The Bigger Picture

Today I visited KCMC Hospital in Moshi. This is the Zonal Hospital for the area within which Muheza sits. I have been slowly piecing together the puzzle of healthcare provision in Tanzania. It has not been easy. From what I think I understand, the structure for ‘conventional’ (as opposed to tribal) healthcare is as follows (all services require payment).

The smallest area is looked after by a Dispensary. Here some very basic medical advice can be sort and certain medicines provided.

Next comes the Health Centres. These cover a slightly bigger area and are fairly substantial (one I visited was actually very plush) and have a number of beds (10 or 20 perhaps), usually for minor ailments, wounds, and basic maternity services. They are usually staffed by one AMO (Advanced Medical Officer) and a number of nurses. I will try and describe the different healthcare roles in more detail at some point in the future. But in simple terms an AMO is a bit like our old fashioned SHO in the UK. Someone who can vary from being very inexperienced to someone capable of performing certain surgical procedures (like C-Section). The two surgeons I am currently working with in Muheza are AMOs. 

These then feed into Designated District Hospitals like St Augustine’s (Teule) Hospital, Muheza. We have 270 beds (but usually have an occupancy between 90-150 and this feels pretty full to me). This is the lowest tier where you will find ‘MD’ doctors (ie have passed through 5 years of medical school). Some may also have a handful of specialists (a specialist has been through medical school and then goes off for a further 3 years training in the likes of Medicine, General Surgery, paediatrics). We have a medical staff of 2 specialists (a paediatrician and a public health doctor with a couple of others away in training), 4 further MD doctors, 8 AMOs and 6 COs (clinical officers).  The expertise in such places does vary. Muheza has always been a ‘high flying’ institution, punching well above its status and often attracting patients from outside our catchment. At one time, it was not unknown for patients to choose to come here instead of other hospitals of a higher tier. This trend has lessened over recent years, but even since I have been here, a few patients have made long journeys to see us (including from the capital!).

Our Regional Hospital, the next tier, is Bombo in Tanga. This has around 400 beds, and several specialists. I have described Bombo in detail in my previous post ‘Boys Road Trip! But then late for the Party’ (11^th Jan).

The final two tiers are the Zonal Hospitals of which there are five in Tanzania and the National Hospital(s). The biggest centre in Tanzania is in Dar es Salaam (I feel a visit coming on). The new hospital in Dodoma (described in ‘Teased with a laparoscope’ [17^th Jan]) has been set up as a second national hospital and is an impressive work in progress.

Just to add some additional complexity to the mix, there are also a number of private hospitals / institutions that offer a variety of services. For example I understand that in Tanga, there is hospital that can perform CT scans and endoscopy.

Wow, writing that makes me feel like I have come a very long way in understanding healthcare in Tanzania. I remember when I arrived in Muheza, I felt completely disorientated and in the dark about how what I was doing fitted in to the bigger picture. Evidently, it is complicated. What I have written above probably oversimplifies things as it is not as simple as if A cant do it then send it on to B, then C etc. A huge factor in what healthcare people can access is how much they can afford. For many even travelling to a bigger institution is prohibitive, let alone paying the fees.

The 'front door'

Back to the focus of this post, KCMC Zonal Hospital in Moshi. This is a 670 bed mammoth. When I arrived, it was every bit as big as I suspected it might be. In size and complexity it is very similar to any DGH in the UK. It felt like a labyrinth of concrete. It also felt like an ‘African’ Hospital, the grounds nicely maintained, but most of the buildings looking very tired (despite best efforts). There is some very interesting history to KCMC. Like many hospitals in Africa, it was built by a combined charity of Christian churches (GSF – Good Samaritan Foundation) and opened in 1971. However, shortly after completion of phase 1 of the development (five were planned), it was reclaimed by the government, only to struggle in such a capacity. Unfortunately, that move resulted in withdrawal of all benefactors and so when the hospital was then handed back to the GSF in 1992, further investment in the hospital was very limited. An arrangement between the GSF and the government was reached which enables the hospital to function, but the politics and logistics are complex. From what I can ascertain, the hospital is ‘owned’ and maintained by GSF, the staff are paid by the government, most of the drugs and supplies come from the government, but most of the equipment is donated. The finances, I understand are troublesome.

This relationship, is difficult. And I can now to some extent better understand the governments agenda to ‘release’ itself of such dependency and achieve overall governance of its healthcare system through its plans to build new government owned facilities in certain places. In Muheza for example, there is such a project to build a new government facility. This is just a few Km away from St Augustine’s Hospital, a mission hospital owned by the Church. This is likely to take many years, but the foundations have now been dug. The flip side to this approach (and my original reaction was to call it ‘bonkers’ and feel very sad) is given that resources are so limited, the money could have been spent very differently. Potentially providing much needed investment in hospitals such as St Augustine’s, which would offer immediate improvements in the quality of healthcare provided. Hmmmm. The ethics and politics of such things are complex. But it is hard to ignore the reality of healthcare ‘on the shop floor’, where we run out of drugs, are lacking basic theatre equipment and the huge issues we face when our elderly X-ray machine breathes its last breath.

