Kolandoto Healthy Hospital Project Summary Report

April 2018

Authors: Annika Danielsson, Daniel Kallus, Andreas Berg, Martin Skilbred, Jon Gunnarsson Ruthman, Jan Burenius and Mikael Mangold

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nurses was moved into the triage room. Since, according to the task-flow, one of the nurses often supported the doctor it meant that if the other nurse was doing the triaging there was not anyone left to observe the patients in the observation room. The group concluded that if the doctor needed assistance when treating most of the patients there would be a need for more staff to ensure that the flow of patients was not interrupted.

EVENT CARDSWhen the discussions were slowing down it was time to introduce the “Event Cards” which were formulated to test how the work flow and design could adapt to difficult events. The event cards for this session had been prepared beforehand. The first event which was discussed was how the department would work if one of the nurses were missing, i.e shortage of staff. Since the discussion of shortage of staff already had come up the group immediately argued that the department could not work smoothly with only one nurse. The group concluded that a team of 1 doctor, 2 nurses and 1 receptionist is the minimum of staff needed for the department. It would be better if the team could be expanded with another doctor or at least an extra nurse.

The second event involved an accident with 15 victims that arrive at the same time to the emergency department. The group explained that the doctor and nurses would go to the waiting room to make a first quick assessment of the patients to see if anyone had to be taken directly to the emergency room or to operation. If that was the case, the doctor will be busy with these patients and there would be a need to call for another doctor to assist the nurses. The receptionist would be the one to call for more staff. I asked the group what they would do if some of the patients in the waiting room needed to lie down while waiting to see the doctor. They say that it would be good if one or two extra

stretchers could be placed somewhere in the department. They would also be needed when transporting patients from the emergency room to the observation room since the beds in the emergency room will be fixed.

DISCUSSIONSIn the end of the session I asked how the placement of sinks could help the staff to remember to wash their hands between each patient. The group was asked to change the placement of sinks to be optimal. The team concluded that it would be optimal if the sink was placed just opposite of the door to be clearly visible when entering the room. One participant added that it would be good to have a clear sign as a reminder to wash hands and maybe also a lamp next to the sink.

The next question for the group to discuss was about how the waste management would work in the department and how the design can facilitate a good waste management. The group immediately started discussing and pointed at the procedure room. They conclude that the procedure room will produce more waste compared to the triage room and would benefit from an adjacent sluice room

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During 2015 - 2017 a collaboration between Kolandoto Hospital in Tanzania and the Swedish NGOs Involvaid, Engineers Without Borders and Architects Without Borders resulted in hospital infrastructure improvements worth 963 KSEK. All implementations were chosen by the hospital management team with the intention of decreasing morbidity and mortality of patients at the Kolandoto Hospital in the Shinyanga Region.

8 master theses were written by 14 master students from Chalmers University of Technology. The students spent two months each at Kolandoto Hospital. The project included professional visits by nurses, architects, civil engineers and electrical engineers who provided professional support in the planning and procurement of infrastructure improvements.

As a first step a hospital masterplan was created by Kolandoto Hospital with the assistance of a Swedish architect to make sure that subsequent implementations followed the overall development plans of the Kolandoto Hospital. After this first step major project implementations were: increased water availability and improved water quality, stabilized and solar assisted electricity supply, and construction of an emergency department and the creation of a mass casualty plan.

The primary objective of the project was the reduction of morbidity and mortality in the Shinyanga region. Secondary objectives were learning outcomes for the organizations and people involved in the project.

SUMMARY

Dr Elimeleki Katani and Beather Katani

A staff meeting in the church

A link to a google drive folder that contains more information, more pictures and the master theses.https://drive.google.com/drive/folders/1qAPK_HaqMACLDAQ-DGIZwSA3yMdNtx5T?usp=sharing

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Access to health care is both a human right and a humanitarian issue. Investing in health care has direct positive consequences for beneficiaries, but the investments need to be made in a way that ensure long term operation.

