Mombo, TZ: Community Health Centre

and Dental Site Evaluation

Executive Summary

Site Visit: Feb. 12 - 14, 2018

Report Author(s):

Wayne Church, MD Kelvin Hill, DDS

Report Submitted:

March 29, 2018

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Contents

H.C. Report 3 Introduction .......................................................................................................... 3 Recommendations ............................................................................................... 3

H.C. Meetings and Tours 5 Meeting, Mombo H.C. - Feb. 13, 2018 ................................................................. 5 Discussions and Comments on the Facility Challenges and Wishlists Facility Tour: Mombo District Hospital................................................................... 7 Facility Tour: District Hospital, Korogwe ............................................................. 14 Discussion with Dr. James in his office - Feb. 14, 2018 ..................................... 15 Mombo Faraja Cogi Dispensary visit - Feb. 12, 2018 ........................................ 15

Executive Summary 17

Dental Report (Challenges, Observations, Recommendations) 19 Faraja Cogi Dispensary, north of Mombo, Tanzania - February 12, 2018 ......... 19 Soni Dispensary, Soni (on road to Lushoto), Bumbuli DC., Tanzania - February 13, 2018 .............................................................................................. 20 Korogwe District Hospital, Korogwe, Tanzania - February 14, 2018 .................. 21

Canadian Team Members (left to right): Marcia Hill, Dr. Kelvin Hill (ABW Dental Service Manager), Dr. Wayne Church (ABW Medical Program Manager, HAC Chair), Dr. Paulette Comeau (ABW Medical Program Manager), Barbara Wade (HAC Secretary), Eric Rajah (not pictured) - local Dr. Joseph Cleophace 3rd from left, Mombo Dev. Secretary Zaina Fongo far right

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Mombo, Tanzania Executive Summary Mombo Health Centre Should ABW recommend investment of donor dollars into the Mombo H.C.? Members from ABW visited the Mombo H.C. on Feb. 13, 2018. They met with the District Medical Officer and physician head. Both were open, forthright and sincere during the visits to the facilities. The district medical officer was knowledgeable of funding issues and potential pitfalls and ABW could proceed in a manner that allows best use of funds. Funding involvement for Mombo H.C. would involve support in a number of areas: building upgrades and new construction, supply of new medical equipment and augmentation of services. These benefits would support the health and safety of the individual patient as well as add services to the community as a whole.

Recommendations

1. The first recommendation would be to undertake a complete physical survey of the site and buildings. This would concentrate on the water supply, including sewage issues, the buildings’ roofs and drainage and the electrical system. The buildings are stained, several ceilings are falling down, and the Centre is negotiating water access with a neighbouring church.

2. The Mombo H.C. is the primary care facility in the area and the go-to for patients and families. A complete reworking of obstetrical services is needed. This is to provide two safe delivery areas and a newborn assessment as well as neonatal resuscitation area. This might need to involve adding on to the present building or a separate structure. Planning should include oxygen availability, resuscitation equipment, and fetal monitoring equipment.

3. The operating theatre building needs major overhaul to continue to provide safe caesarian-sections as well as other surgical services. Hopefully this can be undertaken without involving new construction. Items to be considered include new anesthetic equipment, an improved recovery room, better handwashing facilities, and an upgrade to sterilization equipment and instrument processing.

4. A new surgical ward that includes men and women’s wards and washrooms is necessary to allow separation of medical and surgical patients. This is important for infection control issues. The Mombo H.C. has a mandate to provide full service obstetrical care as well as elective and emergent surgical services. Items two, three and four all have a direct impact on the Centre’s ability to provide safe and timely service to the individual and to the community.

5. Equipment upgrades: these items can be purchased or provided without involving significant building upgrades.

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Ultrasound machine for obstetric use

Neonatal resuscitation equipment and storage

(crash cart)

Doptone for measuring fetal heart rate

Oxygen concentrator Cardiac Monitor Microscope

Amputation saw and ancillary equipment;

for Mombo and Korowge Hospital

Blood bank fridge Adult resuscitation

equipment and storage (crash cart)

Ophthalmoscope

Medium to large size sterilizer

Dental equipment: for multiple sites (see Dr.

