PDF hosted at the Radboud Repository of the Radboud University Nijmegen The following full text is a publisher's version. For additional information about this publication click this link. http://hdl.handle.net/2066/148447 Please be advised that this information was generated on 2021-10-05 and may be subject to change. ІА^ й INTEGRATION OF CHURCH AND GOVERNMENT MEDICAL SERVICES IN TANZANIA EFFECTS AT DISTRICT LEVEL T.W.J. SCHULPEN INTEGRATION OF CHURCH AND GOVERNMENT MEDICAL SERVICES IN TANZANIA. EFFECTS AT DISTRICT LEVEL. lU~~p. Cover design by George Li langa Nyumba ya Sanaa P.O. Box 4904 Dar Es Salaam Tanzania INTEGRATION OF CHURCH AND GOVERNMENT MEDICAL SERVICES IN TANZANIA. EFFECTS AT DISTRICT LEVEL. Proefschrift ter verkrijging van de graad van doctor in de geneeskunde aan de Katholieke Universiteit te Nijmegen, op gezag van de rector magnificus prof. mr. F.J.F.M. Duynstee, volgens besluit van het college van decanen in het openbaar te verdedigen op woensdag 25 juni 1975 des namiddags te vier uur door T1M0THEUS WILHELMUS JOSEF SCHULPEN geboren te Rijswijk 1975 African Medical and Research Foundation Box 30125, Nairobi, Kenya. Promotores: Dr. V.F.P.M, van Amelsvoort Prof. Dr. A.T.L.M. Hertens Financial support for the study and this publication has been given by: MEMISA ("Medische Missie Actie"), Rotterdam. The Jan Oekker-Fund and the Dr. Ludgardine Bouwman-Fund, Amsterdam. MISEREOR, Aachen, West Germany. The Hubrecht Janssen-Fund and the Schuffner-Fund, Amsterdam. This study was made with the co-operation and permission of the Ministry of Health of Tanzania. All results, however, are based on the author's personal observations and experiences. The conclusions in this study do not represent any official policy of the Ministry of Health of Tanzania, and are entirely the author's own responsibility. To: Ineke, whose tolerance and stability saved me from disintegration. CONTENTS Page Chapter 1. INTRODUCTION 1.1 MOTIVES 1 1.2 MATERIAL 4 1.3 METHODS 6 1.4 PRESENTATION 7 Chapter 2. TANZANIA 2.1 GENERAL INFORMATION 2.1.1 Geographic Data 9 2.1.2 Demographic Data 9 2.1.3 Socio-political Data 10 2.1.4 Economic Data 11 2.1.5 Health Data 11 2.2 THE POLITICAL HISTORY AND THE MISSIONARY FACTOR 2.2.1 ГЛе рте-colonial period 13 2.2.2 ГЛе German period (IBв5-1918) 15 2.2.3 The British period (1919-1961) 18 2.2.4 .Independence (1961) 24 Chapter 3. TANZANIA'S MEDICAL SERVICES AND THE CHURCH FACTOR 3.1 THE ROLE OF THE MISSIONS IN THE DEVELOPMENT OF THE MEDICAL SERVICES 3.1.1 The pre-colonial period 37 3.1.2 ТЛе German period 40 3.1.3 The British period 44 3.1.4 Independence 58 1 3.2 THE MISSION MEDICAL COMMITTEE, THE TANZANIA CHRISTIAN MEDICAL ASSOCIATION AND THE CHRISTIAN MEDICAL BOARD OF TANZANIA 75 3.3 THE GRANTS-IN-AID SCHEME 80 Chapter 4. INTEGRATION IN THE PHILOSOPHY OF MEDICAL MISSIONS OF PROTESTANT AND ROMAN CATHOLIC CHURCHES 91 Chapter 5. THE PROCESS OF INTEGRATION IN TANZANIA 114 Chapter 6. INTEGRATION AS SEEN BY CHURCH-EMPLOYED DOCTORS IN TANZANIA 124 Cnapter 7. THE EFFECTS OF INTEGRATION AT DISTRICT LEVEL A COMPARATIVE STUDY OF THE HEALTH SERVICES AS DELIVERED BY GOVERNMENT, CHURCH AND INTEGRATED HOSPITALS 7,. 1 INTRODUCTION 143 7,. 2 THE SURVEY 147 7.. 3 SURVEY RESULTS 7.3.1 Curative activities 148 7.3.2 Preventive activities 155 7.3.3 Outreach activities 158 7.3.4 Training 159 7.3.5 Ouality 160 7.3.6 Management 165 7.3.7 Economy 166 7.3.8 Motivation of staff 169 7.3.9 Religious influence 170 7,. 4 DISCUSSION 170 Π Chapter 8. BIHARAMULO DISTRICT HOSPITAL, A CASE STUDY OF INTEGRATION 8.1 DESCRIPTION OF BIHARAMULO DISTRICT 176 8..2 THE LEVELS OF HEALTH CARE 186 8,.3 THE BIHARAMULO EXPERIMENT 8.3.1 Introduction 192 8.3.2 Curative activities 193 8.3.3 Preventive activities 196 8.3.4 Outreach activities 200 8.3.5 Training 206 8.3.6 Quality 208 8.3.7 Management 213 8.3.8 Economy 214 8.3.9 Motivation of staff 218 8.3.10 Religious influence 219 8..4 DISCUSSION 220 Chapter 9. CONCLUSIONS AND SUGGESTIONS FOR THE FUTURE 224 SUMMARY 241 SUMMARY IN KISWAHI LI 248 SUMMARY IN DUTCH 255 APPENDICES 263 REFERENCES - CITED 281 - CONSULTED 293 ACKNOWLEDGMENTS 297 CURRICULUM VITAE 301 ABBREVIATIONS Α.M.