The Kolandoto Hospital has been cooperating with NGOs and foreign aid organizations for many decades and the track record of successful and sustained projects shows the broad competence of the management team of Kolandoto Hospital. The management team has juggled finances from aid organizations, patient fees, church organizations and state funds in a manner that has enabled the hospital to develop and increase the access to health care for a large portion of the Shinyanga residents as well as the rest of Tanzania.

One of the organizations with which Kolandoto Hospital has been collaborating for a longer period is Involvaid (former I Aid Africa). The Kolandoto Healthy Hospital Project was created as a collaboration between Kolandoto Hospital, Involvaid, Engineers Without Borders and Architects Without Borders in 2014. Involvaid, Engineers Without Borders and Architects Without Borders are smaller Swedish aid NGOs without large donor support and all work is done by volunteers.

INTRODUCTIONThe motivation for working voluntary in these aid organizations vary but we have often agreed on the following key components of our motivation: • Healthcare is a humanitarian issue and will have

direct impact upon people’s lives. • We want to learn from and see if we can overcome

challenges of long term foreign aid projects.

We had some principles which we tried to follow throughout the project: • Decisions on investments were to be made by the

hospital management team. • Ownership of the physical implementations

should be ensured by the decision-making process and by co-financing by Kolandoto Hospital.

• By not leading the physical implementation projects but rather support the Kolandoto Hospital in the procurement of local construction agents we wanted to make sure that maintenance and system upgrades was easily made after the end of the project.

• We wanted to be present for a long time to develop cultural and contextual understanding as a base for project implementations, as well as developing good relations over the years.

A view from the main entrance to the hospitalThe location of Kolandoto and Shinyanga in Tanzania

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Four organizations have collaborated to create this project. They are listed in Table 1. Over the project years many people with different background have participated and contributed. Unfortunately, it is impossible to mention all people here, but some key persons are listed in Table 2.

Email adresses can be found in the google drive folder.

ORGANIZATIONS AND PARTICIPANTS

Table 2: ParticipantsTable 1: Organizations

Person FunctionDr Elimeleki Katani Hospital management team leader

Dr Maganga Dohoi New hospital managment team leader

Wallace Anestesist nurse, medical technician

Methuselah Nkaka Responsible for electricity

Julius Omango Responsible for water and solid waste

Zacharia Ndalahwa Hospital Patron, nurse

Samson Challow Secretary

Emmanuel Magile Anestesist doctor

Jon Gunnarsson Ruthman Involvaid, Project coordinator

Annika Danielsson Architects Without Borders, Project coordinator

Mikael Mangold Project coordinator

Jan Burenius Engineers Without Borders, Project coordinator

Daniel Kallus Civil engineering student, Project coordinator

Andreas Berg Civil engineering student, Project coordinator

Martin Skilbred Electrical engineering student, Project coordinator

Simon Rohlen Electrical engineering student

Nathalie Hansson Environmental systems analysis student

Stina Svärd Environmental systems analysis student

Therance Ndisanga Environmental systems analysis student

Eric Kalisa Twizeyimana Electrical engineering student

Lisa Bergstrand Architecture student

Emma Öhman Civil engineering student

Maria Engver Civil engineering student

Sandra Dawood Architecture student

Emelie Joelsson Architecture student

Organization Description

Kolandoto Hospital

Kolandoto Hospital is run by the African Inland Church Tanzania whose goal is to support individuals, families and communities, both physically and spiritually. The organization is working to try to achieve quality health care for all individuals, regardless of economic status. The hospital has 168 inpatient beds for medical and surgical treatments, and maternal healthcare. It also has a large outpatient department, several clinics and outreach programs. http://www.aictanzania.org/

Involvaid

A small-scale Swedish NGO that works with sustainable and health related development projects through locally identified needs and long term partnerships. http://involvaid.com/

