Karimu Health Program

February 2023

Karimu’s mission to fight poverty in order to enhance the well-being of rural villages in the developing world underscores its investment in health services. Poverty and poor health worldwide are inextricably linked. The causes of poor health for millions are often rooted in economic challenges. Poor health, in turn, traps communities in poverty because they cannot be as productive as healthy communities, decreasing the chances to move above the poverty line. Often, very poor families have to make hard choices – knowingly putting their health at risk because they cannot, for example, see their children go hungry. The costs of doctors’ fees, a course of drugs, or transportation to reach a health facility can be devastating for many families. In the worst cases, the burden of illness may mean that families sell critical assets or take children out of school to help complement the family income.

For this reason, improving the overall health of the communities with which Karimu works is a critical part of Karimu’s strategy to eliminate poverty. 

Background

Health services in Tanzania are provided by government-owned or private health facilities. These facilities can be classified in three categories: dispensary, health center, or hospital. 

Dispensaries, the simplest of the health facilities and the most common in rural areas, provide the most basic medical services to deal with minor illnesses (e.g., upper respiratory infections), treat minor injuries, provide maternal and child health services, and monitor and treat chronic diseases (e.g., HIV). Dispensaries typically operate only during daytime hours. Health centers operate 24 by 7, perform simple operations (e.g., C-sections), deal with major injuries (e.g., fractures), provide services that require more sophisticated equipment (e.g., X-rays or ultrasound machines), and support overnight patient stays for treatment, recovery, or monitoring. Hospitals provide the widest range of medical services including the most sophisticated ones, such as surgery, complex procedures, or procedures requiring more sophisticated and expensive equipment . All health facilities that can provide specialized services are referred to as clinics. Typical specialized services of a dispensary include a maternity clinic or a tuberculosis clinic. The qualification of the medical staff does not follow the accreditations known in the west. Nurses in Tanzania may have a 2 year training by a vocational school or a 4 year training in a college. Doctors’ qualifications vary even more. Depending on their role at a health facility, their qualification varies from a 2-year degree from a vocational school to a 4 year degree from a college plus, possibly, a Master or PhD and practical internships. .

Besides doctors and nurses, health facilities have laboratory technicians, medical attendants, midwives, pharmaceutical assistants, cleaning staff, security guards, etc. The higher the level of the health facility, the higher the number of staff and their qualifications

Most of the medical staff have lived in the big cities, at least during their studies. For this reason, they are used to living in comfortable houses with running water and electricity. Moreover, they belong to the group of people with the highest living standards in Tanzania. As a consequence, it is a challenge to retain the most qualified medical staff in rural areas due to the lack of quality housing. To address this challenge, the government tries to provide housing for the medical staff working in rural health facilities. Dispensaries, in general, provide housing to the head doctor and head nurse and health centers tend to have four houses for their staff covering all doctors and more highly qualified nurses.

Goals

The main objectives of the Karimu Health Program are to improve the overall health of the communities we support while reducing the mortality rate, particularly among pregnant women and young children.  These objectives will be achieved by:

• Expanding access to health services to everyone, including the poorest of the poor who, often, do not have the means to pay for transportation to reach health facilities.

• Improving hygiene practices and other disease prevention measures.

• Enhancing the quality and expanding the types of medical services provided. 

• Retaining highly qualified nurses and doctors. 

Karimu’s activities in the Health Program are tied to the following components:    

1. Construction, reconstruction and expansion of health facilities to ensure that every household within the communities we support has access to a high-quality, basic health service by walking no more than one hour and a health center by driving no more than 30 minutes.

2. Donation of medical equipment and supplies.

3. Retention and enrichment of medical staff based on quality housing, access to ongoing education via scholarships and seminars with volunteer doctors, and automation of reporting tasks using technology.

4. Implementation of the most critical interventions identified by the World Health Organization (WHO) as having the largest positive impact on improving the overall health of communities in rural villages in the developing world.

