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“Psychiatry in primary health care – Teaching and support in Tanzania 3”
and
“Improving Palliative Care in Ilembula Lutheran Hospital”
Report of the project monitoring and seminar trip to Tanzania 11.-25.10.2014
Participants:
Dr Elina Lind, Secretary for Foreign Mission, FCMS
Dr Tapio Pitkänen, Project Coordinator (Psychiatry in PHC)
Dr Liisa Laula, Specialist in Psychiatry
(Dr Leena Uusitalo participated at her own cost)
The purpose of the trip was:
1) to conduct the last annual monitoring visit to the four partnership hospitals of the psychiatric project,
Mchukwi, Matema, Itete and Ilembula, 2014 being the final (extension) year of the project
2) to participate in the Mental Health Seminar for Primary Health Providers in Mbeya in the 15th to 17th Oct
3) in Ilembula also to monitor the Palliative Care Project, started this year
11.10. Saturday
Departure from Helsinki-Vantaa at 7:00 (via Amsterdam), arrival in Dar es Salaam at 21:45. Overnight at the
Double View Hotel in Dar es Salaam.
12.10. Sunday
10 o’clock Sunday service at Kijitonyama Lutheran Church. After the service lunch with Mrs Caroline
Shedafa and her family at their home. Mrs Shedafa conducted the evaluation of the psychiatric project in
2012; the recommendations of the evaluation were carefully considered at the time, and have influenced
the plans of the two extension years of the project, 2013 and 2014. Consequently, major emphasis has
been given on trying to strengthen the sustainability of mental health work within the project catchment
areas after the project funding ceases.
The original plan was to travel to Mchukwi already on Sunday, but a few days before departure from
Finland we were informed that the seminar (for government primary health care workers) that had been
planned for 13th to 14th Oct had to be postponed, due to another seminar at Bagamoyo, arranged by the
Ministry of Health (MOH). Thus, there was no need to be in Mchukwi by early morning, and the decision
was to stay another night in Dar es Salaam. This gave us an opportunity to meet the new scholarship
student of the FCMS, Dr Emmanuel Owden Mwalumuli on Sunday evening at the hotel.
13.10. Monday - Mchukwi
Picked by Mchukwi Hospital vehicle at 9:30 am from the hotel. Arrived in Mchukwi at around 1 pm.
Discussions with various staff members followed by meeting in the afternoon.
Present at the meeting:
Administrator Hyasinta Maneno, Accountant John Nsongoma, N/O, Mental Health Coordinator Gertruda
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Kabika, N/O, psychiatric nurse Azory John Nyenza and the FCMS team Drs Elina Lind, Tapio Pitkanen, Liisa
Laula and Leena Uusitalo. Dr-in-charge Zacharia Rukeba was busy at the operating theatre and could not
attend the meeting, so we had separate discussions with him.
General notes:
 Financial situation of Mchukwi Hospital is still very challenging. Nevertheless, some renovations
had been made during the past year (with private donations), and the key staff members that we
met were very committed and determined to make a way forward. One example of this is the plan
of starting a nursing school at the hospital to help combat the problem of staff shortage in future.
At present, quick turnover of qualified staff is a problem. The benefits in government posts are
much better, causing qualified staff to leave the hospital for more attractive jobs in government
institutions.
 Since April/May the price of the internet satellite connection that the hospital had raised to about
TSH 1 million/month (about 500€). That was far too expensive, and now there is no internet at the
hospital. Some staff members use mobile connections, but for bigger files to be sent (or received)
by email the accountant has to travel to Kibiti (about 8km).
 Between July 2013 and May 2014 Mchukwi Hospital had a service agreement with the government;
treatment for pregnant mothers, children under 5 and elderly people was supposed to be given
free of charge and the costs subsidised by the government. This lead to remarkable increase in
patient numbers, especially deliveries. However, the government subsidy was constantly delayed
and never to full amount (less than agreed; about 55% of the true costs and even that was several
months late). The hospital could not afford treating exempted patient groups free of charge, and
decision was made to discontinue the service agreement. Since then services are charged again and
the increase in patient numbers has stopped. Prices are moderate and only cover about half of the
actual costs, but at least there are no delays in getting the payments.
 There is a government health insurance scheme; by paying TSH 5000/year/family treatment would
be given free. However, many people do not trust the scheme, and therefore are not paying. The
coverage is far from being adequate. For service providers the problem is that payments from the
insurance, too, often come very late.
 Hospital management staff would be very keen to continue cooperation with the FCMS in a new
project in future. However, the most urgent priority area that they recognize is mother and child
health care. It is undoubtedly true that safe deliveries, as well as good care of pregnant mothers
and babies, are vitally important, also in preventing complications that may lead to epileptic
seizures or even mental retardation. Yet, extending prevention of mental disorders to cover safe
motherhood was seen to be beyond the scope of our concept. Moreover, mother and child health
care are very much a priority of the MOH of Tanzania; thus, the government should be pressed to
provide adequate resources. Therefore, although extremely important, it was felt that at present
FCMS is not willing to be involved in a project that would mainly focus on mother and child health.
