Zambia Community Health Workforce: A Report for the Michigan Health Council
By Linda White, Peace Corps Response Volunteer in Zambia and former Director of the Michigan Center for Nursing. The Michigan Center for Nursing is a service of the Michigan Health Council.
“There comes a time when one must take a position that is neither safe, nor politic, nor popular, but he must take it because conscience tells him its right.” – Dr. Martin Luther King Jr. So off I went to Africa, specifically Zambia, with the intent of sharing my knowledge and skills as an experienced health care professional to help make system changes. Zambia is one of many developing countries that have cordially invited change agents to come and give it their best shot. I had no idea that I was going to learn more than I was to teach: to be humbled every day by good people doing so much with so few resources; and to be exposed to a brand of community health that I could not have before imagined.
The Republic of Zambia in Central Africa is a country about the size of Texas with a population of about 15 million people. There are nine provinces that can be likened to our states. Each province has its own capital and a number of districts: similar to our counties. About 60% of Zambians live in rural areas, in small towns or villages far from paved roads; utilities like electricity or running water; or public services like schools or health centers. While English is the official language of Zambia there are more than 70 regional tribal languages spoken throughout the country. These languages are part of the rich culture of Zambia that both contribute to its beauty and its social complexities. In the villages, most people speak Tonga, the major tribal language of Southern Province. And while Zambia is a democratic republic, local government is run by head-men, and tribal councils are the decision-makers on the community level.
I am working in the Southern Province of Zambia in Zimba District as a Maternal Child Health Consultant for the Peace Corps Response Program. Zimba is a new district (approximately 2 years old). Like other districts, it has its own district community medical office with a professional staff that include a district medical officer (physician), a clinical coordinator (nurse) and my counterpart, the MCH Coordinator (who is both nurse midwife and nurse educator.). The project to which I have been assigned project is called Saving Mothers, Giving Life (SMGL, designed to address and decrease the high maternal and infant mortality rates in sub- Saharan African In brief, SMGL began in 2012 as a five-year initiative supported by the Zambian Ministry of Health in partnership with the US Peace Corps, the US Centers for Disease Control, PEPFAR, Boston University, the American College of Obstetricians and Gynecologists, and Project CURE to name a few. The project focuses on the “three delays” that prevent woman from receiving appropriate perinatal care: delay in seeking services, delay in reaching services, and delay in receiving high-quality services. Results of the first phase of the program were evaluated in 2013 and were above expectations. Maternal mortality rates were reduced by 53% in target facilities.
SMGL is a community-based program working from the district-level to the villages through rural health care facilities that are scattered throughout the provinces. In Zimba District there are seven rural health centers some as far from the central district office as 40 miles. Factoring in washboard-like dirt roads, swollen rivers and flooding during rainy season and a dearth of vehicles and fuel for the few vehicles available, outreach and site-visits are a challenge. Conversely, transportation from the villages to health facilities is equally as challenging.
When I first started working with the district community medical (DMO) team in Zimba I was overwhelmed. As I started visiting remote rural medical facilities, I learned that staffing consisted mainly of one nurse, a nurse midwife, and a variety of non-professional, locally trained health care workers. The nurses in the rural clinics are ultimately responsible for the health maintenance as well as the medical care in entire catchment areas of a thousand people or more. They are the primary care workforce responsible for acute care as well as health promotion and disease prevention efforts, and it is not surprising that acute care, treatments and therapies, and follow-up absorb much of their time. Hence the support staff must assist with outreach, social and cultural negotiations and primary prevention needs in these communities.
For the perinatal and newborn population, those support workers are the SMAG (Safe Mother Action Group) volunteers. Much like community outreach workers in the United States, they are recruited from the communities in which they serve, locally trained, and key to health-maintenance and wellness efforts. They enter their roles with a deep understanding of their communities and the challenges those communities face.
While the health facilities are responsible for providing direct health care services and the DMO works with the Ministry of Health to build capacity and promote advocacy, SMAG Volunteers are the health service partners who connect to that health care system. Their many duties and responsibilities include offering interpretation and translation of available services, providing culturally appropriate health education and information, assisting people in receiving the care they need, giving counseling and guidance on health behaviors, advocating for individuals and community health needs, and providing some direct services. In short, they strengthen the relationship between the health care system and the people served.
