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Health Improvement Project Zanzibar: a New Model of Healthcare Delivery

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Health Improvement Project Zanzibar: a New Model of Healthcare Delivery HELPING ABROAD 35 Health Improvement Project Zanzibar: a new model of healthcare delivery MIKE SPENCER CHAPMAN, FIONA GREVILLE-HEYGATE, RAMSAY SINGER, JONATHAN REES, RUARAIDH MACDONAGH The effectiveness of aid programmes in delivering improvements on the ground in resource-poor countries is often questioned. In this article the authors describe a project involving the direct, semi-autonomous running of two hospitals in Zanzibar and highlight the successes they have achieved. Figure 1. The paediatric ward at Kivunge Hospital prior to and after renovation by HIPZ anzibar is a semi-autonomous region of HEALTH IMPROVEMENT PROJECT ZTanzania, consisting of an archipelago ZANZIBAR of islands off the coast of mainland Africa. Health Improvement Project Zanzibar The estimated population of 1.3 million (HIPZ) is a UK-registered charity inhabit two of the largest islands, Unguja established in 2006 by Mr Ruaraidh and Pemba, where the combined doctor- MacDonagh, a consultant urological to-patient ratio is around 1:20 000 (as surgeon based in the UK. Having compared to 1:360 in the UK). Healthcare previously worked in Zanzibar, Mr provision is designed as a three-tiered MacDonagh was approached by the structure of primary, secondary and tertiary Principal Secretary for Zanzibar’s Ministry care. Primary care is provided by 134 basic of Health for assistance in the delivery of Primary Healthcare Units (PHCUs), which healthcare in Makunduchi Hospital: Mike Spencer Chapman, Core Medical are distributed evenly around the two main a 36-bed hospital with a catchment Trainee, Barts Health NHS Trust, London; islands to ensure that all the population area population of around 50 000 in HIPZ Trustee; Fiona Greville-Heygate, have a centre within five kilometres. On the rural south of Unguja, which had Core Psychiatry Trainee, Royal United Unguja, secondary care is provided by two fallen into a state of virtual disuse. In Hospital, Bath; Ramsay Singer, NIHR hospitals: Makunduchi and Kivunge. Tertiary 2007 this led to a 10-year agreement, Academic Clinical Fellow in Clinical care is provided by the largest hospital on giving HIPZ management responsibility Oncology, Maidstone Hospital, Kent; the archipelago, Mnazi Mmoja, located in the for Makunduchi Hospital, with the Jonathan Rees, GP, Backwell and capital Stone Town. In practice, prior to 2006, aim of improving healthcare services Nailsea Medical Group, North Somerset; the hospitals were so dysfunctional that the and systems in the hospital and the HIPZ Trustee; Ruaraidh MacDonagh, secondary care tier was provided almost wider region. Consultant Urological Surgeon, Taunton exclusively by Mnazi Mmoja. This led to and Somerset NHS Trust, Somerset; overcrowding, inadequate staffing, and long In 2012, following the success of Founder and Chairman of HIPZ patient journeys. HIPZ’s involvement at Makunduchi, the TRENDS IN UROLOGY & MEN’S HEALTH SEPTEMBER/OCTOBER 2015 www.trendsinmenshealth.com HELPING ABROAD 36 Ministry of Health requested that HIPZ Identifying realistic, tailored successes. These have included renovation undertake a similar 10-year project at healthcare solutions of staff accommodation, staff training, Kivunge Hospital in the north: a larger, HIPZ aims to improve healthcare through introduction of the hospital manager role 72-bed hospital with a catchment area micro-managing health systems at a local to strengthen leadership and discipline, and population of around 200 000. HIPZ level. This strategy allows us to work in building staff morale and pride by providing now manages the only two hospitals a constructive partnership with staff to an improved work environment that is clean, outside of the capital, providing primary identify already well-functioning projects, has better equipment and offers new services. and secondary care to an area with a troubleshooting ‘on the ground’ issues, and Initially, HIPZ also provided a supplement combined population of around 250 000. understanding the various complexities of to employees’ salaries to encourage failing healthcare projects. engagement with the improvement process; THE HIPZ MODEL this is now transitioning to a performance- International development organisations Providing volunteer doctors from the UK, based approach. have tried many diverse approaches who work with Zanzibari staff on a daily to healthcare improvement in resource- basis, allows us to observe, listen and learn Partnerships with other health poor countries.1 HIPZ has an innovative about area-specific issues. A ‘one-size-fits- development organisations model to achieve this goal in Zanzibar. all’ approach to improving healthcare in A multitude of health development