Current access to health information in Zambia: a survey of selected health institutions
Christine W. Kanyengo, Medical Library, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia. E-mail: firstname.lastname@example.org
Objective: To assess the current situation of access to information by health staff at selected central, provincial, district hospitals and health centres in Zambia.
Methods: Government and non-governmental institutions were visited in the Lusaka Urban District and nine rural districts in the North-Western, Western and Central Provinces of Zambia in 2001. Thirty interviews were held with provincial and district health directors, medical doctors, nurses and clinical officers in district hospitals and rural and urban health centres. In 2006, a follow-up visit was undertaken to the health centres in the Lusaka Urban District in Lusaka Province and the Sesheke District in the Western Province.
Results: There is limited access to health information for health workers in Zambia. In hospitals and health centres, where there is access, it is usually provided in an ad hoc manner without a central policy from the government. In all the places visited, there was also an overwhelming expressed need for different types of information relating to the professional or personal needs of health care workers.
Conclusions: The study found that access to information was very poor. There were some excellent examples of local initiatives showing that, even under difficult financial and infrastructural circumstances, it was feasible to improve health workers’ access to information by using low technology, information access initiatives. These existing local initiatives deserve to be scaled up, while new initiatives should be adopted to improve access to information in a much more structured way. Of paramount importance is the formulation and implementation of an information policy that will guarantee the provision of health information to Zambian health workers.
Zambia is located in Southern Africa and shares borders with eight1 other countries (see Fig. 1). Administratively, it is made up of nine provinces: Central, Copperbelt, Eastern, Luapula, Lusaka, Northern, North-Western, Southern and Western. The provinces are then divided into 72 districts. Although English is the official language of communication, there are seven other official languages that are recognized and used on radio and television. The country's population is estimated at 10.3 million. Nearly 47% of the population are young people under the age of 15.2
Zambia has a high disease burden. Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) prevalence rates are estimated to be at 16% of the adult population between the ages of 15 and 49. Tuberculosis (TB) is a major public health burden, which has been exacerbated by the HIV/AIDS pandemic. Overall, TB prevalence rates for the country stand at 19.7%.2 Malaria is currently the number one killer, with deaths averaging 50 000 per year (47% of all recorded deaths3). Life expectancy at birth is now projected at 37 years because of disease and poverty. Overall poverty levels were as high as 79% in 2004.4
Health staff profile
Health workers included doctors, nurses, clinical officers and environmental health technicians (see Table 1). Although all cadres of health staff can be found in the hospitals, there are no doctors at the rural health centre (RHC) level. In the Lusaka District, doctors can be found in the urban health centres. Nurses, clinical officers and environmental health technicians are found mainly in the RHCs, and are responsible for the running of the centre.
Table 1. Distribution of health workers in Zambia
Zambia has a hierarchical health institutional framework. Health posts provide the first point of access to care. These cater for a population of between 500 households (3500 people) in rural areas and 1000 households (7000 people) in urban areas. RHCs are the other first point of care and have a catchment population of 10 000 people. These are then followed by the urban health centres, which cater for a population of 30 000–50 000 people. The district hospitals are the first-level-referral health institutions and serve a population of 80 000–200 000, with medical, surgical, obstetric and diagnostic services and all the clinical services to support the health centre and health post referrals. The second-level-referral institutions are the general hospitals, which are found in all the nine provinces and have a catchment area of between 200 000 and 800 000 people. The last referral institutions are the three hospitals—the University Teaching Hospital, Ndola Central Hospital and Kitwe Central Hospital. These serve a population of 800 000 and above, and have sub-specializations in internal medicine, surgery, paediatrics, obstetrics, gynaecology, intensive care, psychiatry, training and research.5
The objective of the study was to assess the current situation of access to information by health staff in selected health institutions in Central, Lusaka, North-Western and Western Provinces.
Persons involved in the research
There were two researchers involved in the study: Joost Hoppenbrouwer, from the Netherlands Royal Tropical Institute and Christine Wamunyima Kanyengo from the University of Zambia Medical Library.
North-Western and Western Provinces were chosen based on their poverty levels (76 and 89%, respectively).6 The other consideration in the choice of the study area was that these two areas bordered each other, making it easier for the researchers to travel to the health facilities. In addition, North-Western and Western Provinces were selected because they are slightly more isolated and the Mumbwa District in Central Province was included in the study because it is situated between the Western Province and Lusaka Province. Lusaka Province is where one of the authors is based. It is an urban area and therefore provides a good comparison as regards access to health information between rural and urban areas. The main reason for the selection of the provinces and districts was that, in order to have a reasonably good sample of the overall situation in the country, we wanted to include four out of nine provinces7 of Zambia (see Fig. 2 for the location of all the districts that were visited).
