VISIT BY FRIENDS OF MURAMBINDA (FMH) HOSPITAL TRUSTEES MARY MILLER AND CAROLYN RIGBY, WITH SUPPORTER BETH KIRBY

Friday 28.2.20

Mary and Carolyn arrived Nairobi via Schiphol early morning then flew onto Harare arriving tea-time where we met Beth Kirby a colleague of GPs John and Anne Connolly former doctors at Murambinda Mission Hospital (MMH) who has just finished her master’s degree in Public Health and joined us for the trip.

Saturday 29.2.20

After a night in a small hostel we walked to a local supermarket to buy food for our stay as we were unsure of its availability in Murambinda. We had brought a lot of staples with us and found the supermarket well stocked but empty of customers most likely due to prices being not dissimilar to the UK. We were picked up just after lunch, arriving MMH about 6pm. There were lots of potholes on road and a toll just south of Harare, also 2 police roadblocks but we were waved through.

Administration Building, Murambinda Mission Hospital

Sunday 1.3.20

We attended church at 8.30 which was much enlivened by a very energetic priest giving an interactive sermon on the temptation of Eve- much laughter and other people having their say. We sat on the back row and had intermittent translation by two lovely ladies who laughed and chatted through the service but clearly took their religion seriously. We had to introduce ourselves and then were “exposed” with lots of thanks as we’d put US$ in the collection (the amount was announced!). The highlight was the singing and the gorgeous babies and children. At the end the choir gave a recital of their competition entry from the day before where they had come 6th. It was truly exceptional. We met many old friends and made a lot of new ones.

MEETING WITH DR. KWIRI, DISTRICT MEDICAL OFFICER

After lunch we then met with Dr Kwiri the District Medical Officer (DMO) and Hospital Superintendent who very kindly gave up his Sunday afternoon for us as he was off to Mozambique for a cross-border conference about Coronavirus. He has been acting Provincial Medical Director since January which necessitates 2 days a week in the provincial capital Mutare 200 km away so he is very busy doing his own DMO work in reduced time.

From him we learned

• There are another 2 doctors besides himself along with a clinical officer (like a very advanced nurse practitioner). He feels doctor numbers are less important than their commitment to the work but he ideally feels MMH needs a DMO and 3 doctors (plus another 3 at the larger health facilities in the district which he does not have). His main aim is to retain the doctors he has as they work as an excellent team. • There are unlikely to be any newly graduated (post foundation) doctors coming for their rural practice placement any time soon because of the delay to their studies due to the strike last year and because they are choosing not to get their open practice certificate which is unnecessary for working overseas or for private practice. • Outpatient numbers are down due to transport and user fee costs being beyond the capability of many • Clinically malaria is reduced (poor rains over the season) but recent late rains have caused a spike. There were only 2 cases of multi-drug resistant TB in last year though TB rates are up. And they have very good treatment completion rates. Malnutrition is currently low (good support from donors after Cyclone Idai) but with an expected poor harvest will likely go up unless ongoing support is forthcoming. Births are up, many coming from outside the district. HIV rates are mercifully down, and they only test high risk cases routinely. Anthrax is up as poor animal health.

We thanked Dr Kwiri sincerely for his exceptional hard work and for his help with elective students. He explained that he had been brought up in a rural farming area and is committed to helping the people of rural areas.

VISIT TO MUSASA PROJECT

We then went for a walk and met an old friend Farai Bishi on his way to the women’s refuge- they regularly use him as a volunteer driver. It is called The Musasa Project. There is a very young counsellor and support worker called Lisa who showed us around and there was an assistant house mother on duty for the weekend. There were 8 bedrooms sleeping 2-3 girls some who are only in their very early teens looking after their babies. Some of the girls as young as 6 had been sexually abused or subjected to violence or severe deprivation. One young woman had physical disabilities The Musasa Project provides a safe place and emotional and legal support. We noticed the complete absence of possessions or toys but there was a very calm atmosphere and they were all very welcoming.

Monday 2.3.20

The traditional welcome at morning prayers at 7.30 was as always a very special occasion. The matron Sr. Silindiwe welcomed us. We introduced ourselves and then after songs and prayers and a reading we had the usual shaking of hands from all the staff and lots of hugs.