Some key elements of this approach are low-income countries is simply not effective organisations have a presence in summarised below. across the wide range of economic and Zanzibar, each with its own priorities cultural settings. The close relationship and need for donor accountability. There A formal partnership with the between our leadership team and the team is risk of poor co-ordination between Ministry of Health on the ground enables a targeted approach: organisations, and few have an ongoing A Memorandum of Understanding (MoU) we are selective and specific about the presence on the ground to ensure the was created, giving HIPZ management areas that we support, and ensure that we long-term success of projects. Within responsibility for each of the two hospitals, follow through on all projects we undertake. our hospitals we are well placed to help in collaboration with the Ministry of Health This results in clinically important, high- with these issues, and have had several Zanzibar, for a period of 10 years. impact improvements for relatively modest successful partnerships with other financial investment. development organisations including the The agreement outlined the roles and United Nations International Children’s provisions apportioned to the two Ensuring long-term clinical and Emergency Fund (UNICEF), the United partners. The Ministry of Health would financial sustainability Nations Population Fund (UNFPA) and continue to provide staff, salaries and A core element of HIPZ’s strategy is to Rotary International. basic services, such as certain medications incorporate long-term sustainability into and equipment. HIPZ would support and all projects and healthcare initiatives. NOTABLE ACHIEVEMENTS develop the day-to-day management Fundamental to this has been the Soon after taking on the management of the hospital, provide clinical support identification of key members of staff of Makunduchi Hospital, HIPZ initiated a through volunteer UK doctors, supervise and the support of their personal and monthly collection of data relating to the and fund renovations and building professional development. As per the usage of hospital services, compiled by the projects, and develop systems to deliver MoU, Makunduchi and Kivunge Hospitals hospital manager. As well as allowing the a reliable and consistent health service. will return to a fully locally-delivered early identification of problems and key areas Although generally working within healthcare service at the end of the for development, this has demonstrated a Government regulations, HIPZ funding 10-year period of the agreement. number of successes (Box 1). is spent directly on service improvement and does not go via the Government, thus Maximising the potential of local staff Data from 2009–2014 showed a dramatic ensuring accountability and a degree Having talented, motivated staff in key increase in the use of hospital inpatient of autonomy. clinical, administrative and managerial services. Monthly hospital admission rates positions is instrumental in implementing increased by 193%. Since the establishment In short, the Government has handed improvements and will be essential in of comprehensive emergency obstetric care over the running of a hospital to an NGO maintaining sustainability in a Zanzibari- and general improvements to maternity for a protracted period with the aim of led healthcare service. Consequently, the services, a 116% increase has been seen in improving services. As far as we know, this implementation of measures to improve the number of mothers delivering in arrangement is unique. staff performance has been key to HIPZ’s hospital. Other maternity services, such www.trendsinmenshealth.com TRENDS IN UROLOGY & MEN’S HEALTH SEPTEMBER/OCTOBER 2015 HELPING ABROAD 37 rise in the incidence of cardiovascular Box 1. HIPZ achievements at Makunduchi/Kivunge Hospitals disease in Africa. A BMJ editorial in 2005 reported that cardiovascular disease ‘has reached near epidemic proportions in l Supporting staff to gain recognisable qualifications Africa’, with the WHO reporting in 2002 l Daily teaching and supervision, with incentives for self-directed learning that almost 10% of deaths were due to l Renovating wards, theatres and staff accommodation cardiovascular disease, with hypertension l Building of primary healthcare units to improve primary healthcare in the most prevalent underlying cause.2 conjunction with the current hospital This figure will only have increased in l Provision of a free ambulance pick-up service for women in labour the last decade, as lifestyles continue l Reliable supply chains for delivery of essential medicines and recognising to change. importance of hospital stores in managing stock-taking l Computer training and training in data collection and administration The management of hypertension was, l Free ultrasound and
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