Successful surgical excision of the accessory urethra in a 13-year-old boy with Effmann Type IIA-2 urethral duplication. Case report and literature review.

INTRODUCTION AND CLINICAL IMPORTANCE: Urethral duplication is a congenital anomaly characterized by the partial or full development of an auxiliary urethra as a second urethral channel varying in extent and location. The course of treatment for urethral duplication should be individualized for each patient based on the type of anomaly and the existence of symptoms. In most cases, if the ventral orthotopic urethra is normal, excision of the dorsal auxiliary urethra is almost always curative. CASE PRESENTATION: We report a case of a 13-year-old boy who presented with recurrent urinary tract infection, occasionally having drops of urine at an external pin hole meatal opening on the dorsum of the penile shaft. Several investigations were performed to confirm the presence of the dorsal accessory urethra. The patient underwent complete excision of the accessory urethra, and 12 weeks post-surgery the patient was completely asymptomatic. DISCUSSION: Urethral duplications are rare anomalies. These anomalies have been classified in various ways in the literature, including sagittal and lateral duplications, dorsal and ventral duplications. The sagittal plane is where the majority of urethral duplications occur. Based on the anatomic variation, clinical presentation and severity of the anomaly, urethral duplication treatment should be customized for each patient. An asymptomatic child may require no specific treatment. Total surgical excision of the dorsal accessory urethra appears to offer the best curative solution. CONCLUSION: Excision of the dorsal accessory urethra is usually curative when the ventral orthotopic urethra is normal. Thorough investigation before surgery is mandatory to determine the type of urethral duplication. The most common diagnostic procedures for urethral duplications include cystoscopy, KUB ultrasonography, and micturating cystourethrography. These procedures can help plan surgery, prevent complications such as neurovascular bundle injuries and urine incontinence, and improve patient self-esteem and quality of life.

Surgical excision of acquired urethral diverticulum and single-stage urethroplasty for a 32-year-old male. Case report and literature review.

INTRODUCTION: Urethral diverticulum (UD) is a saccular dilatation of the urethral wall, continuous with the true urethral lumen. It is categorized etiologically into congenital and acquired. The etiology of an acquired urethral diverticulum is thought to be secondary to trauma. The gold standard imaging modalities for diagnosis of UD are retrograde urethrogram (RGU) and micturating cystourethrogram (MCU). Management options include: nonoperative treatment, minimally invasive and open surgeries. Open surgeries comprise a primary anastomosis or, Substitution urethroplasty after UD excision, with the aim of excising the diverticulum, reestablishing the continuity of the urethra, and prevent urethrocutaneous fistula formation. We present a case of urethral diverticulum and bulbar urethral stricture successfully managed by surgical excision of UD and substitution urethroplasty. CASE PRESENTATION: We report a case of a 32-year-old man who had lower urinary tract symptoms following a traumatic urethral catheterization. Investigations done in a peripheral hospital revealed a short, bulbar urethral stricture and direct visual internal urethrotomy (DVIU) was done. Later he presented to us with urine retention, whereupon emergency suprapubic cystostomy was performed. After serial investigations, urethral diverticulectomy followed by single stage urethroplasty with ventral onlay buccal mucosa graft was done. He was followed for 12 months with good surgical outcome. DISCUSSION: The development of Acquired UD has been attributed to several possible factors: pelvic fractures, urethral strictures, straddle injuries, long-term urethral catheterization, endoscopic direct injuries, lower urinary tract infections, and urethral surgeries. Depending on the presentation and investigation findings, management of UD is planned. Conservative management is possible for uncomplicated asymptomatic UD if the patient consents to follow-up. Surgery to remove the diverticulum and urethral reconstruction are required for complicated symptomatic UD; these procedures vary from patient to patient and are individualized. CONCLUSION: It is important to base the choice to do surgery on the clinical presentation. Whether a concurrent urethral stricture is present is a critical factor in deciding on the best course of surgical treatment. In our case we opted to perform a substitution urethroplasty with ventral onlay buccal mucosa graft as our patient had a long bulbar urethral stricture proximal to the diverticulum.

