The most expensive road in the world...

It’s been a busy couple of weeks; the course got a little more demanding and threw up a parasitology exam and last weekend I took a trip to Oldonyo L’Engai. And that’s where I’m going to start.

Oldonyo L’Engai is an active volcano adjacent to Ngorogoro crater. In Masai the name means “Mountain of God” and it lives up to its name by erupting every 30 years, with the last eruption 3 years ago. Climbing it is a physical challenge (perhaps slightly more so that I first imagined) but the appeal is that on a good day you can see the sunrise over the Ngorogoro highlands, the rift valley and the flamingo encrusted Lake Natron. It’s also something slightly different to do, not one of the usual mountains and also something that can be done on a budget (unlike $600 dollars for Mt Meru or $1000 for Kili). With these attributes in mind a group of 8 of us made our  past Arusha, on the road to Ngorogoro and Lake Manyara. At Lake Manyara we turned off for another three hours to the base of the Mountain. It was on this road that our first incident happened.

The first roadblock (literally a metal bar across road) was a pleasant old man by the side of the road who wanted a bottle of water. Our teams’ preparedness meant we had plenty of water for us and a small army, so it was a pleasure to share. We carried on, satifisied with our Samaritanism. An hour later we came across another checkpoint, the L’Engai District entrance. A sign explained that visitors were expected to pay $10 per person, not per vehicle. We stoppend and bartered the price to nearer $60. We got our receipt and slowly negotiated the dirt track ahead, still in good spirits although with a slightly sour aftertaste. Still, I reasoned to myself, “In the grand scheme of things £6 each isn’t a huge amount of money and, hopefully, the money can get somewhere in the community and can be put to use”.

Forty-five minutes down the track we came around a sharp corner and found another roadblock. This time a large sign: “Welcome to Loliondo”. Two lads stopped us and informed us “Ten Dollars”, again per person. I started to get a little irate and spent twenty minutes in the barter. These guys seemed a slightly less professional outfit, and although we still got our “Official” District receipt. They let us off with $40 in total, a cigarette and another bottle of water. We left the “checkpoint” in more subdued spirits. When you enter a game park you pay the expected fee at the gate and enjoy the fantastic animals and plants that Tanzania ispreserving. In this case I was left unsure what I was paying for, one thing it certainly wasn’t was the upkeep of the road. We trundled slowly on. 

Evening approached as we passed the mountain silhouetted by the wide African sunset. A few scattered zebra, wilderbeast and ostrich lined the road and spirits again lifted with the views and the thought of a few hours sleep and food before we started our climb at midnight. We were within 20 minutes of the campsite when an iron post loomed in the distance: Another roadblock. This time an old-timer in a vomitous striped shirt appeared and kindly notified us, by pointing an A4 printout stuck to the wall, $15 dollars to enter the Lake Natron District. This was getting silly. It was late and we were within spitting distance of our destination. There was no way we would turn back and he knew it. But was it “him” who knew it? Another 20 minutes of protestations fell on deaf ears – “don’t blame me – I just work here”. He didn’t even seem to want to barter but then again his hand was the strong as there was no way we would turn back now. Luckily for us his math(s) turned out to be less than exceptional, as he let us through paying about $65 in total. Despite this inadvertent victory we arrived at our campsite later and poorer than we expected.

The mountain turned out to be a real challenge. Starting at midnight and we eventually summited at 8 am and were back down before midday. The views were incredible as the sun rose and, especially the further you get from doing it, I am happy to reflect on a good climbing experience. However, at the time of arrival I was hungry, travel weary and the whole roadblock thing had fucked me right off. But having spent a few days recuperating perhaps there is a little more to it? 

The three hour journey on a poorly maintained road for 9 people (including driver) it cost the group $165. As it happens we continued to pay for the trip. The volcano is impossible to climb without some guidance, not because of technical difficult but the lack of paths – you literally don’t know where to start. After an hour of bartering that night with the “Official” guidesman of the local town we struck a deal at two “official” guides for $250, these “official” guides being school children on holiday.