MEETING WITH SR. FILLYS MADZIYA, LCM Head of Missions

After this we met with Sr Fillys, the newly appointed Mission Director. She kindly explained her role. She has been appointed to integrate the vision of the Little Company of Mary with that of the hospital and hopes to attend to the holistic and spiritual needs of the patients and staff alike. She wants to ensure that for all patients their care is as dignified as possible and that their spiritual needs are catered for. She plans to liaise with other denominations. She hopes to find a place for a chapel where patients can sit and find peace in prayer. The priest still attends weekly and visits all wards and the morning prayers moves around the hospital.

For the staff she wants to foster a workforce that is well-motivated and supported. She has a vision that the Murambinda ethos will be instantly recognisable in all the staff no matter where they may end up working. She hopes they will create a healing environment which be supportive to all, patients and staff alike. She wants a social space for staff where they can recharge their own energies and plans to have motivating pictures and messages displayed throughout the hospital. She hopes that this will help everyone cope with the pressures they are under. This model is already underway in Australia and other places. She is very appreciative of Mary (Miller) and her husband John staying in Zimbabwe throughout all the problems around the 2008 election and subsequently.

We spoke briefly to Mrs Natale at CARC (the Child and Adolescent Resource Centre) which supports children and young people living with HIV, as she was going out on an outreach project to support female care givers by training them in chicken management, financial affairs etc. Empowering women is their aim. We heard about Lewis a recipient of CARC’s fabulous support who is now at university studying psychology and is due back to help CARC during his placement year.

Mrs. Evelyn Natale, CARC Coordinator

MEETING WITH MR. MUDZI, Donor Funds Secretary

We then met with Mr Mudzi our donor secretary to discuss current challenges as he sees them.

He sees the priorities for funding as hospital repairs and renovations, incentives and groceries (10l of oil and 10kg rice and sugar per quarter). They plan to renovate the Matumba (waiting mothers’ shelter) by turning the cooking area which is underused into another sleeping quarter and making a much smaller cooking area outside in a shelter- this has been surveyed by the district engineer and is not thought to be a high cost project.

They really want an isolation ward and a new service vehicle- they plan to auction the existing one.

Solar lighting is also sorely needed-half the hospital is on solar power, but the batteries aren’t working in maternity and children’s ward so they need new ones or repairs. LCM are funding this. The x-ray machine and autoclave still need mains electricity but of the generators used to power these during a power cut one needs servicing and the other needs repairing. The borehole has a solar pump to use when the electricity is off as no water can be pumped from the river.

MEETING WITH SR. TAWODZERA, Sister in Charge

We met Sr Tawodzera- she is the assistant matron and is the acting matron when Sr Silindiwe is unavailable. She is also nurse in charge of gynae and female ward. She attends the exec and advised them on the clinical areas and takes the minutes. She manages staff shortages and absences and liaises between the doctors and nurses.

She feels that medical equipment is well resourced, but the hospital infrastructure is getting very old and the hospital needs constant repairs: painting and floor tiles. For her the number one priority is pharmaceuticals. The non-monetary incentives (groceries) are very welcome. She feels an isolation ward is a priority but wonders where it can be built.

She has worked at MMH 31y.

MEETING WITH MRS. CHIPANGA, HSA

Mrs Elizabeth Chipanga is the Health Services Administrator (HSA) and a very busy lady. She is currently preoccupied by the RBF (results based funding) in clinics- she must visit all 33 clinics every quarter to monitor their activity and support them in administration. User fees <5y and over 65y don’t pay so only 40% should pay but the new user fees mean they often can’t!

She is responsible for the payroll and manages the general hands and kitchen staff and the hospital estate. She feels a big priority is a new service vehicle as the current vehicle is used for rubbish collection and food shopping, so she worries about health and safety. She supports and appreciates the non-monetary incentives. Staff turnover is a big headache- if someone leaves and is not replaced within 3m the post is frozen. There are not enough general hands for ground maintenance, and she feels 2 strimmers would cut down on their work hugely as “slashing” where a metal rod is swung to cut the grass is so inefficient. There is only one driver, so they must borrow from the district and sometimes use locums.

They would like to give the staff subsidised lunches but don’t really have enough kitchen staff (4 in total who work one week on and one week off either 3.30-2.00 or 10.20-7.00). All staff get free bread and tea at breaktime.

Staff accommodation is often dilapidated. It is given at a subsidised rent but all water and electricity to be paid for. She started work at MMH in 2004 and she has a master’s degree in public health. Her husband works in Mutare.

