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

Monday, June 29, 2015

JamiiSawa Office and computer lessons

Volunteering @ MamboViewPoint – 20 May 2015 – 17 June 2015
By Niko Winkel

For more information:

I wake up every morning shortly before sunrise. To the people living here, the days really last from sunrise to sunset. This is also how they keep track of time: 7 A.M. is called the first hour of the day: ‘saa moja kamili’. The night really falls here: within half an hour, the sky is pitch-black (unless the moon is full, when you might even be able to read outside!). Thousands of stars light up in an infinite black sky. When you walk on top of the mountain, where the house for volunteers is located, it seems as if you find yourself in a quiet and immense theater. However, there is some noise: sounds carry far through the valley. A cow, a rooster. And on set times you hear the muezzins, resounding through their speakers. But even more clearly you hear the children by day. There are so many! 5000 people inhabit the village Mambo, and 2000 of them go to primary school.
Computer lessons with Niko
Computer lessons with Niko

Mambo is located two kilometers lower in the valley. Pikipikis drive around. They bring you from village to village (or from MamboViewPoint to a village) for a very small amount (according to Western standards, that is), yet most people walk. They walk endlessly. The students who attended my (by myself developed) Word and Excel lessons over the past month, walked one and a half hour to MamboViewPoint and back. Ally and Josef are MamboViewPoint’s guides. They both live in Mtae, the village visible on the next ridge. They walk every day, even when there is no work for them. It is at least an hour walk. But when you join one of their beautiful hikes alongside the cliff, to the caves or through the rainforest, it seems as if they do not encounter any resistance. Local men are as slim as Twiggy was in her best years. Women too, by the way – even though being slim does not give a woman status here. It is all about work, here in the mountains. Somebody told me people work even harder than they used to do, which, apparently, is partly because of MamboViewPoint’s efforts.
Herman and Marion, the MamboViewPoint couple, left Lienden, The Netherlands six years ago in order to spend the rest of their lives living from the profit of their lodge and living for assisting the local people in building up a healthier life with more prosperity. This is definitely possible: people here are poor, yet often without good reason, since the land is very fertile. Would they give their cow a bit more proper attention and medicine, they would get a lot more milk. Would they give the women who traditionally help mothers give birth a bit more education, they would save lives (child mortality is very high). Would they have a heater that smokes less, they won’t sit in their clay houses breathing smoke all day long. Babies sleep there as well: you can hear them, but the heavy fog obstructs you from seeing them. Long diseases are the major cause of death here.

Dinner @ home with the local computer teacher Henrish

Dinner @ home with the local computer teacher Henrish

Water facilities should be touched upon as well. MamboViewPoint organizes the digging of wells and the building of the Blue Pumps of Fairwater. Those pumps work for thirty years. It is not just a matter of installing them: MamboViewPoint takes care of the pumps and ensures the fact that people cannot use them freely, since that would miss the whole point of sustainable development.
Since the beginning of 2015 MamboViewPoint’s community development projects are organized from the new foundation ‘Jamiisawa’ (solidarity).

My own goal was something entirely different. Of course, it was a participating observation. My own project is, indeed: getting to know Tanzania from the perspective of good development projects that employ international volunteers. I am no nurse, no agricultural expert, no technician, no social worker. Yet, most international volunteers are not either. Even worse: they are about twenty years old and do not have a single expertise that ordinarily would justify the fact that you are coming to teach the local people something (sorry, youngsters). 

My productivity in four weeks: developing and shaping the library consisting out of 250 titles. I built a computer system for it, which Hoza (Jamiisawa’s manager) can use to keep track of the management and borrowing processes. Hoza is very content with it.
I also made an extensive PowerPoint presentation that teaches Word and Excel to beginners. Jamiisawa hired Henrish to teach students. Six computers are lined up in Jamiisawa’s classroom: four are small tablets and two are big laptops with a Spanish keyboard. I now know the symbols you get when you press one of the keys (many actually refer to something else). The upside-down question mark, for instance, is actually a ‘)’. Rafael, a retired Spanish teacher, visited MamboViewPoint a number of times. He taught English to kids at the primary school, and left a couple of old laptops. Hoza’s laptop is also Spanish, and I taught him Word and Excel very intensively.
Hoza’s other project is copying: people often need a copy of something. An identity document, a contract, whatever: they climb the mountain in order to use the area’s only copy machine for 300 shilling per copy (which ends up in the community fund, even though people do not know this). Hoza keeps track of this in an Excel sheet. I inserted some formula and secured the sheet. The only thing he has to do is keeping track when, for whom and how many copies he makes. He had already made a lot of mistakes, so the money they had in stock was not in accordance with what they thought they had.