I enjoyed my visit to KCMC enormously. I was welcomed so very warmly and it was a privilege to be given the time to be shown around. Once again, I was struck by the dedication and resourcefulness of the staff. There are yet again many inspiring individuals in such a place. It was notable how many staff were around, but as one of the leading hospitals in Tanzania, it has a lot of ‘trainees’. Whilst this post is now becoming very long, I learned so much again:

Ø  Surgical services in this hospital are divided up in much the same way as you would find in the UK. They have a General Surgical department, Urology, Orthopaedic and ENT. They also have O&G.

Ø  The General Surgical staff consists of 3 specialist surgeons (plus one professor who attends occasionally in some capacity), 12 residents and 7-10 interns.

Ø  The anaesthetic staff is made up of 2 specialist, 5 residents, 4 AMOs and 20 Nurse Anaesthetists. They provide an impressive service including quite advanced regional techniques (mainly overseen by the head of service – a very impressive individual). They are supported by a number of links (whilst I was there an American Anaesthetist was present helping to teach further regional techniques). They currently have 100 Nurse Anaesthetist students, which is an overwhelming number to be honest. There has been a recent initiative to expand the number of Nurse Anaesthetists and so last year the hospital’s ‘allocation’ was doubled from 50 to 100!

Ø  They have 35 dedicated GS beds, although they usually have more like 50 patients on the ward – on ward round we attended several patients in the corridor (the norm I am told, collaborated by the numbering on the walls of such additional bed spaces).

An ICU bed space

Ø  They have a dedicated surgical ICU (shared across all the specialties). It has a ‘clean side’ and an ‘septic side’. I think it has about 12 beds in total. There are also two or three other ICUs in the hospital.

Ø  They have 5 surgical theatres which are similar to what we have in Muheza. Although they have much better kit. For example many more attachments for the beds, advanced anaesthetic machines and diathermy in every theatre. The burden of emergency work hugely impacts on the scheduling of elective procedures. Whilst I was there a major trauma was in one of the theatres.

Ø  Discussing their instruments, it seems they are of a similar standard to what we have in Muheza before I arrived. Many of the scissors are blunt, needle holders slip and plenty of other desirables missing.

Ø  They have diathermy in every theatre and re-use disposables like we do (although their sterilisation process may not be quite as rigorous as ours now is (although we did not cover in depth what they do).

Theatres. So many students!

Ø  Their case mix as general surgeons is impressive. They will tackle almost anything, from head and neck tumours, pneumonectomies’ (lung resections), through to most abdominal procedures. On the colorectal front (like Dodoma) they perform an AP for any cancer of the rectum. I got the impression that outcomes from these more radical procedures is certainly not what we would expect in the UK, with mortality rates high (I would love to quantify this more clearly, but there was so much to cover in such a small space of time). They regularly perform laparoscopic surgery (lap choles, lap appendicectomy) but this is very dependent upon the availability of the senior surgeons.

Ø  They do mesh hernia repair and for the last 2-3years have done that as the default in all patients. When I asked how this was possible, I was told that they get consignments of prepared ‘mosquito net’ mesh from a link with Surgeons in Northumbria. This link team visit every year, bringing with them supplies. I am very interested in this activity and will look to make contact and hopefully collaborate further in the future. (The discovery of such a link that I did not know existed despite all our research and enquires last year, highlights another challenge in Global Health Development – that of communication, collaboration and ‘visibility’ of such activities).

Ø  The fees for surgery are similar in structure to Bombo and Dodoma. 100,000TZS for minor surgery, 250,000TZS for major surgery (including hernias) and 400,000TZS for laparoscopic surgery.

Home made normal saline

in transit!

Ø  They certainly seem to have better procurement strategies, both using the government MSD (Medical Supplies Department) as well as a number of other sources. Again, this is something that I would like to learn more about. Interestingly, they also make their own normal saline solution.

Ø  They have excellent access to laboratory blood tests (I can testify to this from the few consultations I observed on the ward rounds). I am told they can even do a CRP, but rarely use it.

Ø  They have good X-rays services and have one CT scanner but no MRI (a hope for the future). They have a good USS service, but will sometimes need to seek out clarification / repeat imaging if a specific question needs answering.

Ø  They also have an endoscopy service, performing both OGD and colonoscopy. Sadly, I did not have time to visit the department today.

It was a fantastic visit and I made some very important links. One of the surgeons I met with is a council member of the Surgical Society of Tanzania, an organisation I have been trying to learn more about.  I understand it is still an organisation in infancy, but I now have a contact and have discovered that they hold an AGM in May, which gathers most of the surgeons in the country together (about 100 I am told). Might I be able to return for this I wonder?!

So much to think about…. Again!