Hospital administration

It took some time to get a rough idea how things work here, although it is clear that there are quite some challenges and shortages. In this post, I'll try to sketch a few organisational problems.

Until January I mainly just observed, to find out how things are working, to get to know the people, and to give a helping hand here and there. Actually, I'm still not having a real overview of how things work. What complicates running a (public) hospital in Tanzania is the fact that the hospital has no decisive power to run the hospital. Many things are decided upon at various higher levels, i.e. by regional, central and other authorities. An example: all employees are employed by the Ministry, and the Ministry appoints employees to the different health facilities in the country.

I started helping to improve the income from patient fees in our hospital. A part of the hospital's budget doesn't come from the government, but comes directly from patient fees. Although its portion is relatively small (about 25% of total income), this is the hospital's only source of income that is in its own hands (i.e. not dependent on the government). Patient fees are supposed to cover the expenses for medicines, laboratory tests and medical supplies and small equipment. Our prices haven't been reviewed for a while and I'm currently helping to review our price list. Besides these patient fees that are directly paid by patients, approx. 10% of Tanzanians have a health insurance (mainly because it's mandatory for all civil servants). So they don't pay at our hospital, but the hospital has to claim this money back from the national health insurance fund (NHIF). With some employees I am currently working on these claims. It is quite some work to complete all forms (one per patient), but we're managing to bring more money in.

Again some nice new photos on our 'Foto'-page, including the beach house we're we stayed for the last two months.

Maartje and Méru

Around New Year's we flew to Dar es Salaam to meet my BFF Maartje at the airport. Amazing how she made so many new friends without speaking a word of Kiswahili. One of them happened to have a taxi (actually all of them) and brought us to the ferry. We had decided to celebrate New Year's Eve at Zanzibar and we had managed to book and confirm Shehe bungalows in Jambiani (east coast of Zanzibar) one week earlier. However, after our ferry trip to Stonetown, the promised taxi driver from this hostel was not around. A shabby man with a big car brought us to Jambiani and there he confessed not to know the location of our hostel. We asked around and found it, but despite our reservation it turned out to be fully booked. It was dark night already and thanks to a complete power cut the situation became a bit awkward, especially when the owner of the hostel asked ‘a friend' to bring us in his tinted car to another hostel with no name 4 km away. Fortunately, the next day by daylight this place appeared to be the most beautiful hotel with no name ever, panoramic sea view and delicious breakfast. We watched a sailing regatta, walked along the beach, met Kristine (who I know from Nijmegen) and enjoyed. New Year's we celebrated at rasta run beach bar Kimte with hippy-tourists at a campfire and some rather boring African drums, however drinking failed cocktails and dancing with the most important people around was fantastic. On the 2nd of January we took a flight from Zanzibar to Arusha by (precision air), where we had booked a tour at African Smart Safaris (recommended). Arusha is not so much worth visiting, although Indian food at ‘Big Bite' is the best we ever had. In 4 days / 3 nights we climbed mount Meru, which was tough but gorgeous. We saw ‘the usual fauna' giraffes, zebra's, warthogs, dikdiks, impala, monkeys, and as a nice surprise very cute chameleons and 1001 butterflies. The sceneries were beautiful: lush green forest, bushland, moorland, the view on Kilimanjaro. On the second day we climbed 1000 meter, made a little detour to ‘little meru' to keep the muscles warm, slept 4 hours and continued in the middle of the night to reach the very top (4562m). After an exhausting 5 hour climb we arrived there exactly 5 minutes áfter sunrise :). Sleeping little and climbing so many meters doesn't improve your headache, nausea and feelings of being broken, but the rewards were worth everything. A breathtaking view over the valley and colourful sky behind Kili, being above the clouds, enjoying a cup of tea and biscuits brought by our caring guide... see our photos! We climbed the slippery stone slopes and steep volcano ridge in the dark, so only on the way back we experienced the fear of looking into deep canyons :) Respect for the cook, who served us popcorn, soup and incredible nice food every day. We finished with a nice detour by car to see flamingo's! Letteke en Maaike, thanks for recommending mount Meru! I hope strongly that the headache I had now will not develop into altitude sickness when we climb Kili in June with Yvette, Lotte and Irma.

