Hospitalized for poverty: orthopaedic discharge delays due to financial hardship in a tertiary hospital in Northern Tanzania

Background
Musculoskeletal injury contributes significantly to the burden of disease in Tanzania and other LMICs. For hospitals to cope financially with this burden, they often mandate that patients pay their entire hospital bill before leaving the hospital. This creates a phenomenon of patients who remain hospitalized solely due to financial hardship. This study aims to characterize the impact of this policy on patients and hospital systems in resource-limited settings.

Methods
A mixed-methods study using retrospective medical record review and semi-structured interviews was conducted at a tertiary hospital in Moshi, Tanzania. Information regarding patient demographics, injury type, days spent in the ward after medical clearance for discharge, and hospital invoices were collected and analyzed for orthopaedic patients treated from November 2016 to June 2017.

Results
346 of the 867 orthopaedic patients (39.9%) treated during this time period were found to have spent additional days in the hospital due to their inability to pay their hospital bill. Of these patients, 72 patient charts were analyzed. These 72 patients spent an average of 9 additional days in the hospital due to financial hardship (range: 1–64 days; interquartile range: 2–10.5 days). They spent an average of 112,958 Tanzanian Shillings (TSH) to pay for services received following medical clearance for discharge, representing 12.3% of the average total bill (916,840 TSH). 646 hospital bed-days were spent on these 72 patients when they no longer clinically required hospitalization. 7 (9.7%) patients eloped from the hospital without paying and 24 (33.3%) received financial assistance from the hospital’s social welfare office.

Conclusions
Many patients do not have the financial capacity to pay hospital fees prior to discharge. This reality has added significantly to these patients’ overall financial hardship and has taken hundreds of bed-days from other critically ill patients. This single-institution, cross-sectional study provides a deeper understanding of this phenomenon and highlights the need for changes in the healthcare payment structure in Tanzania and other comparable settings.

Colorectal cancer in northern Tanzania: A retrospective, descriptive study of patients with histologically confirmed diagnoses at a tertiary referral hospital

Background: Colorectal cancer is one of the most common cancers worldwide with increasing incidence and mortality in low- and middle-income countries. Data from Tanzania shows a six-fold increase in incidence in the
past decade with increased morbidity and mortality rates. This study was conducted to characterize the clinicopathological pattern of colorectal cancer as well as to assess the challenges in treatment.
Methods: A retrospective analysis of histologically confirmed colorectal cancer cases at Arusha Lutheran Medical Centre between January 2015 and December 2020 was done. Data were extracted from patients’ clinical records and analysed using SPSS version 25.
Results: Total of 57 patients were included in this study. Males outnumbered females by ratio of 1.2:1. The median age of presentation was 57years with most patients being 61-70years of age. Most of our patients were urban residents (63.2%), 52.6% had health insurance and 35.1% had other comorbid conditions. Most of our patients (68.4%) presented as elective cases, and most (71.5%) had advanced disease (stage 3 and 4). The most common presenting symptoms were rectal bleeding (42%) and abdominal pain (23.3%). The mean duration from symptom onset to presentation was 14.6months. The rectum was the most common involved site (47.4%). Adenocarcinoma was the most common tumor histology (94.7%), majority being moderately differentiated (42.1%). 59.6% underwent surgery, and 25.9% received adjunctive therapy. The mean follow-up time of patients after surgical intervention was low at 5.8months as majority of the patients were lost to follow-up.
Conclusions: There is poor uptake of treatment options – surgery and adjunctive therapy – necessitating further appraisal for related factors. Also, advanced disease presentation and poor patient follow-up highlights underlying system challenges.

