A Public Private Partnership in Tanzania:

Transcription

1 A Pubic Private Partnership in Tanzania: CCBRT, Dar es Saaam City Counci and Private Loca and Internationa Partners Integration of High Quaity Materna & Chid Heath with HIV/AIDS Services into an efficient Comprehensive Disabiity Programme

2 EXECUTIVE SUMMARY In deveoping countries, most persons iving with disabiity have an impairment that can actuay be cured. If they had access to the right medica attention aong with quaity treatment, eg up to 80% of peope with bindness in Tanzania coud have their sight returned to them. Improving quaity of ife for persons with disabiities is the primary aim of CCBRT (Comprehensive Community Based Rehabiitation in Tanzania). However, most persons with disabiities are poor to very poor. To hep achieve the goa of equity in heath care, the Non-Governmenta Organization (NGO) has deveoped the Robin Hood system of heath care financing, whereby patients contribute up to 50% of the cost to serve a with the same high quaity care. Much was achieved during ,500 consutations and 7,000 surgeries were carried out at the Eye Department in Dar es Saaam. Whie in the Rehabiitation Department over 1,600 surgeries were performed. These surgeries incuded fistua repair, pastic surgery, neurosurgery for chidren and reconstructive surgery for chidren born with congenita deformities. Pans are aready in pace to deveop a rehabiitation centre through which a wider range of services wi be provided. CCBRT originated from a desire to enhance peope s quaity of ife and to rehabiitate patients into the community. Striving to achieve these aims is fundamenta to CCBRT s activities. Many chidren with disabiities are excuded from reguar education but being part of a norma schoo environment is what they wish for. Throughout Sub-Saharan Africa, CCBRT has prepared and brought more disabed chidren to norma education than any other organization. As giving ife to a chid remains one of the most dangerous and disabing moments in the ife of African women and infants, improving Materna and Chid Heath (MCH) is one of the highest priorities in poverty aeviation agreements between the Tanzania Government and its Partners. Unti now, however, very few improvements have been made in this area. It is a major chaenge to deveop systems of MCH that are abe to provide high quaity services to both rich and poor whist maintaining financiay viabe. The CCBRT Hospita is an exampe of such a system. CCBRT and its Partners beieve that the probems of materna and chid heath can be addressed in a simiar way. The Dar es Saaam City Counci (DCC), CCBRT and a number of Internationa and Loca Private and Aiance Partners have agreed (or are sti considering) to combine efforts and costs to create a MCH/HIV Hospita in Dar es Saaam. This wi work as a Pubic/Private Partnership compementing the DCC Municipa Hospitas. It woud be an extension of the successfu system of the CCBRT Disabiity Hospita which provides high quaity services and is accessibe to rich and poor. The new MCH/HIV Hospita wi not ony provide MCH/HIV services (education, medica, foow up) to mothers and chidren of today, thereby preventing materna and chid mortaity and disabiity, it wi aso be avaiabe for quaity in-service training to future generations of MCH/ HIV and disabiity medica and nursing staff in Tanzania. As an organization with a focus on improving the ives of persons with disabiities (PWDs), CCBRT aso fees a mora duty to contribute as much as possibe to preventing impairment and disabiity, rather than ony serving the ever growing numbers of persons with disabiities whose impairments and disabiities coud have been prevented.