After this we went back to DSM by bus, which was even more frightening than the worst parts of Mount Meru. In DSM we were warmly hosted by our VSO-godfather Robert for our car quest. Three days of beer, pizza, many jokes (about each other) and many hours at the car dealer later we finally got our new car (see the previous story for ‘buying a car in dar' details). Driving down to Mtwara was a great adventure, to be on (and off) the road with our own car was awesome. This 600 km took about 11 hours; 60 km of the road is not yet finished (i.e. non-existing), and we were lucky that it hadn't rained for a while. We saw buses driving like crazy (and the results of that, see picture), if possible we never want to do that trip by bus.
I'm so happy that Maartje came to visit us, to see her again and also to show her the places where we live and work. On the day we came back, we moved into a new beach house, our third one, even closer to the beach. This one has a big living room and a kitchen; a great place to live. It's owned by the Benedict's from Ndanda and is frequently visited by other VSO volunteers and other nice people. Maartje spend the week reading all her and our books, more than we did in the past 3 months :) We caused the circuit breakers to trip (=we lieten de stoppen doorslaan) and we forgot to close the leaking gas bottle so that after 1 night it was empty. We had to improvise with headlights etc: it felt like camping in our new house, Maart sorry for suffering.
On Friday, Maartje, Tim and I visited the hospitals New Year / farewell to retirees' party. When entering the big empty party hall we had to choose our favourite drink for the night, of which we received 1,5L each :) Thanks to unexpected delay of food being served, we finished all this beer before eating and people start dancing. The fun part was when Tim was asked to come forward to open the champaign and to divide the 1 bottle over >100 people who were present. People drink beer and soda from the bottle, and the champaign is best poured in their bottles. Nice. During the wikiendi (weekend), Maart and I visited Mikindani, such a nice place to relax and play board games like boa, party&co and scrabble, very enjoyable!
When Maartje bought a ticket for her flight back to Dar, just at that moment electricity switched off and the details were written on a post-it, hilarious. They guaranteed that this would be a valid ticket and after checking in their computer the assured us that this flight could not be cancelled, only by God (Inch'Allah).Very promising, but precision air would not be precision air if they would fly precisely on time. So the 55 minute flight was only delayed 4 hours (not cancelled indeed) and Maartje easily got the connection in Dar to Amsterdam. Miss you!

How to get a car in Tanzania

Getting your driving licence in Tanzania

Of course we need a 4x4 in Mtwara. The hospital is too far to walk, there is no public transportation to our place. The first fruit stall is half an hour walk; the first shops an hour and the market one hour and a half. Good reasons to buy ourselves a car.

To have a car registered in your name, you need to request a Tax Identification Number (TIN) from the Tanzanian Revenue Authority (TRA). With your TIN-number you can also request a Tanzanian Driving Licence at the TRA, so we thought being efficient to do that all at once. Here's the trick.

1. Present yourself at 8am at the TRA supplying your postal address, full name and copies of passport (they can't make copies there, so make sure you bring them yourself)
2. Line up at another desk where you have to show your paperwork for them to make passport pictures and where you have to give your digital signature which takes some efforts and where they digitalise all your fingerprints in fancy computers donated by the US of A so that Mr Obama can track you everywhere in Tanzania if you're planning to become a terrorist.
3. Wait for some time until someone calls you.
4. Collect your TIN-number and complete the Driving Licence Application Form.
5. Have yourself being told that you need to go to the police station for a Competence Test.
6. Find out at the police station that the officer in charge of driving licences already left his office for the day.
7. Come back on day 2 for the Competence Test. The officer will use your completed Driving Licence Application Form to complete some other forms before he brings you to another officer who looks pretty high in their hierarchy. After presenting yourself to him he will give you a small note on which he scribbles down his signature. Make sure you bring this note to the first officer who will complete his forms and brings you to another officer who writes your particulars in a book.
8. Go to the Regional Head Office further down the road. Climb up to the last floor to find a sleeping police officer at the Driving Licence Desk. Wake him nicely. Hand over your paperwork (don't forget the small note with scribbled signature!) for him to enter this into a computer (at the other place they didn't have computers).
9. Go back to the TRA to show you passed the Competence Test and get new instructions to pay your driving licence at the bank.
10. Go to the bank and pay 40.000 shilling each.
11. Go back to the TRA and show your receipt to collect your driving licence.
12. Wait for further instructions.
13. After an hour or two, find out that the driving licence printer is out of order.
14. Come back on another day to collect your driving licence.

