In 2020, I was part of a research team that conducted a baseline survey commissioned by World Vision Tanzania in two division in Karatu district, Arusha region. We visited health facilities, mainly dispensaries and health centers. I witnessed a critical shortage of healthcare workforce. Some of the health facilities were run by nurses alone. There is a critical shortage in all levels and its impact on healthcare cannot be overstated.

I am a Medical Doctor and General surgeon; my work is nothing if nurses are not there. They play an important role in patient care. To recognize their invaluable efforts and tireless work globally, we all celebrate and mark Nurses Day every May 12. Their role in healthcare and global healthcare security is cherished and celebrated worldwide. This year in Tanzania it was celebrated and observed nationally in Moshi town, Kilimanjaro.

A day among many days in a year, nurses take time out of hospitals and other health facilities and reflect on the yearlong service on patient care. They contemplate on a number of issues, including policy and practice. They always engage the community and government. This year, the Prime Minister was invited as the Guest of Honor. He was represented by Dr. Dorothy Gwajima, the Minister for Community Development, Gender, Women and Special Groups. The theme for this year was about investing in nursing care and respecting rights to secure global health.

Before I take you further, I would like to remind you who is a nurse and what is the nursing profession. A nurse is a healthcare professional with a duty of taking care of a patient. It is one of the trusted professions with a number of activities that forms the heartbeat of healthcare. To become a nurse, someone needs both a certain level of nursing education (a certificate, diploma, or degree) and license from the nursing board or regulatory council. In general, nowadays a nursing role is being expanded to include educating, advocacy, counselling, and research.

In a nutshell, the majority of Tanzanian nurses are general nurses. They always organize outpatient clinics, dispense medication, and take care of inpatient. General nurses also observe the wellbeing of patients through vitals taking, conduct delivery, wound dressing, putting an Intravenous cannula, and prepare and port patients to and from ward and service delivery like theatre and radiology.

Nurses play a critical role in preparation of medical devices, collect patient samples to Lab, clean and bath patients, supervise hospital cleanness, run night supervision, and undertake the role administration during the nights. They also prepare a patient for referral or a dead body for mortuary. Lastly but not least, they discharge doctors order and participate in making clinical decisions during a ward round like stopping or changing medication, recommending transfer or surgical procedures and many other things as directed by attending doctors.

In Tanzania there are different levels of nurses. There are: (1) community nurses, they undergo one year training and are commonly known as medical attendants; (2) Enrolled Nurses (EN) with two years certificate; and (3) Registered Nurses (RN), they do at least a three-year diploma. After earning their diploma, some will go for Bachelors, Masters, and PhDs in nursing and eventually professorial status. There are other channels to some few nursing specialties like ophthalmology, psychiatry, pediatric, anesthesia, and critical care. After a period of training, it is the Tanzania Nursing and Midwifery Council (TNMC) that registers and license them. 

There are several nursing associations in Tanzania. The notable one is the Tanzania Nursing Association (TANNA). Their duty is to promote nursing affairs countywide. There have also been several reforms in Tanzania since independence, ranging from decolonization/Africanization of nursing practice to adjusting the practice to fit universal health coverage policy.

In Tanzania there are around 47,000 nurses and midwives combined (probably the largest healthcare workforce in the country), and there is approximately one nurse/midwife ratio per 1,400 population. This is a slight improvement from “31,618 nurses and midwives” with about “one nurse or midwife ratio per 1,374 population” from four years ago. The WHO recommends one nurse/midwife per 500 population. In other words, nurses in Tanzania are few than it is supposed to be and work ten times than their counterpart in developed countries.

This ratio in rural Tanzania is much higher than the urban. TANNA reports indicate that the nurse-to-patient ratio in public health facilities is around 1:20 against the WHO recommendations of 1:8. One should keep in mind the increasing population and the double health burden of both communicable and non-communicable diseases.

We have all witnessed the government efforts in building infrastructure for healthcare delivery. The primary healthcare policy strategy of every village to have a dispensary and every ward to have a health center has received a significant implementation since 2006. District hospitals and other reforms to form regional referral hospitals have widened the scope of healthcare infrastructure. Special hospitals and consultant hospitals have been expanded and received an addition of new services like dialysis, cancer care, transplant services, and emergency units. The nursing profession, however, hasn’t grown to match the recent and upcoming development.

These poor nurse-to-patient ratio and lack of significant growth in the nursing profession can be translated to poor performance and low quality of healthcare services delivered by nurses in the country. I want to believe almost all the challenges that overwhelmingly face the healthcare are contributed by the shortage of healthcare personnel with poor ratios. And, in the wake of COVID 19, we have learnt the hard way the role of resilient healthcare systems with adequate staffing of our health facilities.

I hold a view that the challenges of the nursing profession, apart from the long working hours with associated burnout and eventually low quality, includes the following:

1. Poor working facilities, currently in our country we still have patients admitted in hospitals where they sleep on the floor, 2-3 patients share a hospital bed.

2. Lack of customer care practices and training, currently nurses experience significant friction with patients during their service just by lacking some customer/client care skills.

3. Lack of specialized nursing training. I am aware training for theatre nurses in Mbeya Tanzania was ceased. A general nurse won’t be efficient to do a specialized care. We need an expansion of nursing education to offer specialization like surgical nursing, dialysis nursing, pediatric and neonatology nursing, oncology nursing, and transplant. The same for cardiothoracic, and many other subspecialties of medicine.

4. Motivation (remuneration and recognition) should be taken into consideration, otherwise corruption and other forms of poor performance will mutate daily without forgetting paying them risk allowances on top of other fiscal and non-fiscal motivation packages.

5. Investing in the nursing profession and care is crucial. We all witnessed the COVID-19 financial support in building resilient healthcare (ICU rooms being built and equipped), yet we haven’t seen development of nursing staff who will nurse the patients in the constructed ICUs. This is something that should be looked into promptly and seriously. The government, as a major stakeholder, employer, and custodian of standards of the nursing profession, should create an enabling environment for such investment to happen. Improve and modernize both nursing training and practice. Give them capacity, instill confidence, patriotism, and mastery of the nursing profession. Transforming knowledge-based to competence-based nursing education, benchmark standards of nursing care to the middle-and higher-income countries.

I propose structures and commitments of all stakeholders to transform the current nursing care and mold it to fit the current healthcare needs and standards. Setting aside resources is a steppingstone to nursing care improvement in our country. Sidelining it means strategically ignoring the healthcare safety and quality to more than 60 million Tanzanian countrymen and women.

I conclude my reflection on the nursing profession by an African proverb, which says “a bird that flies off the earth and land on an anthill is still on the ground” meaning we should raise our standards and investments in nursing care and profession in Tanzania since it’s not only the heartbeat, but also the backbone of healthcare in our country.