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Medical Care and Socialism: Problems and Prospects in Tanzania
by Walter & Gail Willett
Tanzania is an East African country of approximately 16 million people known to many Americans only as the site of Mount Kilimanjaro, Serengeti game park, and the movie “African Queen.” The country was a German colony until World War I and subsequently became a British protectorate called Tanganyika until independence in 1960. In 1964 the Arab Sultan of Zanzibar was overthrown in a popular uprising, and shortly thereafter the island of Zanzibar joined the mainland in a federation which became known as Tanzania. Swahili is the mother tongue of Zanzibar and the coastal areas. Since Independence, it has become the language for primary education and official use and is thus widely spoken throughout the country.
Tanzania has a wide variety of environments ranging from a hot, humid coastal area to vast arid plains and moist, cool and fertile mountain ranges. Its population is one of the least urbanized in the world; less than 10% live in towns or cities. The vast area with a low population density has made the delivery of health and other social services difficult. Partly for this reason, a national villagization program has been carried out within the past several years. Mass movements of the rural population have occurred so that virtually the whole rural population now lives in villages. It has been the intention that production in these villages be on a communal basis, but this has been realized only to a variable degree, largely depending on local traditions.
Internationally, Tanzania has been in the vanguard of support for the liberation of Southern Africa, and most African liberation movements have had their headquarters in Dar es Salaam at one time or another. While unequivocally supporting the liberation movements, Tanzania has sought to maintain friendly relations with both East and West. Of note are the important contributions China has made to Tanzanian development including the construction of the Tanzam Railway linking Dares Salaam with land-locked Zambia.
Since 1967 Tanzania has committed itself to a socialist form of development. This article deals with socialist development in the health sector and attempts to examine progress to date as well as contradictions that have arisen in the course of this development.
Tanzania faces health problems typical of most Third World countries. The top three causes of death are pneumonia, measles, and diarrhea. Malaria, malnutrition, intestinal worms, tuberculosis, and leprosy are also very common. 16 percent of children die before the age of one. In spite of this, a high birth rate causes the population to grow at a rate of nearly 3% a year.
What distinguishes Tanzania from most other countries with these problems is a stated policy of socialist development, including a commitment to improving the health of all the people.1 This paper will describe the development of health services in Tanzania and offer some subjective observations of their function at present.
At the time of Independence in 1960 Tanganyika had fewer than 20 trained doctors of its own and a small number of medical auxiliaries. Government health services were concentrated in several racially segregated urban hospitals, of course with a disproportionate share of facilities for Europeans. Mission hospitals in rural areas accounted for almost half the number of beds nationally but were concentrated in a few more developed areas of the country.2 The emphasis in both government and mission health services was overwhelmingly on curative medicine, rather than public health, and thus did little to alter the pattern or incidence of disease.
The main economic efforts of both German and British concentrated on large agricultural estates, such as those which produced sisal (from which rope is made), and required a large mobile labor force. Poll taxes were created to force male workers to leave their village subsistence agriculture and to work on these estates in order to earn money and pay their taxes. Disease prevention programs were largely related to keeping this labor force healthy. However, the effect of this economic pressure was often to remove needed labor from the village agricultural system, causing a deterioration in the nutritional and health status of mothers and children left behind, to say nothing of the social disruption and disintegration also produced.3 In areas where male labor was not siphoned off, the same economic forces caused a replacement of subsistence farming by cash cropping, with similar damaging effects.
The newly independent government initially emphasized the training of doctors and did little to change the basic character of health services, which had very minimal impact on the health of the majority of Tanzanians. In 1967, under the leadership of President Julius Nyerere, Tanzania re-examined the direction of its development, and decided that the current direction was not likely to benefit the majority of the population.4 With support from workers and peasants, the principles of socialism and self-reliance were declared. In the initial phases the controlling sections of the economy such as banking, insurance companies, and import-export trade were nationalized. Health and education became the major foci of the national effort.
