Zambia is a low-and middle-income country (LMIC) with a population of about 17 million people. For a long time since the independence in 1964, the University Teaching Hospital (UTH) was the only tertiary hospital that offered most of the specialised medical services. Zambia has a specialist surgical workforce of 1.48 per 100,000 population whilst the Lancet Commission on Global Surgery has recommended attainment of close to a minimum of 20/100,000 by the year 2030.
During our training as medical students and specialists we saw many patients from all parts of the country referred to UTH for specialist management of their conditions. The greater majority was from the rural areas with little or no means to keep up in the big city as they waited to be attended to by the specialist. It is against this background that in 2014, we started an outreach programme called “Kutusa Initiative” meaning help, and whose theme is “paying back to your community.” It involves organizing our fellow doctors of various specialties in undertaking charity medical services to the less privileged rural communities biannually. This entails that these doctors commit their time, resources and skills in order to reach out to the patients in rural areas. Moreover, there is transfer of knowledge and skills in form of mentoring the medical stuff in those rural hospitals visited. The rural hospitals are responsible for the mobilisation of patients requiring specialised medical services. The core group consists of a general and an orthopaedic surgeon, a gynaecologist, a paediatrician, an ophthalmologist, and an anaesthesiologist. Since its inception, we have seen more than a thousand patients and have conducted more than 150 surgical operations which include hysterectomies, laparotomies, thyroidectomies, herniorrhaphy, open reduction, and internal fixation (ORIF) of bone fractures among others. The hospitals where these outreach services have been conducted are: Maamba District, Chikuni Mission, and Mpongwe Mission Hospitals. Each outreach has had its own stories to tell but we hereby share only three of the most recent outreach conducted in December, 2017.
The gynaecologist first found Ms X lying in bed, with a low grade fever and a history of having undergone a manual vacuum aspiration (MVA) of the uterus for an incomplete abortion. Having re-examined the patient, her blood results and abdominal ultrasound, the gynaecologist, made a clinical diagnosis of a perforated uterus. Seeing that the patient was hemodynamically stable and acquiring informed consent a mini laparotomy was done under spinal anaesthesia and this ended up into a hysterectomy because the uterus was not only perforated but necrotic. This patient recovered well before complications from sepsis could set in. Such lives are easily lost not because of negligence but the non-availability of qualified personnel to make the correct diagnosis and timely decision.
A physiotherapist technologist took advantage of the Kutusa Initiative team and presented a 9 year old girl with malunion of the right humerus with a fixed elbow deformity secondary to a supracondylar fracture. Being her dominant side, a number of activities were limited. The patient was obviously socially withdrawn and the parents were worried for their girl child. After being assessed by the orthopaedic surgeon and anaesthetist, the patient underwent ORIF to correct the malunion and elbow deformity. The patient recovered very well and this brought a smile not only to the patient but the parents as well.
We had a patient with a euthyroid goitre, pressure symptoms and a slightly low haemoglobin whose operation we postponed to either our next visit or be referred to the provincial hospital due to lack of a functioning electric cautery knife. It was obvious that the patient preferred that the operation is done from her local hospital, close to her family. Postponement of this case was cardinal as it hinged on the safety of the patient as she was mild anaemic, the electric cautery knife would have helped minimise the blood loss.
From the stories we have shared you would be marvelled at the level of commitment and team work on the part of the health workers at the rural hospitals. We conduct operations from morning till late in the night every day of the outreach period because there is usually one emergency theatre and an elective theatre. And these workers sacrifice their overtime working hours at no cost because they equally want to see that the patients in their communities are attended to. On the last day of the outreach due to time constrain we end around midday, we hurt to see that some patients are turned back because we have to drive back hundreds of kilometres to either our homes or to the next outreach site dependant on the schedule. As we celebrate World Health Day 2018, under the theme Universal Health Coverage, Kutusa Initiative highlights the fact that anaesthesia is pivotal in any surgery thus in order to reach global surgery by 2030, there is undying need to increase not only the surgical work force through specialist training but coupled with infrastructure, equipment, drugs and consumables all of which are intertwined in the delivery of safe surgery to the patient. The World Health Organisation has prescribed that in order for a country to promote health equity, the cardinal facet is moving towards universal coverage through universal access to the full range of personal and non-personal services.
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