Back from the Field - Isabella Schultz

Tanzania, a Sub-Saharan country, has a population of 66.5 million with roughly 49.1% living in absolute poverty based on the international standard (World Bank Open Data). It comes as no surprise that this country is the site of many international aid organizations coming together to improve the development of the country’s economic and health sectors. As shown by the sustainable development goals (SDGs), there is a direct correlation between economic growth and improved health of a country (UN 2016). As a country that continuously receives donor aid, mishandling of funds is present in healthcare discourse. Many patients and medical providers alike question how there is such a wide difference between the aid and results seen in maternal health. These questions and conversation often culminate in ideas or thoughts of the presence of corruption in the medical sphere. This summer I focused on understanding the relationship between the changes made to the medical supply chain and the effects that were created for hospitals and health centers in the Rukwa region of Tanzania.

The Rukwa region is located on the western side of the country, sharing Lake Tanganyika with the Democratic Republic of Congo and borders part of Zambia. This region is predominantly an agricultural zone and is commonly referred to as a rather rural region by other parts of the country. This area is known for its production of maize and rice nationally and for fish within the region. Most of the residents of this region are not part of the formal economy, instead relying heavily on self-subsistence farming, which typically leaves them with little expendable income. Understanding the population and environment of Rukwa is critical to understanding how healthcare operates within this region. The region is further divided up into four districts: Kalambo, Sumbawanga Municipal, Sumbawanga District, and Nkasi. I spent my time in the Sumbawanga Municipal district. There, two main health facilities serve the surrounding population as well as the entire region: Muzi health center and Kimumana Hospital*.

I collected data through various methods including participant observation and both informal and formal interviews. While most of my data comes from formal interviews, I set up with doctors and district medical officials from the Sumbawanga Municipal district. I also had the opportunity to speak with two local Tanzanians that worked for USAID focusing on maternal health and medical supply chain management. These formal interviews were semi-structured, where I asked everyone about their educational and work background, how the medical supply chain operates, and how it impacts doctors’ ability to provide free healthcare to pregnant women. These questions were roughly configured to provide a more holistic picture of the relationship between the medical supply chain and individual doctors’ ability to provide the best healthcare possible to limit maternal mortality. In addition to investigating the operation of the medical supply chain and medical facilities, I began listening more broadly to people's beliefs and stories about corruption. 

During my two month stay, it became evident that many people were eager to tell me all the things they had heard and seen within the medical sphere, yet hesitated to tell me exact details about their stories like where it had occurred and who had been involved. In the two health facilities that I frequented, I began to learn about the new methods that had been put in place within the last few years to protect patients and eliminate corruption. These new policies demonstrate how fighting corruption is at the forefront of the government's minds yet they have not properly weighed the consequences of policies that have been implemented. One instance that illustrates this is in the handling of collection fees or payments for medical supplies. Each department will provide the patient or family member with a ticket of the price they need to pay. The person who is paying then has to take the ticket to the financial office where someone that is employed by the local bank works to collect the money. Payment must be completed prior to any service being rendered, and unsurprisingly, this often causes a delay in care. In response to these new delays that are self-generated by the long process within the hospital, new habits or workarounds have been created by staff to bypass these complications. The medical consequences of political action and defense against corruption in healthcare offers a unique window to study how medical providers create communities of care. 

These communities of care are also highlighted by disruptions in the medical supply chain and the policy of free maternal healthcare. Both Muzi health center and Kimumana Hospital struggle to provide free maternal healthcare and often experience periods of medical supply scarcity. In these instances doctors face difficult ethical dilemmas about how to proceed with treatment. On one hand, as employees of the national government, they are required to provide services for free; on the other hand, as employees within the region and district levels, there are expectations that service fees are collected to keep the facility running. These expectations even vary between the different facility levels, as health centers are reprimanded for having women pay a service fee or for supplies. I aim to continue exploring how medical supply chain disruptions expose the positional plurality of medical providers, not only as actors of the state but as state subjects that strive to form accessible communities of care, not just for patients but also for each other.