Berega Hospital Development Plan for Reproductive Child Health
(draft 4)
The Problem
Tanzania has one of the worst maternal mortality ratios in the world1, mainly due to the combination of poverty, lack of education, lack of understanding of disease, long distances, poor family planning, and poor transport.
Furthermore, the rate of neonatal and child death is probably even more serious2, but currently difficult to measure in impoverished, isolated rural parts of the country, where as many as 10% of children are expected to die before their fifth birthday. Chronic malnutrition contributes to almost half of these deaths.
Within this context of rural Tanzania, Berega Hospital serves a vast and inaccessible territory of approximately 100 x 70km. This area has just two tarred roads, and, according to the 2012 National Census3, a population of 217,000. Extrapolating from the national data, there are 8,500 births/year, of which only 1000 occur in a health facility.
Many roads are impassable in the rainy months, and others are only negotiable by long, expensive, and dangerous three-person motor-bike rides, (comprising for instance a driver, a labouring woman, and a carer/blood donor). Berega provides the only Comprehensive Emergency Obstetric Care (CEmOC) facility in this territory – ie capacity for caesarean section. Even for those few who live near the main roads, travelling to any other CeMOC facility is both unaffordable and impractical, (70km to Kilosa; 110km to Morogoro; 180km to Dodoma).
Millennium Development Goals (MDGs) IV and V from Tanzanian 2012 census
Of particular importance in developing the health services of this area is the need to address the MDGs IV& V – Under-5 and Maternal Mortality. The national census3confirmed that the rural areas have a particular problem, made worse by the lack of education and lack of access to birth control. Women have large families, and expect some of their children to die – and even perhaps to die themselves.
The maternal mortality ratio for Tanzania in 20123 was 454 women dying for every 100,000 live births, (ie 0.45% of mothers die in each childbirth). The worst in the world is 11001, (1.1%), and the best is 2, (0.002%). As the Tanzanian figure is the average for the entire country, it is likely that in isolated rural areas, the figure for mothers who die in each childbirth is nearer to 1% than 0.45%.
This means that in Berega’s territory, at least 40, and perhaps as many as 80 women per year die in childbirth. Many more suffer chronic disability, such as vesico-vaginal fistula, (VVF). VVF has a profound effect not just on the woman but on the family – she leaks urine from the vagina 24 hours/day. This makes it very difficult for her to live in the cramped conditions of rural village life, and yet the survival of the children depends on her.
The 2012 Census under-5 mortality figure for the country was 8.1%3. This figure will be a considerable under-estimation in the isolated rural areas. This compares with, (for example), 10.1% in Afghanistan2, and 0.2 to 0.5% for most European countries.
In Berega’s territory, where there are 8,500 births/year, this under-5 mortality rate means that perhaps as many as 1000 of these will not reach their fifth birthday, mainly due to the combination of poor nutrition and chronic but easily treatable disease. The under-nutrition is a vital component of the mortality, because of its effect on reducing the capacity to resist illnesses such as diarrhoea and pneumonia. In impoverished rural areas, many children survive mainly on thin porridge, (‘ugali’).
In Europe, North America and Russia, less than 2% of the population live on less than $2/day4. In Tanzania, the figure is nearly 90%4.
The Vision
The vision is to reach out to isolated communities, working with the Traditional Birth Attendants, (TBAs), VHWs and village leaders, to develop a system of assessment and early referral of women with problems in childbirth. The TBA would accompany the woman to hospital.
Furthermore, Berega's outreach to these communities would work with both the TBAs and trained Community Health Workers5,6 in a partnership to enhance ongoing maternal-child health and nutrition, eg improving child nutrition; recognition and early treatment of severe or chronic illness (such as malaria, anaemia, diarrhoea, TB, infestations, HIV); immunisation; registering families and following up the disadvantaged; and family planning. CHWs will also help improve collection of information – eg demography, birth rate, etc.
This would be happening in the context of an integrated community development driven by a planned partnership between:
· the local community;
· Berega Hospital;
· the American community development charity Hands4Africa, (H4A);
· the UK Berega charity Berega Relief Education And Development, (BREAD);
· the UK maternal health charity Ammalife;
· the Anglican Diocese of Morogoro.
