Tanzania country review

Tanzania has enjoyed political stability since independence in 1961 and has no recent history of internal conflict. Although one of the poorest countries in the world with more than one third of its 45 million inhabitants living below the national poverty line (1), Tanzania has had success in attracting donors and investors.  
 
With a health budget well below the African average, the capacity and availability of health care personnel and facilities is low. The World Diabetes Foundation commenced its support to projects to improve diabetes care in Tanzania in 2002 and seven years later a solid network involving multiple partners has been established.

Overview

In 2002, when the World Diabetes Foundation funding was initiated, Tanzania had a diabetes clinic at Muhimbili National Hospital, Dar es Salaam, a diabetes clinic at Bugando Medical Centre, Mwanza, a diabetes clinic at Kilimanjaro Christian Medical Centre, Moshi and some diabetes services at other hospitals at the level of three districts (in Dar es salaam). Today, the country has a network of diabetes clinics in all regions of the country. These clinics diagnose and treat thousands of people with diabetes at primary, secondary and tertiary care level.

No health clinic can function without trained health care professionals. To date, the World Diabetes Foundation has supported the training of close to 800 health care personnel, including medical doctors, clinical officers, nurses and laboratory technicians, many of whom had previously little or no diabetes expertise.

The establishment of clinics and education of health care personnel have improved access to diabetes care significantly. The access was initially concentrated in major urban areas like Dar es Salaam, Mwanza, and Moshi. With the World Diabetes Foundation project, all the regions of the country are now covered at the level of regional hospitals. In the Lake Zone, the access has been delivered at the district and primary care level. The access has therefore supposedly increased from approx 30% of the population to more than 60% (2). The establishment of the clinics and the heightened level of knowledge have also brought about an increased focus on preventing other non-communicable diseases. It is this integrated approach that is the real success in the case of Tanzania.

Establishing clinics and training personnel

Training. In 2004, only about a third of healthcare staff at the regional hospitals were

sufficiently aware of key aspects of diagnosis, treatment, education, and complications in

diabetes. A year later, awareness had risen to 65% due to training.

The first project supported by the World Diabetes Foundation in Tanzania set out to establish diabetes clinics at four regional hospitals to improve care at secondary level in regions which had no access at all to diabetes services i.e. Musoma, Kigoma, Songea and Lindi.  With the success of this project, all the remaining regional hospitals and four referral hospitals were included in the project. By the end of the project in 2006, diabetes care at regional level had been significantly strengthened and an important base was laid for expanding care to primary level in the districts. Two successive projects focusing on four regions in the north western Lake Zone have taken diabetes care to district level with the establishment of a total of 106 diabetes clinics.  

To date, 225 diabetes clinics have been established throughout Tanzania with the support from the World Diabetes Foundation as well as from other donors. Except for 79 privately run clinics, the clinics were established through the Tanzania Diabetes Association and are run and sustained by the Ministry of Health & Social Welfare. Since many access health services in the private health care system, the World Diabetes Foundation supported APHFTA, the Association of Private Health Facilities in Tanzania, to extend diabetes care through private health facilities.

Along with the establishment of clinics, the Tanzania Diabetes Association has offered four-day  training programmes to teams of health care workers from each regional hospital, comprising a doctor, two nurses, and a laboratory technician. The World Diabetes Foundation has supported the development of a diabetes education training manual and diabetes clinical practice guidelines for Sub-Saharan Africa and this material is being used in all workshops and distributed to the clinics as a toolkit for health care providers.

The establishment of clinics and training of health care professionals has brought about a significant change in accessibility of basic minimal care. In 2004, only about a third of healthcare staff at the regional hospitals were sufficiently aware of key aspects of diagnosis, treatment, education, and complications of diabetes. An evaluation in January 2005, a year after the training, showed that the necessary awareness of diabetes had risen to 65% among the trained healthcare workers (3). 

Education key to preventing amputations

Although many serious complications can affect people with diabetes, complications related to the foot take one of the greatest tolls. Of all lower extremity amputations, 40-70% are related to diabetes. 80% of all amputations are preventable. In 2003, a project model called Step-by-Step was first launched with technical and funding support from the World Diabetes Foundation in Tanzania and India jointly and has since been replicated in many countries around the world. The model offers a method for simple preventive measures for screening and treatment of the diabetic foot.

