZ\e^lmha^Zemaphkd^kmkZbgbg`bg MZgsZgbZZg]ihm^gmbZebgm^ko^gmbhglmaZm\hne] Methodology ho^k\hf^ma^f'./Mhroughout the fieldwork component  lmkZtegic plan. School Bulletins 2005. the teamÌs firsmlm^ipZl :eemak^^mri^lh_bgm^ko^gmbhglaZo^ma^ihm^gmbZemh mhk^l^Zk\aZg]ikbhkbmbs^ihm^gmbZebgm^ko^gmbhg ln[lmZgmbZeerbg\k^Zl^ma^gnf[^kh_ldbee^]a^Zema ihbgml'Ma^Fbgblmkrin[ebla^]Zgnf[^kh_ phkd^klmkZbg^]bgMZgsZgbZ'Ahp^o^k%`bo^gma^ ]h\nf^gmlhnmebgbg`ma^^qblmbg`lbmnZmbhghgma^ FbgblmkrÌlg^^]_hkZg^Zk&m^kfZ\mbhgieZg%m^Zf `khng]%pab\ama^m^Zfnl^]mh\k^Zm^Z[Zl^ebg^ ZgZerlblln``^lm^]maZt pursuing school-specific fh]^eh_\nkk^gm\ZiZ\bmrZg]g^mphkdlmkn\mnk^'. 2007. et al. Tanzania. 36 Some of the most relevant recent studies of this issue include the WHO World Health Report 2006. the Global AIDS Program in Namibia. THE TWIGA INITIATIVE 21 . while the Carter Center’s work in Ethiopia. the Norwegian CMI Report. 37 Organizations such as the Capacity Project and I-Tech are doing related system-strengthening work in Tanzania. Kurowski 2003. “Scaling up priority health interventions in Tanzania: the human resources challenge” Health Policy and Planning 20 Feb.0Zg][nbemnihgma^Mhn\a ?hng]ZmbhgÌlhk`ZgbsZmbhgZedghpe^]`^_khffhk^ maZg_hnkr^ZklÌphkdZm. and balance our efformlZ\khll\Z]k^l' 35 HRHSP.. Ministry of Health and Social Welfare Emergency Recruitment Plan (Dar es Salaam). ma^m^Zfa^e]l^o^kZeiahg^Zg]bg&i^klhg]bl\nllbhgl pbmaMZgsZgbZgZg]bgm^kgZmbhgZehk`ZgbsZmbhgl pbmak^eZm^]^qi^kmbl^%. and Christoph Kurowski. bfikho^f^gmlbg\hf[bgZmbhgpbmalrlm^f&pb]^ Ma^l^]h\nf^gmlab`aeb`am^]l^o^kal specific ^gZ[e^klpZlma^[^lmbgbmbZeZiikhZ\a'P^ma^k^_hk^ dghpe^]`^`ZilZmma^gZmbhgZee^o^e%pa^k^eh\Ze _h\nl^]hgjnZebmZmbo^Zg]jnZgmbmZmbo^]ZmZmaZm ]ZmZpZlh_m^gebfbm^]hkhnm&h_&]Zm^' 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'. and Kurowski’s subsequent work on health workforce in Tanzania including Anna Dominick and Christoph Kurowski.^fore beginning fieldwork.

1Mhis has significant b]^gmb_rlrlm^f&pb]^^gZ[e^klmhlniie^f^gmeh\Ze bfieb\Zmbhgl_hk_ng]bg`Zgrikhihl^]^qiZglbhg%Zl efforml' p^eeZl_hkZiieb\Z[bebmrh_lrlm^f&pb]^iheb\r\aZg`^l' Ma^m^Zfma^k^_hk^fZ]^Zihbgmh_oblbmbg`l\ahhel MhZ\ab^ve this. ownership and funding.2h_MZgsZgbZÌl20 Ziieb\Z[bebmy of our findings across TZgsZgbZ%p^ different health work^kmkaining schools and affiliam^] visited a significant number of these in addition to all a^Zema\Zk^_Z\bebmb^l%fZgrfhk^maZghg\^'MkZbgbg` ma^eZk`^%fnemb&ikh`kZfmkZbgbg`\hfie^q^l' l\ahhel\Zg[^`khni^]mh`^ma^kZ\\hk]bg`mhgnf^khnl \kbm^kbZ3`^h`kZiar%lbs^h_lmn]^gm[h]r%mri^Zg] 38 Source: School Bulletin 2005. Tabora. the team ^f[Zkded on field visits to obtain an accnkZm^ob^ph_ G^ZkeraZe_h_ma^mkZbgbg`l\ahhelZk^ikboZm^er ma^\nkk^gmlbmnZmbhghgma^`khng]%]^m^kfbg^^Z\a hpg^]Zg]hi^kZm^]%h_pab\aZln[lmZgmbZefZchkbmr bglmbmnmbhgÌlZ[bebmrmhbg\k^Zl^mkZbgbg`\ZiZ\bmr%Zg] Zk^_Zbma&[Zl^]!>qab[bm0["'. the field team was divided into seo^kZe h_Zeemri^l'Lbg`e^&ikh`kZfl\ahhelfZd^ni2* lfZee`khnilmaZm_Zgg^]hnmZ\khllma^\hngmkr% i^k\^gmh_MZgsZgbZÌlmkZbgbg`bglmbmnmbhgl'Mh^glnk^ li^g]bg`l^o^gp^^dloblbmbg`. 22 ACTION NOW . Zg]lrlm^f&pb]^bgbmbZmbo^l%ma^m^Zf\hf[bg^] Zg]lh_hkma'Ma^m^ZfZmm^fim^]mh\ho^kZ[khZ] [hmmhf&niZg]mhi&]hpg]ZmZ\hee^\mbhgmh^glnk^Z \khll&l^\mbhgh_l\ahhel[rZeeh_mahl^f^Zlnk^l'?hk \hfik^a^glbo^%ikZ\mb\Zelhenmbhg' ^qZfie^%p^oblbm^]l\ahhelbg_hnkm^^gh_MZgsZgbZÌl+* k^`bhgl%\ho^kbg`knkZeZk^Zlpbmahgerhg^hkmph Bottom-up data collection l\ahhel%Zlp^eeZlnk[Zgl^mmbg`lpbmaZlfZgrZl ^b`ambglmbmnmbhgl!>qab[bm0Z"' Since official damZpZlh_ten insufficient. 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.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.

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 .

into a single Ministry of Education and Vocational Training 24 ACTION NOW . Tanzania had two ministries overseeing education: the Ministry of Higher Education.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.EXHIBIT 9 Intake by cadre Visited intake capacity 1. Pe considered it vital for all school-specific ma^m^ZfZg]bgm^kob^p^^l\hee^\mbo^erZll^ll^] k^\hff^g]ZmbhglmhfZbgmZbghkbfikho^\nkk^gm paZmk^lhnk\^lphne][^g^^]^]mhZee^obZm^ma^f' mkZbgbg`jnZebmr'Ma^k^_hk^%_hkma^_^pl\ahhelmaZm Mabl]nZejnZebmZmbo^(jnZgmbmZmbo^ZiikhZ\aa^ei^] aZ]k^\^gmer^qiZg]^]pbmahnmZ]cnlmbg`_hkjnZebmr ^glnk^maZmp^k^\h`gbs^]Zee^qblmbg`^qiZglbhg \hgmkhe%k^\hff^g]Zmbhglp^k^_h\nl^]hgma^bginml hiihkmngbmb^lZm^Z\abgltitution. and the Ministry of Education and Culture. Science and Technology. and helped fill and g^\^llZkrmhkZbl^jnZebmrkZma^kmaZgZ\hgmbgn^] ni]Zte crucial gaps in official records. W^Zf^g]^] bg\k^Zl^bglmn]^gmbgmZd^' ma^l^mhhell^o^kZembf^lmakhn`ahnmZlarihma^l^l Zg]]ZmZmk^g]llab_m^]pbmag^pdghpe^]`^' The top-down perspective Ma^m^ZfZelh^qiehk^]`ho^kgf^gmi^kli^\mbo^l Filtering and analysis hgbfikhobg`Zg]^qiZg]bg`a^Zemaphkd^k :_m^km^lmbg`oZkbhnl]h\nf^gmZmbhgm^fieZm^l%ma^ mkZbgbg`gZmbhgZeer'Mablbgoheo^]bgm^kob^pbg`d^r team designed a school-specific ‘l\hk^\Zk]Ìmhk^\hk] lmZd^ahe]^klpbmabgma^FbgblmkrZlp^eeZlma^ k^e^oZgm]ZmZ%ZgZers^d^r[hmme^g^\dl%Zg]\hlmhnm ma^gFbgblmkrh_Ab`a^k>]n\Zmbhg%L\b^g\^%Zg] ihm^gmbZelhenmbhgl_hk^Z\abglmbmnmbhg'Bg_hkfZmbhg M^\agheh`r'-)FZgy officials were former highly \hee^\m^]_khfma^JnZgmbmrLnko^rhkZg]ma^=bk^\mhk m^gnk^]\ebgb\Zeikh_^llbhgZelZg]bglmkn\mhklZg] h_Iheb\rZg]IeZggbg`Zmma^Fbgblmkr]^m^kfbg^] p^k^\hglmkn\mbo^mahn`am&iZkmg^klbg]bl\nllbg` ho^kZee\hlmZllnfimbhgl' 40 At the time of our fieldwork. These ministries have subsequently been combined. Our team interviewed only officials of the former.

ma^\aZee^g`^lmaZmhg&ma^&`khng]k^Zebmb^lphne] \hfie^qlik^Z]la^^m&[Zl^]a^Zemaphkd_hk\^ lniier& ihl^mhab`a&e^o^eiheb\b^lZg]Zf[bmbhnllmkZm^`b^l' Zg]&]^fZg]fh]^emh^lmbfZm^ma^bfiZ\mh_hnk ln``^lmbhglhgmkZbgbg`makhn`ainmm^gr^Zklbgmhma^ P^nl^]^Zkerf^^mbg`lmhb]^gmb_r^qblmbg` _nmnk^%Zlp^eeZl\Ze\neZm^ma^hg^&mbf^Zg]hg`hbg` `ho^kgf^gmZebgbmbZmbo^lk^e^oZgmmha^Zemaphkd_hk\^ hi^kZmbg`\hlmlh_bfie^f^gmZmbhg' mkZbgbg`\ZiZ\bmrZg]mh`Zn`e officials’ vieplhg ahp[^lmmhbg\k^Zl^mkZbgbg`makhn`ainm'?khf :\\hfiZgrbg`mableZk`^klniier&Zg]&]^fZg]fh]^e ma^l^\hgo^klZmbhgl%p^]bl\ho^k^]l^o^kZelrlm^f& blZlbfie^kbglmbmnmbhg&e^o^e\hlmfh]^e%pab\a pb]^iheb\rhiihkmngbmb^lmaZt could significantly ^gZ[e^l^ZlrZg]\hglblm^gm\hlmikhc^\mbhglh_Zee lniie^f^gmZgy individual school-specific efformlmh possible school-specific intero^gmbhgl'Ma^mhhedbmZelh bg\k^Zl^\ZiZ\bmr' bg\en]^lZ]^mZbe^]nl^k`nb]^_hk^Z\a\hfihg^gm eblm^]Z[ho^' Ma^l^bgbmbZmbo^lp^k^\hgmbgnhnlerk^fined makhn`ahnmma^ikhc^\m%nembfZm^erZeehpbg`ma^ m^ZfmhgZkkhphnk_h\nlmhZlfZeegnf[^kh_ab`a& A replicable process ihm^gmbZeiheb\rikhihlZel':lma^m^Zf]^o^ehi^] Ma^ikho^gZ]ZimZ[bebmy of these tools in the field ma^l^k^\hff^g]Ztions for school-specific and bg]b\Zm^lmaZmma^rZk^Ziieb\Z[e^Zg]k^ieb\Z[e^bg lrltem-wide efforml%eZm^k\hgo^klZmbhgl[^\Zf^ hma^kl^mmbg`l'Mablho^kZeef^mah]heh`r^glnk^l _hknfl_hkm^lmbg`Zg]k^fining our ideas. 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 Working together _Z\bg`lbfbeZk\aZee^g`^l' P^]^]b\Zm^]Zln[lmZgmbZeZfhngmh_mbf^mho^mmbg` final results with k^rlmZd^ahe]^klbgma^`ho^kgf^gm :nl^_neg^qmlm^iphne][^mh]^o^ehima^mhhedbm Zg]Zmma^bg]bob]nZel\ahhel%nlnZeer]nkbg`k^i^Zm _nkma^kbgmhZghgebg^&[Zl^]fh]^e\hfie^m^pbma oblbml'MablZiikhZ\a^glnk^]maZme^Z]^klabiZm[hma bginml[Zl^]hg\Zk^iZmapZrl%\ebgb\Ze`nb]^ebg^l% gZmbhgZeZg]eh\Zee^o^elhpg^]Zg][^eb^o^]bgma^ Zg]ma^bkanfZgk^lhnk\^k^jnbk^f^gml%Zlp^eeZl ikhihl^]lhenmbhgl' ihineZmbhg]^fh`kZiab\l%^m\'%mhfZd^ma^fh]^e mknerZiieb\Z[e^mhhma^k\hngmkb^l^qi^kb^g\bg`a^Zema BmZelha^ei^]^glnk^maZme^Z]^klp^k^fhmboZm^] phkd_hk\^lahkmZ`^l' mhmZd^ma^g^\^llZkrlm^ilmhpZk]bfie^f^gmZmbhg% bg\en]bg`\hg]n\mbg`bgm^kgZeg^`hmbZmbhglmhbg\k^Zl^ Bn the meantime.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 THE TWIGA INITIATIVE 25 . the school-specific damZ\hee^\mbhg li^g]bg`hgbg\k^Zlbg`phkd_hk\^ikh]n\mbhg% aZla^ei^]ma^Fbgblmkr`ZbgZ\\^llmheh\Ze bg\hkihkZmbg`l\ahhehimbfbsZmbhgbgmhgZmbhgZe bg_hkfZmbhgmaZmpbeebg_hkf_nmnk^iheb\rbgbmbZmbo^l lmkZm^`b\ieZgl%Zg]nlbg`ma^k^\hff^g]ZmbhglZg] Zg]linkhma^ka^Zemaphkd_hk\^bgm^ko^gmbhgl' Z\mbhgieZglmhl^^d^qm^kgZe_ng]bg`' 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 The toolkit mhma^\hngmkrÌla^Zemae^Z]^klabiZg]^gZ[e^ma^fmh MhZllblmma^FbgblmkrbgZll^llbg`ma^k^fZbgbg` \hg]n\mln\ak^ob^plbgma^_nmnk^' .

