Sikitu thinks back on her many years of experience with public hospitals as she sits in a queue with her son Hassan Abdul waiting for her pediatrician at the Muhimbili National Hospital.
“I’m now a mother of four, two sets of twins. During my first pregnancy, I went to a government hospital and was told by the nurses that delivery would be free of charge. This made me happy. I felt that at last the government had heard our cries.”
But Sikitu’s new found hope was soon crushed after hearing harrowing stories from fellow pregnant women.
“I started attending the clinic when I was three months pregnant. While there I heard stories from my fellow mothers-to-be that delivery wasn’t free as the nurses have promised. They told me that every pregnant woman had to pay or buy from their own pockets essential facilities for delivery like cotton, gloves, blades, etc. I didn’t believe what they were telling me. So I kept attending the clinic without buying anything, waiting for my time of delivery in nine months.”
“I told my husband about it and he said it wasn’t true, that I should continue attending the clinic and not listen to what people were saying. During my last month before delivery, I only carried a small bag containing khanga and vitenge to cover the baby. My husband gave me cash to cater for my meals and such stuff.
“When I reached the hospital in deep labor pains, a nurse asked me if I had everything in my bag. I said yes. Then another nurse asked me if I had money for a delivery kit. I said no,” she narrated.
Sikitu said the money she had was only for buying food and transport.
“There were three nurses. One was shocked to hear that I didn’t have a delivery kit. I told them that I was told by another nurse on my first day attending the clinic that delivery was free. As I sat there in shock and tears because of being told I was supposed to carry a delivery kit, I started bleeding and I felt my baby was about to come out.”
Sikitu added: “One of the nurses said infant mortality is high in this country because mothers-to-be think that delivery is free. Let her die or her child die. Then another woman who was also in labor gave me her delivery kit so that I can deliver my baby safely.”
Sikitu’s story echoes that of many Tanzanian women who think that maternity services are free in public hospitals, and are surprised when asked for money during delivery time.
The Minister for Health, Community Development, Gender, the Elderly and Children, Ummy Mwalimu, acknowledges that most government clinics or hospitals do not offer free delivery services as stipulated by government policy, while in some of these hospitals mothers-to-be have to bear with abusive language from nurses.
According to Mwalimu, all public hospitals and health centres in the country are directed not to charge pregnant women any fees, reiterating that maternity-related services are supposed to be provided for free.
She warned that any employer, especially those in the private sector, found to have fired female staff without giving them their due benefits will face the full wrath of the law. Likewise for employers who provide maternity leave but deny the new mothers their salaries during the leave period.
“It is wrong for hospitals or clinics to charge expectant women any money for maternity services, and employers who deny them their maternity leave rights are committing an offence as well,” she stated.
Out of the 700 health centers in Tanzania, only 117, roughly 16 percent, provide emergency maternity services.
According to a survey done by the Ifakara Health Institute, 78.6 percent of mothers in the rural areas had their last delivery in health facilities while 21.4 percent had their last delivery at home or on the way to hospital. Reasons for delivering at home include abrupt occurrence of labour pains, long distances to health facilities, lack of transport money, and unfriendly experiences with health care providers.
A simple logistic regression model indicates that mothers’ education levels, number of children, cost of transport, estimated distance to the nearest health facility, and occupations are strong predictors of preferred places of delivery. However, after controlling the potential confounder, the multivariable logistic regression model demonstrates a significant association between delivery at the health facility, the number of children, and transport cost.
The survey was to identify the main drivers of delivery costs in health facilities and the financial consequences for households among rural women in Tanzania, a country with a policy of delivery fee exemptions. It selected a representative sample of households in a rural district in western Tanzania. Women who gave birth within five years were asked about payments for doctor's/nurse’s fees, drugs, non-medical supplies, medical tests, maternity waiting home, transport and other expenses.
Wealth was assessed using a household asset index and estimating the proportion of women who cut down on spending or borrowed money/sold household items to pay for delivery in each wealth group.
In all, 73.3 percent of new mothers reported having made out-of-pocket payments for delivery-related costs. The average cost was 6,272/- , with transport costs hitting 53.6 per cent and provider fees 26.6 per cent per cent being the largest cost components in government facilities.
Shortage of medical doctors
Deliveries in mission facilities were twice as expensive as those in government facilities. Nearly half (48.3 percent) of mothers reported cutting down on spending or borrowing money/selling household assets to pay for delivery, with the poor reporting this most frequently. Out-of-pocket payments for facility delivery were substantial and driven by high transport costs, unofficial provider payments, and preference for mission facilities, which levy user charges.
The new findings appear to be ironical because it has been widely argued that Tanzania suffers a shortage of trained doctors in public hospitals. Currently a doctor in Tanzania serves 25,000 patients , a long way off the World Health Organisation (WHO) proposed doctor-to-patient ratio of 1:10,000 for developing countries.
An spot-check by The Guardian at the Muhimbili National Hospital maternity wards indicates that each maternity block experienced an acute shortage of attendants even before verification of academic certificates was carried out. Hence the sacking of medics increased the burden on the remaining workers, who are obliged to work even on their days off.
“At least seven attendants have been sacked from Block B. It is no longer a secret because their names have already been published and attached to the notice board, where everyone can see them,” said one nurse who declined to give her name because she was not a spokesperson of the hospital.
The nurse said at least 30 officials were required to serve each maternity block, and the department is frequently inundated by an increasing number of out-patients and in-patients from across the country, hence the need for the management to take urgent measures to address the issue.
“This has surely brought significant changes in the administration, especially when it comes to arranging shifts during the day and at night. For instance, I was supposed to be home resting, but my boss told me to come to the office this morning,” said the nurse.
The nurse asked the hospital management to put in place strategies to resolve the issue, saying they were overwhelmed as a result of demand of maternity and child healthcare before and after delivery.
Last year, the health ministry announced a 1.1bn/- budget for the 2017/2018 fiscal year. Members of Parliament had earlier ratified the Abuja declaration which calls for the health sector to be allocated with 15 percent of the entire government budget.
The government had set aside 160bn/- to upgrade 150 health facilities countrywide. When launching a 1.2bn/- maternity ward at the Amana regional hospital recently, Prime Minister Kassim Majaliwa said the government is currently executing a plan to improve health service provision at ward level, including building more maternity wards, laboratories and theaters.
In 2010, according to Najaliwa, there were only 6,321 health centres but the number increased by 9.9 per cent to 7,680 facilities by last year.
Private sector support
The AMSONS Group of Companies has meanwhile promised to build two more new women's wards at Mwananyamala and Temeke hospitals, a move aimed at complementing the government efforts in social development especially in health sector.
AMSONS Group Director Edha Nahdi made the commitment after officially launching the new ward at Amana hospital, built by AMSONS Group at a cost of 1.2bn/-. He said after the completion of the ward at Amana hospital, their focus is on building more wards of the same standard at Mwananyamala and Temeke hospitals to help pregnant women deliver in healthy conditions.
“We want expectant mothers to be happy during delivery, so modern delivery wards must be available in many hospitals all over the country,” said Nahdi.