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PLoS One. 2017 Oct 17;12(10):e0186074. doi: 10.1371/journal.pone.0186074. eCollection 2017.

Continuing professional development for medical, nursing, and midwifery cadres in Malawi, Tanzania and South Africa: A qualitative evaluation.

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International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America.
Department of Global Health, University of Washington, Seattle, WA, United States of America.
School of Nursing, University of Washington, Seattle, WA, United States of America.
Department of Medicine, University of Washington, Seattle, WA, United States of America.
Department of Epidemiology, University of Washington, Seattle, WA, United States of America.
Training for Health Equity Network (THEnet), New York, NY, United States of America.
School of Health Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
Commonwealth Nurses and Midwives Federation, London, United Kingdom.



As innovations in the prevention and treatment of HIV and TB advance, continuing professional development (CPD) of health care workers (HCWs) remains a high priority, particularly in sub-Saharan Africa where dual TB/HIV epidemics are compounded by severe HCW shortages. There is further need to examine CPD programs to identify challenges and effective solutions to strengthen HIV/TB-related CPD.


Qualitative evaluations in Malawi, Tanzania and South Africa (RSA) were conducted using key informant interviews (KIIs) and focus group discussions (FGDs) in each country to identify barriers and enablers of effective HIV/TB-related CPD. Key stakeholders represented CPD implementers, regulators, and developers. HCWs were purposively sampled from high disease burden districts; each HCW completed brief, semi-structured questionnaires and participated in a FGD. KII and FGD results were combined into key themes spanning across countries using a grounded theory approach.


Fifty-two KIIs were conducted: 17 in Malawi, 19 in Tanzania and 16 in RSA. Eighty-nine HCWs (24 from Malawi, 38 from Tanzania and 27 from RSA) completed questionnaires and participated in FGDs. Primarily, lack of sustainable financial resources and limitations in coordination of CPD result in poor accountability for CPD oversight and reduce CPD quality assurance. Healthcare worker shortages limit CPD opportunities, creating disparities in CPD access. CPD irrelevance and imbalance between HCW-identified CPD needs and current programs reduce enthusiasm for CPD. Facility-level constraints, including poor infrastructure and weak supply chains, restrict implementation of CPD skills and knowledge. Challenges are more severe in rural settings.


To address identified gaps, sustainable funding, strong leadership and collaboration at every level are needed to strengthen CPD regulation and accreditation systems; increase CPD accessibility in the workplace; and create enabling environments for CPD implementation. Together, these improvements may improve TB/HIV CPD quality and patient outcomes.

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