Health and Health Care in Tanzania
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Source: ProCOR <procor@usa.healthnet.org>
[Moderator comment: The following is a special article, which we repro-
duce from the Lancet by permission from the publisher. This is part of
a series of articles that we have periodically posted on ProCOR which
address the larger health and health care issues, especially in the im-
poverished Africa. Soon, we plan to archive similar past and future ar-
ticles on ProCOR's web site:
http://www.healthnet.org/programs/procor.html under "Special Communication." We welcome your comments. Samer Jabbour]
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Tanzania: still optimistic after all these years?
AUTHOR: John S Yudkin
SOURCE: Lancet 1999; 353: 1519-21 (copyrights, the Lancet)
INSTITUTION: Centre for Diabetes and Cardiovascular Risk, Department of
Medicine, University College London Medical School, G Block, Archway
Wing, Whittington Hospital, Archway Road, London N19 3UA, UK (Prof J S
Yudkin FRCP) (e-mail: j.yudkin@med.ucl.ac.uk)
It all had a very familiar feeling. Ward 1, Mwaisela Block of Muhimbili
Medical Center, Dar es Salaam, a male medical ward in the University
teaching hospital where, as a senior lecturer/consultant, I did my ward
rounds twice a week between 1975 and 1977. The same derelict infra-
structure, the same greying sheets. The nurses were different, but in
the same white and blue jackets and trousers or pink dresses and wel-
coming me with warm greetings in Kiswahili. But this visit, only my
second in 21 years, showed up more differences than similarities.
I hadn't been prepared for the impact of "cost sharing", a policy in-
sisted upon by the World Bank and the International Monetary Fund to
help reduce Tanzanian expenditure in the non-productive public sector,
which health care supposedly represents. I was introduced to a rural
farmer, a man of 45 with a debilitating peripheral neuropathy that had
left him unable to walk. He had been an inpatient for 2 months because
the only investigation he had been able to afford to date was a full
blood count. The HIV test was beyond his resources. But any such diag-
nosis would have little but prognostic significance. Tanzania spends
only around US$3�20 per person per year on health care (a quarter of
what the World Bank estimates necessary to provide basic health care).
The spending on pharmaceuticals is around $0�40-0�50 (nowhere near
enough even to cover an essential drugs programme for the whole popula-
tion, which would not, of course, include anti-HIV triple therapy).
This visit to Tanzania was my fourth, one in each of the past four dec-
ades. I was using the opportunity of a conference in Dar esSalaam and
my sabbatical to spend 3 weeks travelling in Zanzibar and Pembra, as
well as in the coastal region of mainland Tanzania. A Winston Churchill
Memorial Trust Fellowship enabled me to do some work for Action Health,
an aid agency supporting sustainable health development projects in In-
dia and sub-Saharan Africa. I was asked to evaluate a request for a
trainer in pharmaceutical management on Pemba and Zanzibar. My first
trip to Tanzania was with Voluntary Service Overseas, working as a
medical officer in an up-country regional hospital for 15 months in
1968-69. And the university and its teaching hospital, as well as the
whole field of pharmaceutical planning and drug distribution, were fa-
miliar from my second visit, in the 1970s. During my 2 years as a sen-
ior lecturer in Dar es Salaam, I researched the issue of appropriate
drug use, and inappropriate drug promotion, leading to some subsequent
work with WHO, other UN agencies, and the Overseas Development Admini-
stration (now the Department for International Development [DfID]).
Reading the works of the Victorian explorers, one is struck by the
sense that most were infected by the "Africa bug". All too understand-
able -- Tanzania to me feels like a second home. In part, it is the
grandeur and beauty of the country: MMBA as they would say in the Yacht
Club (Miles and Miles of Bloody Africa). We spent 2 years there with
young children, one of whom spoke Kiswahili before he spoke English.