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. Although these improvements should help expand the school’s capacity. making it difficult for it to have more than one or two classes per semester.. By investing $6. The school uses the neighboring Geita District Hospital for clinical training and conducts fieldwork at health centres and dispensaries throughout the region. W^ma^g]^lb`g^] pbeeg^^]mhZ]]k^llma^jn^lmbhgh_Z]]bg`g^p Zl^mh_ab`a&ikbhkbmrbgm^ko^gmbhglmhmZk`^mma^l^ l\ahhelZg]nl^ma^himbfZea^Zemaphkd^kirkZfb]mh \hglmkZbgml' l^mikbhkbmb^l_hk\Z]k^]^o^ehif^gm' While the specific consmkZbgmlÇZg]k^\hff^g]^] bgm^ko^gmbhglÇoZkr_khfl\ahhemhl\ahhe%_hkma^ Six major constraints lrlm^fZlZpahe^%mabll^mh_bgbmbZmbo^l_hkhimbfbsbg` Makhn`ahnk]^tailed field interob^plZg]]ZmZ ma^^qblmbg`mkZbgbg`g^mphkdikhob]^lma^fhlm k^jn^lts.i^k\^gmbg\k^Zl^%k^lnembg`bgZg ho^kZee]hn[ebg`h_lmn]^gmbgmZd^' >o^glh%ma^Zgmb\biZm^]bg\k^Zl^bgma^a^Zema workforce will be insufficient to meem^bma^kma^ Findings `ho^kgf^gmh_MZgsZgbZÌl_Z\bebmrltaffing ghZel%hkma^ bgm^kgZmbhgZe`nb]^ebg^l_hka^Zemaphkd^k]^glbmr' Ho^kZee%hnkm^Zf_hng]maZmZaZg]_neh_ikbfZkr . and financial resources. Sengerema COTC is currently expanding dormitory and classroom infrastructure with financial aid from CORDAID. As a result.)mh. Hiring three additional full-time faculty would fill the current teaching gap and allow Sengerema COTC to grow in capacity by approximately 35 percent. we identified six main limitambhglmhl\Zebg` ikhfblbg`g^Zk&m^kfZo^gn^mhZ\ab^obg`]kZfZmb\ nia^Zemaphkd^kmkZbgbg`\ZiZ\bmrbgMZgsZgbZ% ^qiZglbhgh_ma^a^Zemaphkd_hk\^' affecmbg`[hmagZtional and local efforml' Ln\ahimbfbsZmbhgZehg^\Zgk^lnembgZ/.mh0) 1. enabling another 30 to 40 dispensaries in Tanzania to be staffed with a qualified health worker. 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.000 up front and $24. creating 63 places and. a Dutch development assistance agency. within three years.000 per year in faculty salaries. the already over-stretched faculty cannot handle a student-body increase. 26 ACTION NOW . faculty members are constantly away from the school. Sengerema COTC could overcome this one remaining impediment to optimizing capacity.kb]`bg`ma^k^fZbgbg`a^Zemaphkd^k`Zipbee \hglmkZbgmlZk^abg]^kbg`ma^`khpmah_ma^MZgsZgbZg k^jnbk^bgghoZmbo^ZiikhZ\a^lmhanfZgk^lhnk\^ a^Zemaphkd^kmkZbgbg`g^mphkd'Ma^l^\hglmkZbgml fZgZ`^f^gm%Zlp^eeZlmkZgl_hkfZmbhgZeZiikhZ\a^l hi^kZm^Zt both school-specific and sysm^f&pb]^ mha^Zemaphkd^kmkZbgbg`Zg]hi^kZmbhgZelmkZm^`b^lmh e^o^elZg]\^gm^khgebfbm^]_Z\nemr%bg_kZlmkn\mnk^% Z]]k^llZmmkbmbhg'F^]bnf&Zg]ehg`&m^kfbgbmbZmbo^l applicant.

Non-clinical infrastructure: Ma^fhlmikhfbg^gm `kZ]nZmbhgZmmkbmbhg' bg_kZlmkn\mnk^\aZee^g`e we identified is the need for more housing. 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. Clinical faculty: Mhere is also a significant gap in \ebgb\Ze_Z\nemrbgMZgsZgbZ'Phkl^%pbma\ebgb\Ze 6. 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. Non-clinical faculty: Ma^k^blZg^ghkfhnl_Z\nemr \Zfinl%_heehp^]\ehl^er[reZ\dh_\eZllkhhfl% `ZibgMZgsZgbZ'Ma^mkZbgbg`lrlm^f]h^l eZ[hkZmhkb^l%^jnbif^gm%Zg]mkZglihkmZmbhg' ghmikhob]^\hfi^mbmbo^bg\^gmbo^lÇlZeZkb^l% ieZ\^f^gm%lniihkm%ikh_^llbhgZe`khpma%hkch[ 5. Clinical infrastructure: FZgrh_ma^lfZee^ka^Zema lZmbl_Z\mbhgÇZg]a^Zema\Zk^`kZ]nZm^lZk^h_m^g \Zk^_Z\bebmb^leZ\d^bma^kma^iZmb^gmohenf^hk ehlmmh^fb`kZmbhgZg]fhk^en\kZmbo^^fiehrf^gm iarlb\ZeliZ\^mhZ\\hffh]Zm^ZeZk`^kgnf[^k pbmaNGOlhkbgghg&a^Zema&k^eZted fields. 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.129 Year THE TWIGA INITIATIVE 27 . either on or off- 2. lrlm^fb\]blbg\^gmbo^l!lbfbeZkmhmahl^h_ghg& \k^Zting difficnemb^lbgieZggbg`_hk_nmnk^ \ebgb\Zeltaff "%\ebgb\Ze_Z\nemrZg]ltaff ofm^g fZbgm^gZg\^Zg]^qiZglbhg' k^`Zk]\ebgb\Zem^Z\abg`k^lihglb[bebmb^lZlZ =nkbg`ma^]ZmZ\hee^\mbhgikh\^ll%p^]bl\ho^k^]maZm [nk]^g' ^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. 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 1.000 Total student intake. financing arrZg`^f^gml%Zg]ik^&Zg]ihlm& 4. Financial resources: FZgrbg]bob]nZel\ahheleZ\d khng]lZlma^bkikbfZkrk^lihglb[bebmrZg]pbma control over the amount and flow of resources.200 Debottlenecking 1. h_lmn]^gml%Zllnfbg`ZiikhikbZm^_Z\nemr\Zg[^ _hng]hk\k^Zm^]' 3.

data collected from the principal Quantity Surveyor at the Ministry. and clinical officers. and the Touch Foundation’s experience overseeing school expansion projects at Bugando’s university. =^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 [eZgd^miheb\b^lmaZt address them sufficiently'Bg !MO)Zg]ihlm&`kZ]nZm^ikh`kZfl"%eZk`^mkZbgbg` k^lihgl^%p^^fiaZlbs^ma^g^^]mhmZ\de^ma^l^ \hfie^q^l!fnembie^&\Z]k^ikh`kZfl"%lfZeeikboZm^hk specific needs on a school-by-school basis. pharmacy technicians. meaning that MhZ\ab^o^ma^_neeihm^gmbZebfiZ\mh_l\ahhe^qiZglbhg% students from both programs could be taught simultaneously ma^FbgblmkrZg]bmliZkmg^klfnlm\hfie^m^ma^ with minimal or no additional investment in faculty or ZgZerlblZg]]^obl^Z\mbhgieZgl_hkma^k^fZbgbg`. The =hbg`lhpbeek^jnbk^bfie^f^gmZmbhgh_\hg]^gl^] complex currently houses an Assistant Medical Officer school.)) would allow the training center to expand into a robust i^kr^Zkpbmani_khgm\hlmlh_khn`aer. 28 ACTION NOW . and a specialized nursing program [rma^Fbgblmkr%Zlp^eeZlhma^klrlm^f&pb]^iheb\r in Operating Theater Management.1 classroom infrastructure.)fbeebhgZg] Institute of Allied Health Sciences. Taking advantage of such synergies l\ahhelghmZll^ll^]bgmabliaZl^h_ma^]bZ`ghlmb\' will maximize limited resources in the training system and result in a greater return on investment for optimizing School-specific action plans Tanzania’s training network. Adding new training programs himbfbsZmbhgpbeebg\k^Zl^lmn]^gmbgmZd^mhho^k0%. supporm^] _Zbma&[Zl^]l\ahhel%Zg]lfZeein[eb\l\ahhel!hg^&hk [rma^bfie^f^gmZmbhgh_Fbgblmkr&e^]%lrlm^f&pb]^ mph&\Z]k^ikh`kZfl"' ^gZ[e^kl' L\ahhelpbmabg^Z\amri^h_m^glaZk^\hffhg @bo^gmablg^^]_hkbgltitution-specific intero^gmbhgl% \hglmkZbgml'B]^gmb_rbg`ma^l^ma^f^lZeehp^]nl our final recommendambhglbg\en]^]Z\mbhgieZgl mh^qmkZiheZte our findings to the other 58 health _hk^Z\al\ahheoblbm^]%\hfie^te with final cosmbg` mkZbgbg`l\ahhelZg]manlmhfh]^ema^ho^kZeebfiZ\m Zg]lmn]^gmhnminm^lmbfZm^l[Zl^]hgma^m^g&r^Zk h_lrltem-wide and school-specific efforml' mbf^ebg^l^m_hkf^^mbg`ma^MMAMmZk`^ml'Ma^l^ ]^mZbe^]ieZglikhob]^[hmama^`ho^kgf^gmZg]ma^ Academic medical centers l\ahhepbmaZ\hg\bl^]h\nf^gmmaZmebgdll\ahhe& specific ino^lmf^gmlpbmaik^\bl^bg\k^Zl^lbgmkZbgbg` :\Z]^fb\f^]b\Ze\^gm^kl!AMCl"%pab\abg\en]^Z hnminm!>qab[bm*)"' ngbo^klbmy and affiliam^]m^Z\abg`ahlibmZe%m^g]mheZ\d 41 Costs were determined through interviews with individual school principals. Doubling training capacity ADDING SCHOOLS AT EXISTING Ma^]ZmZ`Zthered in the field shows tham%makhn`aZg TRAINING COMPLEXES Zf[bmbhnlr^mikZ\mb\ZeZ\mbhgieZg\hf[bgbg`lrlm^f& Case Example: Mbeya Medical Training Center wide and school-specific improvements. registered mhZ]]g^pikh`kZflpa^k^ZiikhikbZm^'Ln\alrlm^f nurses. the g^Zker]hn[e^ma^bgmZd^h_ma^mkZbgbg`g^mphkd' Mbeya medical training center has fewer programs and students than other schools with similar clinical capacity. \nkkb\neZ_hkgnkl^lZg]COl%Zek^Z]rng]^k]^o^ehif^gm a school of dental therapy. \aZg`^lmhikhob]^lmn]^gmahnlbg`Zg]bg\k^Zl^ With the vast clinical opportunities provided by the Mbeya Referral Hospital. TZgsZgbZ\Zg Adjacent to one of Tanzania’s four tertiary hospitals. hg`hbg`ZggnZe\hlmlh_Zkhng]*)fbeebhg'-* Dental therapists and clinical officers share the same curriculum for the first year and a half of study. hospital and academic leadership reported m^Z\a^klniier'Ma^l^iheb\b^lpbee^gZ[e^l\ahhelmh that the facility is well equipped to offer additional programs fZqbfbs^makhn`ainmbgma^bk^qblmbg`ikh`kZflZg] for laboratory technicians.

ma^fZgZ`^kbZeZg]Z]fbgblmkZmbo^fZgihp^kg^^]^] Lbg\^fhlmikboZm^l\ahhelmn]^gmlZk^ghm^eb`b[e^ mhhi^kZm^ln\aeZk`^%\hfie^qbglmbmnmbhgl' _hk`ho^kgf^gm\hlm&laZkbg`l\a^f^lhkehZgl%ma^l^ bglmbmnmbhglh\\ZlbhgZeerZeehplmn]^gmlmhk^fZbg Ikh_^llhklZg]]^iZkmf^gma^Z]lZmma^Fnabf[beb pbmahnmiZying full fees or are unable to fill all Ngbo^klbmrh_A^ZemaZg]:eeb^]L\b^g\^l!Fnabf[beb" ZoZbeZ[e^lihml%[hmah_pab\a]^ie^m^l\ahhe[n]`^ml' Zg]. Due to the difficnemrh_ additional dormitories or off-campus housing would \^gmkZeermkZ\dbg`k^`bhgZeieZ\^f^gmlZg]bkk^`neZk k^lnembff^]bZtely in a fifmri^k\^gmbg\k^Zl^bg \hffngb\Zmbhg[^mp^^gl\ahheltaff and gho^kgf^gm lmn]^gmbgmZd^' officials. grZllkhhml lmk^m\a^]mhma^bkebfbmlmhZ\\hffh]Zm^ma^lmn]^gml' ieZgl\Zg^gZ[e^significant ikh`k^llmhpZk]bg\k^Zl^] :]]bg`lmn]^gmlphne]bgfhlm\Zl^lk^jnbk^ mkZbgbg`\ZiZ\bmr!>qab[bm**"'-+ Z]]bmbhgZeiZkm&mbf^hk_nee&mbf^ltaff%Zlp^eeZlg^p ]hkfbmhkb^lZg]\eZllkhhfl' THE TWIGA INITIATIVE 29 .n`Zg]hngbo^klbmb^l%_hk^qZfie^%eZ\d Z]fbgblmkZmbo^lniihkmZg]li^g]ik^\bhnlmbf^ Small public schools k^\hk]bg``kZ]^lZg]mribg`lreeZ[bkZma^kmaZg ik^iZkbg`_hke^\mnk^lhkf^^mbg`pbmalmn]^gml' Ebd^lfZeeikboZte schools. small public schools suffer <ebgb\Ze_Z\nemrf^f[^klZk^Zelhlmk^m\a^]ZmeZk`^ _khfho^klmk^m\a^]_Z\nemrZg]bg_kZlmkn\mnk^' AMCl%mhkg[^mp^^gma^an`^]^fZg]_hkmk^Zmf^gmbg <hgl^jn^gmer%bgo^lmf^gmlbganfZgk^lhnk\^l% ma^bkli^\bZemb^lZg]ma^bkmkZbgbg`k^lihglb[bebmb^l' \eZllkhhfl%m^Z\abg`fZm^kbZel%Zg]]hkfbmhkb^lZk^ g^\^llZkrmhl\Ze^nimkZbgbg`\ZiZ\bmr':aZg]_neh_ Large training complexes lfZeein[eb\bglmbmnmbhglaZo^^q\^ll\ZiZ\bmrk^lnembg` _khfZeZ\dh_bgm^k^lm^]Ziieb\Zgmlhk[^\Znl^ma^r :meZk`^mkZbgbg`\hfie^q^l%lmn]^gmZg]_Z\nemr Zk^mkZglbmbhgbg`_khfhg^mri^h_mkZbgbg`ikh`kZf Z\\hffh]ZmbhglZk^h_m^gma^fhlt significant mhZghma^k' [hmme^g^\d'Lmn]^gmlZk^ahnl^]^gmbk^erhg\Zfinl and no additional space or off-campus housing ?hk^qZfie^%ma^FnlhfZCOMkZbgbg`<^gmk^!COTC" blZoZbeZ[e^'Mablblfhlmghmb\^Z[e^Zmma^mak^^ k^\^gmerlpbm\a^]_khfbg&l^kob\^mhik^&l^kob\^ bgm^`kZm^]ikh`kZflbgF[^rZÇAMO%=^gmZeMa^kZir% mkZbgbg`%[nmbgCZgnZkr+))1bmaZ]ghmr^mk^\^bo^] Zg]Hi^kZmbg`Ma^Zmk^FZgZ`^f^gmÇpa^k^ the 2007 incoming class. the MnlhfZCOTCÌlikbg\biZeaZ]ghb]^Z pa^gabllmn]^gmlphne]Zkkbo^' Ln\aZgbg\k^Zl^phne]ZelhZeehpF[^rZmh Z\\hffh]Zm^Z]]bmbhgZeikh`kZfl%ln\aZlZCOl\ahhe Pabe^ma^l^\hffhgma^f^la^ei^]nlfZqbfbs^ maZm\hne]ib``r[Z\dhgma^AMOikh`kZf':mfhlm lbm^oblbml%\hglmkn\mma^ZgZermb\Zefh]^e%Zg] eZk`^mkZbgbg`\hfie^q^l%\nkk^gmltaffing is sufficient bg_hkfiheb\rk^\hff^g]Zmbhgl%ma^oZkb^] mhaZg]e^mablg^Zk&m^kfbg\k^Zl^'Ma^hg^`eZkbg` lbmnZmbhglbgL^g`^k^fZZg]Fonfb^fiaZlbs^ma^ ^q\^imbhgblma^FonfbmkZbgbg`\hfie^q%pa^k^ continued need for the school-specific acmbhgieZgl' \nkk^gmerma^k^blhgeraZe_ma^_Z\nemrZg]ltaff g^^]^] FnlhfZbeenlmkZm^lZpb]^kblln^3Z]blmbg\meZ\d mhlniihkmma^^qblmbg`EZ[hkZmhkr:llblmZgmikh`kZf' h_fZgZ`^f^gm\ZiZ\bmr\k^Zm^l]rl_ng\mbhgZg] impedes efficiencrbgma^^qblmbg`lrlm^f'Pabe^Z Small private institutions lmkZm^`rmhZ]]k^llmablblnk`^gmerg^^]^]%p^_^em bm[^rhg]ma^bgbmbZel\hi^h_mablphkd' FhmboZm^][rmb`amZg]bg_k^jn^gm_ng]bg`%lfZee ikboZm^bglmbmnmbhglm^g]mh[^ma^fhlt efficiently Bgma^f^Zgmbf^%[r_h\nlbg`Zmma^]^mZbe^]e^o^e% kng_Z\bebmb^l'Ma^l^l\ahhelaZo^ZlfZeegnf[^k \e^ZklmkZm^`b\iheb\riZkZf^m^klbgma^mkZbgbg`Zk^Z h_i^kfZg^gm%]^]b\Zm^]_Z\nemrf^f[^klZek^Z]r can also be addressed. Such school-specific.