About psychiatric services:
 Village outreach work was discontinued from the beginning of 2014 due to lack of funds. No
alternative source of funding could be found to continue services as before. Prior to cessation of
the outreach, all villages were informed. The nearby health facilities were informed that mental
health patients should visit Mchukwi Hospital OPD for drug collection and evaluation. The
psychiatric nurses continue to treat mental patients at the hospital out-patient clinic. Till now, less
than 30% of the previous patients (285 out of 971 in 2013; most of them adult epileptic patients)
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are regularly coming to the hospital to get their medicine. Presumably there are many patients in
the villages without care. Some patients were without medication 2-6 months and then returned.
Some may have sought treatment from other service providers. Before the outreach was stopped,
all patients were given a card telling their diagnosis and treatment; this was to help them get
correct treatment in government health posts or other facilities.
In 30th August a seminar about mental health was conducted for the Government Village
chairpersons (outreach villages), Rufiji Council chairperson, District Medical Officer, District Mental
Health Coordinator, Community Health Management Team members and other selected
participants within Rufiji District (47 participants, including 11 from Mchukwi Hospital itself).
Following the seminar, the Community Health Management Team (CHMT) agreed that mental
health will be included in annual budget. Villagers are also encouraged to join in community health
fund to be able to finance their health needs, including mental health drugs.
Even if the outreach service now has been stopped many achievements could be listed.
Overall knowledge and awareness about mental disorders has greatly improved in the villages.
People now know that mental disorders are not caused by demons, and that they can be treated.
The change of attitude is remarkable compared to what the beliefs were before the project started.
Also new patients are still coming to seek help.
Hospital staff is more aware and more skilful in diagnosing and treating mental disorders.
The seminar for government primary health care workers that now had to be postponed will be
held before the end of 2014. There has already been communication between the government
health workers and the mental health professionals of Mchukwi, and the seminar aims at
strengthening cooperation. One of the problems at government health facilities – apart from lack
of skills - is lack of medicines; they are often out of stock.
Regarding the seminar, a question was raised by the hospital administrator, whether it would be
possible to add funds for follow up/mentoring visits by psychiatric nurses of Mchukwi Hospital to
government health posts after the seminar. After some discussion it was decided that
TSH 500 000 (about 250€) will be added to the seminar budget (either from the project funds or
FCMS own funding) to conduct one follow up visit to all those 14 health posts that will participate
in the seminar. After receiving a report with initial feedback about the follow up visits (whether
found useful), FCMS may consider funding such follow up/mentoring visits 2-4 times a year even
after the project finishes to further facilitate the handing over process.
15 copies of Mental Health in Primary Care (Huduma za Afya ya Akili Ngazi ya Msingi) –books
(published by MEHATA) were given to be distributed to the participants of the seminar.
14.10. Tuesday
Travelling day from Mchukwi to Mbeya: taken by Mchukwi Hospital vehicle to Dar es Salaam Airport;
FastJet flight from there to Songwe airport; shuttle bus from Songwe airport to Mbeya city (about 20km).
Dr Paul Lawala, the psychiatrist of Mbeya Referral Hospital, came to meet and welcome us at Mbeya Hotel.
15.-17.10. Wednesday to Friday - Mental Health Seminar for Primary Health Providers in Mbeya
The seminar had been planned in close cooperation with Dr Paul Lawala. He, together with clinical
psychologist Liness Ndelwa and psychiatrist Francis Benedict from Njombe had prepared most of the
lectures. On behalf of our Finnish team Dr Tapio Pitkanen presented an overview about the experiences of
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the psychiatric project over the years, and psychiatrist Liisa Laula gave lectures about ‘Psychotic disorders’
and ‘Mental development in childhood and adolescence’. All lecture notes had been printed and bound
into a booklet that was given to participants, as well as similarly bound WHO Intervention Guide for mental,
neurological and substance use disorders in non-specialized health settings. The notes were in English, but
the lectures, as well as discussions were mainly held in Swahili. Even without understanding the language it
was encouraging to see how actively the participants contributed in sharing experiences, views and ideas.
Overall, arrangements for the seminar were excellent, and it seemed that the participants also appreciated
it. The seminar was also acknowledged by the Executive Director of Mbeya Referral Hospital, Dr Mpoki M.
Ulisubisya, who visited the seminar to welcome the participants on Thursday.
A short visit to the Psychiatric Unit of Mbeya Referral Hospital was made after the second seminar day.
There are 8 beds for female and 16 beds (+ a number of mattresses on the floor) for male patients in the
psychiatric ward. In psychiatric OPD there are now 5 consultation rooms – the rooms for a social worker
and an occupational therapist are still waiting to be occupied by relevant staff members ie. those posts
have not been filled yet.
The rest, 20 copies of Mental Health in Primary Care (Huduma za Afya ya Akili Ngazi ya Msingi) –books were
distributed to the participants of the seminar in the last day.
A separate report of the seminar by Dr Paul Lawala, including the list of the participants, is attached, as well
as the seminar programme.
