Europe PMC Funders Group

Author Manuscript
Br J Haematol. Author manuscript; available in PMC 2017 September 25.
Published in final edited form as:
Br J Haematol. 2017 June ; 177(6): 838845. doi:10.1111/bjh.14644.
Europe PMC Funders Author Manuscripts

Strengthening medical education in haematology and blood

transfusion: postgraduate programmes in Tanzania
Julie Makani1, Magdalena Lyimo1, Pius Magesa1, and David J. Roberts2,3
1Department of Haematology and Blood Transfusion, Muhimbili University of Health and Allied
Sciences, Dar es Salaam, Tanzania
2National Health Service Blood and Transplant, Oxford Centre, John Radcliffe Hospital, Oxford,
UK
3BRC Haematology Theme and Radcliffe Department of Medicine, University of Oxford, John
Radcliffe Hospital, Oxford, UK

Summary
Haematology and blood transfusion, as a clinical and laboratory discipline, has a far-reaching
impact on healthcare both through direct patient care as well as provision of laboratory and
transfusion services. Improvement of haematology and blood transfusion may therefore be
significant in achieving advances in health in Africa. In 2005, Tanzania had one of the lowest
distributions of doctors in the world, estimated at 23 doctors per 100 000 of population, with only
one haematologist, a medical doctor with postgraduate medical education in haematology and
blood transfusion. Here, we describe the establishment and impact of a postgraduate programme
Europe PMC Funders Author Manuscripts

centred on Master of Medicine and Master of Science programmes to build the capacity of
postgraduate training in haematology and blood transfusion. The programme was delivered
through Muhimbili University of Health and Allied Sciences (MUHAS) with partnership from
visiting medical and laboratory staff from the UK and complemented by short-term visits of
trainees from Tanzania to Haematology Departments in the UK. The programme had a significant
impact on the development of human resources in haematology and blood transfusion,
successfully training 17 specialists with a significant influence on delivery of health services and
research. This experience shows how a self-sustaining, specialist medical education programme
can be developed at low cost within Lower and Middle Income Countries (LMICs) to rapidly
enhance delivery of capacity to provide specialist services.

Keywords
blood transfusion; haematology; Tanzania; medical education

Healthcare in East Africa, as elsewhere, has been transformed over the last decades by
economic growth, widespread public health interventions and the development of health
services. These developments have yielded dramatic reductions in neonatal and childhood

Correspondence: Prof Julie Makani, Department of Haematology and Blood Transfusion, Muhimbili University of Health and Allied
Sciences, Dar-es-Salaam, Tanzania. jmakani@blood.ac.tz; jmakani@muhas.ac.tz.
 Makani et al. Page 2

mortality and the prevalence of many communicable diseases (Global Burden of Disease
[GBD] 2015 Child Mortality Collaborators, 2016). With these changes, the role of non-
communicable disease and the delivery of healthcare at secondary and tertiary level health
facilities assume greater importance, not only for individual patient care, but also to develop
and implement services and polices that reach wider populations locally, regionally and
nationally (Wang et al, 2014; GBD 2015 Maternal Mortality Collaborators, 2016).
Europe PMC Funders Author Manuscripts

Haematology and blood transfusion, as a clinical and laboratory discipline, has a far-
reaching impact on healthcare, both through direct patient care and provision of laboratory
and transfusion services. For example, the determination of haemoglobin is the most
commonly requested laboratory test in sub-Saharan Africa (Njelesani et al, 2014). More
widely, there is a need for specialist services in haematology to improve maternal and child
mortality, and the causes of illness and death due to infectious diseases, such as malaria,
human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and
tuberculosis, can be directly linked to shortfalls in haematology and blood transfusion
knowledge and services, for example, by failure to provide a timely and/or safe supply of
blood [for review see (Roberts et al, 2016)]. Indeed, it is broadly recognised that human
resources for health is a key component to improving healthcare. Improvement of
haematology and blood transfusion may therefore be significant in achieving advances in
heath in Africa.

We found that there was a significant limitation in haematology expertise and training in
Tanzania that was hindering the development of haematology services, including sickle cell
disease (SCD), haematological oncology and blood transfusion. We describe how, over a
decade, we developed training programmes in Muhimbili University of Health and Allied
Sciences (MUHAS) in Dar-es-Salaam, Tanzania (http://www.muhas.ac.tz/, last accessed 10
February 2017). This has had a significant impact on the Department of Haematology and
Europe PMC Funders Author Manuscripts

Blood Transfusion at Muhimbili National Hospital (MNH) as well as other health facilities
in Tanzania. This experience shows how a short- and long-term strategy for building the
capacity of haematology and blood transfusion services can be achieved and could be
replicated in other locations and specialties.

