Tanzania: still optimistic after all these years?

Tanzania: still optimistic after all these years?

ESSAY Essay Tanzania: still optimistic after all these years? John S Yudkin It all had a very familiar feeling. Ward 1, Mwaisela Block of Muhimbili ...

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ESSAY

Essay

Tanzania: still optimistic after all these years? John S Yudkin 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 infrastructure, the same greying sheets. The nurses were different, but in the same white and blue jackets and trousers or pink dresses and welcoming 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 insisted 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 diagnosis 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 population, which would not, of course, include anti-HIV triple therapy). This visit to Tanzania was my fourth, one in each of the past four decades. I was using the opportunity of a conference in Dar es Salaam 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 India and subSaharan 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 upcountry 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 familiar from my second visit, in the 1970s. During my 2 years as a senior 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 Lancet 1999; 353: 1519–21 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: [email protected])

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Overseas Development Administration (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 understandable—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 declaration 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 entire 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 assistants, maternal and child health aides, and medical assistants. When I went back 5 years later, to teach in the medical school, the principles 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 planning and prevention. It was all very optimistic. All it needed was another 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 billion, representing around $260

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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 regimes 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 western governments seem more concerned about making a success of a free market in former socialist economies than about the less obvious difficulties of subSaharan 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 implement. 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 salary 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 allowances—for accomodation, 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 medicine or pharmacy, turn to private practice, or leave their paid job after 3 or 4 h to earn some real money. One friend, a committed socialist, 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 assistants, and pharmacists have been recruited to Botswana, Kenya, or the Middle East, where salaries are better. There is a freeze on new appointments 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.

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What has always struck me about visiting Tanzania is the sense of optimism 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 Thatcherism, I was struck with the fact that the problems my Tanzanian colleagues 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. Certainly, on the surface, things in Dar es Salaam seemed rather easier. The roads were less pot-holed, there were new hotels with elegant restaurants, 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 Bagamoyo, 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 holiday 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 islands’ 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 medical assistants were being trained from the last 1960s onwards, none has a medical assistant. All nine assistants on the island are serving doctor-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 hierarchy. 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 prescribers. Under the essential drugs programme, each PHCU was supplied each month with a sealed kit containing 45 items, with 35 essential drugs, including 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

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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, intestinal parasites, and anaemia cannot be treated. In some PHCUs the nurse prescribers use the dummy iron tablets from packets of oral contraceptive 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 undoubtedly there have been benefits to our export market as a result of development projects in the third world. But there seems something intrinsically wrong when powerful governments, or international organisations, can demand that health-care spending is cut and dept repayment prioritised, especially when many of those governments have themselves benefitted 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 countries 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 subSaharan Africa, emphasising the major social improvements that could accrue by diverting spending on debt servicing to that on health care and education. I would encourage all caring health professionals to add their support. MEDACT is a body of doctors working for social responsibility,

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including the issue of third world debt. What struck me the most during my recent visit was the sense of pleasure, 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 possibility. The University of Dar es Salaam is producing high-quality research, 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) doctors 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 further 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 fellowship, 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 background information; and Prof Eldryd Parry of Tropical Health and Education 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 (telephone +44 [0] 1223 460853; fax +44 [0] 1223 461787; e-mail [email protected]). Jubilee 2000 can be contacted at PO Box 100, London SE1 7RT, UK (telephone +44 [0] 171 620 4444 ext 2169; fax +44 [0] 171 620 0719; e-mail [email protected] uk.org). MEDACT can be contacted at 601 Holloway Road, London N19 4DJ (telephone +44 [0] 171 272 2020; fax +44 [0] 171 281 5717; e-mail [email protected]).

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