According to Dr Lawala the lack of support for mental health work is obvious. There are 2 specialized
psychiatrists in the area, Dr Lawala in Mbeya and Dr Benedict in Njombe. Because of poor working
conditions at Njombe Hospital, Dr Benedict is seriously considering leaving. In the Ministry of Health there
is a person nominated to be responsible for mental health work nationwide, yet, he has never visited
Mbeya. Therefore, a lot of ‘aggressive advocacy’ is needed both in the national, regional and local level to
secure resources and win appreciation for mental health work.
After the third seminar day, on Friday afternoon, the vehicle of the Palliative Care Team of Ilembula
Hospital came to take us to Ilembula. Arrived in Ilembula just before dark.
Before departing we agreed to meet with Dr Paul Lawala once more over lunch at Mbeya Hotel on Friday
the 24th on our way to Songwe airport and back to Finland.
18.-19.10. Saturday to Sunday - Ilembula
The two days of the weekend were mainly free of official meetings. On Sunday after the church service
(7am) in the afternoon we were invited to the home of the hospital treasurer David Kikungwe and the
same evening to the home of the administrator Bryceson Mbilinyi. Both visits, although informal, gave us a
chance to talk about the situation of the hospital in general, as well as the matters concerning the two
projects, psychiatric and palliative.
20.10. Monday – Ilembula
Monday was the day for the official meetings, the psychiatric project in the morning and the palliative care
project in the afternoon.
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General notes:
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The status as a ‘Designated District Hospital of Wanging’ombe’ has made a great difference in the
general financial status of Ilembula Hospital. Since July 2014 the agreement, already signed in 2010,
has finally been implemented. When fully implemented, the service agreement will cover:
- salaries of the staff; the number of staff that are under government payroll is increasing; now 78,
in the end will be 265; in addition there are 12 staff members that have been sent and are directly
paid by the government/ District Council (including second administrator, which has already
remarkably helped in communication with government officials)
- provision of drugs (already now the situation is better than before)
- provision of food for the patients
- ambulance
In government plans Ilembula will also become a Zonal Referral Hospital in near future (like 10
other church hospitals). The other nearby hospitals are Njombe Regional Hospital, St Joseph
Hospital near Makambako, Mbeya Referral Hospital and Chimala Hospital.
ELCT is not providing any financial support to the hospital – yet, is sending auditors every year that
have to be paid and accommodated by the hospital
The hospital is in the process of installing a quick internet cable (instalment costing TSH 20 million).
Two of the three lines can later be sold out, one will serve the hospital. There will be a wireless
network in the whole hospital. All wards have computers already (but not necessarily any staff
capable of using them). The aim is to computerize both hospital management and patient files
(using care2x).
There are several insurance schemes in progress. There is a government plan to have community
health funds in all regions, but it has not been properly implemented in Ilembula, yet. In
community insurance fund the coverage should be more than 50% to be enough. Promotion of
community insurance is actively administered. The payment of the insurance is TSH 10000/ year to
cover 4 family members (bigger families need to pay more than one insurance fee). The hospital
workers are all under national health insurance.
About psychiatric services:
Present at the meeting of the psychiatric project:
Dr-in-Charge Godfrey Ezekiel Mpumilwa, Administrator Bryceson Mbilinyi, Treasurer David Kikungwe,
Mental Health Project Coordinator Dr Owden Mwalumuli, Hospital Matron Agnes Lwiva, Acting Principal of
Ilembula School of Nursing Anipher Nyunza and the Finnish team, Drs Elina Lind, Tapio Pitkanen, Liisa Laula
and Leena Uusitalo
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There is a dedicated psychiatric team to continue the work even after the project finishes. Hospital
has already taken over a lot of the financial responsibility. Until now all outreach clinics have been
run as before. Between January and August 2014 (8 months) the total number of patients treated
at the outreach clinics was 1674, 58% female, 42% male, 19% under 15 years.
However, there are many challenges. Negotiations with the government DMO (District Medical
Officer) of Njombe District last year resulted in a promise to include mental health into the basket
fund budget, but that did not happen in reality. In the meanwhile, the district has been changed
from Njombe to Wanging’ombe. In the newly formed Wanging’ombe district all administration is
also new. The priority of the politicians is not health but infrastructure of the new district.
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Moreover, within health matters the priority is not mental health but rather women, children and
elderly people. Nevertheless, negotiations will be continued.
Availability of drugs has improved compared to earlier years. The provision of the MSD has been
much better than before, and only occasionally some essential drugs have been out of stock.
To reduce the costs of the mental health outreach work two suggestions were made: 1) to share
transportation with other outreach teams (not regarded really feasible because of different needs
of time or different locations of outreach services); 2) to reduce once a month outreach to once in
two months, especially those clinics that are far away. That would save both petrol and manpower
without really affecting the quality of care remarkably.
Between the two meetings we also visited the Nursing School. Ilembula Nursing School was started in 1963.
Since 2003 it has offered accredited certificate and diploma level courses. Currently there are 190 students,
80 in the certificate course and 110 in the diploma course.