Development of doctors and medical training in East Africa

Health services in a tertiary hospital in Dar-es-Salaam, Tanzania
The early medical services in what is now Tanzania were provided by the German
Government and include the seminal research work of Professor Robert Koch on plague,
malaria and sleeping sickness. The Government Chemist, Gustav Giemsa, developed the
eponymous stain for malaria parasites in blood films which is still in daily use in
laboratories around the world (Clyde, 1962). Healthcare in Tanzania later developed from a
network of mission and government hospitals in the last half of the 20th century (Clyde,
1962).

Over time, healthcare in public hospitals was divided into primary, secondary and tertiary
level care. Muhimbili National Hospital (MNH) is a tertiary level health facility that is the
National Referral Hospital in Tanzania. The origins of MNH can be traced back to 1910

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 3

1920, when it was known as Sewa Haji Hospital. In 1956, the name changed to Princess
Margaret Hospital. Soon after independence in 1961, it was named Muhimbili Hospital until
1976 when it was incorporated into the Muhimbili Medical Centre (MMC; Clyde, 1962;
http://www.muhas.ac.tz/, last accessed 10 February 2017).

In 2000, MMC was separated into Muhimbili National Hospital and the Muhimbili
Europe PMC Funders Author Manuscripts

University College of Health Sciences (MUCHS). The essence of separating MMC and
MUCHS was to make MNH more efficient and for MNH and MUHAS to become
accredited centres of excellence for hospital care in Africa as well as a centre for clinical
training of medical and allied health personnel, and an acknowledged centre of medical
research in Africa. MNH is the National Referral Hospital and affiliated MUHAS Teaching
Hospital, which has 1500 beds, admitting 1000 to 1200 in-patients per day, and a weekly
outpatient attendance of 1000 to 1200 (http://www.muhas.ac.tz).

Medical School
The first medical school in East Africa was Makerere University Medical School in 1924,
which was based within the Mulago National Referral and Teaching Hospital complex,
Kampala, Uganda. In 2007 it became the Makerere University College of Health Sciences.
Several doctors from Tanzania were trained in Uganda, but local expertise began to be
developed at Dar es Salaam School of Medicine, which was established in 1963 by the
Ministry of Health with the primary aim of training clinical health staff. In 1968, the Dar es
Salaam School of Medicine was upgraded to a Faculty of Medicine of the Dar es Salaam
University College of the University of East Africa. In 1976, the Faculty of Medicine was
incorporated into Muhimbili Hospital to form the MMC (http://www.muhas.ac.tz).

In 1991, the Faculty of Medicine was upgraded to a constituent College of the University of
Dar es Salaam, with the aim of nurturing it to a fully-fledged university. In 2000, the
Europe PMC Funders Author Manuscripts

Government disestablished MMC and, as described above, created two closely-linked, but
autonomous public institutions; namely Muhimbili University College of Health Sciences
(MUCHS) and the Muhimbili National Hospital (MNH). MUCHS was a constituent College
of the University of Dar es Salaam and in 2007 became an independent university, known as
Muhimbili University of Health and Allied Sciences (MUHAS).

Over the years MUHAS has made significant achievements in terms of increased student
enrolment and development of several new academic programmes. The Department of
Haematology and Blood Transfusion was developed to be responsible for providing
diagnosis, care, consultancy and treatment for haematological disorders.

The human resource issue in haematology and blood transfusion

MUHAS is the main public institution in Tanzania responsible for training all cadres of
healthcare professionals in Tanzania. It has provided pre-service training in haematology and
blood transfusion for doctors, nurses, pharmacists and dentists as well as laboratory
technologists at undergraduate and postgraduate level. Despite this, by 2000, Tanzania had
one of the lowest doctor/patient ratios in the world, estimated at 23 doctors per 100 000 of
population. The strategy of the Ministry of Health and Social Welfare of Tanzania was to

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 4

provide adequate and competent health workers at all levels in management and health
service, and MUHAS responded to the human resource crises by increasing the number of
trainees at all levels.