Luckily the whole procedure is explained on the TRA's wall (see photo).

Buying a car in Tanzania

Down here in Mtwara there are not many options to buy a car, unless you are fortunate to meet another ‘mzungu' (white person) who is just leaving Tanzania and selling his car. 10km on Tanzanian roads trashes a car more than a regular road trip from Holland to Southern France. So, we started looking for a car that has been imported just now... from Japan, as it seems that all cars in Tanzania originally came from Japan.

We learned that cars in Tanzania are much more expensive than back home, not only for a mzungu, but also for Tanzanians. There are not many car factories in Africa and because most cars have to be imported, there is no such thing as a properly functioning competitive car market. Secondly, in every African chain everyone tries to get its bit. First of all the government by putting 65% import taxes on top of the car's value. All cars imported from Japan to Tanzania must undergo a 'Road Worthiness Inspection' (as if all these dumped buses here are ‘road worthy'). Since Fukushima, you need a certificate that proves the car is free from radiation and not a nuclear bomb. On top of that there's a port 'lane' tax because your car is driven off the boat onto that piece of concrete, there's a dumping tax as they feel in Tanzania that the Japanese are dumping their rubbish cars into Tanzania and this is such an inconvenience (keep in mind the cars are in amazing condition). Then if the car is older than 2001 then there's some extra tax it just goes on and on. So we had to reconsider our savings realising that we're losing some weeks of safari. Luckily they say cars don't depreciate that much thanks to the factors described above. Hopefully inflation and deteriorating exchange rates will not interfere with this...

As there are no companies importing cars in Mtwara, we took the opportunity of being in Dar in December to visit as much dealers as we could. We started asking around for second hand cars, but after having been directed to dodgy places with dodgy people and dodgy cars, we learned that a car that just has been imported from Japan is a ‘new' car for Tanzania (no matter how many km it has been driven already there). So we turned to dealers of ‘new cars' of about 10 ten years old and having mileages of around 30.000km (yeah right, but as the dealers they say: mileages always lie).

On our last day in Dar we found the 4x4 we were looking for in a showroom that was still under construction. Their office however was located at the other end of the city so we went there and closed a pretty good deal. In the first week of January (during our holidays) we came back to Dar to inspect the car; to have them doing the registration in our name and arrange for all other required formalities (insurance, road safety sticker, fire sticker and some more) and to pay (in cash). Obviously this process took also some more days than expected but after that we drove happily back to Mtwara (see photos), although the Japanese navigation screen kept on directing us to the Yellow Sea.

Medical Centre Mtwara

Warning from Tim to his non-medical friends: you might want to wait for the next nice holiday story and pictures

The morning meeting
Every Monday, Tuesday, Thursday and Friday: morning meeting at around 8 a.m. In ‘Swanglish' the clinical officer on night shift informs us about the new admissions. The number of patients who died is mentioned, but unfortunately many times we won't find out exactly why they died. As being a doctor, this is frustrating. Two identical operation reports of two caesarean sections are read, including all vital signs which are often exactly as they should be (blood pressure 120/80 mmHg, pulse rate 80 bpm, temperature 36 C). It would be interesting to discuss the indications for interventions, but the doctor who was on call is often not present. CPD (cephalo-pelvic disproportion) is a common diagnosis, which for me is hard to assess. Sometimes I regret not having spent a year in gynaecology. Then the interesting part for mister Tim: finances. The ‘in-charge' of the reception and the drug dispensary read the daily revenues, which is a list of numbers, good to practise our Kiswahili but unfortunately we don't oversee it all.