Engineers Without Borders Sweden

An NGO that works to address challenges linked to the Sustainable Development Goals. Through improvements in education, equality, energy poverty and access to water and sanitation they strive to make a sustainable and long-term impact for local communities and the Earth.https://www.ewb-swe.org/

Architects Without Borders Sweden

An NGO that works for a long-term sustainable, equal and fair development of the built environment across the whole world. http://www.arkitekterutangranser.se/

Some of the people in Sweden during a social after work meeting

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DESIGNS AND IMPLEMENTATIONS

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nurses was moved into the triage room. Since, according to the task-flow, one of the nurses often supported the doctor it meant that if the other nurse was doing the triaging there was not anyone left to observe the patients in the observation room. The group concluded that if the doctor needed assistance when treating most of the patients there would be a need for more staff to ensure that the flow of patients was not interrupted.

EVENT CARDSWhen the discussions were slowing down it was time to introduce the “Event Cards” which were formulated to test how the work flow and design could adapt to difficult events. The event cards for this session had been prepared beforehand. The first event which was discussed was how the department would work if one of the nurses were missing, i.e shortage of staff. Since the discussion of shortage of staff already had come up the group immediately argued that the department could not work smoothly with only one nurse. The group concluded that a team of 1 doctor, 2 nurses and 1 receptionist is the minimum of staff needed for the department. It would be better if the team could be expanded with another doctor or at least an extra nurse.

The second event involved an accident with 15 victims that arrive at the same time to the emergency department. The group explained that the doctor and nurses would go to the waiting room to make a first quick assessment of the patients to see if anyone had to be taken directly to the emergency room or to operation. If that was the case, the doctor will be busy with these patients and there would be a need to call for another doctor to assist the nurses. The receptionist would be the one to call for more staff. I asked the group what they would do if some of the patients in the waiting room needed to lie down while waiting to see the doctor. They say that it would be good if one or two extra

stretchers could be placed somewhere in the department. They would also be needed when transporting patients from the emergency room to the observation room since the beds in the emergency room will be fixed.

DISCUSSIONSIn the end of the session I asked how the placement of sinks could help the staff to remember to wash their hands between each patient. The group was asked to change the placement of sinks to be optimal. The team concluded that it would be optimal if the sink was placed just opposite of the door to be clearly visible when entering the room. One participant added that it would be good to have a clear sign as a reminder to wash hands and maybe also a lamp next to the sink.

The next question for the group to discuss was about how the waste management would work in the department and how the design can facilitate a good waste management. The group immediately started discussing and pointed at the procedure room. They conclude that the procedure room will produce more waste compared to the triage room and would benefit from an adjacent sluice room

Phase I - 2015 Phase II - 2016 Phase III - 2017

Masterplan design Solar cells and UPS installation Emergency department construction and training

Water pump installation Dosatron installation Private and maternity ward design

Eye clinic design

Maternity theatre design and construction

Waste zone construction

X-ray entrance construction

Emergency department design

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Masterplan design

Decades of aid dependent growth has led to inefficient logistical flows of patients, staff, material and air throughout the hospital site which create risks of medical errors, harmful service delays and infections.

A masterplan was developed based on numerous design iterations with hospital management and staff to guide the development of the built environment. The masterplan supports the access to appropriate healthcare in a healing environment free from factors causing illness or injuries. It defines the next 10 larger building projects and the sites for them. It also clarifies good medical zoning and flows to make the hospital site safer and easier to navigate.

The masterplan was created to give the hospital management team increased possibilities to control the development of the hospital. The first two identified building projects were completed during phase III and are in use - the eye clinic and the emergency department. The third project, about the maternity ward and the private ward, has been designed but not built.

2015 - Phase I

A visionary workshop with hospital staff

A workshop to prioritize among projects

An overview of the hospital site and the identified construction projects and priority order in the masterplan

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Water pump installation

One of the main problems that the hospital management brought up in the beginning of the project was a shortage of water. There was one existing borehole with an old pump with poor capacity that provided water to the whole hospital, the nearby nursing college, and the Kolandoto village. The pump broke down often which resulted in times when there was even less available water for the hospital. The shortage of water made it difficult for the hospital to uphold appropriate and safe hygiene standards. It also resulted in a shortage of quality drinking water for the inhabitants of Kolandoto as a whole, posing a considerable health risk.

