Zambian nurses are my heroes. The
challenges that they face between high demands of performance and
documentation with the realities of their work environment (high
patient population, lack of human and material resources, supply
chain failures and institutional bureaucracy) are way beyond anything
I have ever faced. They do their best with what they have at hand,
yet are the ones on the front line who get the blunt of criticism
that performance goals and accurate documentation are not being met.
Some of the nurses get overwhelmed and just do the minimal to keep
receiving a paycheck. Others go above and beyond the call of duty
spending enormous amounts of their personal time caring for the
population around them.
Zambia has a well-designed but poorly
managed rural health system. A nurse may get placed several hours
from the nearest town in places where transport is quite minimal.
They are provided with housing, but this is often in poor condition.
Many of these communities do not have electricity or indoor plumbing.
The clinic will have a solar panel to keep the freezer running for
storing vaccines, and perhaps a gas burner to help with sterilization
of equipment. There will be pit latrines out back.
Often for a population of 10-15
thousand people there will be one nurse and perhaps a support staff
(cleaner/admin assist) and a volunteer or two. The expectation is
that you provide weekly under five, antenatal, post natal, and family
planning clinics along with just regular outpatient clinics for sick
people. Oh, and there is also usually a one or two bed labor ward
which you must cover 24 hours a day (hopefully with the assistance of
a traditional birth attendant). On top of this there is the
expectation that three days a week you go out to one of your smaller
health posts in surrounding villages to offer under-five, antenatal,
and family planning services. Each health post is expected to be
visited once a month. One of our nearby rural health centers actually
has two nurses assigned to it, but one has been away at school for
the last two years and no one was sent in her place. She is still
considered assigned to the post and is expected to return on breaks
and work.
Of course besides all the duties at the
clinic, there are tremendous administrative tasks. Meetings and
in-services to attend, monthly reports to fill out, vaccine and other
supplies to order and sometimes collect from the district offices.
With so much of the funding for health care coming from international
donors, there is tremendous demands on documentation which are
unrealistic for the realities at hand. Too much time gets spent on
meeting these needs and it takes away from the practicality of
providing the needed services. Decisions are made by people far away
in big board rooms without input from these nurses on the ground who
know the realities. It really can lead to high frustration levels and
burn out.
A few examples of what I mean. The
nurses understand the importance of preventing the spread of HIV from
mother to baby. When a mother tests positive she needs a blood test
done called a CD4 to see the extent of her HIV disease to determine
if she can be on a single medicine regimen (which can be managed at
the rhc) or full haart (three medicine regimen) which needs to be
monitored at an ART clinic. These blood specimens need to be
processed within 24 hours at a lab with the appropriate equipment.
Many rural women do not have the money to get themselves to such a
lab. For several years they have been trying to get a system into
place by which a courier on motorbike would visit each clinic monthly
on a scheduled day to transport these lab specimens back to the
hospital and deliver the results. It is a simple system which the
nurses keep advocating for, but the district health office has not
managed to put into place. Most of these clinics already have
environmental health techs who have motorbikes and go to Choma often
and could transport these specimens, but bureaucracy keeps that from
happening. One nurse I know took matters into her own hands and took
the specimens herself to the lab at the district hospital only to be
told they couldn't run them because no official procedure was in
place yet with the district. The district had promised to set up a
courier system and only then would they accept samples from outlying
rural health centers!
There are two large problems currently
which reflect highly on the daily challenges these nurses face. At
the beginning of the year the Ministry of Health wrote into policy
that all pregnant women will be put on life long haart (the three
medicine regimen which requires closer monitoring and follow-up).
This is a great decision, but the implementation is quite difficult
for many of the reasons described above. The problem is the country
has run out of AZT, the single medicine regimen given to pregnant
women whose disease is not so advanced, and which can be managed at
the rhcs. So now all the nurses at the RHCs can do is refer HIV+
pregnant women to an ART clinic for management. If the women can't
manage to get there, then they will receive nothing to prevent the
disease from transmitting to the baby during pregnancy. Full Haart is
the long term solution, but until this can be safely implemented the
AZT option still needs to be available or all the hard work to reduce
the number of babies with hiv will slide backwards.
The second very frustrating thing in
the PMTCT arena is that two months before the year ended the country
ran out of reagents to run the lab test for early infant diagnosis in
babies born to hiv exposed mothers. It was only last week with the
new year that monies were acquired to purchase more. They have begun
work on the back log of samples.
On top of all this, several hundred
nurses were recently fired by the president after striking for a few
days. In September the government had given large raises (up to 200%)
to the support staff (cleaners and groundskeepers). This in itself
was not a bad thing, but the nurses and other professionals such as
pharmacists' salary increment was less than 5%. In hospitals this
means that some support staff are making the same as a new graduate
nurse. The nurses went on strike at two big hospitals in the country
for a few days. The government agreed to remedy the situation in the
next monthly paycheck so the nurses went back to work. The government
did not hold up its end of the bargain so the nurses went on strike
again this time at the main hospital again and two other bigger
hospitals. Though they went back to work within a couple weeks, the
president fired them for putting patients lives in danger. Now weeks
later wards of hospitals are shut down and patient care is truly
suffering but the president will not budge. The deputy Minister of
Health died a few weeks ago of a heart attack purportedly suffered
at the state house when he went to talk to the president about his
actions and to plead on the nurses behalf. The president is planning
on replacing these nurses with new graduates fresh out of school.
Many of these nurses had years of experience, the best of them will
get hired in the private sector and once again the public health
system will suffer.
It is quite frustrating to see this as
Zambia is a country rich in human and material resources. In my eyes
it is simply poor management and corruption that keep the system from
running well. Too many good people get frustrated trying to fix the
system from inside and leave to work with NGOs or the private sector.
In the meantime the health of the country suffers.
