Friday, July 10, 2015

Exploring the health care system in Mambo area

By Geertruid en Hennie
volunteering @ MamboViewPoint in March 2015

After living and working for five years in the Pare Mountains, right across the valley at the bottom of the MVP cliff and many more years elsewhere in Tanzania, we eventually reached the Usambara Mountains, 20 years after we left Tanzania. MVP invited us to assess how MVP could contribute to an improved health care system in the area. A unique opportunity for us, back to the region where our children were born and grew up and where we felt so much at home..
Steep slopes near MVP with the Pare Mountains across the valley;
we lived there high in the mountains, in similar environment.
The 20,000 people of Sunga ward seek health care from traditional healers, drug shops and drugs vendors at the market and/or they go to a nearby dispensary of the government or the Catholic Church. While the government provides generally free health services, people have to pay for the private sector services, either in cash or in kind. What makes them choose the shop, healer or dispensary probably depends on the confidence people have in the service provider and/or on awareness about health, financial resources or on the influence of relatives. Many probably use both systems: the traditional and the modern.
We visited a selection of all the different health care providers in the area and talked to health workers, healers, community members and MVP staff. Each encounter with people offered opportunities to discuss issues related to health and health care.
Relatives visit a patient in Kwai Health Center, one hour from Mambo, run by Usambara Sisters

The government health care system

There are 3 functioning dispensaries that provide curative and preventive services 5 days per week; and 2 dispensaries that are not yet staffed but the building is there and the community is waiting for the services to start.
We visited all the five government health facilities in Sunga ward and a few more in neighboring wards in order to get a good understanding of the level of care, the services provided, the utilization of the services, staffing and the quality of maternity services. The building, equipment and staffing is all very basic and on average 10 patients seek curative care per day. The health services are so different from health care in Europe but also very different from health services in Tanzanian towns. There is not a single medical doctor or even clinical officer in the area, families depend on health workers with lower level education while the referral system to higher levels of care is not well developed yet. MVP staff feels rightfully concerned about the quality of care and so do the people in the villages around. Hopefully the government will soon deploy a few clinical officers who have better diagnostic and treatment skills.
Though the quality of the curative health care needs improvement, the preventive services are quite well organized. Children are immunized; pregnant mothers have access to antenatal care including HIV and syphilis testing and treatment and family planning services are given free of charge
Mother and child visiting Sunga dispensary; 
Meeting traditional healers and birth attendants

The area around Mambo offers a colorful scope of traditional health care providers. We were eager to meet and consult them in order to get a clearer picture of their specific role in the health care of the local people.  Soon after our arrival in Mambo we visited the widow of one of the most respected herbalists in the ward. She now tries to continue the herbal treatment of the villagers and offers herbs and plants for free. A group of women from her area help her look after the herbal garden.  
We do not know whether the herbs are really effective according to our scientific standards and understanding but the herbalist built her wisdom on many years of experience and herbal treatment is well known and often recognized worldwide.  Researchers in Tanzania are studying the effect of different herbs and plants. For common diseases like flue, abdominal pain, or headache treatment with herbs and plants is probably healthier then getting unnecessary antibiotics in a dispensary, as is often the case in Tanzania

The nurse in Mamboleo shows us the very well organized and well-stocked government dispensary

We then visited a totally different traditional healer in Sunga in his consultation room with open shelves full of small glass containers and bottles with different powders. The healer Ramadhani consults Islam based healing booklets and relies on an explanatory model of illness that is very different from our way of understanding illness and health.

Mganga Omari, another healer, living near Mambo Viewpoint, received us warmly and was eager to explain a lot about his way of diagnosing and treating people. He is aware that children need to be vaccinated, takes his own children to the government facilities when they are very ill and actively seeks collaboration with MVP and visitors like us.
The wife of the famous herbalist near Mambo; she tries to offer 
the same services with support from a group of women in her village
During a three days walk through the surrounding villages of Mambo, we met again another healer, well known in his village. He claimed to have strong predictive power, to be clairvoyant: he is able to predict illness even without the patient revealing his/her complaints. When people are not well informed about the human body and how the different parts and organs function, a healer like this man may impress the patient or the relatives.

We asked all healers whether they treat all diseases or maybe only specific complaints or illness. The majority claim that they can treat all diseases except death; a few are more modest and admit that they sometimes refer patients to the government health facilities nearby or to the hospital in Lushoto.

