God first - the rest later

Today was a very emotional day for Cait and me. We went to an AA meeting this morning with Dr. Petro. When we arrived in our jeep, the meeting members poured out of the church and surrounded us with singing. Both Cait & I cried. 

After they introduced themselves, we introduced ourselves and told our stories - both of us had brothers with addiction. Then four members of the AA group told their stories. 

Each story began with “God First!” to which the members respond, “the rest later.” Or “Alcohol” with the response “is powerful, cunning, and takes everything.” Then we all danced with joy. 

by Cindy and Cait

“One of the most significant developments that I’ve seen at Ilula Lutheran Hospital”

That’s how one Minnesota doctor described the presence of a digital health record in Ilula Lutheran Hospital’s (ILH) inpatient and outpatient wards. I spent the morning with Joshua, the head of Ilula’s IT department. He showed me the system and answered all my questions. Then, we toured the facility to see all the computer installations.

 

Ilula uses a system called “CareMD.” Doctors carry tablets during their rounds to enter diagnoses, lab requests, medications and other notes. Lab and pharmacy requests are sent immediately to the respective departments. Nurses have a desktop at their nursing station for entering their information. On the wards, they still to write orders and medication schedules in designated books.

Medical Records registration desk today

 

All departments, inpatient and outpatient, have computer workstations – the wards, the outpatient department, Reproductive and Child Health, dental, pharmacy and lab. The system can generate many kinds of reports. I reviewed a report of the last 26 days with the top 10 diagnoses. Other reports include diagnoses by age and gender.

 

Can you guess what the top 10 diagnoses are for the past 26 days? (1) Other, (2) hypertension, (3 and 5) pneumonia, (4) HIV, (6) gastroenteritis, (7) allergic reactions, (8) peptic ulcer, (9) cystitis, and (10) urinary tract infection. I found the list surprising, as did many of my fellow travelers.

 

The server is protected by UPS to prevent loss of patient data during power outages and surges. A back-up copy of all data is made every evening in case of a larger system failure.

 

Some system capabilities are not yet available. Perhaps the most important is a pop-up indicating the Standard Treatment Guidelines (STG) for Tanzania when a diagnosis is entered. Currently, not following the STGs is the most common reason for the National Health Insurance Fund to deny a claim. If the system to alert the provider at the time of treatment, it would greatly reduce insurance denials.

 

I was impressed when I learned from both Joshua and Ilula’s administrator, Alamu Kikoti, that ILH had purchased the software and hardware from revenue flows. They received a loan and are repaying it from patient revenues.

See the changes. 

Medical Records files today

Medical Records office in 2016

by Cindy

Saturday Clinical Outreach

 Saturday part of our team joined the Ilula outreach group to service a village beyond the last dispensary. Nursing staff,dental providers ,lab staff,pharmacists,and physicians all  went together in 3 vehicles on muddy slippery minimally improved roads. Upon arrival we were provided a wonderful breakfast at the pastor’s house before starting clinic. 

     The clinic is a school converted for the day to a clinic with a building for lab and a provider and a second bank of classrooms for extracting teeth,weighing babies and  seeing medical patients. In about 4-5 hours we saw over 130 patients accompanied  by multiple family members and weighed over 80 babies.Multiple teeth were extracted,many medical patients were seen with multiple outpatient lab tests completed and tens of drugs prescribed and filled. It could have been chaotic but the clinic was well organized,efficient and appeared appreciated by the community. Outreach is usually monthly to this village.

     We received a second generous meal again at the pastor’s house before departure. Our feast consisted of rice ,chicken,greens and beans; more than ample for our adventure home.