30 ACTION NOW . because official staffing requirements Doubling output \Zgik^o^gmma^Fbgblmkr_khfhi^gbg`g^pa^Zema \Zk^_Z\bebmb^l[^_hk^ma^r\Zg[^_neerltaffed.' Ikhob]^_nee_ng]bg`_hkln\\^ll_neMD lmn]^gml ma^>gkhee^]Gnkl^!EN)mkZbgbg`_khfmak^^r^Zkl mh\hfie^m^fZlm^klikh`kZflbg^q\aZg`^_hkZ mhmph%Zg]K^`blm^k^]Gnkl^!RN) mkZbgbg`_khf \hffbmf^gmmhm^Z\a' _hnkr^Zklmhmak^^'Ma^g^p\nkkb\nenfpZl bfie^f^gm^]gZmbhgZeerpbmama^+))1bgmZd^'Hg\^ -' KZbl^\hlml_hk_hk^b`glmn]^gml%^li^\bZeerZm bfie^f^gmZmbhgbl\hfie^m^%ma^\hf[bg^]bfiZ\m gnklbg`Zg]COl\ahhelpbmaab`a^klaZk^lh_ pbee[^Z+. and opened in the near term. Ta^Fbgblmkr bfie^f^gmZ[e^lrlm^f&pb]^\aZg`^l' ]^lb`g^]mabl\Z]k^mh[^ma^e^Z]bg`\Zk^ikhob]^k *' >g\hnkZ`e and subsidize off-campus housing.EXHIBIT 11 :]]bmbhgZeer. the team deo^ehi^] Mhe firsmblma^]^o^ehif^gmh_Zg^p\Z]k^%<ebgb\Ze l^o^kZeiheb\rhiihkmngbmb^lmhZ]]k^llfZchk :llblmZgml!CAl)%nlbg`Z\hg]^gl^]CO\nkkb\nenf \hglmkZbgmlZg]lniie^f^gmma^phkd[^bg`]hg^Zm \hglblmbg`h_hg^r^Zkli^gmbgma^\eZllkhhfZg]Z ma^eh\Zee^o^e'Mhe team identified four immediam^er second year spent in field internships. New cadres and curricula Bgk^lihgl^mhma^l^\aZee^g`^l%ma^FbgblmkraZl System-wide policy shifts to enable growth eZng\a^]g^pbgbmbZmbo^lmaZmpbeebg\k^Zl^a^Zema G^mphkdhimbfbsZmbhgZelh]^i^g]lhg`ho^kgf^gm& phkd^kmkZbgbg`\ZiZ\bmrZg]_^^]bgmhma^ho^kZee e^]lrlm^f&pb]^bgbmbZmbo^l'Makhn`a\hgo^klZmbhglZm Mpb`Zikh`kZf' ma^FbgblmkrZg]bg\hf[bgZmbhgpbma]ZmZZg]mahn`aml _khfManzanians in the field. fZqbfbs^ma^gnf[^kh_g^p_Z\bebmb^lmaZm\Zg[^ \hglmkn\m^]%ltaffed.) output Zg]%Zehg`pbmama^bgm^kbfltaffing requirements..i^k\^gmbg\k^Zl^bgZggnZebgmZd^' _hk^b`glmn]^gml' 42 Source: 2008 Twiga model (see note 17).mh. 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' Ma^l^mphbgbmbZmbo^lZk^\kn\bZemhkZib]erbg\k^Zlbg` ma^gnf[^kh__khgmebg^phkd^klZoZbeZ[e^mhltaff New programs School-specific in existing Curriculum ma^g^p]bli^glZkb^lieZgg^]bgma^MMAM'Ma^rpbee optimization complexes changes a^ei[khZ]^gZ\\^llmha^Zema\Zk^Z\khllma^\hngmkr 2009/2010 Expanded output (est. team analysis. Zmma^]bli^glZkre^o^e%kZgdbg`Z[ho^ma^mphgnkl^l Zg]hg^eZ[hkZmhkrm^\agb\bZgZelhk^jnbk^]Zm^Z\a +' MkZglbmbhg_khfhim&bg\hgmkZ\mnZe^fiehrf^gm g^p_Z\bebmr' _hkk^mbk^^l!^ll^gmbZeerfZg]Zmhkrk^mbk^f^gm pbmaZ\nf[^klhf^Zii^Zelikh\^ll"mhhim&hnm Ma^l^\hg]blZk^obl^]%fh]neZkbs^]%Zg] ZnmhfZmb\k^abkbg`' lahkm^g^]gnklbg`\nkkb\nenfmaZmpbeek^]n\^ .

without altering rates of annual workforce loss due to leave for upgrading coursework.and in-service attrition due to emigration and non-clinical work.500 63.%g^Zker]hn[ebg`\nkk^gm MZgsZgbZ%pah]^\b]^mhphkdbga^Zema\Zk^hnmlb]^ bgmZd^gnf[^kl'. across all cadres.400 workforce training 2009-2019 workforce 2009 2009 output 2019 2009-2019 Potential 2019 Attrition Health workforce 2009-2019 workforce 2019 88.r+)*2mabl^qiZg]^]mkZbgbg` h_MZgsZgbZ%hkpahe^Zve the health care field g^mphkd%bg\en]bg`g^pikh`kZfl%pbeeZ]]ZlfZgr Zemh`^ma^k'BgohengmZkrZmmkbmbhgbg\en]^l]^Zmabg Zl++%/))g^pa^Zemaphkd^klmhma^lrlm^f'-.500 Training 52.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. death in service and retirement. 2008 Twiga model (see note 17).800 40. THE TWIGA INITIATIVE 31 .000 25. Calculations based on halving both pre."'-- 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. 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\^ account for over one-fifmah_ma^ZggnZephkd_hk\^ehll Zmmkbmbhg%g^Zkerlbqmri^k\^gmh_bg\k^Zl^]makhn`ainm Çb'^'%^b`ammahnlZg]h_ma^w-2%)))phkd^kl^qi^\m^] pbee[^lhZded up by filling slots vZ\Zm^]makhn`a mh[^ehlm[^mp^^g+))2Zg]+)*2'<nmmbg`ma^ Zmmkbmbhg'>o^glh%ma^phkd_hk\^phne]]hn[e^ho^k ohengmZkrZmmkbmbhgkZm^bgaZe_phne]k^]n\^maZm m^gr^ZklZg]ma^ho^kZeeldbeee^o^eh_ma^a^Zema gnf[^kmh_hnkmahnlZg]%bg\k^Zlbg`ma^phkd_hk\^bg phkd_hk\^phne]bg\k^Zl^!>qab[bm*+"' +)*2[rZefhlmm^gi^k\^gmmh. 44 Source: Ministry of Health Interviews.800 63. death.000 – nearly 20% 48.000 Health Health Optimized Attrition Health workforce 25.900 52.000 11% output Highly skilled 2009-2019 Voluntary 8. and retirement of approximately thirteen percent across all cadres.400 48.+%)))!>qab[bm*.000 B_bfie^f^gmZmbhgh_[hmalrlm^f&pb]^Zg]l\ahhe& Zmmkbmbhgbg\en]^lphkd^klpah\ahhl^mhe^Zo^ma^bk specific initiambo^l[^`bgl[reZm^+)**%ZggnZebgmZd^ ihlmlmhmZd^in[eb\a^ZemaihlbmbhglpbmaNGOlbg pbee^q\^^]0%/))[r+)*.

. case eqZfie^l ihlm&`kZ]nZm^phkd^klbg\hgmbgnbg`mhmZd^iZkmbg _khflbfbeZker\aZee^g`^]ln[&LZaZkZg\hngmkb^l%hk mkZbgbg`ikh`kZflZlg^perfbgm^]_Z\nemr' makhn`aZgZerlblZg]k^l^Zk\a' Develop a ‘scheme of service’ for health educators Pabe^fhlmh_ma^l^b]^Zlmhn\ahgmkZbgbg`%ma^r h_m^gmZk`^mhma^kiaZl^lh_ma^a^Zemaphkd^k A^Zema^]n\Ztors are classified and compensam^] fZgZ`^f^gm\r\e^%_khfk^\knbmf^gmZg]ieZ\^f^gm Z\\hk]bg`mhma^bk\ebgb\ZeikZ\mbmbhg^klmZmnl%fZdbg` mhikh]n\mbobmr%ikhfhmbhg%Zg]k^m^gmbhg' it difficult to design incentive schemes specific to m^Z\a^kl' Optimize student selection and allocation <k^Zmbg`Zl^iZkZte classificambhg_hka^Zema^]n\Zmhkl >gkheebg`lmn]^gmlZml\ahhelbgma^bkahf^k^`bhgl phne]^gZ[e^`k^Zter fleqb[bebmr'Ma^=bk^\mhkZm^h_ pa^g^o^kihllb[e^%iZkmb\neZkerbgCOZg]^jnboZe^gm :]fbgblmkZmbhgZg]IeZggbg`bl\nkk^gmer]^o^ehibg` \Z]k^l%Zg]bgltituting confirmambhg]^Z]ebg^l Zl\a^f^h_l^kob\^_hka^Zema^]n\Zmhkl'BmfZr[^ _hklmn]^gmlmh\eZbfma^bklihmlZml\ahhelphne] [^g^ficial to eqiZg]Zg]ni`kZ]^mablikh`kZf' ]bl\hnkZ`^ZmmkbmbhgZg]^gZ[e^l\ahhelmh[nbe] pZbmbg`eblts to fill lasm&fbgnm^hi^gbg`l' Ensure prompt and consistent payment of salaries Ma^g^mk^lnemphne][^Zk^]n\mbhgh_pZlmZ`^bg FZgra^Zemaphkd^klk^fZbgln[c^\mmhZmak^^&fhgma mkZbgbg`\ZiZ\bmr[rbg\k^Zlbg`ma^ihm^gmbZe_hk ikh[ZmbhgZkri^kbh][^_hk^ma^y can receive their firsm mkZbg^]phkd^klmhebo^Zg]phkdbgma^k^`bhglpbmabg iZr\a^\d'IZrbg`lZeZkb^l_khfma^lmZkmh_l^kob\^fZr pab\ama^rp^k^mkZbg^]' a^eid^^ig^pa^Zemaphkders in their firsmr^Zkh_ l^kob\^%Zab`a&kbldmbf^_hkZmmkbmbhg' Encourage healthy competition :]]bmbhgZeer%Zlma^EZd^Shg^]bZ`ghlmb\m^Zf Offering incentives. such as a $50.[rik^o^gmbg`]^Zma&bg&l^kob\^makhn`abfikho^] Pabe^dghpe^]`^&laZkbg`fZrl^^f\hngm^k& ^fiehr^^a^Zema\Zk^Zg]bg_^\mbhg\hgmkhe%kZblbg` bgmnbmbo^_khfma^ihbgmh_ob^ph_\hfi^mbmbhg% ma^k^mbk^f^gmZ`^_khf.000 grZgm ]^m^kfbg^]%Zemahn`afZgrknkZehkk^`bhgZe \hfi^mbmbhg_hkma^l\ahhemaZm[^lmnl^l_ng]lmh ieZ\^f^gmlZk^_ng]^]hgmbf^%ebfbm^]eh\Ze bg\k^Zl^\ZiZ\bmr%\hne]^g\hnkZ`^bgghoZmbhg':g fZgZ`^f^gm\ZiZ\bmrÇ\hf[bg^]pbmaZ\\hngmZ[bebmr ZggnZe\hg_^k^g\^_hkikbg\biZelh_^Z\al\ahhemri^ Zg]]^ebo^krblln^lÇh_m^gk^lnembga^Zemaphkd^kl phne]Zelh_Z\bebmZm^ma^laZkbg`h_[^lmikZ\mb\^lZg] ghm[^bg`iZb]_hknimhmphr^ZklZ_m^kmZdbg`nima^bk ^g\hnkZ`^bg_hkfZtion flow bemp^^gl\ahhel' ihlml' 32 ACTION NOW .mh/)%Zg]bgbmbZmbg`hg& bmphne]Z\mnZeerlmbfneZm^`khpmalbg\^%Zm^Z\a lbm^bg&l^kob\^ni`kZ]bg`\hnkl^lÇ]hn[ebg`bgmZd^ \hg_^k^g\^%l\ahhee^Z]^klphne][^ng]^kik^llnk^mh \hne]k^lnembgZmkbiebg`h_ma^phkd_hk\^' ]^fhglmkZm^g^pZg]bgghoZmbo^mabgdbg`' Further systemic opportunities Invest in workplace improvements and teaching resources BgZ]]bmbhgmhma^_hnkd^rlrlm^f&pb]^^gZ[ebg` EZ\dh_m^Z\abg`k^lhnk\^lpZl\hglblm^gmer\bm^] bgbmbZmbo^lZg]bfikho^]k^m^gmbhg%p^ghm^]Z [r_Z\nemrZlma^bk`k^Zm^lmaZk]labiÇfhk^h_m^g gnf[^kh_ikhfblbg`bgbmbZmbo^lmaZm\hne]_nkma^k ^o^gmaZgehplZeZkr':ee^obZmbg`mablikh[e^f\hne] lmk^g`ma^gma^a^Zemaphkd_hk\^bgMZgsZgbZ'FZgr bfikho^[hmama^k^m^gmbhgkZm^h_mnmhklZg]ma^ h_ma^l^b]^Zlhkb`bgZm^]pbmaikbg\biZelZmma^ jnZebmrh_mkZbgbg`%Zlp^eeZlbg\k^Zl^bgm^k^lm[r oblbm^]l\ahhel%Fbgblmky officials.

Provide incentives for rural placement [hhlmfhkZe^%ikh]n\mbobmr%Zg]k^m^gmbhg%Zlp^eeZl bg\^gmbobs^bg\k^Zl^]bgm^k^lmbgma^a^Zemaphkd^k :mik^l^gm%a^Zemaphkd^klZk^iZb]Z\\hk]bg`mhma^bk mkZbgbg`lrlm^fZ_m^k`kZ]nZmbhg' e^o^eh_mkaining. Specific memkb\l% ln\aZlma^i^k\^gmZ`^h_lmn]^gmlln\\^^]bg`hg Permit periodic rotations of health workers lmZg]Zk]bs^]^qZfl%\hne]^g\hnkZ`^ab`a&jnZebmr m^Z\abg`' A^Zemaphkd^klpblabg`mh\aZg`^ihlmlfnlm k^lb`g_khfma^bkihlbmbhglmakhn`ama^\^gmkZe :ggnZeltaff eoZenZmbhglpbma[hgnl^l_hk^q^fieZkr a^ZemafbgblmkrZg]ma^gk^Ziier':s with financial i^k_hkfZg\^\Zgl^ko^ZlZihp^k_nemhhemh[hhlm bg\^gmbo^l%lbfieb_rbg`ma^ikh\^llh_khmZmbhg[^mp^^g k^m^gmbhgZg]fhkZe^'LbfbeZker%ikhfhmbhgl[Zl^] ihlmlZg]ikbhkbmbsbg`phkd^kl_khfaZk]labiihlmlbg hgl^kob\^Zg]ma^jnZebmrh_k^l^Zk\a\hg]n\m^]% ltaffing choices would decrease the risk of accepting a kZma^kmaZghglmZg]Zk]lln\aZlgnf[^kh_in[ebla^] knkZehkaZk]labiihlm' Zkmb\e^l%a^eimh\k^Zm^bg\^gmbo^lmZk`^mbg`bfikho^] ikh]n\mbobmrZg]\hffbmf^gm' Place graduates in home regions 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 r^Zklh_`hh]l^kob\^%hk_hkhma^kZ\ab^o^f^gml%\hne] THE TWIGA INITIATIVE 33 . with no differential for the vZkrbg` \aZee^g`es of different posml'AZk]labiiZr_hkknkZe ihlml\hne]_Z\bebmZm^ma^]^iehrf^gmh_phkd^kl Develop a performance management system mhngihineZkZk^ZlZg]bfikho^k^m^gmbhg%Zehg` Pa^g\hfi^glZmbhgZg]ikhfhmbhgk^flecm pbmabg\^gmbo^lln\aZl_k^^Z\\hffh]Zmbhg!pbma lmZg]Zk]bs^]Z\ab^o^f^gm&[Zl^]f^mkb\l%bmbl^Zlb^k hpg^klabio^lmbg`Z_ter five years of serob\^"Zg] mhnl^mahl^mhhelZlbg\^gmbo^lmhbfikho^ltaff `nZkZgm^^]^]n\ZmbhgZeehpZg\^l_hkma^bk\abe]k^g' ikh]n\mbobmrZg]i^kformance.

