Zambia .... or the crazy world of NGOs

One of the things C & I really wanted to understand once on the ground in Zambia .... was quite how the seemingly simple intervention for PMTCT (at its most basic just one tablet for the mum at delivery .... to the WHO recommended treatment - which is still less mind you than the extended preventative treatment any of us would get in the west - of one or two anti-retroviral drugs from 28 weeks and then syrup to the baby for anything from 1 day to a week after delivery .... and exclusive breast feeding - meaning absolutely NOTHING but breastmilk not even water - for 6 months if you can't guarantee safe water or continuous supply for formula feed ... which is essentially the whole of sub-saharan africa) needed to be integrated into the whole system of ante-natal care as a whole .... especially in more rural areas ....

An African health minister once warned me of NGOs that often enter countries with promises of quick-fix interventions e.g. a programme of vitamin A supplementation which was feted to cure all children of blindness at a cost of just 7 million dollars ... which in order to be implemented actually put on the overstretched national health system a cost of 77 million ... which clearly the NGO didn't consider in its costs .... i think today - we've all learned our lesseons somewhat but trying to triangulate this whole new approach to addressing the health system's needs ... yet avoiding the temptation to try and fix everything .... and still show results in the short term to please your donors .... is a complicated politricky dance ....

We visited urban and rural clinics packed to the rafters with expectant mothers and children pressed against all the sick and the competing for the attention of the heroic clinical staff .... rudimentary government labs and sleek NGO funded training centres ... pharmacies ..... community groups .... government ministries (its amazing that you can just get appointments with health ministers - imagine doing that at home! see - that is the indignity of being poor and having to welcome every idiot with a cheque book) ..... and swish NGO offices (fully complete with fleets of white 4x4s with tall flagpoles that sweep imperiously over rural roads .... C&I had a tiny starlet which showed us up totally as a pimply teenager in this very grown-up world of NGO multinationals)

I developed a huge respect for poor african health ministeries who have to juggle the demands, (well and not so well intentioned) interventions and directives of local organisations, NGOs, donor agencies, private sector etc etc .... one visit to the central medical stores showed boxes piled up from all over the world - condoms from the US, China, Sweden etc etc .... drugs from India ... bicycles from Germany .... bed nets from Britain ... all heaped up .... and they have to make sure that the they all get out to the right clinics spread across the country (often taking upto a week to travel) and coordinate expiry dates plus the politricks of difference agencies only wanting the clinics they support to receive the drugs they donate (yes i'm outing the Japanese)

This NGO driven agenda was most evident when we visited a rural clinic about 2-3 hours outside Lusaka .... where an amazing young clinical officer (sort of more than a nurse but not quite a Dr) ran a clinic with one other nurse for a catchment area of more than 10,000 people .... he provided a full set of services for his patients .... including the dual-therapy PMTCT that we are struggling to implement even in rich South Africa .... he proudly showed us the computer and printer carefully covered in plastic sheeting on his desk donated by an NGO so that he could use a patient 'smart-card' system and electronic medical record system that's being rolled out through an american PEPFAR initiative as a health system improvement .... however he still draws graphs of his quarterly achievements by hand (displayed behind the desk) and the pharmacy stock room was down to its last bottle of AZT and other ARVs (not to mention non-HIV drugs...) .... because no one has ever really taught him how to use the machine except for the smartcard .... and he still relies on copying everything painstakingly by hand ... because electricity tends to only be on for a couple of hours a day ....

When we were about to leave .... he refused at first to shake my hand .... "i won't say goodbye to you my sister until you promise me a borehole for the clinic" .... i was flabbergasted .... a borehole! but he had a computer!! He emotionally admitted that they had no water at the clinic so one of the two of them had to spend two hours a day fetching water to keep on hand for deliveries at the clinic, plus their own needs ..... a borehole would cost 11,000 kwatcha .... probably the half the cost of the unused printer on his desk ..... this is Development gone Mad.