Farai Madzimbamuto

What is the way forward for health in Zimbabwe

Zimbabwe’s Government of National Unity (GNU), established on Feb 13, 2009, faced immense challenges: a collapsed economy with 94% of the population without a job and almost 50% needing food aid; a severe cholera epidemic; HIV/AIDS prevalence of more than 15% in adults aged 15–49 years; and a collapsed health system. The GNU responded to the issues of the health sector by holding an inclusive summit and adopting an ambitious 100-day recovery plan for the health sector. Here, we describe the recent health crisis and its causes, and make proposals for an eff ective and sustainable health system. Zimbabwe was once a beacon of hope in Africa, improving health tremendously after independence in 1980. A declining national income, a huge national debt, economic structural adjustment, recurrent droughts, widespread HIV/AIDS, and a weakening health system all contributed to the deterioration of Zimbabweans’ health since 1990. Between 2000 and 2005, the gross national income (GNI) per head declined by 54%. The latest estimate of US

Review of causes of maternal deaths in Botswana in 2010

340 places Zimbabwe among the world’s poorest countries: all the income gains of the past 56 years have been wiped out. Economic decline has driven the exodus of Zimbabweans, with over 3 million of the total population of 13·5 million estimated to be living outside the country; the funds remitted by them are the main source of income for many families. For those having no access to external funds the situation is dire. Between 1990 and 2006, life expectancy at birth plummeted from 62 to 43 years, mostly from increased young adult mortality from HIV-related conditions. Mortality rates of children younger than 5 years and infants rose from 77 and 53 per 1000 livebirths in 1992 to 82 and 60 in 2003, respectively. Maternal mortality rose from 168 per 100 000 births in 1990 to 725 per 100 000 in 2007. Tuberculosis incidence increased from 136 per 100 000 in 1990 to 557 per 100 000 in 2006. These indicators are related to the high prevalence of HIV/ AIDS, which was estimated at 26% in 2000 in adults aged 15–45 years but declined to 15·3% by 2007. In 1994, 80·1% of children aged 12–23 months had received all basic vaccines compared with 74·8% in 1999 and only 52·6% in 2006–07. By early 2009, hospitals in the country were hardly operating, with massive shortages of essential medicines and supplies. Although most hospitals are now functioning again, shortages are still commonplace and patients usually need to buy medicines, intravenous fl uids, and sutures. Women delivering in rural clinics must bring candles, cotton wool, methylated spirit, gloves, and even fresh water. The physical infrastructure of most government health facilities is decrepit, and ambulances sparse. The recent cholera outbreak further exposed Zimbabwe’s collapsed infrastructure and its health system. Between August, 2008, and July, 2009, 98 591 suspected cholera cases were reported, including 4288 deaths. The epidemic resulted from the breakdown of urban water and sanitation systems, leading to contamination of piped water and shallow wells. The case-fatality rate peaked at almost 6%, greatly exceeding the 1% WHO norm, indicating the weakened health system and poor access in rural areas. Total health expenditure per head fell by 56% between 2000 and 2005 to

A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement

21, of which

The HIV epidemic in Zimbabwe—The penalty of silence

9 was government expenditure. External funding contributed 21% of total health spending, a low proportion compared with that in most African countries. Under the previous government, which was led by Zimbabwe African National UnionPatriotic Front (ZANU-PF) party, bilateral donors channelled funds to specifi c activities such as HIV programmes and family planning. Therefore, 58% of currently married women use modern contraceptive methods, and about 100 000 people were receiving antiretroviral treatment by the end of 2007. However, antiretroviral treatment coverage at 17% is the lowest of any country in southern Africa, with an estimated 570 000 people needing treatment. Furthermore, HIVpositive patients displaced by political violence and those aff ected by stock-outs of common AIDS medicines or closure of treatment facilities have been unable to reestablish treatment. In 2005, Zimbabwe was losing an estimated 20% of its health-care professionals every year; 18 000 nurses have left since 1998. Although some heroically continued to work for minimal rewards, by the end of 2008 many had stopped working. By this time, a government doctor’s salary had fallen to less than

Integration of HIV care into maternal health services: a crucial change required in improving quality of obstetric care in countries with high HIV prevalence