Advanced prostate cancer with brain metastasis presenting with isolated severe headache without urinary symptoms.: Case report and literature review.

INTRODUCTION AND CLINICAL IMPORTANCE: Brain metastases from prostate cancer are uncommon, occurring in fewer than 1 % of cases of metastatic prostate cancer. Brain metastasis can cause cerebral edema, neurologic symptoms, and may be misdiagnosed as primary brain tumors on imaging if thorough investigations are not done. It is difficult to identify and diagnose brain metastasis from prostate cancer since the intracranial metastatic process and presentation are poorly understood and limited to case studies. Most patients with brain metastases from prostate cancer exhibit a variety of metastatic symptoms; however, this patient's presentation was defined by only isolated intense headache. Our goal is to draw attention to the uncommon instance of brain metastases from prostate cancer in addition to reviewing the literature on the advances in treatment for prostatic cancer with metastasis to the brain. CASE PRESENTATION: We report the case of a 67-year-old male with metastatic prostate adenocarcinoma into the brain, presenting with isolated severe headache with no prostate cancer symptoms. Following extensive radiologic examination, metastatic deposits were detected in the left side of the brain with multiple intracerebral and cerebellar vermis lesions. Multiplanar T2 weighted abdominal pelvic MRI visualized the primary lesion in the prostate which was confirmed by histology. After a month following surgical castration, the patient reported resolved headache and resumed his daily activities. The patient's serum PSA decreased from 7.8 ng/ml to 0.3 ng/ml during a 12-months follow-up with no neurological symptoms. CLINICAL DISCUSSION: Prostate cancer rarely causes brain metastases, and the percentage of all brain metastases that originate from prostate cancer is seldom updated. It can be difficult to distinguish between primary brain lesions and metastatic brain prostate cancer, particularly when there is just one lesion present. Despite the recently developed diagnostic approaches, symptomatic patients exhibit a variety of clinical manifestations that vary depending on the location of the metastatic focus. These manifestations include headache, seizures, and focal neurological deficits, in addition to some common non-focal manifestations like confusion and memory deficits. Our patient had a PSA of 7.8 ng/ml at the beginning and the DRE results were normal, clinically prostate cancer was not thought to be the main cause of brain metastasis. Abdominal pelvic MRI was performed to investigate the primary lesion and confirmed the presence of prostate cancer with extra prostatic extensions. Adenocarcinoma prostate cancer was found to be the main cause when histopathology was done. CONCLUSION: This report reviews the literature on brain metastases from prostate cancer and points out that while very rare, brain metastases from prostatic cancer do occur and should not be overlooked, particularly in light of the recent advancements in prostatic cancer therapies that may extend the patient's survival. Gadolinium-enhanced MRI is necessary to confirm or rule out brain metastases if it is suspected, as well as to monitor prostate cancer patients.

Isolated testicular tuberculosis mimicking testicular malignancy in a 45-year-old male treated at a tertiary hospital. Case report and literature review.