Hill’s report)

Oxygen concentrator for dispensary

Drill and bits for doing burr holes: Surgical tools

for Korowge Hospital

Cardiac Defibrillator

6. A mortuary is needed. A plan exists but the Centre does not have funding. This benefits

both individuals and the community. This project can be considered outside of the other projects and could be added earlier or later.

7. An ambulance is needed. This would benefit both the individual and the community. The project can be considered on its own, either earlier or later. Providing an ambulance includes a complete set of logistics for the H.C. to consider: storage, a driver, EMTs, maintenance, and supplies.

8. An x-ray facility is needed. This project would benefit both the individual and the community. This project can be considered separately from others, either earlier or later. Digital x-ray equipment is in use at Korogwe Hospital and Narok District Hospital, Kenya. Both places had issues with the ability to provide patients with copies of their x-rays.

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Tuesday 13 Feb. 2018 Meeting, Mombo H.C. Present: Dr. Cleophace, Dr. James Frank - medical director, Barb, Paulette, Wayne, Keith, Marcia, Eric As a group, we met formally in the director’s office. We presented our Canada mugs and souvenirs. Then we had a general discussion of the health centre and their needs and wishlists. Later, we embarked on a tour of the facility. The tour covered all the buildings except the main pharmacy, laundry, and staff housing. The previous evening we had met informally with the medical director of the region, Dr. James. Impressions: The doctors are pleasant and easy to talk to. Dr. James is more fluent with his English and accustomed to speaking and presenting. Both doctors seemed straightforward and answered questions directly. Discussions and Comments on the Facility Challenges and Wishlists

1. Lack of Mortuary - this is a community and H.C. need. Fifty percent Muslim population - deceased must be buried within 24 hours but often there are issues for families coming from a distance. Possible legal issues with MVAs. Mombo is on the main highway. There is no funeral service facility in town. District hospital is 46 km (40-45 min away). There is space for a mortuary. They have a proposal but no final costing. Alternate methods: refrigerated storage units - can buy in Dar es Salaam. There is a French company that makes over refrigerated storage units and outfits them with shelves etc. - markets worldwide. Possible cultural issues with a portable unit. There is a need for a small area for family to gather, mourn, etc.

2. Lack of Ambulance - there is a budget for operating an ambulance, but the current ambulance is broken down and supposedly beyond repair. The district hospital is using a modified truck or Land Rover as its ambulance. It does not have a proper ambulance either. There is always a need for this service and when it’s lacking, private vehicles are pressed into service. My impression is that ambulances function less in a capacity for providing rapid, potential life-saving therapy and more for onsite first aid and then transport to H.C. or dispensary. Not sure how well-equipped ambulances are or what training the EMTs have. Supplying and organizing and maintaining an ambulance is ongoing work. No idea of budget or whether refurbished units are available.

3. Ultrasound Machine - no machine at present. Would be within the scope of practice as two doctors are on site. Training is available. The District Hospital has a unit. Use would be primarily for Obstetrics: twins, growth, position, fetal heart, and movement.

4. X-Ray Machine - the district hospital has a digital machine. E.g. the patient from Mombo would go to the District Hospital for the x-ray of his fractured arm and then take the x-ray back to Mombo for treatment. The images could then be taken with them or transferred electronically. The use of x-ray would be for multiple conditions especially trauma and infections. It would be within the scope of practice for the facility. It would probably require a new building. In Narok County Hospital - the digital x-rays were being copied onto CDs which were given to the patient. Also patients were taking pictures of their x-rays with their cellphones. The two digital x-ray units that we saw in Tanzania and Kenya (Narok) both suffered from inability to produce an image or report that could be provided

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to the patient. There was usually a lack of supplies for a printer or chemicals for the film processor.