Translation of a Socialist Health Policy into a National Program
Given a commitment to provide health services to all the people, over 90% of whom live in rural areas, a program was developed to provide the facilities and train the staff. The total economic resources available in Tanzania for this task are small – on the order of 3 dollars per person annually. It became obvious that the health services must be based close to the people, and be delivered primarily by auxiliaries.5
Under this program the primary unit for both preventive and curative services is the dispensary, serving 5-10,000 people. This unit is headed by a Rural Medical Aid who is a primary school graduate with 3 years of training. A Maternal Child Health Aide, who has 18 months of training, provides routine immunizations and nutritional supervision for children as well as obstetric and family planning care for women. A Health Auxiliary, to supervise sanitation and preventive programs is also associated with the dispensary.
The next largest component of the health system is the Rural Health Center, which is headed by a Medical Assistant who has had 3 years of training after secondary school. The Health Center serves a population of about 50,000, has 20-30 beds and cares for simple inpatient problems as well as offering outpatient treatment and basic preventive services. District, Regional, and National Referral hospitals are headed by doctors and deliver primarily inpatient curative services.
Tanzania plans to have the entire system completed and staffed by 1980 and seems to be keeping fairly close to schedule. Almost all of the approximately 2000 planned dispensaries and more than half of the health centers have been constructed and are functioning. At present approximately 90% of the population is within walking distance of a health facility. Although often using make-shift buildings and nearly always short of teaching staff, the training schools for health workers are operating and graduating large numbers each year. Fully trained Rural Medical Aides now staff approximately half the dispensaries, although informally trained health workers staff the others. Maternal Child Health Aides and Health Auxiliaries have been graduating from training schools for the past two years, and by 1981 are expected to be sufficient in numbers to staff all dispensaries. The ability of the medical auxiliaries is impressive and their service, particularly in the area of Maternal Child Health, is extremely popular and growing rapidly every year.
Even when the system is completed it will probably not be able to provide for all the basic health needs of the population. Largely for this reason another level of health worker has been created – the village medical helper (VMH) whose function is similar to, and probably largely inspired by, the Chinese “barefoot doctor.” This person is chosen by his or her village and receives 3 months training. Upon return to the village, the VMH treats simple problems and carries out basic health education. This work may be the VMH’s contribution to the village communal efforts, or the village may choose to compensate him/her otherwise.
The Role and Education of the Doctor
Except in the case of a few medical specialists in the referal hospitals, the role of the doctor in Tanzania goes far beyond the diagnosis and treatment of illness in individuals. Virtually all medical graduates are employees of the Ministry of Health, and most serve as District or Regional Medical Officers. As such, doctors must assess health priorities within their districts or regions and allocate the scarce resources accordingly. This is done in conjunction with District and Regional political leaders, as well as the district officers of education, agriculture, water supply, and other departments. In addition, a doctor will supervise large numbers of Rural Medical Aides, Medical Assistants and other auxiliaries. S/he must monitor their work, be available for consultation and is normally in charge of their continuing education. This requires long hours spent traveling over bumpy, dusty roads, usually in dilapidated Land Rovers, to visit the widely scattered dispensaries. Most doctors also have considerable responsibility for the basic education of one or more cadre of health workers, as many district hospitals will have attached to it a training school for nurses, rural medical aides, or other health workers.
The education of doctors in Tanzania therefore involves considerably more than the usual medical education which focuses on disease and its treatment. The single medical school is located in Dar es Salaam and was started 15 years ago. It currently graduates 50 doctors per year. Public health training, including extensive field work, is incorporated in all 5 years of medical education. By the time a student graduates s/he has worked in villages, dispensaries, health centers, and district hospitals and knows the difficulties of these jobs first hand. S/he has also personally participated in village nutrition and infectious disease surveys and thus has first hand experience in measuring the prevalence of common health problems as well as relating them to social and environmental factors. Participating in the education of these students for 3 years was a most rewarding experience as they were almost without exception serious and hardworking. Public health has, world over, been traditionally the least popular of subjects for medical students, and Africa has in general been no exception. Although it is certainly not the favorite course of many Tanzanian students, virtually all have realized its central importance. Most encouragingly, public health has become the most popular program for postgraduate study in Tanzania.
