I would be most grateful if you could kindly publish the attached article in your highly esteemed and most independent media outlet in Zambia today.
S. Joshua Nkama
I read the article by Given Mutinta in the Zambian Watchdog online with a very heavy heart. I had similar experience of the Zambian healthcare system in 1986. It is more than three decades since independence and the public healthcare system in Zambia is probably worse off than it was at independence.
Modern healthcare does not come cheap, and that is because while as one would be armed with a stethoscope, blood pressure machine and a thermometer, with a handful of ‘magic bullets,’ 50 years ago and set up a medical practice, modern medicine is more scientific, more evidence based and more technically demanding. Furthermore the burden of disease in the community is heavier and more complex due to among many factors, ease of travel and longevity of life. Having said that, we know that the major causes of morbidity and mortality in Zambia are communicable diseases, such as malaria, tuberculosis, infectious diseases and several diarrhoeal diseases of both adults and children. These diseases are not only preventable but also curable in the main and theoretically could be eliminated. The scourge of HIV/AIDS has exerted a huge burden on the delivery of health services in the country. Thank God for the cooperating partners who are giving so generously to alleviate the suffering of many Zambians. There are not enough resources in the country forZambiato tackle the problem of HIV/AIDS without external assistance. As long as highly active antiretroviral drugs remain expensive, we will continue to depend on external help to finance these treatments. However, as patents expire and more of these drugs become generic, the prices will come down, and the country must be prepared for this.
The question is: What can be done to improve our healthcare system so that it can be fit for purpose? Here, I would like to humbly make a few suggestions.
- EXPAND PRIMARY HEALTHCARE SERVICES.
As I have stated in the introduction, the vast majority of diseases that afflict the Zambian people are communicable and thus preventable. There are 150 political constituencies in the country and each of these gets a substantial amount of funding. These constituencies can be the basis of primary healthcare centres.
(a) How many Centres?
These centres could be responsible for immunizations, school health services and health education. There is a very good model of services that was in use in the mining communities on the Copperbelt. Each town had several clinics which could provide simple health services including uncomplicated maternity care. Each was run by a Registered Nurse in charge and visited by a medical doctor once every day. All the residents within the clinics’ catchment areas would be registered there and their health records kept there as well. No one would be allowed to go to the hospital without being seen at the clinic initially. Each of the clinics would be supplied with a fully equipped Ambulance for emergency evacuation as well as an ordinary transporter. If there are 13 million people inZambia, I reckon that to begin with we can build 1,300 such Clinics for each to cater for 10,000 people. This would also work out to approximately 10 per constituency.
Each clinic would be manned by a Clinical Officer, a laboratory technician, and a Registered midwife and a Radiographer assisted by several nurses and auxiliary staff. 10,000 people inZambiawould be in approximately 1,000 to 2,000 households. This is not a large register to keep at the Clinic. There is no need for Clinical officers at hospitals. This cadre of staff are well suited to deal with minor ailments. To boost Clinical Officers morale, their own career advancement profile may be laid out to include greater responsibilities and higher training to degree level.
What kind of building would this clinic be? I reckon that it would be equivalent to the size of a 5 bedroom high cost area house. The clinic would have a delivery suite, a recovery room, a laboratory, an ultrasound and radiography room. A dispensary with a stock of drugs on the ‘essential drugs’ list is also added. The dispensary will be supervised by the district Pharmacist or Pharmacy technician. I am certain that there is some government housing stock that is yet unsold that can be converted for this purpose.
- IMPROVE DIAGNOSTIC CAPABILITIES.
Hit and run and guesswork medicine is costly. The cost is substantial not just in terms of finances but in terms of life as well. Not every pneumonia will respond to the same antibiotic and not every sore throat needs an antibiotic. Where there are inadequate diagnostic facilities, there will always be waste, and delays in treatment. Delays in accurate diagnosis and therefore treatment mean that a communicable disease is allowed to spread and suffering is prolonged. Take for example, a person who presents with fever and cough. He admits to loss of weight. The practitioner may prescribe a course of antibiotic for 7 to 10 days. After the course, there being no improvement, he may send the patient for a Chest x-ray. The chest x-ray shows features compatible with pneumonia. Is it tuberculosis or is it pneumonia (inadequately treated)? If it is TB, this patient is spreading the infection in the community. If it is pneumonia, he may be hospitalized for nothing. The importance of good diagnostic facilities, whether laboratory or radiographic cannot be over emphasized. The State must invest in 1,300 such centres to support these clinics. If the funding is inadequate, it may be possible to pool a number of clinics under one diagnostic centre.