The aim would be the enhancement of the transport, data collection, economy, education and facilities for currently isolated communities. A number of other charitable organisations are interested in providing start-up support, for instance the Diocese of Worcester, and Kofia.
The Strategy
We have selected the community of Mnafu to begin the programme. The aim, ultimately is to reach a point of self-sustainability in health and community development. We will only to move on to address the needs of other isolated communities, when we feel that we have learnt sufficient lessons from Mnafu, and when to move on will not reduce the prospect of Mnafu and the surrounding communities achieving self-perpetuating development.
Phase 1A: Community Base - Reproductive Child Health CHWs
At the centre of the project will be bespoke Community Health Workers, learning lessons from and communicating with similar Tanzanian projects5,6. A team of mature, trained,7,8,9female RCH Community Health Workers will approach the community of Mnafu. At first they will be accompanied by the Project Lead Dr. Abdallah, (who is also the Head Doctor of the hospital, and Maternity lead. He is just completing his Masters in Public Health, with a specific interest in maternity outreach in rural Tanzania). The CHWs will be recruited from staff who have worked for many years in maternity in the hospital.
Their role in the first year will principally be the gathering of information, and the establishment of partnership. Amongst other duties, they will need to:
- Meet village and school leaders and establish credibility and shared purpose;
- Meet mothers and hear their story, and learn about their perceived needs;
- Meet TBAs and learn of their practices, their concerns, and their ideas;
- Meet Village Health Workers (VHWs) and discover what records and registers they keep, what the problems are, and what their thoughts are on solutions and priorities; (For the purposes of this paper, the distinction between VHWs and CHWs is that the former are villagers based in the community, whereas CHWs are health workers reaching out from the hospital10 . Nevertheless, there is considerable cross-over in the literature between the two terms.) Where there are no VHWs, the CHWs could help in establishing them.
- Discover what currently happens when there are problems in childbirth;
- Assess other health issues relevant to health and well-being of mothers and children, such as malnutrition; family planning; HIV; STDs; TB; Malaria
- Discuss with the appropriate people about systems for ‘Road to Health’ charts, in particular for monitoring growth and immunisations in pre-school children. This would, in the fullness of time, work alongside a mature schools health programme for children of school age.
- Attempt to obtain raw data on rates of death and serious complications, and try to enhance future collection of such data;
- Assess the current frequency of attendance of women from Mnafu (and environs) to Berega, and determine what problems they come with, and what outcomes currently occur.
Whilst this is occurring from the hospital side, H4A, using their own funding, would have begun their programme by enhancing the transport possibilities from Mnafu. At the same time, they would have begun the negotiations to begin food and cash-crop agriculture to the community, as well as to begin the building of a facility which in future could be used as a clinic.
Phase 1B: Hospital Base
At the same time that these beginnings are being made in the community, the hospital will be looking internally at its processes and patient pathways, to optimise the care for mothers and babies when they reach the hospital.
In relation to mothers, minimum standards of care have been set out in a hospital charter, which came from the hospital staff themselves, in order to work together to improve outcomes. An example is the 30-minute decision-to-readiness time for emergency caesarean. The entire Charter is available on the blog site.
With regard to children, Phase I needs to concentrate on:
- Emergency Triage Assessment and Treatment, (ETAT), which involves the recognition of sick children, and appropriate management, especially in the first 48 hours;
- Ward protocols for the Children’s ward and the Premature Baby Room, to include screening for and treatment of malnutrition (and any underlying causes), as well as routine daily feeding of children;
- The initiation of Road to Health charts for those under-5s that do not have them.
Phase 2
When trust and partnership have been established, the next phase of work would be to begin to bring women into Berega for giving birth. Whether this were all women, or selected ones, would depend very much on the results of liaison with the TBAs. There may be local solutions to some of the problems, and these should not be ignored.
It is clear that, given the long distances and the speed with which complications can occur in labour, the ideal would be for all women to deliver in a CeMOC facility. This, however, is impractical for many years yet, and the project will explore the most suitable working compromises – which will evolve with time.