However, to focus on the roadblocks, the most striking aspect for me was that these were not prices to be paid across the board, on the contrary it was purely about being foreign. For the driver, myself (speaking some basic bartering Swahili) and my Kenyan friend there was minimal resistance to dropping to a free “local” pass. Secondly, as is often the case with bribery it was all veiled behind a degree of organization and beaurocracy. Each site had it’s own “Official” receipt.

You walk around Moshi town and you see plenty of “Wazungu” (colloquial for white tourists, interestingly derived from Swahili “kuzunguka” – to travel around without a clear purpose). They are driving 4x4’s to and from Safari, eating and drinking in expensive coffee shops and buying souvenirs. Those that do live here generally live comfortably on a western salary with big cars, nice houses and employ people around the house (this actually describes my home set up perfectly). This contrasts violently with the average Tanzanian persons life. It’s visible in the street and in the villages with kids who can’t afford to go to school or people who don’t have home to live it. And it’s represented statistically by the 88.5% who live on less than $1.25 per day (2009).

But does this huge socioeconomic difference mean that foreign visitors should expect to pay more for the same thing that the average Tanzanian should? Is this difference compounded by rich foreigners who flaunt their money on the things that they want and then are shocked when they are asked to pay more for everything else?

Ironically, if we follow free market rules then the answer is that we should pay more. In the situations that people are able and willing to pay the price then the price stays. However if that is the case then this is universal and everyone pays. This is sadly what happens to housing in post disaster/conflict areas. Having spoken to people who live in Juba, and having visited Sierra Leone, local poorer and middle class people are priced out of higher quality housing as NGO and aid workers (with their western salaries) flock in to do their good works.

If our goal is ultimate utility and the redistribution of wealth to those who need it, then again it’s a yes. Being able to afford an airfare to Tanzania is quite a good proxy for being from a significantly higher socio-economic group than the average Tanzanian. So, if we are looking to re-distribute that wealth evenly then its only fair that those who can pay more subsidise services for others.

But why then does this whole roadblock grate so much? I know if I was in the same position again tomorrow I would still barter those guys to the ground, and I would still end up irate about the whole thing. I think it’s for three important reasons. Firstly, I’m not quite sure why I should pay as I’m not visiting a country, entering a specially maintained area (e.g. national park), or paying for the road to be maintained (e.g. French paege). Secondly, the whole thing smacks of poor governance; I have no idea where the money is going and the likelihood of it making it to the community is anyone’s guess.  And thirdly because its applied liberally to all those that look and act foreign which, although it probably does capture a large proportion of those who are able to pay it, is an unjust method of applying it.

In a totally unrelated turn of events, a working visa for Tanzania now costs $500 for 6 months (from $130 per year) and a volunteer visa is similarly pricy. Perhaps its worth asking a few questions: Should we as foreigners pay for the privilege of working in such a beautiful country as Tanzania, much as the Tanzanian does in the UK or US? Should we redistribute our wealth by supporting the government on the assumption that it makes a difference? Or is it an unjust blanket levy imposed on all foreigners in the assumption they are wealthy enough and willing enough to pay? Will people experiences prompt them to tell others and will this deter those people from coming…?

I can’t provide any answers to these difficult questions and maybe only time will tell. But I do know that incidences like the roadblocks will inevitable still piss me off. It’s also worth appreciating that huge inequity inevitably causes disharmony and there will be vents for these.

I did promise this blog wouldn’t be medical, which it isn’t, but I understand its still heavy going… I apologise. I can promise though that the next installment, bar any major mishaps, will be as I’m off cycling around Kilimanjaro and then on to Nairobi. Expect stories of hair-raising and intrepid adventure…

How much does Tanzanian healthcare cost?

Following a couple of beers with an old friend, and a few words of encouragement, I’m feeling a little inspired. And inspiration is something I need to tackle the topic health spending. But, feeling the boldness of my beers, I want to start with this headline.

