“ … we were like tourists in the theatre, the interns assisted almost all procedures … ” Challenges facing the assistant medical officers training for the performance of caesarean section delivery in Tanzania

Background: Training of mid-level providers is a task-sharing strategy that has gained popularity in the recent past for addressing the critical shortage of the health workforce. In Tanzania, training of mid-level providers has existed for over five decades; however, concerns exist regarding the quality of mid-level cadres amidst the growing number of medical universities. This study sought to explore the challenges facing the Assistant Medical Officers training for the performance of Caesarean section delivery 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 AMO training colleges in Tanzania. A semi-structured interview guide was used to interview 29 key informants from the district hospitals, district management, regional management, AMO training college, and one retired AMO. Also, 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 The challenges include: use of outdated and static curriculum, inadequate tutors (lack of teaching skills and experience of teaching adults), inadequate teaching infrastructure in the existence of many other trainees, including 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 for the performance of Caesarean section delivery have the potential to negatively impact the quality of Caesarean sections performed by this cadre. A 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 continuing medical education programmes. Furthermore, the government in collaboration with other stakeholders should work together to address the challenges in teaching infrastructure and providing financial support to this cadre that has continued to be the backbone of primary healthcare in Tanzania. Long-term solutions should consider deploying medical officers at the primary facilities and phasing out the performance of Caesarean section by AMOs. An exploratory case study design that adopted a qualitative approach was used for identifying the challenges facing the assistant medical officers training for the performance of Caesarean section delivery in Tanzania. A qualitative case study was necessary to undertake this study, as the training of AMOs is a real phenomenon that involves social processes [15, 16]. 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 than the rest. The country has seven AMO schools with three located in the Northern zone, two in the Eastern zone, one in the lake zone, and one in the Southern highland zone (Fig ​(Fig1).1). Each AMO school had a capacity of admitting up to 40 AMO trainees [10]. Tanzania has five cities: two located in the northern zone, and the rest located in the 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. The geography of Tanzania indicating a distribution of AMO training schools and study sites by Zones. Key: AMO training school Study sites The provision of healthcare services in Tanzania is organized in a pyramid of three levels: the primary level (comprising district hospital/s, health centres, dispensaries, health posts, and the communities), secondary level (comprising regional and regional referral hospitals), and tertiary level (comprising zonal, specialized hospitals; consultant hospitals; and national hospitals). At all levels, be they rural or urban areas, healthcare 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 a national level with officials 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 implemented whereby one rural district was included in the study. This study involved participants from different levels of the healthcare system who are involved in training, supervision of AMOs after training, and those working with the AMOs. These included: principals from AMO training schools, AMOs’ tutors, AMO trainees, Regional Medical Officers, District Medical Officers, Medical Officers in charge of the district hospitals, Senior AMOs at the district hospitals, and one retired AMO (Table ​(Table22). Study participants (Key Informants and Focused Group Discussants) The purposeful sampling strategy was used to enrol key informants for this study. The enrolment started by identifying the key people who deal with AMOs’ training, supervision, and those who work with AMOs. The latter was implemented through consultation with officials from the directorate of human resources development and training from the Ministry of Health at the section of allied health training and regional and district medical officers from the selected study sites. From the Ministry of Health, the key informants were the officials dealing with overseeing the training of AMOs. These were those dealing with the selection of AMO trainees and overseeing the AMO schools. From the regions and districts, this study involved health managers. In this category, the regional medical officers and district medical officers were included as they are responsible for the work and work environment, permission for further studies, and incentives to the AMOs. At the selected health facilities, this study involved the immediate work supervisors; the medical officers 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, including the performance of Caesarean sections. To get a 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. The latter was identified through consultation with senior AMOs from study sites, and a senior gynaecologist who worked with this 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 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 into Kiswahili were used for conducting the Key Informant Interviews (KIIs) and Focused Group Discussions (FGDs). To ensure quality, experienced research assistants who are fluent in both English and Kiswahili were recruited and trained on the objectives of the study, the guides, the informed consent, and the full research process. Before data collection, the selected informants were contacted by the lead researcher via phone call to set up the appointment for the interview. For the AMO trainees, the principals of the training schools were contacted in advance to organize the FGDs. During data collection, the researchers carried out most of the interviews and FGDs, and the research assistants took 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 to which he had sole access. The transcripts were all kept by the data manager but only shared with the research team for analysis. We used different semi-structured interview guides containing questions specific to each group of informants to carry out 29 KIIs. (Table ​(Table2).2). The interview guides were prepared based on experiences of 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, in the districts, and at a national level concerning assistant medical officers training for the performance of Caesarean section delivery in Tanzania. The interviews were carried out at an office designated by the informant and they were recorded using a digital audio recorder. Each interview lasted between 60 and 100 minutes. We used a semi-structured FGD guide developed based on the competencies detailed in the AMOs’ training curriculum and available literature on task sharing and Caesarean section delivery [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 for acquiring knowledge and skills for the performance of Caesarean sections as stated in their curriculum. The FGDs lasted between 55 and 120 minutes. A researcher moderated all FGDs. All interviews and FGD 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 identified or clarifications 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. Initially, the research team read and reread the transcripts to familiarize themselves with the data before the coding process. The first author developed the initial codebook, based on our study objective and the conceptual understanding of the training of AMOs in Tanzania. The codebook was discussed by all authors, further developed, and a final codebook was imported into NVivo 10 qualitative data analysis computer software. The agreed codebook was tested by independently coding the first two interview transcripts by three authors. Their coding was almost similar and, hence, the codebook was not modified 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 confined 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 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 was also brought into focus. The whole process, although described as a linear process, was iterative at all points to ensure that both the manifest and latent meaning of the data is not lost. 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. 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. All participants were informed that there was no financial compensation for participating in the study and only water was provided during the interview or discussion. The participants’ privacy was assured by not using their names or facility identity during the data collection and dissemination process through written reports and peer-referred publications. The latter aimed to ensure that no one out of the research team could identify the place where data was collected. Permission was requested for the use of an audio recorder during interviews and discussions.