HOSPITAL NUTRITION GARDEN

We visited the hospital kitchen garden and met the gardener Tendai Kunyongana. This year has been a struggle as with 42’C temperatures he struggles to keep the plants watered and they all died. He would like a stronger (solar) pump and a sprinkler to use river water. The winter is better as there are good temperatures and the polytunnel means they can grow tomatoes etc. There was a particularly productive avocado tree.

Mary volunteered to look for funding for initiatives to combat climate change if the Hospital can produce a proposal for upgrades to the garden.

PHARMACY

Mr. Chitswa in the Pharmacy

Mr Chitswa is the pharmacy technician and Yvonne his assistant. Priscilla oversees stock control and Esther is the dispenser. When not serving patients, they make up pre-packs (little packets of medication which saves a lot of time). They see around 130-140 patients a day. The children have a separate pharmacy to avoid cross-infection. Just as in our time the front storeroom has the medicines and the back room the surgicals (disposables)- very ordered and very tidy and very well- stocked, with clear stock cards for each item. They ideally keep 7m stock but usually manage >4m.

NatPharm the government supplier is cheapest (they honour the government exchange rates)- some medicines (for HIV and TB) are freely supplied but NatPharm also sells medicines but they generally have low stock which has to be shared out fairly so you mostly don’t get the full quantities you ask for. If not available from NatPharm the next best option is to source from South Africa or Namibia as they will accept US$. They sometimes need to supply the clinics from these as the clinics are just as subject to NatPharm fluctuations in stock.

It can be a fine balancing act to move drugs around and distribute stock fairly, so no-one goes without. They produce a monthly update for the doctors and nurses so they know about the stock situation and can take steps to ameliorate for this.

We saw the air-conditioned bulk store and also met Mrs Nyomo who has been at MMH 32y and is now dispensing in the children’s pharmacy. Mr Chitswa also told us that there is a drive to encourage men to be more involved in the health of their wives and children as the thinking is that if men understand the nurse’s directions they may be more inclined to support their wives to follow them. If you come as a couple you will get priority treatment and may be offered other health promotion and HIV testing etc.

New Staff Houses

Near to the Hospital in the Growth Point 5 new staff houses are being built- they are near completion. Each consists of a very large living and cooking and eating area with 2 bedrooms and a bathroom. Solar power installed.

Wednesday 3.3.20

DOCTORS’ WARD ROUNDS After morning prayers Mary and Beth went to CARC while Carolyn joined the doctors on their rounds. Together with Mr Arnold Jiyangwa (Clinical Officer), Dr Bviribindi and Dr Patience Mupandaguta, I visited the female medical and surgical wards and maternity before joining Mr Jiyangwa for an elective Caesarean Section. The female medical ward was almost full- there were 9 patients, 5 cases of malaria, 3 diabetics and one severely anaemic patient. The oldest patient with malaria was 89y very unwell and I suspect near death. One of the patients with severe anaemia (Hb 5.7) is suspected to have fibroids- she needs an USS but the hospital can only do obstetric and so this will be sourced privately at the local private clinic where USS are done once a week. There was a very unfortunate 25y old with Type 1 Diabetes who had been started on insulin but for various reasons had stopped it and had come in with a very high blood sugar- she was now stabilised back on insulin but obviously she is at exceptional risk of the same thing happening again. Dr Mupandaguta advised that the lack of glucose testing kits is a frustration. Another elderly patient had presented with diabetic ketoacidosis, not known to be diabetic she was stabilised on insulin and is now converting to tablets. An 18y old and a 50y old had acute malaria. I learnt that nobody except pregnant women take antimalarial prophylaxis, there are campaigns to promote nets and spraying to reduce the mosquito population. More positively another 50y old had been admitted 2 days earlier in coma due to malaria and was now well and sitting up. There were 4 patients on the female surgical ward. A 59y old woman with a fractured femur- she’ll be re-x-rayed after 3 weeks of skin traction and discharged if good signs of healing or if not transferred to orthopaedics at Mutare. A 45y old woman with severe cellulitis after a snake bite has been in hospital just over a week- her wound was debrided when there is good granulation tissue and the infection resolved she will be transferred to Mutare for skin-grafting. Another patient had a submandibular gland infection (she is HIV+) and another has a diabetic foot ulcer, she is 73y and it is on the sole of her foot which is challenging to treat anywhere.