     An adventure it was! Little did we know the impact of the steady drizzle during the midday. Our roads turned to greasy,rutted paths that proceeded up and down what now appeared to be mountains! Our amazing driver used every gear on his  4 wheel drive vehicle. We made it up every mountain  and drove ,not slid on the downhill side. We even drove halfway into the ditch to pass a stalled large truck. Just as everyone was breathing again and releasing their  death grips on the vehicle (or fellow occupants) we came to a road jam of stopped vehicles. 2 trucks were stuck uphill including 1 with large,long timber logs straddling the road. Our calm driver got out of our Toyota and walked in the mud to survey the scene. He returned confident of our passage. While maintaining complete control he went into a puddled huge mud hole then into the ditch while barely clearing a tree on one side and simultaneously missing the large logging timbers on the other side by no more than 2 inches. It was the most incredible driving l have ever experienced! Needless to say he received much gratitude and multiple rounds of applause from the Americans. Such is clinical care in rural Tanzania.

      Now for church and a slower day tomorrow.

Alan

      

     

Return to a Dream

 Tanzania has a peice of my heart.

It has been more than a decade since I have been on African soil. The first time I came to Tanzania, I was fresh out of undergraduate school, and undecided on life direction. This trip, I am established in my career as a certified orthotist prosthetist, and am arriving with new eyes.

The last week here in Tanzania, I have relished existing in a learning mindset, following along with Tanzanian medical professionals and my peer professionals from the United States.

Yesterday felt like a day curated for me. I and several others visited the Regional Hospital in Iringa. I and Cait splintered off from the group to tour the rehabilitation unit and orthotic and prosthetics lab!

It was such a distinct shift of energy, for me.

I got to "talk shop" with the Tanzanians for the first time. I got to talk to African peers who invest in the same profession as me, strive to provide the same patient experience as me, celebrate the same patient successes as me and struggle with the same patient care struggles as me.
We discussed clinical strategies for specific diagnoses, material preferences for different devices, troubleshooting for poor compliance.
Stark difference came only in the form quantity, ease of access to supplies facility conditions.

Instantly, I could newly relate to my fellow professional travelers. There is something truly ineffable in sharing time and space, in a foreign land, collaborating about something you are passionate about.

It is such fun to share the spark of shared interest. The spark has more energy when you find it across the world.

Ideas, goals, visions and hopes began to grow in that moment. Contact information was shared.

Engaging with the welcoming community in and around the Illula Hospital has been magic. More adventures to come.

Lala salama,
Katelyn 

RCH Center Nearly Completed

 Shoulder to Shoulder has been working with leadership of the Hospital and Diocese for several years to plan a Reproductive and Child Health Center (RCH). Funding was secured by a generous donation by then Peter J King Family Foundation and many donors to Shoulder to Shoulder who made it possible to “raise the roof” of this RCH Center and projected maternity remodel.  Construction started in June and is now nearly complete.

Our group toured the building on our first day and were impressed by the beautifully constructed, spacious building. There are tile floors, well-built walls, excellent doors and cabinets as well as a modern exterior. It is located near the entrance on new hospital property and is immediately next to the new Mother’s Waiting House where women near to deliver can stay. 

After the RCH Center is completed, planning will focus on remodeling and expanding the Maternity ward. The architect and contractor for the maternity ward is expected to be Mr Maluli, director of FM Talents Partners. We were able to review the plan for maternity remodel with him. He needs to get updated hospital data as a part of revision of the plan.

It was wonderful for me personally meet Mr Maluli after working with him by email for the past 6 months in order  to send funds after approval by the construction team from the hospital and Diocese. The result is outstanding!

Kent

More on the 10th Ilula Minnesota Healthcare Conference

 Thursday and Friday were devoted to presenting our tenth annual Ilula Minnesota International HealthCare Conference.  Starting in 2014, Shoulder to Shoulder has presented the annual conference for our colleagues in Tanzania.  All our presenters did a great job and all the healthcare professional teams that attended gave positive feedback and will return to their hospitals with quality improvement ideas to implement based on what they learned. We are in the process of compiling the feedback from the evolutions, but the initial informal feedback has been overwhelmingly positive, both from attendees and presenters.

