Tanzania: Telemedicine Set to Improve Health Service
BY JAFFAR MJASIRI:
DR Donald Mawalla, an Obstetrician/ Gynaecologist working with a project that has actively upgraded, renovated or rebuilt 12 rural health centres and five hospitals.
The objective of the project is to safeguard the existence of life-saving to mothers through comprehensive emergency obstetric care in some remote regions of the country. It is organized by World Lung Foundation and sponsored by Bloomberg Philanthropies and Agerup Foundation.
In an interview with our Staff Writer, JAFFAR MJASIRI, Dr Mawalla sheds more light on the significance of this project. Excerpts...
QUESTION: Give a briefbackground of this project and its relevance to the country?
ANSWER: The World Lung Foundation project has actively upgraded, renovated or rebuilt 12 rural health centres and five hospitals to safeguard the existence of life-saving comprehensive emergency obstetric care (CEmOC) in three regions of Tanzania.
The project is organized by WLF and sponsored by Bloomberg Philanthropies and Agerup Foundation of the US. In 2011 more than 21,000 deliveries have been attended and among them almost 2400 Caesarean sections in supported health facilities. A total of 106 health workers have been trained in such courses in rural areas of the country.
Q. How many facilities have been upgraded?
A. Since 2008, the project has actively upgraded, renovated or rebuilt 12 rural health centres and five hospitals to safeguard the existence of lifesaving comprehensive emergency obstetric care (CEmOC) in three regions in Tanzania; Kigoma, Morogoro and Coast regions.
These services include caesarean sections which are carried out in upgraded but hard-to-reach health centres, where there are no physicians. This includes operating procedures at village levels as well as giving blood transfusion. These clinics are situated in very remote areas. The nearest is about 250 km from district hospitals. So far the project has used almost 14 million US dollars.
Q. When did the project start?
A. It started in 2007 and became operational the following year in 2008. The project started in Kigoma. Kigoma was our priority because of the remoteness of the place and the population which was in need of health service. It was a perfect place to start with because poor roads infrastructure and other communication challenges. Other regions where the project is taking place has the same characteristics the same as Kigoma.
Q. What are the phases of the project?
A. First it was to improve the health centres' infrastructure. Then we started training surgeons and anesthetics. We also equipped the facilities various types of equipment; including theatres, power supply such as generators, solar energy and water supply. The construction of health centres' staff houses was done which was meant to make life easier for the medical personnel.
Q. How did the policymakers react?
A. Talking to decision makers was not difficult. Since the project is working within the policy and strategies of the Ministry of Health and Social Welfare. Moreover these facilities belong to the government and will remain in their ownership. Our role, therefore, is to give them (health centres) a wider scope of work.
Q. What were the criteria for choosing the regions for the implementation of the project?
A. This was based on the needs assessment and no political influence prevailed. What determined where the project should go was the locality of the catchment area. We considered the referral point of health centres, as they cannot refer their patients to district hospitals.
For example in Kigoma's Bulungu location was selected for upgrading. The reason is that the area is extremely remote and it takes 10 hours by boat to reach the district hospital.
Q. How has the project helped Assistant Medical Officers (AMO) and nurses in rural areas?
A. Going by Kigoma experience, for example, the Regional Obstetrician is in Kigoma town, therefore, he cannot be everywhere in the region. The transfer of skills to non-physicians and nurses to save the lives of pregnant mothers and new borns is paramount.
The project's objective is to address the obstetrical emergency situation immediately so as to save the lives of the mother and child at the village level. Referring the patient with obstetric emergency condition to another bigger health facility which is far away is difficult due to unreliable means of transport and poor road infrastructure, many of which are impassable during rainy seasons. If this happens, death is imminent.
Q. What is your role as a medical specialist in the project?
A. As medical specialists, our role is to plan and implement the project to be able to reach the goal of upgrading clinics and training their staff by providing them with supportive supervision.
Q. What kind of support do you give them?
A. We do it in two ways. One by physically visiting the health centres, talk to the Assistant Medical Officers (AMOs) and nurses, and listen to their problems and conducting continuous medical education. The specialists also provide mentorship to the personnel. We give them ideas aimed to improve their skills.
We also perform and demonstrate clinical procedures and assist them where there are emergencies. We also take our projectors to the village to show the trainees films on procedures and continuous medical education. We are at the same time in constant communication with health centres' workers through emails and teleconference.