1 per month. Many health workers witnessed violence and some were harassed for treating victims of violence. Health training in Zimbabwe has suff ered badly and the country’s principal medical school—the College of Health Sciences of the University of Zimbabwe in Harare—closed from November, 2008, to May, 2009. Only 40% of academic posts are fi lled; Bulawayo’s new medical school faces even greater staff shortages. Nursing and midwifery schools struggle with 60% of nurse tutor posts vacant. Disregard for human rights has long featured in Zimbabwe’s history. After the elections in March, 2008, thousands of people were beaten or tortured in an attempt to subdue support for the opposition. Political abductions and intimidation continue despite the establishment of the GNU. National recovery cannot take place without addressing human rights and ending the culture of impunity. To restore Zimbabwe’s health sector, the priority must be to meet the population’s most urgent health needs by Lancet 2010; 375: 606–09

Use of oxytocin during Caesarean section at Princess Marina Hospital, Botswana : an audit of clinical practice.

BACKGROUND In Botswana the maternal mortality ratio in 2010 was 163 per 100 000 live births. It is a priority to reduce this ratio to meet Millennium Development Goal 5 target of 21 per 100 000 live births. OBJECTIVE To investigate the underlying circumstances of maternal deaths in Botswana.Method. Fifty-six case notes from the 80 reported maternal deaths in 2010 were reviewed. Five clinicians reviewed each case independently and then together to achieve a consensus on diagnosis and underlying cause(s) of death. RESULTS Sixty-six percent of deaths occurred in Botswanas two referral hospitals. Cases in which death had direct obstetric causes were fewer than cases in which cause of death was indirect. The main direct causes were haemorrhage (39%), hypertension (22%), and pregnancy-related sepsis (13%). Thirty-six (64%) deaths were in HIV-positive women, of whom 21 (58%) were receiving antiretroviral (ARV) therapy. Nineteen (34%) deaths were attributable to HIV, including 4 from complications of ARVs. Twenty-nine (52%) deaths were in the postnatal period, 19 (66%) of these in the first week. Case-note review revealed several opportunities for improved quality of care: better teamwork, communication and supportive supervision of health professionals; earlier recognition of the seriousness of complication(s) with more aggressive case-management; joint management between HIV and obstetric clinicians; screening for, and treatment of, opportunistic infections throughout the antenatal to postnatal periods; and better supply management of medications, fluids, blood for transfusion and laboratory tests. CONCLUSION Integrating HIV management into maternal healthcare is essential to reduce maternal deaths in the region, alongside greater efforts to improve quality of care to avoid direct and indirect causes of death.

Developing anatomical terms in an African language

BackgroundIn 2007, 95% of women in Botswana delivered in health facilities with 73% attending at least 4 antenatal care visits. HIV-prevalence in pregnant women was 28.7%. The maternal mortality ratio in 2010 was 163 deaths per 100 000 live births versus the government target of 130 for that year, indicating that the Millennium Development Goal 5 was unlikely to be met. A root-cause analysis was carried out with the aim of determining the underlying causes of maternal deaths reported in 2010, to categorise contributory factors and to prioritise appropriate interventions based on the identified causes, to prevent further deaths.MethodsCase-notes for maternal deaths were reviewed by a panel of five clinicians, initially independently then discussed together to achieve consensus on assigning contributory factors, cause of death and whether each death was avoidable or not at presentation to hospital. Factors contributing to maternal deaths were categorised into organisational/management, personnel, technology/equipment/supplies, environment and barriers to accessing healthcare.ResultsFifty-six case notes were available for review from 82 deaths notified in 2010, with 0–4 contributory factors in 19 deaths, 5–9 in 27deaths and 9–14 in nine. The cause of death in one case was not ascertainable since the notes were incomplete. The high number of contributory factors demonstrates poor quality of care even where deaths were not avoidable: 14/23 (61%) of direct deaths were considered avoidable compared to 12/32 (38%) indirect deaths. Highest ranking categories were: failure to recognise seriousness of patients’ condition (71% of cases); lack of knowledge (67%); failure to follow recommended practice (53%); lack of or failure to implement policies, protocols and guidelines (44%); and poor organisational arrangements (35%). Half the deaths had some barrier to accessing health services.ConclusionsRoot-cause analysis demonstrates the interactions between patients, health professionals and health system in generating adverse outcomes for patients. The lessons provided indicate where training of undergraduate and postgraduate medical, midwifery and nursing students need to be intensified, with emphasis on evidence-based practice and adherence to protocols. Action plans and interventions aimed at changing the circumstances that led to maternal deaths can be implemented and re-evaluated.