No one was labouring on the maternity side but in the neonatal bay were 2 infants, one had haemolytic disease of the new-born and was very pale and also had birth asphyxia. Another tiny child weighing only 1160g had been born at 30 weeks. On Wednesday there was no electricity (and solar in maternity isn’t functioning and the generator only runs in the day time) and so the incubator was cooling off- she was going to be transferred to the kangaroo method where babies are nestled skin to skin on their mother’s chests.

On the Caesarean Section ward were 3 women, 2 whose labours had been too slow because they had had big babies and another who had had a previous section (they are encouraged to be sterilised during the 3rd section). On the postnatal ward was a baby with physiological jaundice who was responding nicely to exposure to sunlight. Most women with uncomplicated births stay only for 1 day though staff feel 3 would be better. They have seen an increase in their Caesarean Section rate as the relatively nearby Chivhu Hospital has no doctor and MMH as a district hospital is cheaper than the provincial hospitals.

THEATRE

Carolyn was then privileged to accompany Mr Jiyangwa to theatre for a Caesarean Section. The patient had already had a previous section, so it was a planned procedure. The nurse anaesthetist did the spinal anaesthetic and was most attentive. He is working lots currently as one of his colleagues is on long term sick leave and another on annual leave and they are only three. It was a difficult procedure as there was a lot of scar tissue to negotiate but led to the successful delivery of a beautiful healthy baby boy. Mr Jiyangwa is a lovely man extremely competent both at presenting cases on the ward round and in operating. He really enjoys his work. He trained as an RGN and also as a midwife then did a special 2-year course with an attachment in psychiatry and certain surgical procedures to become a clinical officer. This post was created as a response to the shortage of doctors and if he is anything to go by is a very successful development.

Surgical Team

We were very impressed by the knowledge and care of both doctors and the clinical officer which is immensely cheering and substantiates Dr Kwiri’s view that a motivated small team is much better than having lots of unmotivated doctors.

HOSPITAL KITCHEN

The theatre staff are fed by the kitchen, as there is no time for them to go home for lunch, and today we were invited to join them. They had sadza and a beef stew, but we were treated to roast chicken, chips, rice and vegetables by Mr Bernard Ruzengwe. The theatre staff felt rice and potatoes would not fill you up adequately and sadza was especially essential for a good night’s sleep.

DENTAL THERAPY

After lunch we met with Ms Bertha the dental therapist. She joined MMH in April 2019 and did a 3y course in Harare which means she can do almost all dental procedures except root canal work. Prior to coming to Murambinda she was in private practice, but this was a struggle. Last Spring the government opened up posts in district hospital and she lobbied to come to Murambinda as she had heard good things about it from a colleague. There had been no dentist at MMH for more than 5 years and so she has struggled to build up the equipment she needs. She really appreciates the fact that she has enough dental anaesthetic as she knows most places don’t have this. However, she doesn’t have a compressor for her 2 new dental chairs, or a drill or a working x-ray machine or a dental nurse or electricity all the time as her building isn’t hooked up to the generator and has no solar. Despite this she recognises she is new to the place and is hoping that in due course her requests will be granted in the strategic plan. She is restricted to extractions but would truly love to do fillings and cleaning and do more health promotion. Her reputation is spreading, and she is getting busier and busier. Being able to give children toothbrushes would be nice. She lives on site and her children are with relatives, but she hopes to bring them to her soon.

NURSE TRAINING SCHOOL

Next, we visited the nurse training school and met with Senior Tutor, Mrs Josephine Mudzingwa. In January 12 midwives started a 2y training programme in midwifery. Midwifery training so far has only been 1 year, but 2 years gives them an internationally recognised qualification. There will be a second intake in September. Previously they were involved in upskilling primary care nurses (PCNs) over a 1-year intensive course but this programme has now ceased as there are no more to upskill.

We toured the dormitories (the twin rooms are very shabby) especially the floor tiles and the library (well-stocked) but there is a serious shortage of computers and the tutors have only one lap-top between them for preparing PowerPoint teaching session etc. We were able to provide them with an unwanted lap top brought from the UK.

Training School Library

Mrs. Mudzingwa was very grateful for all that FMH and SVMH have done for the training school and for the groceries we give the staff. Also, for the money towards graduation ceremonies. She does feel monetary top-ups would be very much appreciated as the biggest anxiety for many nurses these days is how to pay school fees which are spiralling out of control because of inflation.

