Meet My Heroes

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.