TANZANIA CAN AFFORD TO SPEND VERY LITTLE ON HEALTH.

I’m going to spend the next few hundred words showing how this is true and why I think this is unlikely to change for the near future. 

To start with, a story: I have just spent a fascinating week in Bugando Hospital in Mwanza, on the south east shore of Lake Victoria. It is one of four tertiary referral centres in Tanzania and is a huge 1,000 bed hospital. I was also lucky enough to spend the week observing the ITU facilities, and learning to how ultrasound is applicable in a resource limited setting (as it turns out it is an hugely useful tool).

As I rounded (that’s a US term I just learnt) on the ITU patients we came to a 42 year old man with tetanus. He was going to pull through, but not after some weeks on the ITU, requiring intubation and paralysis. I reflected on this and thought – “Wow, this is an example of truly international standard care, in Tanzania and providing the best possible chance that this man will make it”. But how affordable is this?

So this man, when he comes to leave hospital, will be left with a bill on his bed that somehow he and his extended family will be asked to pay for. In many ways this puts him in a similar position to the gentleman I described previously with ascites, but i’m not going into the user fees question just now. The main point I want to make is that keeping someone alive for four weeks on an ITU, in any setting, is damn expensive. Before factoring in costs of oxygen, nursing and paralysis drugs lets look at a simple example, this man developed a hospital acquired pneumonia and was treated with Ceftriaxone at a cost of $12 for 7 days. Although in the US or UK the cost might be a nearer $150, which in relative terms (GDP/average incomes) is significantly more than in Tanzania, this is still a considerable expense for the patient and the service. 

I want to put this case example in context of the Tanzanian Health Budget. From the HealthSector Strategic Plan III (2009-2015) the projected health spend for 2011/12 is $1,182 million dollars. Of this, $1,062 million is likely to be available. Effectively the Tanzanian Department for Health will have approximately 1 billion USD to spend in 2011. This might seem like a lot of money, but to put it on other figures in Tanzania spends $72 per person, per year on health – according to WHO 2006 statistics. And also lets also reiterate something, these figures include the costs of developing a social welfare system – a budget separate in many developed countries. We will see shortly how these figures compare internationally.

But before we do, lets have a think about whether these figures are accurate for the amount that the average Tanzanian family spends on health per year? The short answer is that they almost certainly underestimate expenditure. They don’t account for informal health payments, either through informal user fees or through traditional healers. They don’t account for privately funded NGO’s which can provide vertical (although some funding for this is included in the "health basket fund") or system based support for health programmes either locally or nationally. In fact, a study by OPM of health expenditure in Sierra Leone found by triangulated household survey that estimates were three times greater than what was previously thought.

However, even if these figures were triple what they are now, how would they compare to the ‘global north’?

In 2007, the US spent $7,290 per person on health. In the same year, the UK spent $ 2,992 (total is over £100 billion!). The proposed merger of Barts and London hospital (where I used to work!) with Newham and Whipps Cross would create a trust with a budget of £1.1 billion pounds. In short the National budget of Tanzania is two thirds that of a large (soon to be foundation) trust in the UK. And, just to move between sectors and add more comparative spice: How does the Tanzanian health budget compare to the top bonuses in the banking world? I’d guess at not too far different…

To achieve a comparative spend on health, per capita spending in Tanzania, not taking into account any changes in population or inflation, would have to increase 100,000% to match the US, and over 40,000% to match that of the UK (or put another way, its per capita budget is 2.4% of the UK’s). In the short-term achieving comparable spending is not a realistic goal.

Looking internally, how much is being spent on externally funded research within Tanzania? The short answer is that we don’t know, but for an idea of some figures we do know: a recent BMJ article gave focus to an HIV prevention trial with a research grant of $37 million, a recent trial in Uganda comparing fluconazole treatment regimes in Cryptococcus (of which much of the information was already known) had a budget of $13 million. Personally I’d be fascinated by knowing how, once you combine all of the trials and all of the foreign based PhD’s in Tanzania, is being spent in these areas. I’d wager that it would be at least 20% of the countries health budget.

