The Zambia general elections are scheduled to be held on September 20 to elect a president and representatives to the National Assembly. Civil society organisations in Zambia have identified the elections as an opportunity to ensure key health issues are a priority issue during the polls. This has been done successfully in various African countries, most recently in Malawi.
The campaign will target leaders who are standing for election, asking them to commit to prioritising equitable and improved access to healthcare services. The campaign will reach out to communities across the country to ensure that issues around the delivery of healthcare services at the local level, in terms of access and quality, are highlighted. This will be done through community meetings with leaders, case studies, roadshows and other popular mobilisation activities, as well as through lobbying political and community leaders. The campaign is being run by a broad range of organisations under the umbrella of the Civil Society Health Forum and Fair Play for Africa.
Chiawa district lies between two mighty African rivers — the Kafue and the Zambezi. The village overlooks the banks of the Zambezi, with Zimbabwe visible on the other side of the water. A small herd of elephants graze at the riverside, buried up to their massive tusks in lush greenery. This may sound like an African idyll but life is hard in Chiawa.
The elephants often destroy the villagers’ crops and vegetable gardens and when the floodgates of Lake Kariba are opened, their fields are submerged and their harvests lost. For subsistence farmers losing a crop means going hungry until the next harvest, leaving few resources to spare when an overburdened health system cannot help them.
Mary Sakala, headwoman of Chimanga Village in Chiawa
“I am responsible for the wellbeing of all 105 households in my village, and I am really not happy with the health centre because they don’t have enough medicine or staff,” she says. “There is just a nurse and a clinic officer and they have to go all the way into Kafue each month to collect their salary, which means they are away for four days. If someone is sick in that time, then we have a problem. Recently a woman gave birth when the staff were away, and then started haemorrhaging while she walked to Chirundu, which is our nearest town, 36km away. There is no transport and no taxis in this area. She died.”
Getting to and from Chiawa is no easy feat. The only way to cross the Kafue River is by a pontoon bridge, designed to float cars and trucks across the water (and this is one place where the term “crocodile infested” is not hyperbole). Villagers can hitch a ride on the pontoon ferry for free, but it only crosses when transporting a vehicle that can pay the 68Â 000 Kwacha fee (R94). Sometimes a truck can be hired from a neighbouring area but that costs about K70Â 000 (R97), in addition to the pontoon fee.
“Last night we were lucky,” explains Sakala. “A 19-year-old woman gave birth but then she started having hallucinations. The clinic here didn’t have the means to help her so we had to get her to the hospital in Chirundu. But we have no cars or buses here as we are far from town. The clinic staff walked to the main road and managed to flag down a car. That driver was kind, and he came to the village to fetch the woman and then drove her to the hospital. That was very lucky because not many cars use that road and most people who drive by don’t stop.”
The government recently abolished user fees in rural Zambia in an attempt to ensure more people could access health services. Unfortunately the Treasury did not allocate additional budget to make up this shortfall.
“They may have scrapped user fees,” exclaims Sakala “but it makes no difference: they didn’t have medicine before and they don’t have it now. The only change is that now you don’t pay to go to the clinic, and only then find out they have no medicine to give you. As an elderly woman it was difficult for me to pay that fee. At least now I can use that money to buy food like rape [a green leafy vegetable] and tomatoes. When they don’t have the medicine we need then we have to go to town and buy them from the pharmacy. If you have to go to town you have to hire someone to take you and it is very expensive. Last year I had to pay K15Â 000 (R21) for malaria tablets and also because I was having problems with my legs. There are 11 people in my household, including my grandchildren. A bucket of maize costs K25Â 000 (R34), so if I spend K15Â 000 on medicine then we don’t have money for food.”
Sakala feels ambivalent about the upcoming general elections. “Our MP is useless. He made promises to get us to vote for him, but he hasn’t done anything for us. Our politicians only come here when they want our votes.”