Different doctors
I'm lucky, to my surprise one of the new AMO's is appointed to work for 3 months in male surgical ward, where I am working. AMO stands for assistant medical officer. Tanzania has a somehow complicated system with different kinds of doctors. ‘Clinical officers' are trained in training colleges (COTC), which takes 3 years. After their training, CO's work in hospitals and health centres in rural areas, which is appreciated because there is a serious shortage of doctors. They are overloaded with patients and able to work very fast, treating malaria, urinary tract infections and hypertension (which can be cured here with 2 weeks of pills) and everything in between. Our hospital has only 5 CO's who are supposed to see out patients in OPD, one of them specialised in HIV. A CO can apply to study for 2 more years to become AMO. We have 15 AMO's, of whom 4 are away for further studies for unknown period. Some are occupied by special tasks like TB coordinator or teacher at the COTC. Four senior AMO's are really experienced in either obstetrics or surgery (herniorraphy, hydrocelectomy, hysterectomy) or eye problems, and four just graduated as AMO. I'd like to learn a lot from them, and to share my ideas with them. But, because I'm younger, female, and less experienced, I struggle a bit to find my place in the unwritten hierarchy. Also Kiswahili is a bigger barrier than expected. Together with an AMO I'm doing ward rounds in male surgical ward, with 10-20 patients. Our hospital has 4 Medical Officers, two of them occupied by administrative issues (of hospital and blood bank respectively), and two are in the medical departments. Finally, 3 MO's are teaching at the nearby COTC and sometimes helping out in the hospital, or joining us when we go out on Saturday. It takes a while to know all names and functions of all these types of doctors.

The clinical challenges, Blaricum I miss you!
Many times I wish dr Gerrits was here, to assess an ‘acute abdomen', to decide something is malignant, to assess a suspected fracture when X-ray machine is out of order or just to teach me new things like making incisions with only a razorblade without s handle and without diathermy. Unfortunately, we don't operate much because material is often out of stock.
Traumatology (orthopedics) is challenging. A young man fell from his motorbike and appeared to have a T-fracture of the distal femur. We decided to use Perkins traction. Romuald, I could have used some advice. We had the equipment but not the experience. We tried our best, but to wait a couple of weeks before you see results of your treatment requires a lot of patience (of doctor, nurse and patient). While I spent a fantastic holiday with Maartje and Tim (story and pictures will follow shortly), the patient was discharged (own request?) and hopefully went to a hospital some hours away where a surgeon will treat him further. We don't have much equipment like pens and bars for traction or external fixation, so whoever has some spare parts... welcome!
We treat dirty wounds with hydrogen peroxide or Eusol, dr Huisman would be proud of me. Inguinal hernias are more complicated here, due to size (bowels guaranteed) and other techniques (Bassini, dr Huisman help, King has nice pictures but who will show me in practice). The first patient I operated on (emergency herniorraphy) died the same night. I didn't want to operate ever again without a tergooise surgeon next to me. I felt really incapable and ashamed, and it is so frustrating that we'll never know why he passed away. Bowel necrosis with shock, fluid overload in this old man, or did he just bleed to death from a badly tied bloodvessel? Horrible idea. My colleague doctor who was on call texted me: 'Our patient is just died. Pole.' A week later, a patient was admitted with impression of appendicitis. Although I was nervous I was also excited and thought about wise lessons: never make a too small incision, step by step how to open the abdomen, will I do a pursestring to hide the stump and should I apply iodine to it? Try to combine the best things I learned in Blaricum. But it turned out differently. While looking for the caecum, I revealed a loop of small bowel which looked necrotic/ injured, with a nearly perforated hematoma, really fragile, the rest of the bowels looked normal. I was surprised, because there was no history of trauma, nor hernia. Now it was time for dr Briel to pop up into my mind, and I'm proud to say: you taught me how to take care of bowel resection and anastomosis! A bit more difficult without GIA, diathermy, double needle mersilene, good supervision, and proper anesthesia, but we managed with some loose clamps, purple sutures made in india (looked like vicryl), and the patient is still alive.

