Zambia is situated in the southern part of Africa covering an area of 752,612 square kilometres. The Population of Zambia is 10.3 million. The country has an estimated HIV/AIDS prevalence rate of 19.7 percent among 15 to 49-year-olds. The prevalent rate among women in some areas was as high as 27 per cent in 1993, but by 1998 it had declined to 17 per cent. During these same years, there was a 42 per cent reduction in HIV/AIDS prevalence rates among 15 to 19-year-olds in Lusaka. This trend was found in other urban areas, and to a lesser extent in some rural areas. The recent sexual behaviour surveys show that the median age of beginning sexual activities for males has gone up from 16.3 years in 1998 to 18.1 years in 2000; youths are delaying the start of their sexual activities. Annual condom sales have grown steadily since 1993. In 2001, 10.1 million condoms were sold and condom use continues to increase among almost all age groups for both sexes.
In Zambia the first AIDS case was diagnosed and reported in 1985.
The human immunodeficiency virus (HIV) infection/acquired immune deficiency syndrome (AIDS) is a major public health problem in Zambia. The National HIV/AIDS Intervention Strategy Plan 2002-2005 has drawn up a very aggressive programme. Its vision is to free the nation from HIV/AIDS under the mission to provide national leadership for a co-ordinated fight against HIV/AIDS in order to eliminate the virus and associated opportunistic infection for the benefit of the society with a goal to reduce HIV/STD transmission among Zambians and reduce the socio-economic impact of HIV/AIDS. It is for this reason that the Ministry of Health is trying to approach this problem from many angles using different types of interventions. Primary Health Care strategy seems to be a right intervention in terms of basic preventive methods but it needs to be supported by other strategies as well to close the gaps. Primary health care is presented by the Alma-Ata declaration as essential health care based on practical, scientifically sound and socially acceptable methods and technology, which is universally accessible to individuals, family and the community through their full participation and at the cost they can afford. Zambia, a signatory to a number of international conversions and declarations including the Alma-Ata, should strive to provide essential basic healthy services to all Zambians. Therefore strategies such as PHC and Telehealth would contribute to bridge the gap between the rural and the urban dwellers.
Access to basic health shows a wide spatial variation, with provinces around the railway track having better access to health services. In urban areas 99 percent of households are within 5 kilometres of a health facility compared to 50 percent in rural areas where most households are 100 kilometres or more away from each Rural Health Centre. Although key government policies emphasize the right of equitable access for all to health and quality health care, the scarcity of qualified health staff in rural health centres or hospitals, long distances, cultural beliefs, gender relations and difficult terrains create major problems for equitable health care delivery in Zambia. Many Rural Districts and Health Centres do not attract medical staff because of poor conditions of service and lack of medical equipment. Doctors resign after being posted to rural areas. According to the survey carried by Kanyengo and Hoopenbruwer, from a total of forty doctors who were posted to Western Province, fourteen
refused to report to the centres. They opted to join private sector because of hardships experienced in the rural areas. The same survey observed that some centres had only one clinical officer; one nurse and an environmental technician manning the centre, for example, Lukulu Rural Health Centre.
Satellite communication
The survey further discovered that at one centre only two
persons were running the centre and one of them was a casual daily employee trained very basically on the job. More shockingly, at one centre it was found that a Casual Daily Employee had been dispensing drugs to patients. The argument is that health delivery system in Zambia faces a lot of challenges and to solve some of these problems, integrating Information Communication Technologies such as TeleHealth would improve access to delivery of quality health care services in remote areas.