Her wish list for the Training School is as follows:

• More gas for cooking • Solar power • New tiling in the two of the dormitories • A lawnmower to free up the 2 general hands from “slashing” • A vehicle for transporting students to examinations and to their rural attachments they hire minibuses, but she fears for their road worthiness.

It was good to meet two of the other tutors assistant tutor Mrs Zvisisai Mutava (prev. Mazuro) and Mrs. Nehanda the Admin Officer. There was no power all day today.

Thursday 5.3.20

Morning prayers again in OPD. We gave a presentation about FMH which was very well received, and we presented Mr Tirivanhu with a framed photograph of himself in his workshop with a message of thanks from FMH. He retired after 32y as head engineer- he was famed for fixing anything and will be a great loss to the hospital. We then heard presentations about the recognition and management of sick infants and children from 2 nursing sisters who had been to a training day which reminded us of lots we had forgotten.

Mr. Benjamin Tirivanhu with the Presentation for All His Years Of Dedicated Service

LABORATORY

Next Mr Garatsa gave us a tour of his laboratory. He works with Mr Kuhudzai his assistant and Charity and Lydia. They do rapid tests for malaria, syphilis and glucose and also do blood cell counts (FBCs), Blood biochemistry (U&Es: creatinine, urea and potassium and sodium). They culture urine and stool and wound swabs and do cholera tests. There is a CD4 count machine and if low they test for cryptococcus. The Gene Xpert machine is functioning well they can do 4 samples at a time with a running time of 2 hours. It is used for new TB diagnoses- follow up samples are done the old- fashioned way at 3 and 6m with culture and microscopy for Acid and Alkali fast bacilli.

They do microscopy for malaria. Reagents are a problem as NatPharm stocks are irregular and the de-ioniser isn’t working as they can’t get cartridges but rely on 20 litre bottles from NatPharm.

MEETING WITH SR. SILINDIWE SHAMU, Hospital Executive Manager and Matron

We met with Sr. Silindiwe, who is both the HEM (Hospital Executive Manager) and Matron. She has good support from her assistant matron Sr Tawodzera. She also has good support from the Executive who meet weekly. She finds her staff very committed and caring and when they had a recent influx of new nurses they integrated well. There are 3 nuns: Srs Silindiwe, Fillys and Faustina (who works in outpatients) and 2 candidates

Sister Silindiwe Shamu

She is pleased with the current Board members. They have organised themselves into 3 sub- committees: Legal and Human Resources, Finance and Administration and the third is Clinical. The subcommittee members have a WhatsApp group and can phone or message each other between Board meetings. They have tasks to do before the next meeting. She organises the meetings and takes minutes. Murambinda Hospital Exec were able to recommend a person as the local representative and it is Mr Chadzimura (retired teacher and married to retired MMH midwife Mrs Chadzimura).

They have had some very generous donations from LCM- the Zimbabwean LCM have funded lots of medication for chronic diseases and LCM international supplied lots of surgicals and instruments. A local Zimbabwean, now resident in Australia, sent a container of equipment after visiting her former home. They are now part of the Diocese of Mutare (previously part of the Archdiocese of Harare) this is proving helpful as the Bishop is Irish and can access Irish charity funds e.g. Misean Cara. The diocese sent their engineer to check out the waiting mothers’ shelter for improvements and they only had to pay his fuel.

Her priorities are a vehicle, the garden, and the doctors’ supplements.

We specifically asked about solar power, there is no solar power to the labs, outpatients, training school, the dental building, pharmacy, FCH (family and child health), staff homes or for streetlights. It is currently not working in children’s ward or maternity; this was fitted by a different supplier from the offices and general side where they have had no issues at all. The better supplier did a survey 3 years ago to install more solar power so we will look at this report and try and source some funding.

MATERNITY

We met with Sr Rumbanduro, the sister-in-charge of maternity. She started work at MMH 1.10.91. Maternity is very busy because of staff shortages at provincial and central hospitals. (Their staff work flexi time so will do 2-3 very long days and not come into work the rest of the week as transport costs are so high whereas all MMH staff live within walking distance so they haven’t implemented this policy). Deliveries are up from 1897 in 2018 to 2158 in 2019. Despite this the quality of their care hasn’t suffered- perinatal mortality is down- 55 deaths in 2018 and 39 in 2019. There have been no post Caesarean complications and maternal mortality is static at 4 deaths in 2018 and 5 deaths in 2019. She is frustrated that staff at the government hospitals just say go to a mission hospital and leave a labouring patient to travel by whatever means possible without an escort which means they sometimes receive moribund patients. Unfortunately, due to the economic downturn, they have lost 3 midwives for greener pastures (usually abroad). New midwifery students have just started which will be a help but prior to January they had no students for 5 months.