In the certificate level there is an introduction to mental health, and in the diploma level there is a course
about management of mental disorders. Teaching about mental health was started about 3 years ago
(nationwide), yet, teaching material is still largely missing. Copies of the lecture notes from the Mbeya
seminar and the WHO Intervention Guide were therefore given to the acting principal Anipher Nyunza, with
the hope that they might be helpful in preparing lectures about mental health. For practical experience
nursing students also participate in psychiatric outreach visits. The principal is currently specializing in
mental health (a 2-year postgraduate training).
Unlike mental health, palliative care is not yet included in the curriculum.
About home based care and palliative care (HBC&PC):
Present at the meeting of the palliative care project:
Palliative Care Coordinator Aida Mtega, Assistant Coordinator, CO Goodyear G. Pangisa, Administrator
Bryceson Mbilinyi, Social worker Regina Joseph, Assistant social worker Ziada Madete and the Finnish team,
Drs Elina Lind, Tapio Pitkanen and Leena Uusitalo
In the meeting with the responsible persons of PC it turned out that it does not seem to be very clear to
them, yet, what it means to run the project together and following the set plans. Communication via emails
has been a problem, and to some extent it was a problem also face to face. Most likely this is mainly due to
the lack of common language. The coordinator of the palliative care, Aida Mtega, is not very fluent in
English and of the Finnish group only Dr Tapio Pitkanen is able to speak Swahili. In the meeting, the
administrator Bryceson Mbilinyi was translating.
The work has largely been continued as before. However, of the 53 volunteers only 23 are left; 23 have
swapped to a government paid project, 2 have died and 5 others quitted. After formation of the new
Wangin’ombe District, since August 2014, a government initiated AIDS control programme was launched
and the regional coordinator nominated. In that programme, volunteers are being paid TSH 35000/month,
whereas the HBC volunteers of Ilembula Hospital only receive TSH 20000/month. Thus, many volunteers
have shifted. Many of them may still visit the same patients as they used before, though. The new
programme is only focusing on HIV/AIDS patients, but majority of the previous patients, too, were suffering
from AIDS. It is not yet clear, how the cooperation and coordination of the two programmes will be
organized. Aida Mtega will meet with the AIDS control programme coordinator to discuss about it, but that
meeting had not yet happened.
Those volunteers that are still within the project continue coming to Ilembula once a month. The day when
we met only 6 volunteers had come, the rest were to come in the 23rd Oct.
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About 4000 patients/year are being looked after by the HBC&PC team and volunteers. Those patients that
can are requested to pay a little amount (cost sharing). One volunteer can have as many as 126 patients to
care for. Aida Mtega with the PC team from the hospital is going for outreach 1-2 times a week.
Among the HBC&PC patients there were currently six cancer patients; one had just died over the weekend
at the hospital.
Till now at least 20 nearby villages are lacking volunteers, so there is a definite need for recruiting and
training new volunteers. To recruit new volunteers means that they first need to have a 3-weeks basic
training course. On such course one trainer has to be appointed by government (but paid by the hospital/
PC project) to follow the government protocol. Each village needs to have two volunteers, one male and
one female. It is possible to have up to 30 participants in the course, thus covering 15 villages (if all are
from new villages and not replacing previous volunteers).
When asked about curriculum for the training of volunteers Aida Mtega showed 5 different booklets that
are being used, most of them produced by the MOHSW. Two were in Swahili, three in English, including for
example national guidelines for voluntary HIV/AIDS counselling and testing (2005).
Planned study tour to Muheza Hospice in Tanga Region was conducted in September 14th to 16th. There
were two participants from the hospital management team (Dr-in-Charge and Treasurer), the rest were
from the Palliative Care team (coordinator Aida Mtega, Assistant Coordinator Goodyear Pangisa and PC
nurses).
Two social workers participated in the meeting. They told about the local government’s initiative to
cooperate in a programme targeting to children living with HIV/AIDS. There was a plan to arrange a special
gathering of such children and youth in Njombe on the World AIDS Day (1st Dec). The special target group
was children and young people between 10-24 years of age, that are neither going to the school nor have
an employment. Group of 5-6 was to be selected from Ilembula. In the following financial year (7/20156/2016) 3 million Tanzanian Shillings could be provided for this particular target group with the condition
that the 1 million that is available for this year is used in a sensible way. Connection between these children
and youth and the HBC&PC did not become very clear. The lack of common language hampered the
discussion quite a bit.
There was also some discussion about local fund raising. Apart from FCMS project funding, some funds had
been received from ELCT Head Office, Arusha. Special collections were also organized in nearby outreach
villages; between 2nd and 30th November such collections were planned to be organized in 11 different
towns and villages.
Lastly we discussed about the plan of Dr Reino Pöyhiä visiting Ilembula again during the first quarter of
2015. The plan was warmly welcomed. Aida Mtega suggested that also the Manager of ELCT Palliative Care
Program, Dr Paul Z. Mmbando, should be informed about the dates, and also about our visit at Ilembula.
At the time, the decision about further project funding beyond 2014 by the Ministry for Foreign Affairs of
Finland had not been received. However, it was clear that all of the funds that were granted for 2014 would
not be finished by the end of the year. Therefore, the second visit of Dr Reino Pöyhiä could be financed
with remaining funds, although approval of the MFA had to be sought beforehand.
