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Investing in Tanzanian Human Resources for Health

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Over the last several years, the world has become aware of the magnitude of the health care crisis in the poorest countries in the world. In Africa, in particular, people are experiencing premature death and suffering from preventable or treatable diseases on an almost unimaginable scale. Life expectancy is actually dropping in sub-Saharan Africa, and death rates are on a scale not seen since the plagues in Europe in the middle ages. HIV/AIDS is a major culprit, and is the disease most familiar to the general public in the developed world. In Tanzania, 25 percent of the estimated responsibility for premature death and disability is attributable to HIV/AIDS. However, infant death, maternal death, malaria, tuberculosis, cholera, inadequate care of physical ailments and a raft of other diseases and conditions are, in combination, responsible for over 75 percent of premature death and disability in Tanzania, according to the Original Global Burden of Disease estimates published by the World Health Organization (WHO)
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Content Preview
Investing in Tanzanian
Human Resources for Health
an HRH report for the
July 2006
Lowell Bryan
© Copyright 2006 McKinsey & Company
Rita Garg
Salim Ramji
Ari Silverman
Elya Tagar
Iain Ware

2

3
Contents
Background
5
About McKinsey & Company
6
About Touch Foundation, Inc.
6
Executive Summary
7
HRH in increasing focus
7
Higher skilled hrh are also necessary
9
Mobilizing an army
9
Benefits are clear
10
Implementation constraints exist
10
Necessary government support is available
11
Case Study: Tanzania
13
Tanzania’s health care crisis is acute
13
There is a significant hrh shortage in Tanzania compared to neighboring countries
16
Higher skilled cadres should therefore be a central priority for investment
18
It is difficult to ensure higher skilled hrh are distributed evenly
19
Addressing the shortage will take many years and require sustained funding
20
Tanzania’s future training output will fall well short of meeting future needs
21
Tanzania is well-positioned to address its hrh shortage
22
Meeting the Challenge Outside Tanzania
26
The health care crisis in the developing world is partly a distribution problem
26
Importing hrh on a large scale from abroad is not a cost-effective solution
27
Comparative advantage in the developing world
28
An hrh system requires a well-balanced pyramid
28
Long lead times are necessary
29
Another critical bottleneck is management capacity
30
Retention is a major issue
31
Touch Foundation Strategy for Tanzania
34
Selected bibliography
37

4

5
the six schools contained within IAHS –
Pharmacy, Lab Technicians, and Radiology.
The schools of Nursing, Assistant Medical
Officer and Nurse Anaesthesia are still
currently contained within BMC.
Field work was also performed in Dar es
Salaam and, in particular, by working with the
Ministry of Health and Ministry of Science,
Background
Technology and Higher Education, to
understand their perspectives and to gather
data. Interviews were also performed with a
The following report was written by McKinsey
wide variety of in-country representatives of
& Company and is based upon work
various not-for-profit organizations including,
performed as part of a pro bono strategy
among others, the World Bank, the World
project undertaken for the TOUCH Foundation,
Health Organization, USAID, and the Clinton
Inc. It follows previous work conducted by
Foundation.
consultants with McKinsey & Company’s
Global Public Health practice, and specifically
In addition, research and phone interviews
their previous report, Acting Now to
were conducted with members of the global
Overcome Tanzania’s Greatest Health
health community including, in particular,
Challenge: Addressing the Gap in Human
authors of various published papers and
Resources for Health, originally published in
reports on related HRH topics. Finally, we
May 2003. ‘Human Resources for Health,’ or
consulted with Weill-Cornell Medical College
HRH, is the term used by the public health
of New York on issues relating to the
community to encompass all categories, or
operation of medical colleges.
cadres, of health care workers, from specialist
physicians through to community workers.
There are a number of underlying issues
regarding the quality of data available on this
The project team undertook extensive field
subject, particularly in the developing world.
work in Tanzania with particular emphasis on
The team made exhaustive efforts to find the
the Bugando Medical Center (BMC, an 850 bed
best available data, but inevitably some of the
regional hospital), the Bugando University
information needed was incomplete or
College of Health Sciences (BUCHS), and the
conflicting. While we believe that our
Institute for Allied Health Sciences (IAHS), all
calculations are directionally accurate, they
located in Mwanza, the second largest city in
may not always be absolutely precise. We have
Tanzania.
erred on the side of our estimates being
conservative relative to the points being made.
The hospital at Bugando, BMC, serves as the
referral center for both the surrounding area,
The authors gratefully acknowledge the
called the ‘lake district’, which includes the
generous assistance provided by Bishop
regions of Kagera, Mwanza and Mara, and the
Aloysius Balina, chairman of both BMC and
rural region to the south, Shinyanga. BUCHS
BUCHS, Dr. Charles Majinge, director of BMC,
currently incorporates two schools – a start-up
Professor Joseph Shija, principal of BUCHS, and
medical college (which has been funded largely
Dr. Frederick Kigadye, secretary for health
by the TOUCH Foundation) as well as three of
with the Tanzanian Episcopal Conference and