Tariro Makumbe and her daughter

Like all staff she thanked us for the groceries we supply every quarter and for the Christmas party but we also heard a consistent message that they would love some financial help as well as school fees in particular have increased and this is a stretch for all. (5-10,000 Zim$ per term- 3 term year for boarding schools). She is particularly grateful for the ultrasound machine which allows accurate dating as before this they occasionally induced a woman who was convinced that she was over her due date but was actually pre-term. The x-ray technician and Dr Mupandaguta can do obstetric ultrasound, she herself can do the basics as taught by Dr Monica the very long-serving previous DMO.

There is currently no working resuscitaire and they desperately need 2 new incubators and solar power.

FAMILY & CHILD HEALTH (FCH)

We then spent some time with Sr Fortunate Nyamutsamba, a very impressive young woman who told us all about the Family and Child Health centre. They provide antenatal and postnatal care and treat all patients under 5y and parents of children under 5y for acute and preventative care. They aim to book pregnant women from 12/40 (to get RBF they need to see them by 16/40) and provide full antenatal care including malaria prophylaxis and iron supplementation, do health education and HIV testing at booking and at 32/40. Her team of 5 nurses provide all immunisations (they achieve more than 95% coverage) and do HIV testing of infants and also see HIV+ children <5y and treat opportunistic infections and give antiretroviral therapy. Ideally, she would like 10 nurses as the documentation burden is enormous. They see postnatal patients and their babies at Day 3, Day 7 and at 6 weeks. She told us that peace and teamwork are their strengths and when anyone has finished their own work they automatically go and help their colleagues. Her biggest challenges are vaccine storage during power cuts as they have no solar or generator back up after hours, they also need water back up as the bore hole water doesn’t reach them. Staff accommodation and numbers are a concern. She also thanked us for the groceries and told us about the challenge of school fees.

OUT PATIENT DEPARTMENT

Mr Innocent Mutazu is the charge nurse for OPD. This provides all OP care not catered for by FCH. There is an emergency room, a minor procedure room (stitches and catheter changes etc.), consulting rooms for nurses and a doctor and HIV counselling and testing. They are open 7.00-4.30 Mon-Fri and 7.00- 12 noon on Saturdays. As well as himself there are 5 RGNS and a couple of nurse aids. Patients wait in the shelter outside the OPD and every morning there is a health promotion session. They register and have their card stamped then have their observations (temperature, BP etc.) taken by a nurse aid. They then see a nurse who may complete their treatment and direct them to pharmacy or for bloods/ dressings etc. or they may be referred to the doctor. One of the RGNs is training in forensics and will see victims of sexual violence and works with the on-site policewoman who is trained in this area and social services. There is a quality improvement area and they meet monthly to discuss the comments left by patients. HIV+ patients have a green book as their patient record. Linda and her colleague Shelter are responsible for the electronic patient management system which records all attendances for HIV follow up and defaulters are followed up and they keep the system up to date with respect to deaths etc. They also offer HIV self-testing for patients to take home or perform on site and it is up to them if they share the result. Sr Faustina an LCM nurse was in the small OPD side room doing dressings, taking blood or collecting other samples, giving IM injections or urgent treatments such as oral nifedipine for malignant hypertension. Finally, there is the payment booth.

Mr Mutazu also thanked us for our support- groceries, the Christmas party and the new OP seating and the imminent tiling of the outpatient department. He gave us his wish-list:

• Diagnostic sets • Fluphanazine decanoate injection for patients with psychoses • A laptop or desktop computer to help in the preparation of statistics • X-ray viewing monitors • Nebuliser • Stretcher beds • Fans • Gowns

Out Patient Department

We had dinner by candlelight with the LCM sisters, which was very pleasant. The power cut continued- no electricity for 48h by Thursday evening and no water as electricity is essential for pumping water from the river. Fortunately, bottled water is available in the Growth Point as when the water does come back its usually undrinkable for a short while, even if boiled.

Friday 6.3.20

Still no power or water in the morning… giving us a small taster of real life at MMH.