Political Consciousness and Professionalism
It is obvious that the transition from a capitalist medical system, where a doctor sells the service of treating disease, to a system where the doctor’s primary role is to improve the health of the population which he or she serves, requires a considerable shift in political orientation. Political education, emphasizing the development of socialism in East Africa, is therefore a part of normal medical training. However, virtually all medical teachers are products of a traditional Western capitalist medical system, and it is inevitable that some of the values associated with this system are passed along in the education process. Although some students might, given the choice, select the considerably more lucrative role of private practice, they all understand the rationale and necessity of the present health policies.
After graduation Tanzanian doctors are required to serve with the government health service for at least 5 years, the first two of which must be in rural areas. It is notable that very few doctors trained in Tanzania leave their country to practice abroad, as is the case in many developing countries.
Political education is also part of the training of all medical auxiliaries. Most of these schools have also implemented projects whereby the students produce a large portion of their own food. The political orientation emphasizes the dignity and worth of all individuals no matter what their type of work may be. Strong political committees exist in virtually all hospitals and insure that workers are treated with respect by doctors and administrators. However, the British medical legacy of authoritarianism on the part of doctors toward both patients and nurses is still in evidence. This medical authoritarianism is often re-enforced by traditional sex roles, especially in the case of nurses, and contributes to a working relationship that, although improving, is still less than satisfactory.
The authoritarian medical tradition together with the pressure of time (in one urban dispensary a survey showed patients were seen an average of 45 seconds each) also leads to a health worker-patient relationship that is usually far from fully developed, and is not likely to be so for some time. It is hoped that the further development of maternal-child health aides at the dispensary level and village medical helpers will facilitate communications relating to health matters.
Conflicts with International Capitalism and Class Contradictions within Tanzania
Clearly the health program that Tanzania is implementing, which attempts to use the small national resources to maximize the health of the people, is in conflict with the traditional capitalist health system which is mainly motivated by the profit in disease. One would hardly expect that such a change in orientation could occur without conflicts and inconsistencies, some of which are described here.
Although Tanzania has attempted to gain control over the important aspects of its economy, it still operates within the international capitalist system. This is seen very clearly with respect to the drug industry.6 The overwhelming majority of illnesses that come to medical attention in Tanzania are infectious diseases that can be treated with simple, safe, and inexpensive medicines.7 For example malaria, diarrhea, and pneumonia (among the most common reasons for seeking medical advice) are best treated with chloroquine, a salt and sugar solution, and penicillin respectively. However, this would not be profitable to the large drug companies in America and Western Europe who have employed more than 140 representatives in Tanzania to push their newest, least proven, and most expensive products. These drugs are marketed in Third World countries with claims not allowed in the U.S. and without warnings of life-threatening complications required of the same manufacturers in their own countries. For example, aminopyrine and dipyrone are minor pain-relieving drugs that may cause fatal suppression of white blood cells and are licensed for use in the United States only in patients with terminal malignant disease. In Africa they are sold in 31 different preparations at a cost of up to 150 times that of aspirin and promoted for the relief of a myriad of minor symptoms.
The amount spent promoting such drugs far exceeds the amount spent on medical education. The predictable result is that large amounts of inappropriate drugs are purchased, while penicillin and other lifesaving drugs are often not available in dispensaries.
For instance, our medical students discovered that one district had ordered a huge amount of dihydrostreptomycin, costing one third of the district drug budget. The drug is promoted as an antidiarrheal agent but has no demonstrated benefit and may well be harmful. An effective treatment is a salt and sugar solution. Tanzania, with the help of China, has started producing and compounding its own basic drugs, but this has of yet had little influence on the activities of the multinational drug companies.