5. Cardiac Monitor - a pulse oximeter may have been present, but it was not witnessed in Mombo. The anesthetic machine was broken. There was no ECG machine. A cardiac monitor, ECG machine, and pulse oximeter should be a necessity. No defibrillation machine in Mombo (uncertain re: district hospital). Needed for OR safety.

6. High-Power Microscope - a microscope exists in the lab. The technician says its higher-power functions were not working. Microscopes are used more in Tanzania and Kenya than in Canada for diagnostic work: Malaria, TB, etc.

7. Ophthalmology equipment - no handheld ophthalmoscope in the H.C. There are two basic types - electrical that uses wall power and can be hardwired and battery operated. They often come as a set with an otoscope for use with ears and mouth and an ophthalmoscope for eyes. They are used for evaluating vision issues: trauma, infections, and cataracts. They are needed in emergency, outpatients and obstetrics - newborn eye checks.

8. Dental equipment - an older dental chair exists - it was used but is now in storage. See Dr. Hill’s assessment. Dental services seem to be provided at H.C. and hospitals. Different levels of trained personnel provide different types of treatment from basic extractions to cleaning and fillings. Ability to provide water and suction during treatment would vary greatly from site to site. Forceps, etc. would need to be in multiple sets and have the ability to be sterilized in a timely manner in order to see a large number of patients. Probably a local supplier would be best for equipment (even Kenya), but all sources need to be checked.

9. Orthopedic equipment - amputations, elective and traumatic are the reason to need orthopedic equipment. They would require a saw and possibly a few specialized items. Need orthopedic consult for detailed list. The district hospital was also asking for this type of help (in talks with their general surgeon). The district does not have an orthopedic specialist. In the district hospital, they do not do orthopedic surgery involving plates or screws, just external fixation for eg. fracture of femur.

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Mombo District Hospital - tour of the facility

The patients are registered in a separate building (paper charts exist but are being transferred onto electronic records). Basic demographics at least are taken and then the patients move outside across to the Outpatient Department.

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There were 5-6 steps up to the OPD which could present difficulty to sick or injured. The waiting areas in hallways were covered but the areas were not overly large and the hallways became crowded. The OPD building had ceilings that were falling down, probably due to water leakage from the roof.

There were two large consultation rooms for the OPD and each had a source of water for handwashing. Urn and tap, not a sink. The OPD pharmacy did not have a large supply of medications.

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HIV- there was a separate area for dealing with HIV patients. There was also a separate chart room for HIV (records were being transferred to an electronic form). RCH Department - this was housed in a separate building. The main reception area had benches and a weigh scale. There were individual exam rooms and a vaccination room. The vaccines were brought to the area in insulated coolers. Washrooms were close by. This area seemed newer and was the most pleasant area of the facility. Unfortunately, the incinerator and generator were also close to this area.

Laboratory - microscope needed upgrading. Hematology equipment was functioning. Chemistry machine not functioning due to lack of reagents (common thread on our visits). Blood bank fridge did not have any temperature monitoring on it. Needed an upgrade. Some basic chemistry would be good - creatinine, glucose, liver function, bilirubin. If all equipment was functioning there is probably no need to increase the capacity. Theatre/OR - two entrances, one up an incline, the second was in the small ER (trauma) room. First area visited in Kenya and Tanzania where we had to take off shoes and put on “theatre sandals” to walk around and visit.

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One operating theatre with outside window - large, tiled, anesthesia machine not working. They use ketamine for C-sections and cases. No oxygen tanks but have oxygen concentrator. Clean instruments kept in large stainless-steel canisters.

Recovery room adjoining. Delivery table here (not sure why). Small electric steam sterilizer on

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floor. Handles OR drapes, gowns and equipment. The used equipment processing room had shelves and sinks. Hallway - two individual sinks for handwashing before surgery. Regular sinks, not hands-free sinks.

Trauma room - two sinks, bed with adequate light, entrance from outside and from main the OR theatre area.

