Core hospital services
For five decades the hospital has focused on maintaining a wide range of services catering for the complex healthcare needs of the community. The priority-setting mechanisms have been guided by the demands of the communities, and the reality presented to the clinicians and households. The hospital has always tried to enable the clinicians to meet the multiple disease profiles presented by the community, as well as attempting to empower and enable the households, women, men and children to prevent diseases through educational and programmatic campaigns focusing on a very broad set of challenges.
In 2006 the hospital had three medical officers (MOs) in clinical service, five assistant medical officers (AMOs) and approximately 20 clinical officers. The MOs and AMOs perform Caesarean sections. The AMOs all are citizens of Tanzania, while the MOs are both Tanzanian and expatriate personnel. HLH has to rely on expatriate professional for some of the specialities, for the time being. However, many Tanzanian students from the Haydom area are now being trained as MOs, with the long-term plan being further specialisation. In addition, HLH recently became a field research site for the National Institute for Medical Research in Tanzania, resulting in an increasing number of Tanzanian masters and PhD candidates working in collaboration with the hospital.
Emergency obstetric and postpartum services
The hospital qualifies as a Comprehensive Emergency Obstetric Care (CEmOC) facility and the health centres as Basic Emergency Obstetric Care (BEmOC) facilities (tables
3 and
4) [
22]. At the hospital, nurse-midwives, RCHS aides and medical attendants staff the maternity ward, with AMOs and doctors covering the whole hospital, being available when called. In 2006 there were 3201 deliveries at HLH. A total of 534 Caesarean sections were performed. This percentage (16.7%) is hospital based. The WHO norm is 5–15% for a population. There are two main factors that are important in assessing Caesarean section rates. The first issue is hospital versus population based figures. Previous research in the catchment area of HLH showed that 56.9% of the women delivered at home and that the population based Caesarean section rate was 2.7% [
6,
28]. The women seek hospital care when complications arrive. Thus, the Caesarean section rate given above does not give a true picture of the population section rate.
The second issue is related to the level of skills of health personnel in performing assisted vaginal deliveries rather than Caesarean sections. The training in use of vacuum and forceps (operative vaginal deliveries) varies among doctors and midwives, both in Europe and Africa. Further, the nurse-midwife training in Tanzania has become more restrictive to the use of vacuum and forceps due to the HIV/AIDS situation. In addition, there may be a scarcity of senior obstetricians or doctors available to train junior doctors in these skills. At HLH the issue of training is currently being critically reviewed.
576 pregnancy complications were handled, with procedures that did not require Caesarean sections (table
1) [
29].
Concerning the issue of skilled birth attendance, Olsen et al. [
30] found 57% of births taking place in a health facility in the Mbulu and Hanang districts, which are both part of the HLH catchment area (table
2). There is a distinction between births taking place in a health facility and skilled birth attendance. We do not have exact figures giving this distinction, as one has to assess every birth in all health facilities in order to find this figure. At the HLH, every birth is attended to by a nurse-midwife, with 4 years of basic training at diploma level. Should complications arise, the doctor on call is summoned and appropriate action taken. The doctor on call is always required to stay on the hospital premises, carrying a mobile radio, in order to be rapidly available. In the case of emergencies, the basic theatre and anaesthetic staff are present at the hospital at all hours, and additional laboratory and theatre staff are collected at their homes by the hospital ambulance, should extensive surgery be required. All necessary intravenous fluids are produced at HLH.
The hospital has an extensive reproductive and child health service which covers large parts of the catchment area. Through this RCHS programme, women are advised to come to the hospital for delivery. Deliveries have been free of charge, but extra expenses such as operative procedures and medical treatment have not been free. However, the extra costs have been strongly subsidised by the hospital during the whole time scope of the programme, in order to make them affordable. The ambulance service has given first priority to delivering women on a 24-hour basis. From 2008, after having received grants from the Royal Norwegian Embassy for an MDG 4 and 5 programme, all ambulance services for delivering women and all costs related to delivery, including extra expenses, are free, in order to mobilise use of skilled attendance at birth in accordance with the aims of the MDGs 4 and 5. In addition, HLH has a nursing and midwifery school at diploma level. We believe these factors encouraging women to come for skilled attendance at birth may contribute to the lower perinatal, neonatal and maternal death rates found at HLH and in the HLH catchment area.
No patient needs to pay before service is given. The costs are calculated at discharge, and at that point in time personal financial constraints are taken into consideration.
