MOTIVATED | Both Petronilla Ngiloi and George Mugambage Ruhago wish to contribute and make a change in the health system.
Waves of warm air rise from the asphalt surface outside the Muhimbili University of Health and Allied Sciences (MUHAS) in the Tanzanian capital Dar es Salaam. The sun overexposes all the colours, and it makes your eyes blink. The concrete buildings of the university offer welcoming shade by effectively shutting out the heat. In a small classroom with a few chairs and tables sit two Health Policy and Management students.
“The allocation of resources needs to be revised. That is something I would like to work with in the future”. George Mugambage Ruhago gets straight to the point without hesitation. As a former public health officer he knows what needs to be done. Both Ruhago and Petronilla Ngiloi are part of a group of professionals taking their degrees through Norad`s Programme for Master Studies (NOMA).
Lack of experience
Like many other African countries the Tanzanian health sector inherited a bureaucratic UK civil service system that remains hierarchical and centralised, even today. In the early 1990s the country started to implement health reforms. The major component was the decentralisation and integration of district level services that started in 2000.
This master degree came at the right time.
“The old reform was created by people without a healthcare background, and it had not been revised until last year. We all hope that after we get our degrees we will be able to contribute and make a change,” says George – and it seems like he cannot wait to get started.
The process of decentralisation was completed in 2003, including the transfer of budgetary control to district level.
“Sometimes it happens that the money gets spent in the wrong places. They could, for example, decide to build dispensers in villages with just twenty inhabitants. The districts lack the experience and capacity to spend the money strategically. We need people with knowledge about the system. This master degree came at the right time,” he says.
In the past district health managers based annual health plans on previous budgets in a non-strategic way.
“That is why we need to educate more professionals and teach them how to disseminate. I cannot do everything myself.” He pauses dramatically and takes a breath before continuing:
“We have to involve district health management teams, because they have the responsibility for channelling the resources. They need to be properly trained.”
We have to motivate professionals to stay and actually work in the sector.
Lack of people
Petronilla has been sitting quietly and listening to her male colleague, just nodding here and there and waiting patiently for the right moment.
“Training is only one of the challenges that need to be addressed. Human resources are another. We need professionals to stay and actually work in the sector. We have to motivate them.” Behind the 50-year old paediatric surgeon’s reflective words lie long working hours and many years of field experience. The possibility of making a change motivated her to put up with two years of juggling job, school and family. Not surprisingly, health professionals in Tanzania are not motivated to stay in the health sector at a time when wages in the sector are low and even low-level civil service employees of government agencies such as gardeners or drivers earn much more.
“Salary is one thing but the working environment and availability of necessary equipment are another. The doctors do not feel recognised.” She looks subconsciously down at her feet and lowers her voice before she continues.
“I visited the region of Tabora with a team of surgeons, and we could see a lack of basic equipment such as anaesthetics. We were able to conduct a brief meeting with the regional officers to inform them about the problem. I hope that our report will help,” she says with a trace of doubt in her voice.
Contrasts
She knows that the day-to-day business is run by local government, but their jurisdiction is still limited and they are too fragmented economically. The National Strategy for Growth and Reduction of Poverty (NSGRP) has found that key obstacles to the provision of and access to health services include long distances to health facilities, inadequate and unaffordable transport systems, poor quality of care, a weak exemption and waiver system for those who are unable to pay for their care, shortage of skilled providers and poor governance and accountability mechanisms. At the same time urban–rural disparity increased. Rural areas and the poor remain disadvantaged both in terms of outcomes and service uptake. The air conditioning is working overtime, and it is getting colder in the narrow, isolated university classroom. We move outside again, where the energy of life and the heat are overwhelming and the contrasts are obvious.
“It is crucial to listen to the communities. We have to offer better conditions to medical professionals if we expect them to work in remote areas. They need better salaries, equipment supply, proper accommodation …”. George could easily continue, but he knows that there are just too many issues to raise them all in a short interview.
We need to strengthen the weak links between policy making and implementation.
The weak link
The government of Tanzania received NOK 175 million from the Norwegian government in 2007 to improve the health sector in the country. The progress that has been made so far is that infant mortality has declined and the number of malaria cases has fallen. Norway is just one of Tanzania’s development partners. The pooled funding of the Health Sector Programme is also supported by the governments of Denmark, Germany, The Netherlands, Canada, Ireland, Switzerland and the World Bank.
“Tanzania is moving in the right direction, but we still need time to educate more professionals and to strengthen the weak links between policy-making and implementation,” says Petronilla – and she is on her way to work.
See also: Making a difference