Sterilizer - there was a large sterilizer in a separate room. It was not functioning. Need to get the company repair person to come or district maintenance person to come. The same unit was at district hospital and it was working. Instruments - were in a jumble on shelf beside non-working sterilizer.

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Main surgeries performed - C-section, appendix, hernias, some laparoscopies, plus trauma. Use ketamine with airway support. Not sure why anesthetic machine not working. Personnel should have expertise to run anesthetic machine if one existed.

On the day of our visit, the doctor was supposed to do an appendectomy - this was postponed and when we the met the doctor the next day it had still not been performed. Obstetrics - department had eight beds (each with sheet and mosquito net). There was an oxygen concentrator in unit (not sure if working.) Delivery unit was at one end - there was a sink in one corner, a small sterilizer and a shelf. The two beds were end to end - each had a wooden ladder to climb onto the bed. No resuscitation equipment in area. No infant warmer. Trumpets for detecting fetal hearts. Area could definitely get hectic with up to five births per day.

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Men’s ward and Women’s ward - combined surgery and medical patients. TV on ward. Toilets and showers with direct access from ward. Each bed with sheet and mosquito net. Toilets and showers not very clean. No separation between clean surgery patients and potentially infected medical patients. Some newer beds with ability to elevate head of bed. No oxygen available unless concentrator brought to ward.

No kitchen facilities - patients rely on family and friends for food. Water - current, shallow well but have plans to connect to deep well located next door at the local church. No cost but need to maintain the pumps! Laundry - the hospital washes the sheets. Patients do their own laundry and spread clothes on the ground to dry. Area not visited.

Sewage - not sure how toilets and laundry areas handle the grey water or sewage.

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District Hospital, Korogwe - tour of the facility

OR Theatre

● Has functioning anesthetic machine using halothane - no scavenging system for gases

● had pulse monitor (no cardiac monitor)

● No CO2 monitor

● Intubations not routinely done

● Do some ketamine and spinal surgeries as well

● Hands-free washing sinks for OR are in place

● Two theatres

● Amputation saw and instruments needed (from their general surgeon)

● Equipment for doing burr holes for subdural hematomas needed (from their general surgeon)

Dental chair - 2 in use (see Kelvin’s report) Obstetrics

● Four delivery beds

● Resuscitation equipment evident

● Warming beds for newborns

● Photo-therapy unit

● Paulette was in attendance just after a birth and the nurse did not seem to realize the newborn was blue and having trouble breathing (it had cried at birth). Paulette turned the baby from back to front and stimulated baby, then the baby perked up. “Helping Babies Breathe” program needed here.

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X-Ray Department

● Ultrasound machine present

● Digital x-ray present - ability to provide image for the patient to take with them was lacking - printer or reagent problems

Mortuary - did not get to see Male and Female wards - did not visit Discussion with Dr. James in his office Feb. 14, 2018 Present: Kelvin, Marcia, Paulette, Wayne, Eric When asked for his priorities of the health centre of Mombo, he replied infrastructure upgrade then improve or add to the capabilities. Finances: Eric had discussion with Dr. James regarding financial issues. (Eric should have a separate report). According to Eric, Dr. James was very up front that monies should not go through his or department hands. We could use estimates and procurement processes of the government if we desired. Mombo Faraja Cogi Dispensary - Visit Feb. 12/18 Present: Barb, Eric, Keith, Marcia, Paulette, Wayne This is a private facility operated and built by a retired clinical officer. He relies on fee for service and donations for his operating expenses. He has a lab technician and at least one other helper. It has one consultation room and one exam room - he does cervical screening. There are two observation beds in a separate room. There is a separate room for maternity care and deliveries. There is separate laboratory building - the technician does microscopy work for diagnosis as well as run a hematology analyzer.

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Wish List

● Oxygen concentrator

● Chemistry analyzer

● Dental help - has technician but no tools, etc Impression Would help with oxygen concentrator if budget allows; the chemistry analyzer is beyond the scope of this dispensary. See dental report for additional help offered. SUMMARY THOUGHTS

1. H.C. Mombo needs a look at overall physical health of structures including roofs and water especially. Also the physical movement of patients within the facility is an issue.

