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5.2.1 Health services coverage plan

'Health service coverage' has two common meanings: the first - ‘hardware’ coverage - means the physical coverage of public and private health facilities, and was outlined for the DSMPHDS in Chapter 3. The second - ‘software’ coverage - means what health services are provided within those health facilities, and this was covered in detail in Chapter 4. Therefore, this section focuses on what changes are required in the physical coverage of health facilities, to improve coverage so that access is more equitable in the city of Dar es Salaam.

At the international level, indicators have been defined that show the level of health service coverage for populations, such as percentage of the population living within 5 km of a primary health facility. Data presented in Table 2.2 showed that the coverage in Dar es Salaam is a little over 70% average. Therefore, there is room for improvement, of increasing coverage to under-served populations. These indicators are used to identify which populations are under-served by health facilities, as geographical proximity is often argued to be a major determinant of health service use. Using geographical information systems (GIS) or alternative means it is then possible to show where new facilities should be located, or where other existing facilities can be upgraded to provide other services (such as inpatient care) to meet population needs. Such an evaluation has been done previously under the Dar es Salaam Urban Health Project (Amer and Thorborg 1996; Amer 1997), as well as other evaluations focussing on the existing health services (Tafesse 1995), utilisation levels (Zambrano 1995), and infrastructure development plans (Mshana 1997; Christen 1998). Since these reports were published, the public health infrastructure has not changed much,

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although in the private sector there have been more changes. This section deals with the health facilities themselves, while later sections address the resources that fill health facilities: the equipment, human resources, drugs, etc.

Infrastructure development can be split into four categories: construction of new facilities, and maintenance, rehabilitation, and upgrading of existing facilities. With a growing population and the currently under-served population, all of these are essential to the adequate health service coverage of the Dar es Salaam population. Maintenance keeps facilities in good order for delivering quality care, and rehabilitation involves a more extensive renovation work to prevent total decay which would require more costly new buildings to be built. Upgrading allows new buildings and services to be provided where the surrounding population is under-served, thus avoiding large increases in administrative costs associated with new buildings in new locations. Finally, new buildings are necessary when populations, especially the poor, are identified that do not use government services on account of poor physical access. This can happen with population growth (through either natural growth or through migration) or when old facilities fall out of use. However, the last population census was 14 years ago in 1988, and comprehensive and reliable data are not yet available on new population estimates by locality.

Construction of new facilities. Amer and Thorburg (1996) identified under-served areas in urban Dar es Salaam. Table 5.1 combines these results with more up-to-date DUHP information to give areas (in the lower section of the table) in need of new facilities. The existing facilities are also listed to show how the new facilities would complement the existing infrastructure.

Maintenance. Maintenance involves giving regular attention to the status of buildings, plants, transport and communication systems, and where there are signs of actual or imminent decay or damage, steps are taken to improve them to keep them clean and in working order. This may involve repairing walls and ceilings, applying new coats of paint where buildings are unsightly or paint is peeling off. Regular and routine maintenance is necessary to prevent health facilities from degrading to the point where they need a more complete rehabilitation work or a new building, which are both more expensive and disrupt the activities of the health facility. Chapter 6 provides the administative functions with respect to maintenance of material resources (refer to the DSMPHDS Maintenance Policy).

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Rehabilitation. In 1996, the rehabilitation status and design types of the government health facilities in Dar es Salaam were reported (Wyss and Subiri 1996). Rehabilitation of most health facilities was complete, and for remaining facilities rehabilitation was planned for 1996/7. Therefore, there are few current needs for rehabilitation of health facilities in Dar es Salaam, although special needs should be identified by the MMOH’s and rehabilitation planned where needed.

Upgrading. Facilities requiring upgrading have already been identified in previous work conducted by DUHP/CMOH. Upgrading falls into four categories:

• Upgrading from a district to a regional hospital.

• Upgrading from a health centre to a hospital.

• Upgrading from a dispensary to a health centre.

• Upgrading building, plants, transport, communication, and support services.

This analysis should be updated and also new recommendations should be based on current (and expected future) attendance rates, using predictions of health service demand. In particular, changes in the private sector should be taken into account to avoid the scenario where some populations become 'over' served (i.e. significantly better served than other areas).

Amer and Thorburg (1996) go on to discuss what the possible solutions are for the under- served areas, including:

1. Do nothing, and rely on the private sector to cater for those living in the above areas. 2. Construct new governmental facilities.

3. Collaborate with the existing non-governmental facilities. Such collaboration may take the form of providing subsidies or closer forms of cooperation.

Options 2 and 3 are the favoured option, as the under-served areas are not very likely to support private facilities, supported by the fact that not many private facilities exist there for the very reason that they cannot keep their businesses running because of the low ability to pay of the local population. Therefore, MMOHs should identify which non-governmental facilities they could work with, and in the longer term build new governmental facilities, assuming funds are available as well as resources to maintain the running of these facilities.

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Table 5.1. Recommended coverage of public health facilities in Dar es Salaam

Ilala Municipality Kinondoni Municipality Temeke Municipality

EXISTING DISTRICT HOSPITALS

Amana hospital Mwanananyala hospital Temeke hospital

EXISTING HEALTH CENTRES

Buguruni health centre Magomeni health centre

Mnazi Mmoja health centre Sinza health centre

Kigamboni health centre

EXISTING DISPENSARIES

Buguruni Boko Buyuni II

Buyuni Bunju Buza

Chanika Goba Chamazi

Gerezani Kawe Chekeni Mwasonga

Kinyerezi Kibamba Gezaulole

Kitunda Kijitonyama Gomvu

Kiwalani Kiluvya Kibada

Majohe Kimara Kimbiji

Msongola Kunduchi Makangarawe

Mvuti (rural) Kwembe Mbagala Kizuiani

Puju Kajiungeni Mabwe Pande Mbande

Tabata Mbezi Mbuti

Tabata NBC Mburahati Mji Mwema

Vingungunti Mbweni Mwongozo

Mpiji Magohe Nunge

Mwenge Rangi Tatu

Tandale Tambuka Reli

Tegeta Toa Ngoma

Ununio Tundwi Songani

Yombo Vituka Kisarawe II NEEDED DISPENSARIES

Msongola-Kitunda (rural) Kisopwa (rural) Keko (urban)

