Backed by Graça Machel and her fellow Elders, the Tanzanian government is introducing healthcare reforms that could revitalise its economic prospects. Lucy Lamble investigates
LL Lucy Lamble
TD Dr Tedros Adhanom
RY Robert Yates
UM Ummy Mwalimu
GM Graça Machel
MR Mary Robinson
FC Fiona Chalunda
TA Without health, people have nothing. Do we want our fellow citizens to die because they are poor? Universal health coverage is a human rights issue.
LL That was Dr Tedros Adhanom on his first day as the Director General of the World Health Organization.
TA About 400 million people have no access to even basic health care. Many more have access but will endure financial hardship. During the coming weeks we will be looking at how best to implement achieving universal health coverage.
LL In this episode we’re looking at the current efforts to bring universal health coverage to Tanzania. I’m bringing a microphone along with me as I join in with an official visit by the Elders.
The Elders are an independent group of global leaders working together for peace and human rights, co-founded by Nelson Mandela. They’re here to offer help and advice to the Tanzanian government in preparation for what they hope will be a new set of reforms leading to universal health coverage.
This is the Global development podcast and I’m Lucy Lamble.
The main event we’re here for today is a tour of a rural healthcare centre and dispensary in Mpamatwa village in Bahi district near Dodoma, the capital of Tanzania. With me on the trip is Robert Yates, project director of the universal health coverage policy forum at Chatham House. I asked Rob to describe the scene as we drove into the village.
We’re just coming into the village now, I can see that huge numbers of people have turned out to greet the Elders.
RY Yes, it’s quite a sight. We’ve been travelling for about an hour out of Dodoma and just turned off the main tar road and have come up a very dusty three kilometre dirt road. You can see that it’s a very dry, arid area. I think the crops have been harvested but it’s absolutely bone dry. It is, I think, a relatively poor district. We’ve seen some houses with tin roofs but others haven’t. So this is obviously a very high need community. And it seems that pretty much the whole community has turned out to greet the Elders. We’re just past the health centre, a dispensary in fact, which is a small building of only about five rooms, I believe. But behind that there’s a massive crowd of about 2,000 people, I would suspect: young school children, elderly people, mothers and babies – the whole community’s come out to see the Elders. There’s a group of dancers as well performing as we arrive.
LL As we arrive we find a much bigger crowd than expected. They’ve gathered outside the clinic to hear their minister for health, Ummy Mwalimu.
UM (Speaking in Swahili)
LL Also here is the rights advocate and former minister, Graça Machel. She’s representing the Elders on the tour today alongside Mary Robinson, formerly the Irish president and the United Nations High Commissioner for Human Rights.
You too have a long connection with the country.
MR Well, my first time coming here was as president of Ireland. I remember we drove through the very crowded streets of Dar es Salaam in an open car, and apart from the fact that it was a wonderful experience, the heat nearly killed me. My Irish skin was suffering.
LL While they recognise reforms made already under the health minister and by the new president John Magufuli, they’re here to help the country speed up its progress towards universal health coverage.
One of the UN’s global goals for sustainable development, also known as the SDGs, asks them to achieve this by 2030. So why Tanzania? Why are the Elders here and why now?
For those of us that have had the privilege of growing up with publicly funded free healthcare it’s undeniably and obviously a good thing to do for the country but it has felt globally a little bit, as one of those things that’s not quite yet been within reach. So why is this the right moment to be advocating and why here in Tanzania particularly?
MR Wel,l obviously every country follows its own path, but we do believe that Tanzania is a country that can be encouraged in its own ambition, it has been building its health. It is doing, for example, good work on the procurement of medicines to bring down the price and make them more accessible so that there are medicines in the dispensaries at the lowest level, which has been a big problem.
They’ve tackled corruption, they’ve tackled those who pretended to be qualified but didn’t have the qualifications and so on. And there is a real sense that they want to move forward. I think where we can help them is to make the case that it’s in the economic interests of this country with its ambition because we know that the president is very focused on building infrastructure, on industrialisation, on becoming middle income and has perhaps underestimated the importance of health and education to provide the productive workforce, to provide the intelligent people, the young people who will be able to give the technical expertise that will be needed to drive that way forward.
LL It’s been evident here, the warmth of the reception that you’ve been received with everywhere, and to see a few remarks yesterday already instantly made the front page of the Citizen this morning. What are the next steps? Obviously you’ve been doing listening, you’ve been doing meetings, you’ve been reaching out publicly. What will you do, as Elders, behind the scenes or in front of them?