There are no official figures on the use of traditional birth attendants (TBA) for the catchment area. The RCHS coordinator at the hospital has contact with the TBAs regularly in order to improve collaboration and referral to the hospital when complications arise. Previously, training of TBAs was a national policy, and HLH participated in this training. This has been abandoned as an international strategy, and thus also as a national strategy. Using the figures from Olsen et al.'s [
30] study of 57% giving birth at a health facility, renders 43% giving birth outside a health facility, either at home or during transport. Presumably many of these will be attended to by a TBA. We also know that some deliver alone [
28].
In 2006 there were 19 maternal deaths at the hospital. Of these, two were direct while 17 were indirect [
29]. From an epidemiological study in the catchment area of the hospital in 1995/96, of 45 total maternal deaths, 29% (13 of 45) were direct obstetric deaths, while 71% (32 of 45) were indirect. Haemorrhage (38.5%) was the main cause of direct obstetric deaths (5 of 13). Cerebral malaria accounted for 44.4% of the total number of maternal deaths (20 of 45) and 62.5% of indirect obstetric deaths (20 of 32) [
31]. From earlier studies the Caesarean section rate in the programme area was 3.6%, the met need for emergency obstetric care was 50.4%, and the proportion of women attending antenatal care at least once during pregnancy was 128% (most probably an influx of women from outside the catchment area) [
28,
30,
32]. In table
2 these results are compared to other studies from Tanzania [
9,
10,
30,
33,
34]. The operating theatre, intensive care unit and laboratory collaborate closely with the maternity ward, giving first priority to emergency obstetric conditions.
Ambulance services
One unique feature of the emergency obstetric programme in this area is the ambulance service. The hospital has two 4-wheel drive vehicles, and in the 1990s approximately 200 kilometres of all-season feeder roads were built out to the villages. Each village has a contract with the hospital to maintain the roads, using the local community. The hospital will supply the machinery needed, while the villages supply the man power. If a village does not repair the roads, it will not receive ambulance or mother-and-child health services. Thus, the village leaders are under pressure from the community to maintain the roads. Each village also has a 24-hour solar-cell run Very High Frequency (VHF) radio placed in the homes of trusted families, with the hospital radio being in the reception where staff is available to respond on a 24-hour basis. Maternal cases are given first priority. In spite of heavy rains and at times nearly impassable roads, the ambulances are almost continuously on the road.
Reproductive and child health services
The programme follows national guidelines using the "Focused Antenatal Care" package recommended by the World Health Organization as standard, as well as the standard vaccination and assessment guidelines for children [
35]. The women are given free prophylaxis and treatment for anaemia and malaria. Furthermore, subsidised insecticide-treated bed-nets are provided for sale at a low cost at all sites, also following the national guidelines. In addition, the attendees are offered a full "prevention of mother-to-child transmission of HIV" (PMTCT-plus) package, which is integrated into the RCHS clinics (see below). From 2007, a syndromic management approach for sexually transmitted infections, with free treatment, was introduced at the RCHS sites. The antenatal attendees are advised to come to the hospital or health centres for delivery, and are familiarised with the healthcare setting through encounters with healthcare staff. The antenatal care clinics also provide information and education to mothers, men and children on a variety of preventive issues through a structured lecture programme at each clinic site.
A total of 28113 mothers and 83007 children were registered in 2006 from all 28 HLH-run RCHS clinics in the catchment area (table
1) [
29].
Prevention of mother-to-child transmission of HIV
HIV positive women, both pregnant and nursing, who have been tested at one of the 51 PMTCT sites mentioned earlier, are offered highly active antiretroviral therapy (HAART) and treatment for opportunistic infections. A follow-up system involving the RCHS, the PMTCT registry, the maternity ward, the care and treatment centre (CTC) for HIV/AIDS and the community home-based care counsellors (CHBCs) has recently been introduced in order to increase the uptake and adherence of both pregnant and lactating mothers to the HAART programme. In 2007, in the maternity ward, the hospital introduced provider-initiated counselling and testing with the opt-out strategy to all delivering mothers, in order to include more HIV positive mothers in the PMTCT programme.
The child is tested for HIV at 6, 12 and 18 months. The women and children are monitored with hospital and home visits by both the staff at the CTC and allocated CHBCs throughout pregnancy, lactation and until 18 months after delivery. Mothers are counselled on infant feeding options. Exclusive breastfeeding is encouraged more than replacement feeding, and mothers are provided with free food and milk aid according to their needs. In order to succeed with abrupt cessation of breastfeeding, the CTC and CHBC staffs follow up the mother closely around the date set for cessation. Social, nutritional and milk support is offered in order to ensure a safe transition. Those living close to the hospital receive milk from the HLH dairy cows, and those living further away are given financial support in order to ensure milk for the baby.