Methods
To alleviate some of the above problems, a multisectoral approach to fight HIV/AIDS should be employed. Additional channels of disseminating information and awareness campaigns would promote behavioural change among the youth and adult population. Some of the methods should include translations of information on HIV/AIDS into local languages, working with cooperating partners and Non-governmental Organisations including people living with HIV/AIDS. Use of condom , voluntary counselling and testing, phone-in-discussions, radio discussion forums, bill boards, partner notification, health and sex education in schools, drama, pastoral counselling, and peer to peer interaction must be encouraged and supported. Discarding harmful traditional beliefs such as “sexual cleansing” by many cultures and direct involvement of Traditional Healers in decision-making would immensely augment government initiatives. Others should include opinion leaders, community leaders, truck drivers, taxi drivers, minibus drivers, marketers, shop owners, former sex workers, models and all influential personalities who can be used as carriers of the HIV messages because their opinion is respected in their respective communities. Without their support, messages may not reach to some sections of the society. Members of the parliament would foster political decision. Since they influence policy decisions they should be involved to spread the messages in their constituencies in the fight against HIV/AIDS. However, the combination of Telehealth technologies would result in a multiplier effect in linking patients and primary health care professionals with specialists located at distant hospitals.
Telehealth architecture
Telehealth is the use and transmission of video, voice and text data for a multitude of health related issues, including, health management, patient care, and health worker training and education, individual and patient education on health maters.
Information Communication technologies include electronic networks, embodying hardware and software, linked by a vast array of technical protocols. In health care delivery, technology plays a pivotal role in ensuring timely and speedy diagnosis as well as in improving the quality of health care. Due to the advancement in Information Communication Technology (ICT) in recent years, many elements of clinical practice and public health can now be accomplished through telehealth despite the physical distance between a patient and the health care provider.
Creating viable and sustainable solutions for isolated communities would require innovation and a multi-faceted approach. Tilting the balance towards an IT system that supports knowledge transfer is one that Africans need to adopt. Primary Health Care workers would be connected to the Internet to access latest data. They would also communicate and consult with their former lecturers and other health workers through e-mail in case of Zambia.
Primary health care providers in remote areas face problems in handling complicated cases as such they have to consult senior doctors located at Ndola Central Hospital or the University Teaching Hospital for a second opinion before they refer cases (which may not warrant a referral) to a higher level hospital. Symptoms presented by certain conditions such as Sexual Transmitted Infections may not be isolated effectively without using efficient laboratories. It is for this reason that a specialist at a higher level should be consulted for second opinion or advice. A junior doctor would consult using e-mail or phone to contact a senior doctor. A junior doctor or any trained health worker may scan and transmit a digitalised image to a radiologist by e-mail as an attachment in case of tuberculosis for diagnosis and advice using Teleradiology application. In case of skin cancer or other skin diseases a dermatologist should be consulted using Teledermatology application to isolate symptoms giving false information. A patch could be scanned and transmitted as an attachment by e-mail.
Teleconsultation would assist junior doctors and other health professionals to consult senior doctors at Central Hospitals and the University Teaching Hospital for advice or a second opinion. This would be done via a telephone, fax, mobile phone, or e-mail or tele-conferencing
This is achievable because of existing infrastructure like fax facilities, telephone lines, (mobile phones provided by Telecel, Celtel and Zamtel in Zambia). In case of Internet services, there are three Internet Service Providers namely Zamtel, Zamnet and Coppernet, which have outlets in a number of places in the rural centres.
Barriers to telehealth
However there are a number of barriers that need to be addressed for example telephone lines are very unreliable and too expensive for many rural clinics to afford; government grants may end up being spent on bills other than the procurement of essential drugs.
Internet connectivity is not reliable due to prohibitive costs and poor network infrastructure and many primary health workers in the rural areas do not even know the existence of such technologies.
Electricity is not stable. There are so many interruptions especially in the rainy season. There is no policy from government to use Telehealth as a strategy to deliver health care services other than radio programmes aired through Neighbourhood Health Centre workers for prevention and care of HIV/AIDS.
Lack of trained human resources to handle Information Communication Technologies among Primary Health Care providers.
Overcoming barriers
To overcome these barriers government should pass a bill to enact a law for integrating Telehealth into the Ministry of Health vision to deliver health care services as close as possible to family members.
HIV/AIDS prevention should be integrated with STI treatment in conjunction with telehealth using appropriate technology such as ordinary radio, ordinary telephone lines, and flying doctor services. In some areas where advanced technologies exist such as the Internet, e-mail, health workers may exchange information among themselves about their patients and general updates.