HRHSP. Lhf^h_ma^fhlmikhfblbg`b]^ZlZk^Zl_heehpl3  K  ZmbhgZebs^ltudent financing through creambhgh_Z gZmbhgZelmn]^gmehZgikh`kZf'  ?  h\nll\Zk\^k^lhnk\^lhgmZk`^m^]\Z]k^l[r ]^fining the ideal composition of the workforce. Health workforce demand calculated based on WHO minimum density targets.)fbeebhg' mhpZk]]^o^ehibg`ma^l^b]^Zl%^Z\ak^jnbk^lZ_h\nl^] ]bZ`ghlmb\%bg\en]bg`ln[lmZgmbZeZ]]bmbhgZe]ZmZ Pbmabgma^m^g&r^Zkmbf^ahkbshg%phkd_hk\^ \hee^\mbhgZg]ZgZerlbl%mh]^m^kfbg^bml_^Zlb[bebmrZg] ^qiZglbhglmbee_Z\^lmak^^\ab^_h[lmZ\e^l'?bklm%hg\^ Ziieb\Z[bebmrbgMZgsZgbZ'Ln\a]bZ`ghlmb\l\hne][^ school-specific optimizambhgaZl[^^gZ\ab^o^]%ma^ \hg]n\m^]bgiZkZee^epbmaMpb`Z^q^\nmbhg' mkZbgbg`g^mphkdpbee[^ZmfZqbfnf\ZiZ\bmr%pbma gh_nkma^khiihkmngbmb^l_hk^geZk`^f^gm'L^\hg]% Hnkm^Zf_hng]maZmma^\hf[bgZmbhgh_obkmnZe ibi^ebg^blln^llmbee]hfbgZm^Zg]Zk^^qZ\^k[Zm^]% e^Zkgbg`bgma^\eZllkhhfZg]]blmkb[nm^]\ebgb\Ze `bo^gmaZmg^pl\ahhel_Z\^Zfbgbfnfh_mphmh mkZbgbg`phne][^e^llk^lhnk\^&bgm^glbo^Zg] mak^^r^ZklÌ]^o^ehif^gm[^_hk^ma^r\ZgZ]fbmma^bk more fleqb[e^bgma^ehg`m^kfmaZg[nbe]bg`^bma^k firsmltudent. Bryan 2006. 2008 Twiga model (see note 17). the team identified a handful of lhenmbhg_hkMZgsZgbZ' Ë`Zf^&\aZg`bg`ÌhkËmkZgl_hkfZmbhgZeÌb]^ZlmaZmfZr a^eiZee^obZm^ma^l^\hglmkZbgmlZg]iZo^ma^pZrmh Ahp^o^k%p^\hg\en]^]maZm[nbe]bg`g^pl\ahhel ma^ikh]n\mbhgh_ZeZk`^kZg]fhk^mZk`^m^]a^Zema _khfl\kZm\aphne]k^jnbk^fhk^_Z\nemrZg]mnmhklbg phkd_hk\^'FZgraZo^[^^g]bl\nll^]Zmhg^mbf^hk addition to significant nep\hglmkn\mbhg'Ma^k^_hk^% Zghma^kpbmabgma^Fbgblmkr%[nmghg^aZlk^Z\a^]ma^ Zgrhimbhgl_hkfZqbfbsbg`^qblmbg`k^lhnk\^llahne] Z\mbhg&ieZglmZ`^' [^^xercised firsm' 45 Sources: Ministry of Health Interviews. 34 ACTION NOW .  L  ahkm^gma^mkZbgbg`ibi^ebg^[r\k^Zmbg`Z.Zlb\ L^kob\^Ikhob]^k\Z]k^Zg]Z\\^e^kZmbg`AMO mkZbgbg`' Beyond Twiga  B fikho^Z\\^llmh_Z\nemr[r^gaZg\bg`gZmbhgZe Zg]bgm^kgZmbhgZe\heeZ[hkZmbhgh_f^]b\ZemkZbgbg` >o^gpbmaln\\^ll_nebfie^f^gmZmbhgh_Mpb`ZZg] l\ahhel%laZkbg`\nkkb\neZZg]ltaff%Zg]bg\k^Zlbg` ma^k^lnembg`Z]]bmbhgh_++%/))g^pa^Zemaphkd^kl% m^\agheh`b\Zelniihkm' MZgsZgbZpbee_Zeelahkmh_bmlZf[bmbhnlmZk`^ml%[^bg`  F  Zqbfbs^nl^h_ebfbm^]mkZbgbg`k^lhnk\^lobZ p^ee[^ehpma^WHOmZk`^mh_+. World Health Report 2006.09 percent.))Z]]bmbhgZephkd^klmhikhob]^Zfbgbfnf lmZg]Zk]h_a^Zema\Zk^mhbmli^hie^!>qab[bm*-"%-. And finally the cosm%[Zl^]Zlbmphne] g^pfnemb&inkihl^mkZbgbg`bglmbmnmbhglhkZeZk`^ [^hg[kZg]g^pbg_kZlmkn\mnk^%[^\hf^lZefhlm \^gmkZebs^]bglmbmnmbhg_hk[Zlb\l\b^g\^lm^Z\abg`' bglnkfhngmZ[e^' Fbgblmky officials have given significant thought to [hmahimbhgl%Zg]Z]]bmbhgZeZgZerlblblk^jnbk^]mh Mh_nkma^kZ\\^e^kZm^ma^`khpmabgma^a^Zemaphkd^k ]^m^kfbg^ma^fhlmZiikhikbZm^Zg]\hlt-effecmbo^ lniier[^rhg]Mwiga. Pabe^[^ehpp^ikhob]^Zgnf[^kh_bgbmbZemahn`aml ^qi^\m^]bg+)*2mhgnf[^kho^k. and 2019 population based on expected annual growth rate of 2. 2005 staffing establishment for required ratio of diagnostic and support staff.a^Zemaphkd^kli^k obkmnZe\eZllkhhfe^Zkgbg`Zg]]blmkb[nm^]\ebgb\Ze m^gmahnlZg]i^hie^'Ma^\hngmkrpbeelmbeek^jnbk^ mkZbgbg`' 2+%.

500 63.) 2019 Financing health worker training Private loans P^]b]ghmZmtempt to solve for all financial issues :\hfi^mbmbo^erikb\^]lmn]^gmehZgikh`kZf k^lnembg`_khfl\Zebg`niikh`kZfl%[nmbmbl\e^ZkmaZm phne]bg\k^Zl^ma^ho^kall flow of funds to teaching financing is seo^k^erebfbm^]ZmgZmbhgZe`ho^kgf^gm bglmbmnmbhgl%fZdbg`l\ahhe^qiZglbhglnlmZbgZ[e^ Zg]eh\ZemkZbgbg`_Z\bebmre^o^el'?bgZg\bg`a^Zema pbmahnmebfbmbg`Z\\^llmh^]n\Zmbhg'Ln\\^ll_ne phkd^kmkZbgbg`bgMZgsZgbZieZ\^lZ`k^Zm[nk]^g ^qZfie^lh_mablZiikhZ\aaZo^[^^gbgbmbZm^] hg[hmalmn]^gmlZg]ma^`ho^kgf^gm'Lmn]^gm [rma^Bgm^kgZmbhgZe?bgZg\^<hkihkZmbhg!IFC) _^^lbgMZgsZgbZ]hghm\nkk^gmerk^flecmma^_nee bgiZkmg^klabipbmaikboZm^&l^\mhk[Zgdlbg[hma \hlmh_^]n\Zmbhg%Zg]ebfbm^]ln[lb]b^lh_m^ge^Zo^ Lhnma:f^kb\ZZg]:lbZmakhn`aZ\hfi^eebg`k^mZbe significant gaps in school resources.789 40.500 25. An efficient ]^o^ehif^gmh_ZikboZm^lmn]^gmehZgikh`kZf' \hee^\mbhgl\a^f^%Ze^`Ze_kZf^phkd%Zg]ZiikhikbZm^ THE TWIGA INITIATIVE 35 .500 40. financial risks.400 Health Net training Attrition Health Health workforce output 2009-2019 workforce workers 2009 2009-2019 2019 needed (est. such as de_ZnemkZm^l%Zg]ma^^qm^gm Hg^himbhgp^]^lb`g^]mhZ]]k^llmablblln^blma^ mhpab\ama^l^kbldlZk^fZgZ`eable.460 48.hma`overnment-provided financial aid bg\en]^%ZmZfbgbfnf%Z\hff^k\bZe[Zgdpbeebg`mh Zg]ikboZm^lmn]^gmehZgikh`kZfl_hkZee\Z]k^l hi^kZm^bm'Ab`abgm^k^lmkZm^l%ma^ghkfbg:_kb\Z%Zk^ Zk^g^^]^]mh^glnk^maZma^Zema^]n\Zmbhgk^fZbgl ikhab[bmbo^'Mhe bank will need to be confident of its accessible to all qualified applicants.000 63.EXHIBIT 14 Still not enough Gap of 92. [nlbg^llfh]^e' :lln\a%_Z\bebmb^lZk^e^_mpbmahnmk^lhnk\^l_hk Ma^ihm^gmbZe_hkZlbfbeZklmn]^gmehZgikh`kZflbg ^qiZglbhghkfZbgm^gZg\^':]cnlmbg`lmn]^gm_^^l MZgsZgbZ\Zghger[^Zl\^kmZbg^][rZll^llbg`kbld% mhk^flecmma^_nee\hlmh_^]n\Zmbhgphne]ikhob]^ ]^m^kfbgbg`ihebmb\Zebgm^k^lmZg]in[eb\Z\\^imZg\^% sufficient resources for schools to plan for and finance Zg]b]^gmb_rbg`\heeZ[hkZmbo^iZkmg^kl%bg\en]bg` ma^bkhpg`khpma'Ahp^o^k%ab`a^k_^^lpbmahnm [ZgdlZg]fnembeZm^kZehk`ZgbsZmbhgl' lniihkmphne]fZd^Zmtendance difficnem_hkfZgr H_\hnkl^%ik^k^jnblbm^l_hkln\aZehZgl\a^f^ lmn]^gml'.800 140.

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. Kaspar Wyss “An approach to classifying human resource constraints to attaining health-related Millennium Development Goals” Human Resources for Health 2004.112 351 124 107 250 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^]' `ho^kgf^gmZg]ma^mkZbgbg`bglmbmnmbhgl'Lmn]^gml Zk^Zek^Z]rZ\\nlmhf^]mhiZrbg`Z\hgmkb[nmbhg :_ng]\k^Zm^][rZgbgm^kgZmbhgZe]hghkfb`amp^ee _hkma^bklmn]b^l%Zg]ma^r\nkk^gmer]hlhpbmahnm a^eiZfhkmbs^ma^kbldl4]hghklaZo^Zek^Z]rlahpg k^\hnkl^mh\hfi^mbmbo^erikb\^]ehZgl'MaZm lhf^bgm^k^lmbgikhob]bg`ma^ihm^gmbZeereZk`^ bglmbmnmbhglpbeemkZgl_^kZ`k^Zm^kikhihkmbhgh_ ni_khgm\heeZm^kZemaZmphne]^gZ[e^ZiikhikbZm^ mkZbgbg`\hlmlmhma^lmn]^gmlblebd^ermh[^Z\\^im^] fbmb`Zmbhgh_kbld_hkma^\hff^k\bZeiZkmg^k' pbmama^kb`amlniihkmbg`_kZf^phkd' Ln\aZl\a^f^Çhi^kZm^][rZ\hff^k\bZe[Zgd% [nmpbmakbldlZiikhikbZm^erlaZk^][rbgm^kgZmbhgZe Defining the optimal workforce pyramid ]^o^ehif^gmiZkmg^klÇfZy offer the mosm Ma^k^Zk^Zgnf[^kh_pZrlmh]^m^kfbg^ma^himbfZe lnlmZbgZ[e^pZrh_kapidly increasing finance for a^Zemaphkd^kldbeefbq!Zg]ihineZmbhg"bgZ\hngmkr' a^Zema^]n\Zmbhg' Our team firsm\Ze\neZm^]ma^ikhc^\m^]+)*2a^Zema 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_+. Press: 2005). for example. Kurowski 2007. Norbert Dreesch..EXHIBIT 15 Increasing intake Projected additional 2015 intake after implementation Estimated 2009 intake 955 731 82 1. et al.400 96 1. 36 ACTION NOW . “An approach to estimating human resource requirements to achieve the Millennium Development Goals” (Oxford U.

ZgZerl^laZo^lhn`ammh`^g^kZte decisive figures for EXHIBIT 16 ma^himbfZeldbeefbq[Zl^]hgmZldli^k_hkf^]bg   inklnbmh_MDGlhkgZmbhgZefhkmZebmrk^]n\mbhg`hZel'-/     Ma^\nkk^gmltaffing shormZ`^bllhl^o^k^Z\khllZee 2.500 insufficient for TZgsZgbZmhf^^mbmla^Zemaphkd_hk\^ g^^]l%ma^\hngmkrpbeeg^^]Zf^Zglh__h\nlbg` 1.000 bg\k^Zl^]k^lhnk\^l!ahp^o^kebfbm^]"hgikbhkbmr     Zk^Zl%[Zl^]hggZmbhgZeZg]`eh[Zea^ZemamZk`^ml' .000 \Z]k^lh_a^Zemaphkd^klbgMZgsZgbZmaZmma^k^lahne] [^ZinlamhfZqbfbs^mkZbgbg`\ZiZ\bmrbg^o^kr ^qblmbg`bglmbmnmbhg'Ghg^ma^e^ll%[^\Znl^mablpbee[^ 1.

"' 2010 2011 2013 2015 2017 2019   .    Ma^\nkk^gmphkd_hk\^bla^Zoberp^b`am^]bg_Zohkh_ 500 gnkl^l%Zg][eZgd^m`khpmapbeeZ\\^gmnZm^mabl[bZl%     pa^ma^kk^flecmbo^h_gZmbhgZeltaffing needs or not    !>qab[bm*.

741 fully-staffed new facilities by 2019 Define the pyramid…   .

