What lies ahead as Muhimbili goes through major reforms?

The Citizen on Sunday’s Health reporter Syriacus Buguzi spoke with the Muhimbili National Hospital’s acting chief executive officer, Prof Lawrence Museru, recently on some of the major hurdles facing the institution and their possible solutions.

Prof Museru, congratulations on your appointment as acting chief executive officer of the Muhimbili National Hospital (MNH). If I may go straight to my questions: President John Magufuli must have appointed you to head MNH, believing you have the ability to tackle the institutions long-standing challenges. What is the biggest challenge that the national hospital has been facing over the years?

Well, first of all I would wish to register my appreciation to Dr John Pombe Magufuli for this great honour. I think the President must have thought I was the right person to address some of the biggest problems that face Muhimbili.

You cannot say there is one challenge actually but the biggest one, which in fact gives rise to most other problems, is underfunding. There is gross underfunding for MNH and this makes it difficult for the hospital to run some of its programmes smoothly.

The underfunding also leads to other problems such as those related to the physical structure of the hospital. First, the buildings are not adequate. We have increased new services such as renal dialysis but the buildings to accommodate the services are not adequate and yet, the number of patients has been increasing.

The buildings that are present require major rehabilitation and we cannot do this without adequate funding. Had there been no budgetary constraints, and without considering payment of salaries or developmental funding, Muhimbili would need about Sh4 billion every month to run efficiently. This means about Sh48 billion shillings annually. The hospital gets only 10 per cent of all the required funding from the government. Underfunding also leads to lack of equipment. We only have a few equipment. For instance, we have opened up new services for renal dialysis and urology but we don’t have enough facilities to enable the doctors in those units to be able to discharge their duties.

Another thing is that there is a major outcry on staff remuneration. This leads to low motivation due to low salaries and inadequate allowances. This has a cascade effect on performance of the staff. The last, is what you have heard about the shortage of medical supplies and medicines, which also has been highlighted by President Magufuli.

Among patients who come to MNH, almost 50 per cent are treated and given free medication according to government’s exemption policy—they include pregnant women, children under the age of five, the elderly and patients with HIV/Aids. All this needs funding, which probably is the major problem.

Is MNH still congested?

A: The answer is ‘Yes’ and ‘No’. And, this is because hospital congestion is not a problem of an individual health facility. MNH is supposed to be a national referral hospital. This means that if MNH is to function optimally, all other facilities within the national healthcare delivery chain must also be functioning properly.

We expect that patients who come to this hospital must have been referred but this is not so in practice. This is partly because the national referral policy does not work properly. This makes Muhimbili assume double roles—as a national referral hospital but also as the Dar es Salaam referral hospital. There are many patients from district hospitals allover Tanzania who are also directly referred to MNH.

There are those who come here because they have been properly referred but there are those who come because they believe we provide better health services than where they come from. In this situation, Muhimbili cannot deal with patients’ congestion without addressing these other issues at the lower level health facilities. That can be better sorted out by the Health Ministry, although Muhimbili can assist through outreach programs and training doctors who help in the upcountry hospitals in managing more conditions instead of bringing them here.

You also told a press conference sometimes back that your office had embarked on the move to decongest the hospital. What about that?

A: Here at MNH, we have started taking action. One major cause of hospital congestion was that patients were overstaying at the hospital as they waited for diagnostic processes to be completed, especially in our laboratories and the imagining and radiology services. Patients had to wait long for operations—especially those who come from upcountry. This is an area we can help address—by making sure that medical investigation results are completed promptly and returned to the doctors in the wards and that decisions are made very fast. We have addressed this and I think we have succeeded so far.

Health systems researchers have always explained that the surest way to reduce the congestion of patients at this referral hospital is to ensure that key diagnostic services and medicines are also made available in other regional referral hospitals. What do you make of this assessment?

It is true what they say.You see, we need to find out the reasons why patients are referred. The major reasons have to do with lack of facilities and expertise. There might be experts in the regional and district hospitals but if there is no enough facilities, the patients’ problems cannot be addressed right there. I am aware that there are specialists of various cadres in the regions but they cannot carry out their diagnoses as required because they lack facilities. If the diagnostic facilities are also improved, we may reduce the number of referrals to MNH to a certain extent.

I have spoken to a good number of MNH staff members and most of them seem to be satisfied with your leadership so far. To what extent do you think you have solved the problems related to the welfare of your staff?

When I was appointed to assume this role, I had to identify the challenges that faced the hospital, within the first days in office. What we (the Health Ministry, staff and I), found out was that the medical staff were grossly demotivated. And, this was because the hospital was unable to pay their due allowances. In some cases, there were those who hadn’t been paid for over ten months. This was a major demotivating factor. So, we sat together, with my management team and said, we deed to sort this out immediately. I ensured that at least all staff got their rights. We did not change their remuneration structures. We drew up a plan and expected to pay all the health workers by the end of this month of February and I am happy to tell you that we paid most of the arrears in December and by January we had cleared all the backlog and we now want to make sure that we pay them regularly.