After testing of the existing borehole water yield and mapping of the current water distribution system a submersible water pump was bought and installed in the existing borehole. The process was undertaken in close collaboration with the water team of Kolandoto Hospital and the hospital management team. A local engineering company was hired to install the pump. The new water pump has doubled the availability of water and reduced the health risks due to shortages of safe drinking water.

2015 - Phase I

Test of borehole water yield

Part of the water distribution system

Installation of the new water pump together with a local engineering company and the hospital water team

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Maternity theatre design and construction 2015 - Phase I

The existing operating theatre for c-sections at the maternity department was not in use in 2015 due to that the hospital could not guarantee the needed hygienic conditions for performing safe c-sections. The building lacked a place for changing clothes, scrubbing before surgery, and cleaning of used equipment and linen. Instead, pregnant mothers who were in need of emergency c-sections had to be transported out of the maternity building, along an outdoor path to go into the general operating theatre, and wait if another surgery was on-going.

A maternity building extension was designed and constructed by a Swedish project team member together with hospital staff and local craftsmen, to counteract these problems. The extension has improved the flows in the building to uphold good hygiene standards. Since completion the extension has been in use on and off. For example, during the beginning of 2016 the maternity theatre was not in use due to missing spare parts for previously donated Swedish medical equipment.

Plastering of the new maternity extension

The finished operating theatre

A view of the maternity theatre extension as well as part of the old building

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Eye clinic design

The eye department used to consist of two buildings – the operating theatre building and one building for both the ward for inpatients and the clinic for outpatients. The outpatient clinic was small and crowded which resulted in poor patient privacy as well as a risk of transmission of infections. Kolandoto Hospital had at the time already in mind to construct a new building for the eye clinic. A design proposal from a local firm had been made, but the design was too large for the available sites.

Assistance was provided in both writing a funding application to send to a German NGO, and with making a new design proposal adapted to the site and spatial needs expressed by staff. The proposal was a clear, calm and comfortable building design based on building techniques adapted to the local climate.

Two years later, in 2017, the Kolandoto Hospital received funding from a German NGO for the building and hired a local contractor to build it.

2015 - Phase I

The previous overcrowded eye examination room

A rendering of a path in the design proposal

A view of the newly constructed eye clinic building

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Solar cells and UPS installation

One larger problem at Kolandoto Hospital were the frequent power cuts which led to medical hazards at the three operating theatres. Installing an UPS-system (Uninterruptible Power Supply) would prevent power cuts mid-surgery; an UPS is working as an instant back-up system for electricity.

Three separate UPS-systems with feeding solar cells were installed in the eye theatre, general theatre and in the maternity theatre. The solar power does not only work as a power bank for the UPS but also as an asset for lowering the cost of electricity. Each individual UPS was therefore also dimensioned for future expansion.

Power cuts during surgery dropped from approximately two to zero times per week. Furthermore, the hospital electricity bill also reduced by approximately 50%. This cost reduction was well received by the Kolandoto Hospital since the hospital economically operate at the margin, and even have challenges in paying staff salaries. In 2018 the Kolandoto management team specifically asked if it was possible to further increase the solar electricity capacity.

2016 - Phase II

One of three rooms for the UPS systems

Solar cells on the maternity ward

Installation of solar cells on a roof

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Dosatron installation

When the water pump was installed during phase I, a water quality test was conducted. The test showed the presence of E. coli in the water. E. coli is an indicator of faecal contamination which can cause water related disease outbreaks and health hazards for the weaker individuals who are staying at the Kolandoto Hospital and in the Kolandoto Village.