360 partially-staffed new facilities by 2019 :gZll^llf^gmh_ma^himbfZea^Zemaphkd^kirkZfb] fb`am[^`bgpbmaZlnko^y of the disease profile across MZgsZgbZZg]ma^g[k^Zd]hpgma^lbqfZchk\Zk^ modified for local interpremZmbhgZg]fnembieb^]_hk iZmapZrl!fZm^kgbmr%\abe]k^g%HIV/AIDS%fZeZkbZ%TB% ma^Zfhngmh_mbf^g^^]^]_hk^Z\amk^Zmf^gm' mkZnfZ"bgmhln[\Zm^`hkb^l'Bg\abe]k^g%_hk^qZfie^% mabl[k^Zd]hpgphne]bgoheo^]blmbg`nblabg`[^mp^^g …to define the task oZ\\bgZmbhglhki^kaZilmk^Zmbg`]bZkka^Ze]bl^Zl^l' Ma^k^lnembg`fh]^ephne][^Zkh[nlm]^\eZkZmbhg Ma^g^t result might be the identificambhgh_Zkhng] h_ma^anfZgk^lhnk\^lg^\^llZkrmhf^^mma^a^Zema mabkmr]bl\k^m^Zk^ZlmaZm_hkfma^\hk^ikbfZkr\Zk^ \hg]bmbhglh_ma^\hngmkr%ikhob]bg`ma^gnf[^kh_ g^^]lh_ma^\hngmkr' _nee&mbf^^jnboZe^gm\ebgb\ZeZllblmZgml%gnkl^l%AMOl% :_m^k[k^Zdbg`]hpgma^]ZmZ[r]blmkb\m%ikbfZkber iarlb\bZgl%Zg]hma^kphkd^klg^\^llZkrmhf^^mma^ hg`^h`kZiab\ZeZg]lh\bZeebg^l%ma^g^mk^lnemphne] ikbfZkr\Zk^\aZee^g`^' b]^gmb_rghmcnlmma^g^^]l_hkMZgsZgbZZlZpahe^ P^k^\hff^g]%ZlZlmZkmbg`ihbgm%ma^Zll^llf^gm [nmZelhma^hnm^k^]`^lh_Zgr\hgmbgnnfhgpab\a mhhe]^o^ehi^][rDnkhpldbbg+))0%pab\aa^eil a^Zema\Zk^phkd^kltaffing decisions are made. 2. THE TWIGA INITIATIVE 37 . ghmhgermhikhc^\mphkd_hk\^]^fZg]l[nmmhfh]b_r Hg\^mablbg_hkfZmbhgbl^oZenZm^]mh`^ma^kpbmama^ ma^ng]^kerbg`ldbeel]^o^ehif^gmikh\^llbg_hkfbg` ldbeefbqh_ma^^qblmbg`ihheh_\Z]k^lbgMZgsZgbZ% ablikhc^\mbhgl'-0Ma^k^lneml\hne]ma^g[^nl^]mh Zg]ma^g\hfiZk^]mhma^g^^]^]Z\mbobmb^l_hk^Z\ah_ ]^o^ehiZgZ\mbhgieZgmhfh]b_rma^mkZbgbg`lrlm^f ma^mabkmr\Zk^iZmapZrl%Z]^mZbe^]hnmebg^h_mkZbgbg` Zg]_neerZeb`g\nkkb\neZpbmaiZ\dZ`^lh_g^^]^] g^^]lphne]k^lnem'Bmlahne][^Zll^ll^]nlbg` ldbeel%bg\en]bg`ma^ihm^gmbZeZ]]bmbhgh_g^p\Z]k^l k^\h`gbs^]WHO`nb]^ebg^lhg\ebgb\Zek^jnbk^f^gml 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.

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

When Ethiopia launched an ambitious plan to increase access to health facilities. and Ma^l^o^k^lahkmZ`^h__Z\nemrblma^ikbfZkr_Z\mhk mZbehk^]mh_Z\nemrZoZbeZ[bebmrkZma^kmaZg\nkkb\nenf ebfbmbg`_nkma^ka^Zemaphkd^kmkZbgbg`^qiZglbhgbg k^jnbk^f^gml' MZgsZgbZ'FZqbfZenl^\Zg[^fZ]^h_ma^^qblmbg` _Z\nemrk^lhnk\^lmakhn`amphmri^lh_bglmbmnmbhgZe :gZmbhgZelrlm^f^gZ[e^l_Z\nemrlaZkbg`%pab\a \heeZ[hkZmbhg3gZmbhgZeZg]bgm^kgZmbhgZe' \ZgmZd^ieZ\^^bma^kmakhn`aZ_hkfZebs^]lrlm^f h__Z\nemr\bk\nbm&kb]bg`hkmakhn`alrlm^fZmbsbg` Makhn`agZmbhgZe\heeZ[hkZmbhg[^mween the five gZmbhgZe\nkkb\nenf]^o^ehif^gmmh^gZ[e^[khZ] MZgsZgbZgngbo^klbmb^lZg]]hs^glh_Zeeb^]a^Zema ETHIOPIA’S PRIMARY CARE PROVIDERS Health officers in Ethiopia are substitute doctors. 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. To enable the use of the equivalent of regional and district hospitals for clinical training.000 15. THE TWIGA INITIATIVE 39 .000 Health Optimized Impact of Attrition.600 74.400 48. The HEWs are trained for one year in special training sites all over Ethiopia. The AHO program is also linked to Ethiopia’s Health Extension Worker (HEW) program.800 attrition from new 6-month cadre 42. Created with the support of the Carter Center. a dramatic increase in the number of Health Officers to manage these facilities was called for. inefficient. 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 laZk^ebfbm^]m^Z\abg`k^lhnk\^l'Ik^l^gmer%laZkbg` institutional collaboration ]h^l^qblt but tends to be informal.500 on workforce 25.EXHIBIT 17 Rapid training provides dramatic increases 53.000 workers – all women – in rural villages under the supervision of an AHO. which aims to place 30. developing a targeted curriculum tailored to the country’s disease profile.500 26.000 Post-deployment Output of new 40.000 6-month cadre 48. Ethiopia’s Accelerated Health Officer (AHO) program is furthering this objective by networking Ethiopia’s universities. and making use of hospitals previously unused for clinical training.500 Impact of new cadre 63. with a role very similar to that of AMOs in Tanzania.

(I-TECH and MOHSW. The number of students he can \hne]]^o^ehiZ`eh[ZeZ\Z]^fb\^q\aZg`^ikh`kZf teach is determined by the size of the lecture theatre and the maZmphne]Zn`f^gmgZmbhgZem^Z\abg`\ZiZ\bmrZg] number of times he can give each lecture.org/resources/pubications-presentations/> (Accessed 29 Apr. <http://www.go2itech. Tanzania Distance Learning Assessment: Assessing the Use of Distance Learning To Train Health Care Workers in Tanzania. the Ln\a^q\aZg`^^qblmlghp[nmm^g]lmh[^ihhker university could multiply its capacity to provide biochemistry \hhk]bgZm^]Zg][Zl^]hgma^ZoZbeZ[bebmrZg]]^lbk^ training while enabling the professor to use his time teaching h_bgm^kgZmbhgZeltaff rZma^kmaZghgma^Z\mnZeg^^]l more specialized courses. 2009). or meeting h_^Z\abglmbmnmbhg':_h\nlhgma^ihm^gmbZe_hk individually with students. bg\k^Zl^]bglmbmnmbhgZe\heeZ[hkZmbhglahne]bg\en]^ b]^gmb_rbg`ghmhgerihm^gmbZe\heeZ[hkZmbhgiZkmg^kl% [nmZelhikhfblbg`ln[lmZgmbo^_h\nlZk^ZlZg] e^Zkgbg`bl\nkk^gmer[^bg`nl^]bglhf^bg&l^kob\^ ihllb[e^Zo^gn^l_hk_ng]bg`' Zg]lahkt disease-specific courses in TZgsZgbZ%lhZgr k^ieb\Zmbhghk^xpansion of those efformlphne]g^^]mh Maximizing limited teaching resources mZd^bgmhZ\\hngmZgy findings and recommendambhgl _khfZk^\^gmZll^llf^gm[rI-TECHZg]ma^Fbgblmkr'-1 BgZghimbfbs^]mkZbgbg`g^mphkd%ma^ZoZbeZ[bebmr h_mkZbg^klÇmnmhkl%f^gmhkl%_Z\nemr%Zg]\ebgb\Ze PaZmblg^\^llZkrblZgZll^llf^gmh_ma^ihm^gmbZe lni^koblhklÇpbee[^ma^fZbg_Z\mhkebfbmbg` _hkobkmnZee^Zkgbg`bgma^MZgsZgbZg\hgm^qm _nkma^k^qiZglbhg'P^ln``^lmmaZmmabl\hglmkZbgm !bg\en]bg`m^\agheh`b\ZeZg]bg_kZlmkn\mnk^\aZee^g`^l \Zg[^iZkmerho^k\hf^pbmaobkmnZee^Zkgbg`Zg] Zg]pZrlmhho^k\hf^mahl^\aZee^g`^l"'Ma^ ]^\^gmkZebs^]mkZbgbg`m^\agbjn^l!>qab[bm*1"%Zl Zll^llf^gmphne]Zelh_h\nlhghiihkmngbmb^lmhebgd Z]him^]bgfZgrhma^k\hngmkb^l' obkmnZee^Zkgbg`mhma^\nkkb\nenf\aZg`^lln``^lm^] [rma^irkZfb]ZgZerlbl' Ma^l^\hne]bg\en]^[hmaik^k^\hk]^]e^\mnk^lZg] ma^nl^h_ltaff am\ebgb\Ze\Zk^_Z\bebmb^lghm\nkk^gmer E^\mnk^klphne]g^^]mh[^l^e^\m^][Zl^]hgma^bk affiliam^]pbmamkZbgbg`ikh`kZflZllni^koblhkl_hk ^qi^ktise in the field and would sign up for a \ebgb\ZeikZ\mb\^' \nkkb\ulum agreed upon by all affecm^]mkZbgbg` bglmbmnmbhglhkk^e^oZgmikh_^llbhgZeZllh\bZmbhgl': Virtual classroom learning lmZg]Zk]bs^]gZmbhgZe\nkkb\nenfbg[bh\a^fblmkr%_hk .nbe]bg`hgma^gZmbhgZeZg]bgm^kgZmbhgZe ^qZfie^%phne]fZd^bmihllb[e^mhnl^ik^k^\hk]^] \heeZ[hkZmbhgihllb[bebmb^l]^l\kb[^]Z[ho^%ZobkmnZe e^\mnk^lZml\ahhelpa^k^ma^k^\nkk^gmerblgh e^Zkgbg`ikh`kZf\hne]_nkma^k^qm^g]ma^k^Z\a [bh\a^fblmkrikh_^llhk'MZi^]bglmkn\mbhg\hne]Zelh h_ebfbm^]m^Z\abg`k^lhnk\^l[r^gZ[ebg`_Z\nemrmh ^qm^g]m^Z\abg`mhk^fhm^Zk^Zl%^ebfbgZmbg`ma^g^^] ikhob]^^e^\mkhgb\o^klbhglh_ma^bke^\mnk^lmhk^fhm^ _hklmn]^gmlmh[^\^gmkZeereh\Zm^]g^ZkeZk`^mkZbgbg` l\ahhel%pa^k^lmn]^gml\hne]ma^g[^g^fit from the bglmbmnmbhgl' mkZbgbg`pbmahnm\aZg`bg``^h`kZiab^l'=blmZg\^ 48 International Training and Education Center on HIV (I-TECH). \hgmkb[nm^mhbgghoZmbo^\nkkb\nenf]^o^ehif^gm' By recording his lectures and replaying them in another session. as done by Weill Cornell Medical College in Qatar. a single biochemistry Makhn`abgm^kgZmbhgZebglmbmnmbhgZe\heeZ[hkZmbhg professor is responsible for instructing all MD students (two pbmaZg^fiaZlblhgghkma&lhnmaebgdZ`^l%MZgsZgbZ hundred per incoming class). conducting research.bfie^f^gmZmbhgh_^&E^Zkgbg`f^mah]heh`b^l%a^g\^ e^o^kZ`bg`mahl^_Z\nemrmaZm]h^qblm' MULTIPLYING CAPACITY At Muhimbili in Dar es Salaam. 2009) 40 ACTION NOW .

ZlmkZbgbg`lbm^l' This approach would have the secondary effect of improving patient care in the utilized hospitals.800 56.5 Impact on workforce 25.500 63. as well as <ebgb\Zeltaff and clinical infrZlmkn\mnk^Zk^mphh_ increasing the potential that graduates would choose to stay ma^lbq\hglmkZbgmlmhl\Zebg`nimkZbgbg`\ZiZ\bmrZm to practice in those geographic locations. by accessing the medical officers and specialists working in the six regional and 46 Distributed clinical training district hospitals of the Lake Zone. However.900 8.400 48.400 learning programs 35-40 40. l\ahhelZ\khllma^\hngmkr':mik^l^gm%ghmZeeh_ma^ THE TWIGA INITIATIVE 41 .500 2.000 Health Optimized Additional Attrition Health workforce training training output 2009-2019 workforce 2009 output 2009-2019 2019 Mh^glnk^maZmlmn]^gmlZ[lhk[ma^fZm^kbZe%mnmhkl k^`bhgZeZg]]blmkb\mahlibmZelZk^nl^]Zl\ebgb\Ze phne]g^^]mh[^ZoZbeZ[e^mhZglp^kjn^lmbhgl%Zg] mkZbgbg`_Z\bebmb^l%e^Zving significant untapped p^^derl^e_&Zll^llf^gml\hne][^Z]fbgblm^k^]mh mkZbgbg`\ZiZ\bmrbgma^k^fZbgbg`_Z\bebmb^l' f^Zlnk^lmn]^gmikh`k^ll' Ma^ikbfZkrbfie^f^gmZmbhg\aZee^g`^blma^ ZoZbeZ[bebmy of sufficient technological infrZlmkn\mnk^ EMPLOYING DISTRIBUTED TRAINING Zg]lniihkmZ[e^mh]^lb`gZg]kngZk^ebZ[e^ AT BUGANDO bg_hkfZmbhgZg]\hffngb\Zmbhgm^\agheh`r!ICT"& Tanzania’s five university-based medical schools would [Zl^]mkZbgbg`ikh`kZf'Ln\aZikh`kZf_hkflma^ provide a strong foundation for employing distributed _hng]Zmbhgh_P^bee<hkg^eeÌlg^pf^]b\Ze\hee^`^bg training.EXHIBIT 18 Accelerating with virtual learning Output of virtual learning programs Post-deployment attrition from virtual 11. while dramatically multiplying the number of \nkk^gmer^fiehr^]Zl\Zk^_Z\bebmb^lhgerZg]ghm students it prepares for clinical practice in the zone. The Weill Bugando university uses the tertiary =haZ%JZmZk%_hk^qZfie^%Zg]\hne][^nl^]Zlma^ referral hospital of the Lake Zone – Bugando Medical Centre _kZf^phkd_hkln\aZikh`kZfbgMZgsZgbZ' – as its teaching hospital. Bugando could focus LbfbeZker%]blmkb[nm^]\ebgb\ZemkZbgbg`phne] its growth on classroom teaching and building non-clinical fZd^nl^h_ma^k^`bhgZeZg]]blmkb\mahlibmZel capacity.500 2.

<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 .

