An estimated 2 million girls and women live with fistula

worldwide. Each year there are an additional

130,000 new cases.In other words: every four

minutes somewhere in the world a girl or woman

gets a fistula.

Sources: World Health Organization, 1998L. Lewis Wall, The Lancet, 2006

I never heard of fistulabefore I got one.

I thought I was the only woman in the world leaking urine and faeces.

Now I know there are so many other girls and women with fistula!

An unknown problem

photos: Mwanzo Millinga

70 percent of the girlsand women in the

’Risk and Resilience’study got their fistula atthe age of 20 or older.

For many, this wasnot their first delivery.

Source: Women’s Dignity, EngenderHealth,et al., 2006

Don’t think fistula is onlya young girl’s problem.

I got fistula when I was 29 years old.I am 54 now, and am so happy I will

finally get surgery and be dry.

photo: Mwanzo Millinga

The majority of the women in the fistula study isolated

themselves from other community members,

remaining in their homes as much as possible and

forgoing public events like funerals, celebrations and

visiting neighbours.

Source: Women’s Dignity, EngenderHealth, et. al., 2006

“I feel shame. They laugh at me.They turn their lips up, and others

leave the moment I enter to take my tea with them.”

The disgrace of fistula

Although fistula makes itdifficult for women to

participate actively in their community, they are not

abandoned. All the women in the fistula study

received some form of help from their family or

community.

Source: Women’s Dignity, EngenderHeallth, et. al., 2006

My husband has paid foreverything – the bus, the hospital, the medicines….He saved my life,

but it will take him years to pay back the loans.

Alone,but not neglected

One out of three Tanzanians report that

their family did not have enough clean water over

the past year.

Source: Afrobarometer 2005

“Imagine you have fistula. You have to walk six hours to get one bucket

of water. Now, you have to decide how you are going to use the water

– for washing, drinking, bathing, and cooking, or for yourself.”

Precious water

photo: Mwanzo Millinga

The majority of thewomen in the fistula study

wanted to deliver their baby at a health care facility of some sort.

However, fewer than half set aside money – ranging

from USD 3.50 to 50.Preparing for delivery was

difficult, due to lack of money and the hospital

being too far away.

Source: Women’s Dignity, EngenderHealth, et. al., 2006

Being ready

I was prepared for my baby – I’d saved some money, I knew where to

go and my husband asked a neighbour to bring me there on his

bicycle. All women in my village should have a plan like this.

If only I had been told that my blood pressure wastoo high, I would have gone to

the hospital for delivery.

Sources: Ministry of Health (RNC/NMCP) JHPIEGO, 2004Demographic and Health Survey 2004/05

photo: Sala Lewis

Theory vs. reality

According to the official guidelines of the Ministry of Health and Social Welfare in Tanzania, antenatal care services should include: physical examination from head to toe; check for blood count, blood pressure and urine; screening for syphilis and HIV; provision of tetanus toxoid vaccination; anti-malaria medicines and iron supplements; health education, including information about pregnancy, labour and delivery.However, reality is often different. For example, out of every ten of the poorest women in Tanzania, only four have their blood checked during antenatal care. For the wealthiest women, almost 9 out of 10 receive this service.

More than half of the poorest women in

Tanzania say they face big problems in accessing

health care because the facility is too far away and

they need to take transport to get there.

Source: Demographic and Health Survey2004/05

When my family realized I neededprofessional help, I had to walk

four hours to the main road.There I waited for a bus, but only

one passed and it was already full.

Access tohealth services

Sources: World Development Report 2006National Institute of Medical Research, Ministry of Health and Social Welfare, 2006

The nearest hospital to my village is40 kilometers away. I can get to the local health

centre, but it cannot do operations at all.

Safe delivery

In Tanzania, one woman out of every 66 who give birth, will die. In the USA, one woman out of 5,882 dies during childbirth. A caesarean section can save the life of a woman who has an obstructed labour. In Tanzania, 65% of government hospitals provide caesarean section, but no health centres or dispensaries provide this life-saving service.

In rural areas of Tanzania,there is usually one

medical officer caring for 45,000 people or more.

In Ruvuma region,there is just one doctor for 250,000 people. In Dar es

Salaam there is one doctor for 14,700 people.

In Germany there is onemedical doctor for every

280 people.

Sources: Ministry of Health Personnel Census 2002, draft

World Development Report 2004

I was lucky.I got to a hospital with a nurse and a doctor who took good care of me.But I know women from my village

who have died during childbirthbecause no one could help them.

Professional help

photo: Dorthe Friis Pederson

The maternity ward was packed with women – on beds, on the floor, everywhere. There were only five

nurses. I saw one woman deliver without any help.Source: World Development Report 2004

How healthcare ranksTanzania spends $12 per person per year on health. This compares to approximately $6,000 in USA, $3,100 in Australia, $70 in China, and $33 in India.

Sources: UNFPA Tanzania budget estimates, 2006

Money well spentSpending 8 percent of Tanzania’s annual health budget on required delivery kits, skilled health workers, and emergency obstetric care would ensure all pregnant women a safer childbirth.

What is more important – education, water, infrastructure, or healthcare? The budget is limited

and we have to make choices. Difficult choices.

photo: Dorthe Friis Pederson

Source: World Development Report 2006

“Our income has decreased because only myhusband is working. There are times when we don’thave food. Washing daily is costly, you must buy the

soap. This money could be used for other things.”

Less income, more expenses

Almost half of Tanzanians live on less than 1 dollar a day; almost three quarters live on less than 2 dollar a day.In poor families, everyone has to contribute to thehousehold income.

Source: Demographic and Health Survey 2004/05

Money determines where one gives birth.I didn’t have enough money to deliver in a health

facility, so I delivered at home.

A costly service

Half of the poorest women in Tanzania say that getting money for treatment is their single biggest obstacle while seeking health care. Twenty five percent of thewealthiest women also experience this problem.

More than 60 percent ofTanzanians believe that

the current government isfighting corruption well.At the same time, if you ask 7 Tanzanians if they

paid some kind of bribe to get medicine or medical

attention in the past12 months, one person

will say ‘yes’.

Sources: Afrobarometer 2005

“The nurse at the facility told me,‘If you don’t pay Tshs 15,000 (US$15)

you will never get a blood transfusion. If you have to die, better die.’ ”

Unhealthy practices

photo: Dorthe Friis Pederson

Very few people are aware of their health rights. It’s important that they

know, so they can demand them.

The right to informationWidely disseminated messages about health rights – including respectful treatment by health workers, and mechanisms of complaint – can enable citizens to demand their rights and hold government accountable.

One man’s voiceSpeaking out against bad health services is risky. You will be remembered. But individual acts of courage can bring change to thousands.

How can the clinic staff deny a desperate young woman

transport for the sake of US$ 6?

photo: Dorthe Friis Pederson