ABSTRACT THE CHALLENGE OF INTEGRATING A RDU TRAINING MODEL INTO THE REALITY OF A HEALTH SYSTEM CONTEXT Problem Statement: The Dar es Salaam Urban Health Project (DUHP) is aimed at structural and functional rehabilitation of public health services in Dar es Salaam. One of the objectives is to improve quality of health care. A program to promote rational drug use (RDU) was implemented and evaluated. After a baseline drug use indicator study, Standard Treatment Guidelines (STGs) were elaborated and disseminated with concurrent training of all health care providers. A comprehensive training model was established. Compliance with STGs improved significantly. Training for RDU was then integrated into general training activities of the municipalities. Despite significant training activities, technical quality of care remained weak, and hence the effectiveness of training was questioned. Objectives: To investigate the training situation by identifying training needs and evaluating all training activities; to identify needed changes in structure and coordination of training activities. Design: Situational analysis with in-depth interviews of 19 key informants and 90 semistructured questionnaires among providers (dispensary, health center, hospital) by convenience sampling. Setting and Population: Dar es Salaam public health sector, comprising three municipal hospitals, four health centers and some 60 dispensaries; all health staff involved in service delivery as well as health management. Outcome Measures: Training received, training needed, training structure, and constraints. Results: The survey revealed that clinical training suffers from poor structure, including planning, coordination, methodology, coverage, and evaluation. Findings included small and variable coverage, random selection of trainees, no targeting of training to level of care, disadvantaged rural staff, little evaluation and follow-up, and poor coordination and recording. Among constraints, insufficient training, lack of equipment, guidelines, supervision, incentives, and staff rotation were noted. Conclusions: The original RDU training model was successful but not sustainable. Integration into the municipal health system affected training at various levels. Insufficient funding, capacity, and leadership, staff rotation, and internal and external pressures prevented successful continuation. To introduce change, consideration of the complex factors of a health system context is essential. On a human resource level, staff rotation, basic needs and work pressures, incentives, and motivation and supervision are determinants of performance. Health system and human resource management are equally important for implementing and sustaining activities. Training must be linked to the prevailing human resource context within a health care system. Following a review of study results, a policy for clinical training was elaborated by broad consultation. Tools for training coordination were developed. The policy is currently being implemented.

BACKGROUND AND SETTING  The Dar es Salaam Urban Health Project (DUHP) is aimed at structural and functional rehabilitation of public health services in Dar es Salaam, Tanzania.  One of the objectives is to improve quality of health care.  A program to promote rational drug use (RDU) was implemented and evaluated.  After a baseline drug use indicator study, Standard Treatment Guidelines (STGs) were elaborated.  A comprehensive training model was established and Standard Treatment Guidelines (STGs) were disseminated with concurrent training of all health care providers.  Compliance with STGs improved significantly.  Training for RDU was then integrated into general training activities of the municipalities.  Despite significant training activities, technical quality of care remained weak, and hence the effectiveness of training was questioned.

STUDY OBJECTIVES To investigate the training situation by  evaluating all training activities  assessing training needs and  identifying needed changes in structure and coordination of training activities.

METHODS 1  Design: Situational analysis with in-depth interviews of 19 key informants and 90 semistructured questionnaires among providers (dispensary, health center, hospital) by convenience sampling.  Setting and Population: Dar es Salaam public health sector, comprising three municipal hospitals, four health centers and some 60 dispensaries; all health staff involved in service delivery as well as health management.  Outcome Measures: Training received, training needed, training structure, and constraints.

RESULTS 1 The survey revealed  Clinical training suffers from -poor structure, including planning -weak coordination -lack of methodology -weak coverage -lack of evaluation.  Findings included -small and variable coverage -random selection of trainees -no targeting of training to level of care -disadvantaged rural staff -little evaluation and follow-up -poor coordination and recording.

RESULTS 2 The survey revealed  Lack of comprehensive training plan  Weak role of training cordinators  Constraints noted were: -insufficient training -lack of equipment -lack of guidelines -poor supervision -lack of incentives -staff rotation

RESULTS 3

RESULTS 4

INTERVENTION  Following a review of study results a policy for clinical training coordination was elaborated by broad consultation.  Tools for training coordination were developed, including: -list of providers -training calendar -training inventory -plan of operation -certificates -post training performance indicators  The policy is currently being implemented.

DISCUSSION  The initial RDU training was vertical and implemented with external technical assistance  The RDU training model was successful but not sustainable  Integration into the municipal health system affected training at various levels  Insufficient funding, capacity, and leadership, staff rotation, and internal and external pressures prevented successful continuation  On a human resource level, staff rotation, basic needs and work pressures, incentives, and motivation and supervision are determinants of performance.

CONCLUSION AND RECOMMENDATIONS  To introduce change, consideration of the complex factors of a health system context is essential  Health system and human resource management are equally important for implementing and sustaining activities  Training must be linked to the prevailing human resource context within a health care system  Integration of a vertical program into general activities needs very close follow-up, resources, capacity and political will