2oblbm^] bl]^fined and releoZgm]ZmZbl\hee^\m^]' l\ahhel%Zlp^eeZlma^Zmm^g]Zgmlrlm^f&pb]^\aZg`^l'  =  ^o^ehiZgZ\mbhgieZgbgpab\ama^\hee^\m^]]ZmZ >q^\nmbg`ma^l^ieZglpbeek^jnbk^ma^Fbgblmkr blZgZers^]mh\k^Zm^Zgbfie^f^gmZ[e^phkdieZg' mhl^\ure sufficient funding. HnkZiikhZ\apZl]^lb`g^]ZliZkmh_Zmak^^&iaZl^ Bfie^f^gmZmbhg_hk^Z\ah_ma^Z\mbobmb^l]^l\kb[^] ikh\^llfhobg`_khfma^lmkZm^`b\h[c^\mbo^h_^qiZg]bg` bgmabll^\mbhg\hne][^`bgZllhhgZlk^lhnk\^lZk^ a^Zemaphkd^kmkZbgbg`mhma^k^ZebsZmbhgh_maZm`hZe' ZoZbeZ[e^_hk_ng]bg`Zg]lniihkm' Ma^mak^^iaZl^l![khZ]er]^fined) are necessarr_hk ^o^krikhc^\mhkZ\mbobmr`^Zk^]mhpZk]bfikhobg` The 39 visited schools and system-wide initiatives: execution a^Zemahnm\hf^lfhk^`^g^kZeer%Zg]Zk^Zl_heehpl3 H_hnkk^\hff^g]Zmbhgl%ma^\hfihg^gmkbi^_hk  <  hg]n\mZgbgbmbZe]bZ`ghlmb\bgpab\ama^ikh[e^f ^q^\nmbhgblma^Z\mbhgieZglmhhimbfbs^ma^.. while planning begins on the Z\mbobmr_hkpab\ama^]bZ`ghlmb\aZlcnlm^g]^]' Mabllmkn\mnk^e^g]lbml^e_mhZmak^^&lmZ`^ mbf^ebg^Çghp%g^qm%Zg]lhhgÇpbma^Z\aZ\mbobmr lbfnemZg^hnlerikh`k^llbg`hgbmlhpgmkZc^\mhkr' Implementation To do now. LbfnemZg^hnlbfie^f^gmZmbhgaZlma^Z]oZgmZ`^ of maximizing efficiencrZg]li^^]h_^q^\nmbhg3 pa^g^q^\nmbhgbl\hfie^m^!h_hg^Z\mbobmy) efforml \Zg[^`bghgma^Z\mbobmr_hkpab\aZ\mbhgieZggbg` aZlcnlt been finished. the team identified seo^kZebglmbmnmbhglmaZm ]bZ`ghlmb\lZg]]kZ_mZ\mbhgieZgl_hkZeeh_ma^ \hne]Z\ab^o^^\hghfb^lh_l\Ze^Zg]Z\\hffh]Zm^ ihm^gmbZehiihkmngbmb^lmaZm`k^phnmh_ma^Mpb`Z Z]]bmbhgZelmn]^gmlpbmafbgbfZebgo^lmf^gm% ]bZ`ghlmb\%lhf^h_pab\ap^hnmebg^]bgma^ k^lnembg`bgZgZggnZelmn]^gmbg\k^Zl^h_m^gmh ik^obhnl\aZim^k' mp^gmri^k\^gmho^kZg]Z[ho^bg\k^Zl^]bgmZd^ZlZ k^lnemh_himbfbsZmbhg' KZma^kmaZgZ]oh\Zm^bff^]bZm^^q^\nmbhgh_Zee ihllb[e^k^\hff^g]Zmbhgl%ma^k^_hk^%mablk^ihkm Ln\\^ll_ne^q^\nmbhgpbeek^jnbk^ldbee^]ikhc^\m Z]oh\Zm^liZkZee^eZ\mbobmb^l[Zl^]hgma^g^\^llZkr fZgZ`^f^gmZg]fnembeZm^kZe\heeZ[hkZmbhgmh^glnk^ g^qmltep of each identified recommendambhgÇ Z\ab^oZ[e^ZggnZemZk`^ml_hkmkZbgbg`makhn`ainm%Zl pa^ma^kmaZmg^qmlm^i[^Z]ZmZ&`Zma^kbg`]bZ`ghlmb\% p^eeZlZfnembr^Zkbfie^f^gmZmbhgieZgmaZmbg\en]^l Z\mbhgieZggbg`%hk_nee&[ehpg^q^\nmbhg' hg`hbg`^oZenZtion and modificambhg' THE TWIGA INITIATIVE 43 .. engag^ZiikhikbZm^ bfie^f^gmZmbhgiZkmg^kl%Zg]^glnk^ihebmb\Zelniihkm  N  g]^kmZd^Zg^q^\nmbhgiaZl^%bgpab\ama^ _hkk^\hff^g]^]iheb\rlab_ml' phkdieZgblbfie^f^gm^]Zg]bgbmbZek^lnemlZk^ f^Zlnk^]' Mabl^q^\nmbhgiaZl^pbeebg\en]^ghmhger^qiZg]bg` Mhe school-specific acmbhgieZglZg]lrlm^f&pb]^ ^qblmbg`ikh`kZfl[nm\ZibmZebsbg`hglrg^k`b^lmhZ]] bgbmbZmbo^lhnmebg^]bgmablk^ihkmZk^k^Z]r_hkma^ g^pikh`kZflmh^qblmbg`l\ahhel'Makhn`ahnmhnk mabk]iaZl^'Ahp^o^k%p^p^k^ghmZ[e^mh\hfie^m^ research.

2mkZbgbg`bglmbmnmbhgl%p^ \hne]ma^bkhiihlbmbhg[^ho^k\hf^8 \ho^k^]Z[khZ]\khll&l^\mbhgh_MZgsZgbZg`^h`kZiar Zg]ihineZmbhg]^glbmr'>qmkZiheZmbg`_khfl\ahhelh_  Ahppbeem^Z\abg`jnZebmr[^fZbgmZbg^]8 lbfbeZklbs^%ikh`kZf%Zg]\nkk^gmbgmZd^%p^bg\en]^]  PaZmldbeelZk^^ll^gmbZe_hkZ]bli^glZkrphkd^k8 ma^k^fZbgbg`.Remaining schools: action planning  :  k^ma^k^lmZd^ahe]^kl^bma^kpbmabghkhnmlb]^ma^ `ho^kgf^gmpahphne]hiihl^mablbgbmbZmbo^%Zg] While visiting the firsm... 44 ACTION NOW .. Hg\^mablchbgmm^ZfaZl]^o^ehi^]ma^k^fZbgbg` :eeh_ma^Z[ho^\Zg[^`bgbff^]bZm^erZg]k^eZmbo^er l\ahhehimbfbsZmbhgieZgl%ho^kZee_ng]bg` bg]^i^g]^gmer'Ma^g^qmlmZ`^blmhphkdmakhn`ama^ k^jnbk^f^gmlfZrg^^]mh[^Z]cnlm^][^_hk^ieZgl _heehpbg`l^mh_blln^l' Zk^bfie^f^gm^]'Ahp^o^k%`bo^gmaZmp^\ho^k^] g^Zkerlbqmri^k\^gmh_MZgsZgbZga^Zemaphkd^k The 39 visited schools: monitoring and evaluation mkZbgbg`\ZiZ\bmr%p^[^eb^o^maZmZgrZ]cnlmf^gmlZk^ :lp^ikh`k^llbgmheZm^klmZ`^lh_bfie^f^gmZmbhg% ebd^ermh[^fbghk' bmpbee[^\kn\bZemhZ\mbo^erfhgbmhkik^obhnler ^q^\nm^]l\Zebg`&niikh`kZflmh^glnk^maZmma^rZk^ Transformational approaches: diagnostic and conceptual ikh`k^llbg`hgl\a^]ne^Zg]aZobg`ma^Zgmb\biZm^] development bfiZ\m%Zlp^eeZlmhZiiere^Zkgbg`l_khfmahl^ Ma^bfie^f^gmZmbhgh_Zgrg^plrlm^fb\hk Z\mbobmb^lmh_nmnk^^g]^Zohkl' mkZgl_hkfZmbhgZeZiikhZ\apbeek^jnbk^kb`hkhnl]ZmZ \hee^\mbhgZg]ZgZerlblh__^Zlb[bebmr%bfiZ\m%Zg] The remaining schools: execution \hlm_hkMZgsZgbZ'Mablpbee^gmZbeZglp^kbg`ln\a Hg\^Z\mbhgieZglaZo^[^^g]^o^ehi^]_hkma^ jn^lmbhglZl_heehpl3 k^fZbgbg`mkZbgbg`l\ahhel%^q^\nmbhgh_mahl^ieZgl  P  aZm]ZmZblk^jnbk^]mh\hg]n\mZ\hfie^m^\hlm& \Zg[^`bg%_heehpbg`ma^iZmm^kg]^o^ehi^]pabe^ [^g^fit analysis? ^q^\nmbg`ieZgl_hkma^bgbmbZe.2l\ahhel'E^llhgl e^Zkg^]_khfmaZmbgbmbZe^q^\nmbhgiaZl^phne]Zelh [^Ziieb^]' 48 See note 9 for explanation of number of institutions.nmZ\\nkZm^Z\mbhgZg]bgo^lmf^gmieZgl\Zgghm phkdlhgl^o^kZe_khgmllbfnemZg^hnler' [^]^o^ehi^]lhe^ermakhn`a^qmkZiheZmbhg4^Z\a school is different and musm[^bg]^i^g]^gmer BgmablpZr%bfie^f^gmZmbhgh_iaZl^] visited and assessed according to its specific bfie^f^gmZmbhgikh`kZflmZk`^mbg`^bma^k ^qiZglbhghiihkmngbmb^l'P^Zgmb\biZm^maZmmabl mkZgl_hkfZmbhgZeZiikhZ\a^lhklniihkmbg`a^Zema ikh\^llphne]mZd^ZiikhqbfZm^erhg^r^Zk%Zg] phkd^kfZgZ`^f^gmlmk^g`ma^gbg`\hne][^k^Z]r lahne][^ng]^kmZd^gZlZchbgmo^gmnk^[^mp^^g _hkeZng\a[rma^mbf^himbfbsZmbhgbl\hfie^m^]' ma^bfie^f^gmbg`iZkmg^kZg]ma^MZgsZgbZg `ho^kgf^gm' .to do next.1bglmbmnmbhglbghnkikhc^\m^]mhmZe \hlt of school-specific optimizambhgZg]bghnk MablZgZerlbl]h^lghm%Zg]lahne]ghm%aZo^mhpZbm Zll^llf^gmh_himbfbsZmbhgÌlho^kZeebfiZ\m%^o^g ngmbema^l\ahhehimbfbsZmbhghkfhk^]^mZbe^]lrlm^f& mahn`ap^p^k^ghmZ[e^mhoblbmZg]Zll^llma^f pb]^bgbmbZmbo^lZk^\hfie^m^'KZma^k%ma^l\ahhe i^klhgZeer'-2 himbfbsZmbhgikh`kZf\Zgl^kve as a kick-off for a fnembr^Zka^Zemaphkd_hk\^bfikho^f^gmieZgmaZm ..

2006.*Zl :lbfie^f^gmZmbhgikh`k^ll^l%fhgbmhkbg`Zg] p^eeZlZgZermb\ZemhhedbmlmaZmebgd]ZmZmhieZggbg` ^oZenZmbhgpbeeZllnf^Zgbg\k^Zlbg`ereZk`^khe^Zl ikh\^ll^l'Mablpbee^gZ[e^`ho^kgf^gmZ]fbgblmkZmhkl fhk^ikh`kZflZk^^q^\nm^]Zg][^`bgmh`^g^kZm^ mhfh]^ehnmma^bfieb\Zmbhglh_iheb\r\ahb\^lZg] k^lneml%Zlp^eeZle^llhgl_hk_nmnk^Z\mbobmb^l' bfie^f^gmZmbhgikbhkbmb^l[^_hk^^q^\nmbhg' Transformational approaches: execution Decentralization Bfie^f^gmZmbhgh_ma^mkZgl_hkfZmbhgZeZiikhZ\a^lÇ Bfie^f^gmbg`ma^l^k^\hff^g]ZmbhglliZglfZgr lmn]^gmehZgl%ma^a^Zemaphkd^kirkZfb]%Z\\^e^kZm^] e^o^elh_Z]fbgblmkZmbhg%_khfma^\^gmkZeFbgblmkr mkZbgbg`%bglmbmnmbhgZe\heeZ[hkZmbhg%Zg]obkmnZe to each individual school principal. THE TWIGA INITIATIVE 45 .. see Management Sciences for Health and The Capacity Project.Zl^]hgma^l^^Zkeb^klmZ`^l% ?hkZlbg`e^Fbgblmkr]^iZkmf^gmmhfhgbmhkikh`k^ll ^q^\nmbhglmkZm^`rpbeeoZkr[rZ\mbobmr%_khfeZng\abg` Zmg^Zkerhg^ang]k^]mkZbgbg`bglmbmnmbhglihl^l ibehmikh`kZflbglhf^\Zl^lmh[^`bggbg`gZmbhgZe significant challeng^l'?nkma^k%Z\hfik^a^glbo^ khee&hnmbghma^kl' mkZbgbg`^qiZglbhgikh`kZffnlmbgoheo^ghmhger 49 For a more detailed study on capacity for Human Resources management in the Tanzanian health ministry. Strengthening Human Resources Information Systems Aug. 2007. the workforce pyrZfb]% pbeeg^^]mhho^k\hf^mhZ\ab^o^ln\\^ll_ne lahkm^gbg`ma^ibi^ebg^%bglmbmnmbhgZe\heeZ[hkZmbhg bfie^f^gmZmbhg'Ma^l^\aZee^g`^lZk^iZkmb\neZker pbmabgm^kgZmbhgZengbo^klbmb^l%Zg]obkmnZee^Zkgbg`Ç Z\nm^pa^gbm\hf^lmhhg`hbg`ikbfZkr]ZmZ ma^bgbmbZe]bZ`ghlmb\lmn]b^lpbeeikhob]^ma^]ZmZ \hee^\mbhgZg]ZgZerlbl%]^\^gmkZebsbg`fZgZ`^f^gm Zg]ZgZerlblg^\^llZkrmh\k^Zm^bfie^f^gmZ[e^ Zg]ho^klb`am%Zg]^glnkbg`lmZd^ahe]^k Z\mbhgieZgl' \heeZ[hkZmbhg'. 50 For more on one initiative to implement a computerized Human Resource Information System in sub-Saharan Africa..) New ideas: diagnostic and conceptual development Capacity constraints Ma^Z[ho^]bZ`ghlmb\lh_mkZgl_hkfZmbhgZeb]^Zl L\Zk\^k^lhnk\^lZg]ma^g^^]mh[ZeZg\^ma^bgm^k^lml fZrZelhk^o^Zehma^kikhfblbg`Z\mbobmb^lmaZmpbee h_ZoZlmZkkZrh_bgm^kgZelmZd^ahe]^kl%Zlp^eeZl ma^fl^eo^lk^jnbk^_nkma^kbgo^lmb`Zmbhg' ]hghkl%NGOl%Zg]hma^k`ho^kgf^gmfbgblmkb^l%aZo^ abg]^k^]ma^Fbgblmkrbglrlm^fZmb\Zeer`Zma^kbg`Zg] ZgZersbg`]ZmZ%]kZ_mbg`^ob]^g\^&[Zl^]Z\mbhgieZgl% . Effecmbo^ learning – would build on the findings and demZbel bfie^f^gmZmbhgk^jnbk^l[ZeZg\bg`gZmbhgZe]bk^\mbhg ]bl\ho^k^]Zg]ieZgg^]_hkbgma^Z[ho^]bZ`ghlmb\ Zg]fhgbmhkbg`pbmaeh\Zehpg^klabiZg]ho^klb`am' Zg]Z\mbhgieZglmZ`^l'. Report of a Human Resource Management Assessment of the Tanzania Ministry of Health Oct. see The Capacity Project.Transformational approaches: action planning Implementation challenges ?or the five trZgl_hkfZmbhgZeZ\mbobmb^l]^l\kb[^] Ma^k^Zk^Zgnf[^kh_\aZee^g`^lmaZmMZgsZgbZ Z[ho^Çltudent financing.and to do soon Zg]bfie^f^gmbg`ma^iheb\rhgmkZbgbg`^qiZglbhg' :llnfbg`gh]kZfZmb\\aZg`^lbgiheb\rhk]bk^\mbhg aZo^h\\nkk^]_heehpbg`_nkma^k]bZ`ghlmb\ikh`kZfl% Ma^k^\hff^g]Zmbhglh_ma^Mpb`Z]bZ`ghlmb\aZo^ the following series of efformlpbeeg^^]mh[^ [^^g^qmkZiheZm^]mhma^^gmbk^mkZbgbg`g^mphkd% ng]^kmZd^g' [Zl^]hg]ZmZ\hee^\m^]Zmho^khg^mabk]h_ma^ gZmbhgÌlmkZbgbg`bglmbmnmbhgl'Bghk]^k_hkmabl All health training schools: monitoring and evaluation ZgZerlblmhaZo^eZlmbg`oZen^%bmfnlm[^\hnie^] pbmama^]^o^ehif^gmh_]ZmZ\hee^\mbhglrlm^fl%.