INTRODUCTION AND IMPORTANCE: Tuberculosis is prevalent in African countries especially in sub-Saharan Africa where HIV/AIDS is common. While Testicular tuberculosis is uncommon in the young as well as the elderly, pulmonary tuberculosis is commonly observed in these populations. History, physical examination, scrotal ultrasonography, and fine needle biopsy are important in diagnosis of suspected cases of testicular tuberculosis. Anti-TB therapy is the mainstay of treatment to ensure complete resolution of the lesion. However, in a few cases, orchidectomy is required for both diagnosis and treatment. When treating testicular tuberculosis, it is crucial to do a thorough assessment and investigations to exclude testicular malignancy because tuberculosis can present similarly to a testicular tumor. CASE PRESENTATION: We report a rare case of right sided isolated testicular tuberculosis in a 45-year-old male who came with right sided testicular pain and swelling. Blood workups and testicular tumor markers were all normal, scrotal ultrasound reported right heterogenous testicular mass with avascular areas of necrosis and septated fluid collections in the tunica vaginalis with features suggestive of testicular tumor. Right orchiectomy through inguinal approach was done, findings included testicular mass with pus pockets and caseous necrosis occupying the whole testis. Specimen was sent for histopathology which revealed chronic granulomatous inflammation, most likely tuberculosis, and ZN stain confirmed the diagnosis of testicular tuberculosis. In accordance with national TB guidelines, the patient had anti-TB medication for six months, and after 12-months serial follow-up, the patient had completely recovered. CLINICAL DISCUSSION: Genitourinary tuberculosis is the second most common form of extrapulmonary TB after lymph node tuberculosis. 0.5 % of genitourinary TB involves the testes; On the other hand, isolated testicular TB as presented in our patient, is extremely uncommon, thus may mimic other testicular conditions including testicular tumor, so the diagnosis is challenging. It is important to accurately diagnose testicular TB and differentiate it from other scrotal pathologies especially testicular malignancy as the management is totally different. Testicular tuberculosis is diagnosed by tissue Cytology using FNAC or after an orchidectomy. It requires early, regular, full course combined anti-tuberculosis treatment. The drug treatment method uses three to four anti-tuberculosis drugs for 6-9 months. Surgical treatment is necessary if there is no response to drug treatment or in cases of abscess formation. CONCLUSION: Testicular TB is a curable disease, but its diagnosis remains challenging. It is often missed owing to its non- specific symptoms. Thus, testicular TB should be suspected in patients with a notion of contagion or history of tuberculosis. Some of the radiological features are highly suggestive of testicular TB. FNAB could prevent unnecessary orchidectomy. In our case, the presentation was typically mimicking a testicular cancer and the patient underwent trans inguinal orchiectomy, and histology and ZN stain confirmed the diagnosis followed by subsequent six-month anti TB therapy.

A rare case report of ectopic-adrenal paraganglioma with inferior vena cava infiltration. Case report and literature review.

INTRODUCTION AND IMPORTANCE: Phaeochromocytomas are neuroendocrine neoplasms arising from chromaffin cells of the adrenal medulla and are known as intra-adrenal paragangliomas. On the contrary, paragangliomas are non-epithelial neuroendocrine neoplasms that produce other peptide hormones such as norepinephrine, epinephrine, and dopamine. In a setting with limited resources, such a condition may result in inaccurate diagnosis and treatment, which may lose a patient life if left untreated. In addition, PPGLs present a surgical challenge to many surgeons who are not thoroughly prepared. CASE PRESENTATION: We describe a case of extra-adrenal paraganglioma in a 27-year-old female who presented with symptoms of heartbeat awareness for almost a year and abdominal swelling for three months. Physical examination revealed a palpable mass around the umbilicus. Abdominal pelvic CT scan revealed a well-circumscribed mass in the central retroperitoneum displacing the IVC laterally and abdominal aorta medially with no invasion of surrounding structures. Results for pheochromocytoma workup showed elevated levels of 24-h urine Vanillylmandelic acid (VMA), and 24-h metanephrine excretion. Laparotomy through extended midline incision was done with successful excision of the tumor. The blood pressure, which was initially high normalized after surgery. DISCUSSION: The diagnosis of a malignant EAP is commonly made based on recurrence and the development of metastasis to lymph nodes or to other organs. Our patient presented with similar symptoms as pheochromocytoma. Compared to the commonly stated 10 % risk for pheochromocytomas, people with EAPs have been observed to have a 20 % to 50 % incidence of malignancy. EAPs account for at least 15 % of adult and 30 % of pediatric pheochromocytomas and are frequently found in the Zuckerkandl organ. Pheochromocytoma symptoms may manifest asymptomatically in patients with EAPs, or they may occur because of compression of nearby tissues. Surgical excision of the tumor is always the best option in managing EAP. CONCLUSION: Extra-adrenal paragangliomas can be successfully managed surgically, provided there is a multidisciplinary team, and the tumor location is well recognized and can reduce the chance of tumor metastasis.