But it is more to do with the people and the politics. When I went,
with my wife, in the 1960s, we were two young and enthusiastic doctors
arriving in a young and enthusiastic country. Julius Nyerere, the
President, had recently put forward a powerful statement of principle,
the Arusha Declaration, recognising the dearth of natural resources in
a population involved mainly in subsistence agriculture. This declara-
tion introduced an equitable system of access to education and health
care. A programme of building primary-care dispensaries was initiated,
so that, during the next 10 years, more than three-quarters of the en-
tire population were living within 5 km of a health-care facility. And
in parallel, training of health workers was largely oriented to the
needs of prevention and primary care: rural medical aides, health as-
sistants, maternal and child health aides, and medical assistants. When
I went back 5 years later, to teach in the medical school, the princi-
ples of rural development and prevention were strong; medical students
were selected partly for their commitment to their communities, and
spent several months in the villages learning about health care plan-
ning and prevention. It was all very optimistic. All it needed was an-
other 20 years.
In the late 1970s, the dark clouds were just beginning to build up on
the horizon. A series of events conspired together to undermine the
Tanzanian experiment even more than those of similar approaches in
other developing countries. In the mid-1970s the huge rise in oil
prices led to pressure on other items that need foreign exchange, such
as pharmaceuticals and vaccines. The world prices of coffee, cotton,
and cloves, fell by more than half, further limiting the country's
ability to buy abroad, or to repay debt. In addition, Tanzania led the
events resulting in the overthrow of Idi Amin, much supported in words,
but not in kind, by the western world. And finally, the impact of AIDS
has been enormous. In some parts of Tanzania, as many as a quarter of
the economically active population have died, with dire effects on both
the economy and the demands for health care.
Tanzania asked the International Monetary Fund (IMF) for help in 1979,
and this request resulted in the imposition of a Structural Adjustment
Programme. Several changes followed: devaluation (17/- shillings to
UK�1 in 1977 to 1050/- shillings to �1 in 1998), investment switched to
cash crops instead of subsistence crops, and there was less spending on
health care and education. Tanzania has a national debt of US$7�8 bil-
lion, representing around $260 for every man, woman, and child in the
country, or around 1!s years' GDP per head. The cost of servicing that
debt is around $275 million per year, which is over a third of total
export earnings, and more than three times what the Tanzanian Ministry
of Health spends on its total health-care budget.
Things have been made more difficult by the overthrow of the old re-
gimes in the former Soviet Union and eastern Europe. In the 1970s and
1980s, Tanzania received substantial aid from East Germany, the USSR,
Bulgaria, and Poland. Not only has this support dried up in the past 8
years, but also the international lending organisations and many west-
ern governments seem more concerned about making a success of a free
market in former socialist economies than about the less obvious diffi-
culties of sub-Saharan Africa.
During the past 5 years, total spending on health care and on education
has fallen by around 40% in real terms, largely as a result of the
pressures of the IMF, and the increased costs of debt repayment. There
has also been an attempt to recoup some of the money spent on health
care, for example, by the introduction of "cost-sharing" arrangements,
whereby patients pay for investigations and other components of health
care. Despite the stated aim of ensuring that the poorest individuals
are not excluded by such schemes, these intentions are difficult to im-
plement. Consequently, increasing numbers of people are forced to buy
what may be inadequate courses of substandard drugs from village shops
or market traders.
The rigorous control of public-sector salary increases means they have
failed to keep pace with inflation. I met up with friends from my
teaching days who were now senior consultants and academics, on a sal-
ary of around $140 per month, with the costs of goods in the market or
the shops similar to those in the UK. In the past, people were paid al-
lowances -- for accommodation, transport, and so on, which could almost
double the basic salary -- but these have not been paid by the Ministry
of Health for the past 3 years. So, across the public sector, as in
many other countries experiencing rapid inflation and spending cuts,
many teachers and health-workers have taken to requesting "help" to
make things happen, such as being admitted to hospital or a school, or
getting on an operating list, or having clean sheets. Others, in medi-
cine or pharmacy, turn to private practice, or leave their paid job af-
ter 3 or 4 h to earn some real money. One friend, a committed social-
ist, refuses to do private practice, so as a senior physician spends
his evenings and weekends delivering sacks of maize in a pick-up truck
he bought working overseas as a postgraduate.