*)fbeebhg!TSH..+ phkd^kl' But these figures do not indicam^ma^_nee\hlmh_ :lma^Fbgblmkr\hglb]^klahpmhZeeh\Zm^ bfie^f^gmZmbhg%Zlma^r]hghmmZd^bgmhZ\\hngmma^ bfie^f^gmZmbhgk^lihglb[bebmb^l%ma^\hfiZkZmbo^ bfiZ\mmaZmbg\k^Zl^]ikh]n\mbhgh_a^Zemaphkd^kl Z]oZgmZ`^lh_^Z\aihm^gmbZee^o^eh_bglmbmnmbhgZe pbeeaZo^hga^Zemaphkd^klZeZkb^l'MablbfiZ\mblghm ho^klb`amlahne]]kbo^ma^]^\blbhg&fZdbg`ikh\^ll' g^`eb`b[e^3pbmabgm^gr^Zkl%lZeZkb^lh_ma^Z]]bmbhgZe ?hkbglmZg\^%gZmbhgZe]bk^\mbhg%ho^klb`am%Zg] a^Zemaphkd^klpbeekbl^mhZiikhqbfZm^er*++fbeebhg Z\\k^]bmZmbhgblbfihkmZgmmh^glnk^\hglblm^gm ZggnZeer%khn`aer]hn[e^ma^^lmbfZm^]\hlmh_a^Zema jnZebmrh_\Zk^%^jnbmrh_l^kob\^ikhoblbhg%Zg] phkd^klZeZkb^lbg+))0'.+fbeebhgbghg^&mbf^\hlml% bgm^glbo^k^lihglb[bebmb^l]hpgma^ebg^%ln\aZlma^ pbmanimhZgZ]]bmbhgZe*)fbeebhgbgbg\k^f^gmZe k^\knbmf^gm%ieZ\^f^gm%Zg]^oZenZmbhgh_a^Zema ZggnZe\hlml!>qab[bm*2"'. and might be more Mhinmmablbgmh\hgm^qm%bg+))/%ma^eZlmr^Zk_hkpab\a ZiikhikbZm^_hk\nkkb\nenf]^o^ehif^gm%]ZmZ \hfie^m^[n]`^m]ZmZblZoZbeZ[e^%ma^a^Zemal^\mhk ZgZerlbl%iheb\rZg]ieZggbg`' [n]`^mpZl.11[beebhg"%Z\\hngmbg` 51 Source: 2008 Twiga Model (see note 17).]blmkb\ml%k^\^bo^]bk^\m_ng]bg`_khf bgm^kgZmbhgZe]hghkl%Zg]fZgZ`^eh\ZemkZbgbg` Information distribution Zg]hma^kikhc^\ml]^lb`g^]mhf^^mma^bklmkZm^`b\ h[c^\mbo^l'>Z\ah_ma^+*k^`bhgZea^ZemafZgZ`^f^gm K^lihglb[bebmr_hkma^a^Zemaphkd_hk\^]h^lghm m^Zfl\hkk^lihg]lmhma^k^`bhgZee^o^eh_`ho^kgZg\^ k^lb]^lhe^erpbmabgma^Fbgblmkr'<aZg`^lmhik^& Zg]l^mllbfbeZklmkZm^`b\mZk`^ml_hkbmlk^`bhgl'Ma^bk l^kob\^mkZbgbg`pbeeZff^\mabkbg`%]^iehrf^gm%Zg] ikbfZkrk^lihglb[bebmrblmhho^kl^^ma^]blmkb\me^o^eh_ k^m^gmbhg'IeZggbg`Zg]bfie^f^gmbg`mkZbgbg`& a^Zema\Zk^%ahp^o^k%lhma^rk^\^bo^gh]bk^\m_ng]bg` k^eZm^]bgbmbZmbo^l%ma^k^_hk^%pbeeZff^\mgnf^khnl mhbfie^f^gmikh`kZfl' lmZd^ahe]^kl'Bg_hkfZmbhgflhpl[^mp^^gfbgblmkb^l% [^mp^^g]bk^\mhkZm^lpbmabg^Z\afbgblmkr%Zg] :gnf[^kh_a^Zema&mkZbgbg`&k^eZm^]Z\mbobmb^lZk^ [^mp^^g`ho^kgf^gmZeZg]ghg&`ho^kgf^gmZe [^`bggbg`mh[^`ho^kg^]Zmma^shgZee^o^eZlp^ee% lmZd^ahe]^klpbee[^^ll^gmbZemhZ\ab^o^Z pbmahg`oing efformlmh[nbe]fZgZ`^f^gm\ZiZ\bmr \hfik^a^glbo^Zg][khZ]erZ\\^im^]\ZiZ\bmr pbmabgma^`ho^kgf^gmÌl^b`amShgZeK^lhnk\^ ^qiZglbhg' <^gmk^l' Cost of system optimization =^e^`Zmbg`ikbfZkrk^lihglb[bebmr_hkbfie^f^gmZmbhg mhhg^h_ma^l^fb]]e^Z]fbgblmkZmbo^e^o^elphne] P^ikhc^\mma^\hlmh_bfie^f^gmbg`ma^Mpb`Z enable more efficient use of the centrZeFbgblmkr% k^\hff^g]ZmbhglÇ[hma\hfie^mbg`ma^Z\mbhg pab\a\Zgma^gmkZ\d^b`amshg^lkZma^kmaZgg^Zker ieZgl_hkma^. 46 ACTION NOW .in[eb\bglmbmnmbhgl%[nmZelh_Zbma&[Zl^]Zg]ikboZm^ <hgo^kl^er%eh\Zehpg^klabi^glnk^lmaZmeh\Ze mkZbgbg`_Z\bebmb^l' dghpe^]`^Zg]k^eZmbhglabilh_mknlmZk^e^o^kZ`^] ZiikhikbZm^er%^gZ[e^lkZib]k^Z\mbhgmh\hffngbmr Bgma^MZgsZgbZglrlm^f%]blmkb\mhk\hng\bea^Zema g^^]l%Zg]fb`am[^fhk^ZiikhikbZm^_hkho^kl^^bg` fZgZ`^f^gmm^Zfl]^o^ehilmkZm^`b\ieZgl_hk \hglmkn\mbhgZg]\hee^\mbg`ikbfZkr]ZmZ' MZgsZgbZÌl**. k^ebZ[e^gZtional resource flows. team analysis through extensive qualitative and quantitative field work.2oblbm^]l\ahhelZg]Zll^llbg`%Z\mbhg hg^ang]k^]bg]bob]nZel\ahhel'MablpbeeZelheZrZ ieZggbg`%Zg]^q^\nmbg`ieZgl_hkma^k^fZbgbg` _hng]Zmbhg_hkma^]^\^gmkZebsZmbhgh_hma^k]ZmZ& l\ahhelÇmh[^Zkhng].

MablpZl^jnboZe^gmmh+'. However. “Effects of policy options for human resources for health: an analysis of systematic reviews”The Lancet Feb. $7.4m (TSH 47.-[beebhg"[r+)*1'B_ma^MZgsZgbZg 15 ^\hghfr\hgmbgn^lmh`khpZmbml+))0kZm^h_0'* 10 i^k\^gm%ahp^o^kngebd^erbgma^\nkk^gm\ebfZm^%ma^ `ho^kgf^gmphne][^Z[e^mh\ho^kmablZ]]bmbhgZe 5 \hlmpbmahnmbg\k^Zlbg`[^rhg]hg^i^k\^gmh_GDP 0 ie^]`^]Zlbg+))1!>qab[bm+)"'. See Tanzania.4bn) to the ministry HQ.+[beebhg"phne][kbg`ma^ 20 Zeeh\Zmbhgmha^Zemaphkd^k\hfi^glZmbhgmh+/0 fbeebhg!TSH.0 2010 2015 2020 Ahp^o^k%ZlmablpZlg^Zker]hn[e^ma^i^k\^gmZ`^h_ _hkg^Zker^e^o^gi^k\^gmh_ma^MZgsZgbZg`ho^kgf^gm GDPZeeh\Zm^]mhmabl[n]`^mZk^Zbgik^obhnlr^Zkl% [n]`^m'.doc>. Health Sector Public Expenditure Review (PER) update FY 2006. team analysis through extensive qualitative and quantitative field work. TSH 16bn of the central ministry budget. et al.%ma^MZgsZgbZga^Zema[n]`^maZl`khpg g^p_Z\bebmb^l%^jnbif^gmZg]\hglnfZ[e^lbgmahl^ ZggnZeer[rZgZo^kZ`^h_+1i^k\^gm'>lmbfZm^] _Z\bebmb^l%ln[lb]bs^]]kn`lmhlmh\dg^p]bli^glZkb^l% figures for 2008 confirm thamma^a^Zemal^\mhkZ`Zbg Zg]lh_hkma'Lhbmbl\e^ZkmaZmk^[nbe]bg`ma^a^Zema Z\\hngml_hk*)'0i^k\^gm%pbma.1m (TSH 6. suggesting that the total FY2008 MTEF budget of over TSH 682bn is not necessarily indicative of actual allocation and expenditure. millions 55 a^Zemal^\mhk[n]`^m'Mablbg\k^Zl^pZl\k^Zm^]bgiZkm [r]hn[ebg`ma^i^k\^gmZ`^h_GDPZeeh\Zm^]mha^Zema 50 phkd^k\hfi^glZmbhg!mhhg^i^k\^gm"'.5m (TSH 89. $5.EXHIBIT 19 [beebhg!TSH/')/0mkbeebhg"'BmghplahplZgZeeh\Zmbhg The implementation hurdle h_*-2fbeebhg!TSH*10'-[beebhg"_hka^Zemaphkd^k \hfi^glZmbhg%Zgbg\k^Zl^mhg^Zker+2i^k\^gmh_ma^ $.worldbank. bmk^fZbglmh[^l^^gpa^ma^kmablZeeh\Zmbhgh_ fbeebhg!TSH12[beebhg"ÇpZlZeeh\Zm^]mha^Zema _ng]lpbee[^lnlmZbgZ[e^Zg]pa^ma^kma^MZgsZgbZg phkd^k\hfi^glZmbhg'.7m (TSH 25. nominal allocations exceeded actual expenditure by about ten percent in 2005. 2008: 668-674. 53 This figure excludes Consolidated Fund Services (CFS) – essentially public debt..org/ healthnutritionandpopulation/Resources/281627-1114107818507/082007DCP2TanzaniaFinalPERReportFY06. including TSH 113. 57 See Mickey Chopra. and TSH 58.9bn) to Local Government Authorities (LGAs). 2006.3bn of the Local Government Authorities./ B_hnkk^\hff^g]ZmbhglZk^bfie^f^gm^]Zg]ma^ 25 a^Zemaphkd_hk\^`khplZlZgmb\biZm^]%ma^bg\k^Zl^ h_*++fbeebhg!TSH*. and 2007..-Mp^gmr&mak^^i^k\^gmh_maZm[n]`^mÇ0*'. 55 The nominal 2007/08 Medium Term Expenditure Framework (MTEF) allocated TSH 187. and $20.3bn) was allocated $38. All budgetary figures are similarly calculated. <http://siteresources. 56 Source: 2008 Twiga Model (see note 17). 54 The $71. including the largest hospitals. Zehg^blngebd^ermh[^ihllb[e^' 52 Last year for which salary information was available.*1fbeebhg!TSH/-1 \Zk^mkZbgbg`g^mphkdnlbg``ho^kgf^gmk^lhnk\^l [beebhg"h_ma^MZgsZgbZg`ho^kgf^gm[n]`^mh_-'1. THE TWIGA INITIATIVE 47 . Ministry of Health and Social Welfare.9bn) to Parastatals. 23. CIA World Factbook.1bn of grants to parastals.4bn to Personnel Emoluments for the Health Sector. 2006 and 2008 MTEF and PER.. ^\hghfr\ZgfZbgmZbgablmhkb\Ze`khpmakZm^l`bo^g i^k\^gmh_ma^`^g^kZe`ho^kgf^gm^qi^g]bmnk^maZm `eh[Ze^\hghfb\ik^llnk^' r^Zk%Zg]Zebmme^ho^kaZe_h_hg^i^k\^gmh_ma^ MZgsZgbZgGDP' ?nkma^k%Zg^qiZg]^]a^Zema\Zk^lrlm^fpbeebg\nk Z]]bmbhgZe\hlml3\hglmkn\mbhgZg]fZbgm^gZg\^h_ Lbg\^+)).25m (TSH 9bn) to Regional Administration.

000 200 _hkZ\ab^obg`Zd^y firsmlm^iÇab`a^kmakhn`ainm 20. H^g\^%]ZmZfnlm maZmZiierghmhgermhMZgsZgbZ[nmmhma^`khpbg` [^\hee^\m^]Zml^o^kZeihbgmlZehg`ma^\aZbgmh^glnk^ field of health workforce intero^gmbhg%^gZ[ebg` maZmma^bginmh_bg\k^Zl^]lmn]^gmbgmZd^k^lnemlbg gZmbhglmhmkZ\dma^bfiZ\mh_iheb\rhgmkZbgbg`& ma^^qi^\m^]hnminmh_bg\k^Zl^]Z\\^llmh\Zk^' 48 ACTION NOW .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 bg\k^Zlbg`^jnbmrh_Z\\^llmha^Zema\Zk^l^kob\^l 250 30. implementing solutions offered by our team iZkmg^klabilZlp^eeZlmkZ]bmbhgZe[beZm^kZeZg] lahne]e^Z]mhZ]hn[ebg`h_lmn]^gmbgmZd^pbmabg fnembeZm^kZe`ho^kgf^gmZllblmZg\^'Ahp^o^k%lhf^ _hnkr^Zkl'MkZgleZmbg`mablbg\k^Zl^]bgmZd^bgmhZ fhk^kZ]b\ZehimbhglfZr[^g^\^llZkrmhbg\k^Zl^ ikhihkmbhgZm^`khpmah_ma^a^Zemaphkd_hk\^]^i^g]l ikboZm^bgo^lmf^gmbga^Zema\Zk^'P^]bl\nlllhf^ Zefhlm^gmbk^erhgZmmkbmbhgkZm^l'Mablln``^lmlmaZm h_ma^l^bghnk\hfiZgbhgk^ihkmhghnkEZd^Shg^ ma^Fbgblmkrpbeeg^^]mh\Zk^_neermkZ\dZg]k^lihg] BgbmbZmbo^' mhZmmkbmbhgkZm^lbgk^Zembf^%mh^glnk^maZmma^ bg\k^Zl^]makhn`ainmh_ma^mkZbgbg`lrlm^fblghm [^bg`ehlmmh`khpbg`Zmmkbmbhg' Monitoring and evaluation CnlmZlZmmkbmbhgkZtes affecmma^bfiZ\mh_bg\k^Zl^] A significant obsmZ\e^mh`ho^kgf^gmZ\mbhgmh lmn]^gmbgmZd^%ma^ieZ\^f^gmh_`kZ]nZtes affecml Z]]k^lla^Zemaphkd_hk\^blln^lblma^eZ\dh_k^ebZ[e^ ahpZg^geZk`^]phkd_hk\^bfikho^lZ\\^llmha^Zema bg_hkfZmbhghgma^k^eZmbo^oalue of different policr \Zk^4phkd^klfnlm[^bgma^kb`amch[lZg]bgma^ ZiikhZ\a^l'.1Hnkk^l^Zk\aaZlrb^e]^]Zl^mh_f^mkb\l kb`ameh\ZmbhglmhfZde a difference. millions Z\ab^o^[^mm^ka^Zemahnm\hf^lZ\khllMZgsZgbZ[r 300 35. millions $.000 50 5.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 $.000 gZmbhgpb]^'Ma^k^\hff^g]ZmbhglbghnkZiikhZ\a mZd^nimabl\aZk`^%eZrbg`hnmZieZgh_Z\mbhg Salaries 25.000 But improving throughput is not sufficient to improve a^Zemahnm\hf^l_hkMZgsZgbZgl4`kZ]nZmbg`a^Zema 0 0 phkd^klfnlm[^k^\knbm^]%abk^]%k^mZbg^]%Zg] 2006 2008 2010 2012 2014 2016 2018 2020 ]^o^ehi^]%Zg]Zgnf[^kh_lniihkmbg`lrlm^flfnlm [^fZbgmZbg^]'Bg_hkfZebsbg`Zgbfie^f^gmZmbhg @bo^gma^khe^maZmikboZm^Zg]_Zbma&[Zl^]ikhob]^kl ieZg%Z\dghpe^]`bg`Zg]Z\\hngmbg`_hkma^l^^jnZeer Zek^Z]rieZrbgMZgsZgbZga^Zema\Zk^]^ebo^kr%Z bfihkmZgmZg]\aZee^g`bg`^e^f^gmlh_Zkh[nlma^Zema in[eb\%ikboZm^%Zg]_Zbma&[Zl^]iZkmg^klabiblma^hger lrlm^fpbee[^^ll^gmbZe' ebd^er_ng]bg`f^\aZgblf' Placing and retaining workers Ma^MZgsZgbZg`ho^kgf^gmbl\nkk^gmerl^^dbg`Z lnlmZbgZ[e^_ng]bg`fh]^e%k^erbg`hgln\a :s noted.