In Tanzania, 14 foot care teams of doctors and nurses have been trained and 14 foot care clinics established in 14 regions. These teams disseminated their knowledge to more than 100 medical officers and almost 200 nurses thus cascading the learning. Among more then 26,000 patients with diabetes screened at the clinics in 2004/2005, 36% were found to have high risk feet (4). More than 500 patient education sessions were held to empower patients to care for their feet better, detect problems earlier and seek timely help when problems arise. The Step-by-Step foot project resulted in improved foot ulcer management for diabetic patients and a reduction in the number of documented lower limb amputations. While 9% of the reported patients with foot ulcers ended up with an amputation in 2005, a year later the rate was reduced to 6.5%. The overall aim is to reduce amputations by 50%.

Based on the positive impact from the first Step-by-Step project, the Foundation continues to support the follow-up project named “A Step Ahead of Step-by-Step” extending foot care with another 30 foot care teams and 30 additional clinics in the regions. Furthermore, the World Diabetes Foundation supports a project to improve the level of foot care by specifically training orthopaedic surgeons to perform limb saving surgery rather than amputations if and when surgery becomes necessary. Starting late 2009, the World Diabetes Foundation will also support a project to train ophthalmologists and ophthalmic nurses to improve eye screening and care among patients with diabetic retinopathy at the Muhimbili National Referral Hospital in Dar es Salaam.

Children’s programme

As a special service to children with type 1 diabetes, a child support programme was initiated in 2007 at five clinics with the support from the World Diabetes Foundation’s fundraising programme. Currently, 133 children are supported under the programme and according to diabetes educator at the Kilimanjaro Christian Medical Centre Sr. Sijah Mallya the project has made a difference of life and death to the children: “This has made an immense difference,” she says. “Previously, many children died – now they are able to get free insulin and optimum diabetes care if they come to the clinic.”

The fundraising project supports children from a poor or disadvantaged background with free insulin, glucometer, glucose monitoring strips and diabetes care. The project is administered by the Tanzanian Diabetes Association and supports children and youngsters with type 1 diabetes at five referral hospitals in urban and peri-urban areas of Tanzania. The estimated cost for supporting a child is USD 450 a year. In addition to the medicine and required equipment, the project also supports children's camps and purchase of refrigerators for the type 1 diabetes clinics as well as computers for updating of patient registries.

So far, the overall results of this fundraising project are positive. First of all, children survive longer and more children are being diagnosed early with diabetes. Acute complications such as diabetic ketoacidosis are reduced significantly. This is partly due to improved diabetes management at the referral hospitals. The parents also increasingly recognise the importance of good glycaemic control, impact of diet and exercise on diabetes treatment. A majority of the children with diabetes under the project are in primary school and those who success, proceed on to secondary school.

Accessibility and affordability

Part of creating access to care is also making care affordable. While access has definitely been created, it remains a challenge for many people with diabetes to always afford care. Today, more than 137,000 people with diabetes in Tanzania have access to affordable treatment and health education in the diabetes clinics, established by the Tanzania Diabetes Association, and run by district, regional and referral hospitals. Consultations are free of charge, while insulin and other medicines and laboratory tests are heavily subsidised by the Government or, for the poorest patients, free. 

The investment in preventing diabetes complications is a simple equation. It costs just USD 3 to educate a person with diabetes to take care of his feet to prevent foot ulcers - but an estimated USD 650 to amputate a limb and another USD 524 for a limb prosthesis. Costs like these put people living on less than a dollar a day into lifelong indebtedness, sentencing them to a life of dependence through their inability to work and support a family (5).
 

Amputations. Of all lower extremity amputations, 40-70% are related to diabetes. 80% of all

amputations are preventable.

Catalytic partnerships

It is very important to the World Diabetes Foundation that its funds are directed to people with the greatest burden and most in need: namely for diabetes projects in the developing countries. The strategy is to act as a catalyst - help others do more - making a much greater impact than the Foundation’s size would suggest. The World Diabetes Foundation seeks partnerships with established organisations in the areas of health, diabetes and development aid to build on existing structures and resources that help bring diabetes higher on the global health care agenda. Through these partnerships the World Diabetes Foundation aims to raise global awareness of diabetes and help find the resources to address and potentially limit the epidemic.

