Washington, DC — An innovative rehabilitation project for Tanzania's leading public hospital has improved the quality of the nation's health care, paved the way for a national anti-retroviral drug program and served as a model for other countries, says a Tanzanian health official and project partners. The project still struggles to overcome low staff morale, as was highlighted this week when the hospital's senior doctors joined intern doctors in a labor strike.
Tanzania Care is a $24 million public-private partnership between Tanzania's Ministry of Health, the Abbott Laboratories Fund and Axios International to build an outpatient care facility and renovate the laboratory at Muhimbili National Hospital, train more than 1250 staff and improve 77 voluntary HIV counseling and testing centers scattered throughout the country.
Project staff said rehabilitating the hospital and training new staff are necessary steps before rollout of anti-retroviral therapies begins on a wider scale. Prime Minister Frederick Sumaye announced a national ARV roll-out plan last Thursday to treat 100,000 Tanzanians by 2006. Tanzania Care officials say they will be ready.
"What Tanzania Care is doing is connecting the dots," said Executive Director Jeff Richardson. "The tools, the resources have been made available."
Richardson says the effort is innovative because it doesn't focus on a specific program, but strengthens the health infrastructure that underpins all other efforts. For example, Abbott Laboratories is donating medical equipment for the lab, but is also training repair staff to fix machines when they break, he said.
Dr. Zacharia Berege, Director of Curative Services for Tanzania's Ministry of Health, said that the government is increasing spending on HIV/Aids, and is happy to have partners in the private sector with even more funds and expertise to contribute.
Muhimbili used to be Tanzania's premiere hospital, Berege said, but years of neglect have eroded its facilities and lowered staff morale, as doctors and nurses worked unpaid for months at a time. Maintenance workers were not trained to fix medical equipment, so when expensive diagnostic machines broke, they were discarded. Berege said that since the laboratory has been refurbished and staff retrained, patients are happier with the quality of health care.
"We are headed towards the right direction," he said. "The outpatient numbers are soaring. When the hospital is fully operational, I think even more people will come."
Rising patient numbers are already threatening to overwhelm the hospital, according to a May report from The Guardian, a Tanzanian newspaper.
Treatment at the hospital "is laden with unnecessary delays caused by bureaucracy that is helped on by staff indifference to emergencies," the newspaper reported.
A Muhimbili spokesman told The Guardian that the "delays would continue until rehabilitation of the hospital is complete."
But Berege says some overcrowding may continue even after construction is finished as patients "jump the line," skipping referral hospitals to seek treatment at Muhimbili, which now offers a higher standard of care. The Guardian reported in March that 80 percent of maternity cases do not have referrals, but are going directly to Muhimbili.
Patients without referrals must pay for services, just one of several changes made in the fee structure last year to recover costs and reduce crowding at Muhimbili. Berege said the fees do not cost patients more than they were paying before, but that the structure of payment has changed.
Previously, patients paid one rate when admitted and were billed for additional services separately. Berege said the old fee structure made it difficult to recover costs spent by the laboratory and pharmacy. The new fee structure has increased the amount patients must initially pay, Berege said, but this includes all lab tests and prescription drug costs that patients need. He said many patients were startled by the initial increase in the fee, which at $10 was about five times higher than previously paid.
"It was a reorganization," Berege said. "Now they're paying at a single point."
The new fee structure has increased the hospital's revenue from about $10,000 each week to $26,000 each week, said Adam Kichawele, Director of Information Management Systems at Muhimbili. The hospital has also improved the computer system to manage patient records more efficiently, he said.
Berege said the increased revenue will allow the hospital to provide better services and pay the staff better, which he hopes will improve staff morale.
A "fast-tracking" service has also been introduced to speed up treatment, in which patients pay more for quicker service. The restructured fees and "fast-tracking" have been criticized in the Tanzanian press.
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Tanzania Care staff say this criticism is misguided, as the project is necessary to improve the nation's health care system.
"I think the concern is genuine, but I think what is needed is to educate the stakeholders," said Dr. Kenneth Lema, executive director of the Axios Foundation-Tanzania. "If Muhimbili does not recoup some of these costs, then it will never be sustainable."
In an interview last month, Lema said the single greatest challenge for Tanzania Care so far has been working with hospital staff to improve customer service and shift the hospital to incentive-based rewards based on the speed and quality of care.
As was made clear by the labor strike this week, there are still unresolved issues with the hospital's staff, which Lema and Berege acknowledged. Labor leaders are meeting with Muhimbili's management this week to try to resolve the strike. The doctors are requesting payment of salary arrears, a pay raise and a smaller workload, The Guardian reported.
But Berege said he is hopeful that in the long run the changes at Muhimbili will increase the staff's confidence in the hospital.
"They are quite excited because they see the changes," Berege said. "It is encouraging them to work."
