Budget Shortfalls Cripple Health Services In Tanzania Public Hospitals

By Kizito Makoye

DAR ES SALAAM, Tanzania — The scene of a pregnant woman screaming while giving birth on the cold-tiled floor of Sumbawanga district Hospital in Tanzania’s southwest highlands, three years ago, evokes horribly vivid memories for Jesca Chokala, who was barely able to help her.

“I had never seen something like that before. It was the most traumatic experience of my life,” recalls the 25-year-old hospital cleaner.

Racked by excruciating labour pains and an irresistible urge to give birth, the woman, who had arrived at the hospital around midnight, didn’t find any midwife to help her deliver.

Standing in a semi-squatting position, on the edge of the hospital corridor, the heavily pregnant woman pushed out her baby, who landed on the ground and began crying, Chokala recalls.

This incident explains how acute shortage of midwives and scarcity of medical supplies are plaguing health service delivery in Tanzania’s public hospitals.

The east African country has one of the world’s highest maternal mortality rates at 556 deaths per every 100,000 delivering mothers, according to 2016 data from the National Bureau of Statistics. In the United States the figure is 11 and it’s even lower in other developed countries.

While the majority of Tanzania’s population lives in rural areas, social services including hospitals are miles away.

Armed with a mopper, Chokala tried frantically to find the midwife to help the desperate woman.

“I found myself helpless. I didn’t know what to do,” she told Health Policy Watch

Dressed in a shiny yellow apron, Chokala, who was in a routine midnight cleanliness shift, luckily found the midwife and they both rushed to help the patient.

When they arrived, they found the shocked mother standing over her child with a gush of blood oozing from the umbilical cord, which had ripped as the baby dropped on the ground. Chokala looked powerlessly on as the nurse rolled up disposable gloves to save the baby who was still engulfed in a pool of shrill tears.

Despite her ordeal, the woman and her baby were taken to the labour room and they luckily survived.

While Tanzania has made remarkable progress in health service delivery, challenges persist as expecting mothers and new born babies are still at high risk of untimely death, according to 2016 Service Delivery Indicators (SDI) survey conducted by the World Bank. Patient neglect after birth is a major cause of death to mothers and their newborns in Tanzania in the first week after a delivery, the survey suggests.

Serious challenges persist in getting more health workers out to Tanzania’s rural areas, which have only 9 percent of the country’s doctors and 28 percent of its health workforce, according to the report.

In comparison, Dar es Salaam, Tanzania’s largest city, with 10 percent of the country’s population, is home to 45 percent of all doctors.

Although pregnant women at Sumbawanga hospital had become used to receiving free antenatal care, their families often bear the costs of what the health centre is unable to provide, local residents said.

The shortage of supplies coupled with dilapidated physical infrastructures in Tanzania’s Rukwa region have hindered the hospital’s ability to provide better healthcare, said Boniphace Kasululu, Rukwa Regional Medical Officer.

A study titled, “Working in Scarcity, Effects on social interactions and biomedical care in Tanzanian hospitals,” conducted by Washington University in St. Louis (US), shows dwindling donor funding coupled with systemic corruption affects health service delivery in Tanzania’s public hospitals.

Across the country, nurses and doctors often cite the shortage of personnel and medical supplies, as a key barrier to improving not just maternal health but health service in general. While Tanzania is reportedly performing well on priority health indicators, reports suggest lack of effectiveness in health financing has crippled the country’s abilities to achieve more.

Austerity measures triggered by the 2008 financial crisis, combined with heavy reliance on donor funding, has disrupted operations in Tanzania’s public hospitals and the healthcare sector in general, the government said. Because the government runs its annual budget on a cash basis depending on tax collections, the treasury is often riddled by financial doldrums, thus affecting service delivery sectors.

At Sumbawanga hospital, shortage of supplies and financial problems are a daily topic of conversation among nurses and doctors.

According to sources, patients’ relatives are often being told to buy catheters, urine bags, dissolvable sutures or antibiotics to protect loved ones from post-operative infections. Reports suggest pregnant women are sometimes confined in the maternity ward for days before receiving the first dose of prescribed drugs, thus risking contracting infections.

“We operate in a very difficult circumstances because of lack of important supplies,” said Penina John, a midwife at the hospital.

Medical Stores Department (MSD), the autonomous state agency responsible for procuring, storing, and distributing medicines and supplies in government health facilities, has long stopped taking orders on credit after citing huge unpaid bills from public health facilities.

“We are still deeply committed to provide medicines and supplies to all Tanzanians at affordable prices” said MSD Director General Laurean Bwanakunu.

According to him, the agency’s capital fell from approximately $38.6 million in 2008 to $11.9 million in 2015 due to unpaid debts.

While foreign donors have long used aid as a tool to induce change and guide Tanzania’s heath policy through so-called General Budget Support (GBS), which, in 2016, amounted to

approximately 48% of the national budget, they have virtually failed to achieve their desired objectives. The structure of the GBS created many challenges as donors substantially cut their foreign aid budgets in the wake of the 2008 financial crisis.

“Our development partners rarely fulfil their budget promises and are becoming unpredictable,” said Phillip Mpango, Tanzania Finance Minister in the Parliament.

At the district level, the dwindling funding in the heath sector has also affected social relations between health workers and patients, who frequently accuse nurses of selling free drugs and supplies. While the health workers repeatedly deny the allegations, they rarely dispel the rumours.

“I don’t think it is right to point an accusing finger on nurses who are simply trying to help,” said Adelvina Temu of Tanzania Midwifes Association.

At a national level, there is a widespread narrative about systemic corruption in the health sector.

Health workers in public hospitals often cite low salaries, poor working environment and lack of essential supplies as factors affecting their work.

Wages are low – about Tanzanian shillings 432,000 (US$198.50) a month for a trained nurse – which compares to the pay of a teacher 530,000 (US$242).

The Rukwa region had long been dogged by allegations of financial mismanagement and lack of transparency, which has also affected the hospital’s operations, aid and investment. The withdrawal of donor funding in 2011, for instance, was most likely due to the 2008 global financial crisis and looting, which infuriated the donors, according to sources knowledgeable with the hospital’s operations.

The nurses expressed the sense of impotence when they are unable to provide quality care to the pregnant women seeking their services in the maternity ward.

“I think,” said John, “patients should be told in advance to prepare the money for buying certain items the hospital is unable to provide for free.”

 

Image Credits: Issa Michuzi.

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