3 Tanzanian Heath Services: history and today Historicay, in Tanzania as esewhere in Africa, it was mainy the Church and missionary institutions which provided heath care in rura areas (where most of the peope were iving). Governments took care of the cities. After Independence, thousands of pubic heath centers were buit by the new African governments. However, in the ast 20 years, most peope providing heath services eft to work at private urban hospitas or abroad. These urban, private hospitas serve midde cass and weathier patients ony, eaving the 80 to 90 % poor peope in cities (mosty iving on ess than 1 US$ per day) to government heath services. In practice this means they are deprived of being attended by one of the few medica doctors, many of whom have other responsibiities in management, administration and teaching. Nurses or cinica assistants take care of the patients heath probems, being the ony affordabe staff. These medica empoyees fee bady paid, and mora and working ethics are consequenty often ow. The ack of tradition in forma management makes corruption easy and norma. In Dar es Saaam, the City Counci (Government) Heath system has to serve 3 miion peope with affordabe care. Preventative services and curative first ine care have priority and 62,000 patients are served per week. AIDS, Maaria, Tubercuosis and Choera are striking hard on the ever increasing and thereby impoverishing popuation. These diseases have prompted a great fexibiity in priorities from the 56 dispensaries, 5 heath centers and 3 district hospitas which make up the Pubic Heath system, and are spread over the whoe city. At present 60% of bed capacity in District Hospitas is used for AIDS patients and the system is greaty overstretched. The Word Heath Organization (WHO) estimates that 10% of any popuation has a disabiity, meaning that some 25% of the entire popuation, such as famiies, caregivers and communities of persons with disabiities, is adversey affected by the presence of disabiities (UN, Despouy, 2004). Ony 2% of peope iving with a disabiity in deveoping countries have access to rehabiitation and appropriate basic services (DFID, 2000). Disabiity services rights, community and hospita based A survey conducted in 1994 on the avaiabiity and accessibiity of services for persons iving with disabiities in and around Dar es Saaam confirmed the need for a comprehensive and accessibe programme. CCBRT was created with an overa objective to improve the quaity of ife of persons iving with a disabiity, their famiies and caretakers. Since then and in response to the high needs it grew fast to become one of Africa s argest muti-component disabiity programmes. More specificay for the coming five years, it aims to impact the ives of 500,000 poor bind, physicay impaired, deaf, epieptic and otherwise disabed, as we as their care takers (90% women) by providing comprehensive home, community and hospita based medica, rehabiitation and education services. It targets especiay women and chidren, focusing on the urban and peri-urban areas of Dar es Saaam. CCBRT now intends to further expand the area of inreach intervention to so far underserved target regions such as Pwani, Morogoro, Tanga, and the isands of Zanzibar and Pemba with a tota popuation of 10 miion peope. CCBRT is a muti-component disabiity programme. It comprises a community-based rehabiitation (CBR) programme as we as hospita-based services, an internationa training programme, an orphans programme and a hoistic HIV/AIDS programme in coaboration with the City Authorities. It aso provides human rights and ega aid counseing to those iving with HIV/AIDS or other disabiities, and to orphans and their famiy members at 3 paces in Dar es Saaam.