However, by 2005, there was a crisis in the Department of Haematology and Blood
Transfusion, which had one qualified haematologist, retired but working on contract, three
Europe PMC Funders Author Manuscripts

specialists in internal medicine and three medical doctors requiring training in haematology.
This was the highest concentration of healthcare professionals specialising and working in
haematology and blood transfusion in Tanzania and overall the stark fact was that there was
only one trained haematologist in a country of 40 000 000 people. Quite apart from the
delivery and development of haematology services, there was a problem of delivery
regarding haematology teaching and training to all health staff.

The factors that caused failure to maintain a core of sustainable specialist staff included the
regional and international 'brain drain' of medical and nursing staff and depletion of staff
through illness, including HIV and failure to invest in medical undergraduate and
postgraduate training (Eastwood et al, 2005; Naicker et al, 2009). There was considerable
internal migration with few doctors remaining in public teaching and clinical institutions. In
addition, the focus on provision of public health and high-profile, special, vertical
programmes, such as HIV, with substantial funding that enabled good remuneration and
good working conditions, meant that Muhimbili had not been able to attract and retain staff.
Monthly wages for a medical doctor with postgraduate specialisation in a public institution
were less than $1000 dollars, while in a not-for-profit, non-governmental organisation, the
range would be $2000 - $3500 per month. These problems of internal migration that
preclude maintaining an adequate core health service cannot be underestimated.

As a consequence of all these factors, both MNH and MUHAS were not able to employ or
Europe PMC Funders Author Manuscripts

retain their staff; in 2004, MUHAS had only been able to employ 40% of the lecturers it
required to train. The failure of clinical specialities to attract trainees was also reflected in
postgraduate training, where between 1975 and 2005, 121 doctors received training in adult
and childhood diseases (Internal Medicine and Paediatrics and Child Health) while only two
had trained in haematology. In comparison, a postgraduate programme in public health,
which started in 2000, has trained 101 public health specialists (Fig 1).

Addressing the crises in haematology and blood transfusion

There was therefore an urgent need to develop and strengthen capacity in haematology and
blood transfusion, particularly as evidence emerged of the importance of human resources in
achieving the Millennium Development Goals (Chen et al, 2004). Capacity-strengthening
needed to address three main areas; training, service and research, and simultaneous actions
were required for this to be effective and to show significant impact. This need for training
requires considerable financial investment and long-term approaches to investment.
Unfortunately, this is not attractive to many funding agencies and programmes, which
require quick, short-term success. Indeed, most programmes opt to focus on one aspect with
realistic, achievable goals at the expense of the other two. For example, vertical programmes
in HIV and blood transfusion would involve the establishment of centres and clinics, with

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 5

training consisting of a series of short workshops and seminars. This approach, whilst
achieving certain goals in the short term, e.g. number of workshops conducted or the number
of clinics may not result in long-term, sustainable healthcare outcomes. This is illustrated by
maternal mortality rates where, despite relatively good indicators and conditions of maternal
healthcare (high antenatal clinic attendance rates, comparatively well-developed primary
healthcare infrastructure etc.) this has not been accompanied by a reduction of maternal
Europe PMC Funders Author Manuscripts

mortality, still estimated at 5291500 maternal deaths per 100 000 live births. It is probable
that better haematology and blood transfusion services are some of the many factors
required to improve the quality of complex clinical care needed to reduce maternal mortality.

At Muhimbili we looked to develop active programmes of undergraduate and postgraduate

training and professional development for clinical and laboratory staff. We used the training
of doctors in haematology and blood transfusion as an example to illustrate the issues that
need to be addressed. With the absence of qualified haematologists to provide the training,
one option was to send Tanzanians to train outside the country. Table I shows that this
approach would be expensive and further deplete services because it involves long periods
outside the country. In addition, it may not cover training in clinical issues that are relevant
in Tanzania. The alternative solution was based on developing strong clinical and academic
links with well-established departments outside Tanzania and would involve trainers coming
to Tanzania, complemented by Tanzanians spending short periods in well-established
departments. We therefore developed a plan built around these aims.