Ministry of Health and the Central Board of Health should lobby for funds from the government and cooperating partners to purchase equipment for Telehealth, which should include: IP phones, digital cameras, camcorders, and digital scanners, computer server, wireless radio link, computers, hubs, printers etc. to be used for connectivity between remote sites and Central hospitals where most specialists are located. Some sites would use a leased line using (Zamtel or Zamnet or Coppernet ISPs) infrastructure with a dial-up as a backbone, or a dedicated line
HIV/AIDS communication strategies should be developed with due consideration to culture, gender relations, religion/spirituality, and political structure.
These interventions are very critical in breaking the barrier to reach the community.
Results
Some secondary sources indicate that using a number of the above interventions has helped to reduce the spread of new cases of HIV/AIDS because many people have had access to various communication channels. Other interventions have also yielded positive results. For instance USAID in Zambia supported youth mass media campaign, Helping Each Other to Act Responsibly (HEART), stressing abstinence for youths who are not sexually active and condom-use for those who are.
The campaign produced 5 television advertisements and an award-wining music video titled “Abstinence is Cool” In the second projects’ phase, 22 radio spots in seven local languages were produced to target the rural youth.” The mass media campaigns have helped to reach 70 percent of urban youths and 37 percent of the rural youth through messages around abstinence, consistent use of condoms and that “you can’t tell by looking” if someone is HIV positive. In February 2001, 499 Commercial Sex Workers were treated for various STDI related problems and a total of 996 were linked to consultants for advice. The lessons learned from such initiatives is that working together with international partners like USAID and others can maximise access to information about HIV/AIDS and eventually reduce the spread of the disease by transferring knowledge to the people. It is reported that in 2001 HIV/AIDS messages were printed on 800,000 fertilizer sacks reaching an estimated 100,000 farmers and HIV/AIDS awareness messages were included in the post-harvest surveys reaching more than 8,000 rural households. It is common knowledge to assume that the majority of Zambians whether young or old are aware about the pandemic in one-way or the other. In fact the Central Statistics Office confirms that 99 percent of women and men in Zambia have heard of HIV/AIDS. About 77 percent of women and 79 percent of men know that a healthy-looking person can have AIDS. However, women and men in the age group of 15-19 years are less likely to know that a healthy-looking person can have the AIDS virus than respondents in other age groups.
Conclusions
In urban areas people may be reached through the print and electronic media. The people in the village may be reached using other interventions such as oral media (interpersonal communications such as drama, story telling, music, dances opinion leaders, community leaders, etc.) Modern studies indicate that a combination of strategies will be the most effective way of reaching almost everybody. Using telehealth technologies will enhance and improve communication among health workers in Zambia. The combination of primary health care services, health information, oral communication and appropriate technologies can assist to reach the unreachable in the fight against HIV/AIDS. What is critical is compliance knowledge alone is not enough but abstinence for those who can, use of condom for those who are active, sticking to one partner for those who are married and Voluntary Counselling and Testing should be done all the time before marriage and at any time one wants to know his/her status.
Recommendations
Interventions focused on behaviour change communications such as the Helping Each Other to Act Responsibly Together (HEART) campaigns for the youth, increase access to condom use, voluntary counselling and testing, community care and support services, policy development on HIV/AIDS, political will among politicians, TV and radio discussions, telephone discussions, Information Technology Communication Policy and Oral Communication (interpersonal communication) must address the social and health factors which do influence individuals, communities and government to make decisions to fight HIV/AIDS.
Interpersonal communication among the youth in Zambia
The government, through the Ministry of Health and the Central Board of Health, should source funding and invest it in Information Telecommunication Technologies. Central Board of Health has most of the District Health Centres connected to its server.
A telemedicine centre
What is being awaited is the Parliament’s approval for integrating Telehealth as a strategy to compliment other channels of communication. Information Technology Communication seems to be the most efficient and effective way of delivering health care services to most of the people.
References
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