Our first course was presented in January 2014 with 30 attendees.  Based on extremely positive feedback from the initial conference, our partners in Tanzania encouraged us to significantly expand the conference to offer this educational experience to a much larger audience of caregivers.  As a result, we expanded the conference to include all 26 Southern Zone Lutheran Hospitals and the program has grown to include 130 healthcare professionals.   From each hospital we invite one doctor, one nurse, one pharmacist, and one administrator. 

Our conference is based on 5 principles:

1. Lifelong Learning.  We believe all professionals should contribute to a culture of learning and continuously learn to improve our practice.  

 2. Interprofessional teamwork.  We include nursing, pharmacy, administrators, and physicians in both the attendance and presentations.  We emphasize teamwork throughout the conference.  We each bring unique knowledge and skills to share; specifically Tanzanian presenters emphasize tropical medicine and HIV, American presenters emphasize the growing global problem of chronic and non-communicable diseases.

3. Mutual Respect.  We emphasize the ability for all our participants to teach and learn from each other, in spite of our differences in practice setting, culture, and socioeconomic situation.  We include local leaders in planning the conference and select topics based on feedback from participants.  Presentations are delivered by both US and Tanzanian professionals.  The program is based on a foundation of a longstanding and ongoing relationship. The second day of the conference was clinical talks delivered entirely by Tanzanian health professionals. 

4. Continuous improvement.  Learning should drive improvement in practice.  This year we devoted the entire first day to learning about quality improvement. 

5. Sustainable Impact.  We believe that education and improvement are some of the most valuable ways to promote a sustainable positive impact on the health of our partners’ communities.

Our conference is accredited by the Education Department at the Fairview to provide participants with educational credits for participation in this program.

Funding for the course is provided through generous contributions from several foundations and individuals including Global Health Ministries, The Peter J King Family Foundation, and Fairview Health System. All funds raised go entirely to hosting the conference, and support for local Tanzanian staff to attend, including meals, travel and lodging expenses.  We want to thank all our donors for their generous support. I would also like to thank fellow Course Directors Dr. Mufwimi Saga and Fr Manfred Mjengwa, Shoulder to Shoulder founders Randy Hurley and Gary Moody, Ken Olson, and all the presenters for all their hard work and critical contributions.  Special  thanks to Cindy Wilke, Shana Steinbeck, and Judith Kiliani for presenting on quality improvement. 

We believe that fostering leaning through the conference principles is one of the important ways we can improve the health of the population in and around Ilula. Overall the conference was a great chance to learn together, build relationships, and plan together to improve healthcare in Tanzania.

State-of-the-Art Wastewater System

On the first day we started our hospital tour at the decentralized wastewater treatment system(DEWATS). What a complex, state-of-the-art system!

Mr Kikoti, Dr Malamala and Dr Petro led us to the DEWATS site at the bottom of the hillside below the guesthouses and nursing dormitory. Oscar Mbekenga, CEO of Obsen Environmental Engineering in DAR, explained the construction and operation of the system. We learned that he had been trained in Europe so that may explain his knowledge and skills for the sophisticated 3 stage waste treatment system.

Oscar showed us the nearly completed first treatment stage. The raw sewage enters two oval biogas chambers and methane producing organisms digest the organic material to produce methane gas. A biogas outlet pipe transports gas to be used in the hospital to heat water or any other combustion purpose. Next, we could see where water will overflow into a multi-chamber, baffled settler where remaining solids settle and treated water continues. 

He then walked with us to see where water will overflow into a yet-to-be-built root treatment system of a planted, gravel filter for final treatment to make it suitable for agricultural irrigation. 

The result will replace the century old, minimally functioning septic tanks with a system that protects the ground and water from contamination, produces methane gas for heating needs of hospital and ends with treated water for irrigation. 

Our group asked many questions to clarify details and Oscar was able to answer them all. 

For me personally, I feel a bond with Oscar because he and I shared frustrating problems in getting the first wire transfer of funds to get to his bank account. We can now laugh about tens of  thousands of dollars held in the SWIFT banking system for 2 weeks but at the time it was a quite a scare. Subsequent banking adventures had no drama. Meeting Oscar in person and hearing his detailed explanation of the system was a great experience!