A new post-graduate training course in haematology and blood transfusion

MUHAS had an established three-year postgraduate training course that lead to a Master in
Medicine (MMed). Unfortunately, due to the lack of trainers, this programme could not be
offered for over 10 years. In addition, MUHAS was encouraging the development of a two-
Europe PMC Funders Author Manuscripts

year programme of super-specialisation for doctors with postgraduate degrees in internal

medicine, paediatrics or pathology. Therefore, there was an opportunity to develop a two-
year postgraduate training programme leading to a Master of Science (MSc) in Haematology
and Blood Transfusion. These two postgraduate programmes, MMed and MSc, were revised
and developed with links established with Oxford University (Prof David Roberts and Dr
Julie Glanville) and other haematologists from UK institutions, i.e., Whittington Hospital
(Dr Bernard Davies and Teresa Marlow), Great Ormond Street Hospital (Dr Amrana
Qureshi), Northwick Park Hospital (Dr Cecil Reid) and London School of Hygiene &
Tropical Medicine (Dr Sharon Cox, seconded to MUHAS).

A syllabus was developed based on the previous MMed in Haematology and incorporating
relevant areas covered in the syllabus for specialist training for the membership of the Royal
College of Pathologists for Haematology in the UK. An important part of the training
programme was to incorporate a rotation through laboratory and clinical specialties in
Tanzania as well as in the UK. There were modules on basic sciences related to haematology
and introduction to core clinical and laboratory haematology and specific modules on red
cell disorders and bone marrow failure syndromes; blood banking and transfusion medicine;
bleeding and thrombotic disorders, haematological malignancies and advanced concepts in
haematology and blood transfusion. Lectures were supplemented by seminars and case-

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 6

based discussion in all these areas. This was an active learning model and students gave case
presentations, journal club presentations and seminars, and were supervised and assessed by
senior staff.

The formal lectures and seminars were but an introduction to haematology and the core of
the course was rotation in laboratory haematology and blood transfusion, clinical
Europe PMC Funders Author Manuscripts

haematology, medicine and paediatrics. Students were actively involved in delivering

services and clinical care and had specific duties. In the laboratory, they learnt laboratory
methods with interpretation of results in routine analysis, morphology, including performing
and interpreting bone marrow analysis, coagulation and haemoglobinopathies. During
clinical rotations, they were responsible for all haematology patients in the medical and
paediatric ward, attended service and teaching ward rounds and presented patients to the
weekly Departmental case review and ward rounds. They attended general haematology and
sickle cell clinics, coagulation clinics and specialist paediatric sickle cell clinics. This
clinical component of the course was innovative for Tanzania and also in comparison with
many other courses for haematology in Africa where the focus has largely been on
laboratory work. The extensive clinical training mirrors the training of clinical
haematologists in the UK and has already allowed expansion of clinical services in
haematology, particularly in SCD and paediatric oncology.

Assessments
Students were assessed by completing log-books, continuous assessment tests, end-of-
semester examinations, including clinical and laboratory assessments and final written,
clinical and laboratory examinations. Internal moderators were recruited from other
departments in MUHAS, including paediatrics, internal medicine and pathology; external
reviewers for the final examinations are usually from universities in neighbouring countries,
for example, the University of Nairobi, Kenya
Europe PMC Funders Author Manuscripts

Development of laboratory services

As training required functioning clinical and laboratory facilities for diagnostic and
therapeutic services in haematology and blood transfusion, there were active efforts to
improve these areas. This included continuing professional development and in-service
training, training visits and short courses and workshops for specific skills, establishment of
standard operating procedures for laboratory services and management protocols for clinical
care. For example, specific workshops and visits were held for training in high performance
liquid chromatography (HPLC) testing for haemoglobinopathies and for detection and
identification of anti-red cell alloantibodies through visits of expert staff from the UK
(Teresa Marlow). This improved standards of healthcare, clinical guidelines and laboratory
operating procedures ensuring quality management through audit, evaluation and
implementation.

Research projects
One important objective of the post-graduate training was to develop and support active
programmes of high quality scientific research in the field of haematology and blood
transfusion. Areas of research that could be addressed included anaemia, SCD, haemato-

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 7

oncological conditions, coagulation and blood transfusion. In addition, it was envisaged that
insight into haematological aspects of other research programmes and health fields, e.g.
malaria, HIV/AIDS, maternal and child health, would be strengthened. The sickle cell
clinical and research project was already underway and has developed further since 2005.
The cumulative number of individuals enrolled has increased from 400 in 2005 to 4000 in
2015 (described in more detail in this issue (Tluway & Makani, 2017).
Europe PMC Funders Author Manuscripts

A key part of the overall MMed training was a short research project. Time was allocated for
preparation of proposals, submission of ethics, collection and analysis of data and report-
writing. Some funding was provided for sample collection and analysis. Topics covered
included antenatal screening for SCD, detection and analysis of alloantibodies in sickle cell
patients, the incidence and causes of anaemia in HIV and the incidence of anaemia in heart
failure. This work was valuable in its own right for learning and preparation for a role as a
specialist, which will inevitably involve assessment, commissioning and evaluation of new
services and therapies and writing local and national guidelines and policies. Some of these
projects have been published (Magesa and Magesa, 2012, 2015; Meda et al, 2014; Rwezaula
et al, 2015). Work on SCD and the treatment of iron deficiency in heart disease has led to
external funding for newborn screening for SCD and also for advanced post-graduate work
for a PhD in the field of iron deficiency and heart disease (Makubi et al, 2014, 2015, 2016).