Toward mandatory health insurance in low-income countries? An analysis of claims data in Tanzania

Many low-income countries are in the process of scaling up health insurance with the goal of achieving universal coverage. However, little is known about the usage and financial sustainability of mandatory health insurance. This study analyzes 26 million claims submitted to the Tanzanian National Health Insurance Fund (NHIF), which covers two million public servants for whom public insurance is mandatory, to understand insurance usage patterns, cost drivers, and financial sustainability. We find that in 2016, half of policyholders used a health service within a single year, with an average annual cost of 33 US$ per policyholder. About 10% of the population was responsible for 80% of the health costs, and women, middle-age and middle-income groups had the highest costs. Out of 7390 health centers, only five health centers are responsible for 30% of total costs. Estimating the expected health expenditures for the entire population based on the NHIF cost structure, we find that for a sustainable national scale-up, policy makers will have to decide between reducing the health benefit package or increasing revenues. We also show that the cost structure of a mandatory insurance scheme in a low-income country differs substantially from high-income settings. Replication studies for other countries are warranted.

An equity analysis on the household costs of accessing and utilising maternal and child health care services in Tanzania

Background
Direct and time costs of accessing and using health care may limit health care access, affect welfare loss, and lead to catastrophic spending especially among poorest households. To date, limited attention has been given to time and transport costs and how these costs are distributed across patients, facility and service types especially in poor settings. We aimed to fill this knowledge gap.

Methods
We used data from 1407 patients in 150 facilities in Tanzania. Data were collected in January 2012 through patient exit-interviews. All costs were disaggregated across patients, facility and service types. Data were analysed descriptively by using means, medians and equity measures like equity gap, ratio and concentration index.

Results
71% of patients, especially the poorest and rural patients, accessed care on foot. The average travel time and cost were 30 minutes and 0.41USD respectively. The average waiting time and consultation time were 47 min and 13 min respectively. The average medical cost was 0.23 USD but only18% of patients paid for health care. The poorest and rural patients faced substantial time burden to access health care (travel and waiting) but incurred less transport and medical costs compared to their counterparts. The consultation time was similar across patients. Patients spent more time travelling to public facilities and dispensaries while incurring less transport cost than accessing other facility types, but waiting and consultation time was similar across facility types. Patients paid less amount in public than in private facilities. Postnatal care and vaccination clients spent less waiting and consultation time and paid less medical cost than antenatal care clients.

Conclusions
Our findings reinforce the need for a greater investment in primary health care to reduce access barriers and cost burdens especially among the worse-offs. Facility’s construction and renovation and increased supply of healthcare workers and medical commodities are potential initiatives to consider. Other initiatives may need a multi-sectoral collaboration

Spatial clustering of maternal health services utilization and its associated factors in Tanzania: Evidence from 2015/2016 Tanzania Demographic Health Survey

Background: Utilization of maternal health services is the most significant component of safe motherhood, with severe effects on mother and child health. Though early and timely utilization of maternal health care services is recommended, many women do not access them. This study is aimed at examining the spatial clustering of maternal health services utilization and its associated socio-economic factors in Tanzania.

Methods: The secondary data analysis was conducted using Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015-16. Spatial clusters of high and low use of maternal health care were detected using the Bernoulli model implemented in SaTScan™ software. The multiple logistic regression model was used to identify the predictors of maternal health services utilization in Tanzania.

Results: The Spatial analysis revealed that antenatal care and delivery care are heterogeneous across regions. High utilization was detected in Eastern and East-central regions, while low utilization was detected in northern and northwest regions. Moreover, mother’s age, education level, wealth status, and several children were identified as predictors of the use of antenatal care and delivery care.

Conclusion: Results suggest spatial variation across the regions, though the data are insufficient to identify factors associated with a specific cluster. More data and analysis are needed to establish factors associated with high and low utilization of maternal health care services.