5. Training of midwives.

Overview of the Program

There are four phases in the Karimu Health Program.   Phase 1 - Creating the Foundation for a Healthy Community - The goal of this phase is to ensure that every household within the community has access to high-quality, basic health services by ensuring that no one has to walk more than an hour to the nearest health facility. Karimu will work with the communities and the government to construct new dispensaries and/or upgrade and/or expand existing ones to ensure that all households can reach a health facility within a one hour walk.  Access to quality healthcare is supported by an agreement with the government to maintain a minimum level of staff, equipment, and medicine at health facilities..

Karimu will also help implement a series of interventions whose combined effect will improve the overall quality of community health and of the health services provided by the health facilities available in the area.

Phase 2 - Supporting Medical Staff Retention and Excellence - In order to sustain the health improvements achieved in Phase 1, it is critical that we maintain the medical staff long-term.  Availability of housing for the medical staff is essential for their retention in rural areas.  Karimu, in partnership with the community and the government, will provide build ro renovate housing for the most critical members of the medical staff.

Phase 3 - Expanding the Medical Services through a Health Center -  This phase will be implemented when the households within the communities we support do not have access to a health center or hospital by driving at most 30 minutes. Karimu will work with the communities and the government to construct a health center if necessary to enable residents to reach a health center or hospital within a 30 minute drive.    It will also enable critical healthcare interventions requiring facilities or equipment only available within health centers.

Phase 4 - Achieving Medical Excellence - This phase is optional and will be implemented only when there is the need to provide specialized services requiring highly sophisticated equipment and/or highly specialized medical staff within an existing health center or hospital.  In this case, this phase may also implement the related interventions.

Roles and Responsibilities

Karimu:

• Build new dispensaries, health centers, or renovate existing ones.

• Support the medical staff, midwives, and community in the implementation of key interventions recommended by the WHO in consultation with local medical staff and key medical governmental officials. 

• Build or renovate staff housing to an agreed minimum standard housing for at least the head doctor and head nurse of each dispensary.

• Donate furniture, equipment, and supplies as agreed to with the government in order to fulfill the requirements set by the Tanzanian Ministry of Health (which follow the recommendations of the WHO).

• Provide scholarships for up to 70% of area nurses to reach a diploma level in order to improve the quality of medical services. Each nurse will receive only 1 scholarship for education to be completed within 6 years.

Medical Staff: 

• Keep all Karimu donations and medical equipment in good condition and ensure its proper use.

• Keep the health facility, including bathrooms, clean on a daily basis.

• Ensure the proper disposal of waste, eliminating the need to openly burn material or to dispose of it in an open area by appropriate use of the incinerator and placenta pit.

• Maintain the buildings, assets, equipment, and facilities ensuring that all repairs are completed within one month of first damage identification.

• Promote hand washing and good hygiene practices at the health facility. 

• According to the recommendations set by the Minister of Health following the WHO guidelines, the dispensary medical services include outpatient services, maternal and child health services, vaccinations, treatment of minor illness and injuries includingHIV, STDs, malaria, and tuberculosis.

• Fully participate in all training provided by Karimu and commit to fully implement and consistently follow the interventions recommended by the WHO.

• Have well specified and very visible opening, closing, and break times.

• Commit to be at the health facility during all work hours unless sick or given permission for an absence.

• Record all data required by the government and by Karimu and share it with Karimu monthly to assess the effectiveness of the program.

• Ensure all medical supplies, including medicines, are locked in the medical storage room at all times and those in the dispensing room are kept safe and secure, eliminating the risk of being stolen, lost, or misused. Keep the medicines away from direct sunlight and excessive heat. 

• Ensure there are records of all supplies received, used, scrapped or sold. Such records must be shared with Karimu on a monthly basis.

• Keep complete records on all patient visits at the dispensary, all prescriptions, diagnoses, exams and laboratory results, as well as all other activities. These records must be shared with Karimu on a monthly basis.

• Visit all areas farther than 45 minutes walking distance from the clinic at least once a month  to provide specific medical services.

