“…we were like tourists in the theatre, the interns assisted almost all procedures…” Task sharing and the training of Assistant Medical Officers in Tanzania.

Background: Tanzania is among the countries that adopted task sharing as a strategy of addressing health workforce shortage. Although the strategy has existed for over five decades, concerns are upon the quality of the training of the mid-level cadres amidst the growing number of medical universities. This study sought to explore the challenges facing the training of the Assistant Medical Offices, AMOs (a mid-level cadre) in Tanzania. Methods: An exploratory qualitative case study was carried out in four regions to include one rural district in each of the selected regions and two AMOs Training Colleges in Tanzania. A semi-structured interview guide was used to interview 29 Key informants from the district hospitals, district management, regional management, AMOs training college and one retired AMO. In addition, four focus group discussions were conducted with 35 AMO trainees. Results: Training of AMOs in Tanzania faces many challenges. The challenges include; use of outdated and static curriculum, inadequate tutors (lack of teaching skills and experience of teaching adults), Inadequate teaching infrastructure in existence of many other trainees to include interns, and limited or lack of scholarships and sponsorship for the AMO trainees. Conclusions: The challenges facing AMO training not only affect the quality of the graduates but also affect the realization of task sharing strategy that requires that task sharing should not compromise the quality of services produced by the task-shared cadre. It is high time for revising the AMOs curricula and train the tutor through continued medical education programmes to reflect the dynamics of medical education. The government in collaboration with other stakeholders should work together to address the challenges on teaching infrastructure and scholarships to this cadre that has continued to be the backbone of the primary health care in Tanzania.


Introduction
One of the strategies adopted by many countries globally to lessen the burden of health workforce shortages in the provision of health care services is task-sharing [1][2][3]. Tasking sharing is the name given to the process whereby less specialized health workers take on some of the responsibilities of more specialized workers in a cost-effective manner without sacrificing the quality of care [4]. Many countries in Africa and other parts of the world have associate clinicians that receive different levels of training and carry out different tasks at varying levels and thus labelled differently [1][2][3]. However, despite the vital role played by task-sharing in addressing the health workforce crisis, this strategy still suffers many challenges. In some countries, the challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance of health workers [5,6].
In Tanzania task sharing strategy dates back to the 1930s when the country started to create country-specific cadres to provide services mostly in rural areas. These cadres included the Clinical Assistants, the Rural Medical Aides, Clinical Officers and many other [7,8]. In the early 1960s, with the growing population, the critical shortage of medical doctors, urbanization of medical doctors and the long-time training required for the medical doctors; the country embarked to train a middle-level cadre of clinical practitioners that will perform those roles that were primarily meant for medical doctors at the district level; these were the Assistant Medical Officers, AMOs [8].
The AMO is an upgraded Clinical Officer who after working for a minimum of three years undergoes a formal two years residency training in internal medicine, paediatrics, surgery, obstetrics and gynaecology and community medicine [8]. The training of the AMOs is under the ministry responsible for health and it takes place at an AMO training school located in the selected referral or regional referral hospitals. By 2014, Tanzania had seven AMO schools located in four different zones of Tanzania. Four of these AMO schools are under the private-public partnership between Faith-Based Organizations (FBOs) and the government. After the two years of residency training, the AMO trainees are awarded an Advanced Diploma in Clinical Medicine. Based on the World Health Organization classification of associate clinicians, AMOs qualify to be senior Associate Clinicians [9]. Therefore, after training AMOs are expected to provide clinical care, including emergency obstetric and surgical care at the district level and below.
A study carried in Mwanza and Kigoma regions in Tanzania revealed that over 85% of Caesarean sections and most of the other obstetric surgeries were performed by AMOs [10]. The situation of the two regions, Mwanza in the lake zone and Kigoma in the western zone are typical of many regions in Tanzania. Furthermore, by 2012, the country's health workforce profile revealed that the AMO served a proportionately bigger population than the MD. The AMOs population ratio stood at a national average of 1:13,000, with regional variation from 1:13,000 in Dar es Salaam to 1:120,000 in Kagera while that for MD was at 1:25,000 with regional variations as well [11]. The latter happens in a country that has less than 50% of the total required health workforce, less than 40% of the required medical doctors with only 25% of the doctors serving the rural population [12]. In overall, above 70% of the population in Tanzania reside in rural areas [13].
Despite the known contribution of the AMOs in addressing the health workforce crisis, anecdotal information reveals that their training succumbs many challenges that if not addressed will inevitably have adverse effects on their roles as a cadre in task sharing strategy. Some of the stated challenges are the shortage of tutors, limited sponsorships and limited career path for the Amos graduates. This study, therefore, aimed to explore the challenges facing AMOs training in Tanzania.