Kent

Ilula-Minnesota International Medical Conferece

 

The Ilula-Minnesota International Medical Conference, held in Iringa, Tanzania, brought together doctors, nurses, pharmacists and administrators from southern Tanzania Christian hospitals and the U.S. to talk about healthcare advancements and share knowledge. Held over two days, attendees learned about a quality improvement model, tools, and advancements in specific healthcare practices. I’ll let one of the doctors in attendance describe the specific health care practices. In this blog, I’ll talk about the specifics related to administration.

The first day of the conference was all about the quality improvement model and learning about and using process improvement tools such as pareto, run and flow charts. Most participants were new to this methodology and tools. Key themes included keeping it simple, starting small and expanding, recognizing that all improvement requires change, and viewing all work as a process.

On the second day of the conference, I led a break-out session of the administrators – attended by approximately 30 individuals. In our break-out session, we discussed topics that were highly relevant to all the hospitals. Our topics were: competition, insurance denials, compliance with electronic medical records, new streams of revenue, customer care and quality improvement.

Competition

Competition is recent in Tanzania, especially the rural area. The government built health care facilities throughout the country, often close to existing faith-based health facilities. The facilities are new and fully staffed due to the government’s higher salaries and reported lax management style.

We discussed that faith-based facilities have a competitive advantage because the community trusts them, and they offer prayer to patients, families, and staff. We focused on using this new competition to improve care and service to the community. SafeCare is an internationally accredited standard for resource-restricted settings. As members of the Christian Social Services Commission, a SafeCare self-assessment tool is available free of charge to the hospitals. Many of them believe they will try this new tool.

New Revenue Streams

Participants shared examples of new revenue streams that they were exploring, like adding specialty doctor services, reducing the amount of denials from the claims submitted to the National Health Insurance Fund, and producing agricultural products like maize, trees, sunflowers, and goats. The discussion was especially welcome as the hospitals shared how they had worked to overcome pitfalls in beginning and operating these new ventures.

Conclusion

In conclusion, the Ilula-Minnesota International Medical Conference provided a valuable platform for knowledge exchange, networking, and innovation, paving the way for a more collaborative and resilient global health community.

Cindy Wilke

Eight Days in Tanzania: The Tungamalenga Dispensary

The Hurley family (Randy, Kari, daughter Angela and 7 yr old grandson Wyatt) were in Tanzania 10 days before the medical group arrived to coincide our visit with Wyatt’s Christmas break schedule. We were able to visit Barnabus Khawage, the recently retired clinical officer at the Tungamalenga Dispensary. The new clinical officer is Dr Asajili Sanga; Dr Asajile was born and raised in Ilula Tanzania and is a graduate of the Ilula Clinical Officer training school. As it is here in the USA, it often is hard to attract health care professionals to serve in rural locations. In the USA, as in Tanzania, most training programs are located in urban areas and once finished with training, it is often difficult to attract health care professionals to practice in rural locations. One of the original goals of the Ilula Health Institute was to identify local students, train them locally then have them serve locally in rural dispensaries operated by the Tanzanian Lutheran Diocese. Mission accomplished: Dr Asajile is a great example of that philosophy in action! Tungamalenga is paired with Shepherd of the Valley Lutheran Church in Apple Valley: they recently completed construction of a lab at this dispensary.

Randy and Kari Hurley

Dr Asajile at Tungamalenga Dispensary

The recently constructed outpatient lab

Examples of lab tests available: (for comparison Tsh 2500 is approximately USD $1) UPT: urine pregnancy test; Widal test is a typhoid test; MRDT (Malaria rapid diagnostic test) and HIV testing are provided by the government at no cost

Meet Happy

 It is finally my turn for jet lag to kick in as I lay restless in my bed. I guess it is a good time to post to the blog. I’d like to tell you about Happy, the social worker at Ilula Hospital. Ilula Hospital is a faith based institution and is the reason for Happy’s pull to this place. She started at Ilula as a community officer and went back to school to obtain her bachelors degree in social work. I admittedly did not know much about social work in Tanzania and was inspired by how she leads and drives every decision with her super big heart. A very caring heart. She is compelled to advocate for the children and specializes in social work for children who experience abuse (sexual, physical, emotional, neglect).  On a typical month, she helps find a safe home for 15-40 children. Yes, each month! 