Nzasa (rural) Msawusi (rural) Kisarawe 11(rural)

Pugu Station (rural) Mluwazi (rural) Kurasini (urban)

Karakata (urban) Madale (rural) Kurasini (urban)

Majumba Sita (urban) Msewe (urban) Mbagala Kuu (urban)

Kipawa (urban) Hananasif (urban) Yombo Kilakala (urban)

Mabibo, ext (urban) Mabibo, UFI (urban) Kigogo (urban)

5.2.2 Administrative kits/ resources (see also section 5.2.3 below)

Administrative kits and resources required for the DSMPHDS were identified during the last MPHMA exercise in 1996. Table 5.2 below shows the required resources identified from this exercise. While this list was defined as the standard minimum, there may be some differences with more recent exercises (see section 5.2.3 below and Appendix 2).

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Table 5.2. Administrative kits and resources requirements in offices/health facilities District medical office District hospitals Health centres Dispensaries

Item Qty. Item Qty. Item Qty. Item Qty.

PLANNING

Air conditioner 3 Air conditioner 13 Calculator 5 Motorbike 1

Computer/printer 2 Ambulance 1 Air conditioner 3 Notice board 2

Cupboard 1 Arm chair 10 Arm chair 3 Safe 1

Computer table 3 Book shelf 5 Benche 15 Office chair 10

Cupboard 3 Car pickup 1 Book shelf 1 Filing cabinet 2

Arm chair 2 Car saloon 1 Car pickup 1 Office table 5

Filing cabinet 3 Computer/printer 3 Clock 5 Desk calc. 1

Motorbike 1 Exec. desk Desk 8 Computer/printer 2 Stove burner 1

Notice board 3 Filing cabinet 15 Cupboard 5 Clock 1

Visitor chair 4 Motorbike 1 Desk calc. 5 Bench 4

PROGRAMME SUPPORT Notice board 10 Exec. desk 3 Cupboard ₂

Air conditioner 4 Office chair 30 Filing cabinet 4 Refridgerator 1

Car pickup 1 Office table 10 Notice board 4 Type writer 1

Cupboard 4 Refridgerator 2 Office chair 5 Ex. Desk ₁

Arm chair 4 Safe 2 Office table 4 Secretarial resources*

Exec. desk 4 Tel. extension 40 Refridgerator 1

Filing cabinet 4 Telephone 1 Safe 1

Notice board 4 Visitor chair 16 Tel. extension 10

Visitor chair 8 Calculator 20 Telephone 1

Secretarial resources* Cupboard 5 Visitor chair 8

Secretarial resources* Secretarial resources*

* Includes paper, pens, staplers, tape, rulers, etc.

5.2.3 Medical-related equipment

Inventories have been conducted in all health facilities in recent years, and also a plan at the national level is being implemented to make a data base on the equipment situation of all facilities throughout Tanzania. For the MPHMA, the most important aspect of equipment to focus on is what equipment is required to provide the minimum package. For this, a comparison is needed of what equipment is available with what is required, and to estimate the costs of meeting the shortfall in equipment. While there exist minimum equipment requirements at the national level, listing equipment requirements by type of health facility, it was considered to be more appropriate to base the requirements for new equipment based on (1) the health services each facility should provide; (2) patient attendance; and (3) the age and reliability of current equipment stocks. Therefore, the health facilities themselves were involved directly and asked what equipment they need in order to provide the health services listed in Chapter 3, as being the minimum package that should be provided by the public health delivery system. While the budget implications of such a list may not be affordable in the short term, the MMOHs should prioritise equipment requirements, based on judgements about the priority services discussed in Chapter 3. A more complete analysis, done at a later stage, will also consider the expected upgrading decisions of each facility. The overall purpose is to define a feasible plan for equipment upgrading, with budget

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implications specified. For other issues related to equipment, such as maintenance and management responsibilities, refer to Chapter 6.

One such exercise of evaluating equipment needs was conducted in Ilala district. The results of this exercise are presented in Appendix 2. In summary, the costs of re-equipping Ilala MMOH would be 97,560,000 Tsh; Amana hospital management 134,796,000 Tsh; Amana hospital service departments 567,060,000 Tsh; health centre management 35,424,000 Tsh, health centre service departments 128,385,600 Tsh, and one sample dispensary a total of 14,450,472 Tsh. All these figures include a 20% additional cost to account for items that have been excluded, and expected price increases through inflation and possible exchange rate variations over the coming years. This gives a total of 963,225,000 Tshs for the MMOH, hospital and health centres, with an added 216,757,000 Tshs for dispensaries (assuming 15 times the cost of the sample dispensary). Combined, the value of equipment needed adds to around 48% of the annual budget allocation to Ilala district (see Chapter 3), thus demonstrating that only a small proportion of the equipment needs can be satisfied in the immediate future (i.e. a 1-2 year time period), and reinforces the recommendation that a prioritisation exercise is needed. However, the equipment lists provided in Appendix 2 at least serve as a basis for planning expenditure of the capital budget, and enables the district to respond quickly to donors who would like to make equipment donations or where there are sudden rises in equipment budgets due to increased flow of funds to the health sector. Also, these lists should be adjusted over time, as needs change and as items are purchased and other equipment fall out of use and need replacing.

5.3

Drugs