From dispensaries to consultant hospitals, the Tanzanian healthcare system is a decentralized, multi-tiered referral system. During our first two weeks in Tanzania we visited the different levels to observe how the various facilities provided health services.
Simulation baby at the dispensary
A total of 11 people piled into a rented dala dala – a Tanzanian public transport system – and headed towards the dispensary. Simply put, the journey resembled a 4D rollercoaster movie where the seats unexpectedly jerked the consumer around in all directions. The path to the dispensary was unbelievably dusty, hilly, and unpaved. How a sick person could be transported to and from the dispensary was a complete mystery to me.
This particular dispensary served the Meru tribe in the area. With one doctor, nurse, and a nurse assistant, the dispensary provided rapid malaria, HIV, and syphilis testing, painkillers, antibiotics, dysentery medication, condoms for males, family planning, and pre- and post-natal services. Although pregnant women could deliver at the dispensary, complicated cases in need of C-sections were referred to the next level: the health center.
The health center
The Mareu health center offered out patient care, reproductive and child health, CTC (Counseling, testing, and care) for HIV, family planning, adolescent sexual health, vaccination for children under five, PMTCT (prevention of mother to child transmission), tetanus shots, and TB screening. This particular health center had recently upgraded from a dispensary in name. However, they lacked supplies, staff, or infrastructure to function as a health center. With two nurses, one clinical staff member, and two registered nurses, the center functioned five clinical officers short for a facility that ran 24 hours.
Although this facility had intermittent electricity, the staff did not depend on biotechnology to administer their services. For example, I observed a cone-like stethoscope with a metal plate soldered onto the narrower edge. The health staff used this equipment to monitor fetal heart rate – a sound that I was surprised they could distinguish past the mother’s stomach, uterus, and fluid. Without biotechnology the patients had no access to ultrasounds, echocardiograms, and other precision assays. Yet, without technology the patients had access to doctors with skills that those trained in a “tech-savvy” world may not have.
The district hospital
Compared to the dispensary and health center infrastructure, Meru district hospital was beyond large. The hospital had an enormous compound with grassy plots scattered between numerous buildings. Several plots had wet kangas – a traditional Tanzanian cloth – and blankets strewn out in the sun to dry. Ambulatory patients and families alike communed on these open areas. The open landscape enabled natural ventilation that contrasted with engineered vents aerating multi-story hospital buildings that I had grown up with.
This facility had a laboratory, operating theater, x-ray and radiology department, health care services for family planning and pregnant mothers, in patient wards, pediatrics, TB clinic, diabetes clinic, HIV treatment, pharmacy, maternity ward, dental treatment, physical therapy, and laundry facilities. Initially I gawked at the numerous specialized services Meru district hospital provided. From briefly observing the outward lists and infrastructure, I believed that this hospital had plentiful resources to provide care. Yet, not long into the tour, the matron discussed that even in this seemingly well-supplied facility, staff shortages diminished quality of care. Thus many staff members learned experientially while providing services where most hands were needed.
The regional hospital
Mt Meru hospital
The regional hospital had the first two-story building that I had seen thus far. They even had a parking lot filled with cars, and nurses’ day ribbons wrapped neatly around poles throughout the hospital. Yet, similar to the district hospital, Mt. Meru regional hospital grappled with challenges that hindered equal provision of affordable care to all patients in the hospital. Here, budget shortages underpinned human resource deficiencies, equipment and drug scarcities, and infrastructural failings. Due to inadequate finances, Mt. Meru attempted to deter self-referrals in order to treat referred patients who required services provided only by the higher tier regional hospital. At Mt. Meru, opening a file costs 3000-5000 shillings. Yet for self-referral patients, the cost is 10 000 shillings (this is about 5 US dollars). Despite their efforts, the regional hospital continued to function at a deficit.
The referral hospital
Kilimanjaro Christian Medical Center (KCMC)
The ultimate facility at Tanzania: the referral hospitals. We visited KCMC (Kilimanjaro Christian Medical Center). As the first teaching hospital that I toured in Tanzania, KCMC had a modern and well-maintained infrastructure. At KCMC the staff had distinct roles that shaped their responsibilities, skills, and physical location unlike the “jack-of-all-trades” mindset in previous health facilities. Staff had an official hospital badge identifying their name, credentials, department, and position. Furthermore, each department at KCMC had its own physical location including their own surgical theater.
However, KCMC had infrastructural challenges that underpinned patient overflow in specific departments. Built between 1965-1971, the main KCMC buildings remained unchanged while the patient influx steadily increased. Thus, rooms built using 1965 capacity approximations could not accommodate current patient populations. In the surgical ward alone, many occupied patient beds were lined along the hallway due to lack of space.
Climbing the healthcare pyramid tier, I observed increasing biotechnology and field specialties. Yet, even at the most “prestigious” hospital – KCMC – doctors faced challenges that stunted their ability to provide quality care to all incoming patients. Thus no matter how excellent a facility appeared to be, each dispensary, health center, regional and district hospitals, and referral hospitals had difficulties specific to its context.
I had initially come into this week wanting to learn about the one success method that eradicated all difficulties at a health care facility. However, I am reminded once again that no permanent solution exists. Even when solutions are implemented, the solutions create a new environment – social, infrastructural, and economical – where unexpected challenges arise.
At first glance the recurrent problem-and-solution resembled the Korean story of the broken clay urn: a man laboriously pouring water in a broken clay urn in hopes to bring home a full pot of water. The urn with the hole represented the never-ending cycle of problems; the water embodied the continuous stream of solutions; and the hope for a full urn reflected the hope for a permanent answer. This depiction presented a bleak world with continuous tribulations.
However, I wonder if my black and white conception of problems and solutions as sadness and happiness represents reality. Perhaps problems and solutions are natural facets of a chaotic life, and not necessarily distinct negative and positive entities. Thus if problems exist as a reality, approaching challenges in the Tanzanian healthcare system with the mindset to eradicate could lead to more unexpected consequences. Rather, one sustainable approach to healthcare issues in Tanzania could simply be the understanding that problems and solutions will always be present.