X-RAY DEPARTMENT

We started the day meeting Mr Shonhiwa in x-ray. He’s been here 5 years now and lives on the mission with his family. They have a very good x-ray machine. X-ray film is in short supply, but they have the facility to view x-rays stored on his computer. Unfortunately, this is not networked so the doctors must repeatedly go to x-ray every time they want to view an x-ray. Mr Shonhiwa is also a trained obstetric ultrasonographer (as is Dr Mupandaguta) and he does obstetric USS but only for cases of concern. He also does the ECGs. These take place in a small room off main outpatients. There is a second ultrasound machine but no specific room in maternity to keep it in. No-one is trained in anything other than obstetric ultrasound, so these are referred to the private doctor in Murambinda where USS is done weekly.

ACCOUNTS DEPARTMENT

At 9 am we met Mr Taruvinga the long-serving Accounting Assistant. His main remit is user fees. He works with 2 clerks. There is another accounting assistant Joseph Mapanzure working on other financial areas and Mr Mudzi helps as well but user fees are Mr Taruvinga’s responsibility.

As previously described the Zimbabwe economy is struggling. Having introduced the RTGs/ bond note early last year as all the US$ were used up paying for imports/ services received from overseas they then made transactions in US$ illegal unless given dispensation. Initially the government pitched the conversion rate as 1:1 but rapidly revised this to 2.5. Officially during our visit, it was 17.5 but all vendors use the unofficial-market rate which is increasing day by day. During our visit they were working on 1:32.

Hospital User Fees

With regards to user fees the government introduced new rates in January 2020 which has caused despair. Instead of Z$ 6 for an adult consultation it was increased to Z$80 and for adolescents (those aged 6-12y) it is Z$40. The daily admission rate is Z$80/ 40 as well. Pregnant women are charged Z$240 for a normal delivery and Z$1000 for a Caesarean Section. Add to this a daily admission rate plus any medication etc. it is well beyond the means of virtually all patients. Wages have not kept pace and most of the rural population of Zimbabwe have no cash income. Also, there is a big lag in what the medical insurers are paying out. Under 5’s and over 65y are free. No one is turned away from MMH. They did look at a debt collection service but realised this was not only against the ethos of the hospital it was also completely cost ineffective. Debt collectors take a cut and if someone can’t pay, they really can’t pay. They therefore have many debtors. They do talk to patients and encourage them to pay what they can, send bulk SMS messages reminding that payment is due, negotiate payment plans and involve community leaders and village health workers. Those who can pay do mainly do eventually especially those who live within walking distance and really value MMH as their healthcare facility. However, patients are coming from far away especially for maternity services as government facilities (e.g. Chivhu and Wedza, usually have no doctors, few midwives and no equipment) so this exacerbates the problem. In 2019 they were owed Z$ 45,000. This is going to be much more from the beginning of 2020. This is understandably very stressful for Mr Taruvinga. Patients can pay by cash, eco-cash or direct bank transfer. They can’t accept payment in kind because of infection control concerns but also concerns that the goat etc. offered in payment may have been stolen. Occasionally they do accept offers of labour e.g. in the garden.

Everything the hospital needs to run the hospital: electricity, water, pharmacy, fuel, provisions, cleaning materials etc. have rocketed in price. They also need to pay for insurance. Because of inflation insurers are reviewing their rates quarterly! Pharmacy is currently 100% donor funded whereas user fees would usually aim to cover 60% of the cost of drugs and disposables.

One bright spot is the garden which does turn a profit and probably could do more. When taking into account the food they didn’t have to buy they made Z$ 11,668 in 2019 less Z$ 3,000 in expenses.

External funding is much reduced they do receive US$16,000 per quarter from the global health fund but this is a drop in the ocean. There has been no government grant for > 10y. All the external donors who did support after a coalition government was formed in 2008 e.g. health transition funds etc. have now stopped. ZACH (Zimbabwe Association of Church Hospitals) did step in recently with an emergency payment for electricity.

We felt rather depressed after this- we had heard it all from various sources during the week, but Mr Taruvinga is extremely eloquent and clear in his explanations and both sad and sanguine at the same time. Nobody we talked to could see any light in the tunnel.