6
formerly of the Ministry of Health, for their
• to provide funding and management
aid in arranging interviews and in providing us
resources for local programs that develop
with data. We are also extremely grateful to
human resources for health (HRH) in
the Tanzanian Ambassador to the U.N., Dr.
impoverished countries
Augustine Mahiga, for his on-going and
consistent support of our efforts.
• to build awareness around problems in
health care delivery in poor countries, and
All of the authors of this report are
• to collect, store and provide access to
consultants with McKinsey & Company. The
leading information about global health,
lead author who directed the work, Lowell
and to share the knowledge gained from
Bryan, served in his dual capacity as a
TOUCH-funded programs.
McKinsey director and as President of the
TOUCH Foundation. Salim Ramji also assisted
The foundation is located in space donated by
in directing the team’s efforts, while Ari
McKinsey & Company in New York. Its major
Silverman managed the project team on a day-
donors are the Citigroup Foundation,
to-day basis. The team also drew upon some
McKinsey & Company, Sandy Weill
thirty volunteer associates and analysts to
(Chairman Emeritus, Citigroup), Stroock &
support their research. Considerable help was
Stroock & Lavan, LLP, TOUCH’s board of
also provided by members of McKinsey’s
directors, and a number of private individuals.
global public health practice, specifically
Judith Hazlewood, Srividya Prakash, and
Michael Conway, and by TOUCH staff Rebecca
Brodsky and Angus O’Shea.
The opinions expressed in the report are those
of the authors and may not necessarily

About McKinsey & Company
represent the opinions of McKinsey &
Company, or the directors or employees of, or

McKinsey & Company is a global
donors to, the TOUCH Foundation.
management consulting firm, serving clients
across the public, private and nonprofit
sectors. Since 1926, McKinsey has helped
business leaders address their greatest
challenges, from reorganizing for long-term
growth to improving business performance
and maximizing revenue. Our primary mission
is to help our clients achieve distinctive,
substantial and lasting improvements in their
performance, and to build a firm able to
attract, develop, excite and retain exceptional
people.
About TOUCH Foundation, Inc.
The TOUCH Foundation is a new not-for-profit
corporation which began operations in
January, 2005. TOUCH’s mission is threefold:

7
available to diagnose diseases, provide drugs
(even if those drugs are readily available), and
to treat patients. HIV/AIDS, in particular, requires
enormous numbers of health care workers to
administer the tests necessary in order to
diagnose the disease, counsel the patients and
convince them to be treated, and administer
the necessary drug regimes.
Executive Summary
But the pool of available health care workers
is severely inadequate relative to the need for
them, and in many cases the skills required far
Over the last several years, the world has
outweigh those available from existing supply.
become aware of the magnitude of the health
Small-scale pilots can produce good short-term
care crisis in the poorest countries in the
results – they can use donor money to borrow
world. In Africa, in particular, people are
a sufficient supply of health care workers from
experiencing premature death and suffering
their current jobs, then spend them on
from preventable or treatable diseases on an
targeted, limited projects. However, this
almost unimaginable scale. Life expectancy is
approach simply proves the fallacy of
actually dropping in sub-Saharan Africa, and
borrowing from Peter to pay Paul: in HRH
death rates are on a scale not seen since the
terms, these programs only reveal the extent of
plagues in Europe in the middle ages.
the need and not the identity of the solution.
HIV/AIDS is a major culprit, and is the disease
In short, these projects cannot be scaled-up to
most familiar to the general public in the
become major implementation programs
developed world. In Tanzania, 25 percent of
simply because the health care workers needed
the estimated responsibility for premature
are not there in the first place. In Tanzania,
death and disability is attributable to HIV/AIDS.
some have estimated that an additional 10,000
However, infant death, maternal death,
skilled health care workers are needed just to
malaria, tuberculosis, cholera, inadequate care
diagnose and treate HIV/AIDS cases before any
of physical ailments and a raft of other
other issues can be addressed. According to the
diseases and conditions are, in combination,
Tanzanian Ministry of Health’s 2001-02 HRH
responsible for over 75 percent of premature
census, this number compares with a base of
death and disability in Tanzania, according to
only 25,000 skilled HRH in the country.
the Original Global Burden of Disease
estimates published by the World Health
HRH in increasing focus
Organization (WHO).
As the world in general, and the global public
The HRH issue appears to be moving to center
health community in particular, has begun
stage in the global public health arena, thanks
marshalling resources to address this crisis, it
to the efforts of people such as Tim Evans of
has hit a brick wall. While the causes of
WHO and Lincoln Chen of the Harvard School
premature death or suffering are largely
of Global Public Health, among others. These
preventable, and often certainly treatable,
issues were extensively covered in the Joint
there is an absolute global shortage of health
Learning Initiative (JLI) report, Human
care workers – particularly in Africa –
Resources for Health: Overcoming the Crisis,