A dosatron which adds an adjustable dosage of chlorine was installed to disinfect the water. Trainings were provided for the Kolandoto technical team to operate and run the dosatron. The same company that installed the water pump and the UPS and solar electricity system was hired for the installation to ensure that the hospital easily could receive technical support if needed.

2016 - Phase II

A shed for safe storage of chlorine

Installation of the dosatron in the pump house The dosatron adds chlorine to disinfect the water

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Waste zone construction

The waste zone had deteriorated because of a lack of funding and the need to prioritize more central hospital functions. While the waste zone itself is not an immediate health risk for the patients, a functioning waste system is. It is much easier to implement proper infection control if the hospital waste zone is working well. In addition, the staff concerned with handling waste are exposed to health risks if the waste zone is not safe to operate.

As a minor project implementation, the waste zone was given a new roof and new tools were purchased for safe separation and management of waste fractions.

2016 - Phase II

The waste zone before the changes

Construction of a new roof over the waste zone

An enclosed waste zone with a roof over the incinerator as well as the trash storage place before burning

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X-ray entrance construction

The masterplan identified the emergency department as the second larger building project to be made. To provide proper emergency department services a functioning x-ray and imaging department is key. The masterplan identified that the flows in between the site for the emergency department and x-ray department had to be simplified to not cause dangerous delays in the care. In addition, the door to the x-ray department was too small for stretchers to come through, which resulted in patients being dangerously carried on mattresses instead.

A reorganization and primarily a new entrance situation to the x-ray department was designed together with staff. A new waiting area, a new wide entrance door, and a new reception window was constructed and installed. The entrance to the x-ray department is now located in close connection to the emergency department and the general operating theatre which makes it easily accessible. The waiting area is outside with solar shading to make it comfortable. The door to the room with the x-ray machine is wide enough for injured patients to be safely transported on a stretcher.

The new layoutThe proposal is to add a new, wide double door, to the x-ray room and create a new space for waiting patients. The reception is moved to match this new flow and is now conveniently positioned between the x-ray and the ultrasound. Patients from the emergency department will be able to find the radiology department easily.

From Emergency Department

Lisa Bergstrand, 2016-03-11

2016 - Phase II

The new wide X-ray entrance door

The new entrance situation at the x-ray department

The outdoor waiting area with solar shading creating a comfortable place to sit and wait

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Emergency department design

Kolandoto Hospital did previously not officially provide emergency health care, although there was a need for it and patients did arrive at the hospital in a state of emergency. The emergency flow of patients was undefined, inefficient, and caused dangerous delays in providing critically ill patients with care. To build an emergency department was the second large building project in the masterplan. In addition, having an emergency department is one criteria of fully becoming a ‘Council Designated Hospital’, which is an official type of hospital receiving certain government funds.

A design proposal for a new emergency department building was developed through a design process that focused on participative methods to generate the best ideas adapted to local health care requirements and the local culture.

Since the design proposal was made as part of an architectural master thesis it became a bit too large and difficult to construct. After the thesis was finished the building design was simplified and made smaller and more economically realistic.

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nurses was moved into the triage room. Since, according to the task-flow, one of the nurses often supported the doctor it meant that if the other nurse was doing the triaging there was not anyone left to observe the patients in the observation room. The group concluded that if the doctor needed assistance when treating most of the patients there would be a need for more staff to ensure that the flow of patients was not interrupted.

EVENT CARDSWhen the discussions were slowing down it was time to introduce the “Event Cards” which were formulated to test how the work flow and design could adapt to difficult events. The event cards for this session had been prepared beforehand. The first event which was discussed was how the department would work if one of the nurses were missing, i.e shortage of staff. Since the discussion of shortage of staff already had come up the group immediately argued that the department could not work smoothly with only one nurse. The group concluded that a team of 1 doctor, 2 nurses and 1 receptionist is the minimum of staff needed for the department. It would be better if the team could be expanded with another doctor or at least an extra nurse.