Barriers to accessing follow up care in post-hospitalized trauma patients in Moshi, Tanzania: A mixed methods study

Disproportionately high injury rates in Sub-Saharan Africa combined with limited access to care in both the acute injury phase and for injury patients requiring continued care after hospital discharge remains a challenge. We aimed to characterize barriers to transportation and access to care in a cohort of post-hospitalized injury patients in Moshi, Tanzania. This was a mixed-methods study of a prospective cohort of trauma registry patients presenting to Kilimanjaro Christian Medical Center between August 2018 and January 2020. We conducted standardized patient/family surveys and in-depth interviews at a 2-week follow up visit after hospital discharge, and focus groups with healthcare providers. Quantitative results were analyzed using descriptive statistics and multivariable logistic regression using R statistical software. Qualitative results were analyzed using thematic analysis through an iterative process using NVivo software. A total of 1,365 patients were enrolled in the trauma registry, with 169 patients followed up at 2 weeks. Over half of patients at follow-up, 101 (59.8%), reported challenges in traveling. The majority of patients were male (80.3%). Difficulty in traveling since injury was associated with female gender (aOR 5.85 [95% CI 1.20–33.59]) and a need for non-family members escorts for travel (aOR 7.10 [95% CI 1.43–41.66]). Those who reported assault or fall as the mechanism of injury as compared to road traffic injury and had health insurance were less likely to report challenges in traveling (aOR 0.19 [95% CI 0.03–0.90]), 0.11 [95% CI 0.01–0.61], 0.14 [95% 0.02–0.80]). Transportation barriers that emerged from qualitative data included inability to use regular means of transportation, financial challenges, physical barriers, rigid compliance to physician orders, access to healthcare, and social support barriers. Our findings demonstrate several areas to address transportation barriers for post-injury patients in Tanzania. Educational interventions such as clarification of doctors’ orders of strict bedrest, provision of vouchers to support financial challenges and alternate means of transportation given physical barriers and reliance on social support may address some of these barriers.

Quality of life among out-patients with long-term indwelling urinary catheter attending Urology Clinic at a Tertiary Hospital in Northwestern Tanzania

Background
This study aimed to determine quality of life (QoL) among patients living with long-term indwelling urinary catheter (IUC) at home in the Northwestern Tanzania. To the best of our knowledge for the first time in Africa, we report on quality of life for patients living with a long-term IUC at home.

Methods
This was a descriptive cross‑sectional study conducted between December 2016 and September 2017. A total of 202 out-patients aged 18 years and above living with a long-term IUC were conveniently recruited. The QoL was determined using WHOQOL‑BREF tool. Quantitative data were entered into Microsoft Excel for cleaning and coding, then into STATA software version 13.0 for analysis. Descriptive statistics were used to compute means and standard deviations for numerical variables as well as frequencies for nominal and ordinal variables. Significance of association between various variables and QoL were tested using t test with equal variances. Inferential statistics applied included an independent sample’s t‑test for comparing numerical socio-demographic variables. A P-value < 0.05 was considered statistically significant. The mean score indicating good QoL according to our study is a mean score of 50 and above. The higher the score the higher the QoL.

Results
Median age of participants was 69 (IQR 61–77) years. Majority of participants were males (195, 96.5%), married (187, 92.6%), and having primary education (116, 57.3%). Generally, the QoL was poor in all the domains: mean score for physical health being 36.67 ± 0.89, psychological 29.54 ± 0.87, social relationship 49.59 ± 1.61, and environment 26.05 ± 0.63. Married participants were slightly better under social domain 51.1 ± 1.6 than singles 31.1 ± 5.4; P-value 0.001. Those with primary education & above were slightly better in environmental domain 26.1 ± 0.7 than those with no formal education 23.5 ± 1.5; P-value 0.039.

Conclusion
QoL of participants with a long-term IUC in Northwestern Tanzania is generally poor in all domains. Those with primary education & above and the married were slightly better in environmental and social domains respectively. We recommend on the needs of improved social economic status and the importance of close follow up at home for the married participants living with long-term IUC.

The role of telepathology in diagnosis of premalignant and malignant cervical lesions Implementation at a tertiary hospital in Northern Tanzania

Introduction
Adequate and timely access to pathology services is a key to scale up cancer control, however, there is an extremely shortage of pathologists in Tanzania. Telepathology (scanned images microscopy) has the potential to increase access to pathology services and it is increasingly being employed for primary diagnosis and consultation services. However, the experience with the use of telepathology in Tanzania is limited. We aimed to investigate the feasibility of using scanned images for primary diagnosis of pre-malignant and malignant cervical lesions by assessing its equivalency to conventional (glass slide) microscopy in Tanzania.