Further developments of teaching

An initial series of lectures was delivered by visiting specialists in clinical and laboratory
haematology from the UK. At all times, it has been essential that MMed students were
actively involved in teaching undergraduates, biomedical scientists and nursing staff.
Following the graduation of the initial cohort of four MMed and MSc students, the staff of
MNH and MUHAS have given an increasing proportion of the lectures and seminars. So
now 95% of teaching is done by faculty members from Tanzania. The nucleus of clinical and
Europe PMC Funders Author Manuscripts

research work has also attracted other funding and links, and 5% of the faculty is now
supported through the American Society of Hematology health volunteers programme.

There have also been long-term haematologists joining the Department from Europe.
Initially, a specialist registrar in Haematology (Dr Julie Glanville) was able to spend six
months at MUHAS and this was an invaluable start to establishing a clinical rotation. More
recently, Professor Lucio Luzzatto (previously Head of Department at Istituto Toscano
Tumori, Florence, Italy, The Memorial Sloan-Kettering Cancer Institute, New York, USA
and the Hammersmith Hospital, London, UK) has joined the Department and is now
teaching and conducting clinical and basic science research. Furthermore, Professor
Luzzatto is working with MUHAS to develop a short one week course on Advances in
Haematology in Africa which will be provided from 2018 (see editorial in this issue
(Roberts et al, 2017).

Exchanges and secondments have not been one-way. At the start of the programme, funding
was obtained from the Association of Physicians of Great Britain, Tropical Heath Education
Trust (THET) and the Nuffield Department of Medicine, University of Oxford to fund short-
term exchanges for MMed, MSc students and senior medical, nursing and laboratory staff
with twinned Departments of Haematology at Northwick Park Hospital, the Whittington

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 8

Hospital, the John Radcliffe Hospital and National Health Service Blood and Transplant,
Oxford. These attachments for a month were necessarily limited to observing clinical and
laboratory work. However, they offered students an insight into the structure and working of
busy clinical departments in the UK. The treatments observed were naturally quite different
to those seen and available in Tanzania. However, it was clear that for visitors from
Tanzania, it was the teamwork and attention to patient care, more than any technical feature
Europe PMC Funders Author Manuscripts

or therapeutic modality that made a lasting impression.

The outcome of the programmes

Overall, 17 medical doctors have enrolled in the MMed and MSc training programmes in
Haematology and Blood Transfusion. Ten haematologists have graduated from the course
and have been joined by one haematologist trained in South Africa. A further seven students
will graduate by 2018 and so will have increased the number of trained haematologists in
Tanzania from 1 to 18 in just over a decade.

The haematologists have been able to provide comprehensive clinical care in adult and
paediatric haematology and provide consultation and laboratory haematology services for
the main teaching hospital in Dar es Salaam (MNH) and graduates from the course are
Directors of Laboratory Services and the Clinical Haematology Service at MNH. One
haematologist now works for the National Blood Transfusion Service (NBTS) where he is
the first member of the NBTS medical staff to be a trained haematologist.

The effects of the programme cascaded onto training courses for other people who work in
healthcare. MUHAS and MNH are one of the few centres in East and Central Africa to
provide formal postgraduate training in haematology and blood transfusion. The
improvement in capacity in training at Muhimbili has improved the quality of the training in
haematology and blood transfusion for other healthcare workers at undergraduate and
Europe PMC Funders Author Manuscripts

postgraduate level. Given that Muhimbili is responsible for training the largest proportion of
healthcare workers in the country, it is anticipated that there has been an overall
improvement in the calibre of people who go out and work at all levels of healthcare.