To be patient
Wednesday 9 a.m. I see some nurses mopping the floor in OPD, no doctor around, it annoys me but fortunately I don't see many patients. Suddenly, I see about 80 patients waiting outside in the burning sun, children, elderly, pregnant. Wednesday is cleaning day. Same story in all wards and theatre, patients just have to wait, and I have to be patient.
Somehow, every day has its frustrations but in the evening I consider the good things. We did a ward round together. We encouraged PITC (provider initiated hiv testing and counselling). I taught some students basic psychiatry because they asked. I did my first c-section and everybody survived. We are getting prepared for an urologist who will pay us a 2 day visit in February. I'm finding out what surgical patients have to buy in the pharmacy (2 sutures, 6 pairs of gloves, small bottle of iodine, spirit, canula, iv giving set, 3L ringer lactate) because the hospital has no money at this moment to provide it.
Driving home we pass by the post office: we got mail! Thanks everybody!! Sitting on the veranda with Tim, enjoying a beer, some pineapple, the view and sounds of the ocean, life is good. Always look on the bright side of life!

Desemba in ZanziDar

In the first two weeks of December, our organisation VSO called us back to Dar for their annual conference and for another week of Swahili training. We took the opportunity and made our first weekend trip to the island of Zanzibar. Zanzibar is a federal state within the country Tanzania (TanZania is the united republic of and Zanzibar and Tanganyika- the latter being the mainland of Tanzania). Where anywhere else in Tanzania traces of the past are hard to find, in Stone Town (the capital of Zanzibar) you are walking through some centuries of mixed Arab, African, Indian and European influences. Its heydays were when the Omani Sultan moved its capital to here, but sadly enough, under these Sultans Zanzibar became the centre of the East African slave trade to the Arab world. We stayed with Peter & Jane, a very hospitable Canadian couple who made our stay pleasant and comfy. We wondered through the souk with its cacophony of noises and odours, got lost in a labyrinth of small old Arabic alleyways, admired impressive old carved wooden doors and a old Persian hammam, went to the old slave market, and at night we ate in the Forodhani Gardens where dozens of vendors sell their food in the open air. But above all, we enjoyed being in a tourist destination with bars and restaurant with drinks (ice coffee!) and food (desserts!) and service (no hours waiting!) up to (more or less) international standards. And all of that with a white sand beach with breathtaking and panoramic sun sets over the clear blue Indian Ocean. We took the tourist chasing safari sellers for granted...

After this weekend we had to leave Zanzibar to go to the annual VSO conference in Dar Es Salaam. It was good fun to see some fellows back and interesting to hear each other's experiences throughout the country. After the conference we got another week of Swahili training- pretty useful, but still way too short to have proper conversations... but we're improving- step by step. We also used these two weeks in Dar to buy some of the things we cannot get in Mtwara, such as Santa Claus hats J.

We finished our two weeks of travelling around with a visit to Nyangao, a rural village in Mtwara region. We were invited by Jim and Pam for their farewell party. The setting of such an event was a bit new to us: all people were sitting in the same direction, as an audience, facing Jim and Pam who were sitting behind a table listening to many, many speeches. They got many presents, amongst which a living chicken. As they had no idea what to do with it, they took it home and started feeding and caring it. Until the next day the giver showed up insisting to slaughter it immediately. And so it happened...

The last two weeks in Mtwara we worked, did some swimming, played volleyball, had a xmas bbq at the beach and bought two new bikes. This month the short rainy season started, which means that hard rains falls down every now and then. Not that it makes the climate cooler- one hour of sun after such rainfall and the air is hot and humid again.

Right Now we are back again in Zanzibar, starting a one week holiday to celebrate New Year's Eve here and to climb Mount Meru next week. More about that will follow next time!

Christmas greetings from Tanzania!

Settling down in Mtwara

Hi all,

First of all many thanks for all your loving messages through our website, facebook and mobile phone!

After one week we had to move out of our beach house as some rich expatriate offered the landlady more than we can pay. We are now put in another beach house in the same garden, however this one is shared. We now have a one-size-fits-all bed/living/lounge/study/dining room with a small bathroom. We bought an iron and a watercooker (for native English speakers: kettle), borrowed a cooker from a friend, and we manage very well to live a cosy life here. It took us a week before we got a second chair in our room, so we don't have to sit on the floor anymore. Now the only things still lacking are a cupboard so that we can finally unpack, and a good quality mattress. We have to admit that we enjoy what we have now. Meanwhile, we continue our house hunt. It turned out that the housing market in Mtwara is quite tough. That is, in areas where it is safe enough to live for foreigners, prices are skyrocketing due to gas companies settling in Mtwara. To be continued...