Methods
An exploratory case study design that adopted a qualitative approach was used for identifying challenges facing the training of AMOs in Tanzania. A qualitative case study was necessary for undertaking this study as the training of AMOs is a real phenomenon that involves social processes [14,15].

Context of the study
Tanzania is divided into seven geopolitical zones, namely: Northern, Eastern, Central, Western, Lake, Southern highlands and Southern zones. The south, west and central zones are considered more rural compared to the rest zones. Tanzania has five cities, two located in the northern zone, and the rest located in eastern, lake and southern highland zones. Dar es Salaam, the largest business city that contains the largest number of the health workforce in the country is located in the eastern zone.
This study was carried out in four rural districts (Handeni, Kasulu, Kilombero, and Masasi) located in the four zones (Northern, Western, Eastern and Southern in that order), two AMO schools (one in the northern zone and one in the eastern zone) and at the national level with officials from the ministry of health responsible for the health workforce development and training (table 1). The selected AMO schools involved one that was owned and managed by the ministry of health and one under the public-private partnership. The four zones were purposefully selected to include rural zones, a zone with an AMO school under public-private partnership and a zone with AMO school that is under the ministry of health. The choice of zones with AMO schools also considered the presence of one AMO school in town and one in a rural area. In each zone, a random selection of rural districts was done whereby one rural district was included in the study.

Study population
This study involved participants from different levels of the health care system that are involved in training, supervision of AMOs after training and those working with the AMOs.

Sampling strategy
The purposeful sampling strategy was used to enrol key informants for this study. The key informants were Ministry of health officials dealing with the training of AMOs, Regional Medical Officers, District Medical Officers, District Medical Officers, Medical Officers in charge of the district hospitals, Senior AMOs at the district hospitals and one retired AMO.
For the focused group discussion, a convenience sampling strategy was used to obtain AMO trainees. Participants who were present during the data collection period and agreed to participate in the study were enrolled from the two AMO schools. In each AMO school, two focused group discussions were conducted one with male and one with female AMO trainees.

Data collection involved Key-Informant Interviews (KIIs) and Focused Group Discussions
(FGDs).

Key Informant interviews
We used a semi-structured interview guide to carry out 29 KIIs and four FGDs (table 2).
The interview guide was prepared based on experiences on the training of AMOs and task sharing in the country as documented from the available literature [8,16,17]. The questions in the guide solicited information on the challenges at the AMO schools, at the districts and at the national level.
The interviews were carried out at a designated office of the informant and it was recorded using a digital audio recorder. A research assistant accompanied the researcher took field notes during the interview. Each interview lasted between 60 and 100 minutes.

Focused Group Discussions
We used a semi-structured FGD guide developed based on the competencies detailed in the AMOs' training curriculum and available literature on task sharing [7,8]

Data management
In order to ensure quality, experienced research assistants were recruited and trained on the objectives of the study and the full research process. During data collection, the researchers carried out most of the interviews and the research assistants were taking field notes. Audio records of the interviews were transferred into a computer by the Data Manager and kept in a PIN folder in a computer that is only accessible to him. The transcripts were all kept by the Data Manager but only shared with the research team for analysis.