MNH has had a history of being the epicentre of doctors’ strike before spreading countrywide. Most times the problem began with intern doctors complaining of delayed payment of their dues.How useful are intern doctors to your hospital and what’s the situation with the new batch of interns? How have you dealt with their financial challenges?

A: Intern doctors are useful in a number of ways. Internship period is time to learn for the young doctors but as a country we need them. If a doctor does not complete internship, he/she cannot be registered by the Medical Council of Tanganyika (MCT). Therefore, it is the duty of Muhimbili to make sure that the interns are well supervised and trained so that they move to their next ladder in their career but also serve their country as fully fledged doctors. If they don’t, it means that as a country, we will not get the medical staff we need.

But still, in medical practice, the interns have a clear role to play at the hospitals all over the world. In medicine practice there is a hierarchy. That when a patient comes into the hospital, the first doctor to meet will be the most junior doctor, who in this case is an intern. Then the patient goes on to the next, and then next, until he/she meets the most senior doctor and this is how we are able to help the patients but also make sure that the junior doctors learn their practice.

When I came into office, I found that the interns had their complaints, which they had already presented to the management of the hospital. Some were already sorted out but others were not yet. We sat down with the doctors and their leaders.

One of their major complaints was the payment of their night call allowances—the interns were not sure of when and how they would be paid. We resolved this during our discussions. We agreed as the management that the interns should be paid their call allowances when they come to work at night.

This has been solved to a greater extent but they still have other problems such as lack of accommodation. You see, Muhimbili used to receive few interns in the former days but due to increased enrollment in medical schools, we are receiving a greater number in the recent years, so we have run shortage of space. We can now accommodate a maximum of 70 interns but we receive far more numbers than this. There is no quick solution to this. This, we will work on as part of our long-term solutions.

We understand that the interns are posted here for a yearlong experience but they also help to bridge the human resource gap. Do you have exact figures of the shortage of staff facing the hospital? What department is the most affected?

A: We have shortage of staff in almost all areas, the nurses, doctors, physiotherapists, speech therapists, you name it. I will explain this in a number of ways. First, there is an absolute shortage. For example, there are only two speech therapists at this hospital and probably these are the only ones in the country. For doctors, we are also facing an acute shortage in areas of super specialties. We are envisaging that MNH will soon turn into a super specialist hospital, so we need doctors of that caliber. In the department of internal medicine, for example, we lack specialists in units such as neurology and nephrology. We have a shortage of almost 40 per cent of the nurses.

There are complaints about the shortage of medical supplies in health facilities countrywide. You explained earlier that underfunding affects the availability of medicines and medical supplies but what’s the situation at MNH currently? Is the MSD drug shop here at MNH a panacea to the challenges facing patients in affording medicines?

This is one of the problems which were identified by President Magufuli but also the top Health ministry officials are concerned about it. The President’s wish was that patients should not get out of the hospital to buy medicine. He suggested that they should obtain all medications within the hospital instead of going to private pharmacies to buy expensive drugs. To us (at MNH), this has been a guiding directive. We have reduced the problem by five per cent—it’s difficult to reduce it by 100 per cent. What we have done is strengthen the revolving drug Fund.

We make sure that we stock enough medicine within the hospital. We sell this medicine to all private patients, those who are pre-paid for on credit and those who pay by cost sharing. So, I can say we now provide medicine to more than 90 per cent of all the patients that come here.

They don’t have to buy expensive medication outside the hospital. But the problem again is that we provide almost 40 per cent of the patients with free medication because they are exempted by policy and they are still unable to pay. The idea of setting up the MSD shop is that MNH would now be able to purchase drugs which we don’t have so that we can sell it to our patients. The MSD brought the service here and it has been complementary to the services we offer. So, we have no major problem of medicine at this hospital now. Those who still buy from outside, are probably those who prefer certain brands of medicine—nit actually the generic medicine required.

What are your short-term and long-term plans for developing this hospital to serve satisfactorily the role of being a national referral hospital?

A: The short-term plans are to solve the problems that exist at the hospital. This includes motivating the staff. I talked of paying their arrears and allowances but there are still complaints that what they are getting is not enough. We still have nurses for example attending a night call allowance and being paid Sh10, 000.

It is difficult to work at night. But I told all the employees that there is no way we can increase such allowances if the hospital does not increase its revenues. The other area is to ensure that we give our specialists the required working facilities. We want to improve our operating theatres and the hospital’s physical structures.

The long term plans, to me, are actually to make sure that we spearhead the government’s efforts to cut down the number of patients being referred abroad. If MNH can’t do this, it means that we have failed. If the number of patients going abroad keeps increasing, then it means that things are not working properly.

We will probably not be able to bring it to zero percent because in India also, where we refer our patients, they still refer to other countries. To me this is a central plan. But how will we succeed? We will do this by making sure we have well-trained health personnel and building the local infrastructure. So, all in all, I want to maintain MNH’s status as national referral hospital.