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Crafting programs in Zambia for limited resources

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Interview with Christopher Warren, Logistics Coordinator for almost three years in Kapiri M'poshi, Zambia. He was also interim Head of Mission during his final four months in Zambia.

Can you describe the project MSF runs in Kapiri, Zambia?

"The MSF project in Zambia revolves around the clinical care and treatment for people living with HIV/AIDS, along with the prevention activities that are also implemented. The prevalence in the country is approximately 17 percent.

"In Kapiri, where our project is located, prevalence is closer to 25 percent. The project works within Ministry of Health structures, based out of a district hospital and fifteen rural health centers. We classify them as big and small. In a big health center, a person can receive clinical diagnosis, care for opportunistic infections, and ARV refills.

"In a small health center, due to the lack of sufficiently trained medical personnel, people can receive care for opportunistic infections, counseling, and testing.

"In addition to our HIV/AIDS work, we have responded to annual cholera outbreaks in Lusaka and throughout the rest of the country. Cholera is endemic in Zambia, it coincides with the rainy season. At the beginning of the rains we see the first cases of cholera."

How has MSF responded to emergencies in Zambia?

"Initially, when we have started the project, MSF was entirely responsible for the clinical care. But in the most recent years, we have worked in collaboration with the Ministry of Health to provide technical support, both medically and logistically, in the running of cholera treatment centers. At the request of the Ministry of Health and upon our recommendation, we have built temporary structures that they can then staff with their own Ministry of Health people. We also provide medical and logistics people to observe and provide technical support without having direct supervision responsibilities.

"We are also looking at scenarios related to the situation in Zimbabwe, both with the informal migration patterns and the scenario where there could be a rapid influx of refugees from this country.

"MSF has also responded to seasonal flooding in various parts of Zambia by examining populations' access to health care and providing essential medicines to cut-off health facilities."

What has MSF achieved so far in Kapiri?

"There are a number of things that we have achieved. Foremost, we have demonstrated that people living outside of large urban centers can receive quality care and treatment for HIV/AIDS. We have lobbied successfully with the government and, in part, we have been responsible for the free provision of ARVs.

"We also have been successful in showing that some of the tasks and responsibilities that were formerly held by doctors can be successfully handed over to clinical officers or nurses, something that allows a greater number of medical human resource personnel to be able to successfully treat, diagnose, and care for people living with HIV/AIDS."

What are these tasks and responsibilities?

"Testing and counseling in particular, had at one point to be done by a doctor or clinical officer. Now, counselors can do finger testing. Nurses are also able to prescribe, rather than doctors or clinical officers. That has an huge impact, because in our project, in all the health centers rather than the hospital, there are no doctors. So by implementing task shifting, changing responsibility, and building up criteria, you can improve the access."

What are the challenges ahead?

"The challenges ahead are twofold. One is that people living in rural areas gain access to the care related to HIV/AIDS - and there we have constraints both with the distance and the sheer size of the country. There are a lot of people that we suspect to be infected, who don't know their status yet, because they live so far away. Then, if we are lucky enough that they are aware of their status and seek treatment, the next obstacle is that there are not adequate human resources from the Ministry of Health to care for people.

"Distance is another challenge we are facing, because we have a significant territory to cover. But it also has implications for the patients, since they have to travel long distances to receive care. For example, some of them may be diagnosed at a small health center, maybe within 15 or 20 kilometers of where they live, but if they are diagnosed positive and need to receive drugs and care, then they will have to be referred to a larger health center and that could be at an even greater distance.

"And the consequence is that we have many people who start their treatment but stop it after a while. And that has repercussions for their health, but also concerns about resistance."

How does MSF deal with people who start HIV/AIDS treatment and stop their treatment afterwards?

"MSF tries to find those people and there is a lot of community involvement, with different support groups, defaulter tracing, home-based care. In the context of Zambia, these are all things that really can - and probably should - be managed at a community level. We really encourage that. In fact, if we can work with volunteer counselors to help them do their job better, it's going to be improved. But the gap really will be on who is eligible or qualified to care and treat in a health structure."

Are there people in Zambia who do not want to see if they are infected or accept their status?

"They don't want to know their status, they don't want others to know that they know their status, whether it is positive or negative. They don't want to know the status of their children, even if they know their own personal status. There is a lot of stigma, there is a lot of worry, a lot of fear - fear within your community, fear within your own family, and it has a paralyzing effect."

You worked with MSF in Zambia for almost three years as logistics coordinator, and later on as a head of mission. How did the project evolve while you were there?

"I've seen the physical expansion of the programme in terms of geographical distribution from the hospital to the fifteen centers. I remember when we reached the milestone of a 1,000 patients, we were very excited about that, and now we should be looking closer to 5,000. Those are significant numbers and we recognize that with these successes we should be able to find other partners within the government structures as well as the NGO community to take-over the project.

"Our programme is specifically designed to work within an environment with limited resources. The Ministry of health of Zambia has limited resources as well. We therefore identify some of those limiting factors and we seek to enhance and expand their limits, so that when we withdraw, it can be a combination of the Ministry of Health resuming responsibilities with the support of another NGO."