Social and economic underpinnings and their effect on the provision of healthcare
Tanzania is many things.
For those drawn to the vision of Hemingway-esque safaris, of wide savannas and dense forests all under a snow capped mountain, Tanzania is Nirvana. In the Hemingway short story "The Snows of Kilimanjaro", Harry Street, a lazy, indifferent and cynical writer, reflects on his life, his successes and failures. Today’s Harry judges his success and failure by catching a glimpse of the majestic “Big Five” animals. With energy and passion that Harry lacked, his inheritor’s goals and dreams are met in places with names like Ngorogoro and Serengeti and Selous. Twenty thousand other heirs to Harry’s legacy follow each year, each seeking to see elephant and rhino and leopard and buffalo and lion. Paradoxically, Tanzania’s truly indigenous occupiers remain its largest source of foreign income.
That picture aside, Tanzania is poor, one of the poorest countries in the world. Larger than twice the size of California, 36% of its nearly 40 million people live below the poverty line as reported by the Government of Tanzania. More than half its citizens live on less than 70 cents a day. The GDP per capita ranks 188 out of 194 countries: a mere $800; Gross National Income is $350. As a comparison, in Europe it is $34,000; Latin America and Caribbean $4,800 and even neighboring sub Saharan countries average $850. Tanzania has an external debt of $8 billion and servicing this debt accounts for 40% of total government expenditures. Every World Bank or African Development Bank loan exacerbates this problem even if the project meets its goals. Many do not. It is valid to ask if the purpose of all these study projects is to further learning and understanding or to keep local bureaucrats in their jobs.
In developing nations there is hope; in the underdeveloped there is little but despair. Tanzania is not a developing country; rather it is in that group termed under-developed, characterized by highly dependent economies chiefly producing primary products for the developed world while importing back finished goods; traditional, rural social structures; high population growth; and widespread poverty. Coffee beans are grown and harvested by small landowners, sold for little profit and sent raw to Switzerland to be returned by Nescafe as coffee to be purchased by Tanzanians at high prices. The scenario is the same for cotton returned as clothing and wood as furniture.
The median age of the population is less than eighteen; the birth rate per woman is more than five; infant mortality is among the highest in the world; Malaria and HIV are a scourge; Typhoid, Plague and Leprosy common. The current AIDS crisis, even at its admittedly understated level, nevertheless will decrease the gross domestic product by 15–20% by 2010. If the real incidence is higher as international public health authorities believe, that effect could be catastrophic. Few will live long enough to become contributing productive adults who can pass on skills to the rapidly increasing younger generation. Civil and social order could literally cease functioning within a decade of that happening.
Notwithstanding this the population increases by almost 4% annually. Logic would indicate that feeding this burgeoning populace would seem within the means of an agrarian country. It is not. Though agriculture is the foundation of the Tanzanian economy, less than 5% of its vast land resources are arable. Amazingly, these bleak resources account for half of the national income, three quarters of exports and provide employment opportunities for 80 percent of Tanzanians. Still, hunger is an every day issue for most of the population.
Whereas in Western Europe and the Americas, agriculture was patently enhanced by the use of draft animals, in most of sub Saharan Africa this growth did not happen as oxen and horses were victims of the tsetse fly. Post feudal Europe population centers saw transport systems such as roads escalate as the necessary means to get bigger agricultural production to market. In Africa this never happened. Here, agriculture is transparently local.
Agriculture in Tanzania is dominated by small peasant farmers cultivating between two and seven acres. Without tractors or draft animals, 70 % of Tanzania’s almost exclusively domestic food crops are cultivated by hand. For these difficult tasks, women constitute the main part of the agricultural labour force. Productivity is poor due to substandard skill levels and technology and on unreliable and irregular weather conditions. Simply put, the vast majority of agriculture is grown in individual gardens not farms. Subsistence growing such as this allows a family to produce for its own needs and maybe a little extra with which to barter with a neighbor. Tradition plus the quality of the soil and the lack of irrigation do not permit consolidation of these efforts.
The growth of population coupled with low agricultural outputs has brought the country to the point of being unable to provide sufficient foodstuffs for its own people. The numbers are staggering: 80% of the Tanzanian workforce cannot feed 100% of the people. In developed nations, 5% do so. The textbook short-term remedy is to import food and to pay for it with exports of industrial goods. In Tanzania that is problematical. Accounting for only about 10% of Gross Domestic Product, Tanzania's industrial sector is one of the smallest in Africa.
The industrial sector is also dominated by foreign corporate ownership together with a growing white South African sphere. Thus, even if manufacturing growth were to be seen, the earnings from these efforts would most probably not be retained in country. This is evident now in areas such as gold mining in which the most difficult jobs are performed by local unskilled labour while earnings from these activities are sent overseas after a relatively small payment to the Tanzanian Government.
There exists a small middle class, almost exclusively in Dar-es-Salaam, and is composed principally of multi-generation Tanzanians of Asian decent who account for 1% of the population. Retail shops, information technology providers, import-export companies and cross-licensing operations are most commonly conducted by this faction.
The indigenous peoples, 99% African, representing more than 130 tribes are ranked lowest on most economic indicators. Education should be part of the solution but the numbers of native Tanzanian children completing school are decreasing. In part this is the result of mandatory payments for secondary education which though small, nonetheless in traditional large families means that one or two of the older sons may be sent to school and the remainder, particularly young girls, not. Coupled with this is the growth of fundamental Islam on the mainland and the corresponding drop off of young women attending mixed-gender schools. Finally, the dire economic circumstances of the country as a whole compels parents to have their children work in a desperate attempt to survive. If that was not enough, the effects of HIV-AIDS have impacted the numbers of teachers especially in rural areas.