The volunteer role in disease prevention and health promotion is essential to the wellbeing of the families in Zambia. For example, their influence on the increase in institution-based maternal care, particularly institutional deliveries, has been measured. The proportion of women who delivered in a health facility increased substantially, from 44% in 2001/2002 to 67% by 2013/2014 (CSO 2014). Similarly, the proportion who delivered with a skilled birth attendant also rose from 43% in 2001/2002 to 64% in 2013/2014 (CSO 2014). The percentage of births that took place in health facilities rose during SMGL Phase 1 (from June 210 to May 2013) from 63% to 84% in Zambia (a 35% increase). The core of their influence has been helping decreasing delays in decision-making regarding seeking maternal health care.
But the program also has challenges. The SMAG volunteers are just that, volunteers. Some are traditional birth attendants who are no longer practicing, traditional community leaders, or other respected community members. They are both men and woman, young and old. They are dedicated, passionate and committed to their work that may bring them many miles away from their homes at any time during the day or night. They assume great responsibility of pregnant women and their newborns. They do what they do with no monetary compensation and few resources.
I met a SMAG volunteer at one of our rural health facilities that is building a new maternal-child clinic building. Finishing the facility has been a challenge: Several doors did not fit casements; they ran out of interior paint; and the actual construction took longer and was more costly than expected. The person who reported all of this to our district team (I will call him the project manager, Joseph) was a SMAG volunteer. He had been overseen the project from its inception. When I spoke to him, I sensed his compassion and dedication not just for this project, but the whole community. Joseph offered an earful about the community’s health needs. Chief among them are the orphans – children who live “under the trees.” They have no family and no place else to live. Joseph and his fellow volunteers make regular rounds throughout the community to supply food and temporary lodging for these children. Their priority is providing them physical protection. . But just as important to Joseph is influencing their behavior so they do not repeat the lifestyle practiced by their parents that includes early pregnancies and risk behaviors that invite illness and disenfranchisement. One of Joseph’s goals is to make sure these children attend school, and he views education as a key to their future health: “Some of these children had mothers who were very young when they were born and either died or were unable to care for them. They had babies because they did not have anything else to do, with education you can have choices.”
Joseph sees no end in the work that he does. His reward? Children who are no longer living under trees. He has also taught himself to read English. He is content to work as a SMAG volunteer for no pay, and would like to have his own Bible because while he knows it well, he can now read the book on his own.
The social determinants of health span the globe. And while the challenges vary depending where you are standing, the issues are the same: poverty, lack of education; impossible geographic barriers; non-negotiable cultural and social mores; poor or no access to health care to name a few. Here in Zambia despite my pre-departure preparation and years of work in trying to push the health promotion/disease prevention rock up the hill, my vison is blurry. I had every reason to believe that I could push that rock faster here. But the old bromide, “You had to be there,” holds true. Nothing could have prepared me for the Zambia where I live and work. I will not be making huge changes here. But I will be helping my colleagues, particularly the SMAG volunteers, in their quest to reach a population that desperately needs them. Once an ambassador seeking champions, I have found true health ambassadors in Zambia and they are champions. Helping them do what they do to the best of their ability – full scope of practice if you will – is my aim. I am here for them and to support them every way that I can.
I had a conversation recently with a boy who lives in my compound. We were putting my bookcase together from many pieces that came in a big box with minimal instructions. There were doors on the bookcase, and I had instructed him to put them on incorrectly. They needed to be removed and reattached. It was getting late, I was getting increasingly frustrated. There was no power because electric power shedding is the norm in Zambia, and this was not the kind of work you can do by candlelight. I suggested that we quit and finish the next day. He said: “No Auntie Linda. We can finish this today.” And then he offered, “You know, all humans make mistakes.” I agreed. And without hesitation he concluded, “We just try to fix it and don’t do it again.” Humbled about learning about perseverance from this young, thoughtful Zambian I took his lead and made good use of the light that was left.
As Henry David Thoreau wrote, “I desire to speak somewhere without bounds; like a man in a waking moment, to men in their waking moments.”
Linda White Peace Corps Response Volunteer- Zambia (2015-2016) Saving Mothers, Giving Life Zimba District
Disclaimer: The content of this article is that of Linda White and does not necessarily reflect the views of the US Government, the Peace Corps or the Zambian Government.