“…we were like tourists in the theatre, the interns assisted almost all procedures…” Challenges facing the training of Assistant Medical Officers in Tanzania


 Background: Training of mid-level providers is a task sharing strategy that has gained popularity in the recent past for addressing critical shortage of health workforce. In Tanzania, training of mid-level providers has existed for over five decades, however, concerns are upon the quality 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 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 The challenges include; use of outdated and static curriculum, inadequate tutors (lack of teaching skills and experience of teaching adults), Inadequate teaching infrastructure in existence of many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 findings of this study underscore that the challenges facing AMO training have the potentials to negatively impact the quality of care rendered by this cadre. Holistic approach is needed in addressing these challenges. The solutions should focus on reviewing the curriculum, deploying qualified tutors and improving the competencies of the available tutors through continued medical education programmes. Furthermore, the government in collaboration with other stakeholders should work together to address the challenges on teaching infrastructure and financial support to this cadre that has continued to be the backbone of the primary health care in Tanzania. Long term solution should consider to deploy the medical officers at the primary facilities and phase out the AMOs. Finally, challenges facing mid-level providers in Tanzania and similar settings are similar, thus these findings can be used as a starting pointing in addressing them.

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 ndings of this study underscore that the challenges facing AMO training have the potentials to negatively impact the quality of care rendered by this cadre. Holistic approach is needed in addressing these challenges. The solutions should focus on reviewing the curriculum, deploying quali ed tutors and improving the competencies of the available tutors through continued medical education programmes. Furthermore, the government in collaboration with other stakeholders should work together to address the challenges on teaching infrastructure and nancial support to this cadre that has continued to be the backbone of the primary health care in Tanzania. Long term solution should consider to deploy the medical o cers at the primary facilities and phase out the AMOs. Finally, challenges facing mid-level providers in Tanzania and similar settings are similar, thus these ndings can be used as a starting pointing in addressing them.

Background
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 to mid-level providers (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 sacri cing the quality of care (4). Many countries in Africa and other parts of the world to carter for shortage of health workers have developed the Mid-level Health Providers (MLP) in different aspects (5). The MLP is a health provider that is trained for 2 to 3 years after secondary education (that last around 10 to 12 years), authorized and regulated to provide health care services in an autonomous manner (5). A good example of the MLPs are the Associate Clinicians, a cadre that was developed in efforts to curb for the shortage of physicians in many countries (2). The associate clinicians receive different levels of training and carry out different tasks at varying levels and thus labelled differently (1)(2)(3).The World Health Organization (WHO) classi es associate clinicians into two broad categories based on their level of training and scope of practice, the associate clinicians and the advanced level associate clinicians (6). However, despite the vital role played by the MLPs 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 other health workers (7,8).
In Tanzania the training of MLPs dates back to the 1930s when the country started to create countryspeci c cadres to provide services mostly in rural areas (  (9,10). 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 O cers, AMOs (10).
The AMO is an upgraded Clinical O cer 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 (10). 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 classi cation of associate clinicians, AMOs qualify to be advanced level associate clinicians (6). Therefore, after training AMOs are expected to provide clinical care, including emergency obstetric and surgical care at the district level and below (table 1).
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 (11). 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 pro le 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 (12). 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 (13). In overall, above 70% of the population in Tanzania reside in rural areas (14).
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. Speci cally, this article aimed to explore challenges related to training infrastructure, nancial support, curriculum and human resources.

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 (15,16).

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. The country has seven AMO schools with three located in Northern zone, two in Eastern zone, one in lake zone and one Southern highland zone ( g 1). Each AMO school had a capacity of admitting up to 40 AMO trainees (10) Tanzania has ve 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.
Organization of the health care services provision in Tanzania is in a pyramid of three levels. The primary level (comprising of District hospital/s, Health centres, dispensaries, Health posts and the communities), secondary level (comprising of Regional and Regional Referral Hospitals) and tertiary level (comprising of Zonal, specialized hospitals, consultant hospitals and National hospitals). At all levels be in rural or urban areas, health care services are provided by both public and private health facilities.
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 o cials from the ministry of health responsible for the health workforce development and training. 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 both rural and urban zones and zones with AMO schools operating under public-private partnership and those operating under the ministry of health (public alone). 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. These included participants from; Principals from AMOs training schools, AMOs tutors, AMO trainees, Regional Medical O cers, District Medical O cers, Medical O cers in charge of the district hospitals, Senior AMOs at the district hospitals and one retired AMO (table 2).

