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Tazama na Tunza: public health in Tanzania.

Ruth Chorley won the CPHVA MacQueen Travel Bursary for Public Health in 2013. She had dreamed about developing health work in Tanzania and winning the award spurred her on to making the dream a reality.

Tanzania (UK) Trust is a small charity whose objectives are to promote and protect physical and mental health, and advance education and the Christian faith in partnership with the local church and community. The vision of 'Tazama na Tunza' (Swahili, meaning 'Look and Care') is to care for those who have chronic conditions in the local community.

In 1990 my family and I had been living in Dodoma, Tanzania for four years, where I was working as a nurse with the Diocese of Central Tanganyika, setting up a community HIV care and education project. I became involved with a partnership between the Dodoma Capital Christian Church (CCC)--a large but very poor congregation, with their rural church plants--and a small UK-registered charity, Tanzania (UK) Trust (referred to here as 'the Trust'). The partnership was built over 24 years by personal friendships involving annual trips to Tanzania and trips from our Tanzanian partners to the UK. Over recent years group trips to work with the church and community in Dodoma have developed.

In 1990 a small mission medical service in Dodoma was running alongside the government hospital and public health service (which has now closed) and other private health services. All health services have to be paid for directly by patients (whether government or private) with a few exceptions. Sixty per cent of the health services are government run, but have minimal resources. As a result, most people only seek health care in acute situations and there is very little consistent chronic condition management as very few can afford the treatment.

Tanzania has the poorest doctor-patient ratio in the world, with one doctor per 52,000 population (the figure in the UK is 1:420). Tanzania rates 167 of 193 countries in global mortality ratings (World Health Organization (WHO), 2013). Tanzania is a country at peace, unlike most of the other countries below them in the ratings. Life expectancy is 59 years of age, and 55% of the population have access to clean drinking water and 33% to improved sanitation. The HIV rate is 5.6% of the adult population, with only 30% of those infected receiving ARV therapy. Sadly, there are many fraudulent medications that are labelled and sold as a specific drug but consist of chalk or similar (including antibiotics and many prescription-only medicines). There is almost no health education on chronic disease management at patient level so the vast majority of patients I visit have no idea how to help themselves.

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Over the past three years I have been visiting those with health problems in the Dodoma community and discussing a way forward with the local doctor, the local church and the Archbishop. The TAG church has a vision to set up health centres in every major area and work on this has already started. The local doctor sees the main need locally as health education and health promotion over chronic health conditions and we are in partnership over this joint vision. For the last three years I have been recording the lack of diagnoses, the main conditions, specific gaps in health knowledge and the prevailing health and social issues. The overriding factor is sheer poverty; if you live in a mud brick house with no bed, few clothes and no food for tomorrow, accessing a diagnosis for any condition is nearly impossible, as seeing a doctor and receiving treatment has to be paid for.

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The vision has grown of training a chronic healthcare team of volunteers in the community who live locally. The team has support from the local doctor in attaining correct diagnoses and initial treatment, sponsored initially by the Trust. Alongside this, a plan to build a health centre has been agreed, which will provide effective medication at a reasonable price and, long term, would make the project self-sustainable. The Trust will provide the finance for the initial new build and support for diagnoses if needed.

The CCC church community will own the Tazama na Tunza project and the health centre, when built, developing its own financial planning for sustainability. The Trust will continue its annual visits to update the Tazama na Tunza team in health knowledge, to encourage them and to oversee how the project is going overall, with the local doctor and TAG church.

The expected outcomes will be:

* The team of local volunteers who have been trained in chronic health care will gain the respect and trust of the community

* The community will benefit from correct diagnoses and health promotion on chronic conditions to promote health and to prolong healthy life (with or without chronic conditions)

* A health centre will be built in the Dodoma CCC plot of land, which will become self-sustaining in the long term and provide safe, effective medication at minimal cost.

OBJECTIVES

Long term

To provide effective, affordable, sustainable health care, run by the community, for the community in the CCC area of Dodoma.