Methods
In this laboratory-based study, assessment of hematoxylin and eosin stained glass slides of 175 cervical biopsies were initially performed conventionally by three pathologists independently. The slides were scanned at x 40 and one to three months later, the scanned images were reviewed by the pathologists in blinded fashion. The agreement between initial and review diagnoses across participating pathologists was described and measured using Cohen’s kappa coefficient (κ).

Results
The overall concordance of diagnoses established on conventional microscopy compared to scanned images across three pathologists was 87.7%; κ = 0.54; CI (0.49–0.57).The overall agreement of diagnoses established by local pathologist on conventional microscopy compared to scanned images was 87.4%; κ = 0.73; CI (0.65–0.79). The concordance of diagnoses established by senior pathologist compared to local pathologist on conventional microscopy and scanned images was 96% and 97.7% respectively. The inter-observer agreement (κ) value were 0.93, CI (0.87–1.00) and 0.94, CI (0.88–1.00) for conventional microscopy and scanned images respectively.

Conclusions
All κ coefficients expressed good intra- and inter-observer agreement, suggesting that telepathology is sufficiently accurate for primary diagnosis in surgical pathology. The discrepancies in interpretation of pre-malignant lesions highlights the importance of p16 immunohistochemistry in definitive diagnosis in these lesions. Sustainability factors including hardware and internet connectivity are essential components to be considered before telepathology may be deemed suitable for widely use in Tanzania.

Essential Emergency and Critical Care as a health system response to critical illness and the COVID19 pandemic: What does it cost?

Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, low-cost care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in low resource settings with Kenya and Tanzania as case studies.

The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.

The costs per patient day of EECC is estimated to be 1.01 USD, 10.83 USD and 32.84 USD in Tanzania and 1.76 USD, 14.86 USD and 37.43 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13.11 USD and 17.33 USD for severe and 297.30 USD and 369.64 USD for critical COVID-19 patients in Tanzania and Kenya, respectively.

EECC, an approach of providing the essential care to all critically ill patients, is low-cost. The components of EECC are basic and universal and, when assessed against the existing gaps in critical care coverage and costs of advanced critical care, suggest that it should be a priority area of investment for health systems around the globe.

The spectrum and burden of in-patient paediatric musculoskeletal diseases in Northern Tanzania

Background
Musculoskeletal diseases (MSD) are a major contributor to the global burden of disease and disability, and disproportionally affect low- and middle-income countries; however, there is a dearth of epidemiological data. Affected children often face increased morbidity, social isolation and economic hardship.

Aim
To assess the spectrum and burden of paediatric MSD in children aged 5–18 years admitted to a major referral hospital in Tanzania.

Methods
This was a retrospective cohort study of children aged 5–18 years admitted to Kilimanjaro Christian Medical Centre (KCMC) whose initial diagnosis was recognised as a musculoskeletal condition by the International Classification of Diseases-10 between 1 January and 31 December 2017.

Results
During 2017, 163 cases of confirmed paediatric MSD were admitted to KCMC, representing 21.2% of all admissions of children aged 5–18 years (n = 769). Bone disease was the most common diagnosis. They comprised 106 (65.0%) traumatic fractures, 31 (19.0%) osteo-articular infections, 9 (5.5%) malunions and 3 (1.8%) pathological fractures. Congenital defects and rheumatic disease were relatively uncommon, accounting for only 6 (3.7%) and 4 (2.5%) MSD admissions, respectively.

Conclusion
The majority of cases of MSD were related to fractures, followed by osteo-articular infections, while recognised cases of rheumatic disease were rare. The study, although small, identified the sizeable burden and spectrum of paediatric MSD admitted to a hospital in Tanzania over a 12-month period and highlights the need for larger studies to inform the optimal allocation of health resources.