Last Saturday we went to the bank to open a bank account. One week earlier, Tim had visited the NMB Bank where they told him to bring, amongst others, passport size photos with a blue background and an introductory letter of our employer with a copy of our passports and a passport size photo with blue background attached, with a stamp that covers letter, copy and photo. Hence, we went to see a photographer where we had to sit before a blue curtain for this professional to take with his digital camera (made in China) and make our passport size photos which were overexposed and on which we look very pale and sweaty, but which were confirmed to be exactly what authorities like banks require.

Someone recommended the Exim Bank to us and we thought to give it a try although still expecting the same hassle as we would have at the NMB Bank. At least we had our passport size photos with blue background ready. But it turned out to be a success story: after 1,5 hour we got our account number. After having introduced ourselves at the first counter, we weretold that it was not possible to open a joined account, because nowadays they only have ATM cards that can be used by one person. Hamna shida (no problem). Then we were guided to the next room, where Tim had to fill in some forms and sign in a box smaller then 1x2 cm, which was so difficult that he needed 7 attempts after the first 6 having been rejected. After having obtained our bank account number we had to go to another counter to write a note with the amount you want to put on your account, then back to the very first counter where somebody wrote this amount in a book, and finally we queued to hand this money over to the cashier. Then, surprisingly, we were ready and can come back in 3 weeks to receive the ATM card. Easy.

Next week we will go to the Tanzanian Revenue Authority to ask for a Tax ID Number, which will enable us to get a Tanzanian driving licence and to register your own car (yes, we want to buy a 4x4).

In these first months, Marije will be introduced to all wards and medical activities in the hospital. Every two weeks, she is accompanying another doctor in another ward. After this period, she will make her analysis about where she can add value to the hospital. These two weeks, Marije is spending her time at paediatric ward (after two weeks in maternity ward). VSO's motto is to share knowledge and skills, so until last week I persisted on working together with a colleague rather than taking over their work. But this week some doctors were travelling causing a real shortage of them, and I was persuaded to do some ward rounds myself. Surprisingly, this turned out to be a pleasure since the paediatric nurse spoke English, used guidelines and was very willing to counsel mothers about everything I suggested. Most children are admitted with malaria, which is very common and favourite because it is one of the few diseases we can diagnose and treat. Fever and B/S:NPS (blood slide that shows: no parasites seen), is challenging. Pragmatic treatment is: cotrimoxazol in mild cases, ceftriaxon in severe cases. A 6 month old neonate with deep jaundice: very frustrating because we can't check bilirubine, we don't have phototherapy and internet is so slow that studying the subject is impossible. Next week a German paediatrician from Masasi will visit us for a training, hopefully I can consult him. I'm very happy with all the books I brought here, WHO paediatric pocket book and IMCI charts, NTC notes, Kings surgery, Oxford tropical medicine and my own notes from internships (especially from Ghana where I learned more than I realised). But when ‘simple' things like Hb-reagent, X-ray films and metronidazol and urinecatheters are frequently out of stock,things gets really difficult.

Next Tim more news about mister Tim's daily business.

During the weekends there is plenty of choice to enjoy ourselves: village Mikindani with swimming pool, Italian restaurant in Lindi (100km north) with real Italian pizza and lasagna with parmesan cheese (we left our phone number, they'll give us a call when they have tiramisu!), and weekly live performances of Bongo flava in nearby Makonde beach club. See pictures :)

We want mail

Most streets in Mtwara have no street names and houses are not numbered. This makes a postman's job pretty awkward; and therefore mail is not delivered at houses. All mail is collected at the post office instead. Last weekend, we opened a p.o. box (see photos) to receive your letters, birth- and wedding announcements, chocolate sprinkles, pepernoten, greeting cards of canals, windmills, tulips and black-and-white cows, and whatever you feel like sending us. Please send it to our attention at:

P.O. BOX 1305

MTWARA

TANZANIA

Experiences from other foreigners in Mtwara showed that delivery may take 1 week up to 5 months.