Short term

* To train and regularly update the training of a team of local volunteers in chronic healthcare condition identification and care: the Tazama na Tunza team.

* To provide an initial support structure to the Tazama na Tunza team of practical and financial support, encouragement and envisioning.

* To plan and build a local health centre in the community built with local skills and expertise to comply with the Tanzanian government's directives on how to build a health centre.

* To agree with our partners in Tanzania on the vision and the practicalities of the above; specifically, what each partner is responsible and accountable for. In essence, that the trust provides the initial finance, support and medical teaching for the project and that the CCC church provides a room as a base for the volunteer team, a plot of land for the building of the health centre and oversees the building and management of the health centre.

* To ensure the Trust and CCC church continue to build partnership through trust, understanding and shared lives and expertise.

DESCRIPTION AND RATIONALE

Over the last three years I have visited the chronically sick at home during my annual visits to Dodoma. This has highlighted that there is extremely limited knowledge, management, self-care and chronic disease management. We encourage people to drink at least eight mugs of clean water a day as adequate water consumption as most patients only have two mugs a day and this is in a hot, dry climate. The reason for this is poverty, as water has to be collected and often paid for, and boiled to make safe, which means having to buy charcoal for fuel. I have come across a few patients who understand and manage their health well. These become health champions and presently we have two: for diabetes and HIV.

In discussions with the local doctor and pastors we agreed to train some local volunteer health workers in chronic disease management. In 2014 two nurses and a prayer warrior volunteered to join me for the trip to Tanzania. We trained 35 volunteers, from all backgrounds, including semi-literate to master's degree, from teenagers to a granny who is happier speaking in her tribal tongue of Kigogo than in Swahili. A Tanzanian nurse we had previously helped to train joined us and the local doctor. In the mornings we divided into four teams. Each team (of about eight people) visited four houses in the mornings, spending up to an hour at each house, holistically assessing the patients' needs, advising them how to manage their health and training the volunteers in this work. If they did not have a diagnosis from a doctor the Trust paid for them to get a correct diagnosis so that the Tazama na Tunza team could care for the patients in the correct way.

In the afternoons we did classroom teaching in chronic conditions: the local doctor and nurse covered the tropical and cultural conditions (chronic malaria, worms, typhoid and TB); and the UK team covered the rationales for general health and universal health conditions (skin conditions, diabetes, HIV, heart conditions and epilepsy). We did a lot of drama and interactive teaching to ensure that there were as few cultural and language barriers as possible, which was interesting as well as enjoyable. When teaching mental health the volunteers struggled to grasp concepts like depression, anxiety and psychoses - but when they were asked to act it out they knew exactly what I had been trying to get across. These conditions seemed to be unrecognised and undiagnosed.

The cultural acknowledgement of any project is a building and the Archbishop said we must have a dispensary. There are many fake drugs in circulation, and we need to be able to rely on any medication, such as metformin, phenytoin and erythromycin, that are bought. The actual meaning of dispensary turned out to be 'health centre', with eight rooms as a minimum, including injection, dressing and diagnostic rooms. The project now includes the need for a health centre, which will eventually be self-sustainable. The Trust agreed to fund the building of the project and is now seeking financial support for this. The CCC Church agreed to manage and oversee the project. A plot of land has already been allocated and the building drawings done, including a water tank above the dispensary, toilets and electricity.

Our visit in April showed that the community is aware of their needs --we were asked to visit many homes of different backgrounds and faiths. We visited a whole range of conditions, and none of them were minor or time wasters. Everyone wanted to know about their health and how to help themselves. We had spent considerable time writing a booklet on the chronic conditions in Swahili and we had 300 printed.

These were very useful and we used them as a constant teaching tool.

EXPECTED OUTCOMES

* Success: Enthusiasm for Tazama na Tunza project.