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 bgo^lmf^gmlbgbg\k^Zlbg`\ZiZ\bmrZk^ghmma^gehlm' lrlm^fl_hk]^iehrf^gmZg]k^m^gmbhgh_phkd^kl bgknkZeZk^Zl%^glnk^lma^k^ebZ[bebmrh_]kn`lniier% Measuring impact. modifying initiatives bfikho^l\ZiZ\bmrZmma^ikbfZkr\Zk^e^o^e%bg\k^Zl^l k^lihglbo^g^llh_ma^k^_^kkZelrlm^f%Zg]Z]]k^ll^l Ma^WHOaZl]^fhglmkZm^]Z\hkk^eZmbhg[^mp^^g hma^klrlm^fb\p^Zdg^ll^l' a^Zemaphkd^k]^glbmrZg]Z\\^llmh[Zlb\l^kob\^l% ln\aZlldbee^][bkmaZmm^g]Zg\^Zg]\abe]ahh] f^Zle^loZ\\bgZmbhgl'Ma^pb]^oZkbZmbhgh_lmZmblmb\l hgk^eZm^]a^Zemahnm\hf^lebd^fZm^kgZefhkmZebmr% ahp^o^k%[^mp^^g\hngmkb^lpbmalbfbeZka^Zema phkd_hk\^]^glbmb^lln``^lmlmaZmZgnf[^kh_hma^k _Z\mhklÇ_hk^qZfie^%hi^kZmbhgZep^Zdg^ll^lebd^ mahl^ghm^]Z[ho^ÇZelh\hgmkb[nm^mhbfikho^] a^Zemahnm\hf^l' LhahppbeeMZgsZgbZZg]bml]hghkldghpb_mabl bgbmbZmbo^blaZobg`Zihlbmbo^bfiZ\m8Ma^Zglp^keb^l bgZ]]bmbhgZebg_hkfZmbhg`Zma^kbg`'?hk^qZfie^% Zd^rFbee^ggbnf=^o^ehif^gm@hZe_hka^Zemabl fZm^kgZefhkmZebmr'@Zma^kbg`]ZmZhg\abe][bkma& k^eZm^]]^ZmalZg]ma^gnf[^kh_Zmm^g]^][bkmalhg Z]blmkb\m&[r&]blmkb\m[Zlblphne]a^eima^Fbgblmkr mh]^m^kfbg^[hmapa^ma^ka^Zemahnm\hf^lZk^ bfikhobg`Zg]pa^ma^kbfikho^f^gml\Zg[^ebgd^] mhbg\k^Zl^]phkd^k]^glbmr%gnf[^kh_Zmm^g]^] [bkmal%hkhma^k_Z\mhkl%ln\aZlbfikho^]Z\\^llmh f^]b\bg^lhkbfikho^]mkZbgbg`' GhmhgerpbeemablZiikhZ\aZllblmma^MZgsZgbZg `ho^kgf^gmbg_nmnk^iheb\rieZggbg`Zg] ikbhkbmbsZmbhg%bmpbee]^fhglmkZm^mhhma^k `overnments and potential funders how significant 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 .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.'+mh1'.)'-fbeebhg' \Z]k^Zkkbobg`Zmihlm%fho^f^gmh_phkd^kl_khf :mmaZmkZm^%]hn[ebg`ma^a^Zemaphkd_hk\^pbee knkZemhnk[ZgZk^Zl%Zmmkbmbhg_khfin[eb\mhikboZm^ bg\k^Zl^a^Zema&phkd^k]^glbmr[r/+i^k\^gm%_khf \ebgb\l%Zg]phkd^kikh]n\mbobmr'BgZgr^o^gm%Z .

and ensuring a specific.)fbeebhgbgmhmZe%^q\enlbo^ phkd^klpahZk^ZoZbeZ[e^'PaZm\Z]k^lh_phkd^kl h_a^Zemaphkd^klZeZkb^l'Mhis efformpbeek^jnbk^ Zk^ma^[^lmmhl\Ze^ni_hkZ`bo^g\hngmkr8Lahne] _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 . 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 Lmbee%hnkZiikhZ\aZlbmlmZg]lphne]a^eimh]hn[e^ hgpa^k^mhbgo^lmbga^Zemaphkd^kmkZbgbg`Zg] ma^\ZiZ\bmr_hka^Zemaphkd^kmkZbgbg`ho^km^gr^Zkl ahpmh]^iehrZg]fZgZ`^ma^k^eZmbo^er_^pa^Zema ZmZ\hlmh_cnlmho^k*. [nbe]bg`Zlmkhg`[nlbg^ll\Zl^_hk^Z\abglmbmnmbhg% \k^Zmbg`bg]bob]nZeZ\\hngmZ[bebmrZmma^l\ahhe( bglmbmnmbhge^vel. 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 Hnk^qi^kb^g\^bgMZgsZgbZaZllahpgmaZmma^k^bl bgmhma^_nmnk^'Ma^k^_hk^bmblbfihkmZgmmh\hf[bg^ 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 mkZbgbg`lrlm^f'Ghk]b]p^fh]^eZgrmkZbgbg` Ma^\hk^ikh[e^fblmaZm%^o^gpbmaZg^qiZg]^] ^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 r^m^qblm'Bglm^Z]p^ZiikhZ\a^]ma^ikh[e^f_khf bgikh]n\mbobmr%\Zk^^khiihkmngbmb^l%k^lhnk\^ ma^i^kli^\mbo^h_ma^^gmbk^a^Zema^\hghfr'=bk^\m ZoZbeZ[bebmrZg]_h\nl%Zg]a^Zemaphkd^kk^m^gmbhg' ikboZm^l^\mhkbgo^lmf^gm%i^kaZilng]^kibgg^][r Ma^l^ikh[e^flpbeek^fZbg]^libm^bg\k^Zl^] ehZgikh`kams and other financing options.

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.\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_+. sufficient facilities.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 . and so forma'.

Weill Bugando University College Head. Mtwara Principal Clinical Officer Training Centre Mbeya Dental School Mama Eliaremisa Ayo Assistant Director. Zacharia Berege Director for Distance Learning Director of Hospital Services Dabney Evans Kilimanjaro Christian Medical College Ministry of Health and Social Welfare Executive Director.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. Institute of Human Rights. Institute of Medical Health Allied Sciences Mbeya School of Theater Management Sciences (DMLS) Ruhua University College (RUCO) Ndosi Aston Dr. Human Mama Tabu Chando Matt Gordon Resources Director. Medical Student. CTC and OPD. About Associate Dean. Bishop Aloysius Balina Mary J. Rene Bonsubre Principal VSO Volunteer. Instructor. Haule School of Medicine Muhimbili University of Health and Allied Associate Dean.Appendix – List of Interviewees . Rev. Administration and Personnel Multilateral Policy Advisor Ministry of Health and Social Welfare Ministry of Health and Social Welfare Department of International Development (DFID) UK Professor Mohammed Bakari Edwin Chitage Director of Undergraduate Students. School of Nurse Tutors Ministry of Higher Education of Health Sciences Muhimbili University of Health and Diocese of Shinyanga Allied Sciences Professor M. Mtwara Dr. Emory University Hadija Athumani Dr. Gemba Bagamoyo Nurse Training Centre Regional Hospital. School of Medicine Peter Michael Benderra Father Angelo Dutto Muhimbili University of Health and Acting Principal and Faculty member Director. Nurse Training. Year 3 Professor Ambrose F.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 Rt. Chuwa Director of Higher Education Chairman. School of Pharmacy Muhimbili University of Health and Sciences Muhimbili University of Health and Allied Sciences Allied Sciences 52 ACTION NOW .

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

Senya Principal Training Coordinator – Nurse Training Director. Mteta Engineer. B. Matthew Ndomondo Dr. Allied Health Training. Advanced Nursing Studies Dr. Amos Mwakilasa Head. Institute of Assistant Director. Yengo Ministry of Higher Education Mbeya Referral Hospital Academic Head. Nanyaro Director-General The Aga Khan University – Tanzanian Principal Mbeya Referral Hospital Institute of Higher Education Tanga Nurse Training Centre Dr. Mtani Director. Edward Silayo Senior Lecturer. Shayo Dean. Office of the Director of Policy Dr.Professor Jacob Mtabaji Vernand Ndemetria S. Planning. Mark E. Ndawi Dr. Mumghamba Dr. Mwakalukwa Mfungo Nyandigira Health Sciences Assistant Director. School of Dentistry Acting Principal Instructor. 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.S. Christian Schmidt Dr. Medical Officer Training Centre Dental Officers Allied Sciences Muhimbili University of Health and Dr. Ifakara Health Professor Abdulla Rajab Training and Research Centre Osiah Mwasulama Senior Education Officer Laboratory Director Mavis L. 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. Emmanuel Mwandu Karin Anne Wiedenmayere Weill Bugando University College of Chief Medical Officer Senior Specialist. Allied Health Sciences Rwezaura Tibaijuka Human Resources Weill Bugando University College of Head. School of Radiology. Director of Hospital Services Emily Nyakiha Kilimanjaro Christian Medical Centre Dr.S. School of Advanced Muhimbili University of Health and Tanga Assist. Internal Medicine Nurse Tutor Ministry of Health and Social Welfare and Pediatrics Bagamoyo Nurse Training Centre Weill Cornell Medical Centre at Dr. L. Elifuraha G. Deo Mtasiwa Acting Principal H. Sydney Ndeki Pediatrics Consultant. Emmanuel N’gwamkai Dr. Pharamcy Health Sciences Kolandoto Nurse Training Centre Swiss Tropical Institute. Human Head. Swai Bukumbi School of Nursing and Midwifery Pediatrician. Eleuter R. School of Pharmacy. School of Nursing. Samky Program Zainab S. Shangali Chief Medical Officer Sengerema Nursing School Head. Continuing Ed. Iringa Primary Healthcare Institute Mama Shamu Principal & Iringa Zonal Training Centre Principal Sengerema Clinical Officer Training Centre Mtwara Nurse Training Centre Dr. Zonal Training Centres Bugando Medical Centre Ministry of Health and Social Welfare 54 ACTION NOW . Institute of Ministry of Health and Social Welfare Health Sciences Allied Health Sciences Weill Bugando University College of Mama E. William Nyagwa Allied Sciences Pheby Murusuri Chief of Party. 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. Dr.B. Allied Health Sciences School Ministry of Health and Social Welfare Kilimanjaro Christian Medical College Edward Ngowi Dr. Robert Peck Masiah Veneranda Human Resources Clinical Instructor.G. Tanzania Principal The Capacity Project Dr.

nk^Znh_LmZmblmb\lZg]FZ\kh :]Zfl%FZkn:k^`Zpb%DZkbg."!?^['+)+))0"3**.!?^['+.%+))1"3//1' Tanzania Ministry of Health. @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).!=Zk^lLZeZZf%+))/"' K^lhnk\^l_hkA^Zema3K^jnbk^f^gmlZg]:oZbeZ[bebmr <ZiZ\bmrIkhc^\m'Strengthening Human Resources bgma^<hgm^qmh_L\Zebg`&NiIkbhkbmrBgm^ko^gmbhglbg Information Systems.0*%bll'2/*. “Effecmlh_iheb\rhimbhgl_hkanfZg FZgZ`^f^gmL\b^g\^l_hkA^Zema<ZiZ\bmrIkhc^\m%Report k^lhnk\^l_hka^Zema3ZgZgZerlblh_lrlm^fZmb\k^ob^pl' of a Human Resource Management Assessment of the The Lancet.krZg%Ehp^ee%^mZe'Investing in Tanzanian Human Dnkhpldb%<akblmhia%DZliZkPrll%LZebf:[]neeZZg]:gg^ Resources for Health: an HRH study for the Touch Fbeel'ÉL\Zebg`niikbhkbmra^Zemabgm^ko^gmbhglbg Foundation!G^pRhkd3F\Dbgl^r<hfiZgr%+))/"' MZgsZgbZ3ma^anfZgk^lhnk\^l\aZee^g`^ÊHealth <ZiZ\bmrIkhc^\m%GZmbhgZeBglmbmnm^h_F^]b\ZeK^l^Zk\a Policy and Planning ++!.^k`lmkhf%A^e`Z Bgm^kgZmbhgZe%Tanzania Service Provision Assessment ?h`lmZ]%=^eeZLa^kZmm%C^ggb_^kEbgdbgl%Kh[^km Survey 2006%Gho'+))0' L\a^ki[b^kZg]FZrZ]ZRhnll^_&?hq'É:gZiikhZ\amh ^lmbfZmbg`anfZgk^lhnk\^k^jnbk^f^gmlmhZ\ab^o^ MZgsZgbZ%Fbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^'Emergency ma^Fbee^ggbnf=^o^ehif^gm@hZelÊHealth Policy Recruitment Plan !=Zk^lLZeZZf"' and Planning+)!.+))/"' LZkZ.^gg^mt.0*%bll'2/*."!+)).H\m'+))/' <kbli%Gb`^e%.É:`^g]Z_hk@eh[Ze:\mbhgÊ FZk'+))15ammi3((ppp'WHO'bgm(phkd_hk\^ZeebZg\^( _hknf(*XZ`^g]Z-@:\tion_final."' phke]&_Z\m[hhd(`^hl(ms'amfe' FZ^lmZ]%HmmZkHuman Resources for Health in Tanzania <ahikZ%Fb\d^r%LZeeZFngkh%ChagG'EZobl%@nggOblmZg] !<ak'Fb\a^elhgBglmbmnm^. ChbgmE^Zkgbg`BgbmbZmbo^'Human resources for health: overcoming the crisis!<Zf[kb]`^3@eh[Ze>jnbmr BgbmbZmbo^%+))-"' Bibliography Dhhm%CZZiZg]KbdI^^i^kdhkg'ÉMa^A^ZemaL^\mhkbgma^ +*lm<^gmnkr4inmmbg`a^Zemalrlm^fllmk^g`ma^gbg`bg i^kli^\mbo^Ê!_hkma\hfbg`"' .+))-' =hfbgb\d%:ggZZg]<akblmhiaDnkhpldb'ÉAnfZg MZgsZgbZFbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^%ammi3(( k^lhnk\^l_hka^ZemaÇZgZiikZblZeh_ma^lmZmnljnhbg ppp'fha'`h'ms(' MZgsZgbZfZbgeZg]'ÊCner+))-' MZgsZgbZFbgblmkrh_Ab`a^k>]n\Zmbhg%L\b^g\^l =k^^l\a%Ghk[^km%<Zkf^g=he^Z%FZkbhK M^\agheh`r%ammi3((ppp'flma^'`h'ms(' =ZeIhs%:e^qZg]k^@hn[Zk^o%Hkobee MZgsZgbZGZmbhgZe.pdf>.:n`'+))0' Ehp&Bg\hf^<hngmkb^lÇ<Zl^lmn]b^l_khfMZgsZgbZ <^gmkZeBgm^eeb`^g\^:`^g\r'ÉMZgsZgbZ'ÊWorld Factbook Zg]<aZ]Ê!Ehg]hg3Ehg]hgL\ahheh_Ar`b^g^Zg] +))1%ammil3((ppp'\bZ'`ho(eb[kZkr(in[eb\Zmbhgl(ma^& Mkhib\ZeF^]b\bg^%CZg'+)).' Zg]MZgsZgbZFbgblmkrh_A^ZemaZg]Lh\bZeP^e_Zk^' Dnkhpldb%<akblmhia%DZliZkPrll%LZebf:[]neeZ% Labour Market Study for the Tanzanian Health Sector: GÌ=b^dahkR†fZ]cbZg]:gg^Fbeel'ÉAnfZg Draft 4.%+))1"3/12' Human Resources for Health.!?^['+.b^g\^@ZpZgZlZg]Bfh`^gLaZki'ÉMkZbgbg` F\Dbgl^r<hfiZgr' Acting Now to Overcome Tanzania’s ma^a^Zemaphkd_hk\^3l\Zebg`ni%lZobg`ebo^l'ÊThe Greatest Health Challenge: Addressing the Gap in Lancet."3+/0' THE TWIGA INITIATIVE 55 .(^g(bg]^q'amfe' @eh[ZeA^ZemaPhkd_hk\^:eebZg\^%5ammi3((ppp'`apZ'hk`(7' @eh[ZeA^ZemaPhkd_hk\^:eebZg\^.

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