GM Now we will leave the government, the civil society organisations to take their time to absorb whatever are the suggestions of encouragement which we have given to them to see how they incorporate. But there is openness to continue to engage and if they feel that there is anything which the Elders can facilitate for them to have, for instance, a plan which in stages will lead them to achieve universal health coverage. There’s openness for that. But immediately I think now we’ll leave it to them to think and they will ask us and we will watch. We are very good friends with some of them. If we believe there is not enough progress we can approach them in a very constructive way. But it is a work in progress together.
LL Tanzania, like many developing countries, expects clinic users to pay to access health. There’s a national insurance scheme for employees and a community health fund scheme to reach more people. But currently insurance is taken up by only a quarter of the country’s population. The other 75% have to pay out of their own pocket.
At this clinic here in Tanzania’s Bahi district, the number of people with health coverage is even lower, at just 4%. Just before we head off on the tour I meet Fiona Chalunda. The NGO she works for is, like the Elders, helping the government to bring about reforms. Speaking to her explains just how important clinics like this are here.
Do you mind just introducing yourself and telling me about your NGO?
FC Yes. My name is Fiona Chalunda; I work as an adviser on health financing and medicine supplies management from the Swiss Tropical and Public Health Institute. We’re implementing reforms together with the government of Tanzania.
LL And typically who would use a facility like this?
FC Most of the people here would use this facility, particularly because this is a very rural setting and most of the time we find women and children, especially, attending such facilities because men are sometimes very mobile so they can even attend through private in other areas.
LL Thank you so much for your time and good luck with the reforms.
We’re inside the local health clinic now with about half a dozen small rooms all very tidily organised. There’s a lot of emphasis on hand washing. It’s good to see that there’s solar power in the facility and beds in most of the rooms.
UW What we do actually keep here is only at least 135 essential medicines. We don’t put every medicine but focusing on life saving. So we trace them – how many every month – they have to report online to the minister of health in order to monitor the availability of tracer medicines.
Excellency, we’re embarking on expanding community health workers in Tanzania. We are very grateful to the government of Ireland, they are supporting us in terms of training community health workers. So we want at least in every village to have two community health workers so they can sensitise on issues of family planning, nutrition, early marriage and everything.
MR And in the village itself. [Lots of people speaking at once]
LL According to Rob Yates this is a typical centre where people in Tanzania would first access healthcare. So we’ve been hearing universal health coverage as though it’s an absolute normal part of standard speech – what does it actually mean?
RY Universal health coverage is quite simply that everybody in society gets the health services they need, and that’s not just curative services but preventative services and rehabilitative services, palliative care – all sorts of public health services as well; and in accessing those services that they don’t suffer any financial hardship. It’s as simple as that.
LL It’s a big transition for a country to make, though, to go from user fees to providing healthcare through tax systems or any other kind of approach.
RY To achieve that goal of universal health coverage really what you’re looking at is moving to a publicly financed health system. Moving away from a system where people are buying and selling services that they would sell restaurant meals or buy a television. We know that that type of free market approach of a privately financed system will never ever reach universal health coverage. And one only has to look at the US to see where that ends up.
So I think countries around the world are very much learning that it’s vital to have a system whereby healthy and wealthy members of society are forced to pay for services for the sick and the poor. They’re not going to do it voluntarily. There’s this big role for the state in forcing through that publicly financed system.
Now that can be quite a political challenge to do that when there are vested interests who don’t want to move in that direction, but what we see from around the world is that it’s governments and political leaders are recognising that investing that political capital and bringing that system around is really fantastic for the country. It brings huge health benefits; it brings enormous economic benefits but also I think it brings massive political benefits that everyone in society recognises that this is a much more sensible and efficient and fair way to finance a health system. And really that political leaders that show that courage and bring about that change often not only does this help them get re-elected, it can potentially turn them into national heroes.
LL Who’s managed to make that transition and how did they get there?
RY Yes Indonesia, a fascinating example of a country that I think had been showing very slow progress towards universal health coverage particularly given it’s a middle income country now. But where the former governor of Jakarta took a much more radical and rapid approach really providing universal free healthcare to everyone in the city handing out millions of cards entitling people to free healthcare, doubled the budget to pay for it and it was very, very successful, very popular and I think was really one of the major reasons that he was so successful in winning the presidential election in 2014. And, clearly, you can see what we’re hoping is that this idea will permeate into other countries, for example, here in Tanzania.
LL That’s all for this episode of the Global Development Podcast. You can subscribe via iTunes, SoundCloud or any podcasting app. And you can also listen to other episodes on theguardian.com/global-development. My name is Lucy Lamble and the producer is Gabriela Jones.
Thanks for listening. Goodbye.