Given that there is a strong and growing body of opinion that tropical disease have good evidence and guidelines that are in many places not applicable because drugs and resources not available. If you were running the business of improving health outcomes for SSA, how much would you consider is worthwhile spending on R+D while current practice is so poorly resourced?

To summarise, there is a huge, huge deficit in health spending in Tanzania compared to the western countries, which is mirrored across much of Sub-Saharan Africa (SSA). In Tanzania, current real-term increases in health spending are measured in double digit percentages, but the reality is that without increasing health expenditure factorially it will be impossible to impose a western style health system (with all the specialist, expensive services that it entails) as there simply won’t be the money. Some people will tell me to stop being such a pessimist about this and that i'm trying to devalue what is and can be achieved. My answer is this: Imagine the UK health system being asked to cut its budget to approximately 2.4% of what it currently spends, and ask yourself the question, could it still provide a fraction of what it currently provides? No, the healthcare we practice is too expensive, and if its too expensive for that then its too expensive for Tanzania now and for the foreseeable future.

But, why is this important now? 

Tanzania, along with other SSA countries is facing a crisis of funding for health right now. With the ease of access to healthcare information citizens are, rightly, demanding access to a high standard of healthcare. Unfortunately, in many cases, these services are something that the service cannot afford. For example, Tanzania has only a handful of CT scanners. As a citizen you are either lucky enough enough to live near a hospital that has one, in which case they are being asked to pay for this high cost service (between $100 - $120).  Or, if they live further away (or the hospital scanner is broken - such as in Bugando) they don't get that service. Essentially at the moment, the lack of funding means that either the patient pays or the service isn't provided, both of which have adverse outcomes.


A recent study of catastrophic healthcare related expenditure in Nigeria (also free PDF on web) found that, over the period of one month, almost a quarter of households in the poorest quintile (and 15% overall) experienced a health catastrophe that cost over 40% of their total non-food expenditure. The costs of healthcare are crippling those not the poorest in society, but also those in the middle classes of SSA, its not a giant leap of imagination to see what these costs are replacing, education, clothing etc. 

The case of the CT scanner also continues to highlight the quality of service that can be provided on a budget 2.4% that of the UK. In many cases the argument could be made that a head CT is of little value - there is only one neurosurgical unit in Tanzania, however for the diagnosis of infective space occupying lesions and many other situations it is of huge value.


So, what should we do about it?

This is the most difficult question that fundamentally boils down to three possible answers, spend more, spend more wisely or do nothing at all. 

For those who choose to design systems of care for resource limited care the challenge is greatest. Following an understanding that not all services available globally can be provided (at present) tough choices on rationing will have to be made. This is probably also important for those western doctors who think that helping to create a state of the art cardiothoracics centre is the most pressing issue for their country of choice, when in fact building a western style (and western costing) service right now will only be a drain and burden on a cash strapped service.  

Are we spending too much on research and not enough on actually supporting health outcomes? I would argue priorities need to be considered carefully. We need to make sure we are implementing all of the best practice we already know, and this really does mean going back to basics, for example, do all district hospitals have basic antibiotics to treat pneumonia? Or, how close are we to ensuring that all anaesthetics have adequate monitoring? But it also means making sure that if we are doing research that all resource poor countries stands a good chance of being able to implement the results. That means doing research that has the capability already in place to roll out the results. For example, from resource limited countries we know that Artesunate gives better outcomes in severe Malaria, or we know that Amphotericin B gives better outcomes in Crytpococcal Meningitis than fluconazole, but how far are we from implementing these changes to the majority of those in the countries who need it? As far as i can see in most cases a long, long way. 