I had the opportunity to hop into the hospital vehicle with her and a few colleagues Meade, Diane and Katelyn. The vehicle fit 2 people in front, three in the middle row and one “seat” in the way back (the back did not have a seatbelt and Meade graciously took that spot and was an amazing trooper along an extremely bumpy ride). We drove about an hour and a half east of Ilula into the mountains, driving along a congested highway of truckers (and some monkeys!). Happy brought us to a region called Nyanzwa ward and we stopped to pick up the chief of police from Ruaha mbuyuni police station. Her name was Umpendo. The two of them have been partnering together since 2019 to educate the community about child abuse, the laws that pertain to it, and how to safely report. We continued another 30 min down more bumpy roads to the schools. The duo spoke at 4 schools (elementary and middle school aged) and educated the children with songs (No Touch-y Touch-y) and teachers (stern reinforcement of the Tanzanian law). We ended our day in jail. No, not locked up but rather to see Umpendo’s police station that she governs.

Happy is an important person at Ilula Hospital. Her services are needed in this community and is yet another way for Ilula Hospital to continue to serve its patients, including those who do not have a voice. She has a goal to return to school for her masters degree. When asked why, she of course brought it back to the children of Ilula area and how to better serve the hospital. She hopes a masters degree with increase her knowledge of Tanzanian law to better represent the Ilula children in court. In addition, she hopes to bring government supported research to the Ilula area, looking into areas of child abuse. 

Happy is all heart and a critical role to the Ilula Hospital team. I was so glad to be able to get a small glimpse into her work and share memories with everyone along for the bumpy ride to the villages. 

Shana

Heartwarming hospitality

 A group of us (Kent, Cindy, Jennifer, Alan and Diane) traveled to Ihimbo Dispensary (medical clinic) today.  We were joined by Dr. Petro, Secretary of Health for DIRA (the Iringa Diocese) and Kirsten Levorson, Director of Bega Kwa Bega. We were warmly greeted by staff and given a tour and an update of the current usage of the Dispensary. This was personal for Alan and me, since Alan’s parents, Will and Jan Carlson, helped fund the facility, which was expanded and dedicated in 2009. Sixteen years later, the rooms are clean, records are organized and the facility is well maintained. We were impressed.

As moving as the arrival at Ihimbo Dispensary was, the best was yet to come. Next up was a service at the church at Ihimbo, where pastors and many church members gathered to extend their hospitality and appreciation for having the medical facility available to them. Alan and I were truly humbled and in awe of their gratitude. We were treated to the gift of song by two different groups. At the end, our entire group was given gifts from the local people to show their gratitude. Next up was lunch at the pastor’s house, prepared and served with love by community members.

It is hard to put into words all the emotions of today. People are people, no matter our skin color, nationality or financial status.  To respect each other and show love and gratitude is a a gift. I am joyfully overwhelmed and pray to show love and gratitude to others as we were shown today. 

Diane 

“We live well together” - Meet Dr Mussa Nguva

This post is dedicated to Mussa Ngova and his role in patient care at Ilula Lutheran Hospital. As the solo dentist in our group, I. have had the privilege of spending most of the past two days in the one room dental clinic, with dental therapist Mussa Ngova. 