A semistructured, open-ended interview schedule was constructed with the aim of eliciting information on both qualitative and quantitative data from the respondents. The interview schedule was first piloted in September 2000 in health facilities in Lusaka District and with institutions such as the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the Churches Health Association of Zambia (CHAZ) and Chainama Hills College of the Health Sciences (Clinical Officers Training). The goal was to identify key stakeholders in health information delivery in Zambia. The schedule was then finalized and used as a guide when conducting the face-to-face interviews with the respondents. The information that was collected from the respondents included general background information; information regarding key public health problems in the respective districts; current access to health information; and opportunities and constraints in accessing health information. After the interview schedule was finalized, study visits were arranged by making appointments with the provincial health directors in the respective provinces to seek permission for the researchers to have access to health personnel in the relevant health facilities. The researchers also sought clearance from the Central Board of Health (CBoH) to carry out the study within the respective districts. Visits were made from 19 February to 3 March 2001. The districts where the study was carried out were Mumbwa District in Central Province, Solwezi, Mwinilunga and Kabompo Districts in North-Western Province, Lusaka District in Lusaka Province and Kaoma, Lukulu, Mongu, Senanga and Shangombo Districts in the Western Province (see Table 2).
Table 2. Location of the health institutions visited
|Central||Mumbwa||2||District Health Office||Supervisory office for all health facilities at the district level|
|Lusaka||Lusaka||2||Urban Health Centre||Not attached to a hospital|
|Central Board of Health||National implementing agency for the Ministry of Health|
|North-Western||Solwezi||4||Provincial Health Office||Supervisory office for all health facilities in the province|
|District Health Office||Supervisory office for all health facilities at the district level|
|Kapijimpanga Rural Health Centre||Not attached to a hospital|
|Mwinilunga||3||District Health Office||Supervisory office for all health facilities at the district level|
|Katuyola Rural Health Centre||Not attached to a hospital|
|Kabompo||District Health Office||Supervisory office for all health facilities at the district level|
|Kashinakaji Rural Health Centre (CMML)||Not attached to a hospital|
|Luansongwa Rural Health Centre||Not attached to a hospital|
|Western||Kaoma||2||District Health Office||Supervisory office for all health facilities at the district level|
|Lukulu||3||District Health Office||Supervisory office for all health facilities at the district level|
|Lishuwa Rural Health Centre||Not attached to a hospital|
|Mongu||4||Provincial Health Office||Supervisory office for all health facilities in the province|
|District Health Office||Supervisory office for all health facilities at the district level|
|Lewanika General Hospital||Hospital|
|Lewanika Nursing School||Nursing school|
|Senanga||3||District Health Office||Supervisory office for all health facilities at the district level|
|Urban Health Clinic||Not attached to a hospital|
|Shangombo||1||District Health Office (based in Senanga District)||Supervisory office for all health facilities at the district level|
In order to get a good overview of the different points of view and issues facing different health workers, we talked to key people from different levels and backgrounds (doctors, nurses, and administrators at RHCs, district and provincial hospitals, district health offices (DHOs), provincial health offices (PHOs) and the Central level). At the PHO, we interviewed the Health Management Information System (HMIS) Manager as the PHOs did not have any librarians in post. There were no librarians employed in any of the institutions visited. At the hospitals we interviewed the managers of administration and a doctor, clinical officer or nurse, depending on whoever was available. At the DHO, the interviews were with the district directors of health and their support staff. In the RHCs visited, there was usually one member of staff running the centre and that was the person interviewed. In one RHC in Lukulu, a classified daily employee (CD) was interviewed. A CD has no specific training but has acquired skills on the job, usually through observation and attending short courses. The RHCs were chosen on the basis of their accessibility (i.e. whether the access road to the RHC was in good order). The only good tarred road was from Lusaka to Solwezi and Mongu to Lusaka. The rest were not tarred and required a four-wheel drive vehicle to navigate the mostly gravel and sandy soils.