"A successful reconstruction of remnants of corporal bodies and penile urethra after Total Glans Penis amputation following surgical circumcision in a 5-year-old boy". A case report and literature review.

INTRODUCTION AND IMPORTANCE: Circumcision is the most common surgical procedure done in boys. Its complication varies from minor to severe. In most of African countries circumcision is often performed by traditional circumcisers. The management of penile glans amputation depends on the duration before presentation with auto-transplantation being the favorable management in acute phase of presentation. The amputation of the glans is a serious complication of circumcision because it can derange the urinary and sexual functions of a patient and may lead into psychological instability and low self-esteem. CASE PRESENTATION: We report a case of total glansectomy in a 5-year old boy who presented 12 months after surgical circumcision which was done by inexperienced medical personnel at his house. Patient presented with a pinhole urethra opening, missing glans, buried phallus with remnants of corporal bodies. Penile exploration was done, with successful significant phallus stump of about 5 cm, phallus reconstruction and meatoplasty was achieved. Partial Skin thickness grafting of the phallus stump was performed. At six- month follow up, the patient had both satisfactory cosmetic and functional outcomes. CLINICAL DISCUSSION: Total glansectomy is a rare surgical emergency with auto transplantation being the best option in acute management however successful outcome for a delayed glansectomy depends on proficient surgical penile exploration and comprehensive post operative care. Based on the clinical presentation, the goals of management for our patient were to achieve a largely patent urethral opening in the long term and to prevent further urethral meatal stenosis as well as achieving adequate phallus stump for sexual function. CONCLUSION: The amputation of the glans is a serious complication of circumcision because it can derange the urinary and sexual functions of a patient if neglected. Findings on this case report highlight the importance of raising awareness among traditional health care workers to prevent urinary and sexual function disabilities. Prevention of penile amputation can be prevented by providing proper training for circumcisers and providing public education for hospital circumcision.

Nonacademic Attributes Predict Medical and Nursing Student Intentions to Emigrate or to Work Rurally: An Eight-Country Survey in Asia and Africa.

AbstractWe sought to identify independent, nonacademic predictors of medical and nursing student intent to migrate abroad or from rural to urban areas after graduation in low- and middle-income countries (LMIC). This was a cross-sectional survey of 3,199 first- and final-year medical and nursing students at 16 training institutions in eight LMIC. Questionnaires assessed demographics, career intentions, and preferences regarding selected career, location, and work-related attributes. Using principal component analysis, student preferences were reduced into four discrete categories of priorities: 1) work environment resources, 2) location livability, 3) altruistic job values, and 4) individualistic job values. Students' preferences were scored in each category. Using students' characteristics and priority scores, multivariable proportional odds models were used to derive independent predictors of intentions to emigrate for work outside the country, or to work in a rural area in their native country. Students prioritizing individualistic values more often planned international careers (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI] = 1.16-1.78), whereas those prioritizing altruistic values preferred rural careers (aOR = 1.82, 95% CI = 1.50-2.21). Trainees prioritizing high-resource environments preferentially planned careers abroad (aOR = 1.38, 95% CI = 1.12-1.69) and were unlikely to seek rural work (aOR = 0.60, 95% CI = 0.49-0.73). Independent of their priorities, students with prolonged prior rural residence were unlikely to plan emigration (aOR = 0.67, 95% CI = 0.50-0.90) and were more likely to plan a rural career (aOR = 1.53, 95% CI = 1.16-2.03). We conclude that use of nonacademic attributes in medical and nursing admissions processes would likely increase retention in high-need rural areas and reduce emigration "brain drain" in LMIC.

Where teachers are few: documenting available faculty in five Tanzanian medical schools.