The second event involved an accident with 15 victims that arrive at the same time to the emergency department. The group explained that the doctor and nurses would go to the waiting room to make a first quick assessment of the patients to see if anyone had to be taken directly to the emergency room or to operation. If that was the case, the doctor will be busy with these patients and there would be a need to call for another doctor to assist the nurses. The receptionist would be the one to call for more staff. I asked the group what they would do if some of the patients in the waiting room needed to lie down while waiting to see the doctor. They say that it would be good if one or two extra

stretchers could be placed somewhere in the department. They would also be needed when transporting patients from the emergency room to the observation room since the beds in the emergency room will be fixed.

DISCUSSIONSIn the end of the session I asked how the placement of sinks could help the staff to remember to wash their hands between each patient. The group was asked to change the placement of sinks to be optimal. The team concluded that it would be optimal if the sink was placed just opposite of the door to be clearly visible when entering the room. One participant added that it would be good to have a clear sign as a reminder to wash hands and maybe also a lamp next to the sink.

The next question for the group to discuss was about how the waste management would work in the department and how the design can facilitate a good waste management. The group immediately started discussing and pointed at the procedure room. They conclude that the procedure room will produce more waste compared to the triage room and would benefit from an adjacent sluice room

2016 - Phase II

During one of many participatory workshops

A render of the proposed emergency deparment

The plan of the proposed emergency department

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Emergency department construction and training

In addition to the spatial and physical needs to provide emergency care, the hospital staff was not trained in emergency care and there was no mass casualty plan in place.

A procurement process was carried out by the hospital management assisted by two Swedish engineering students, to find a suitable local contractor to construct the building. A contractor was selected, who then constructed the building in six months. In addition to the construction of the emergency department, simple Swedish medical equipment, such as stretchers and trolleys, were sent to equip the emergency department. To provide training for the staff a series of meetings, workshops and mass casualty trainings was conducted.

Kolandoto Hospital Emergency department is the first in the region. Two years prior to the construction, meetings were held with regional medical officers to anchor the plan of building an emergency department at Kolandoto with mass casualty capacity. A learning outcome was that construction errors can be avoided by having a physical 3D model available for the contractors and workers at the construction site.

2017 - Phase III

The emergency department under construction

People acting injured during a mass casualty training

The finished emergency department building seen from the entrance of the hospital

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Private and maternity ward design

The third large building project identified in the masterplan was the private ward and maternity ward. The current maternity ward does not have enough capacity as it shares the building with the private ward. The congestion of inpatients poses a risk of transmission of diseases and infections. With an increasing number of patients coming to give birth at the hospital for free, it is even more needed to expand the facilities. At the same time there is a growing demand for private care. Constructing a new private ward with higher standards in terms of sanitary facilities and single/double patient rooms is therefore an income opportunity for the hospital since patients seeking private care pay more.

Design proposals for a new private ward and maternity ward was made in close collaboration with both staff and patients. The private ward is designed to resemble a village with smaller houses. In the proposal the maternity ward is extended to occupy the whole existing building. A new extension is included to accommodate mostly single/double patient rooms. The outdoor spaces are designed to provide social and healing spaces.

2017 - Phase III

A planning workshop with staff

A rendered view from a patient room in the proposal

A plan showing both the new private ward ‘village’ like buildings, and the long maternity ward building

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ECONOMY

Table 3: Donations by funding organizations [KSEK]

Table 4: Project expenses [KSEK]