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21.10. Tuesday
Travelling day from Ilembula to Matema (the vehicle of the Palliative Care Team with a driver was hired for
the travels again). There was some heavy rain on the way, but luckily that was where the road was paved.
We reached Matema just before dark in the evening.
22.10. Wednesday – Matema
In the morning we first joined the hospital clinical meeting and morning prayer. The impression of the
clinical meeting was that remarkable proportion of all patients were maternal cases, and there had also
been several deliveries during the past 24 hours. Total number of inpatients was 53. After a short round in
the hospital, we had a meeting about psychiatric work. The meeting was held in the new psychiatric unit/
counselling room that was constructed as part of the project. The rooms were ready, but the unit was still
lacking furniture.
The Dr-in Charge Christopher Mwasongela was not in Matema during our visit, thus, we did not meet him.
One of the two nurses responsible for mental health work, Hezron Ntanjo, was also on leave, but we had
met and discussed with him at the seminar in Mbeya. It was not quite clear why only one representative
(Hezron Ntanjo) from Matema came to the seminar (and even he a day late). But at least there was a
shortage of staff and heavy work load preventing Richard Amasa of leaving the hospital.
Present at the meeting:
Hospital Secretary Efron Y. Chaula, Acting Dr-in Charge Heinke Schimanowski-Thomsen, Treasurer Fadhili
Mwantolwa, Psychiatric nurse Richard Amasa and the Finnish team, Drs Elina Lind, Tapio Pitkanen, Liisa
Laula and Leena Uusitalo.
In Matema, there were over 8 million Tanzanian Shillings of unused project funds in the beginning of 2014.
Thus, the remaining funds of 2200 Euros were not transferred until in the beginning of October. It was
highlighted that all project funds have to be used by the end of the year, as the project is ending. Because
of funds remaining from previous year, most mental health activities had been continued as before.
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outreach clinics had been run in all 10 villages (as before), 6 of the villages are reached by land,
4 are along the coast of the Lake Njassa and are reachable by boat (the need for a boat was
discussed again).
14 school visits (primary schools) were planned, but only 11 of them conducted; education given
was mainly about epilepsy, to raise the awareness and understanding. Lack of funds was the main
reason for not visiting all 14 schools.
achievements and future prospects:
- patients are now aware that they can be treated
- yet, most patients cannot afford to pay for their medicines
- minimal level of services that can be maintained is to give medication to those patients that
come to the hospital and to continue giving mental health education
annual mental health budget is about 2.6% of the total budget of the hospital
General notes:
(Based on discussions at the meeting above and with the hospital secretary Efron Chaula later in the
afternoon)
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financial status of the hospital remains critical
there is service agreement with the government covering mother and under-five care and CTC;
government is giving 300 million Tanzanian Shillings a year to run these services. However, about
double amount would be needed to cover all those costs
total number of staff is about 70, 26 of those are under government payroll (increased)
to purchase drugs from the MSD, government support is 66 million TSH/ year
there is a problem of long delay of getting funds from CHIF (community health insurance fund); no
compensation had been received since August 2013 (well over a year)
23.10. Thursday – Itete
It took 1 hour 15 minutes in the morning to travel the 33 kilometres from Matema to Itete.
Like in Ilembula, in Itete, too, the designation within the government health care system (Busokelo Council
Designated Hospital) has already greatly improved the personnel and financial status of the hospital.
Present at the meeting:
Dr-in-Charge Lee Mwakalimga, Administrator, Rev. Samwel J. Mwansasu, Matron Tumwitikege Nazareth,
NOP Stephen Mwakiyolile, Health Secretary (Busokelo) Luciana Makabila, Social worker Imani D. Mbelimbe,
Cashier Noel Meshack and the Finnish team, Drs Elina Lind, Tapio Pitkanen, Liisa Laula and Leena Uusitalo.
General notes:
 service agreement/designation as council hospital means that:
- the hospital is still owned by ELCT (Konde Diocese), but the work is shared between the Diocese
and the government in collaboration
- government policies have been adopted in all work
- in addition to hospital’s own staff there are staff members seconded by government
- more than 10 of the former staff have been transferred under government payroll
- total number of staff including those seconded by government is 135 (need is up to 214,
if all posts were filled)
- Dr Lee is the only medical doctor; in addition there are 5 clinical officers (3 seconded by Busokelo
District/Council)
- of the nurses 9 are seconded by the District Council
- hospital is eligible to get all medicines from government; both MSD and private pharmacies
(through basket fund)
- exempted groups include: pregnant woman, children under five, elderly and psychiatric patients
 with all the changes hospital is still in transition period
About psychiatric services:
 mental health is now included in the budget of the basket fund
 NOP Stephen Mwakiyolile has been named as the coordinator of mental health in Busokelo
District/Council (another psychiatric nurse Simon Mwaitalako has similarly been nominated as
coordinator of Home Based Care)
 some outreach clinics (6 dispensaries in Busokelo) are now also getting medicines from MSD
 after the project funding ceases, there will be a problem in running the outreach clinics (lack of
funds for fuel and allowances)
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the minimum level of services that can be sustained will be seeing patients at the hospital OPD
and home visiting to nearby patients
of the total hospital budget, the budget of psychiatric department is about 4% in 2014
Overall impression of Itete Hospital was that there was a lot of new hope for future and enthusiasm to
develop the services. Collaboration between the former hospital staff and staff seconded by the
District/Council seemed smooth. When asked staff members told that they were happy with the situation
now.