BACKGROUND: Faced with one of the lowest physician-to-population ratios in the world, the Government of Tanzania is urging its medical schools to train more physicians. The annual number of medical students admitted across the country rose from 55 in the 1990s to 1,680 approved places for the 2015/16 academic year. These escalating numbers strain existing faculty. OBJECTIVE: To describe the availability of faculty in medical schools in Tanzania. DESIGN: We identified faculty lists published on the Internet by five Tanzanian medical schools for the 2011/12 academic year and analyzed the appointment status, rank, discipline, and qualifications of faculty members. RESULTS: The five schools reported 366 appointed faculty members (excluding visiting, part-time, or honorary appointments) for an estimated total enrolled student capacity of 3,275. Thirty-eight percent of these faculty were senior lecturers or higher. Twenty-seven percent of the appointments were in basic science, 51% in clinical science, and 21% in public health departments. The most populated disciplines (more than 20 faculty members across the five institutions) were biochemistry and molecular biology, medicine, obstetrics and gynecology, pediatrics, and surgery; the least populated disciplines (less than 10 faculty members) were anesthesiology, behavioral sciences, dermatology, dental surgery, emergency medicine, hematology, ophthalmology, orthopedics, otorhinolaryngology, oncology and radiology, psychiatry. These figures are only indicative of faculty numbers because of differences in the way the schools published their faculty lists. CONCLUSIONS: Universities are not recruiting faculty at the same rate that they are admitting students, and there is an imbalance in the distribution of faculty across disciplines. Although there are differences among the universities, all are struggling to recruit and retain staff. If Tanzanian universities, the government, donors, and international partners commit resources to develop, recruit, and retain new faculty, Tanzania could build faculty numbers to permit a quality educational experience for its doctors of tomorrow.

Identity formation and motivation of new faculty developers: A replication study in a resource constrained university.

INTRODUCTION: Previous studies on the identity development and motivation of faculty developers have occurred with seasoned developers in a research-rich environment. We sought to determine if the findings of those studies could be replicated with novice faculty developers in a resource-constrained environment. METHODS: We interviewed 15 novice faculty developers from Muhimbili University of Health and Allied Sciences (MUHAS) who, at the time, had led faculty development activities for no more than two years. We conducted a qualitative analysis sensitized by the previous findings. RESULTS: Results were very similar to the previous work. The developers described compartmentalized, hierarchical, and merged identities. The impact was on their teaching as well as on others at MUHAS and on the institution itself. The motivations related to mastery, purpose, duty, satisfaction, and relatedness. CONCLUSION: This replication led us to conclude that identity development as a faculty developer occurs even in novice developers who do faculty development as only part of their work and despite constrained resources and a different culture. These developers find the work richly rewarding and their motivations benefit the institution. This body of research highlights how faculty development provides benefits to the institution as well as engaging career opportunities.

Medical and nursing students' intentions to work abroad or in rural areas: a cross-sectional survey in Asia and Africa.

OBJECTIVE: To assess medical and nursing students' intentions to migrate abroad or practice in rural areas. METHODS: We surveyed 3199 first- and final-year medical and nursing students at 16 premier government institutions in Bangladesh, Ethiopia, India, Kenya, Malawi, Nepal, the United Republic of Tanzania and Zambia. The survey contained questions to identify factors that could predict students' intentions to migrate. Primary outcomes were the likelihoods of migrating to work abroad or working in rural areas in the country of training within five years post-training. We assessed predictors of migration intentions using multivariable proportional odds models. FINDINGS: Among respondents, 28% (870/3156) expected to migrate abroad, while only 18% (575/3158) anticipated a rural career. More nursing than medical students desired professions abroad (odds ratio, OR: 1.76; 95% confidence interval, CI: 1.25-2.48). Career desires before matriculation correlated with current intentions for international (OR: 4.49; 95% CI: 3.21-6.29) and rural (OR: 4.84; 95% CI: 3.52-6.66) careers. Time spent in rural areas before matriculation predicted the preference for a rural career (20 versus 0 years: OR: 1.53, 95% CI: 1.19-1.98) and against work abroad (20 versus 0 years: OR: 0.69, 95% CI: 0.50-0.96). CONCLUSION: A significant proportion of students surveyed still intend to work abroad or in cities after training. These intentions could be identified even before matriculation. Admissions standards that account for years spent in rural areas could promote greater graduate retention in the country of training and in rural areas.