Sampling strategy
The purposeful sampling strategy was used to enrol key informants for this study. From the Ministry of health, key informants were the o cials dealing with the training of AMOs. These were those dealing with the selection of AMO trainees and overseeing of the AMO schools. This study also involved the immediate supervisors of the AMOs after they have graduated. In this category the Regional Medical O cers and the District Medical O cers were included as they are the immediate managers responsible for their work and work environment, permission for further studies and responsible for their incentives.

The other group of supervisors involved the Medical O cers in charge of the district hospitals and Senior
AMOs at the district hospitals. These are responsible for supervising and overseeing the day to day practice of the AMOs to include the clinical services provision. To get the perspective of changes that have taken place in the training and scope of practice of AMOs, one retired AMO who was trained and practiced as an AMO and later trained as a Medical Doctor was included in this study.
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
Data for this study were collected between September 2015 and February 2017. Semi structured Interview and Focus Group Discussion guides developed in English and later translated to Kiswahili language were used for conducting the Key-Informant Interviews (KIIs) and Focused Group Discussions (FGDs). In order to ensure quality, experienced research assistants who are uent in both English and Kiswahili languages were recruited and trained on the objectives of the study, the guides, the informed consent and the full research process.
During data collection, the researchers carried out most of the interviews and FGDs and the research assistants were taking eld 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 was only accessible to him. The transcripts were all kept by the Data Manager but only shared with the research team for analysis.

Key Informant interviews
We used different semi-structured interview guides containing questions speci c to each group of informants to carry out 29 KIIs. (table 2). The interview guides were prepared based on experiences on the training of AMOs and task sharing in the country as documented from the available literature (10,17,18). The questions in the guides solicited information on the challenges at the AMO schools, at the districts and at the national level in relation to the AMOs' training. The interviews were carried out at a designated o ce of the informant and it was recorded using a digital audio recorder. 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 (9,10) to carry out four FGDs with AMO trainees from the two AMO schools involved in this study. In each school, we carried two FGDs, one with the female and the other with the male AMO trainees. The number of participants in each FGD ranged from 7-12. In total 35 AMO trainees participated in the four FGDs. From the FGDs, we explored challenges related to the training of the AMOs in relation to gaining knowledge and skills as stated in their curriculum. The FGDs lasted between 55 and 120 minutes. A researcher moderated all FGDs.

