Does bad luck come in threes? Well, in some places in this world death comes in “three delays”.
Imagine you are expecting your firstborn in rural Tanzania. Since your water broke you are trying to cope with contractions on the floor of your mudhouse, supported by female relatives. It is two days now but you are still far from hearing the first cry of your baby. What you don’t know is that your labour is obstructed. “Delivering a firstborn simply takes time, like most things you do for the first time”, that’s what everyone tells you. You are too exhausted to suggest otherwise, your face is boiling, you have developed a fever, but everyone blames the heat and the effort of labour. Without any skilled attendance, nobody makes the link between your prolonged ruptured membranes and the chance of an infection. Slowly you feel like you are sinking into a bog. It is only when you are losing conscience that the emergency of the situation starts to dawn on the others. You have hit your first delay: delay in the decision to seek care.
It is 15 kilometres as the crow flies from your hamlet to the closest health care facility, which is at the other side of the hills. This is why Matongo valley, your home ground, is called “the hidden valley”. More than 10.000 people live here in hamlets, dispersed all over the valley, hidden between two ridges. Unfortunately you don’t have wings and no means of transportation, nor money to pay for it. There is no other option for your family than to transport you on a hand pushed wheelbarrow over a rugged small path across the hills. It takes 5 hours, and while the sun burns mercilessly you drift in and out of consciousness and your pain is unbearable. When you approach Kiagata Health Centre, the second delay has hit you: the delay in reaching care.
There is a long line of people waiting outside. When your family members force their way to the maternity ward, they try to look for medical staff to notify them about your emergency. The hallways are so crowded with women in serious labour that they have to leave you outside. It takes a long time to convince an already overworked nurse-midwife to take a look at you. She presses her ear to a Pinard horn to hear your baby’s heartbeat. Your family begs her to give them the verdict. She mumbles something about suspecting fetal distress. It doesn’t really get through to you and your situation is deteriorating. What you need is an immediate c-section, but the operating room is occupied and there is no hope they can operate on you any time soon. Finally, a nurse starts infusion therapy. You are still in the yard of the hospital, you are seriously dehydrated and it is nearly impossible to find a proper vain to insert the catheter. In any case, it is not needed anymore. You have been hit by your third delay: the delay in receiving adequate health care, and this last hit has proven fatal, for you and your baby. The world has lost a mother, a child, a partner, a daughter, a sister. The world has lost somebody like you, and this could have been avoided.
Tanzania's hidden valley
This remote community of Matongo is located in the Mara Region. In 2013, the locals decided to team up with their District Council and NGO Tanzania Development Trust to address the urgent need for local health care and to create a dispensary (a cottage hospital) in their “hidden valley”. The first step was to build a staffhouse which currently allows for running monthly clinics. However, a clinic where mothers can enter at any moment in time is still a long cherished dream. The District Council has committed to contribute in building the clinic, to allocate funds to assure its equipment and staffing and they have promised to give the project priority in connecting it to the electricity network in 2017. NGO Tanzania Development Trust will create a borehole so that a continuous water supply can replace the hauling of water by donkey cart. The community has made 30.000 bricks and has already built the foundation and walls of the clinic. However, to complete the construction of the clinic in 2017, additional resources are necessary and your help can turn tears into smiles . Add your stone today and join the crowdfunding, so that the "hidden valley" doesn't become the "forgotten valley".
When Janet Chapman, Campaigns Manager and Project Officer at Tanzania Development Trust, visited Matongo valley last year, she saw a huge crowd of pregnant women under a tree, next to the foundations of a clinic, yet to be built. They were gathering because they were hoping to see the nurse who visited once a month on a motorbike, either for themselves or their small babies that they carried on their backs. “I was with Rhobi Samwelly, Tanzania Development Trust’s local representative for Mara region who runs the Safe House for girls refusing FGM in Mugumu”, mrs. Chapman told us. “They were extremely happy to see the nurse, and grateful because she had managed to get a water pump set up in this village, saving these women a walk of several kilometers to fetch water. What struck me most about these women was their patience, good humour and fortitude. They had walked long distances to get here and waited patiently for many hours. Even when it began to rain, no one complained.”
Tanzania Development Trust is a small-scale charity. They have been working in Tanzania to relieve poverty and improve health since 1975. They focus on realising small projects with a big impact and thanks to the work of volunteers they can spend all donations on the projects involved.