4 In 2007, the CCBRT counts on 300 committed and skied heath and socia workers. CCBRT is aso strongy focused on capacity buiding through training of varying eves of staff in a areas of work. CCBRT is a nationay registered NGO and its constitution and registration enabes it to estabish programmes wherever in Tanzania it so desires. It pans to expand its disabiity services in three main areas 1 : (a) extending its services as expained above, (b) intensifying its capacity buiding component and creating a rehabiitation centre to cover some of the services which do not, as far yet, exist such as speech therapy, (c) the production of personaized mobiity and position devices for chidren with cerebra pasy and other impairments/disabiities. Mother & Chid Care (MCH) The heath services under most pressure in Tanzania are those affecting peope with no financia and poitica cout: mothers and chidren. 80% of the popuation consists of women and chidren. The city has no speciaized obstetric unit where deiveries are safe and where difficut cases can be brought. Neither is there a pediatric hospita. It seems accepted as an overa probem in Sub-Sahara Africa, that Heath budgets of African governments are inadequate to dea with obstetric cases. 2 Reports become ever grimmer, with many women deivering babies unattended. In Tanzania, ony 35.8% of deiveries take pace in the presence of a trained person 3. The infant mortaity rate (IMR) in Dar es Saaam stands at 12% 4. Women think increasingy that it is safer to deiver at home (even though this might not be the case). The most dangerous period in a woman s ife is that of pregnancy and specificay of deivering a baby and for the infants to be born. Studies increasingy show the overwheming impact of mother chid care on the ife expectancy of mothers and newborn babies. As far as materna deaths (1,64 %) 5 and peri-nata deaths (10,3 %) concern in Dar es Saaam, it is known that for each mother or chid dying through peri-nata conditions, many more remain disabed, often however with no reiabe figures avaiabe. During a recent research project - Peri-nata Care Assessment 6 in Dar es Saaam, it was shown that 25.4 % of fresh stibirth death and 48.3 % of neonata deaths were due to birth asphyxia, which is aso known as a major cause of disabiity in newborn babies. A survey by CCBRT on the causes of cerebra pasy in chidren served by the CBR Program (Community Based Rehabiitation Program) showed that 75% of the mothers coud ceary reate the cause of impairment of their chid to incidents surrounding the birth of the chid. The CCBRT Fistuae (VVF) department figures aso indicate that most fistuae are due to sub-standard mother chid care. The city of Dar es Saaam does not have a hospita that can bridge the gap between the three overcharged District Hospitas and the Muhimbii Nationa Hospita (MNH). As pregnancy, deivery and chidhood happens across a socio-economic groups of the popuation, there is a great need to be fied. What is acking in Dar es Saaam is a hospita that is open to a who need MCH, with high quaity services, with affordabe prices and good management, incuding an education component (for staff and for the expecting parents), aong with day to day monitoring and evauation. 1 CCBRT Disabiity detaied Four-Year pan avaiabe 2 Kasonde, WHO, Unicef, Tanzania Reproductive and Chid Heath Survey, Kidanto HL et a. Perinata mortaity in Muhimbii Nationa Hospita Dar es Saaam, Tanzania. Proceedings 8th ECSAOGS conference, Dar es Saaam, November Urassa DP, Nyamtema A, Rwebembera A, Kidanto H, Massawe S, van Roosmaen J, Lindmark G. Dar es Saaam Region Perinata Care Needs Assessment. Report to Axios, 2006, from Muhimbii University Coege of heath Sciences, Muhimbii Nationa Hospita, City Medica Officer of Heath, Leiden University Medica Centre, The Netherands and Uppsaa University, Sweden. 6 Urassa DP et a.,

5 HIV/AIDS makes poor peope even poorer The strong connection to poverty means that poor peope, and in particuar those with disabiities and their famiies are more ikey to get HIV/AIDS. At the same time, they are far ess ikey to benefit from any type of mainstream HIV/AIDS service deivery. This situation undermines the effect of any rehabiitation efforts. HIV/AIDS destroys ives, famiy income and jeopardizes the future of miions of chidren. Trained and experienced heath workers and community eaders are equay decimated thus further compromising the achievement of (other) deveopment goas. So far, HIV service deivery has been very fragmented, eading to haf soutions. The ack of services and human resources at community eve is hampering wide scae impementation of successfu interventions such as ARV treatment. Moreover, stigma and ack of confidentia testing opportunities contribute to very ate testing for HIV which eads to a deayed start of ART and subsequent discouraging resuts. The chaenge is to deveop a mode that provides hoistic HIV care starting with HIV counseing and testing in the eary stages of the infection (or even better: before infection ever woud take pace), foowed by prevention of further transmission, nutrition, medica care and ART, home based care, ega aid and services for AIDS orphans. Mother-chid services have been identified as an idea entry point for preventing disabiity, and for the provision of hoistic HIV care. Once pregnant mothers have been HIV tested, there is an opportunity for HIV prevention and treatment services for the whoe famiy. Such services incude PMTCT and provision of ARV, but provide aso an opportunity to secure a safe deivery and strengthening of antenata and postnata services. These efforts combined woud hep prevent mother and chid mortaity as we as disabiity in both. A tripe chaenge for CCBRT: How to 1) contribute to prevention of disabiity through improved MCH, 2) mitigate the consequences of HIV/AIDS and 3) at the same time make those quaity services accessibe to the poor and to the disabed as we? It is a major chaenge to deveop systems of heath care that are abe to provide high quaity services to both rich and poor whist maintaining financiay viabe. CCBRT s Disabiity Hospita is an exampe of a success story in creating such equity in heath care, with high quaity medica and rehabiitation services accessibe to rich and poor. CCBRT and its Partners beieve that the probems of mother & chid are and HIV can be addressed in a combined system. As proper mother and chid care is required by a peope, and as such a responsibiity of the community at arge, to be provided 365 days a year and 24 hours a day, it wi be more financiay viabe in case it is organized as a Pubic/Private Partnership. This coud utiize the management skis and creativity of the Private sector (oca and internationa), and the financia support, pubic endorsement and support from the Nationa and Loca Government. The Board of CCBRT and the City Counci of Dar es Saaam have thereto decided to join efforts in a Pubic Private Partnership, to achieve high quaity disabiity and mother & chid care with integrated hoistic HIV/AIDS Services. By doing so, equity in care shoud be achieved. Equity is defined as accessibiity and affordabiity for a socia casses. 5