The bottom line is of course money. In a world of spiraling healthcare costs Tanzania cannot and will not keep up. The fact is that its much worse, spending per capita is around 1% of that of the USA and, without the most radical of revolutions, this isn’t going to change for a long, long time.If Tanzania is to be expected to run a healthcare system that competes with western countries then budgets will need to increase (through whatever means) not by 10 or 20% but by 100 or 200%. I don't know how this funding gap can be bridged but, to me anyway, its clear that without a huge attempt at this, the changes we see will be very slow.

I want to end on a positive note. Our gentleman with tetanus will be on ITU will be on ITU for more than 4 weeks, but he will almost certainly survive as they do in most cases from Bugando. I think that makes an incredible story. Maybe in the near future we, in our western bubble, will start to look over our shoulder at resource limited countries to find out how they do things cheaper and get better, equivalent results?

Recognising Tanzania’s impressive stance on Biodiversity

In attempt to move away from medicine, a subject to which I will no doubt return, this week I wanted to talk about my animal encounters of the last week, both within our house and beyond. I have chosen this topic partly because it has featured memorably in my experiences this week, but also because of the contrast it highlights between the diversity and volume of animal and plant life which is being protected in the developing country of Tanzania, and the mundane biodiversity left in the UK and other developed countries.

Our house is set in a leafy 20m x 20m garden that hosts several notable animals of which four are definitely worth mentioning. Firstly, we have the bush-babies. They live in the roof and the best thing about them is their regularity - you can set your watch by them - at 11:30 pm you will hear them scamper out and into the garden. They then cackle and gambol through the tree-tops before venturing back at 4 am. Secondly, we have the eagles. These are not regular visitors but this week we had a pair and their young child in the tree-tops. They are huge, elegant creatures whose unfortunate effect is to scare off all other birds. Thirdly, we have the (quite large) fruit bat who hangs out under our rafters by the verandah and swoops away at dusk. Finally, and my favorite, is the small bird who is seen and not heard as, during the early mornings and late evening, s/he answers your whistles with a direct copy!

But these four aren’t enough to warrant a topic by themselves. On the way to Mwanza, I’ve spent the weekend in Ngorogoro and the Serengeti. During the two days we saw everything there is to see – elephants and rhino, elands and dikdik, lions and leopard. We traveled through temperate forest and open savannah. As we crossed the midriff of the Serengeti there were thousands and thousands of wilderbeast and zebra, and other animals – a scale of which I had never totally comprehended. The Serengeti and the animals its holds are in immense proportions, and during the migration no doubt swell even further.  

This talk of animals brings me to the point of this weeks blog. Tanzania has an amazing diversity of animal and plant life, from the well-traveled safari route to the chimpanzees in Ngombe stream to the crocodiles of Ruaha and amongst its other tens of national parks. Its really impressive to see that a country that is, in terms of its GDP, one of the poorer in the world cares prioritises spending its scant resources in looking after these. It’s done this in a way that the west, when it developed, did not: Bar a few localized spots, where in England has retained its original flora and fauna? Arguably there is self interest involved, but with the huge number and size of its parks, there are those that clearly aren’t out there to purely make money, and I am sure other profitable uses could be found for the land.

So, in a world where we are starting to realise the true value of biodiversity I am incredibly impressed that Tanzania devotes such large sections of its country to protecting it, and I hope that other countries can realise the benefits that it has beyond the country’s borders. Finally, a caveat for Tanzania, the good work it does is most impressive and far outweighs, to my mind, its ecological challenges. But they are also there, it definitely has a problem dealing with waste sustainably and, in common with other developing countries, there is a need to grow in a carbon neutral way. But this does not detract from its good work that remains, as I say, the most impressive.

A final, and unrelated note, on Mwanza where I am now based for the coming week. What a strange city. It sits on the south-east corner of Lake Victoria and is Tanzania’s second largest city (fighting it out with Arusha) and the main trade port with Uganda. The most striking things is that it is made up of these huge 50-100m high rocky outcrops with giant boulders, sometimes teetering, over peoples houses. A rock climbers paradise, but I can’t imagine that it makes the easiest place to build a home.