The unattractiveness of public-sector work has led to other crises in
Tanzanian health care. Large numbers of doctors, nurses, medical assis-
tants, and pharmacists have been recruited to Botswana, Kenya, or the
Middle East, where salaries are better. There is a freeze on new ap-
pointments in the Faculty of Medicine, where no senior academic has
been appointed for 3 years. In the Faculty from the mid 1970s until the
mid 1980s, there were some 20 to 30 postgraduate students doing a 3-
year higher degree in medicine, surgery, obstetrics and gynaecology,
community medicine, anaesthetics, or pathology. But during the past 3
years, the number of enrolled students has dropped to single figures,
and not one has continued through to graduation since 1994. The reason
is that, at the time of my visit, the students had not been paid any of
their educational allowance for 3 years, and had had to rely on their
junior doctor's salary.
What has always struck me about visiting Tanzania is the sense of opti-
mism of the people, and their incredible hospitality. My last visit was
in 1989, when I spent 6 weeks visiting the university, Action Health
volunteers on Pemba, and up-country Tanzania where I had worked 20
years ago. Going from an inner-London district general hospital that
had been subjected to 10 years of "efficiency saving" under Thatcher-
ism, I was struck with the fact that the problems my Tanzanian col-
leagues faced were far beyond anything I could have coped with. But
people got on with it, and believed things were going to improve. The
old friends and former students were so pleased to have me revisit;
there seemed to be a great respect accorded to people who didn't forget
them and abandon them.
This time around, the warmth of the greetings was just as effusive.
There was amazement that I could still converse, and make jokes, in
Kiswahili. And yet it wasn't quite as positive as it once was. Cer-
tainly, on the surface, things in Dar es Salaam seemed rather easier.
The roads were less pot-holed, there were new hotels with elegant res-
taurants, and the shops were full of goods--at a price. But in the
slums and the countryside things were more difficult. Tourism looks
like being the foreign-exchange provider of the next decade. But what
is not clear is whether a German aid project building a new road to Ba-
gamoyo, where four new German holiday resorts have been developed, is
likely to have the same benefit for the people of Tanzania as a primary
health-care project. Indeed, in northern Zanzibar, there are rumours
that 10 000 people may be moved from their villages so that a new holi-
day complex can be developed.
Revisiting Pemba after a 9-year gap provided a startling contrast. If
Tanzania as a whole has suffered economically over the past 20 years,
the islands of Zanzibar -- Unguja, sometimes called Zanzibar island,
and Pemba -- have suffered more. The financial crisis in Indonesia led
to a 90% fall in the price of cloves, which were the East African is-
lands' main export, so from being the better-off partners in the union,
Zanzibar has fallen upon hard times. What has made things worse is
that, as a result of a disputed election in 1995, all European Union
bilateral aid has been withdrawn, including the DANIDA essential drugs
programme, and support of the German and the UK DfID aid programmes.
The island of Pemba, with a population of 400 000, has just two doctors
-- one a medical officer of health and one currently on maternity
leave. Of the 51 primary health-care units (PHCUs), for which the medi-
cal assistants were being trained from the last 1960s onwards, none has
a medical assistant. All nine assistants on the island are serving doc-
tor-type functions in the three hospitals, and over half of the total
have been lost to the private sector in the past 4 years. Less than
half of the PHCUs have nurse prescribers, the next rank in the hierar-
chy. In the remaining units, health care is being provided by health
assistants (whose 2-year training enables them to work in preventive
health), or by orderlies who have learnt prescribing on the job. The
other island, Unguja, has 18 medical assistants for the 58 PHCUs; of
the remaining PHCUs, a greater proportion than on Pemba have nurse pre-
scribers.
Under the essential drugs programme, each PHCU was supplied each month
with a sealed kit containing 45 items, with 35 essential drugs, includ-
ing 4000 tablets of chloroquine and 4000 of aspirin. Today, the US
$0�50 per person per year for pharmaceutical supply is insufficient to
provide more than 1000 chloroquine tablets, 1000 paracetamol tablets,
and five vials of procaine penicillin injection to the average unit,
which means that all drugs have run out by just over halfway through
any month. Even on the first of the month, bacterial infections, intes-
tinal parasites, and anaemia cannot be treated. In some PHCUs the nurse
prescribers use the dummy iron tablets from packets of oral contracep-
tive pills to treat anaemic patients. And while the vaccines are still
being provided through the UNICEF essential programme of immunisation,
the kerosene for the refrigerators in the PHCUs must come from the
Health Ministry budget, and is frequently unavailable. Over the past 2
years, the measles immunisation rate has fallen from 86% to 62%, and
young children are dying in increasing numbers from this disease, and
other preventable diseases.