Q. How do you get feedback from the designated health centres?
A. Every month a nurse or AMO who is assigned to file a report from the centre writes to us. The report captures all the activities that have taken place at the clinic for a period of one month. It includes total patients who delivered babies at the clinic. It also indicates the mode of delivery whether it was normal delivery, C-section or a vacuum extraction.
The report also gives the outcome of the procedure of all what happened. They have to report if there was no problem experienced, or the number of patients who had complications and details of complications. It also documents the outcome whether it was death, "near miss" or survival.
Furthermore they have to submit non-clinical needs or problems such as lack of drugs, instruments and problems with generators or water pumps, vehicles and fuels and other problems. Also a special report is required on administration of anaesthesia and the procedures he has performed and other problems that arise.
Q. What happens after receiving the reports?
A. We work critically on the reports to find out any problems which can be rectified or tackled by our office.
Q. You mentioned telemedicine. How does it work?
A. The country is very big. And communication is still a challenge because of poor infrastructure. In some regions it is difficult to reach rural areas where majority of Tanzanians live. In order to reach the health workers in such areas we need communication, hence, the urgency of telemedicine.
Q. Can you explain what telemedicine is in this context?
A. Telemedicine is a conference or meeting which is conducted through telephone, drawing participants from various health centres and hospitals in a specific area to discuss, in a nutshell, what has transpired during the week.
It is an opportunity to highlight problems and discusses the magnitude of the problems. One of the specialists among the four of us working with the project normally moderates the discussions. We then share experiences while everyone is on the telephone line. Everyone gives suggestions and exchange views on the best way to handle the medical case arising from the discussions.
The objective is to achieve uniform care countrywide. If a medical practitioner has handled a clinical case in a wrong way, once the corrections are made during the teleconference, someone else will not repeat the same mistake next time.
Q. What does the post course assessment entail?
A. It is a refresher course assessing our people after training them. When they go to health centres to work after a period of time we bring them back for two weeks to assess their performance and share experiences with them. And it is also meant to conduct a continuous medical education on specific areas.
It gives us the picture of our training and points out to the shortfalls of our training programme, so that we can make improvements. We have also started on the site supervision. We post the specialists to remote health centres to work with the staff for a week.
Q. What are the challenges in telemedicine?
A. We face a lot of challenges since we have just began this programme. Sometimes we experience the problem of connectivity, because of poor reception or network. Also there are some areas in the villages where the coverage is poor or not existing at all. But we are optimistic that once the fibre optic project is in full swing it will address some of these shortfalls. Airtel is supporting the telemedicine programme.
We invite any other interested parties to support the telemedicine programme. We are also working together and closely with the department of telemedicine in the Ministry of Health and Social Welfare to start video conference trials. The Ministry along with many other faith-based NGOs are working towards the same goal of upgrading the health centres and hospitals around the country.
Q. Are there any challenges facing the project?
A. These range from funding to human resource. At the health centres after upgrading the clinics, deliveries and surgeries are now being performed. The utilization rate of the health facility has gone up because of the increased number of dispensaries which feed to the health centres.
Many people in the villages are aware of the improved services that are now available at the health centres in the village. Therefore, there is an increase in the number of patients visiting the rural health centres that are covered under the project.
Therefore it becomes overwhelming to the existing staff in the centres. These people are coming to the health centre not just because the services are available, but it is the quality of services which are very good. The patients, I should say, feel safe and secure to get treated in the health centres at the village. As a consequence of this improvement of health centres the staff are overworked.
Maybe the centre had two AMO who were dealing with five deliveries a month, suddenly after the changes they have to handle 100 deliveries a month. Of course, these are not just normal deliveries; there are still only two people who are outstretched and overworked.
At the same time the allocation of consumables to the health centres remain the same. They continue to face shortage of drugs, etc. Oftentimes the project has to send emergency supplies while these centres are waiting for the government assistance to increase the allocation.
Q. What about the project giving incentives to the centres' staff?
A. We cannot do much to the doctors and nurses in these centres in terms of monetary package.
Q. What is the future of the project?
A. At the moment the cost of training and upgrading the health centres are met by donors. But this particular project is coming to an end in 2015. What will happen and what will be the future is everyone's guess. However, we are working with the Ministry of Health and Social Welfare to find a way of sustaining the project.
It is very clear to every one of us that there is no shortcut to success, apart from investing more in this project which is important in reducing maternal mortality. For some reason if these health centres stop functioning, the community will lapse into miserable life.
Source: Tanzania Daily News (Dar es Salaam)