When the transfer policy is decided, one potential model is that TBAs will thereafter accompany women-in-need to hospital for childbirth. Whether they will be paid a small amount for their involvement will depend on how the plans unfold after community liaison, and will be heavily influenced by policy and evidence. Whatever model is adopted, it will need to be self-sustaining financially. There is, however, considerable scope for this, given what families currently pay – for instance for those women who transfer in using private transport, and subsequently need to pay for caesarean and /or extended stay.
When women have successfully followed this pathway, and delivered healthily in hospital, these will then become ‘flagship pregnancies’. The RCH CHWs would follow-up those women and babies back in the community, to try to enhance breast feeding, family planning, immunisation, growth charting, under-5s nutrition, and prevention and treatment of diarrhoea, malaria, worms, and other chronic conditions. This would be centred at a purpose-built health and community facility.
At the same time, registration of families would help ensure that no-one was left behind and that measurement of the effects of intervention might be realistic.
The aim would be to produce a high-profile cadre of mother and babies who have survived childbirth and early child-rearing healthily. These would then encourage others to do the same.
Phase 3
Assuming an appropriate unfolding of the first two phases, the need would then arise for fully staffing the clinic facility at Mnafu, upgrading its resources and equipment, and later providing a birthing facility for uncomplicated women. The upgrade of the building would be provided by H4A, in association with the community itself.
In relation to staffing, and in readiness for arriving at phase 3, Berega needs now to begin its application to begin a Clinical Officer (CO) training programme. In rural Tanzania, COs are the front-line staff. Having achieved a high standard and good grades in high school, student COs are trained for three years in the management of childbirth, and of all common illnesses. Clinical Officers can staff a clinic and birthing facility, and are especially taught in regard to the recognition of those patients who need to be transferred to hospital.
Not just COs but also nurses are needed for dealing with the extensive health care needs of Berega’s population. As with COs, it is important for Berega to have a sustainable strategy of training its own nursing staff. The existing nursing school (SONAB), which trains to Diploma level, recently had its first graduation but is only part-way through the staged expansion to full capacity. It is vital, then, that the growth of CO education does not impede the completion of SONAB’s plans, but rather works with it in collaboration, and enhances it.
Fundraising for building the classrooms, offices and student accommodation for this combined ‘Health Education Institute’ has already begun. There are significant set-up costs, especially in relation to buildings. The SONAB building plans will be melded with the CO training needs, to produce a composite building strategy. This will mean that the funding gap in CO and nurse education will be principally in the first three years. These costs will be considerably reduced by the existence of H4A’s already-purchased compressed earth technology, which will provide very high quality building materials at the lowest possible cost.
After the buildings are complete, fees and other income of the Health Education Institute will need to be set at a level which is self-sustaining, and which will pay for both the faculty and the day-to-day costs.
Plans are being developed for recruitment of a supplementary visiting faculty to enhance the training at no extra cost, enabling the School in future to be self-sustaining on training income.
Phase 4 – the long term vision
As educational opportunity improves for the children of Mnafu, we hope eventually to be training as nurses and COs youngsters who have come up from Mnafu schools. COs, after practising post-qualification for a minimum of two years, can then carry on and be trained as ‘Assistant Medical Officers’ (AMOs), who are in effect the doctors and obstetricians in rural Tanzania. Although the tendency is for COs to look for work in less rural settings, it would only take a few of the best students to stay on, to enable the gradual building of a motivated and locally-derived sustainable workforce. The same comments apply to senior nurses and to future educational faculty.
The cost of expanding the staff of Berega to offer positions to graduates of the School would be readily covered by the increased income related to numbers of patients treated. In maternity alone, there are more than seven times as many women currently delivering in the community as deliver in the hospital.
Once CO training is established, and both hospital staff and training faculty are self-perpetuating, it raises the prospect of future expansion of the School of Health, for instance to increase training of laboratory workers or CHWs.
The long-term vision is to have an economically viable community, with good health and educational facilities, and a lattice-work of COs, CHWs, VHWs and TBAs working within a well-oiled mechanism for early transport of the needy to high quality high-tech facilities at Berega Hospital.
As soon as the lessons had been duly learnt from Mnafu, Berega could then begin outreach to another community in need, until all of the isolated communities have been reached.
References
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