Data analysis
All interviews and FGDs transcripts were transcribed verbatim. The Swahili transcripts were then translated into English before the analysis. The research team cross-checked the accuracy and completeness of translations against the original notes before coding.
Any gaps identified or clarifications needed were discussed and corrections made accordingly.
In the beginning, the research team read and re-read the transcripts to familiarize with the data before the coding process. The team met together where each one coded at least two transcripts and met together to discuss the codes and coding process for harmonization or clarification and finally agreed on the final codes. Two separate researchers coded at least one similar transcript. After agreeing on the codes and coding process the team distributed the transcripts among each other for the coding process. All the coded transcripts were then organized by using NVIVO 10 qualitative analysis software.
Qualitative content analysis was used to guide the analysis. Codes were extracted from the reduced meaningful unit. Similar codes were grouped together and through abstraction, sub-categories were formed. Through comparison and checking and rechecking of similarities and differences between the sub-categories, the sub-categories were sorted to form categories to reflect the manifest content of the text that were supported with suitable quotes from the transcripts. Further interpretation of the categories was then used to ensure the latent meaning is also brought into focus. The whole process although described as a linear process, it was iterative at all points to ensure that both the manifest and latent meaning of the data is not lost.

Ethical considerations
Ethical approval was obtained from the Muhimbili University of Health and Allied Sciences Research and Ethical Review Committee. Permission to conduct the study in the four study settings was granted by the Ministry of Health. Written informed consent was obtained from each participant after receiving explanations about the study aim and they were informed that their participation was voluntary and they were free to decline or withdraw at any time in the course of the study. Participants' privacy was assured by not using their names during the data collection process and even identity of the health facility was covered to ensure that no one out of the research team could identify the place where data was collected. Permission was requested on the use of audio recorder during interviews and discussions.

Results
From the interviews and FGDs, we found that the training of AMOs was challenged by; non-responsive static curriculum, limited sponsorships, human resources inadequacy and limited teaching infrastructure (figure 1).

Figure 1: Challenges facing AMOs' training in Tanzania
The use of non-responsive static curriculum for AMOs training The use of static non-responsive curriculum attributed to lack of regular revision and low emphasis on basic science courses in the curriculum was among major challenges facing AMOs training in Tanzania.
From the AMOs tutors, we found that the curriculum that is key to the training of AMOs

Limited sponsorship for AMOs training
Across health facilities and colleges, AMO trainees and junior AMO reported having attempted self-sponsorship as a response to the failure of the government to provide sponsorship to them. They added that, as government employees, AMO trainees used to receive sponsorship from the government once they were admitted. However, they reported that the scholarships were decreasing gradually and nowadays it has remained at the discretion of each council. They added that most of the councils have failed to provide the scholarships. Majority of the AMO trainees were now attempting self-sponsorship that affects themselves and their families.

Inadequacy in human resources
The challenges of human resources manifested as an absolute shortage of tutors and relative shortage in terms of experienced tutors and lack of pedagogical teaching methods.
Informants from the AMO schools stated that despite the desire of producing high-quality

Limited infrastructure for AMOs training
Informants in this study revealed the existence of limited infrastructure that challenges the delivery of quality training to the AMOs. Across AMO schools, shortage of teaching materials and space for practical training were stated as the main setback to the AMOs training. With regards to the teaching materials, overhead projectors, teaching models, computers, skills laboratory and books were the main outcry of the trainees and trainers.
The challenge was reported to be more pressing at the government-owned schools.
"…We used to have enough teaching models but as time goes, they get old and now we have remained with just a few. …. We have only two overhead projectors, more than two teachers cannot go to the classes at the same time …we have only one printer and a photocopier, all of them are aged, so it is a challenge during the examinations period.
We also do not have a computer in the office so everyone uses a personal laptop if have one…It is really challenging…" (KI-AMO training college).
Limited space for practical training was complained hospitals by students and junior AMOs across training institutions and district to limit them from acquiring the desired competencies. They added that in most AMO schools, there were many other groups of trainees and the hospitals were small and thus at the time it was not possible for them to get a chance to even see a patient during surgery due to existence of other groups. Some AMOs added that sometimes they were not even included in the schedule for practical training due to lack of space to accommodate them.
"…There are many challenges as I said in the beginning; we were like tourists in the theatre and ward rounds because of the existence of Interns who assisted almost all procedures, Medical students who were also struggling to assist and the residents. In this situation, how do you expect an AMO student to learn? …" (KI-Kigoma).