MEETING OF THE HOSPITAL EXECUTIVE COMMITTEE

After a much-needed tea-break we were then honoured to attend a meeting of the Hospital Executive Committee. It was diminished from usual as Dr Kwiri was away in and Mrs Chipanga (HAS) and Sr Mudzingwa (Training School) were absent but we had a flavour of these very useful meetings. In attendance were Sr Silindiwe Shamu, Sr Fylis, and Sr Tawodzera. The minutes of the previous meeting were reviewed, and progress reports given. Those not attending had reported to Sr Shamu. All others reported on their areas. Matters of note were

• They had found a scrap metal merchant for the old lockers, beds etc and would get a good price. • They had sold the old Landcruiser but failed to sell the T35 and were thinking of using the money from the Landcruiser to buy a new engine for the T35 which is otherwise sound. • There is an increase in malaria cases and lots of mosquitoes about, so they are negotiating with the PMD to have the mission sprayed • They are reviewing their security provider. ZRP (police) offer this for a fee and this is to be explored. They had been out to give advice and recommended clearing vegetation and repairing the fence. A new wall and barrier (boom gate) are planned at the entrance. • The hospital strategic plan is in the process of being drawn up-Dr Duri (Clinical Lead of the Hospital Board) has sent some questions to be considered by the Heads of Departments and a meeting is to be called but it was suggested the heads get the questions now so they have time to get information before the meeting.

VISIT TO MURAMBINDA FOSTER HOME & SECONDARY SCHOOL

In the afternoon we visited the Murambinda Foster Home. Currently there are 6 children resident all junior school age.

We were also taken to Murambinda B secondary school which Carolyn had visited along with Dr David Stableforth 4 years ago as their star pupil Prudence (supported by the foster home) had won an essay prize. She is now at boarding school and looking at going to university. After that visit funds had been sourced (separately from FMH) for some chairs and desks and a borehole so we were treated to the choir performing for us and all the pupils. Mr Usavi is the Head teacher and been at Murambinda B since 2002, there are 34 teachers and 845 pupils. The school has the most basic of facilities, but its results are third best after the 2 boarding schools in the district. They let all the neighbouring rural homes use the borehole which is working well. There is much more need though- none of the teachers’ houses have power- ZESA runs just by them but they cannot afford the meters (US$150 each) and desperately need more chairs and desks as many classes take place with pupils seated on the floor. They would also love a laboratory.

We returned home about 4pm and thankfully there was power and water, so we were able to have a much-needed shower before dining with the Mudzis.

Saturday 7.3.20

An early (5am) start to drop Beth off at the airport for her flight to Victoria Falls. We travelled with Sr Shamu, Mr Mudzi and Sr Faustina. Kennedy Tirivanhu drove us very capably negotiating the million potholes safely. Sr Faustina started us off with a prayer for our safe journey and in particular asked God to make the other drivers on the road take due care… Sr Shamu and Mr Mudzi heroically sat in the back of the pick-up on a mattress.

MEETING WITH HOSPITAL BOARD MEMBERS

Mary and I were then taken to St Anne’s for breakfast with Sr Mary and at 10am we met with members of the hospital board. This was a really positive experience. Dr Duri sent apologies as he was busy with some other charity work but the chairperson Mrs Flavia Muyambo (a human resources and management consultant) who has been involved with the other LCM health facility at Mashambabzou, Ms Joy Ndekwere the board treasurer and a practising accountant, Mr Kafesu a legal practitioner, Sr Mary representing LCM and Mrs Mbuka who works as the administrator for the Jesuit run Zambuke House which gives training in welding and building skills and a home for boys aged 15-18y from the streets of Harare.

L to R: Mrs. Ndekwere, Mrs. Mbuka, Mr. Kafesu, Mrs. Muyambo, Sr. Mary & Sr. Shamu

They were very interested in FMH, what our vision was, how we operated who we were and expressed grateful thanks to us. We had a wide-ranging discussion about all aspects of our findings, and they will send us a copy of the strategic plan to be hopefully finalised by the end of April. They agreed with Mary that a good Annual Report is essential. They find fund-raising within Harare very difficult as everyone is struggling but were interested in our proposals system and will liaise with Mr Mudzi about this. They are keen to work with the Executive to produce the strategic plan and will use their own resources to train the Executive in management skills.

A quick lunch then we dropped Mary at the home of Dr. Frances Cowan as she was staying on for a few days and took Carolyn onto the airport for her flight home.

We thank everyone at MMH for their time and patience and openness and we are so inspired by their passion and commitment for Murambinda. We hope that our visit will lead to continuing excellent relationships and greater fundraising and will help inform our funding decisions. All donors should be aware that no FMH funds were used for this visit which was entirely at our own expense. All photos are here by permission of those photographed.