Avoidable maternal and neonatal mortality In a recent study on the maternal and perinatal health in underserved remote areas in Tanzania, 84% - 96% of all maternal deaths and perinatal neonatal deaths were considered avoidable. The WHO estimates the number of maternal deaths in Tanzania to be 8200 in 2015 (with an 80% uncertainty interval from 5800 to 12000) and its maternal mortality rate to be 398 (with an 80% uncertainty interval from 281 to 570). In the list of ten countries with the highest numbers of maternal deaths, Tanzania ranks sixth.This begs the question which interventions are effective when addressing maternal and perinatal mortality in rural and resource limited settings. Addressing the “three delays” illustrated above is generally considered key. This can be done through decentralising emergency obstetric and neonatal care services and upgrading remote rural health centres. When these lower-level facilities are equipped with a maternity ward, power, water, a staff house, an operating room and trained personnel, they can cope with basic obstetric emergencies. This would also require setting up an adequate referral system, staff training, and a constant supply of basic materials and drugs.
Organisation of Healthcare in Tanzania
Let me give you a simplified crash course in how the Tanzanian health system is organised. On top of the pyramid, you find the Consultant Hospitals or the National Referral Hospitals, which are teaching and university clinics with medical specialists and specialised departments. Then there is the layer with Regional Hospitals or Regional Referral Hospitals, which are found in each of the 30 regions. From these, patients can be referred to the national referral hospitals but they also have their own medical specialists and specialised departments. Here, they have experienced general doctors and medical assistants who are trained in the school for Medical Assistants. The third layer is composed of the District Hospitals or Council Hospitals, with a couple of doctors and a medical assistant but without specialised departments and with only a limited amount of beds. Fourthly, there are the Health Centres, providing small-scale inpatient treatment (about 20 beds) and outpatient medical care like mother-child-clinics and vaccinations. A team generally exists of a doctor, a senior and a junior Medical Assistant, midwives, nurses, a laboratory assistant and preventive health care workers. The Health Centres supervise the fifth and final layer, the Dispensaries. A Dispensary is a health care outpost that serves as the first tier of local health care. It is a small hospital with a pharmacy, run by a doctor, an assistant medical officer and some nurses. Apart from direct medical assistance and cures, they provide mother-child-services, vaccinations, prevention and health education and administer medication. Many dispensaries have a maternity ward, a room for minor operations and a staff house. Dispensaries are a crucial chain in the Tanzanian health care system. Remote areas can be quite isolated and inaccessible and the infrastructure limited, which makes these dispensaries even more important than Health Centres, District or Regional Hospitals might not be reached in time or referral might be delayed.
Invest in dispensaries: the backbone of health care
Most Tanzanians - almost 70% - live in rural areas, where dispensaries and health centers form the backbone of the health care system. Unfortunately for them, the Tanzanian health care system is plagued by some serious mismatches in terms of allocation of funds and staff. The problem occurs on several levels. While, for instance, the top layer of the system serves a relatively small portion of the population, it receives by far the biggest slice of the health care budget. And of the money invested at the local levels, around a third goes to the dispensaries even though they serve the majority of the population (Boex et al., 2015). Within the bottom layer, the dispensaries, there is a mismatch with regard to the allocation of funds and staffing when compared to the number of patients they serve (Tidemand et al., 2014).
In its Development Vision, the Tanzanian authorities express the ambition to deliver good and accessible primary health care to all Tanzanians by 2025. (MoHSW, 2014-15). In this respect, investing in dispensaries in areas yet uncovered, such as Matongo valley, is paramount and will save the lives of mothers and children. Let’s join hands and make this reality!
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Nyamtema, A.S. et al. (2016. Enhancing Maternal and Perinatal Health in Under-Served Remote Areas in Sub-Saharan Africa: a Tanzanian Model. Plos One 11(3):30151419. doi:10.1371/journal.pone.0151419 Online available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795747/
Ministry of Health and Social Welfare (MoHSW) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF International 2015. Tanzania Service Provision Assessment Survey (TSPA) 2014-15. Dar es Salaam, Tanzania, and Rockville, Maryland, USA: MoHSW, MoH, NBS, OCGS, and ICF International. See: https://dhsprogram.com/pubs/pdf/SPA22/SPA22.pdf
Tidemand, P., et al. (2014). Local Government Authority (LGA) Fiscal Inequities and the Challenges of ‘Disadvantaged’ LGAs. London: ODI.