Manual laparoscopic skills development using a low-cost trainer box in Tanzania.

OBJECTIVES: To explore the feasibility and effectiveness of guided practice using a low-cost laparoscopic trainer on the development of laparoscopic skills by surgeons in a resource-poor setting. DESIGN: This was a prospective trial involving a pretest/posttest single-sample design. Study participants completed a background survey and pretest on the 5 McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) tasks using a simulator developed and validated by researchers from the University of California, San Francisco. On completion of a 3-month guided practice course, participants were again tested on the MISTELS tasks and completed an exit survey. SETTING: The Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania. PARTICIPANTS: Fourteen Tanzanian surgery residents and specialists completed the study. RESULTS: Most of the subjects were surgical residents (64.3%). Only 2 participants (14.2%) had previous laparoscopic training, and baseline laparoscopic surgical experience was limited to intraoperative observation only. Study subjects practiced the MISTELS tasks for an average of 8.67 hours (range: 4.75-15.25) over the 3-month course. On the posttest, participants improved significantly in performance of each of the MISTELS tasks (p < 0.001). Total scores on the tasks increased from 24 ± 44 on the pretest to 384 ± 49 on the posttest (p < 0.001). All study participants were satisfied with the course, found the training personally valuable, and felt that their laparoscopic skills had improved on completion of the training. CONCLUSIONS: We have demonstrated the feasibility and effectiveness of training with a low-cost laparoscopic trainer box in Tanzania. Study participants achieved impressive posttest scores on the 5 MISTELS tasks with minimal baseline laparoscopic exposure. We feel that guided training by an expert was key in ensuring correct technique during practice sessions.

Surgical task-shifting in a low-resource setting: outcomes after major surgery performed by nonphysician clinicians in Tanzania.

BACKGROUND: Little is known about the breadth and quality of nonobstetric surgical care delivered by nonphysician clinicians (NPCs) in low-resource settings. We aimed to document the scope of NPC surgical practice and characterize outcomes after major surgery performed by nonphysicians in Tanzania. METHODS: A retrospective records review of major surgical procedures (MSPs) performed in 2012 was conducted at seven hospitals in Pwani Region, Tanzania. Patient and procedure characteristics and level of surgical care provider were documented for each procedure. Rates of postoperative morbidity and mortality after nonobstetric MSPs performed by NPCs and physicians were compared using multivariate logistic regression. RESULTS: There were 6.5 surgical care providers per 100,000 population performing a mean rate of 461 procedures per 100,000 population during the study period. Of these cases, 1,698 (34.7 %) were nonobstetric MSPs. NPCs performed 55.8 % of nonobstetric MSPs followed by surgical specialists (28.7 %) and medical officers (15.5 %). The most common nonobstetric MSPs performed by NPCs were elective groin hernia repair, prostatectomy, exploratory laparotomy, and hydrocelectomy. Postoperative mortality was 1.7 % and 1.5 % in cases done by NPCs and physicians respectively. There was no significant difference in outcomes after procedures performed by NPCs compared with physicians. CONCLUSIONS: Surgical output is low and the workforce is limited in Tanzania. NPCs performed the majority of major surgical procedures during the study period. Outcomes after nonobstetric major surgical procedures done by NPCs and physicians were similar. Task-shifting of surgical care to nonphysicians may be a safe and sustainable way to address the global surgical workforce crisis.

Partnering on education for health: Muhimbili University of Health and Allied Sciences and the University of California San Francisco.

In 2005, Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania and the University of California San Francisco (UCSF) in the United States joined to form a partnership across all the schools in our institutions. Although our goal is to address the health workforce crisis in Tanzania, we have gained much as institutions. We review the work undertaken and point out how this education partnership differs from many research collaborations. Important characteristics include: (i) activities grew out of MUHAS's institutional needs, but also benefit UCSF; (ii) working across professions changed the discourse from 'medical education' to 'health professions education'; (iii) challenged by gaps in our respective health-care systems, both institutions chose a new focus, interprofessional team work; (iv) despite being so differently resourced, MUHAS and UCSF seek strategies to address growing class sizes; and (v) we involved a wider range of people - faculty, administrators, students, and residents - at both institutions than is usually the case with research. This partnership has convinced us to exhort other academic leaders in the health arena to seek opportunities together to enlighten and enliven our educational enterprises.