Since the course started, the population of Tanzania has increased from 40 million to 55
million, so in spite of this there still remains, in broad terms, a single haematologist for
several million people. There is clearly an enormous unmet need for haematological services
outside Dar es Salaam. Through the Ministry of Health of Tanzania and its partners, sickle
cell services have been strengthened in Dodoma, Mwanza, Kilimanjaro and Zanzibar. One of
the MMed graduates is developing the Haematology Service at Sinza Hospital, Dar es
Salaam in the Dar Region and another at the Bugando Hospital and University in Mwanza,
Tanzania (Table II).

The MMed and MSc programmes have provided the critical mass of expertise to allow
development of services and training in Tanzania. The programme was developed at
relatively little cost with approximately 35,000 of external funding (Association of
Physicians, THET, Royal Society Conference Grant and Oxford Tropical Network, Nuffield
Department of Medicine, University of Oxford) and 90,000 from a UK Department for

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 9

International Development grant to develop services and facilities to achieve the Millennium
Development Goals. The rotation of staff through hospital departments and their clinical
work has offset their stipends and salaries while they were training. There was also the
considerable advantage that the postgraduate training is directly relevant to the local clinical
conditions and the course work, through laboratory and ward work, discussions and research
projects, directly contributed to immediate and future care of patients.
Europe PMC Funders Author Manuscripts

The total cost and effort of setting up the programme has been rewarded by a self-sustaining
cadre of haematologists who can now train future postgraduate medical staff,
undergraduates, nursing staff and laboratory staff. This critical mass will now allow the
Department to chart its own course as new opportunities and priorities arise. As Tanzania
has long promoted sustainable development, it is fitting that MUHAS and MNH have built a
sustainable programme for postgraduate training.

Limitations of the programme

There were administrative and organisational hurdles to set up a clinical rotation, as this was
a new concept for a discipline that was previously seen as a laboratory specialty. However,
these were soon addressed and adding the clinical component has allowed clinical services
to expand, with the establishment of a clinical haematology unit in the Department of
Internal Medicine at MNH.

The initial concept of the programme, gaining external funding and maintaining the
programme, would perhaps have been difficult for a department that was not so actively
engaged in research work that draws on very significant external funding. However, a
substantial, but less ambitious programme, could be replicated in other specialties. There is a
pressing need in many areas among medical specialties, such as nephology and neurology,
and in other areas that are crucial for clinical care, such as anaesthesia, where there are just a
Europe PMC Funders Author Manuscripts

handful of specialists in the country. This situation is similar throughout sub-Saharan Africa.
For example, there are few nephrologists in sub-Saharan Africa, with many countries having
<1 nephrologist per million population; some have no nephrologists at all (Naicker et al,
2010).

Developing a large number of medical specialists is not the sole objective of a programme of
medical education. There must always be a concern about the concentration of medical
specialist in large centres and a uneven distribution of healthcare. This has been a perennial
problem, highlighted by the polemic and persuasive book 'Health Care for the Developing
World' by Maurice King (King, 1967) and these concerns were at the heart of the movement
for Primary Health Care and Health for All by the Year 2000, envisioned by Halfdan Mahler
and Ken Newell nearly half a century ago (Brown et al, 2016). The central element of the
Primary Health Care movement was that healthcare should be appropriate, affordable and
accountable. Development of specialist services is now relevant, achievable and has
significant impact on clinical care. It seems now that developing specialist services locally to
address the increasingly complex care of a progressively more urban population is in the
spirit of these principles (Makani & Roberts, 2016).

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 10

The programme of medical education in Haematology has benefited healthcare in Tanzania

across a broad range of areas and may be a helpful example for other locations and other
specialties.

Acknowledgements
Europe PMC Funders Author Manuscripts

This work would not have been possible without the enormous contribution in teaching from Dr Bernard Davis and
Teresa Marlow, Dr Cecil Reid, Dr Amrana Qureshi, Dr Julie Glanville, Dr Claire Hutchinson, Dr Trish Scanlan, Dr
Sharon Cox and Professor Lucio Luzzatto. We would also like to thank the medical, nursing and laboratory staff
and MUHAS and MNH who have helped to develop and support this programme, including senior university and
hospital staff, particularly Dr James Rwehabura. This work was funded by the Association of Physicians, the Royal
Society, the Royal College of Physicians, THET, Tropical Health Network at Oxford University, Department for
International Development (UK) and American Society of Hematology. The work was supported by the British
Society of Haematology, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre
Haematology Theme at Oxford University Hospitals and NHS Trust and the University of Oxford. Finally, we
would like to thank Wendy Slack for her administrative support during the programme and her careful editing.