In the evening we had been invited for dinner at Stephen Mwakiyolile and her newly married wife Tumbe.
The hospital treasurer, Yolam Mates Lamsi, was away and only returned after the meeting. We met him
briefly the following day before leaving Itete.
A donation of 350 000 TSH was made to be used for the audit costs of the psychiatric project in 2015.
24.10. Friday
Travelling day; from Itete to Mbeya, Mbeya to Dar es Salaam and leaving for Finland.
In the morning we participated the morning meeting and prayer of Itete Hospital before leaving for Mbeya.
As agreed before, we had lunch at Mbeya Hotel with Dr Lawala. A week after completing the seminar Dr
Lawala was happy with the outcome and cooperation – and so were we. Dr Lawala gave detailed financial
report of the seminar with copies of all vouchers as was the agreement. After all costs had been covered
there was an excess of 171 440 TSH, which he returned in cash.
The FastJet flight from Mbeya/Songwe took us to Dar es Salaam Julius Nyerere International Airport. Before
late evening departure for Finland (via Amsterdam) we had dinner together with Dr Manento Ernest
Mtango and his wife Mary Ernest Mtango at the airport restaurant. Dr Manento Ernest Mtango’s post
graduate studies (Master’s in Obstetrics and Gynaecology) have been supported by a group of Finnish
donors through FCMS scholarship programme. The studies were almost finished, and took about 4 years.
He and his wife have been invited to visit Finland in March/April 2015.
Night flight to Amsterdam followed by flight to Helsinki-Vantaa; arrived at 1:20 pm. Farewell to travelling
companions.
Summary and conclusions
It was encouraging to see that mental health work was still going on in all partner hospitals despite the
remarkable reduction in project funding in 2014. In Mchukwi all outreach clinics had been discontinued,
though, and patients were only seen at the hospital, with the consequence of about 2/3 drop in patient
numbers (by October). All project funding in 2014 had been channelled in trying to hand over the village
level psychiatric care to the government health posts and dispensaries in former outreach sites. If
successful, this will ensure sustainability and continuous availability of primary level mental health care
integrated in the existing government health care structures. The level of the quality of care will initially
deteriorate, but if supervision can be provided the situation may gradually improve again. The seminar for
health post workers had to be postponed till November. It was agreed that FCMS (with or without funds
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from MFA) will fund at least one follow up/ mentoring visit by Mchukwi Hospital psychiatric nurses to all
health posts attending the seminar. If regarded useful, this kind of follow up/ mentoring visits could be
supported with FCMS’s own funding in future, too. Alternatively, a specific project to support handing over
period could be planned and applied.
In Ilembula and Itete the designation of the hospitals as district/council hospitals had remarkably
strengthened their financial situation, as the government health authorities were taking increasing
responsibility of funding. Both hospitals were still in transition period; positive steps were already taken,
but the agreements with the government had not yet fully materialized. In Ilembula the hospital had
already taken over funding of ongoing psychiatric outreach work (after project funding had finished) even
though that had not been included in the hospital budget. In Itete, psychiatric unit was already included in
the general budget, as well as in the district/council basket fund budget. The long term coordinator of the
psychiatric team in Itete had also been appointed the coordinator of mental health in the new Busokelo
District/Council.
In Matema the reduction of project funding had been somewhat minor, due to funds carried over from the
previous year. The general financial situation of the hospital remains critical, thus, despite dedicated staff
members running the psychiatric services, future seems very challenging. The construction of the
psychiatric unit had been completed, but the furniture was still missing.
In all four hospitals worries were expressed about future funding. Yet, all shared the view that during the
project years at least awareness about mental disorders within the communities has greatly increased;
patients and their relatives now know that treatment is available, and many false beliefs have become less
strong.
The cooperation in arranging the seminar with Mbeya Referral Hospital Psychiatric Unit/ Dr Paul Lawala
was also very encouraging, both beforehand and during the seminar. Arrangements of the seminar were
excellent and also financial matters were dealt proficiently and trustworthy by the hospital administration.
The option of continuing collaboration in a new project, largely focusing in promoting mental health
through advocacy, education and strengthening existing services, will be seriously considered. Application
to MFA of Finland for a new project can be submitted at earliest in May 2015. If accepted, the new project
could start in 2016.
The palliative care project at Ilembula has only been running since the beginning of 2014, although the
work itself has been going on much longer. There seemed to be some confusion about following the plans
set for the project, as well as about the meaning of partnership with FCMS in the project in general.
Communication has not been easy by emails, and was a bit complicated even face to face, presumably
largely due to lack of common language. Another trip of Dr Reino Pöyhiä to Ilembula in early 2015 was
agreed mutually important, both for training purposes and for clarifying and strengthening the idea of true
partnership in aiming at improving (not only funding) palliative care services at Ilembula.
