The future of Zambia’s health care on wheels

Patients queue up to be seen by volunteer doctors and nurses at a mobile clinic, operated by Doctors Outreach Care International in Ndola, Zambia.Photo: Jorrit Meulenbeek

Volunteer doctors and nursing students distribute medication from a mobile clinic in Ndola, Zambia.Photo: Jorrit Meulenbeek

One of the doctors examines a child outside the mobile clinic operated by Doctors Outreach Care International in Ndola, Zambia.Photo: Jorrit Meulenbeek

Volunteer doctors and nursing students distribute medication from a mobile clinic in Ndola, Zambia.Photo: Jorrit Meulenbeek

Doctor Brian Malao talking to a patient outside the mobile clinic operated by Doctors Outreach Care International in Ndola, Zambia.Photo: Jorrit Meulenbeek

A nurse gives instructions to a patient about the medication she is about to be given from the back of a mobile clinic truck in Ndola, Zambia.Photo: Jorrit Meulenbeek

Nursing students prepare medication for distribution inside a mobile clinic operated by Doctors Outreach Care International in Ndola, Zambia.Photo: Jorrit Meulenbeek

A volunteer doctor takes the details of a mother and her sick child outside a mobile clinic in Ndola, Zambia.Photo: Jorrit Meulenbeek

Patients queue up to be seen by volunteer doctors and nurses at a mobile clinic, operated by Doctors Outreach Care International in Ndola, Zambia.Photo: Jorrit Meulenbeek

A volunteer nurse gives instructions to two young patients about the medication they are about to be given from the back of a mobile clinic truck in Ndola, Zambia.Photo: Jorrit Meulenbeek

A volunteer doctor discusses the condition of a sick child with its mother, outside a mobile clinic operated by Doctors Outreach Care International in Ndola, Zambia.Photo: Jorrit Meulenbeek

Nursing students prepare medication for distribution inside a mobile clinic operated by Doctors Outreach Care International in Ndola, Zambia.Photo: Jorrit Meulenbeek

The mobile clinic operated by Doctors Outreach Care International in Zambia consists of a single truck, specially adapted for this purpose. It was donated by cement company Lafarge, which also provides a driver and pays for the necessary drugs.Photo: Jorrit Meulenbeek

Volunteers packing up a mobile clinic after they have attended to patients in Ndola, Zambia.Photo: Jorrit Meulenbeek

Mobile hospital trucks gathering dust in the parking lot at Ndola Central Hospital, Zambia, where they have been parked since August, only months after they were bought by the previous government using a 53 million Dollar loan from a Chinese bank.Photo: Jorrit Meulenbeek

While the doctors and nurses are yet to arrive, people are already queuing up behind the small truck. Some forty women, men and children have made their way here, despite the heavy rains earlier in the afternoon. The truck's generator rumbles as people fill in their forms, have their vitals checked and wait to be seen by one of the doctors.

This is Mackenzie, a shanty compound on the outskirts of Ndola, Zambia's former mining capital. Even though it is only a few kilometres outside this well-developed town, there is no clinic here. The nearest alternative is a long walk from here and not nearly as good, as it often has very few drugs on stock and has no qualified medical personnel apart from a nurse.

This is the state of the Zambian health sector in a nutshell. While one would imagine mobile health facilities such as this one, operated by Doctors Outreach Care International and sponsored by cement company Lafarge, to be serving in far flung rural areas, they are just as needed here, only a five minute drive outside one of Zambia's largest towns.

The bad state of the roads poses limits on how far this outreach can really reach out. "But in the end, people here are just as deserving of good health care as those living in the rural areas," says doctor Brian Malao, one of the doctors volunteering here today.

"We mainly do testing for diseases like TB and malaria and supply people with the necessary drugs," Malao explains. While operations cannot be done in this unit, Malao and his colleagues can at least diagnoses the most common diseases and refer people to the hospital if necessary.

Hot debate on mobile hospitals

While Doctors Outreach Care International was one of the first to start providing mobile health care in Zambia, the government has recently followed their example. Or at least it has tried to.

In April of last year, now former Zambian president Rupiah Banda proudly presented the result of a 53 million dollar deal he had struck with the Chinese. His government had ordered nine state-of-the-art mobile hospitals, one for each Zambian province.

These units, each consisting of seven heavy trucks, had everything on board, from a small operating theatre to a laboratory and a pharmacy. With the advent of these hospitals, so it was presented, people in the rural areas would no longer have to travel far for good quality health care. The hospitals would now be able to come to them.

To many Zambians, this simply sounded too good to be true. How would the already under-resourced health sector ever manage to staff and supply these units? And would this money, acquired as a loan from a Chinese bank, not have been better spent on building and upgrading regular clinics in the country's remote areas?

With elections around the corner, government-friendly media desperately tried to quench the debate by reporting the hospitals' first success stories. But now, only months after the mobile hospital units were bought, they are surrounded by silence. Employees  at one of the district hospitals where the mobile units are currently parked, confirm they have not been moving since August. Does this mean critics' fears over sustainability have already materialized?

Dr. Emmanuel Makasa, who works as an Orthopedic Surgeon at the University Teaching Hospital in Lusaka, thinks this might partly be the case. Makasa was involved in Zambia's first mobile health projects with Doctors Outreach Care International and FLYSPEC (Flying Specialists). He was also secretary general of the Zambian Medical Association and is now heading the Surgical Society of Zambia.

"Mobile hospitals are not wrong, they are needed, but they are very costly," Makasa says. "For seven trucks, you also need seven drivers. And they all need fuel and maintenance."

But his main worry is how government plans to staff the units. "Human resource is the number one problem in the Zambian health sector," he explains. "The University of Zambia currently only delivers an average of fifty doctors per year, so where will they get the people? They would have to be pulled from other programmes."

In 2010 there were only 910 qualified doctors working in Zambia, serving a total population of almost 13 million. That is less than half the number recommended by the World Health Organisation. And what is worse, almost 50 percent of these doctors work in the capital Lusaka. (Human Resources for Health Country Profile, 2010)

Looking for the way forward

Makasa suggests the focus of mobile hospitals should be different. "They are too expensive to go and provide general health care, treating common colds or malaria, because anybody can do that. What is lacking most is specialized care, for people who have tumors or fractures , who need an operation."

That is why he personally sees more in the American units, consisting of a single truck. "Let the eye surgeons get their own unit, the one they really want. It can just be parked in Lusaka, then they can do outreach for one week every month, to do just eye surgeries," he sums up his ideal scenario. He suggests that the mobile units that have already been bought could still be converted  for this purpose, as well as for disaster management.

His colleague Brian Malao at the Doctors Outreach Care mobile clinic agrees the mobile hospital project may have been 'exaggerated' in terms of size and ambition. He believes the government should rather have focused on expanding the existing Zambia Flying Doctor Service by buying a number of helicopters.

Officially speaking there is no need for any of these suggestions, as there is no problem at all with the mobile hospitals. "They will still be operating as planned, the money is there, budget has been allocated," assures doctor Welani Chilengwe, director of Mobile and and Emergcy Health Services under the Ministry of Health.

The recent change of government, after former opposition party Patriotic Front won the September elections, is cited by others as the reason for the mobile units gathering dust in the parking lot. Ironically, the same Patriotic Front was one of the fiercest critics when the units where first bought, and implied they were just an expensive campaign tool for then president Banda.

Several health workers confirm that the new government has since been consulting experts to discuss the way forward. But answering questions in parliament, vice-president Guy Scott has already hinted that his government wants to continue using the mobile units in one way or the other now they have already been bought.