О. = Assistant Medical Officer A.N.C. = Ante-Natal Clinic ест. = Christian Council of Tanzania С.M.S. = Church Missionary Society C.M.B. T. = Christian Medical Board of Tanzania C.W.C. = Child Welfare Clinic D.A. = Dispensary Assistant D.H.O. = District Health Officer (= Sanitary Ins pec tor) D.M.O. = District Medical Officer D.M.S. = Director of Medical Services E.N. = Enrolled Nurse G.N.P. = Gross National Product I.P. = In-patients L.A. = Local Authority M.A. = Medical Assistant M.C.H. = Maternal and Child Health M.M.C. = Mission Medical Committee M.P.H. -team = Mobile Public Health Team N.E.C. = National Executive Committee N.U.T. A. = National Union of Tanganyika Workers O.P.D. = Out-patient Department O.U.A. = Organization of African Unity R.M.A. = Rural Medical Aid R.M.O. = Regional Medical Officer S.R.N. = State Registered Nurse T.A.A. = Tanganyika African Association T.A.N. U. = Tanganyika African National Union T.C.H. 0. = Tanzania Catholic Health Organization T.C.M. A. = Tanzania Christian Medical Association T.E.C. = Tanzania Episcopal Conference IV T.F.L. = Tanganyika Federation of Labour U.M.C.A. = Universities Mission to Central Africa V.A. = Voluntary Agency Technical Remarks: The currency is expressed in Tanzanian Shillings (20 T.Shillings = 1 T.£) The mean exchange rate for the period of the study was 17 T.Shs to £1 Sterling. Prior to 1969 the exchange rate was 20 T.Shs to £1 Sterling. Chapter 1. INTRODUCTION 1.1 MOTIVES Medical work has always been a major field of interest of the Churches. When western countries reached a certain stage of development and wel­ fare work became the State's responsibility or was financed by govern­ ment-assisted institutions, the poor state of health in the developing world became the major concern of the Churches. Mission medical workers sailed out to all parts of the World and laid the basis for a western medical care network, often under the most difficult conditions. As colonial governments were mainly concerned with public health within the services and medical care in their administrative centres, medical care in the rural areas became the main responsibility of the Missions. When the emerging countries reached independence, local Churches replaced the Missions and continued providing medical care for the rural areas. With assistance from their overseas sister Churches the network was rapidly expanded and it is estimated that at present over $300 million is spent on the more than 2,300 church medical institutions in developing countries (Bryant,1969:304). In countries like Tanzania, Malawi, Cameroon, Zambia, Ghana and Kenya the number of church hospital beds constitutes between 25 and 45% of the total number of beds. This contribution to medical work by the Churches is still increasing; it seems that development aid received through private institutions is often more acceptable in some parts of the developed world than interstate aid activities. With the present realization that the huge inputs in medical care have been relatively ineffective in improving the health of rural popul­ ations in developing countries, new ways of delivering health care are being sought. Apart from the realization that more emphasis on the an­ thropological' aspects of the medical work was needed (van Amelsvoort, 1964), new methods of health care were also sought. A symposium at 1 Makerere in 1966 (King а.о.) brought about world-wide attention to the problem. One of the results was the establishment of the Christian Medical Commission by the World Council of Churches in 1968. Innumerable discussions, publications and pilot projects have ta­ ken place, but none of them has given a suitable solution. Since 1970 the Chinese model of health care has gained enormous popularity (Horn, 1969,1971,1972; Sidel,1972; Chi Wen,1974; Smith,1974) and has been re­ garded by some as the panacea for health problems in the developing world. Others advocate the Cuban (Navarro,1972) or Iranian (Dadger, 1971) models, but the different social structures make it impossible for any of these systems to serve as models for all other developing countries. W.H.O. has tried to help by issuing an avalanche of publications, (e.g. 1954,1960,1961,1967,1969,1971,1973) but these are all theoretical studies and apparently do not give practical solutions to the problems. It also came to the conclusion that it seems improbable that any inter­ national model or "standard" for health services will be developed (W.H.O. 1973:105). As the churches play such an important role in the health care of most developing countries, this might be the most stable pillar on which a new health care system could be built. But the thinking of some church medical workers and their leaders should change drastically. As long as systems are employed whereby patients are attended in a church dispensary only after producing their religious instruction card, or after attending a church service or the prayers of the church medical worker, a new system cannot easily be developed. As long as different church denominations refuse to co-operate in their medical efforts by continuing to build medical centres near each other, or by giving differ­ ent types of treatment or food to patients of different denominations, a new system cannot easily be developed.