Addressing the workforce capacity for public health surveillance through field epidemiology and laboratory training program: the need for balanced enhanced skill mix and distribution, a case study from Tanzania

Introduction Skill mix refers to the range of professional development and competencies, skills and experiences of staff within a particular working environment that link with specific outcome while responding to client needs. A balanced skill-mix and distribution of core human resources is important to strengthen decision-making process and rapid responses. We analysed graduates´ information of the Tanzania Field Epidemiology and Laboratory Training Program (TFELTP) between 2008-2016, distribution of skill-mix and the surveillance workforce-gaps within regions. Methods Trainees´ data of nine cohorts enrolled between 2008 and 2016 were extracted from the program database. Distribution by sex, region and cadres/profession was carried out. An indicator to determine enhanced-skill mix was established based on the presence of a clinician, nurse, laboratory scientist and environmental health officer. A complete enhanced skill-mix was considered when all four were available and have received FELTP training. Results The TFELTP has trained 113 trainees (male=71.7%), originated from 17 regions of Tanzania Mainland (65.4% of all) and Zanzibar. Clinicians (34.5%) and laboratory scientists (38.1%) accounted for the most recruits, however, the former were widely spread in regions (83% vs. 56%). Environmental health officers (17.7%) were available in 39% of regions. The nursing profession, predominantly lacking (6.2%) was available in 22% of regions. Only two regions (11.7%) among 17 covered by TFELTP presented complete skill-mix, representing 7.7% of Tanzanian regions. Seven regions (41%) had an average of one trainee. Conclusion The TFELTP is yet to reach the required skill-mix in many regions within the country. The slow fill-rate for competent and key workforce cadres might impede effective response. Strategies to increase program awareness at subnational levels is needed to improve performance of surveillance and response system in Tanzania.


Introduction
A functional public health surveillance system is essential for improving response to public health events. One of the qualities of an effective system is competent and highly skilled human resources [1][2][3][4][5][6]. Field Epidemiology Training Programs (FETPs) have been introduced in many developing countries in sub-Saharan Africa and Asia [3,4,[7][8][9][10]. These programs were designed to create a pool of highly skilled health workers who could effectively strengthen public health surveillance and efficiently respond to public health threat including outbreaks [1][2][3]8,10]. The program was modelled after CDC Epidemic Intelligence Service (EIS) program that has been running for decades [11]. The training strategy adopted by FETP is competency-based where trainees are coached while providing services. The trainees spend over 70% of their training time in the field working and 30% of the time in class doing didactic. Since the inception of these programs, there has been remarkable improvement in disease detection and response in sub-Saharan Africa [4,5,12,13].
In 2008, Tanzania Ministry of Health started Field Epidemiology and Laboratory Training Program (TFELTP) in recognition of the need to strengthen epidemiological and surveillance capacity in the country [3]. Since then, several cadres including clinicians, laboratorians, environmental health officers, nurses, pharmacists and vetenerians were enrolled. The response to have a wide range of professions was important to strengthen management capacity to address both communicable and non communicable diseases [3].
To-date, a number of personnel with varying professions and disciplines have been trained in the program [3,6]. The program is a partnership between the Ministry of Health, Community Development,  [3]. Trainees of TFELTP are drawn from various regions of Tanzania with entry requirements covering a wide range of disciplines with two (2) years of experience [3,14,15]. That inclusion ensures continuum of mix skillful workforce needed for implementation of the Integrated Disease Surveillance and Response (IDSR) system [1,4,10,[14][15][16][17][18]. During and after the training, trainees and residents are involved in supervision and response to outbreaks in several parts of the country and internationally [5,13,14]. Thus, this training model and the design of the TFELTP, adopted from EIS [11] provides a comprehensive and extensive learning opportunities through exposing trainees to long field work experiences where challenges, multisectoral interactions, cross-sectoral collaboration and other strategies for implementing surveillance activities are acquired [1,3,9,15]. Having TFELTP graduates who have mixed skillful is thus important, as they all provide a wider scope of varying knowledge, improve the decision-making processes, and understandability of possible consequences and risks that are necessary for instituting rapid and efficient response actions [17,[19][20][21]. A balanced and a well distributed skill mix in human resources also ensures effective implementation of IDSR [16,18,[20][21][22]. Regardless of the evidence that the presence, coverage and distribution of FELTP trainees at subnational levels in number of countries [4,5,10] have improved disease surveillance and response to outbreaks and public health events, and management of health care systems [9]; there is no information on how the programs have managed to reach the required surveillance skill mix at subnational level. This paper analyses information from the Tanzania FELTP program, aim to document the distribution of TFELTP trainees, in terms of professional characteristics, and also quantifies the skill-mix that has been established at regional level since commencing of the program in 2008. The paper then quantifies the skill-mix gap required for performing core surveillance actions and, explore strategies to fill the gaps. Lessons learnt from this analysis are relevant not only to field epidemiology training programs but also to the departments responsible for implementing IDSR strategy particularly in guiding strengthening surveillance workforce. and dental surgeons (2 trainees, females) ( Table 1). Distribution of the professions in the regions is presented in Table 2

Discussion
We present here information on the status of the Tanzania FELTP in filling up the workforce for public health surveillance system at subnational levels. The program has successfully enrolled nine cohorts with over 99% of the candidates graduate each year. About two-third of the graduates are currently working at public sectors serving at districts, regions and national levels, a fifth are in the private sector including non-governmental organisations, and around three-percent in bilateral organizations (Source: TFELTP Documentation, Unpublished materials). This incredible achievement has been observed in other FETPs [5][6][7] and other applied epidemiology trainings [24]. The model of training used by FELTP provides opportunity to acquire practical skills gained at field, conducting analysis and practical involvement in surveillance activities [3,25].
"Learning by doing," maintains a spontaneity and significance that are essential to addressing the public health challenges [9,25] that discerns the abilities, capacities and capabilities of FELTP trainees during implementation. Most of TFELTP trainees were observed to be clinicians, laboratory scientists and environmental health officers.