References
Brown TM, Fee E, Stepanova V. Halfdan Mahler: Architect and Defender of the World Health
Organization Health for All by 2000 Declaration of 1978. American Journal of Public Health.
2016; 106:3839. [PubMed: 26562105]
Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, Cueto M, Dare L, Dussault G,
Elzinga G, Fee E, et al. Human resources for health: overcoming the crisis. Lancet. 2004;
364:19841990. [PubMed: 15567015]
Clyde, DF. A History of Medical Services in Tanganyika. Government Publishing House; Dar-es-
Salaam, Tanzania: 1962.
Eastwood JB, Conroy RE, Naicker S, West PA, Tutt RC, Plange-Rhule J. Loss of health professionals
from sub-Saharan Africa: the pivotal role of the UK. Lancet. 2005; 365:18931900. [PubMed:
15924988]
GBD 2015 Child Mortality Collaborators. Global, regional, national, and selected subnational levels of
stillbirths, neonatal, infant, and under-5 mortality, 19802015: a systematic analysis for the Global
Burden of Disease Study. Lancet. 2016; 388:17251774. [PubMed: 27733285]
Europe PMC Funders Author Manuscripts

King, M. Medical Care in Developing Countries. Oxford University Press; Tanzania: 1967.
Magesa AS, Magesa PM. Association between anaemia and infections (HIV, malaria and hookworm)
among children admitted at Muhimbili National Hospital. East African Journal of Public Health.
2012; 9:96100. [PubMed: 23136704]
Magesa AS, Magesa PM. Association of anaemia with micronutrient (iron, folate and vitamin B12)
deficiencies among children admitted at Muhimbili National Hospital in Dar es Salaam, Tanzania.
East African Journal of Public Health. 2015; 11:889895.
Makani J, Roberts DJ. Hematology in Africa. Hematology/Oncology Clinics of North America. 2016;
30:457475. [PubMed: 27040965]
Makubi A, Hage C, Lwakatare J, Kisenge P, Makani J, Rydn L, Lund LH. Contemporary aetiology,
clinical characteristics and prognosis of adults with heart failure observed in a tertiary hospital in
Tanzania: the prospective Tanzania Heart Failure (TaHeF) study. Heart. 2014; 100:12351241.
[PubMed: 24743164]
Makubi A, Hage C, Lwakatare J, Mmbando B, Kisenge P, Lund LH, Rydn L, Makani J. Prevalence
and prognostic implications of anaemia and iron deficiency in Tanzanian patients with heart
failure. Heart. 2015; 101:592599. [PubMed: 25539945]
Makubi A, Hage C, Sartipy U, Lwakatare J, Janabi M, Kisenge P, Dahlstrm U, Rydn L, Makani J,
Lund LH. Heart failure in Tanzania and Sweden: Comparative characterization and prognosis in
the Tanzania Heart Failure (TaHeF) study and the Swedish Heart Failure Registry (SwedeHF).
International Journal of Cardiology. 2016; 220:750758. [PubMed: 27393861]
Meda E, Magesa PM, Marlow T, Reid C, Roberts D, Makani J. Red blood cell alloimmunization in
sickle cell disease patients in Tanzania. East African Journal of Public Health. 2014; 11:775780.

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 11

Naicker S, Plange-Rhule J, Tutt RC, Eastwood JB. Shortage of healthcare workers in developing
countries Africa. Ethnicity & Disease. 2009; 19(Suppl. 1):S1-60S1-64.
Naicker S, Eastwood JB, Plange-Rhule J, Tutt RC. Shortage of healthcare workers in sub-Saharan
Africa: a nephrological perspective. Clinical Nephrology. 2010; 74(Suppl. 1):S129S133.
[PubMed: 20979978]
Njelesani J, Dacombe R, Palmer T, Smith H, Koudou B, Bockarie M, Bates I. A systematic approach
to capacity strengthening of laboratory systems for control of neglected tropical diseases in Ghana,
Europe PMC Funders Author Manuscripts