2. Safety of obstetrics services and theatre services should be a high priority. Possible structural upgrades and alteration of facilities needed. See separate listing.

3. Additional ward with washroom facilities needed to allow separation of medical and surgical patients.

4. Mortuary and ambulance should be considered.

5. X-ray facility is a need, possibly more long term.

6. Smaller budget items:

a. Larger sterilizer if current model is unrepairable

b. Microscope

c. Ophthalmoscope

d. Amputation saw

e. Cardiac monitor

f. Dental equipment - if chair is working

g. Blood bank fridge

OPERATING THEATRE - basic structure is functioning.

1. Needs upgrade to handwashing sinks.

2. Sterilization needs:

a. Fix primary machine

b. Contact service representatives or technicians from Korogwe Hospital

c. Medium to large sterilizer (steam) needed in short and long term.

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3. Anesthetic Machine - not certain what is wrong with current machine. Now using Ketamine and that has its own problems for C-sections and intra-abdominal surgery.

4. Recovery room lacks purpose as well as oxygen and monitoring equipment.

5. Instruments and drapes need upgrading. Request for amputation saw and relevant instruments should be granted. Not sure why amputations are prevalent - trauma, infection. Elective cases should probably go to Korogwe hospital (amputations).

6. Cardiac monitor needed.

7. Oximeters needed. OBSTETRICAL UNIT - Mombo H.C.

1. Current design of unit does not seem functional. The only entrance to delivery area is through the general ward. The delivery area is crowded with two delivery beds. There is no area to do infant resuscitations or just basic care and warming.

2. There is a sink in the corner and a stand for instruments and the sterilizer. The oxygen concentrator was in the ward.

3. There should be improvement in accessibility and function. Perhaps a redesign with additional space. Upgrades to washrooms and privacy are needed. Would an on-demand shower for hot water be a good thing?

4. Better organization of resuscitation equipment is needed so that it is not lying around gathering dust.

5. Moving from the delivery area to the operating theatre for C-sections involves going outside through some dirt areas as well as a sloping stairway.

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Tanzania Dental Site Evaluation Trip (10-17 February 2018, Kelvin and Marcia Hill)

Faraja Cogi Dispensary, north of Mombo, Tanzania - February 12, 2018

Contact/Host: Waziri Juma Semarundu, Director

Challenges: No dental services available.

Observations: Clinic appeared clean and maintained. There is a retired clinical officer with

additional training in dental procedures who is helping at this clinic, but his skills are presumed

to be limited and not current. He showed us the booklet from his dental course that was well

worn from apparent use. No designated space for dental procedures but there is room for a

portable chair in the observation rooms. The director’s dream is to build a separate dental

building next to the laboratory in the rear of the main clinic. Autoclave available and apparently

functioning.

Recommendations: Provide a head lamp and a limited selection of forceps and elevators to

facilitate the clinical officer’s desire to perform simple extractions. Follow up in one year to

assess use and further need.

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Mombo Health Centre, Mombo, Tanzania - February 13, 2018

Contacts/Hosts: Dr. Frank Chiduo, Korogwe District Medical Officer and Dr. K. J. Cleophace,

Head Physician for Mombo Health Centre

Challenges: No dental services available. Lack of dental equipment. Have dental chair. Previous

dental therapist got transferred, planning to train existing clinical officer. Main problem no

forceps.

Observations: There is a room designated for dental treatment in an adjunct building adjacent to

the out-patient entrance to the health centre. It is dark and in disrepair with an old dental chair

and miscellaneous bits of equipment stacked in the corner next to the door. No way to establish

functionality of the chair but based on the broken wire sticking out of the base it is not looking

good. The chair may still go up and down but probably not worth investing time in the old

suction unit and compressor. No dental light.

Although the main autoclave for the hospital is not operating, there is a small functioning

autoclave in the surgical unit that could be used for dental instruments. We met Clinical Officer

Derick Joseph who in April is to begin the three-month course to become a Dental Therapist (?).

