Crafting programs in Zambia for limited resources

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. So, 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 and we 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 Zimbabwe, both with the informal migration patterns and also 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 MSF has 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. "Also we 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 huge impact, because in our project, in all the health centers rather than the hospital, there are no doctors, so by implementing task shifting and 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 and 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 know their status and they 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 they 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 but they do not continue treatment. And that has repercussions for their health, but also concerns about resistance."

How does MSF deal with those people that start HIV/AIDS treatment and stop?

"MSF tries to find those people and there is a lot of community involvement, with different support groups, with defaulter tracing, with home-based care. These are all things that really can be and should probably in the context of Zambia be managed at a community level. We really encouraged 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 in a health structure to care and treat."

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 be 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 stigmatism, 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 program, 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 program 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, to expand their limits. So when we withdraw, it can be a combination of the Ministry of Health resuming responsibilities with the support of another NGO."