• Ensure that all equipment (including TV and Media Player) remains in the clinic at all times and is used only for showing the educational material prepared by the government and/or Karimu.

• Run the educational material non-stop during all operating hours of the dispensary, following the schedule jointly prepared with Karimu.

• Nurses receiving educational scholarships commit to maintain employment at a ward-based health facility during their studies.

Midwives:

Fully participate in trainings provided by Karimu. Commit to fully implement and consistently follow the interventions.

Government:

• Staff the dispensary with qualified and sufficient medical staff and provide the furniture, equipment, supplies, and medicine as defined by the Minister of Health following the guidelines of the WHO.

• Support the medical staff in the implementation of the interventions. 

• Provide the budget needed to maintain and operate the clinic services and maintain the clinic structures.

Health Interventions

Much can be done to improve health and healthcare outcomes in the developing world. The 2018 Universal Health Coverage and Essential Packages of Care (published by Disease Control Priorities Network, and funded in 2010 by the Bill & Melinda Gates Foundation) defines a concrete set of priorities for universal health coverage grounded in the economic reality and health needs of low- and middle-income countries. Core to this work is the definition of the “highest-priority package” which defines those health interventions most essential and readily implementable, even for countries with few resources. The interventions range from family planning to childbirth and child care, from nutrition to sanitation, from disease specific interventions (e.g. malaria, TB, HIV,...) to mental health, from chronic illnesses to emergency procedures, and more.

In 2019, a Karimu volunteer tasked with driving an overall approach to improving community health studied the  research and deeply analyzed the highest-priority package. Correlating the recommended interventions with publicly available Tanzanian health data, data from the local health clinics, and surveys of the local medical staff, he identified those interventions that seemed most pertinent for the local Ayalagaya and Arri wards. This work was then reviewed and refined in collaboration with the District Secretary of Health, Dr. Madama, and the head doctor at Dareda Mission Hospital, Dr. Lorri. 

They eliminated interventions that they believed were already well implemented and changed the priorities of others based on their experience working directly with patients resulting in 92 interventions that can be rolled out as part of the Karimu Health Program based on existing or planned resources and capabilities. In some cases, the interventions may be partially rolled out based on government initiatives, but Karimu may be able to enhance the efficacy based on applying additional resources. In other cases, no work has been funded by the government. 

We anticipate that it will take several years to roll all these interventions out, but we hope to complete them by the Sustainable Development Goal period (2030) referenced in the publication above. We also continue to work with local staff to identify opportunistic tactical interventions based on local medical treatment records. 

Doctors Madama and Lorri prioritized the interventions into 3 major groups: 

1. Highest priority interventions that can be implemented with existing dispensary services

2. Second priority interventions that can be implemented with existing dispensary services

3. Highest priority interventions that require health center level services for implementation or are related to such services. For example, interventions related to C-sections cannot be rolled out until we have C-section capabilities within the ward in our proposed health center.

Within major groups, Karimu will prioritize interventions based on local medical input, Karimu volunteer and staff capacity, and available funding.  Each intervention, once planning has completed, will have objectives, target audiences, funding needs, key metrics, and exit criteria which will be detailed in the linked project page.

Current Program Status (Feb 2023) 

Ayalagaya Ward

Phase 1 - Construction is complete and interventions are in progress. Completed projects are: 

• Dispensary in Dareda Kati in Nov 2016

• Expanded the internal facilities of Dareda Kati dispensary in June 2020 to fulfill program requirements 

• Expanded the external facilities of Dareda Kati dispensary in May 2021 to fulfill program requirements 

• Dispensary in Gajal in May 2020.

Ongoing projects are:

• Health facility maintenance: Maintenance inspections of Dareda Kati and Gajal health facilities and staff housing are conducted quarterly and maintenance repairs are being handled in a timely fashion. 

• Health interventions are underway and conducted simultaneously across both Ayalagaya and Arri wards.

