Education of Medical Personnel in Tanzania

Background

Traditionally, churches have contributed significantly to the medical services of developing countries. Even today, about half of the hospital beds and rural health services in Tanzania are operated by churches. In the early years after the country gained its independence (1961, when the country was known as Tanganyika), many hospitals were nationalized. But the government is now returning them back to church control.

The problem is that neither the government nor the churches have enough resources to operate them. Patients themselves have to contribute an ever increasing share of the cost, and Tanzania is one of the poorest countries in the world. The very poor are unable to obtain proper medical services in either church or government facilities and the government health care budget for each Tanzanian is 65 cents per year.

Current Needs

The needs, therefore, are twofold: to obtain the resources to continue the services in the existing hospitals and dispensaries, and to educate Tanzanians at all levels of medical practice -- doctors, nurses, midwives, radiographers, and technicians skilled in maintenance and repair of medical equipment. And expatriates are expensive. Sending agencies may consider that the money necessary to maintain one foreign doctor in Tanzania would be sufficient for five to eight Tanzanian doctors.

The recent emphasis of churches has been on primary health care. Certainly there is a need for trained health care workers in the villages, and preventive medicine should be applied to maximum use. For example, prenatal care in the villages needs additional staff. However, emphasis should not mean exclusivity. Rural health services need the backup of hospitals, and we need schools to train medical professionals from public health educators to nurses and doctors.

The Tanzanian Health Care System

Tanzania has a well-balanced system with four layers:
1. Rural health centers and clinics
2. 140 district hospitals, usually with assistant medical officers, and sometimes one or two medical doctors
3. 20 regional hospitals, with some specialists
4. Four referral hospitals: Kilimanjaro Christian Medical Center (KCMC) in Moshi, Muhimbili Medical Center in Dar es Salaam, Bugando Hospital in Mwanza, and the Mbeya hospital in southern Tanzania.

The Lutheran, Roman Catholic, and Anglican Churches are involved at all levels. The Muslim community has no medical facilities for the general public. The Aga Khan hospitals are treating private patients only.

Conditions in Tanzania are quite different from those in the United States and Europe. Hospitals, including KCMC, are more community oriented. Specialists visit rural areas and smaller hospitals for consultations. KCMC has a strong Department of Community Health that works in close cooperation with the medical services of the Northern Diocese of the Evangelical Lutheran Church of Tanzania. Through this cooperation, we began a major research project investigating the incidence and distribution of rheumatic heart diseases in children and young adults. Workers in the field, specialists from KCMC and its laboratory and radiologic facilities, were brought together in this effort. More projects under preparation will investigate other health problems common in the country. These examples illustrate that in Tanzania and other developing countries, progress in the fight against diseases depends on the integration of all levels of medical services. We do not have the luxury of keeping preventive and curative medicine separate.

Medical Training in Tanzania

Medical Doctors (MDs)
The University of Dar es Salaam at the Muhimbili Medical Center has a full medical school for undergraduates and some graduate schools. They graduate between 20 and 30 M.D.s each year -- less than half of the 60 needed to replace those who retire. This does not take into account the population growth, let alone the needed expansion of medical services. The total of 1,200 MDs for a population of 32 million equals about one doctor for almost 27,000 people. Prior to the recent political changes, the former Soviet Union and its allies trained about half of the Tanzanian doctors. However, it is clear that Tanzania needs to expand its own medical training. In October 1997, we opened a medical school at KCMC. Specialty training in some fields will also be offered.

Assistant Medical Officers (AMOs)
The 1,200 AMOs play a major role in the delivery of medical care in Tanzania. Unfortunately, recognition by colleagues and administrators is very low compared to that of MDs, although they do the same type of work. AMOs were first trained in a three-year course to be Medical Assistants. After working at that level for five or more years, mostly in rural health centers or district hospitals, they are eligible for two more years of training in one of the referral hospitals. Upon graduation, they obtain the title of "Doctor," and are licensed to practice medicine like MDs. They have more experience than an intern who has just graduated from university, but are a little short in theoretical knowledge. KCMC has been involved in this program for many years, graduating 40 AMOs every two years. With the recent opening of the medical school at KCMC, the AMO program will be gradually phased out and transferred to Tanga. The other AMO training center is at the Bugando Hospital in Mwanza.

Assistant Medical Officer-Specialist
Four specialties are taught: ophthalmology, radiology, anesthesiology, and dermatology. All four programs are based at KCMC. The curricula of these schools are designed to train Assistant Medical Officers to work in the more remote regional hospitals. These hospitals need people with specialized knowledge, but have limited facilities and would not be able to attract MD specialists. The duration of the AMO-Specialist course is two years. There are approximately 100 or more graduates who are now working in the regions.

Nurses and Midwives
Training for nurses from grade A registered nurses to nursing assistants takes place in numerous church and government hospitals. Most nurses are also taught midwifery. Specialized programs teach ophthalmic, pediatric, and other types of nursing.

Radiographers
There is a three-year course for registered radiographers in Dar es Salaam and a two-year course for radiographic auxiliaries in Mwanza.

Training in Tanzania vs. Training Abroad

The East Africa Medical Assistance Foundation is a strong advocate for training in Tanzania for a number of reasons. First, the diseases that are prevalent in Europe and the United States are different from those found in Africa. Although we should teach about all kinds of diseases, more time should be spent on local problems. For example, vascular diseases, which are the number one problem in the West and occupy a large portion of our medical activities, are rare in Africa. On the other hand, osteomyelitis and rheumatic heart diseases have almost disappeared from the industrial countries but are encountered almost daily in Africa. Second, the same considerations also apply to socio-economic conditions. Third, if at all possible, the language of instruction should be English. Students in Russia, Holland, or Germany need more than one year to acquire enough proficiency in these languages to follow academic lectures. Fourth, cost. The amount of money required for one student in a Western country could train three to five of these students in Tanzania. It is, therefore, far preferable to strengthen the availability and the quality of training in Tanzania.