Year 2015 2016 2017 3 year totals

Kolandoto Hospital 10 20 33

Engineers Without Borders (with the support of Ramböll Foundation) 30 80 210

Involvaid 30 57 26

Chalmers Mastercard 35 50 50

Chalmers Vänner 35

Ulandsföreningen 25

ARQ stiftelsen 50 50

SPP "Klart du kan!" 50

Hjalmar Granholms minnesfond 15

Chalmers MFS administrationsavgift 78

Edith och Egon Plomgrens donationsfond 20 20

Liljewall arkitekter 40

Total funds for projects 155 317 522 994

MFS Student travel grants 81 155 108

Ernst M Frimans stipendiefond 15 21

Architects Without Borders travel grant 15 15 15

Total funds for travel expenses 111 191 123 425

Total yearly income 266 508 645 1419

Year 2015 2016 2017 3 year totals

Water pump + pump test 50

Maternity theatre extension 40

Minor ventilation fixes 5

Solar and UPS power 232

Dosatron + chlorine shed 89

Waste zone 5

X-ray entrance 10

Minor sanitation fixes 2

Emergency department 513

Emergency department equipment 13

Dosatron repair 3

First flush 1

Total implementation expenses 95 338 530 963

Exchange rate costs 3 11 17

Total project expenses 98 349 547 994

Funds moved to next years budget 57 -32

Total travel expenses 105 191 129 425

Total yearly expenses 203 540 676 1419

Year 2015 2016 2017 3 year totals

Kolandoto Hospital 10 20 33

Engineers Without Borders (with the support of Ramböll Foundation) 30 80 210

Involvaid 30 57 26

Chalmers Mastercard 35 50 50

Chalmers Vänner 35

Ulandsföreningen 25

ARQ stiftelsen 50 50

SPP "Klart du kan!" 50

Hjalmar Granholms minnesfond 15

Chalmers MFS administrationsavgift 78

Edith och Egon Plomgrens donationsfond 20 20

Liljewall arkitekter 40

Total funds for projects 155 317 522 994

MFS Student travel grants 81 155 108

Ernst M Frimans stipendiefond 15 21

Architects Without Borders travel grant 15 15 15

Total funds for travel expenses 111 191 123 425

Total yearly income 266 508 645 1419

Year 2015 2016 2017 3 year totals

Water pump + pump test 50

Maternity theatre extension 40

Minor ventilation fixes 5

Solar and UPS power 232

Dosatron + chlorine shed 89

Waste zone 5

X-ray entrance 10

Minor sanitation fixes 2

Emergency department 513

Emergency department equipment 13

Dosatron repair 3

First flush 1

Total implementation expenses 95 338 530 963

Exchange rate costs 3 11 17

Total project expenses 98 349 547 994

Funds moved to next years budget 57 -32

Total travel expenses 105 191 129 425

Total yearly expenses 203 540 676 1419

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The Kolandoto Healthy Hospital project was started with the intention of overcoming challenges commonly faced in development aid projects. The Swedish project group wanted to do good development aid without creating aid dependency and still contribute to the alleviation of suffering.

All these projects could not have been possible without Dr. Katani. He played a key role in many ways. He has guided us in our work, he has made sure people at the hospital understands us, and he has always had the strategic foresight so that priorities are made correctly.

Another strength of the project has been the involvement of people in the aid organizations from many different professional backgrounds: architects specialized in hospital design, engineers specialized in water, sanitation and electricity, and nurses specialized in health care planning and mass casualty training. All collaborated and contributed with expertise from their individual backgrounds to create a project with a broader perspective. Furthermore, the students were able to spend much time at the Kolandoto Hospital which assisted communication, common understanding and collaboration in critical periods of the project.

After phase I we tried to apply for funding from Forum Syd. Our application was rejected because the methods that were used in the project were needs-based rather than human-rights-based. Forum Syd were correct in not giving the Swedish project group the funding, the projects have all been need driven to some extent. However, it might be a mistake to not fund projects which are built upon functioning long-term projects which are founded on friendship and common values. Important elements of avoiding to create aid dependency are mutual understanding and mutual value driven activities. More about this can be read in the thesis of Andreas Berg and Daniel Kallus.

The Kolandoto Healthy Hospital project have been successful in meeting the overall challenges, but in some cases, we question the long-term impact of our activities. In this chapter we present three of the cases with questionable outcome.