Introducing efficient, smokeless stoves
Introducing efficient, smokeless stoves

The computers here are the only ones in the area. Two of the students that attend our classes every afternoon, are teachers at a primary school in Kwentiindi, a village four ridges and valleys away. They listen carefully when I do magical things on the computer. Especially Excel is fun: I notice myself enjoying playing with it (“look, when you enter this, and you press that key..” and the subsequent astonishment in their eyes when all numbers change instantly). 
These guys are teachers with a moderate knowledge of the English language, even though they teach English themselves. The other students attend secondary school and are between the ages of fifteen and nineteen (although guessing an age is difficult: I initially thought that the two teachers were students). Their English is even worse. They do not know how to say something like “I do not get it yet, can you explain it again?” and only say “yes.” Do you understand? Yes. Don’t you understand? Yes. When Henrish – I practically am the teacher’s teacher – teaches the students, he looks over their shoulders, gazes at the screens, and seems to be mastering the students and matter. Yet, this is only appearance: Henrish knowledge is limited as well. Even though I explained him time and again that creating space in a Word document should not be done by using the ‘space’ key (“Henrish, spaces are invisible devils: they move your text over the edge of the paper when you change something”), he continues to do it. Repeat, repeat, repeat: Marion says. I am actually the same: she always needs to repeat things to me. Well, Marion, I get it now. Development happens slowly. Herman’s and Marion’s stories about their projects and developments during the past five years are characteristic of this: sustainable development does not happen overnight. Nevertheless, it is sustainable. It lasts. There is a lot of development happening here.

Bringing smartboards to the primary schools
Bringing smartboards to the primary schools

I had one other project. Using Excel, I built an administrative management system for the Jamiisawaa foundation (which employs eleven people: some temporarily and some permanently). This system will hopefully account for a good start for Herman. It was secondary work: work for the foundation, without being in direct contact with the locals. Yes: I had an office-job on top of Mambo’s mountain. Even that is possible! It actually seems quite surrealistic.

Everything I described so far accounted for about half of the hours I spent at MamboViewPoint and its Jamiisawa foundation. MamboViewPoint is the organization that funds many community projects. Jamiisawa is the foundation led by locals and is not subjected to business taxes.
The other half of my time allows for getting to know the area better. Together with one of MamboViewPoint’s guides, you can do fantastic hikes through the mountains. Volunteers can do such (half- or full-day) hikes for free. I also got Swahili lessons from Josef for three weeks (an hour every morning). There are, moreover, colorful markets on set days in different villages. Multiple times Hoza or someone else took me to visit a school. We, for example, delivered instructive school plates (smart boards) at schools. Makanyaga made those: he works as an artist for Jamiisawa and is involved in the ‘drop-in project’ that overlooks children who dropped out of school. Makanyaga painted a big mural on the longest wall of my room, depicting my own family (according to photos I gave him) in a Kilimanjaro-like environment. Gijs from Alphen aan den Rijn (The Netherlands) began a circus in which kids perform. During the weekends, kids ride their unicycle down the mountain.

MamboViewPoint also shows their guests opportunities to contribute. You can, for instance, plant trees. It is useful to restore the former tree population: the Eucalyptus trees that consume a lot of water (and other trees as well) actually need to be replaced by local tree species. You can also sponsor a smart board. When you become a ‘Friend of Mambo’ you will be in the system, which allows you to sponsor many great projects. This is very rewarding, since everything will end up at the right place.

Artist Makanyaga paining Niko's friend and children in the volunteer room
Artist Makanyaga paining Niko's friend and children in the volunteer room

During this period I was the only volunteer at MamboViewPoint. It was a relatively quiet time, there were not many tourists. Sometimes ‘overlanders’ who travel through Africa by jeep dropped by. When there were tourists, things instantly became livelier. I was just here in mid-winter! In terms of the weather this was obvious as well: I was wearing a sweater most of the time. By night the temperature dropped to ten degrees Celsius. The Kilimanjaro, 160 kilometers away, is usually visible from the mountain’s ridge, but I had bad luck: I did not see it once. Nevertheless, the Kilimanjaro is only the cherry on top: I gazed at the valley every morning, seeing villages 1300 meters below me, the Pare-mountains on the other side and the Mtae-ridge in the east. In the west you can even see the highway from Dar to Arusha. It remains a wonderful sight.

In July a Polish creative agricultural expert, a couple of midwives, a teacher from The Netherlands and a group of students from the United States will visit Mambo. The tourist season is about to start as well. Marion and Herman suffered from the Ebola epidemic quite heavily (which is strange, since Western-Africa is very far away), but their social organization and community projects keep flourishing. Marion just got back from her first visit to The Netherlands in six years. The culture shock was immense: she is glad to be back and had difficulty comprehending how neat the country was (“I would not be able to live there any more”).
I am grateful for having been able to stay at MamboViewPoint for a month. That might sound quite devotional, but I truly mean it. I perceive it as a privilege that I was able to add a month of such wonderful experiences to my life. 

I can now start to translate this story to my own project: GoTanzania ( That is what it was, initially, all about: spreading the word about the real, genuine development organizations that employ volunteers in Tanzania. This was a great start.

Niko Winkel, 19 June 2015.