- INVEST IN LOCAL DISEASE RESEARCH
TheNdolabased Tropical Diseases research facility as well as the National Council for Scientific research and Food and Drug agency must be adequately funded. It is a matter of national security to have your own research facilities that can deal with disease outbreaks, check imported drugs and so on. How can we be sure that the drugs that are being sold in our streets are ‘kosher?’ This world is full of criminals who are ready to profit on the misery of others. Right now, there is a ‘nodding disease’ spreading through southernSudanand just like HIV/AIDS, we sit back thinking that it will not affect us, but it will. Government health policy should be determined by facts and by facts collected by our own people and not wait for the WHO to tell us.
- ENGAGE LOCAL COMMUNITIES IN LOCAL HEALTH NEEDS.
This is crucial to a healthy community. I mentioned briefly about school health services. Local people must be engaged through schools and the clinics to decide their health priorities as well as gauge the success or failures of interventional programs. How do we know that vaccination works? Every year, we hear of outbreaks of cholera and now typhoid. These diseases do not need rocket science to prevent and to kick out. People can be mobilized to build drains and get rid of stagnant water pools in their environment.
- HAVE FOUR HIGHLY SPECIALISED TERTIARY AND TEN PROVINCIAL SECONDARY CARE CENTRES.
Once the primary health care centres are in place, we can have Provincial and district hospitals left to deal with more complicated cases and surgery. Each district general hospital would be led by a medical officer who is also trained in community or public health. The Provincial general hospitals must have a minimum of three general surgeons, two internists (physicians), three Gynaecologists and Obstetricians and two Paediatricians. At this stage, it may suffice to have Utrasonographers and laboratory technicians only in the diagnostic services. Each Provincial general hospital will also have a central sterile services and laundry department as well as Pharmacy warehouse. However, there should be at least four centres of excellence inNdola,Kitwe,Lusakaand Livingstone as tertiary referral centres. Each of these should have a full compliment of all the specialties including supporting services, such as pathology, microbiology, radiology and biochemistry.
How do we fund this program?
I am aware that a greater proportion of the healthcare budget goes into remuneration. It may not be possible to build the infrastructure and at the same time to provide the manpower for this. We need to retrace our footsteps to the ‘golden age’ of Zambian health services. In the early years, doctors and highly skilled nurses were funded by our cooperating partners. This kind of aid is targeted and unlikely to be pilfered. There are thousands of retired good doctors and nurses in the western and developed world who are still strong and fit enough to work for far less while they continue to receive their pension, who would be willing to assist inAfricafor short contracts.
This can be negotiated with the donor countries. There would be enough money left over to build the infrastructure to start with but once these are up and running, more funds would be channeled into remunerating local staff. It is not money that keeps healthcare staff happy in their jobs, but job satisfaction. Every person I have known would like to go home at the end of the day, put his or her feet up, and relaxes while feeling satisfied that they have made a very big difference in someone’s life that day! The salaries and wages budget in the Ministry of Health is enormous as it is already. I do not believe that the state can afford ever, to remunerate Health care staff adequately without external help. It may be time to negotiate with cooperating partners to assist in this, until there is a robust system of personal health insurance in place. This may help to plug the ‘brain drain.’
You may shoot down these proposals or punch a million holes in them, you are most welcome. I am not claiming to have the monopoly of knowledge but I welcome debate, because so far, we have talked and criticized but not offered any constructive views.
The average life expectancy of Zambians is increasing, and the downside of that will be an increasing number of people afflicted with the more expensive diseases that come with old age and affluence. We need to act quickly to ameliorate the heavy economic effects that will come upon us with that situation. There must be very long term planning so that we are not caught unawares.
God bless the Republic of Zambia.