Prepared by:
Elina Lind
Attachments:
1) Report of the Seminar in Mbeya by Dr Paul Lawala
2) TIME TABLE FOR MENTAL HEALTH SEMINAR AT MBEYA REFERRAL HOSPITAL,
15TH TO 17TH OCTOBER 2014 (plan and actual combined)
3) Group photo of the seminar participants
12
Attachment 1.
REPORT: MENTAL HEALTH SEMINAR FOR PRIMARY HEALTH PROVIDERS
15th TO 17th OCTOBER 2014.
INTRODUCTION
The service and friendship link has been established between Finish Christian Medical Society
(FCMS), Ministry for Foreign Affairs of Finland and the Department of Psychiatry and Mental
Health in Mbeya Referral Hospital. This link was made possible by some members of the FCMS
making a visit to Mbeya Referral Hospital in 2013. The three parties facilitated to conduct 3 days
mental health seminar in Mbeya. The similar programs have run in collaboration with the church
Hospital for the past 13 years until 2013. This is the first time the seminar to be organized by
Mbeya Referral Hospital.
The seminar was successfully conducted by involving 18 mental health staff from Mbeya and
Njombe health facilities. Participants came from Mbeya Regional Hospital, Mbeya Referral
Hospital, Njombe Town Hospital, Ileje District Hospital, Rungwe District Hospital, Kyela District
Hospital, Mbozi District Hospital, Ilembula Hospital, Bulongwa Hospital, Itete Hospital, Matema
Hospital, and Mbarali District Hospital. The seminar coordinator went on by giving training
protocols and logistics after introducing everyone to each other. Then facilitators guided the
participants to select the leaders, secretariat with the ground rules to be followed during the training.
Names of the participants and their respective facilities.
S/no
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
NAME OF THE PARTICIPANT
DR. TRIOALA NYENZA
DASHUD MWAKABANJE
DAINA IFWANI
JOAKIM LUOGA
EXAUD MWEMUTSI
HURUMA DOTO
EVETA MCHOMBA
GEOFREY ZOMBE
EMERENSIANA MTEGA
DEBORA DIKOKO
SOFIA MFUNGATI
DR O. MWALUMULI
JOHN MATARA
ROSE PELES
SIMON MWAITALAKO
STEVEN MWAKYOLILE
HEZRON NTANJO
DR. FRANSIS BENEDICT
TITLE
MED. OFFICER
DNO
NO
RN
RN
RN
RN
RN
RN
RN
NO
AMO
RN
RN
RN
RN
RN
PSYCHIATRIST
HEALTH FACILITY
MBEYA REF. HOSPT
ILEJE DH
MBEYA REF HOSPT
MBOZI DH
MBEYA REF. HOSPT.
RUNGWE DH
MBARALI DH
KYELA DH
MBEYA DC
MBEYAREG HOSPT
ILEMBULA HOSPT
ILEMBULA HOSPT
BULONGWA HOSPT.
BULONGWA HOSPT
ITETE HOSPITAL
ITETE HOSPITAL
MATEMA HOSPTAL
NJOMBE HOSPITAL
13
SEMINAR METHODS
Power point presentation slides
Small group discussions
Individual presentations, pre and end of the day tests
Visiting mental health services at Mbeya referral hospital
BUDGET ESTIMATIONS
The budged estimation was 8,150,000.00. The money transfer from FCMS account was completed
on 26th September 2014 amounted 7,973,840.00.
As summarized in the table below
SUMMARY OF BUDGET ESTIMATIONS
Items
Unit cost
(TZS)
Total (TZS)
1.
Venue
70,000
210,000
Participants
80,000
4,800,000
Facilitators
80,000
960,000
20,000
280,000
1,000,000
1,000,000
50,000
150,000
10,000
Total
750,000
8,150,000/=
2.
3.
4.
Tickets
5. Training
materials
6.
Car hire
7. Food &
drinks
14
SUMMARY OF ACTUAL EXPENDITURE
S/No
1.
2.
3.
4.
5.
6.
7.
8.
9.
ITEM
RECEIPTS
Stationery
Venue
Food
Participants
Tickets refund
Facilitators
Supporting staff
Report writing
Total expenditure
Balance
AMOUNT
7,973,840.00
991,800.00
210,000.00
756,600.00
3,927,500.00
234,000.00
1,200,000.00
97,500.00
385,000.00
7,802,400.00
171,440.00
15
FUTURE PLANS FOR MENTAL HEALTH PROGRAMS
The department of Psychiatry and Mental Health has planned to conduct the following programs
which will in short and long terms expected to significantly improve services in primary mental
health. The resources to accomplish goals of these programs are presumed to be internally and
externally supported. The chance for internal support is still lacking. For this reason external
support if made available will be highly appreciated. Among the following listed programs, any
external support to implement them will be acknowledged.