6 Update June 2007 The Government of Tanzania aready has provided CCBRT with a arge pot (4.7 hectares) next to the existing CCBRT hospita at Msasani/Dar es Saaam. CCBRT and DCC have aso deveoped a Memorandum of Understanding (MoU), soon to be signed. In that MoU, the Government has indicated that CCBRT wi become the Regiona Designated Hospita of Dar es Saaam and that they wi approve and provide a yeary buk grant covering the saaries for the staff of the existing CCBRT disabiity hospita as we as for those of the new MCH and HIV Departments that are sti to be buit. It wi aso provide other costs for hospita suppies at the same eve as other Regiona Hospitas. Management wi be in hands of the Board of CCBRT which wi appoint a Manager. Loca and Internationa MCH and HIV speciaists wi be recruited for service deivery and training purposes. The new Regiona hospita wi, in addition to the existing curative and rehabiitation departments, deveop a high voume, high quaity maternity and HIV/AIDS department. This wi provide a number of services: Education to future mothers on reproductive heath and HIV/ARV Hoistic HIV/AIDS services (Vountary Counseing and Testing, ARV, Home Based Care, Lega Aid, orphan care) Post and ante nata cinics as we as doing deiveries Taking care of mother and chid unti eventua post deivery symptoms are gone HIV/AIDS education wi aso be provided to staff of other organizations and private companies, incuding the deveopment of HIV/ AIDS Workpace Poicies. CCBRT is in the process of negotiations with Internationa NGOs and Private Organizations seeking their support. Aso a number of Private internationa and nationa Partners have decided to become invoved with the project (or are considering whether to) whist others are being approached. Commercia enterprises view this type of deveopment as an exciting way to improve their corporate pubic reations to the outside word (Corporate Socia Responsibiity) as we as within their own Human Resource Deveopment (provision of high quaity medica care to staff and famiy). Private companies aso see a business interest as this mode programme wi deveop and be used for teaching purposes for future midwives and other staff invoved with running MCH and HIV/AIDS units in Tanzania. Some aso see a chance that it wi be copied in other countries, as we. The foowing wi be the responsibiities of the Pubic and Private Partners invoved: Pubic Private Government of Tanzania CCBRT - Provide Pot for Hospita (4.7 hectares) - Management of Hospita - Staff Saaries - Engage into Internationa Partnerships - Pay for current expenditures (other cost) Dar es Saaam City Counci (DCC) Internationa Partners - Recognition of CCBRT as Regiona - Private Enterprises 7 : expertise, funding, indirect Designated Hospita Dar es Saaam and direct business interest and commitment - Advise CCBRT Board through Committee - Private INGO: networking, expertise and funding - Contract and foow up Loca Private (Business and NGO) Partners - Knowedge, experience - Resources - Transfer patients. 6 7 Names are sti withhed. They concern a major internationa bank, a major internationa pharmaceutica company, and other internationa and nationa companies.

