“Never seen it like this before”–Impressions from the first 14 days in Moshi, Tanzania
By: Konstantin Felkner and Nina Reichwein
After our first two weeks here at Kilimanjaro Christian Medical College (KCMC) in Moshi, Tanzania have passed we, the group focusing on health systems in transition, want to share our most striking impressions. Our first week ended with a visit to the KCMC hospital, one of the four referral hospitals in the whole country, and within the highest level within the Tanzanian health care system. Divided into 4 smaller groups, we were guided by Sister Mayo, one of the nurses, through an in-depth tour of the different wards. The first striking impression happened to be the large amount of patients queuing to register and ultimately access treatment. As seen in Tanzania, the majority of people are not covered by public health insurance, and thus patients have to register as patients along with paying an administrative fee in advance. The prices can be seen on a list placed in the main entrance, strategically placed close to several ATMs. In order to prevent corruption, the payment method recently changed to electronic payment, thus reducing the physical handling of money. In general, pregnant women, children under five and people over 60 are excluded from the fee.
Besides the lack of equipment and extensive understaffing, the shortage of beds was specifically striking, as the hallways were packed with patients. Even though Kilimanjaro counts as the region with the highest patient doctor ratio nationwide, the waiting times are still long. In order to skip the line, patients can pay up to double the price for the treatment compared to the standard fee.
The last stop of our visit was the administration office, where the patient’s medical records are stored for at least a hundred years. After entering the room, we faced meters of overfilled bookshelves with handwritten patient’s data. In order to keep an overview in this sheer confusion, patients with the same names are distinguished by place of living and religion, rather than date of birth, due to the lack of knowledge associated with birth dates. Since the electronic devices are lacking, medical records are handwritten, with all data collection statistical calculation and ICD-10 coding also done by hand.
This setting builds a strong contrast to the equipment at the university, which was shown to us on our campus tour the previous day. There we got to know the high-end education based laboratory, spacious, and air conditioned rooms equipped with real-time video broadcast for the students, alongside other state of the art technology. Even our valued professor Ib Bygbjerg mentioned, that he has “never seen a laboratory like this before”. Through the next door, we were left speechless by the sight of more than 60 brand new iMac computers. On top of that, we were shown the “Skype Conference Room”with an gigantic screen, that reminded one student of the devices he had only seen once before at the WHO European regional office in Copenhagen. The contrast of the equipment of the hospital compared to the university, was as clear as day and night. There was also a sense of contrast in the fact that in our home countries, we experience a continual struggle for funding within universities, whereas the hospitals often have the highest standard of equipment at their disposal. This indicates a challenge for medical students whose expectations are held high throughout their education, but might face a different reality regarding their working conditions after graduating.
(All of the mentioned aspects are based on student’s observations and health staff’s statements.)
First Impressions of Poland: a health care system in transition
By: Carolin Schöneich, Danielle Agnello, Henry Mark and Marissa Nicole Ray
It’s a little over 2 weeks since we arrived in Poland for our field research module and it has been a great experience discovering Krakow’s prestigious Jagiellonian Universit which is currently celebrating its 650th academic year and of course the delicious Pierogis. A mix of lecturers from the local staff and visits to institutions and hospitals around the city have been a useful way to immerse ourselves into the Polish health care system and gain some first-hand experience that would be unreachable from a classroom in Copenhagen.
During the first week we were given a lecture on Poland’s political and administrative systems, with specific focus on how this influences the health sector. This presentation really helped to cement our broader understanding of the system, such as the health care financing mechanism, which is collected though contributions linked to the labor marker. The National Health Fund (NHF) administers these contributions centrally, and then allocates funds to contracted service providers in all 16 regions (Voivodeships) in Poland. Within the past year there has been high-level political discussions about the role of the NHF, with questions around whether it would be more efficient to further decentralized into smaller and more autonomous regional heath funds, however, it seems that for the immediate future this idea has been shelved.
Of the 10 students here in Poland, four of us are working on the ‘Health Systems in Transition’ theme for our research proposal. So far most of our time has been spent trying to understand the inner workings of the polish health system, such as the financing mechanisms and administrative processes, from the Ministry of Health all the way to the General Practitioners (GPs) clinic. This understanding is important, because even tough various countries around the globe may base their health systems on the same broad theories and ideologies, there are always various idiosyncrasies that make each system unique.
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Through our investigation and during the lectures, a recurring theme – and one that we as a group will focus on during the rest of our trip – is the issue of the waiting times for medical diagnose and treatment; this refers to the number of days, weeks or months that a patient must wait to get an appointment when sick or in need of medical attention. This is a difficult topic to research as the information available is limited and different areas within the health systems seem to ‘suffer’ from it to different degrees.
While visiting the cardiology unit at the University Hospital, a clinician stated that he did not consider waiting times in cardiology to be a major issue. However, during a lecture we learned that waiting times for ambulatory care (diagnostic and specialist consultation) in cardiology were estimated to take an average of 120 days, suggesting that there may be a clear differentiation between the level of care (primary, ambulatory, tertiary) and the amount of time a patient has to wait. In response to this issue, there has been a recent increase in political commitment from the Ministry of Health to cut waiting times, with specific focus on oncology, although so far no official policy paper has been presented.
Spending on health care in Poland has been stable at around 7% of GDP since 2009, placing it slightly above the European-24 average, which is at about 5%. As financing is seen as one of the main barriers to cutting waiting lists, we are left with the question: Will any new policy be accompanied by an increase in funding, or will it simply mean reallocation of funds from one under resources area to another? If so, how can the downstream effects – both positive and negative – of reallocation be predicted? Therefore, one focus of our research is how such a policy will be financed.
To date, this trip has its been an illuminating and educational experience and we are looking forward to the next few weeks, when we will meet various academics and health professionals and have open discussions about the future of the polish healthcare system. We are optimistic and hopeful in our abilities to use outside knowledge and experiences, in addition to new knowledge gained here in Poland to help overcome the issues polish citizens face today.
Eye on Global Health 