From the interviews and FGDs, four categories of challenges facing the assistant medical officers training for the performance of Caesarean section delivery in Tanzania were unveiled. These were: non-responsive static curriculum, limited financial support for AMOs training, human resources inadequacy, and limited teaching infrastructure for AMOs training (table 3).
The use of a non-responsive static curriculum for AMOs training
The use of a static non-responsive curriculum attributed to a lack of regular revision and low emphasis on basic science courses in the curriculum was among the major challenges facing AMOs training in Tanzania.
From the AMOs’ tutors, we found that the curriculum, which is key to the training of AMOs, was written in 2000 (over 15 years ago). This was the first written curriculum since 1963 and it has not 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. It is worth noting that the AMO program is the only course in Tanzania in which graduates are offered an advanced diploma at the end of the course. 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 conflict 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 training and practice in medicine, AMO training has remained static. They added that the AMO curriculum is experiencing 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 officers 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 the 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 they start to work independently. Depending on the council for which the 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 the fresh AMOs to seniors in different departments… When the senior is satisfied that the 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 financial support for AMOs training
Across health facilities and colleges, AMO trainees and junior AMOs reported having attempted self-financing as a response to the failure of the government to provide them with financial support. They added that, as government employees, AMO trainees used to receive financial support from the government once they were admitted. However, they reported that financial support was gradually decreasing, and nowadays it remains at the discretion of each council. They added that most councils have failed to provide financial support. The majority of AMO trainees were attempting self-financing, which 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 difficult 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 to produce a high-quality workforce, AMO schools and the hospitals where AMO are trained face a deficiency 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 traveled for other hospital duties…” (KI- AMO Training College)
Furthermore, informants from the AMO training schools stated that most of the tutors were employed by the AMO training schools immediately following 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 created an unfavorable learning environment for AMO trainees, who have been exposed to the real workplaces compared to fresh graduate medical doctors. Ascribing to the feelings of the AMOs, the tutors expressed that they also felt uncomfortable teaching 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 as a tutor. At first, 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 some time to cope…” (KI-AMO training school)
Some tutors who 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 the training session was limited and thus created a communication gap between the two groups. They stated that this made life harder for the AMO trainees, in the 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… my advice is 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, which challenges the delivery of quality training to AMOs. Across AMO schools, a shortage of teaching materials and space for practical training were stated as the main setback. 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 challenges were reported to exist more 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 they have one…” (KI- AMO training college)
Limited space for practical training was complained of at hospitals by students and junior AMOs across training institutions and districts, limiting them in acquiring the desired competencies. They added that in most AMO schools, there were many other groups of trainees, and the hospitals were small. The latter limited the opportunities for AMO trainees to even observe surgical procedures in the theatre. Some AMOs added that sometimes they were not even included in the schedule for practical training due to a 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)