Yet, there are hundreds of dedicated and committed people, who still
feel it a privilege to serve their communities and who feel proud of
their achievements. However, one cannot help feeling depressed that the
Tanzanian experiment has all been to do with investment for the future,
and believing in that future. But now it is 30 years on, and the future
is here.
I can't help feeling that there is something wrong about the concept of
third world debt. Long past the days of the end of the Empire, we still
have a major say in the wealth and health of many developing countries.
We are happy to get our coffee or our cotton more cheaply, and undoubt-
edly there have been benefits to our export market as a result of de-
velopment projects in the third world. But there seems something in-
trinsically wrong when powerful governments, or international organisa-
tions, can demand that health-care spending is cut and dept repayment
prioritised, especially when many of those governments have themselves
benefited from international loans and debt rescheduling.
Tanzania is the third poorest country in the world. One in six children
dies before the age of 5 years, and its debt is higher than many coun-
tries that have been accorded debt reduction under the highly indebted
poor country (HIPC) initiative. Yet this relief has not been offered,
because for just 1 out of the past 9 years, Tanzania failed to keep up
with its debt-servicing obligations. In consequence, this rescheduling
will not occur until 2002. The Jubilee 2000 campaign is pressing hard
for debt rescheduling for sub-Saharan Africa, emphasising the major so-
cial improvements that could accrue by diverting spending on debt serv-
icing to that on health care and education. I would encourage all car-
ing health professionals to add their support. MEDACT is a body of doc-
tors working for social responsibility, including the issue of third
world debt.
What struck me the most during my recent visit was the sense of pleas-
ure, and surprise, that people felt to see old colleagues returning,
and the hope was expressed on several occasions that I would continue
to remember Tanzania. Doctors and academics feel increasingly isolated
from the international medical and scientific community. Books and
journals become prohibitive in cost, and exchanges between universities
and international conferences are no longer within the realms of possi-
bility. The University of Dar es Salaam is producing high-quality re-
search, in malaria, HIV, epidemiology, and diabetes, but the academic
community is increasingly isolated.
I believe that we can help break down the isolation by encouraging a
programme of institutional pairing and interchange, with Tanzania and
with other similarly affected countries in sub-Saharan Africa, Asia,
and increasingly, eastern Europe. I believe that short visits to these
teaching hospitals and colleges by senior (and even less senior) doc-
tors and teachers would produce exciting ideas for collaboration in
teaching and research. Such interchange would do wonders for morale,
and be of huge educational value, in both a medical and a social sense,
to those travelling--perhaps more than to those with whom they would
interact. And inviting doctors and teachers to visit our hospitals and
universities for 2 or 3 months, perhaps including a conference, would
provide some small sense of belonging to an international community to
people whose horizons have been contracting year on year in the past
decade. Of course there is the risk that such an experiment would fur-
ther encourage the "brain drain", but there are so many people who are
so committed to their country's development and future, that this is a
risk worth taking.
I thank the Winston Churchill Memorial Trust for the award of a fellow-
ship, which enabled me to make this trip. I also thank my colleagues
and friends at Action Health headquarters, in Dar es Salaam and on
Pemba, for their help and hospitality; Tony Burdon at Oxfam for back-
ground information; and Prof Eldryd Parry of Tropical Health and Educa-
tion Trust for help.
Readers wishing to find out more about Action Health, to raise funds or
to volunteer for work abroad, can contact them at
The Gate House,
25 Gwydir Street
Cambridge CB1 2LG, UK
Tel: +44-1223-460-853
Fax: +44-1223-461-787
mailto:actionhealth@compuserve.com
Jubilee 2000 can be contacted at
PO Box 100,
London SE1 7RT, UK
Tel: +44-171-620-4444 ext 2169
Fax: +44-171-620-0719
mailto:mail@jubilee2000 uk.org
MEDACT can be contacted at
601 Holloway Road,
London N19 4DJ, UK
Tel: +44-171-272-2020
Fax: +44-171-281-5717
mailto:medact@gn.apc.org
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