Data analysis
All interviews and FGDs transcripts were transcribed verbatim. The Kiswahili transcripts were then translated into English before the analysis. A team of four researchers with vast experience in qualitative research, health systems, medical education and maternal health cross-checked the accuracy and completeness of translations against the original notes before coding. Any gaps identi ed or clari cations needed were discussed and corrections made accordingly.
Qualitative content analysis as described by Graneheim and Lundman was used to guide the analysis (19). Codes were extracted from the reduced meaningful unit. In the beginning, the research team read and re-read the transcripts to familiarize with the data before the coding process. The rst author developed the initial codebook, based on our study objective and the conceptual understanding of the training of the AMOs in Tanzania. The codebook was discussed by all authors, further developed, and a nal codebook was imported into NVivo 10 qualitative data analysis computer software. The agreed codebook was tested by independently coding the rst two interview transcripts by three authors. Their coding was almost similar and, hence, the codebook was not modi ed at this time. The team then distributed the transcripts among each other for the coding process.
We coded the meaningful units of text to the codes (nodes) that were found to represent that unit. Some of the meaningful units were coded more than once. At this stage, although the data analysis was guided, it was not con ned to the primary codes. Inductive coding was assigned to text segments which represented a new code that was not pre-determined. The new codes were assigned as separate codes or an expansion of the codes available in the initial codebook. All the coded transcripts were then organized by using NVIVO 10 qualitative data analysis software. 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 re ect 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, four categories of challenges facing the training of AMOs were unveiled. These were; non-responsive static curriculum, limited sponsorships, human resources inadequacy and limited teaching infrastructure ( gure 2).
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 was written in 2000 (over 15 years ago), this was the rst written curriculum since 1963 and it has never been reviewed since 2000. The informants added that the failure to review the curriculum is attributed to the dilemma that surrounds the overall structure of the course. Noteworthy, the AMO program is the only course in which graduates are offered advanced diploma at the end of the course in Tanzania. In the contemporary academic system of Tanzania, Advanced diploma courses have been phased out.
"…it has never been reviewed…I know some years back they called us to a review meeting but then came to a con ict with the ministry of education that advanced diploma programmes are no longer in the national academic framework. Since then I have heard nothing about the review of this curriculum…" (KI-AMO training college).
Informants from the district hospitals stated that despite the changes in both the training and practice in medicine, the AMO training has remained static. They added that the AMO curriculum is having serious knowledge gaps in basic sciences that form the foundation of medical practice. The basic sciences are limited to a period of only eight weeks and they are not the only subjects in that period rather they are taught concurrently with clinical rotations.
"…in clinical o cers training, the training on anatomy and physiology is too basic…it was expected that when one joins AMOs training, then the training on physiology, anatomy, biochemistry and other basic sciences be upgraded….surprisingly, eight weeks everything is lumped together with other clinical subjects….then understanding of basic sciences to AMOs is negligible… " (KI-Kigoma).
In Tanzania's health system, there is no formal internship programme after completion of AMO studies. Analysis of the interviews shows that; each council has its own coping mechanism to create an opportunity for "working under the supervision of AMO graduates" before starting working independently. Depending on the council that AMO is working, the time for working under supervision varies from three to twelve months. It is imperative to note that this process is not structured and thus there is no clear-cut goal on what an AMO should gain from this process.
"… When they return from their training, we have senior AMOs and MDs here, so we attach these fresh AMOs to these senior in different departments…When the senior feels that now this AMO can work independently then s/he moves to another department…the duration varies from three months to 12 months for the individuals …" ( KI-Mtwara).
Limited nancial support for AMOs training Across health facilities and colleges, AMO trainees and junior AMO reported having attempted selfnancing as a response to the failure of the government to provide nancial support to them. They added that, as government employees, AMO trainees used to receive nancial support from the government once they were admitted. However, they reported that the nancial support was 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 nancial support. Majority of the AMO trainees were now attempting self-nancing that affects themselves and their families.
"…Some council supports their students and some do not... At your home, you have left children who need school fees… So, it is very di cult to concentrate on a situation when you have no money… sometimes you feel like you have given your family a burden by your decision of coming to school…" (FGD-AMO training college).

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 workforce, AMO schools as well as the hospitals where AMO are trained face a de ciency of teaching staff. The shortage of teaching staff affects the AMOs training to acquire essential skills especially in the clinical rotation where the shortage is worse.
"…the serious shortage is in clinical rotations, as we do not have a single specialist in this AMO School. …., For instance, in obstetrics and gynaecology we have only one registrar and mostly we rely on the only one available gynaecologist at the hospital who sometimes has travelled for other hospital duties …" (KI-AMO Training College) Furthermore, informants from the AMOs training schools stated that most of the tutors were employed to the AMO training schools immediately post their internship without any experience. Given the fact that AMO training is a continuing education that requires proper methods as most of the students are adults, the informants felt that the use of fresh graduates was creating an unfavourable learning environment to the AMO trainees who have seen the real workplaces compared to the fresh graduate medical doctors. Ascribed to the feelings of the AMOs, the tutors expressed that they also felt uncomfortable in teaching the clinical skills due to lack of experience.
"…Immediately after my internship, I applied for a job through the Ministry of health….after six months I was posted here to teach the AMOs. At rst, it was a very hard job as when I reported I found that most of the tutors were also fresh graduates like me…only four were experienced…for the lectures, it was not a challenge, but for the clinical rotations, yeah it took sometimes to cope…" (KI-AMO training school) Some tutors participated in this study added that apart from being medical doctors; they were not equipped with the teaching methodology. Therefore, it was tough for them at the beginning of their work as trainers of adult learners. Trainer and trainee communication in training session was limited and thus creating a communication gap between the two groups. They stated that this was making life harder to the AMO trainees and in long run affecting the quality of the AMOs produced.
"… If it is the problem, I think, it is in the methodology; you know teaching is a profession…. I mean, that ability to deliver a message to the other person and yet understood… So, with regard to that problem, my advice is that it was better for evaluation to be done in the given year and the trainers receive training methodology course…" (FGD-AMO training college).