Phase 2 - Underway. Completed projects include: 

• Housing for the medical staff of the Dareda Kati dispensary  in Aug 2020

• An IT system for Dareda Kati dispensary to improve efficiency and reporting accuracy in March 2021 

• Housing for the medical staff of Gajal in Jan 2022

Ongoing projects are:

• Scholarships for continuing education for the medical staff is planned for 2023.

• Roll out the IT system in Gajal dispensary once funding and priorities allow.

Phase 3 - Construction is complete, the Dareda Kati Health Center is open, and enabled interventions may be planned. 

• Maternity Ward in Oct 2021

• Outpatient Services in Jan 2022

• Overnight Ward in May 2022

• Security building and covered walkways in April 2022 

• Expansion of the IT system in April 2022

• Reproductive and Children’s Health Building in Sep 2022

• Laboratory in Sep 2022

• Mortuary in Dec 2022

Ongoing projects are:

• Medical equipment donations to make the health center fully functional

Phase 4 - No plans

Arri Ward 

In Arri, we are still in the early stages prioritizing sanitation projects and phase 1 construction and interventions.

Phase 1 - Construction started and interventions in progress 

• Tsaayo Dispensary expansion in progress

• TV for Tsaayo in 2022

• Dohom Dispensary

• Solar panel for Dohom in 2022

• Managha Dispensary

• Solar panel for Managha in 2021

See interventions below

Health Interventions Status

In general, we are rolling out interventions in parallel across Ayalagaya and Arri wards except where we are restricted by funding or capability within the ward. Those instances are noted below.

• Increase HPV Vaccinations - (2022 to present) Assure that all girls are getting vaccinated

• Detection and treatment of childhood illnesses - (2021 to present) Deliver education to medical staff based on the World Health Organization and UNICEF Integrated Management of Childhood Illnesses training.  

• Training on Newborn and infant care - (2021 to present) Provide curriculum targeting medical staff, new mothers, and students who care for infant siblings on sanitation practices for newborn umbilical care, breast or bottle feeding, infant cleaning and stool disposal, and safe spaces for infant mobility. 

• Childhood vaccinations - 2021-2022 in Ayalagaya - Survey and analysis confirmed high levels of vaccination (diphtheria, pertussis, tetanus, polio, BCG, measles, hepatitis B, Hib, rubella). Planned for Arri ward in 2023

• Health survey in 2021-2022 in Ayalagaya Ward. Planned for Arri ward in 2023

• Detection and management of acute and severe malnutrition - 2021-2022 in Ayalagaya - Survey and analysis show very low levels of severe malnutrition and no need for further action. Planned for Arri ward in 2023

• Increase syphilis testing and treatment (2021 to present) - Mother-to-child transmission of syphilis remains a leading cause of neonatal death and stillbirth. While most (but not all) expectant mothers are tested for syphilis, their partners are not routinely tested. We are working with clinics and the government to test both expectant mothers and their partners and increase availability of testing supplies from the government. 

• Drug resistant TB - (2021 to present) This has not been found to be an issue in Ayalayagaya and Arri wards

• Expand TB testing and treatment - (2021 to present) Tanzania is one of the 30 countries with the highest burden of tuberculosis (TB) in the world. We are assisting the Babati District in its TB campaign to broaden community outreach and education efforts. This included an assessment of drug resistant TB

• Detect anemia during pregnancy - (2021 to present) A 2021 study found anemia (a hemoglobin (Hb) deficiency) in pregnancy to be persistently high and prevalent among 57% of pregnant women in Tanzania. With the aim of improving maternal and newborn health, Karimu is purchasing Hb meters for clinics that don’t have them as well as Hb test strips to use with the meters while we work with the government to supply them routinely. 

• Hand washing (2020 in conjunction with COVID response) Provide hand washing education, hand washing stations, and soap

• Patient intake, triage, and isolation (2020 in conjunction with COVID response) Educate medical staff on and implement intake and triage practices

• COVID pandemic response (primarily in 2020, but ongoing support as needed)