Immediately, as we had our first few discussions and patients, it was clear that Mussa is engaging, witty, and very knowledgeable. As the hours continued, I observed his deep compassion and empathy for his patients, and his skills as a clinician. He has been at Ilula Hospital since 2014, and upon asking him what has kept him staying there so long, he answered simply: “we live well together.” I was a little confused at first, I had to clarify… he then explained that he has a great relationship with his coworkers and the leadership at the hospital, that he is happy to be a part of the team caring for his patients alongside the other department providers. He spoke also about his passion for oral health education; in Tanzania, preventive dental care (routine twice yearly exams/xrays and cleanings as we have in the US) is not available/practiced, rather patients appoint only when they are having pain. And so we both agreed that “patient education is the prevention.”  He desires to do more in person outreach to the surrounding villages to educate on oral health and prevention methods, but he said the funding to do this (paying for transportation, gas etc) just isn’t available right now. 

As we spent the morning with his patients, I observed Mussa functioning as a dentist would in the US - examining, diagnosing, and then completing treatment (local anesthetic and extracting teeth) and writing prescriptions/giving post op instructions. But unlike in the US (with a team of reception and dental assistants) he also charts, sets up and cleans up after each patient, and sterilizes the instruments. And he does ALL of this for every patient BY HIMSELF - he is the only person in the dental clinic. This alone is a feat - it is grueling work without a break - and he had a very steady and busy stream of patients both days. On top of this, include the emotional drain of caring and calming each very anxious patient; he spent time re-assuring his patients and was empathetic. Side note - yes! in case you were wondering, fear and loathing of the dentist transcends cultures 😂.)  We were both also curious about many things, and asking each other lots of questions, and this definitely added more to his plate.     Lastly, and of most impact, is that Mussa’s working with vastly different resources and technology than what you would find in a typical dental office. 

And yet, Mussa did this all with SO MUCH JOY. And I kept thinking, he has worked hard caring for patients and “lived well together” with the Ilula Hospital team for 10 years - what an amazing health care provider, with such an incredible contribution to the Ilula community.

Arrival

 We’re here! Our long travel day to Tanzania went very smoothly. Flying from Dar es Salaam this morning, I was amazed by the view of the Tanzanian countryside. Driving from Iringa to Ilula was equally picturesque, with lots of activity along the road. We were greeted warmly when we got to the hospital. We had a great tour of all the buildings and were brought up to date on the current projects going on. I can’t wait to see and do more tomorrow. The week is packed with opportunities to get to know the people who live and work here at Ilula Hospital and the Iringa area. 

There will be lots to write about as the week goes on, but getting a good night sleep tonight will be the best way to kick off this Ilula adventure 

Diane 

Today’s the day!

At long last, the departure day has arrived and I am a little jealous. Shana has done a marvelous job organizing. If something does not go as planned, it won't be her fault! As it turned out, almost everyone departed from MSP. Katie flew in from Vegas for a short stay with Uncle Ken and Auntie Birdie, Cait arrived to fly out with the group and Jenn changed her flight to leave with the group. They will catch Cindy in Amsterdam at Ski-Pole. Then off to Dar. Here is a photo of Team Shoulder to Shoulder:

Returning to Ilula

 Good day fellow travelers and other readers. This is a small experiment to make sure that I can post a blog - it's not something I do everyday! I am looking forward to reconnecting with my friends at Ilula Lutheran Hospital. I first visited Ilula Medical Center in 2006 as part of a mission trip with my church, Lord of Life Lutheran in Maple Grove, Minnesota. 

As a health care administrator I was curious about the life and responsibilities of Ilula's administrator. What I found convinced me that health administrators could contribute to Ilula's success in serving their population. After many conversations with Global Health Ministries, we launched Global Health Administration Partners (GHAP) in 2007 with Ilula as one of two pilot programs to test whether we could add value. 

Since that time and through the considerable efforts Shoulder to Shoulder and Ilula's board of goveners, Ilula has grown to be a full-fledged hospital. GHAP has continued to travel to Ilula every few years, walking with the hospital leadership to study issues such as inventory management, medical records management and governance. We have also participated in a few of the Minnesota - Ilula Medical Conferences.

I'm looking forward to seeing the progress Ilula continues to make and to meeting again with Dr Saga and Alamu Kikoti in particular, as well as my fellow travelers from Shoulder to Shoulder.