Outcome: A management committee has been selected from among the volunteers. The team hopes to visit those with chronic conditions at home, enabling them to make healthy changes and encourage them in a healthy lifestyle. The team will also visit new patients and when the diagnosis is uncertain, the trust will pay for that patient to see the doctor and have a correct diagnosis and initial treatment. The local government have already heard about the team and government public health have also come to give them a seminar and work with the team. The trust will sponsor up to two more serious treatments a year, at the discretion of the doctor. To date these have been operations for a uterine fibroid, a large fatty cyst and a thyroid operation on three patients.

* Success: The need for a base for the team where they can keep their records and any medication, meet patients.

Outcome: The trust paid for a room in Mavuno House (the CCC Church and community office) to be prepared.

* Success: Enthusiasm of UK nurses/doctors for supporting and updating the project.

Outcome: The trust is ensuring that a medical team visit annually to update and encourage the team, work with the local doctor and nurse and show accountability as a charity.

* Success: The CCC Church has already allocated a plot of land and drawings have been done to build the health centre.

Outcome: The trust needs to raise the visibility of this project and raise the money, with the long-term prospect of a self-sustaining health centre with good clinical knowledge and expertise, with sound drugs and treatments, in a caring community.

ANALYSIS: STRENGTHS, WEAKNESSES, OPPORTUNITIES, Threats

Strengths

* Long-term partnership already in place.

* Local partners already very keen on project.

* Trust agreed on health vision.

* Ability to work with other like-minded organisations eg, Interhealth in London (a worldwide health support charity) would like to work with us, government public health in Dodoma has also started working with us.

* The need is obvious and large.

Weaknesses

* Relationships working from a distance (UK-Tanzania) with annual visits.

* More medical networking and support locally in Dodoma would improve the care available.

* Everyone involved in the Trust and in the Team are volunteers, and enthusiasm for the work needs to be maintained.

* Success has its own drawbacks and the team may be swamped by the volume and seriousness of needs they encounter.

Opportunities

* The Team could have a really positive effect on the health of the local community.

* Empowerment of the local community to meet their own health needs.

* Health champion encouragement to spread their ways of success.

* Provide good local health care where presently there is none, through the proposed health centre.

* Be part of the bigger vision of the TAG church in Tanzania in having a health centre linked to every large city church.

Threats

* Changes in government policies

* Failure to access enough support to build the health centre

* Being diverted from the vision.

* Being daunted by the size of the health centre project.

* Having enough good medical staff to manage the health centre, when it is completed.

* The need for the project to rest on more than the one local doctor ie, to recruit another doctor in to do the work.

MONITORING AND EVALUATION

Annual trips to the project can ensure that targets are being met, along with regular feedbacks from the Tazama na Tunza team to the trust throughout the year. The targets include:

* Correct diagnoses

* Correct health advice given

* Correct medication use

* Correct use of money and resources

* Correct record keeping.

This can be assessed visually, by the feedbacks and by the records kept (as we already do, as an overseas charity). A Tazama na Tunza bank account has already been set up by the CCC Church.

CORPORATE RESPONSIBILITY

This project is based on a partnership between the Church, community and the trust. The project will be owned by the CCC Church, with practical support from the trust, to benefit the community. The trust is under a 'Memorandum Of Understanding' with the TAG Church, Tanzania.

ACKNOWLEDGEMENTS

I would like to thank the CPHVA Education and Development Trust for their encouragement to look at wider opportunities to effect positive health change in areas where the need is far greater than in the UK.

This is an ongoing project, so if you are interested in being involved, contact Ruth at ruth.chorley@nhs.net. Life is an adventure, to care for others is a privilege, and you don't realise just how important the NHS is until you step outside of it, into areas and conditions unseen in UK. Join the adventure and make a difference!

Ruth Chorley, Community Nurse, Hope Citadel Healthcare CIC, Oldham
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Author:Chorley, Ruth
Publication:Community Practitioner
Article Type:Report
Geographic Code:6TANZ
Date:Dec 1, 2014
Words:2455
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