11 April 2018

Tanzania: Rural Cancer Patients' Dilemma

Each time Dr Godlove Mbwanji sees a cancer patient from Mbeya Region being referred to Dar es Salaam for specialized cancer treatment, over 800km away, he wishes a zonal cancer facility was set up in the Southern Highlands.

Dr Mbwanji, who is the executive director of Mbeya Zone Referral Hospital says, "At our facility, we can only handle cancer patients who just need basic treatment but not when they need to undergo chemo or radiotherapy."

There is no other choice but to refer the patients to Ocean Road Cancer Institute (ORCI), he tells The Citizen. The situation, says Mbwanji, may cause delays for the patients who need early interventions.

It also makes them incur extra costs to travel long distances and face the task of seeking accommodation as they undergo long-term cancer treatment in the city, he says.

To many, such as Christina Lusambo, 40, a resident of Mbeya, the long travels and challenges in seeking referral, is the reason why the cancer may worsen before doctors at ORCI can intervene.

Ms Lusambo realized that she had a swelling in her breast which was initially diagnosed as a boil at health centre near her home in Mbeya. That was way back in 2014. However, it took a year for her to realize it was a cancer of the breast.

Even when she got to know her right diagnosis, it took her several months before she could start the right treatment. Fortunately, she was then referred to Muhimbili National Hospital (MNH) in Dar es Salaam and later to ORCI.

When the time came for her to be put on treatment, another problem cropped up. Ms Lusambo didn't have the right documents to qualify for treatment under the National Health Insurance Fund (NHIF).

"I had to travel back to Mbeya to get my marriage certificate. It was a long travel. I remember to have stayed home for 4 months before coming back to Ocean Road as I had been instructed," she says as she narrates her ordeal to The Citizen during an interview at the ORCI.

She says it took her a long time to enroll on health insurance as a beneficiary on her husband's card. Her husband is a teacher.

"Doctors scolded me when I finally arrived back to Dar es Salaam four months later. They said my cancer had grown and spread largely in my body."

Recently, when she spoke to The Citizen, Ms Lusambo was already undergoing her 6th round of chemotherapy. "I thank God that I am progressing well with chemotherapy," she said, with a sense of hope that she would soon be back on her feet and resume her farming activities in Mbeya.

However, her problem is one that most other cancer patients face in Tanzania.

A nurse who was attending her, Ms Chausiku Chapuchapu, says, "We face a lot of challenges with these patients who come from distant places. Where they come from, their diagnosis takes long."

"By the time a biopsy is taken from their cancer tissue and the diagnosis is made, it's always already too late," says Ms Chapuchapu.

"For patients from Mwanza Region, there is an improvement because they can be diagnosed at Bugando Medical Centre, but in regions such as Kigoma and others in peripheral areas in the country, this is still a big challenge," she says.

In Mbeya Region, Dr Mwanji and other public health authorities who were interviewed by The Citizen believe that it's high time centres such as the ORCI were also extended to zonal referral hospitals across the country but also introduce screening facilities at most lower level.

Lack of awareness

Anitha Chula travelled about 255 kilometres from Mafinga in Iringa to Mbeya Zonal Referral Hospital to screen for cancer of the cervix. She said she did not trust the lower level hospitals.

The 40-year old mother of six, by-passed certain facilities in the referral system, which could have offered her the service.

However, according to Mbeya Regional Medical Officer (RMO), Dr Yahaya Msuya, screening services for cancer of the cervix are offered at district hospitals which Chula by-passed.

Patients such as Chula's case at times pose a burden to Mbeya Zonal Referral Hospital because of lack of awareness on how the referral system works.

When asked by The Citizen whether she knew of the services at lower level health facilities, Chula simply said, "I didn't know."

A nurse at the hospital who screened her, Ms Ruth Fungo, confirmed that she was receiving several of such cases on a daily basis.

"It's quite challenging because it complicates service provision here. What we offer was designed for those who arrive here through the referral system," said Ms Fungo.

"We can't turn them away"

Despite the fact that some of the patients arrive at the hospital without following the referral procedures, they can't be turned away for ethical reasons. So, it remains the hospital's burden to take care of them.

"We simply have to help them but we take trouble to educate them that the same service is also available near their homes," said the nurse as she also hinted on certain patients who simply go to the referral hospital because they live close to it.

But according to Dr Mbwanji, the country's national referral system, despite the great strides made in recent years, it needs major reforms. This is the same in other countries in Africa.

This has created a perception among people that better health services are only available at the bigger health facilities and not the primary ones. But, he says, that does not mean that the lower level health facilities need not be strengthened.

The expert's proposal is backed by a study carried out in 2008, titled: "Referral pattern of patients received at the national referral hospital: Challenges in low income countries," published in the East African Journal of Public Health.

"Efforts to improve referral systems in low-income countries requires that the primary and secondary level hospital services be strengthened and increased so as to limit inappropriate use of national referral hospitals," the study recommended.

In as far as cancer is concerned, Dr Mbwanji proposes that there be capacity building programmes for healthcare workers who serve at lower level health facilities and the provision of necessary medical facilities for diagnosis and treatment.

Data obtained from the Regional Medical Officer's office shows that only 16 per cent of almost 178 wards is covered with health centres in Mbeya Region.

In Mbeya, whose population according to the 2012 census stands at almost two million people, there is 44 per cent coverage with dispensaries, data further shows.

This, according to the RMO, makes Mbeya Referral Hospital and Mbeya Zonal Referral Hospital carry the burden of the service that cannot be offered at the primary level.

"It shouldn't be a necessity for a person to travel a 100 km just to get his or her wound stitched," offers Dr Msuya.


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