Recommendations: Clean and/or paint the dental operatory and ensure good overhead lighting.

Have health centre staff attempt to get the compressor and suction unit working and dispose of

the remaining junk in the room. Move existing functional dental chair, light and suction unit from

Korogwe District Hospital to this site. Purchase selection of forceps and elevators for the newly

trained dental therapist to begin providing uncomplicated extraction services. Follow up in one

year to evaluate further investment.

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Soni Dispensary, Soni (on road to Lushoto), Bumbuli DC., Tanzania - February 13, 2018

Contact/Host: Bakari John Mika, District Dental Officer (Dental Therapist), Dr Raphael Kibata

(Medical Officer, ph: +255 762100054)

Challenges: Lack of dental instruments and supplies. No current dental services except some

scaling. No x-ray capability.

Observations: A new JPS dental chair (equipped with overhead light, delivery unit, curing light,

ultrasonic scaler & tips, high- & slow-speed handpieces), doctor stool, and compressor provided

by ABW were delivered and installed a month or two ago. The chair and compressor are

installed in the clinical officer’s examination room with barely enough room to walk around it.

The chair remains mounted on the base of what appears to be the shipping palate rendering it a

few inches higher than usual. We were told that this is to preserve the chair when cleaning the

floor (or flood?). The attempt to preserve the chair is to be applauded though we suspect that

the base will interfere with movement of the doctor’s stool around the periphery. Mr. Mika is

clearly happy with the acquisition but so far has only been able to use the ultrasonic scaler for

treatment. The primary reason for this is the lack of plumbing for drainage of effluent from the

suction system (powered by the compressor). Currently, the hoses drain out to the floor in front

of the chair. There apparently are plans to cut a trench in the floor for plumbing to drain the

effluent to an exterior holding tank. How this would work was not clear to us. Once suction is

operational, Mr. Mika can provide more comprehensive dental services. Instrument sterilization

is apparently done in the common dispensary autoclave.

Mr. Mika provided a copy of the list of supplies that he has requested from the government

inventory (see Appendix 1). The list is comprehensive though perhaps a little optimistic for initial

services.

Recommendations: Dispensary staff must complete installation of the vacuum lines as soon as

possible to render this chair more useful. Provide a limited selection of examination, preventive

and surgery instruments to allow Mr. Mika to further use his dental skills. Follow up in one year

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to see what the government has provided and evaluate for further investment. At some point

funding will be needed for a dental assistant.

Korogwe District Hospital, Korogwe, Tanzania - February 14, 2018

Contact/Host: Dr. Frank Chiduo, Korogwe District Medical Officer

Challenges: Inspection of this dental facility was at our request, so no requests were presented

to us on their behalf. Some restorative services offered but no x-ray capability.

Observations: The dental unit at this hospital is staffed by one dentist (not present during our

visit) and one dental therapist. This is obviously a functioning dental unit with instruments and

materials on hand to provide extraction and limited restorative services. The functioning dental

chair (with light) is old and worn but serviceable. Toggle switches strapped to the side of the

chair serve as the foot controls. There is a second chair (manual) next to the wall that is used

periodically in the case of a power outage. Stand-alone suction unit. No obvious delivery unit for

handpieces. Good supply of forceps and elevators. Glass ionomer restorative material in

cupboard. Curing light present though I did not see any composite. Sterilization services are

provided by the hospital.

Our sense is that the services offered by the staff of this clinic are limited by the lack of a

delivery unit. An upgrade here would be a boost to the morale of the dental team and allow

them to provide more of the services for which they are trained to the larger population served.

Recommendations: Given that this is the main referral centre for the Korogwe District, it seems

prudent to invest here. Provide a new dental chair package (as at the Soni Dispensary) and

ensure appropriate installation. Provide dental x-ray unit with digital sensor(s). Move the existing

functional dental chair, light and suction unit to the Mombo Health Centre. Follow up in one year

to ascertain return on the investment and evaluate further needs.