Training the healers, raising their awareness about the scientific causes of diseases and treatment protocols is probably not the best way forward. The traditional healers, particularly the faith based healers and witch doctors have their own specific way of understanding illness and good health and have very limited insight in modern medicine. Mutual respect may be the best option.
In the consultation room of the spiritual healer in Sunga; different medicines in the cupboard

Traditional Birth attendants

MVP has strong links with a group of women in Tema who requested support to become more self reliant and better birth attendants. We met the group a few times; strong outspoken women who are learning to speak out, mould their own development and demand support from authorities.

Mganga Omari shows us the roots and herbs he uses in addition to clairvoyance and rituals
Healer in Tema explains the use of the calabash in treating patients
Some women in the Tema group have a lot of experience as birth attendant and few were even trained by the government years ago, but the majority are village women who help out when a neighbor delivers and their experience is limited. A Dutch qualified midwife will soon train the Tema group and with more knowledge and skills the women will hopefully refer most pregnant women to the health facilities. The government wants all women to deliver in a facility but the reality tells us that this is not so easily achievable.  Distance, quality of care in the facilities and culture play a crucial role in health seeking behavior.

The group of TBAs in Tema; motivated to get more knowledge and skills to help their community

Exploring homestay places

Three days long we discovered the surrounding villages of Mambo on foot, together with Maud and JP who were supporting the management of MVP Eco lodge.  We spent 2 nights with local families and visited different community based projects or initiatives during the day: a pottery project; water pumps; vegetable gardens; a dispensary built by the community; some traditional healers and TBA. Everywhere people know MVP and talk positively about the support and opportunities for development received.
Homestay in Tema; we slept in the wing on the right side of the house.
It was a real privilege to stay in the homes of local people, to feel so welcome and sit with the family in the kitchen, watch them prepare the dinner for their children and for us and discuss their main concerns etc. It proved so helpful that we speak Swahili; it makes it so much easier to talk with the people, explain who we are, what we do, think, like… ask questions, laugh together and share some intimate thoughts.

The homes were comfortable and the care was great.  The families had improved the bath- and toilet facility; the children and parents will automatically benefit as well; small steps forward. 
  Preparing the dinner with the neighbor. Women spent a lot of time on food preparation
Mtae village is the capital of the division but just a village with only a few shops, a dispensary of the government and a large Lutheran compound with a church, a large graveyard, a community meeting center and a big health facility that is no longer functioning.  While they are expanding the church building, the health unit will turn into a ruin unless it gets a different purpose. The division has its headquarters here but the office looks small and under resourced. There is no ambulance but the public bus service reaches Mtae village.
The children join the parents and the guests in the kitchen; the stove is made of mud and smoke is controlled through adequate ventilation of the kitchen. The construction of the stove reduces the firewood needed for cooking
Along the village roads we see the farmers preparing the fields for planting and sowing.  In some years the farmers can harvest potatoes three times a year, a high yielding cash crop; with the money they get the farmers buy maize, their main staple food. Around Tema village farmers are working on well-planned terraces to prevent erosion. It is strange that not all villages construct terraces. We pass the a few bridges and a water pump that were constructed with MVP support. The support of Mambo Support Foundation is tangible here.

The environment

What a beautiful area with amazing views across the valley and the steep cliffs; with villages scattered over the hills and valleys and surrounded by tropical forest on a few sides. We walked half way down the steep hills towards the valley, along fields where mainly women and children were busy clearing and planting. After the work the women and children climb up the hill with firewood, grass or maize stems for the cows on their heads. A woman or child will not easily walk without anything on the head or back. Time is too precious for them. They collect firewood, water, and food for the animals at home or goods from the shops or markets. Every walk confirms our impression that women play a key role in the welfare of their families, they seem to always work.

The tropical natural forest, the villages

Joseph, a guide of MVP, accompanied us on a few walks. He knows a lot about the area, the local customs and its people. On our way we meet with children carrying grass for the cattle at home 
with markets and water points where people meet; the fields with cabbage, tomatoes, wild egg plants and maize; the shops with many people selling the same goods; the carpenters and tailors; the roads that are ever bending and all made of gravel or sand; the goats, sheep and chickens everywhere. One pair of eyes is not enough to see it all.  So we will have to come back!  

Fields along the road with elephants grass for the cows, holes for potato planting and cabbage deep down in the valley

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