Site visits were also made to other institutions such as the CHAZ, the WHO, Chainama Hills College of Health Sciences (Clinical Officers Training) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). CHAZ oversees, on behalf of the government, all health institutions that are administered by the church. They operate health institutions at all levels (hospitals, urban and RHCs). The purpose of including these institutions in the study was to identify any health information delivery programmes the institutions had for rural health workers. In 2006, a follow-up visit was carried out to health centres in Lusaka urban district in Lusaka Province and in Sesheke District in the Western Province. These follow-up visits were carried out to see whether the situation regarding access to health information had improved since 2001.
Assessment of the information resources at the health facilities
A physical check on the type of information resources available was carried out. The assessment involved checking on the type of information materials available (i.e. whether they were magazines, newsletters, newspapers, books or journals). We also asked about access to electronic information resources. The available materials were then checked for publication dates.
Data analysis was carried out manually by sifting through the responses and grouping similar themes and categories together.
Hospital libraries and rural health centres
Small libraries, usually consisting of a couple of shelves, were found in district and general hospitals. On the whole, these libraries were poorly equipped; they contained mainly (very) old textbooks, and they lacked subscriptions to scientific journals, or even to free newsletters and publications. In one district hospital visited, a closer look at the records of borrowed books showed that only a few items had been borrowed in a whole year. In principle, all health workers in the district had access to these libraries, but in practice only hospital staff used them.
Access to information was even more limited for RHCs. While some hospital staff had access to electronic information where the hospitals had an Internet connection, this was not the case with the RHCs as over 90% of the ones visited did not even have access to electricity. Their access to electricity was through the use of solar panels which were mainly used for the preservation of vaccines. Most of the RHCs had very little health information materials. None of the RHCs visited had a regular provision of information materials. The RHC staff admitted that they did not receive any information materials, apart from some occasional publications; in most RHCs there was no systematic collection and organization of materials. The most frequently found materials in the hospitals and RHCs were official CBoH materials such as the Integrated Technical Guidelines (ITGs, 1997), various HMIS manuals (1997–1998) and several other publications (1999, 2000). Most of these materials were provided during special training courses the staff had attended. Many of the staff considered the current ITGs not practical enough, being too generic and theoretical, without a clear link to the concrete everyday health situations. They also pointed out that the ITGs contained too few concrete clinical guidelines. In addition, this type of material would need more frequent updates. In the past, some textbooks had been donated to several RHCs. However, they soon disappeared, because when health staff were transferred to another posting, they often took ‘their’ books with them.
District health offices
In general, DHOs had limited health information available, although this varied from district to district according to local circumstances. Some offices had a small collection of textbooks, official CBoH manuals and guidelines and, sometimes, some newsletters were found. For example, Solwezi DHO had received the ‘Blue Trunk Library’ from WHO, and Kaoma DHO had received a special donation of books. The Senanga DHO produced its own newsletter.
Provincial health offices
As a result of the health reforms implemented in the 1990s, PHOs were replaced by regional health offices for a few years. However, they have recently reverted back to the old structure, with the health system administered through the PHO. Their roles have changed from mainly supervisory and managerial before the onset of the health reforms in the 1990s, to technical guidance, support and monitoring. Health information and other materials were usually sent by the CBoH through the PHOs.
Central Board of Health
The CBoH has a small resource centre that caters for health workers all over the country. This resource centre has one member of staff also working on various non-library assignments. The resource centre does not have programmes for disseminating information to the rest of the country. At the time of the research, there were no plans to expand library services countrywide.
Partners in Health Delivery
The different organizations visited, such as CHAZ, have a library which was mostly for in-house use. In practice, only those able to come to CHAZs Lusaka office could benefit from the library service. However, when people come to Lusaka, there is usually little time to consult any library as they are too busy running errands. UNAIDS had a policy of distributing literature produced by UNAIDS as long as the organizations collected the materials themselves from the UNAIDS’ Lusaka offices. Chainama Hills College of Health Sciences has a poorly stocked library that is designated exclusively for the students and faculty of the college. They had no outreach programme to other institutions.
