Saturday the 21st of October was a special day in Sikonge, Western Tanzania, as there were celebrations for the centenary of the hospital started by Doctor Keevill. Br David Howarth represented the PEC, and we both represented the British Mission Board, me being a co-opted member. I first spent three months in Sikonge in 1982 as part of my medical training and felt it was a real honour to return in an official capacity. The day before the celebrations David and I spent the whole day in Sikonge and saw many areas of progress. I will concentrate on the hospital and the many improvements we witnessed. The one thing that has not changed in the Mission Hospital is worship to start the day at 07:30. If staff do not attend this, they must begin work so people of all faiths and those of none tend to go to the service!

The old operating theatre where I had assisted 41 years ago has now two dental chairs and two dentists - this is progress indeed as there was no dental provision at all in 1982. There was a functioning X-ray machine and two ultrasound machines. One of these was very good and could be used to image the abdomen and the heart. In outpatients, which really is a mix of GP problems and A&E ones, there is a form of very simple examination of each patient as they arrive to assess how urgent their problem is (triage). There is one emergency room but as it is not in constant use equipment may need to be obtained from the wards. The laboratory can now analyse vials of blood just as in the UK and look at a slide down a microscope for malaria parasites. There is a stock of blood for transfusions that is obtained from the nearby government hospital.

There are new medical, surgical and children's wards with a central nurses' station with Nightingale wards for male and female patients. All the beds have bed nets to help prevent malaria. Oxygen - there was none in 1982 - can be given via concentrators: this is common in Africa. There are also two private rooms with en-suite facilities if patients elect to pay for these facilities. There is a new child health and anti-natal department. There is provision for HIV/AIDS treatment in outpatients and also in a separate government run building on the site. The laundry is done by hand and dries in the sun. There are disposable gloves rather than the washed one we used in 1982. There are many large vessels of water for staff and patients to wash their hands and liquid soap is used.

There is an excellent new (2019) physiotherapy department with up-to-date equipment and a section that makes prosthetic limbs. We saw one being worn at the home for the last few patients with leprosy who have no one to care for them and it was certainly very lifelike, so much so that I tapped it to make sure it was not a real leg!

You will be aware that to celebrate the centenary of the hospital a fund is being set up to assist those patients who find payment difficult. The hospital has just begun to put this into practise. Their policy states the goal is: 'as a Mission Hospital we want to offer treatment and medicine to every single person in need. No one in need of treatment should leave Sikonge Mission Hospital without getting help due to the lack of ability to pay'.

The policy is based on those of several other mission hospitals. The patient is screened, after treatment if they are very ill, as to whether they need help with payment or provision of food. A social worker does the initial screening, and the doctor determines how urgent the care is. Children under five, pregnant women and those with some specific diseases get some treatment free. Two members of the hospital management team consisting of the senior doctor, matron and chaplain authorise the exemption, though this falls on the senior nurse if it is out of hours. The social worker also helps patients by explaining their treatment and how to take medication when they are leaving. He can help with local languages if the patient has not understood the doctor or nurse. It was interesting to see how wealth was assessed using possessions such as livestock, land, a house, a radio or TV; occupation; means of transport such as by foot, bicycle, motor scooter, ox-cart or bus; and also the patient's physical appearance. Social networks are important and people who attend social gatherings such as funerals will be helped by family and friends. Some are vulnerable as they may be addicted to alcohol or be subjected to domestic violence and so may not be able to pay for their care. The policy also applies to the seven outlying clinics but if the hospital cannot offer the care needed it does not apply in the government total in Tabora. The very poor therefore may not go to Tabora even if this is advised as they will not be able to get there nor afford the treatment.

Two cases will illustrate the way the policy works:

• A 37-year-old man was involved in a road accident. He had a badly broken leg and no money. There is no orthopaedic doctor in Sikonge so he needed to go to Tabora. He could pay later so was given a temporary exemption and taken to Tabora in an ambulance car with two other patients. The hospital in Sikonge will be paid for their part of his care later.
• A child came with a fever that had been going on for four or five days. The child arrived after a motorcycle ride of two hours and the mother had left four other children at home. They were from a poor tribe and lived very traditionally so in this case even if the child was over five years, they may get an exemption of hospital fees.

A traditional healer may also be used at times and even in conjunction with modern hospital medicine. This can make the patient's care more difficult.

Thus, this policy and assessment is used so that the hospital's motto of 'patient first' can always be fulfilled.

Celebration of the centenary or jubilee was an uplifting experience with worship around the commemorative monument that the bishop unveiled and then a five-hour service with many choirs participating, including the hospital choir with their commemorative T-shirts that say 'be servants to one another in love' from Galatians 5 v13. Br Howarth and I gave greetings and Br J¿rgen B¿ytler preached in Kiswahili, but he had given us English translations.

It was a wonderful experience to see many new developments and celebrate with staff, clergy, villagers, and patients something that had begun in mud huts a century ago.

Sr Claire Summers
British Mission Board