The implementing partners for projects supported by the World Diabetes Foundation have been the Tanzania Diabetes Association, the Ministry of Health & Social Welfare, Muhimbili University College and the Association of Private Health Facilities in Tanzania (APHFTA). As a positive spin-off effect, other partners have engaged in diabetes care and helped ensure the long term sustainability of the projects. For example, in the project to establish diabetes clinics, 4 ended up being supported by funds from the World Diabetes Foundation while the additional 34 clinics were supported by the World Diabetes Foundation’s fundraising programme (19), Novo Nordisk (12) and a well wisher from Venice, Italy (3). The sustainability of the project has been ensured by support from the Ministry of Health & Social Welfare  which in turn depends on the diabetes clinics to strengthen its clinic network for non-communicable diseases at regional and district levels. The Tanzania Diabetes Association has worked with the Ministry of Health & Social Welfare  from the beginning and hence is an integral partner of the Ministry's health care delivery system. 

Another example of a new partnership is DANIDA’s (the Danish International Development Agency) co-funding of the regional projects in the Lake Zone. By showcasing the results of the first project the World Diabetes Foundation and Tanzania Diabetes Association succeeded in getting DANIDA on board. The projects are funded with a 1:5 ratio by the World Diabetes Foundation and DANIDA respectively.

“Tanzania provides the classical example of how World Diabetes Foundation initiatives work. A country is in need and some local proactive champions take the initiative to formulate a project and apply for funding. The success of the first few projects has a number of positive side effects: it creates greater confidence and willingness to take on bigger projects and maybe attracts other sources of funding. It encourages other projects involving other local agencies. The projects advocate and attract government attention and support which in the end creates the base and willingness at the Ministry of Health to establish a national program. I am very proud of what we have achieved in Tanzania and the way we have gone about it. Not with extensive amounts of money, but with a responsible approach anchored in local commitment and ensuring sustainability in the long term,” says Dr. Anil Kapur, Managing Director at the World Diabetes Foundation.

Recently, a national task force for elaborating a strategy on non-communicable diseases has been created within the Ministry of Health. Starting in 2009, the World Diabetes Foundation is expected to support a national programme for non-communicable diseases in Tanzania through collaboration with the Ministry of Health & Social Welfare.

At the doorstep of poor people

Back at patient level, one of those who have experienced the change in diabetes awareness and care at close hand is Mr. Ramadhani Mongi, Vice-Chairman at the Tanzania Diabetes Association. He was diagnosed with diabetes in 1979. “When I was diagnosed, most people did not even know the disease. I read about it in a paper and recognised all the symptoms. So, I walked into a hospital and asked if this could be me,” he tells. For him the change in the last ten years has been tremendous: “Uh, there is a great difference! In 2000 there was no specific area where a person with diabetes could go. Today, we have hundreds of clinics and you will always find health staff who has been trained to diagnose and treat diabetes. Another difference is in medical supply. In 1979 there was not enough. Today, you can walk into the pharmacy and get what you need – the challenge may be whether you can afford it. The awareness level is much higher today and we are very proud of that. All this is a result of the awareness work done by Tanzania Diabetes Association,” he says.

Dr. Kaushik  Ramaiya, one of the key persons behind diabetes projects in Tanzania is less verbose yet very concrete in his description of the change brought about in Tanzania: “The most significant change in diabetes care in Tanzania in recent years has been bringing diabetes care to the doorstep of poor people. It may not always be affordable, but it is accessible.”

See an overview of all projects funded in Tanzania

References: (1) 35.7% live below the national poverty line (1990-2004), Human Development Report 2007/08; UNDP; (2) Dr. Kaushik Ramaiya, personal communication; (3) K. Ramaiya: "Tanzania and diabetes—a model for developing countries?", BMJ 2005;330:679; (4) K Bakker, ZG Abbas, S Pendsey: Step by Step, improving diabetic foot care in the developing world. A pilot study for India, Bangladesh, Sri Lanka and Tanzania. Pract Diab Int 2006, 23:8: 365 – 369 (5) K. Ramaiya: "Tanzania and diabetes—a model for developing countries?", BMJ 2005;330:679