Another exploitative activity of international capitalism has been the well-known promotion of bottle feeding by Nestle’s and other companies. Artificial feeding, especially in an environment where strict hygiene is impossible, greatly increases the mortality of infants. Tanzania’s state of “underdevelopment” has been advantageous in this instance in that strong traditions and lack of purchasing power ruled out bottle feeding except in a small minority of urban residents. Government policy now strongly emphasizes the advantages of breast feeding and the risks of bottle feeding. This has thus not become a large problem in spite of the efforts of infant food corporations.
A more complex issue has been class conflict in the determination of health priorities within Tanzania. The stated national policy which concentrates on the development of widely distributed dispensaries and health centers staffed by medical auxiliaries and emphasizes basic prevention services, is clearly in the interest of the country’s workers and peasants. One might expect that the entire medical establishment and upper classes (although small and weak) would not voluntarily give up their perceived priorities, which consist of an emphasis on doctors providing curative service and modern sophisticated hospitals. (Ironically, most of these high technology curative services, such as coronary care units, have not been shown to affect health even in developed countries.8 ) The result has been that, in spite of impressive development in rural areas, urban hospitals still receive a disproportionate share of the national resources, some inappropriate equipment (such as coronary care facilities) continues to be purchased, and the efforts of the multinational drug companies receive some local support.
National class interests were also reflected in the recent controversies regarding private practice. In 1976 the Minister of Health declared that private medical practice was inconsistent with the concept that there should be no profits derived from disease. It was also clear that, although private practice represents only a very small fraction of medical services, the government would in the long run have difficulty keeping doctors in its service when private practice offers the chance to earn up to ten times the government salary. The announcement of the Minister of Health that private practice would be eliminated was very popular as most people realized that private practice meant service for only a small minority of urbanites with money. There were, however, strong protests against this move from some members of the medical community and members of parliament. Subsequently, the Minister of Health formulated a policy whereby private practice would not be eliminated, but rather controlled, including the income of doctors. The translation of this policy into action remains unclear. In summary, Tanzania has committed its health resources to providing the maximal benefit for the masses. The implementation of this policy has been rapid and impressive, although it is too soon to determine its ultimate effectiveness. As with any progressive policy, internal and external contradictions have occurred and are likely to continue. be eliminated, but rather controlled, including the income of doctors. The translation of this policy into action remains unclear. In summary, Tanzania has committed its health resources to providing the maximal benefit for the masses. The implementation of this policy has been rapid and impressive, although it is too soon to determine its ultimate effectiveness. As with any progressive policy, internal and external contradictions have occurred and are likely to continue.
DRUGS AND HEALTH CARE IN MOZAMBIQUE
Sitting around a table piled high with therapeutics journals and bulletins – and lists of drug prices – Mozambique’s Therapeutics Committee is producing a new, shorter list of drugs for the national health service. The current formulary, produced last year, lists 459 products by generic name. And its use is mandatory for subsidised health service prescriptions. But the list is still considered too long.
“Good therapeutics at the lowest price” is the national policy, according to committee head Professor Antonio Ruas. Where drugs are equivalent, the least expensive is chosen. But an attempt is made to include a variety of drugs, both to permit the health service to respond to changing price relations, and to ensure that second and third line drugs are available for most conditions. “In 90 per cent of cases of pneumonia, penicillin is OK. But you must have drugs available for the other 10 per cent,” Ruas explained. For this reason, the committee feels that it will never get down to the 50 or 100 drugs considered basic in some quarters, or even to the 220 on the WHO essential drugs list (see New Scientist, 18 May, p. 442).
Health has been a consistent priority both of Frelimo during the revolution and of the new government. In July 1975, just one month after independence, all health institutions were nationalized and private practice banned. In November 1977, medicine was also socialised. Visits to a doctor now cost only about 25¢ and all hospital, preventive, and maternal care is free. Drug prices are more complex. Private drug sales are still permitted, although the health service now supplies more than half the drugs. A list of 50 essential drug products – for the most common transmissible diseases such as tuberculosis, malaria, parasites and leprosy, as well as basic antibiotics and antiseptics- are free to everyone. For other drugs, families earning less than $100 per month (95 per cent of the population) pay 5 per cent of the government’s bulk purchase price. Higher income groups pay 25 or 50 per cent.