And what of the health of the people?
UN Statistics and WHO comparisons do not tell the story. They are but numbers on a page; numbers that tell us what health experts in Geneva say about “average” families in Tanzania. Try doing that for America or just Texas. Are the demographics for healthcare the same in Galveston as in El Paso? Not according to the American Psychiatric Association.
Traveling across the wide distances of this or most any other sub Saharan country tells you much more. It tells us that even in major (regional) hospitals, those in larger population centres, seventy percent of the beds are occupied by HIV-AIDS patients. Occupied is the operative word because the healthcare system cannot begin to treat these patients even assuming such treatments were available. Recent US programs may move some of these victims to home based programs assuming that efforts to educate rural communities that they need to take care of these people are successful. Till then, other patients who perhaps could be successfully treated cannot be with often tragic results.
The AIDS crisis has also decreased the number of people entering healthcare occupations in never seen before numbers. Currently district health authorities are reporting 60-70% vacancies in approved positions. Most critical are highly skilled professions such as physicians and nurses. Many who complete their training move on to better paying posts in other countries in Africa or to Western Europe. Correcting these problems is a long term issue.
The Tanzanian government is far from self-directed in forming health policy. International organizations from IMF to UNESCO and AfDB all dictate their requirements before monies are made available. Even within the government, the Ministries of Health and Finance as well as the Prime Ministers Office for Regional and Local Government all vie for control. Decentralization, mandated by the World Bank, has placed decision making into the hands of locally elected officials who too often have little knowledge of the complexities of health issues to say nothing of the financial resources to solve them.
Past government policies ultimately failed because they were inadequately implemented and financed. The same is happening today. The health sector is pitifully under-resourced. The current level of finance provided by the government meets only a third of the requirements of the public health system. Donors fund nearly 50% of minimally targeted total health care spending. The remainder remains unfunded, leading to further degradation of the system.
Tanzania is in an economic crisis and healthcare is no exception. Government health care expenditures are falling, reserves of foreign exchange (needed to import vital drugs and equipment) are reduced by currency fluctuations, and structural adjustment programmes have cut back on allocations to the social sectors. The health of the population has declined; mortality rates have begun to increase, and morbidity rates are rising. Healthcare is in crisis.
Worldwide but especially in third world countries, women are the key factor in health seeking activities. The too often repeated scenario of a mother being discriminated against by male health care staff has a direct negative effect on the wellbeing of children and their mothers. In the majority of rural villages, healthcare is provided by native healers and they are trusted far more than the dispensaries or health centers that are either closed or lacking both equipment and drugs.
Accurate data on burden of disease is questionable. Tanzania is a rural country and an individual’s entry into the healthcare system begins at a local dispensary, a government administered echelon with minimum staff and equipment but responsible for up to ten thousand people. The diagnoses agreed here flow up the information trail and are rarely changed. Consequently, the least trained of the medical cadre are those who determine the initial diagnoses and in turn the statistics that are determined from them. Among the top one hundred illnesses, there is no mention of breast cancer or cardiac disease or leukemia. Fevers in children equal malaria; coughs in adults equal pneumonia or TB. Lack of diagnostic equipment and trained staff dictates this and true or not the numbers are published.
At each level in the healthcare hierarchy, dispensary, health center and hospital, equipment is either non existent or is non-functioning, to an estimated eighty percent nation wide. So deep are the shortages of skilled personnel that even if equipment such as an x-ray machine is available, usually from a donor, there is often no technician to use it; no mechanism to process the film (assuming films were available); no radiologist to interpret the film and most importantly, no maintenance system to keep the machine in safe working order.
Adding to the problem is a lack of transport and communication and many rural locations are completely isolated during the rainy season resulting in no transfer of patients up the line from dispensary to health centres and then hospitals, district and regional. Pharmaceuticals and supplies are distributed from a central purchasing source in the capital city and losses of products over and above well known distribution problems are an every day occurrence.
Resulting from years of bureaucratic mismanagement, government hospitals are understaffed, poorly equipped, under funded and often lack electricity, clean water and basic sanitation. The absence of qualified medical and nursing staff anywhere but in the capital makes even simple medical care challenging. Finally, the little qualified staff that exists is often enticed to the private sector by larger salaries or to other countries where they can have both better incomes and a better life style.
Bureaucracy was certainly not invented by Tanzania but its bureaucrats have learned well how to use their status for personal profit. A multitude of studies, investigations, reports and analyses have been conducted in every region and district, many in healthcare. The results are most often known in advance; the effort merely confirms them and of course keeps more staff employed to write and edit the findings. They also serve to increase the debt as many of these programs are not grants but loans and part of the loan pays the bureaucrats.
To affect a paradigm shift in the provision of effective and consequential healthcare will require much more than the good intentions of the Tanzanian government and donor nations and multi-national organizations. The social and economic underpinnings of Tanzania as a whole must change. The non metaphorical question is: are those changes possible within the context of the political dynamics of not only Tanzania but of much of sub Saharan Africa.
It takes a developing nation to even consider beginning to keep its sick alive so that when well they can return as productive citizens. It is easy to let them die but what is then lost cannot be recovered. Tanzania may never be “developed” but it can become a place of hope, a hope that comes from its own people and then is supported by the humanity of others.
It is far too undemanding to say that Africa must help itself and stop there. Rather, should the collective “we” of Europe and North America accept a degree perhaps not of blame but of responsibility.
That answer is far from easy.
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