Justin Chibanga, headman of Chiawa village with 182 households, joins in the discussion. “We can’t rely on the government and we are fed-up. We vote for an MP but then he goes away after we have voted and we don’t see him again. They only come here when it suits them for their political campaigns. Our MP came here in June to launch a mobile clinic. And that was the last time we saw him or that mobile clinic. What is the point of adding mobile clinics when we already have a clinic but they can’t equip it properly? They should put our existing clinic in order first.”
While Chibanga stresses that having an ambulance to transport patients to the nearest hospital would solve many of the problems, the irony is that there is an ambulance in the village. In fact it’s a brand spanking new “water ambulance” boat, designed to avoid bad roads and allow for speedy transport in the rainy season when roads are often impassable.
But the community tells us that the ambulance has never left its riverside mooring as there is no fuel to run it. Apparently the district health office has yet to start budgeting for fuel. And in the meantime, patients who cannot afford transport or who cannot get to the hospital in time will continue to die.
Rosemary Chimwanga, midwife and nurse at Chiawa Rural Health Centre
Chimwanga has worked for the Zambian Ministry of Health for 24 years, and says the system is deteriorating. “It is getting worse in all ways. Firstly, we don’t have enough essential drugs or antiseptics. They deliver drug kits but often items are missing. Up until 2005 we used to get everything we needed in those kits. But this morning I delivered a baby and didn’t even have basics like cotton wool. I’ve spent the last three years working in a teaching hospital in Lusaka but now that I am back in a rural health centre I can really notice this problem. We don’t get the injectables we need, such as Diazepam. When I had a patient who was convulsing I had to give her the drug in tablet form which causes a delay in response.”
As we talk there is a disturbance from the nearby ward, where Zezai Gubo (five) has been admitted with cerebral malaria. She is having convulsions and has ripped the drip out of her arm. Chimwanga moves quickly to soothe the child and calm her mother, but has no gauze or cotton wool to wipe up the blood oozing from around the drip needle. She has no choice but to wipe it with a cloth, something she feels is unhygienic and unprofessional.
“Secondly, we don’t always get the money to maintain and keep the clinic clean so we can’t buy things like Cobra [floor polish] and Jik [bleach]. We used to spend the user fees to buy those cleaning supplies. The scrapping of user fees has led to us seeing an increase in the number of patients but the budget is the same. In fact, sometimes they even reduce the budget when they run short of funds. We have two wards here but we can’t admit patients overnight as we have no budget to feed them. This is a problem because we do have patients who should be admitted because the hospital is far away and transport is expensive.”
Chimwanga explains that it is very difficult to get young nurses to work in a rural health centre where there is no electricity and no running water, and very little in the way of recreation or social activities. “We need to train and hire nurses who have a passion for rural health,” she says “but we also need to ensure we provide more incentives to retain staff. I am not just talking about allowances for working in remote areas, but also incentives like running water and a flush toilet. There is no bank here, so I have to go into town each month to get my salary, and that also costs me money.”
The clinic and its staff and patients rely on a nearby borehole for water and pit latrines for sanitation. The latrines are, of necessity, situated a slight distance away and a trip to the bathroom during the night can be dangerous, with elephants and hippos and grazing in the area which is close to the river. It is easy to see why young nurses might be reluctant to give up the comforts of city life.
“When I deliver babies I put water in a bucket and have to wash my hands in that between deliveries. Running water is the kind of incentive rural health workers need.”
Jelita Mboza, patient at Chiawa Rural Health Centre
“I have got a very bad toothache so I have come to ask for help here at the clinic. I am very happy now that we don’t have to pay the user fee, because I can use that money to buy food. Also we need to pay for transport if we are referred to the hospital in Chirundu, and it is very difficult for us to pay for it. They say there are mobile clinics but we only saw them once, when they were launched. They haven’t come back.”
Jacob Kaneya, environmental health technologist, Lungobe Rural Health Centre
In theory Kaneya’s job is to focus on preventing outbreaks of disease such as bilharzia, cholera and malaria. But the reality of working in an under-resourced rural health clinic is that he often has to turn his hand to a range of other medical interventions — including delivering babies.