7 This Pubic Private Partnership wi aim at the foowing targets and indicators of success over a 5-year period: 1. Comprehensive Community and Hospita Based Disabiity services: Prevention/reduction of disabiity through the provision of abiity restoring/impairment reducing surgeries; Eye surgeries 5,000 Orthopaedic and pastic reconstructive surgeries 5,000 Fistuae surgeries 1,200 Neuro-surgery 800 Provision of corrective devices to fuy or partiay restore the abiity to see, hear, to be mobie or to function; Low Vision devices and spectaces 100,000 Orthopaedic and Mobiity devices 10,000 Hospita/centre based provision of therapy/advice sessions to increase abiity or reduce impairment; Eye examinations 00,000 Physiotherapy sessions 50,000 Other (epiepsy),000 Community based therapy sessions by community heath workers and professionas; Home based therapy sessions 10,000 Community based group sessions 1,000 Community based functiona training in daiy iving skis 250 Forma/incusive education to increase chances of integration, empoyment and of sef reaization; Visuay impaired/bind In coaboration with The Society of the Bind Physicay impaired 00 Hearing impaired 00 Orphans 500 Disabiity Hospita and Community Programme Staff Trained to Achieve Cear Goas: Mother Chid Care Component: (Tota Deiveries 37,4158) Actua Situation Objective Difference in Muhimbii of Project (reaizing that Nationa Hospita (Reduction the projects wi often as to MDG) receive ate referras) Mortaity - Lives of mothers 613 (= 1,64 %) 9 50% reduction mothers saved Mothers dying 11 Mothers dying surviving (MDG: reduce 3 4) 7

8 Mothers morbidity/ disabiity due to compications prevented 9,808 Mothers 12 sick and/or /disabed (= mortaity x 16) 50% reduction (See 9.) (MDG: reduce 3 4) 4,904 mothers not sick/ disabed Chidren preserved from orphan status 1,839 chidren orphaned (= mortaity x3) 919 ess chidren orphaned 919 chidren preserved from orphan status Perinata ives saved 4,489 chidren dying 13 (= 12 %) 14 50% reduction (See 9.) (MDG: reduce 2/3) 2,244 ives of chidren saved Perinata disabiity prevented 4,489 (= 12 %) (estimated at east equa to perinata deaths) 50% reduction 2,244 chidren not disabed Perinata HIV infection prevented (PMTCT) 10% of women HIV+ 40 % transmission = 1,496 chidren HIV+ 65% reduction 972 chidren HIV prevented MCH Staff Trained and Guided to Achieve Cear Goas: HIV/AIDS Hoistic Care Component: Education on HIV/AIDS, Reproductive Heath, Maaria, TB (37,415 x 3) Peope aware of HIV status (number new peope (re) tested by MCH + HIV project) HIV+ peope timey on ARV, abe to educate chidren (aso referras) Persons not widowed and economicay more viabe Young orphans prevented (20,000 x 3) Orphans inheriting the beongings of their parents (through ega aid) Orphans prevented from becoming street chidren (estimate) HIV/AIDS Staff Trained and Guided to Achieve Cear Goas 112,245 80,000 20,000 20,000 60,000 2,000 1, In 5 years: year 1 = 15 per day; year 2 = 25 per day; years 3-5 = appr..35 per day. 9 Urassa DP, The Baobab Hospita wi aim at saving a ives, and certainy aim higher than a 50% reduction in the actua figures. However, it is important to consider that other hospitas, from rura as we as urban areas, wi make very ate transfers towards the Baobab hospita which wi consideraby increase the mortaity rate. We wi however aim to increasing the expertise of the hospita to dea with materna trauma and hopefuy be abe to reach our utimate aim of decreasing the rate by 75%. 11 This figure excudes women deivering at home. 12 Osen B et a. Estimates of materna mortaity by the sisterhood method in rura northern Tanzanian: a househod sampe and an antenata cinic sampe. BJOG 2000; 107: This figure excudes chidren born at home. 14 Kidanto HL et a. Perinata mortaity in Muhimbii Nationa Hospita Dar es Saaam, Tanzania. Proceedings 8th ECSAOGS conference, Dar es Saaam, November ,415 is the number of deiveries: each ady wi be required to bring at east 2 other persons for education (daughter, husband, partner, sister,...)

9 The Budget16 Requirement and Composition of the Regiona Designated Hospita wi be as foows (Euro). Grand Tota (5 financia years) = 28,355,111 Euro + Pot + ARV Medicines for 20,000 patients. 16 Minor cacuation differences are due to the fact that decimas were not copied from exce sheet. 9