Teaching and educational scholarship in Tanzania: faculty initiative to improve performance of health professions' students.

Well-educated and competent health professionals influence the health system in which they work to improve health outcomes, through clinical care and community interventions, and by raising standards of practice and supervision. To prepare these individuals, training institutions must ensure that their faculty members, who design and deliver education, are effective teachers. We describe the experience of the Muhimbili University of Health and Allied Sciences (MUHAS) in encouraging improvements in the teaching capacity of its faculty and postgraduate students triggered by a major institutional transition to competency-based education. We employed a multi-stage process that started by identifying the teaching and learning needs and challenges of MUHAS students and faculty. Collaborating with the University of California San Francisco (UCSF), MUHAS responded to these needs by introducing faculty to competency-based curricula and later to strategies for long term continuing improvement. We demonstrate that teaching faculty members are keen for local institutional support to enable them to enhance their skills as educators, and that they have been able to sustain a program of faculty development for their peers.

Health professions educators as agents of change in Tanzania: creativity to implement new curricula.

Muhimbili University of Health and Allied Sciences (MUHAS) strives to instill in its graduates skills and competencies appropriate to serving the Tanzanian population well. MUHAS leadership, working in collaboration with educators from the University of California San Francisco (UCSF), selected and trained an interdisciplinary group of faculty members to promote effective teaching. We describe the development of this group of faculty change agents - now known as the Health Professions Educators Group (HPEG). The HPEG invigorated the education environment at MUHAS by: engaging many colleagues in special training events that introduced new methods for teaching and assessment; encouraging innovation; and developing strong mentoring relationships. HPEG members piloted courses in education to prepare all postgraduate students as peer educators, teaching assistants, and as candidates for faculty future appointments. Creation of a 'teaching commons' reinforces the new focus on innovative teaching as faculty members share experiences and gain recognition for their contributions to quality education.

Tanzania's health system and workforce crisis.

This introduction to Tanzania's health system and acute workforce shortage familiarizes readers with the context in which health professions education takes place. The paper touches on poverty rates, population growth, and characteristics of the health system. The critical shortage of trained health staff is a major challenge facing the health sector, aggravated by low motivation of the few available staff. Other challenges facing the health sector include lack of effective staff supervision, poor transport and communication infrastructure and shortage of drugs and medical equipment. We recommend appropriate action be taken by the government and other stakeholders to provide more financial and human resources for the sector while ensuring their efficient and effective utilization to improve services delivery.

Emergence of a university of health sciences: health professions education in Tanzania.

From independence in 1961 Tanzania approached development with an ambitious, socialist agenda, including plans for educating its health workforce to reach rural villagers whose needs German and British rulers had relegated behind those of Europeans, Indians, and Arabs. The new nation's health system was to provide services by employing non-elitist university graduates and auxiliary health workers - educated using resources of poor Tanzanians. This article documents how the Muhimbili University of Allied Health Sciences (MUHAS) evolved from independence, gaining its charter in 2007. Faculty face overwhelming challenges to prepare graduates to lead a health system where the workforce numbers, in every category of auxiliary and professional, have not kept pace with a population that has quadrupled since 1961. The article reviews development of what are now the MUHAS Schools of Dentistry, Medicine, Nursing, Pharmacy, and Public Health and Social Sciences - in their social and economic context. It closes with reflections about important changes for MUHAS since independence. MUHAS and other health professional schools need to collaborate, sharing meager national resources, to dramatically scale up enrollment. Graduates lead the health system and the many schools that educate health workers from village health post managers through referral hospital specialists and researchers. The text is accompanied by a detailed timeline.