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 o ce 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 ndings 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 (10,20,21); and the long history of this cadre of its own kind in the Eastern, Central and Southern Africa (10); the AMOs training is facing multi-dimensional challenges. These challenges are related to the curriculum used in AMOs training, nancial support to AMO trainees, human resources and the teaching infrastructure. These challenges altogether 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 (10). According to WHO, task sharing should not compromise the quality of services rendered by that group where such tasks are shared (22).
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 (23,24). 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 (25). 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 (26,27). 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 ndings, the AMOs' curriculum is not adding up from the clinical o cers' training, this makes the understanding of AMOs as upgraded clinical o cers shaky. The authors feel that it is high time for the clinical o cers' and AMOs training to be streamlined to make the concept of upgrading a reality. By streaming the curriculum, it will help to better de ne the career path for this cadre that has sometimes termed as a dead-end career.
Another immediate challenge posed immediately after the training of AMOs at the AMOs training schools, was the lack of a formal internship program. With the de ciencies in the curriculum and its implementation, an internship program is vital for consolidating the skills and competencies for quality services by the AMOs. Unlike Tanzania, some countries have formalized internship programs after graduation of the associate clinicians that varies between 6 and 18 months (2).
While training of AMOs is focusing on addressing the shortage of health workforce, our study has revealed the training of AMOs by itself is affected by the inadequacy of the workforce both in number and skills. This nding re ects what is reported by the Ministry of Health whereby the training institutions were reported to suffer from a shortage of 74% of the required workforce (28). The use of inexperienced tutors who are fresh graduates and who have not received the teaching methodology course as revealed in this study poses many challenges in the process of imparting knowledge and skills to the AMOs. As AMOs training is a mature-age entry, as it takes trainees who have pre-service training and clinical experience in many areas, it demands tutors who have adequate experiences in both teaching and services provision who can give practical examples from the eld.
The challenges associated with infrastructure and existence of multiple trainees and thus limited opportunities for practical training as unveiled by this study bring another dilemma in the AMOs training in Tanzania. Although not explicitly the same as what our study has documented, studies from different places in Sub-Saharan Africa reveal inadequacies in the training of the associate clinicians (8,(29)(30)(31)(32). Limited teaching materials as revealed in this study, bring in the challenge of quality of graduates. The control of exams, the acquisition of practical skills before touching real patients and other practical skills are compromised. Not only for Tanzania but countries where associate clinicians are trained and the question of limited resources is a subject, priority should be given in provision of the basics in training for quality of care to be guaranteed.

Trustworthiness
According to Dahglen and Granheim (19) trustworthiness of a study in a qualitative study is attained when the ndings of such a study are worth believing. The four Guba's criteria were used to enhance the trustworthiness of the ndings of this study (33); credibility, dependability, transferability, and con rmability (33). The credibility of the ndings 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 con rm that the ndings re ected 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 ndings of this study is enhanced through the description of the study setting, context, data collection process, and analysis.

Study limitations
This study is not without some limitations. First, social desirability may have limited the ndings of this study as data collection was led by medical doctors and thus the AMOs may have felt that they should provide desired answers instead of truth value. However, triangulation of methods of data collection, researchers and sites offset this limitation. Second, only four districts out of 185 districts were involve with only two AMOs training schools. The latter limit generalizability of the ndings. However, as this was a qualitative study the main focus is transferability which was ensured through thick description of the study setting and approach.

Conclusions
Training of the Assistant Medical O cers as revealed in this study is facing many challenges and thus ultimately threatening the quality of health care services provided by this cadre. For the AMOs to reliably ful l the aim intended for this cadre, it is high time for revision of its curriculum to align it to competencybased education. 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 nancial support 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, while these ndings are true for the AMOs, we feel that the challenges facing training of Mid-level providers in Tanzania are similar. Therefore, these ndings can be used as a starting point to address  To provide clinical care to all patients, to provide obstetric and surgical care. To perform administration and resources mobilisation functions particularly for those heading Health centres, hospitals and even districts.  The geography of Tanzania indicating distribution of AMO training schools and study sites by Zones Key: AMO training school Study sites