While we were installing the submersible water pump in phase I we tested the water quality of the borehole. The water was positive for E. coli at 13 CFU/100ml. We had been asked to assess the issue of fluoride levels, but not E. coli levels in the water. The fluoride issue was found to be too expensive and complicated to solve. For the E. coli we decided to recommend the installation of a dosatron for disinfection of the water to protect vulnerable groups.

In doing this recommendation we acted against one of the principles of responsible foreign aid. We introduced a problem and a solution rather than listened and understood what the hospital management wanted. A dosatron require daily maintenance, and in addition, the installation of the dosatron had practical challenges.

These issues make it questionable if it was correct of us to recommend the installation of a dosatron. We took the decision to recommend a dosatron since E. coli positive water is a severe risk factor for vulnerable individuals at the hospital. The dosatron was installed during phase II and it is now operational thanks to good communication within the hospital management and the work of the technical team at Kolandoto Hospital.

CONCLUSIONThe dosatron

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To avoid creating aid dependency we tried to support Kolandoto Hospital in their negotiations with the authorities. The authorities do not always send funds on time and some categories of staff get their salaries with a long delay. By fulfilling all the criteria of a ‘Council Designated Hospital’ (CDH) it should be possible for Kolandoto Hospital to get funds from the authorities for more of the services they provide to the community.

The CDH process was the focus of the master thesis by Natalie Hansson and Stina Svärd during phase II. We started this project, perhaps with a limited understanding in the Swedish project group. Natalie and Stina concludes that there is a certain passivity of the hospital management in relation to government promises. It is possible that the projects described in this report have contributed to the distrust between the hospital and the authorities by making it economically more rational to focus on aid agencies rather than the authorities.

In phase III we supported the construction of an emergency department. This is a larger change in local health care provision, especially since it is the first emergency department in Shinyanga region. Besides having numerous workshops with staff management and patients, and designing the building one year in advance we also:

• Had meetings with the authorities at all levels 2 years in advance. During these meetings the Swedish visitors tried to take as little space as possible.

• Assisted in the training of specialized staff and provided expertise in the creation of a mass causalty contingency plan.

Yet we must ask ourselves, did we contribute to aid dependency and poor regional medical infrastructure planning? In Sweden the construction of the first municipal emergency department in a municipality would take many years and involve much more work and more careful planning. Kolandoto is not the center of the municipality, should the first emergency unit ideally have been built in Shinyanga town instead?

The hospital management team has been clear in their priorities and the authorities have given us the permissions. But are we stuck in colonial patterns of infrastructure planning?

To some extent the answer to the above questions are: Yes, the projects are part of the patterns of development aid that builds dependencies. But it is a more complex issue. First of all, the hospital management team are capable of keeping many separate agendas and priorities. They juggle funds from different sources and are still able to see to the best of the inhabitants of Shinyanga. A problem of the theories about human-rights-based aid is that it can disregard peoples’ capacity and will to do good. Dr. Katani, the hospital management team and the technical team have made these projects work. The installed equipment is maintained and have been repaired without involvement of Swedish counterparts.

Most important of all, the projects have reduced morbidity and mortality rates in the Shinyanga region.

The CDH processPriorities in regionalhealth care development

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This project could not have been realized without the help of many people, organizations and funds. Thank you to all students from Chalmers University of Technology - you all spent much time at Kolandoto and you worked hard. Thank you to all companies and donor funds who supported the project. Thank you to all members of the NGOs that have worked hard in this project for many years. And most importantly, thank you to all the people in the Kolandoto Hospital management, staff and technical teams, you all contributed to this project and together we have made this project happen.

ACKNOWLEDGEMENTS

Kolandoto Hospital has a sister hospital called Mkula Hospital. It faces similar challenges of shortages of water and electricity as Kolandoto Hospital did at the start of this project. A first survey of Mkula Hospital was made in 2017, and is a first base for a new project there during 2018 and 2019.

The windpowered water pump at Mkula Hospital

Large rock formations with a view over Kolandoto Village and its surroundings

A continuation