Mozambique is also studying traditional remedies. This policy is based on the experience of Frelimo in the liberated areas on the north of Mozambique before independence three years ago. “During the war, some traditional healers did help- curing illnesses and treating wounds. But others did not help. In traditional society, the witch doctor is an intermediary between man and the supernatural. Some of those people wanted to develop a similarly strong position in the liberated areas. So Frelimo decided it must fight obscurantism while using the true knowledge of the people.”
Since independence, virtually all the Portuguese doctors left (Ruas is an exception) and have been replaced by foreign volunteers. In common with many developing countries, Mozambique does not have enough doctors and is training paramedical workers. Two groups of these will be able to prescribe drugs – medical agents, with six years of schooling and a two-year course; and medical technicians, with nine years of schooling and a three-year course. The agents will head rural health centres; 45 have been trained so far. The technicians will head rural hospitals; 63 have been trained so far.
Drug purchasing is the other area in which Mozambique has made a radical change. Each year, the government publishes its proposed drug order and invites countries and drug companies to bid on individual items. The colonial government also bought drugs annually through an international tender, but it was not open to socialist countries. This new policy has sharply increased the number of suppliers, which also change from year to year.
Quality control remains one of the major concerns of the Therapeutics Committee. Mozambique is setting up its own pharmaceutical industry and hopes by 1980 to have testing facilities that it can use to check both its own production and imported drugs. In the interim, however, it must trust to luck and reputation. A few low bids have been rejected because of fears about quality. And, in general, “we have more confidence in the socialist countries”, according to committee member Carlos Marzagao.
Problems remain in the drug field. Drug company representatives still operate in Mozambique. They encourage doctors to prescribe drugs not listed in the formulary and to send patients to private chemists to purchase them. In at least one instance, a drug representative urged a doctor to ignore Ministry of Health instructions for tuberculosis treatment and always prescribe the third line treatment, which the Ministry warns is “extremely expensive”.
Perhaps the biggest difficulty is drug supply. Ruas and Marzagao admit that even essential drugs are not always available, especially in rural areas. Transport is a particular problem. Although the Ministry of Health now has its own lorries, there is still no road linking the north and south of Mozambique! Perhaps most serious has been that there was no way to predict demand for drugs, which has increased sharply, as more people use the new health service, so there has been significant underordering. Rising incomes since independence have also increased the demand for private drugs.
—from New Scientist, Sept. 1978.
The authors lived in Tanzania from 1974 to 1977. Walter taught community medicine at the Faculty of Medicine in Dares Salaam and Gail worked in several positions as a nurse. They now live in Cambridge, Mass.
- Nyerere, J.K.: Ujamaa, Essays on Socialism, Oxford University Press, Dar es Salaam, (1968)
- vanEtten, G.M. Rural Health Development in Tanzania, Van Gorcum Publishers, Assen, Netherlands (1976)
- Turshen, Meredeth, “The Impact of Colonialism on Health Services in Tanzania,” in Int. Journal of Health Services, 7:7 (1977).
- Nyerere, J.K.: Ujamaa, Essays on Socialism, Oxford University Press, Dar es Salaam, (1968); Gish, O., “Resource Allocation, Equality of Access, and Health,” International Journal of Health Services 3:399 (1973).
- Gish, O., “Doctor Auxiliaries in Tanzania,” The Lancet, 2:1251,(1973); Gish, O., “Resource Allocation, Equality of Access, and Health,” International Journal of Health Services 3:399 (1973)
- Shivji, I.G. Class Struggles in Tanzania, Chapter 8. Tanzania Publishing House, Dares Salaam (1975) (Available outside East Africa from Heinemann Educational Book Ltd., London)
- Yudkin, J.S. “Provision of Medicines in a Developing Country,” The Lancet 1, 810-812 (1978)
- Speight, ANP “Cost-effectiveness and drug therapy,” Tropical Doctor 5:84 (1975); Illich, Ivan Medical Nemesis, Bantam Books (1976)