Sunday, November 23, 2014

The history of a water pump in an African village

A  case study  Mtindili / Mbawai  subvillage, November 2014
Blue Pump installed by Mambo View Point / Jamii Sawa
At 1728 m altitude in the Green Valley near Mambo Village, Tanzania

By Niek Hoorweg, MSc & Professional Volunteer @ Mambo View Point eco lodge

Description of the area around Mambo village

The village of Mambo is composed of several sub villages, including Mtindili. Mtindili is actually a valley with remnants of a dry riverbed. The river / stream is said to have been perennial until 30 – 40 years ago. Now it only contains water for several hours during peak discharges after a shower. The major part of the valley has fertile soils and is largely terraced for agriculture. The main crops are potato intercropped with beans and maize.
At the high end of the valley there is a small independent catchment area (Mbawai) with plenty of water until recently. At the high end of the valley a traditional hand-dug well was constructed about 7 meters deep. This traditional well is now running dry and users (mainly children) are spending hours for fetching water which is not clear.

Niek with the new Blue pump

Environmental restoration and -management
Our team was asked to drill a well upstream of the traditional well. The first test drill failed by hitting bedrock at only 3 m depth and expectations were low. However, the second test drill reached a depth of 10 m and a subsequent pump test yielded 33 buckets , 10 liters each. The standard survey screen casing (2 m) was from 5 - 7 m in a rather non-defined aquifer. This yield would normally not justify the construction of a tube well with Blue Pump, costing around 3.000 Euro’s.
However, upon request of the Village Water Committee it was agreed to construct the well under strict conditions :
-          Cut all Eucalyptus trees (invasive species) around the (upper) edge of the catchment area
-          Replace these trees by planting local varieties like Mvumo, Mshai and Mkuyu.
-          Introduce strict supervision by the Village Water Committee.
The interesting status of this small Green Valley is that no agriculture is allowed (by village by-law). Only one month per year, the green pastures are open for grazing cattle after the Idd ul Fitri feast at the end of the Ramadan. 

The drilling team in action

History of water supply around Mambo village
A.   German settlers (Thirties)
The earliest foreign interventions for water management were done by German settlers.
They constructed a dam at the edge of Shagayu forest. This was a successful effort by colonists in the Thirties, reflecting high quality civil engineering. The water was mainly used for irrigation purposes, but the water quality was probably good enough for drinking purposes. In the meantime the valves of the dam are broken and the water supply dried out since most water is taken higher up for drinking water and (illegal) irrigation.

The dam which is still strong but not functional since the valves are broken

TIRDEP (Eighties)
Tanga Integrated Rural Development Project was running parallel to the Dutch rural water supply project in Morogoro : Mradi wa Visima (1978 – 1992). In fact TIRDEP procured their equipment for shallow wells from Morogoro. First they provided a kangaroo spring pump but later changed to the the Morogoro model called SWN 80 pump (Sociale Werkplaats Nunspeet, introduced in 1980). The design of their installed  handpumps is exactly this SWN 80 Pump On several places some leftovers from foundations or even working samples are found. Most of these pumps however collapsed and the holes were not well preserved and became unusable like in Mbawai.
The remaining’s of a Kangaroo spring pump which were placed during the seventies

A.   World Bank (1996)
A concept master plan was developed by the World Bank during the mid-Nineties. Mr  Ibrahim (79 years) remembers how he was involved in that process in his function of Mtendaji (Village Executive Officer). However, the WB did not succeed in raising sufficient funds for implementing their plans.

A traditional well

A.   Idara ya Maji, Water Department Tanga (2000)
As far as I know, Idara ya Maji for some time has run a rehabilitation programme for handpumps in Tanga Region. Their standard hand pump is the SWN 80 model, as introduced by the Dutch and is still placed by the government.
In general their program involved replacing the yellow pumps of the TIRDEP –range. In the case of our Green Valley, the existing traditional HDW (Hand Dug Well) was modified to host a hand pump. The ring well was fully covered (with wood and cement) with a pre-cast cement pump stand in the middle. The newly installed pump was beyond repair when we visited this well with the Water Committee in April 2014. A few weeks later it was removed to give clients access to the water by using the bucket-and-rope system.

The left overs during a visit from Blue pump sponsor Ralph Tuijn (right on the photo)

B.   Mambo View Point (2011 – present)
The next (known) intervention came from Mambo View Point eco lodge in September 2014. We know that local (environmental) management is a key to sustainable Operation and Maintenance (O&M). The Green Valley has no distinct aquifer , but the soil is somehow saturated with water from a depth of 6 m onwards. Hence, our drillers kept drilling and reached even 12 m, with volunteers from the village (Nguvu Kazi) ! So far this is our deepest tube well, with the longest screen (6m).
We used a PVC screen which is produced in Tanzania and comes in standard tube lengths of 6 m.
The drilling team now also masters the skill of making slots during a laborious exercise using a hacksaw and much patience…
And the newly installed Blue Pump is expected to last (almost) forever. This valley has the potential of becoming a “show case” for sustainable O&M. We will coach this process with inputs from the newly established office of Jamii Sawa (NGO), the implementing partner for village development projects.

One of the few SWN 80 pumps which is still working but in a terrible condition. This one was replaced by the government in 2010