Access to safe surgery top of the agenda

It is Thursday evening, Rose Mjema and her 80-year-old uncle, both residents of Hedaru, Kilimanjaro are walking slowly towards the gate, they had just seen a specialist at the Eye Department at The Kilimanjaro Christian Medical Centre.

Her uncle is visually impaired after he developed complications two years ago and his recent visit to the centre came following months of postponement due to complications related to age and financial difficulties.

“At first I thought it was just his age, but as time passed by and he gradually started to lose his sight and that is when we made a decision to take him to the hospital. He was operated on one eye early last year and we were given another appointment to return later on the same year, but we delayed coming back because he was scared of facing another operation. However, we were forced to come back after his second eye got worse,” says Rose

According to Rose they had come all the way to KCMC because the facilities at the centre are much better compared to those in government hospitals.

Even when they had to pay higher costs they realised he would be comparatively handled better at the KCMC than at any other place.

“We first took him to a health centre and all they did was to give him some eye drops which didn’t bear any results. The thought of him losing his sight, made us choose to come here straight to see the specialist,” says Rose

Their case isn’t an isolated one and it highlights the challenges facing patients with surgical cases particularly those who seek specialist surgery.

Many hospitals across the country face acute shortage of permanent surgical or medical specialist, healthcare workers with formal specialty, and medical facilities.

Dr. Sarah Urassa is the Director of Hospital Services at Kilimanjaro Christian Medical Centre and according to her referral system is faced with a number of challenges that cause a lot of burden at the top level hospitals.

She says most top level hospital receive a lot of patients from the lower level because of the gaps which exists in the health system.

According to her lack of medical healthcare workers and other medical facilities makes it hard for patients to receive the proper services.

“Some of the challenges faced in the lower levels of the healthcare delivery chain for surgical case to be exact, are shortage of blood for which is a big problem, operating theatres where some of the health centres happen to have only one, and this makes it difficult if they have several surgical cases which require immediate attention, says Dr Urassa.

She adds: Some of health centers can’t treat patients or do surgery but because they don’t have oxygen facilities, they end up bring their patients at the top level hospitals.

KCMC hospital which is one among the four Zonal Consultant hospitals in Tanzania serves 15 million people from the Northern zone including Kilimanjaro, Arusha, Manyara,Tanga and Singida Regions.

They often receive cases that other hospitals fail to treat and almost 50 to 55 percent of this cases are referral mostly from accident casualties.

“Some of the cases we receive include problems with urinary system, optical cases, nervous system this is because the medical specialists are few especially in other hospitals,” she says.

She says the referral system needs to be improved by sensitising the community so that they understand how the system works.

“As a hospital our job is to save lives, so when someone comes to seek medical help we cannot turn them away, instead, we help them even if their case could have been solved at the lower level,” she explains.

Dr Jonas Mcharo is the acting Kilimanjaro Regional Medical Officer, he believes there are two critical things that have to be put into consideration when looking at the health system which are needs and wants.

According to him, the needs include both communicable and non-communicable diseases which closely need to be addressed by the health system.

He says Tanzania has a good referral system except that people prefer giving themselves self-referral because they believe that by going to certain hospitals they will get good services and this obviously leads to overcrowding.

“ Most citizens prefer going to government hospitals, but there are some people with a perception that the health centre available in their communities can’t meet their expectations, meaning they can’t be treated from whatever they are suffering from,” says Dr Mcharo.

He adds: When they see these dispensaries and how small they are, they still believe that things are still the same, hence they go for basic health services at the top level hospitals. But the truth of the matter is, most of these facilities have been improved tremendously to meet the health demands the community because government has allocated funds to these health facilities.

But even then he admits that some services are not available in most health centers except at regional hospitals such as Mawenzi Regional Hospital which serves patients with mental problem in the whole zone.

“Here we see up to 500 patients per day, this is because there are few specialised doctors .The best thing to do is to ensure that communities utilize services available at the health facilities and also to educate them on how the referral system works,” he advises.

The Lancet Commission on Global Surgery estimates that at least 20-40 surgical specialists are needed in a population of 100,000 people.

Tanzania’s density of specialist surgical workforce is 0.31 physician surgeons, obstetricians and anesthesiologists per 100,000 population.

Furthermore, the high expenses involved are known to delay seeking care and are often a major factor in the decision not to seek care at all.

Lack of affordable, quality healthcare traps families into poverty where a third of households have to borrow money or sell assets to pay for health care.

Therefore, to address these challenges, the Ministry of Health, Community Development, Gender, Elderly and Children in collaboration with Safe Surgery 2020 officially launched the National Surgical, Obstetrics and Anaesthesia Plan (NSOAP) drafting process by convening Working Groups in Dar es Salaam.

“In order to promote the health of its citizens and avoid the death and disability that arises from a lack of surgical anaesthesia and obstetric care, the ministry has engaged with SafeSurgery2020 to develop a National Surgical Anesthesia and Obstetric plan,” says Prof. Mohamed Bakari, the Chief Medical Officer.

“This would be one of the first national surgery, anaesthesia and obstetric plans in the world making Tanzania a leader in this field.”

“Imagine being unable to access surgical treatment for life-threatening and disabling conditions like an emergency Caesarian section, maternal hemorrhage, road accidents, and others, “ said Ms Asha Varghese, The Director, Global Health at the GE Foundation.

“This is the unfortunate reality for 5 billion people globally who lack access to safe surgery. The launch of NSOAP is the first step to building the ecosystem for safe surgery and providing the much needed access for the people of Tanzania.”

The need for a National Surgical, Obstetric and Anaesthesia Plan has been informed by various studies highlighting the urgent need to prioritize safe surgery in Tanzania.

A study carried out using the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care in 2012 found that the average travel distance for patients receiving surgical care is 119 km in Tanzania.

The Lancet Commission on global surgery recommends that by the year 2030, 80 percent of the population should have access to emergency surgical care within 2hrs.

However, the current proportion of Tanzania’s population that cannot access surgery within two hours remains unknown.

The National Surgical, Obstetric and Anaesthesia Plan will therefore bring together clinicians, practitioners, implementers, and policymakers to work on solutions to the current state of the surgical system in Tanzania, identify what developments are necessary for a functional surgical system as well as identify which of these should be prioritized for the next seven years.

The plan aims to improve access to quality, timely and affordable services as well as coordinate the existing efforts to avoid overlap.