Similar tendency has been seen in other FETPs including Kenya [26],
Jordan [27], India [7] and many more including EIS [11]. This pattern might be driven by selection criteria, (original) requirements (e.g. qualification with a Bachelor´s degree which was not always available in some professions) and national priorities, on the other hand, poor awareness of the benefits of such a training to other disciplines might be a contributing factor [26,28]. As the program grows and considering surveillance technical demands and capacity requirements at the subnational level, there is a need to establish strategies to improve awareness through sharing successes and lessons learned to create demand.
Skilled workforce and well distributed from national to subnational levels, allows prompt response to public health events [1,4,12,16,19].

A high proportion of trainees originated from Dar es Salaam region,
where the course is conducted [3], and ministries and national departments were formally located (currently moved to Dodoma). It best-placed to access good internet connection than those in upcountry. That being the case, it is important for the program to monitor such patterns and make strategies to reach applicants from remote regions, newly introduced regions, regions with financial hardships, with poor connectivity and those that have not been covered at all [4,26]. On the other hand, deliberate recruitment of national level staff may be done to strengthen the central unit, nevertheless, decentralization of responsibilities, skills and capacities at sublevels is vastly needed [26]. Impact and importance of skill mix in clinical outcomes have been studied by a number of scholars [29][30][31][32]. It has proven that, skill-mix decisions save more lives, guide proper allocation of resources and create cost-effective systems [32][33][34]. In disease surveillance and response, we expect optimal efficiency when responsible staff have similar capacity, understand roles and responsibilities and the interactions needed in expertise. Within 8-years of the TFELTP, our analyses observed gaps in enhanced-skill mix in more than half of the regions indicating a slow rate in filling complete skill mix throughout the country. Tailored strategies such as introduction of short-term training frontline public health workers might fill the observed gap [12,26,35]. In addition, there is a need to establish financial support from local sources (regions and districts health budget) for those interested to join the course. Some provinces in South Africa have been reported to pay for their staff to attend FELTP [28].
FELTP was designed to provide competency-based training for those involved in disease surveillance and response [1][2][3]. Most countries in sub-Saharan Africa had adopted and have been implementing IDSR strategy for about two decades [36]. Core aims of IDSR include training, which makes FELTP an important engine to the success of the strategy. In a recent review on challenges on implementation of IDSR, inadequate training and uneven resources (human and financial) were mentioned among the main concerns that affect almost all IDSR functions [37]. Proposed strategies to overcome this include institutionalization of IDSR training in regular public health curricula [37,38]. The FELTP advanced and intermediate courses provide an opportunity to cover this knowledge and skill gap at both hands, epidemiology and laboratory capacities, that can be extended to those working in the lower levels via a cascade model using FELTP alumni. Findings from this study have highlighted the status of enhanced skills at different professions and regions. Triangulating these results with the observed challenges in implementing IDSR, provide a relevant guidance to TFELTP on how to prioritize its focus in strengthening and filling the skill gap to maximize effectiveness of surveillance system [14,37]. Although our approach managed to map existence of enhanced skill-mix required to perform surveillance activities in regions, this study also face some limitations. First, is the assumption that having trained staff translates to competence in performance, which is not necessarily the case. However, with the scarcity of health human resources, increasing the number of health workers with acquired field and practical enhanced-skills is a critical stage in strengthening the surveillance systems and outcomes of disease outbreak responses. Secondly, the data was analysed at regional level, which in the health system structure, act as advisory and supervisory body and not day-to-day implementation level. It is possible to mask relevant findings that could be observed if data were disaggregated at fine spatial scales. A retrospective longitudinal analysis on performance of surveillance indicators at district level is highly recommended.

Conclusion
In summary, the Tanzania FELTP has strengthened the skills, technical knowhow and capacities of surveillance workforce in the country.
However, the program is yet to reach the required skill mix ratio in many regions in the country, despite its establishment in 2008. The slow fill rate for competent workforce might impede effective response. The program should take initiatives to involve more local stakeholders, at subnational health authorities and to create awareness on benefits of the program to improve applications, sustainability and maintain equitably distribution of skilled workforce hence performance of surveillance system in Tanzania.

What is known about this topic
• There is a clear evidence on improvement on effectiveness of public health surveillance systems in countries with established FELTPs; • Trainees from the FELTPs have been a strong hold for the epidemiological aspects of many countries indicating competence and enhanced skills when responding to public emergencies.

What this study adds
• A clear need to evaluate and monitor performance of the FELTPs on strengthening and creating a sustainable public health workforce; • Highlights gaps, and emphasizes on need to strengthen networks, continuing awareness of the programs and importance of skill-mix in surveillance workforce; • Introduce an easy tool which can be linked with other aspects to monitor effectiveness of surveillance system in countries.
database for the trainees. We thank Mr. Evord Kimario of the National Institute for Medical Research, for his assistance in the production of the maps. We are grateful for the financial support received from AFENET on supporting scientific writers and provision of technical support to the FELTP.