Piloting a new approach – reflections from Dr Greenan

What a difference a year can make! When I had to leave Zambia in March 2020, after just 5 weeks of doing On-Call Africa (OCA)’s mobile clinics, I knew I’d be back again – and after completing my GP training in early April, the timing was perfect (pandemic aside) for a return trip. And so, two months ago, armed with a negative COVID test, paperwork proving my need to travel to work and a bag packed with as much PPE as I could carry, I set off from Heathrow.

Coming back to somewhere I had worked before had its advantages – I knew Livingstone well, knew some of OCA’s staff and had experience of the Zambian healthcare system, so in some ways I knew what to expect. However, the way we are working now has changed drastically. With mobile clinics out of the question as long as the pandemic is ongoing (and who knows when it will end?), OCA set about working out a new, even more sustainable model of working. Instead of running mobile clinics in three different outreach posts each week, coordinated with the local rural health facilities, volunteers are now placed in one rural health facility for the duration of their placement, working together with and supporting staff to identify and implement quality improvement projects. And so Ellie and I, the guinea pigs of this new model, have found ourselves splitting our time between the base in Livingstone and Kanyanga, a rural health post in Zimba district.

Suggestions are welcome at Kanyanga Health Post

Kanyanga, as a Rural Health Post, should serve a population of 3500. Instead, almost 25000 people live in its catchment area (which also covers 15 outreach posts up to 40 km away), and are served by two nurses, one clinical officer, one environmental health technician, and eight community health volunteers – these are unpaid volunteers who work incredibly hard to serve their communities. As you can imagine, its a busy clinic! In our time here so far, we’ve seen everything from axe-wounds to inhaled foreign bodies, malnutrition and liver disease, as well as the endless stream of minor illness and coughs and colds visiting the clinic. As well as helping out in the clinics, our role is to observe the general running of the health post and try to find solutions to some of the problems. On my first day at Kanyanga, I was overwhelmed by the challenges I saw: the nearest hospital (Zimba Mission Hospital) is 2 hours away on poor roads, and transport is infrequent and too expensive for many to use, which results in more complex cases being managed at the clinic. District-level drug shortages lead to medication stock-outs (for example there have been no asthma medications at Kanyanga for at least 6 months), and poverty and water scarcity combined with poor levels of health literacy mean there is a high level of preventable disease seen. We clearly cannot ‘fix’ everything during our three months here, however we can start to make suggestions and implement small changes. Some of the projects we have started include, improving the antibiotic prescribing rates by training staff and educating patients in order to try and tackle both the risk of resistance but also the frequent drug stock-outs. We have also been working on improvements to the maternity assessment and referrals system to try and get the most high-risk pregnancies identified early and referred to Zimba for delivery, but there is still significant fear and resistance to this among patients. For those who rely on the monthly outreach services to access healthcare (staff travel out on the clinic motorbike), we are trialing a new outreach kit this week to try and streamline the services provided – and this has been well-received by the staff! And this is all just phase 1 of the project: more volunteers will arrive after we leave to continue the projects we have started and develop others. Similar cycles of assessment and implementation will also take place at other rural health facilities. As part of the bigger picture, OCA plans to tackle some of the larger infrastructure problems by installing solar panels so that the maternity unit will have power, and a new bore hole to improve access to water at Kanyanga. We are also looking at ways to fundraise for a new mother’s shelter: this is where pregnant women, who often have to travel long distances to attend Kanyanga, stay in the lead-up to delivery to ensure that they are close to the clinic for delivery: the current shelter is very basic and not an appealing place for a heavily pregnant woman to stay.

The new outreach kit in action

One of the major benefits of this new way of working is that there is the potential for sustainable long-term improvements. By embedding ourselves within the community and working alongside the Zambian healthcare staff, we can work together to come up with solutions to problems. We’ve had meetings with staff, patients, village headmen and the District Health Office director to ensure that any suggestions we have are realistic and in-line with the community’s needs and ministry of health aims. The goal of sustainable improvements is what drew me to OCA last year, and we spent a lot of time then training community health workers and carrying out health promotion sessions with the communities  we worked in to try and achieve this. The new way of working feels like an even bigger step forwards in that direction.

And what about COVID-19? Zambia as a whole has thankfully had relatively low rates of infections and deaths, apart from a small spike in January. In Livingstone, wearing masks inside shops and restaurants is compulsory, however otherwise there are no real social restrictions. At Kanyanga, patients and staff wear masks and hand-washing is encouraged, but access to testing is limited, and so it is difficult to get an idea of the number of cases, especially since cough is one of the most common presenting complaints. I was lucky enough to receive both of my doses of vaccine before I came out here, and in the last couple of weeks the Astra-Zeneca vaccine has been available both in Livingstone and rural areas as part of Covax, meaning that most of the healthcare staff we work with have now received their first dose. There is sadly still marked vaccine hesitancy among the lay community, which is now being tackled with public health campaigns, but a good start has been made nonetheless. As the risk of a third wave across the world increases and puts pressure on over-stretched hospitals, the projects we are working on to strengthen primary care services in rural Zambia feel even more relevant.

Aside from work, our living situation in Kanyanga is a pretty comfortable set up: we stay with a local family who live about a 5 minute walk from the health post. We take large safari-style tents, and have mattresses, a gas stove and a solar panel for charging electronics: very 21st century bush-camping! We share toilet and shower facilities with the family (as well as befriending their children, dogs and goats). Despite spending more time in the bush overall than we did last year on mobile clinics (6 to 10 days at a time currently),  the level of comfort is a definite improvement, and it does feel like a home away from home! We tend to spend the morning helping out at clinic, and use the afternoons collecting data for our projects or running teaching sessions for staff.  Football is the main extra-curricular activity here, and we’ve spent afternoons cheering on our colleagues on the local football pitch. Once the sun goes down and it starts to get a bit chilly, we have the starlit sky to admire, before retiring to our tents with a book or some Netflix downloads. Our weeks back in Livingstone are also very flexible, we take advantage of the internet access to do some planning and preparation for the clinic weeks, but also have plenty of time to take in the tourist sites: Victoria Falls is just up the road and its easy to organise a trip into the local national park, and (depending on the current COVID restrictions) even visit some of the neighbouring countries. Writing at a time when travel from the UK is still heavily restricted, I feel more than lucky to have one of the wonders of the world on my doorstep.

Our home away from home

So yes, COVID-19 has led to huge changes in the way OCA will work going forwards. Having experienced both mobile clinics and rural health post placements, I think that the new model has some clear advantages in terms of long-term sustainability, which has always been part of  the ethos of OCA (as it should be within the aims of any NGO). I’m really excited to keep in touch with OCA and its future volunteers based at Kanyanga to see how it continues to develop once I’ve returned to the UK. Who knows, I may even return one day to see the changes first hand!