Comparison between MMed Anaesthesia programmes in the SADC

Abstract This paper traces the rise of the HIV pandemic in Zimbabwe and also traces the history of official silence about it. The paper argues that women are a particularly vulnerable group, but are often the most deprived of treatment. The spread of the disease within the Zimbabwean diaspora is also described and it is pointed out how British asylum procedures can discourage bearers of the disease from seeking medical opinion and help. The medical profession within Zimbabwe itself is castigated as not having been ready to take a stand against silence and on behalf of patient choice and empowerment, and the Zimbabwean situation is contrasted with those in Uganda and South Africa. The paper makes a passionate call for engagement nationally, professionally and internationally with the Zimbabwe pandemic.

Anesthesia for Cesarean Delivery: A Cross-sectional Survey of Provincial, District, and Mission Hospitals in Zimbabwe

BackgroundThe failure to reduce preventable maternal deaths represents a violation of women’s right to life, health, non-discrimination and equality. Maternal deaths result from weaknesses in health systems: inadequate financing of services, poor information systems, inefficient logistics management and most important, the lack of investment in the most valuable resource, the human resource of health workers. Inadequate senior leadership, poor communication and low staff morale are cited repeatedly in explaining low quality of healthcare. Vertical programmes undermine other service areas by creating competition for scarce skilled staff, separate reporting systems and duplication of training and tasks.DiscussionConfidential enquiries and other quality-improvement activities have identified underlying causes of maternal deaths, but depend on the health system to respond with remedies. Instead of separate vertical programmes for management of HIV, tuberculosis, and reproductive health, integration of care and joint management of pregnancy and HIV would be more effective. Addressing health system failures that lead to each woman’s death would have a wider impact on improving the quality of care provided in the health service as a whole. More could be achieved if existing resources were used more effectively. The challenge for African countries is how to get into practice interventions known from research to be effective in improving quality of care. Advocacy and commitment to saving women’s lives are crucial elements for campaigns to influence governments and policy -makers to act on the findings of these enquiries. Health professional training curricula should be updated to include perspectives on patients’ rights, communication skills, and integrated approaches, while using adult learning methods and problem-solving techniques.SummaryIn countries with high rates of Human Immunodeficiency Virus (HIV), indirect causes of maternal deaths from HIV-associated infections now exceed direct causes of hemorrhage, hypertension and sepsis. Advocacy for all pregnant HIV-positive women to be on anti-retroviral therapy must extend to improvements in the quality of service offered, better organised obstetric services and integration of clinical HIV care into maternity services. Improved communication and specialist support to peripheral facilities can be facilitated through advances in technology such as mobile phones.

Non-citizens and maternal mortality in Botswana: a rights perspective

Abstract Background Oxytocin is widely used for the prevention of postpartum haemorrhage. In the setting of Caesarean section (CS), the dosage and mode of administrating oxytocin differs according to different guidelines. Inappropriate oxytocin doses have been identified as contributory to some cases of maternal deaths. The main aim of this study was to audit the current standard of clinical practice with regard to the use of oxytocin during CS at a referral hospital in Botswana. Methods A clinical audit of pregnant women having CS and given oxytocin at the time of the operation was conducted over a period of three months. Data included indications for CS, oxytocin dose regimen, prescribing clinicians designation, type of anaesthesia for the CS and estimated blood loss. Results A total of 139 case records were included. The commonest dose was 20 IU infusion (31.7%). The potentially dangerous regimen of 10 IU intravenous bolus of oxytocin was used in 12.9% of CS. Further doses were utilized in 57 patients (41%). The top three indications for CS were fetal distress (36 patients, 24.5%), dystocia (32 patients, 21.8%) and a previous CS (25 patients, 17.0%). Estimated blood loss ranged from 50 mL – 2000 mL. Conclusion The use of oxytocin during CS in the local setting does not follow recommended practice. This has potentially harmful consequences. Education and guidance through evidence based national guidelines could help alleviate the problem.