8
published in 2004, and the recent World
(Exhibit 1). Even governments could
Health Report 2006, Working Together for
dramatically improve productivity, provide
Health, published by WHO.
good jobs to retain HRH, stop the brain drain
and attract HRH workers back to health care
So what are the answers to the HRH crisis? The
delivery, there would remain an absolute
major levers identified in the previous
shortage of health care workers in poor
McKinsey report were to:
nations.
• improve the productivity of the existing
The response to the health care crisis must,
healthworkforce
therefore, include a dramatic, sustained

increase in the number of local citizens who
provide better pay and working conditions
can be attracted to the health care delivery
to health care workers locally
field and trained appropriately, and this is the
• reduce the ‘brain drain’ of HRH and to treat
focus of this report.
diseases within the workforce in order to
reduce attrition
In parallel, though, we also believe that efforts
need to be made to improve HRH productivity
• attract health care workers who have left
and retention. Tanzania, like many other
the system back into health care, and
developing countries, faces several challenges

in absorbing HRH training output effectively
increase the training of new workers.
into the public and private sectors. Issues
All of these major levers are important. The
include deployment in areas of greatest need,
following report, using Tanzania as a case
providing the workplace conditions, tools and
study, demonstrates the foundational
pay to make the workforce productive, and
importance of the need to vastly increase
retention of this scarce talent – and doing all
production of skilled health care workers
of this in a financially sustainable manner. It
will be critical for Tanzania and other HRH
Exhibit 1
An increase in HRH . . .
. . . saves lives . . .
. . . and improves overall health

7,000 new
Conservative estimate
1.0 million lives saved of
30 year
clinically skilled
x
of average 5 lives
x
=
mothers and children only –
careers
HRH by 2015
saved per year*
an average ~$100 per life**
. . . leads to more
. . . increased
. . . and positive
attractive jobs . . .
income flow . . .
economic development.
* Conservative estimate since this includes only lives saved from maternal, infant, and under 5 conditions based on WHO-JLI regression analysis
** $10,000 cost per HRH trained (conservative using fully-loaded operating costs)