Kenya, Malawi and Sri Lanka. PLoS Neglected Tropical Diseases. 2014; 8:e2736. [PubMed:
24603407]
Roberts DJ, Field S, Delaney M, Bates I. Problems and approaches for blood transfusion in the
developing countries. Hematology/Oncology Clinics ofNorth America. 2016; 30:477495.
Roberts DJ, Cooper N, Bates I. Haematology in lower and middle income countries. British Journal of
Haematology. 2017; doi: 10.1111/bjh.14639
Rwezaula SS, Magesa PM, Mgaya J, Massawe A, Newton CR, Marlow T, Cox SE, Gallivan M, Davis
B, Lowe B, Roberts D, Makani J. Newborn screening for hemoglobinopathies at Muhimbili
National Hospital, Dar es Salaam Tanzania. East African Journal of Public Health. 2015; 12:948
955.
Tluway A, Makani J. Sickle cell disease in Africa: An overview of the integrated approach to health,
research, education and advocacy in Tanzania, 2004-2016. British Journal of Haematology. 2017;
doi: 10.1111/bjh.14594
Wang H, Liddell CA, Coates MM, Mooney MD, Levitz CE, Schumacher AE, Apfel H, Iannarone M,
Phillips B, Lofgren KT, Sandar L, et al. Global, regional, and national levels of neonatal, infant,
and under-5 mortality during 19902013: a systematic analysis for the Global Burden of Disease
Study 2013. Lancet. 2014; 384:957979. Erratum in: Lancet. (2014) 384,956. [PubMed:
24797572]
Europe PMC Funders Author Manuscripts

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 12
Europe PMC Funders Author Manuscripts

Fig 1.
Graduates from Muhimbili College of Health Sciences for MD, MMed and MPH
programmes 19962005. MD, Doctor of Medicine; MMed, Master of Medicine; MPH,
Master in Public Health; MUCHS, Muhimbili University College of Health Sciences.
Europe PMC Funders Author Manuscripts

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 13

Table I

Estimated costs for training in haematology and blood transfusion for doctors.
Europe PMC Funders Author Manuscripts

Place Qualification and Duration Duration Annual cost (estimated)

UK MRCP + MRCPath 3 years + 5 years $75 000
USA Internal medicine + haematology 3 years + 4 years $75 000
haematology/laboratory 3 years
South Africa Fellowship (pathology or medicine); certificate 4 years + 2 years $25 000
Tanzania MMed (haematology) 3 years $12 000
MMed and MSc 3 years + 2 years
West Africa Fellowship in Haematology 5 years $25 000

MMed, Master of Medicine; MRCP, Membership of the Royal Colleges of Physicians; MRCPath, Member of the Royal College of Pathologists;
MSc, Master of Science.
Europe PMC Funders Author Manuscripts

Br J Haematol. Author manuscript; available in PMC 2017 September 25.

 Makani et al. Page 14

Table II

Specialists trained in haematology and blood transfusion in Tanzania.

Europe PMC Funders Author Manuscripts

Name Degree Year of graduation

MSc Super-specialisation. 2-year programme for specialists with postgraduate degree (internal medicine, paediatrics, pathology)
1. Abel Makubi MD, MMed, MSc 2010 Haematologist, Department of Haematology, MUHAS
2. Iragi Ngerageza MD, MMed, MSc 2017
3. Mwajuma Ahmada MD, MMed, MSc 2018
MMed Super-specialisation. 3-year programme for medical doctors
4. Alex Magesa MD, MMed 2011 Head, Department of Laboratory Services, MNH
5. Stella Rwezaula MD, MMed 2011 Head, Clinical Haematology Unit, Department of Internal Medicine,
MNH
6. Elineema Meda MD, MMed 2011 Haematologist, MNH
7. Abdu Juma MD, MMed 2013 Haematologist, National Blood Transfusion Service
8. Mbonea Yonazi MD, MMed 2015 Haematologist, MNH
9. Samira Mahfudh MD, MMed 2016 Haematologist, Sinza Hospital, Dar es Salaam
10. Neema Budodi MD, MMed 2016 Haematologist, MNH
11. Clara Chamba MD, MMed 2016 Haematologist, Department of Haematology, MUHAS
12. Erius Tebuka MD, MMed 2016 Haematologist, Catholic University of Health and Allied Sciences,
Mwanza
13. Flora N. Ndobho MD, MMed 2017
14. Mwashungi Ally MD, MMed 2017
15. Oliver Isengwa MD, MMed 2017
16. Stella Malangahe MD, MMed 2017
17. Helen Tom MD, MMed 2018
Europe PMC Funders Author Manuscripts

MD, Doctor of Medicine; MMed, Master of Medicine; MNH, Muhimbili National Hospital; MSc, Master of Science; MUHAS, Muhimbili
University of Health and Allied Sciences.

Br J Haematol. Author manuscript; available in PMC 2017 September 25.