Early in the morning of May 15, two large white Range Rovers pull up to the gates of the Mtandi Clinic, a well-kept compound on the outskirts of the southern Tanzanian city of Masasi.
The Rev. Geoffrey Monjesa, development officer for the Anglican diocese of Masasi, confers with the drivers as the passengers, a delegation of Canadian volunteers and staff of the Primate’s World Relief and Development Fund (PWRDF), the relief and development arm of the Anglican Church of Canada, get out and stretch their limbs in the morning sunlight.
Monjesa and Zaida Bastos, director of PWRDF’s development partnership program, then lead the delegates across the compound’s freshly mown lawn to where two women are standing in front of the main building. Their names, the delegates learn, are Magdalena Mwidadi and Emanuela Hokororo, a nurse/midwife and a doctor, respectively.
Speaking in a mix of English and Swahili (which Monjesa interprets), Mwidadi and Hokororo begin to tell the clinic’s story, highlighting the challenges and the progress that has been made in delivering health care to rural Tanzanians.
Built in the 1990s as part of Partners for Life, a PWRDF project to combat the HIV/AIDS epidemic sweeping sub-Saharan Africa, the main building is a reminder of a time when stigma against those suffering from the disease ran so deep. The entrance had to be specially designed to disguise someone entering the part of the clinic where testing took place.
A lot has changed in 20 years, says Mwidadi, who started working at the clinic as a volunteer in its early days.
In the 1990s, HIV/AIDS was a death sentence; just getting people to agree to be tested was difficult. But with the advent of anti-retroviral drugs, it became possible for individuals living with the disease to have something approaching a normal life. This, in turn, meant people were more willing to be tested and seek treatment.
The clinic began to take on an expanded role. It became one of the focal points of a PWRDF project on nutrition and food security, a large component of which involved maternal and newborn health, which wrapped up in March 2017.
Through this project (known locally as the Community Health Improvement Program, or CHIP), new buildings were added to house a maternity ward, and PWRDF provided a regular stock of drugs and medical supplies.
But as Mwidadi, Hokororo, Monjesa and Bastos lead the delegation around the compound, they stress that one of the most important elements of the program is simply teaching women better health practices.
“It is important to educate them, instead of just giving them medications,” Monjesa explains. “We need to continue with education regularly, because it is easy for them to forget.”
This means providing women with information about nutrition and child health as women prepare to give birth, and stressing the importance of having medical professionals present at the time of birth.
In a baseline assessment before the project began, the child mortality rate in Masasi was 117 per 1,000 births. And even in 2014, 60% of women were giving birth at home without the assistance of a medical professional.
The goal had been to reduce mortality to 100 per 1,000 births, in part by increasing the number of births taking place in clinics. But when an external evaluator was asked to assess the project’s impact, it was discovered that the number had fallen to 65 per 1,000 births—in large part because 94% of women are reportedly now giving birth in clinics.
Bastos, who has been involved in PWRDF’s work in Tanzania since 1997, says the change is remarkable, but that the real test will be whether or not it signals a permanent shift in people’s attitudes toward health care.
“What we hope is that the change of behaviour that we brought in this period will remain and improve, so that people no longer need to be told ‘you need to go’ but they make it part of their life habit,” she says.
Due to the success of the CHIP project, in 2015 it became a model for a second, larger project called All Mothers and Children Count (AMCC) that will run until 2020.
The AMCC project will provide medicine and education to several dispensaries both within Masasi and neighbouring Tunduru.
A matter of trust
By mid-morning, the shaded platform at the centre of the compound is filled with young women and infants waiting to be seen by the nurses, who are busy weighing babies and checking to make sure they are in good health.
Several young men are waiting on motorcycles by the entrance, and Bastos remarks on the significance of this—getting men actively involved in routine, health checkups of their partners and children, she says, is an important sign of progress.
But while Mtandi Clinic continues to grow, barriers to providing health care in southern Tanzania remain.
According to the Rev. Linus Buriani, who works closely with Monjesa on an AMCC project currently underway, a big part of the challenge lies in building the local population’s confidence in the dispensaries and clinics.
Government policy stipulates that pregnant women and children under five can get free treatment; everyone else is encouraged to pay into local community health funds that function as insurance pools.
For $10,000 TZS (about $6 Canadian) a year, a household can purchase a card that will give them a year’s access to medical treatment and drugs at a dispensary. But because the government is not always able to ensure a regular supply of medicine, there have been times when patients have been diagnosed and then told to purchase the drugs they need at a pharmacy.
This decreases confidence in the community health fund, says Buriani. Fewer people pay into it and consequently, there is less money to purchase drugs and confidence deteriorates even further.
This also makes people more likely to turn to traditional healers, who Buriani does not think are fully up to the task.
“Traditional birth attendants…they are not specialists, they don’t have technology, they don’t have the skills, maybe, to solve some of the complications during the delivery,” he says. “It is a matter of educating people, but that’s the culture—the culture sometimes is a very strong thing.”
Ultimately, the PWRDF project is designed to serve as a stopgap measure, allowing for the provision of drugs to the clinics and dispensaries to build local confidence in the system and trust in the clinics before the government takes over.
“When we phase out in 2020, the government will continue working with our effort, so we are working very closely with the government officials,” he says. “We, as church, are contributing to the government effort—we’re not doing it 100%.”