Discussion
We aimed to explore the challenges facing AMOs training in Tanzania. Our findings have highlighted that despite the fact that in Tanzania, AMOs form the backbone of the district health system and thus the backbone of the primary health care [8,18,19]; and the long history of this cadre of its own kind in the Eastern, Central and Southern Africa [8]; the AMOs training is facing multi-dimensional challenges. These challenges are related to the curriculum used in AMOs training, sponsorship to AMO trainees, human resources and the teaching infrastructure. These challenges threaten the quality of AMO graduates.
The AMOs' training survived around 40 years without a written curriculum, the latter opens many questions on how the training was carried out in terms of imparting knowledge, skills, competence and quality assurance. AMOs perform tasks shared with medical doctors as a way of curbing the critical shortage of doctors in the country [8].
According to WHO, task sharing should not compromise the quality of services rendered by that group where such tasks are shared [20].
Despite having stayed without a written curriculum for many decades, our study revealed also that the existing curriculum that was written over 15 years ago has never been revised. This happens in the AMOs training while the medical practice is changing rapidly and many medical schools in the country have been revising their training curricula regularly [21,22]. The existing curriculum has paid little attention to the basic sciences while they are pivotal in understanding the causation of the disease and why certain decisions must be made regarding their treatment [23]. The world has transcended rapidly to competency-based education as a way of ensuring that the quality of education is improved by having competent graduates [24,25]. Therefore, it is high time for the AMOs curriculum to be reviewed and changed to a competency-based one as opposed to the knowledge-based that exist. Furthermore, as revealed by our findings, the AMOs'

Trustworthiness
According to Dahglen and Granheim [31] trustworthiness of a study in a qualitative study is attained when the findings of such a study are worth believing. The four Guba's criteria were used to enhance the trustworthiness of the findings of this study [32]; credibility, dependability, transferability, and confirmability [32]. The credibility of the findings of this study was enhanced through the triangulation of informants with experiences and rich information on the study questions. In order to enhance the credibility and dependability of this study, we used the triangulation of data collection techniques, study settings, and researchers. Data were collected using interview guides and a focus group discussion guide in four different zones with different cultural and socio-economic activities. In order to confirm that the findings reflected informants' perspectives rather than the researchers' understanding of the question under study, categories were inductively generated using content analysis and presented with the support of sub-categories and quotes. The transferability of the findings of this study is enhanced through the description of the study setting, context, data collection process, and analysis.

Conclusions
Training of the Assistant Medical Officers as revealed in this study is facing many challenges and thus ultimately threatening the quality of health care services provided by this cadre as a task-sharing strategy. For the AMOs to reliably fulfil the aim intended for this cadre, it is high time for revision of its curriculum to align it to competency-based education. Furthermore, resources should be solicited and regular review of the curriculum be conducted. As the AMO training is an in-service programme aiming at improving the performance of an existing cadre, rather than an addition of new workforce, provision of sponsorships by the government or through other development partners need to be given high consideration to ensure the quality of this training. Employing experienced tutors and provision of teaching methodology course to all tutors before they start teaching and refresher's training regularly is another important strategy that can help in resolving the challenges pertaining human resources at the AMO training schools.
For infrastructure, efforts should be invested in renovating the existing infrastructure and improve the supply for this cadre to attain the needed competencies. Finally, our findings reflect the situation by the time when this study was carried out.

List of Abbreviations
Not applicable

Ethical Approval and Consent to participate
Provided and detailed in the method section

Consent for publication
Contained in the ethical approval

Availability of data and Materials
T transcripts are available. However, sharing is limited for confidentiality reasons. Figure 1 Challenges facing AMOs' training in Tanzania