9
stakeholders to address these issues in tandem
birth, complicated births, physical trauma,
with the expansion of HRH to ensure the
cardio-vascular conditions, etc., that require
country enjoys the full benefits of such
higher skills than those possessed by most
training.
clinical officers and nurses. Unfortunately, in
some countries, a large fraction of health care
In any case, we feel that efforts in these areas
workers have almost no formal training at all.
will not be able to make any real progress in
In Tanzania, through interviews with the
this crisis over the longer term without a
Ministry of Health, we discovered that these
greatly expanded supply of HRH.
‘unskilled attendants’ appear likely to be
phased out over time.
Higher skilled HRH are also necessary
Essentially we believe that a functioning
This report stresses not just the need to train
health care system requires a balanced mix of
lower skilled health care workers, but also the
higher-skilled and lower-skilled workers and
even greater need to train more highly skilled
that unskilled attendants are an ineffective
health care workers. Some may consider this
substitute. Hence any solution must aim to
somewhat counter-intuitive: conventional
produce an appropriate balance of skills in as
wisdom has sometimes held that more lower
short a time as possible, particularly
skilled workers – such as nurses and clinical
considering the differing lead times required.
officers – are necessary, especially given the
lower cost of training, the relative speed of
Mobilizing an army
their training, and the need to disperse health
care workers in rural or remote areas which
During our research we discovered that the
often lack a sufficient critical mass of cases to
first thought of many who hear of the extreme
justify treatment by medical doctors.
HRH shortage is that the developed world
should mobilize a large population of health
It is certainly true that greatly increased
care workers and send them to Africa.
supplies of lower skilled cadres of workers are
Unfortunately the reality is the opposite case:
needed. However, it is particularly important
the developed world is, in fact, importing
to increase the supply of the higher skilled
health care workers from poorer nations.
doctors and assistant medical officers (who
Reasons for this ‘brain drain’ are simple: it
receive similar clinical training to doctors, but
costs far less to educate and pay health care
not as much education in biomedical sciences)
workers in poor nations than in rich ones, and
since these cadres are needed to train the lower
the reward for being a health worker in a rich
skilled cadres. Significant training by higher
nation is much greater.
skilled HRH is required to enable lower skilled
HRH to be effective in the diagnosis and
Any strategies designed around using existing
treatment of diseases such as HIV/AIDS, malaria
rich-world learning institutions can therefore
and tuberculosis, as well as to perform a wide
be quickly dismissed on pure economic
array of important health care diagnostic
grounds. The cost of educating HRH and
functions.
exporting them from rich nations to poor
nations is prohibitive. Educating a doctor in
Even more importantly, there are many
the U.S., for example, costs ~$500,000. We
conditions such as infant malaria (requiring
have found that educating the same in a
whole body blood transfusions), premature
country in sub-Saharan Africa will cost

1 0
around $50,000. As a consequence, a $10
worker trained, even those in lower-skilled
million investment in medical doctor
categories, will result in approximately 150
education in the U.S. produces some twenty
unique lives being saved over the worker’s
doctors, whereas the same investment in the
length of service, only counting the impact on
developing world will produce over two
maternal and child (under five) deaths. We
hundred.
believe this estimate is too conservative, but
better numbers comparing mortality rates to
More to the point, we estimate that even if
HRH supply are not available.
you were somehow able to mobilize the some
35,000 HRH volunteers needed from the rich
The full impact of enabling better diagnosis
world into Tanzania alone, just to meet the
and treatment of other causes of premature
minimum standards determined by the
death and disability, such as HIV/AIDS, malaria,
Ministry of Health’s 1999 guidelines for
tuberculosis, etc., that can be gained by adding
staffing levels for health care institutions, and
each additional health worker to the
pay them minimum wages plus housing and
workforce is undoubtedly far, far greater.
transport, it would cost nearly $3 billion a
Greater still is the full impact of training
year. This sum represents about eleven percent
higher skilled health workers who, when
of Tanzania’s total GDP. The sheer numbers of
remaining in clinical service, have the ability
skilled workers required, and the logistical
to train others and to provide better clinical
difficulties involved, suggest that this task
service. We believe a crude guess of 350 lives
would be roughly akin to mobilizing an army.
saved per HRH produced (i.e., about one life
saved per month over a thirty-year career)
One of the few bright spots in the challenge to
would be more realistic.
increase the supply of HRH is that poor nations
can be an ideal place to train health care
Implementation constraints exist
workers. Nations such as the Philippines and
India are demonstrating the cost-effectiveness
The challenge in training a sufficient supply of
of their approach, but in Africa, there is
health care workers is that it is a pipeline
another unfortunate advantage in HRH training:
problem – and this pipeline will take years to
an ample supply of cases. Given that
fill before results can be seen. In Tanzania it
abundance, health care workers can learn
takes five years to train a doctor, two years to
more, more quickly, in a poor nation than in a
train an assistant medical officer (and that
rich one, provided the appropriately-skilled
after they have already received three years of
trainers exist. A German specialist working at
training to become a clinical officer), and two
Bugando pointed out that in Germany, he
years to train a nurse.
spends sixty percent of his time on paperwork;
in Tanzania, he spends ninety percent of his
Moreover, if a new training facility is to be
time with patients.
built and staffed with faculty, it can take even
longer to become operational. For example,
Benefits are clear
from the time of the decision to start a
medical college (by the founders of BUCHS in
While the value of training more HRH is
Tanzania) to the first student enrollment took
beyond dispute, it is helpful to attach some
ten years. The good news, however, is that
numbers. Based upon WHO data published in
while new schools have a long gestation
the JLI report, on average, every health care
period, the capacities of existing schools can

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