The health centre has a clinic officer who runs tests on patients and prescribes medicine, as well as a nurse. “We are actually supposed to have two nurses. My house is here on the clinic grounds, but my colleagues live elsewhere, so once they go home I am only trained health worker here.” He raises an eyebrow and chuckles: “Let’s just say I have delivered lots of babies in the middle of the night.”
Kaneya’s work includes educating the 7Â 200 people in his area about a range of issues from using bed nets, spraying for mosquitoes and treating water to ensure it is safe to drink. “Prevention is better than cure,” says Kaneya. “If we had the resources to do preventive work properly, we would not need to use so much medicine.”
A key aspect of Kaneya’s work is an outreach programme, travelling on a motorbike to remote rural villages to vaccinate children under-five against polio, diphtheria, measles and tuberculosis. But for the past month he has had no petrol to refuel his motorbike. The cooler in which the vaccines are kept is run on kerosene, and they have none of that either. “For the past month we haven’t been vaccinating children. We had to send all our vaccines to Mumbwa [a nearby town] where they have electricity, as we could not keep them at the correct temperature. We are supposed to get fuel from the district health office, but they say they don’t get the money from head office.”
Distances in sparsely populated rural areas often present a major stumbling block. “We can deal with basic cases here, but for serious cases or for patients with complications they have to go to the hospital in Mumbwa. It is about 35km away and they have to provide their own transport, which costs about 14Â 000 Kwacha each way (R21). Public minibuses are quite scarce in this area so the prices are higher. We have enough drugs to treat flu, coughs and diarrhoea but we have a problem getting Praziquantel to treat bilharzia. People have to travel to Mumbwa to buy it from the chemist. The medicine costs 10 000 Kwacha (R15) and that is after they have paid for transport. That is very expensive and people around here can’t afford it”.
User fees for patients in rural areas have been scrapped in an attempt to ensure poor people can access health services. Unfortunately the revenue lost to clinics is not replaced by the Department of Health, which means health workers often have to make difficult choices.
“We haven’t seen a huge surge in patient numbers since the user fees were scrapped,” explains Kaneya. “We those fees to buy kerosene for the vaccine fridge and petrol for the motorbike, but now we have to rely on the District Health Office in Mumbwa for those things. They tell us their grants have been reduced since the Global Fund withdrew its money and now they don’t have enough money to run the whole district. I feel very sad that corruption has led to hindering progress in providing health services to our communities. Because of a few individuals in government, the poor people who don’t know anything about that corruption case are suffering. This also leads to health workers becoming demotivated, even though we keep trying to do our best.”
Kapula Chindumba, community volunteer Lungobe Rural Health Centre
“I have been a volunteer here since 2006. I am actually retired — I used to work in the Department of Agriculture. I was taken to Chainama for a course on training and counseling and I got a certificate. After training I realised how essential it is to work on HIV issues.
“I do voluntary counseling and testing for HIV, and I can tell you the rates are dropping in this area because of the education around HIV and Aids. People come here, from age 12 to people in their sixties, because they trust us to be confidential, and because they can talk to us.
“We used to get a small stipend, but now the budgets have been cut after the Global Fund has cut the money, so I don’t know if we will get that money again. But I still come to help because otherwise the clinic staff would be overwhelmed — this clinic is very overpopulated. I have a small farm, and a lovely wife so I am free to make my contribution to society.
“I felt very bad when I heard about the corruption. Our high officials were very careless — that money was really helping us, and they mismanaged money which was supposed to develop this country.”
Ady Moomba, patient at Lungobe Rural Health Centre
“I have brought my baby in because he has diarrhoea and is vomiting. I live in Maphoko which is about 2km away. I rode here on my bicycle. It is better now that we don’t have to pay to come to the clinic because now I can use that K500 (75c) to buy salt, or I can save it in case we have to travel to the hospital in town. The queues are longer now than before because people don’t have to wait to find the money before they come to the clinic for treatment.”