Service area
Recommended program
Current status
Supervision
Mentorship and
supportive supervision
Outreach clinics
Not done
Outpatient clinics
Estimated cost per
year
7,000,000/=
Not done
5,000,000/=
Mental health
promotion
Psychiatry and mental
health skills for service
providers
Psychiatry & Mental
health knowledge and
skills for primary care
clinicians
Public exhibitions
Research
Rehab services
Primary and secondary
school education
programs
Annual seminars
Teaching of primary care
clinicians (Mbeya AMOs
School)
Nane nane public
exhibition
Conducting collaborative
research with Universities
in Finland
Development of Uyole
rehab village
Prepared by:
Dr. Paul S. Lawala (MD, MMED)
Psychiatry and Mental Health Specialist
Mbeya Referral Hospital
P O BOX 419,
TEL: +255716 388 124 / +255755866363
MBEYA
TANZANIA
Attachment 2.
Not done
10,000,000/=
Have been going on for
some years now
Thanks for October
2014 seminar
Not existing
25,000,000/=
Done periodically
1,000,000/=
Planned to select areas
of interest, drafting a
proposal
Very poor level of
development to suit
rehab services
16
TIME TABLE FOR MENTAL HEALTH SEMINAR AT MBEYA REFERRAL HOSPITAL,
15TH TO 17TH OCTOBER 2014
DAY 1, 15TH OCTOBER 2014
TIME
8.30 – 9.00 am
9:00-9:50*
9.00-9.15 am
9:50-10:00
9.15 - 9.50 am
10:00-11:00
11:00-11:30
11:00-11:15
9.50- 10.20 am
11:15-12:00
EVENT
Official opening, introduction to each other
RESPONSIBLE PERSON
All
Day 1 Pretest
Participants
Finnish colleagues experience in conducting
mental health services in Tanzania
Tea break
Dr Tapio Pitkänen
Mental health services in Tanzania, strengths,
challenges and opportunities.
Dr Paul Lawala
10.50-11.30
12:05-1:10
Community perspectives of mental illness in TZ
and their effects to treatment of mental disorders
Ms Liness Ndelwa
MSc, Clinical Psychology
11.30-12.30 pm
1:10-1:40, cont.
2:15-2:50
1.10-2.00 pm
1:40-2:15
12.30-1.10 pm
2:50-3:40
Participants experiences in managing mentally ill
patients, case scenarios. Their views on how to
improve services at primary levels
Lunch break
Participants
Introduction to mental illness, assessment of
mentally ill patients. Common and severe mental
disorders
Treatment of mental disorders – general
considerations
Community involvement in care of mentally ill
patients in Tanzania
End of day 1 test
Dr Francis Benedict
End of Day one
All
2.00-2.30 pm
3:40-4:40
2.30-3.00 pm
4:40-5:40
3.00-3.30 pm
5:40-6:00
3.30-4.00 pm
6:00
*Actual timetable in italics
All
All
Dr Francis Benedict
Ms Liness Ndelwa
Participants
17
DAY 2, 16TH OCTOBER 2014
TIME
8.30 – 9.00 am
9.00-10.30 am
EVENT
Recap for day 1
Mood disorders 1. Depression: Identifying
symptoms and management interventions
Tea break
10.30-11.00 am
10:10-10:50
11.00- 12.00 pm Mood disorders 2. Bipolar disorder
10:50-12.00
12.00-12.40 pm Psychotic disorders
12:00-1:00
1:00-1:15
Visit of the Executive Director of Mbeya
Referral Hospital
12.40-1.30
Seizure disorders
1:20-2:30
1.30 -2.00 pm Lunch break
2:30-3:10
3:10-3:30
Mental development in childhood and
adolescence
2.00-2.50 pm
Developmental disorders
3:30 – 4:30
2.50-3.20
End of day 2 test
4:30-4:40
Visit to Mbeya Referral Hospital,
Psychiatric Unit
RESPONSIBLE PERSON
Dr Paul Lawala and
Ms Liness Ndelwa
All
Ms Liness Ndelwa
Dr Liisa Laula
Dr. Mpoki M. Ulisubisya,
MD, MMED, MBA
Dr Paul Lawala
All
Dr Liisa Laula
Dr Francis Benedict
Participants
All
DAY 3, 17th OCTOBER 2014
8.30- 9.00 am
9.00- 10.30 am
10.30-11.00 am
11.30-1.30 pm
10:45-11:40
11.20-12.00 pm
11:40-1:00
12.00- 12.40 pm
1:10-1:40
2:05-2:40
12.40-1.10 pm
1:40-2:05
1.10-1.40 pm
2:40-3:05
1.40- 1.50 pm
3:05-3:15
1.50-2.00 pm
3:15-3:30
Recap for day 2
Behavioral disorders
Tea break
Dementia
Participants
Dr Francis Benedict
Substance related disorders
Dr Francis Benedict
Somatoform disorders
Ms Liness Ndelwa
Dr Paul Lawala
Lunch break
Future plans for mental health programs MRH
End of day 3 test
Dr Paul Lawala
Closure: Remarks
All
Participants
18
Attachment 3.
Participants of the Mental Health Seminar in Mbey 15th – 17th October, 2014 (Photo E. Lind)