The mothers are given HAART until certain weaning has taken place, and should the staff be in doubt this is extended until 18 months after delivery when the child is tested the final time. Should the mother need HAART further for her own sake, its provision is continued.
In 2005, in the catchment area, 12 749 women were tested in the PMTCT/RCHS clinic sites. Of these, 52 women were found to be HIV positive, and 26 (50%) of these were enrolled in the HAART programme [
36]. In 2006, there was a temporary drop in testing and uptake (42% uptake into PMTCT programme) due to the reorganisation from a vertical to an integrated HIV programme, but from 2007 the integrated programme was in place (table
1) [
29]. This will hopefully lead to an increased rate of testing and uptake into the PMTCT programme. A national study in 2003–2004 showed an HIV prevalence of 2% in the Manyara Region and 3.2% in the Singida Region [
37]. A previous study in the catchment area of the hospital showed an HIV prevalence of 2.0% (95%CI:1.34–2.97) among antenatal attendees [
38].
Integration of services
During the last two years of programme implementation the HIV services have been integrated from a vertical programme into normal hospital activities, largely through the RCHS, maternity and medical departments. This involves assigning the personnel regular working hours and salaries instead of using an allowance system. The allowance system paid per service rendered or per day of outreach or other type of work was more expensive than a system of regulated salaries. Furthermore, transport and activity costs and routines are planned in conjunction with the rest of the services provided. More importantly, the integration secures unified planning and reporting using the same internal control system. It also ensures a coordinated use, remuneration, motivation and training of staff, a unified organisational culture and improved interaction and synergies between departments and within the management structure. Currently PMTCT, VCT, RCHS and CTC services are coordinated with regards to all these aspects of quality and management issues.
Costs and Payment
The total programme costs for the hospital, including all preventive and clinical care services and training, amount to approximately 3.2 million United States Dollars (USD) per year. Only 15–20 percent of the hospital income comes from patient fees, which are heavily subsidised at the outset. Approximately 6–7% of the budget is financed by grants from the Tanzanian government, and the remaining funds are covered by donors (mainly the Norwegian government through the Royal Norwegian Embassy) and gifts. One of the main contributors to poor patients being able to use the hospital is the fact that no payment is required for any service until discharge. This includes clinical as well as ambulance services, thus ensuring rapid help for the patients. If the patient has problems paying at discharge, the social worker at the hospital contacts village leaders in the patient's home village requesting information on the patient's economic situation. If they confirm the patient's situation, the debt is written off as exempted debt. In this manner, no matter what their income, all patients receive medical care. The exempted debt varies from year to year (from 8% to 20% of total cost-sharing income) according to harvest and rain conditions.
Educational aspects
Education is an important aspect of improvement of maternal and perinatal health [
39]. In the Manyara region, figures from the Demographic and Health Survey (DHS) from 2004 for women and men's education show that 31.8% of women and 9.4% of men had no primary school. 49.3% of women and 51.7% of men completed primary school. 3.8% of women and 3.4% of men had secondary school and the median number of years of schooling for both women and men was 6.1 years. For Singida region the figures were similar, with median years of schooling being 6.1 for women and 6.2 for men [
10]. In the HLH catchment area there were 22 secondary schools in 2007.
In a recent study published on risk factors for maternal death from the HLH catchment area, 70% of both women and men in the study had between 1–7 years of formal education [
40]. In this study, we found that the woman's educational level was not significantly associated with increased risk of maternal death. However, women with husbands who had no education had a significantly increased risk of maternal death. This may be an indication of the culture of the decision-maker's influence on whether the woman is allowed to seek obstetric care or not. The aspects of illiteracy and education in relation to maternal complications are discussed in detail in the study referred.
The HLH has always recognised how important education is for the survival of the mothers and their babies. Thus, from the early 1960's until the present time, the hospital has contributed substantially to building of primary and secondary schools in the whole wider catchment area. A secondary upgrading school functioned for approximately 10 years in the 1990's in order to assist staff and students to pass the national form four exams. Further, since 1983 the hospital has had a nursing and midwifery school, first at certificate level, and since upgraded into diploma level, producing 20 new nurse-midwives per year. HLH is currently planning to build a vocational training school for the area. Apart from formal education, HLH has since the early 1970's had an extensive RCHS work, with an outreach programme covering remote rural villages in a range up to 100 kilometres from the hospital. Every session has an hour's education on health related issues for the women attending, as described earlier. From 2003, 74 villages are reached by the HIV preventive work, where one offers VCT and educational sessions on HIV, sexually transmitted diseases (STDs) and general pregnancy, delivery and health related issues.