Current access to health information
The lack of current access to health information in Zambia needs to be set within a context of serious constraints regarding the basic conditions needed to deliver quality health care. There is no significant change in the situation regarding access to health information between the study in 2001 and when a follow-up one was carried out in 2006. When asked to rank their basic needs, access to information was not always mentioned by health workers as one of the first priorities because it does not seem to immediately and visibly affect the quality of service delivery. It was, however, considered a precondition for maintaining basic standards of professionalism, knowledge and health care quality by all those interviewed. Pakenham-Walsh et al.8 maintain that ‘providing access to reliable information for health care workers in developing countries is potentially the most cost-effective strategy for improving the quality of health care delivery.’ The same argument is made by the WHO:9
‘... evidence shows that having information does help health workers to do their jobs better, as long as certain provisos are met: the information must be relevant to the job and available when needed, and workers must have a degree of confidence in the information's quality’.
Godlee et al.10 make a similar point: ‘Lack of access to information remains a major barrier to knowledge-based health care in the developing world’. In order to address this, the different levels of the health care system in the country need to each play a distinct role in ensuring access to information, so as to achieve economies of scale.
Low use of the available materials
The use of the information materials was found to be low even in places where resources were available. In addition, regarding constraints to information access (in terms of facilities, distance, materials and equipment), an important barrier is the lack of a ‘reading culture’, caused by lack of access to reading materials. Respondents argued that most of them read for examinations only. They attributed this lack of reading culture to their heavy work load brought about by staff shortages. As a consequence, health workers are forced to work long hours, leaving little time to read. This current lack of a ‘reading culture’ can also be attributable to the absence of information materials that are practical, easily accessible and easy to read; such as newsletters, rather than scientific journals or sophisticated information which is not relevant to local needs.
In RHCs, some of the materials found were too advanced. Certainly, a collection of the Blue Trunk Library would not be suitable for some Zambian health workers, especially those based in RHCs, as it would be too technical. They require materials that are very easy to read and understand. The Ministry of Health (MoH) also needs to employ qualified librarians who understand the information needs of health workers, so that health information is carefully packaged and targeted to suit the needs of the various groups.
The lack of a rigorous continuous medical education (CME) requirement by the regulatory authorities, that would enable them to read and look for current information, was also cited as a reason for the absence of a reading culture. Finally, the fact that many resources are out of date is a disincentive to read.
Lack of an information policy
There was no policy on library and information service provision at the MoH, leading to several consequences. Firstly, as indicated earlier, some of the staff ‘appropriated’ the materials when they were transferred from one health centre to another. It is always difficult to ascertain what materials are owned by which health centre, as there are no inventories. This means that library collections cannot grow, as whatever donated materials there are, are likely to be appropriated by some staff when they move from one station to another. The reason for this was their fear of not finding any information materials at their next posting. Solving this problem requires the creation of an adequate inventory system at DHO and health centre levels so as to avoid loss of materials, books and other reading materials. The importance of employing qualified librarians within the Ministry so they can spearhead the process would go a long way in solving the problem of access to current health information.
Inaccessibility of available health information resources
As already argued, information materials at DHOs are accessible for all health workers in theory, but this is not so in practice. Available information is often kept in the director's office and access is restricted for a number of reasons; such as difficulties in using someone's office, especially one who is a supervisor. Another important constraint is the fact that RHC staff only visit the DHO once a month. In some areas this is even less, especially during the rainy season. During the time they visit the DHOs, RHC staff have many responsibilities to take care of: procurement of personal and work-related supplies (such as drugs); arranging transport; repairs; reporting to the DHO. These visits usually take place on the day when their salary is due to be paid. Thus, in reality, reading opportunities are very limited during visits to the DHO, even if health information is available. Therefore, it is important to have a lending system in place. In most districts, information materials can be borrowed, usually for a period of 1 month (until the next visit to the DHO). However, this does not allow health workers to have continuous access to (basic) health information where and when they need it. RHC staff need basic reference materials at their own workplace to be effective in the delivery of health care. Borrowing books from a scarcely equipped DHO library is insufficient to satisfy the information needs of RHC staff.
The role of policy making institutions
While the PHOs may play a relatively modest role in directly providing access to health information to health workers, they are pivotal in creating a stimulating local information policy environment in which DHOs are encouraged to take on a proactive role in providing access to health information through various channels.
The PHOs also play an important role in coordinating local and provincial information dissemination and exchange, as well as in communicating local and district information needs to the central policy-making levels. PHOs can also play a direct role in providing information to the districts, as evidenced by the newsletter produced by the Western Province PHO.
Direct access to information for managers and health workers depends largely on what is available at the district level and below. However, as with the PHOs, the central level (CBoH and MoH) has an important role to play, mainly in overall guidance, support and policy development. Currently, the CBoH and the MoH do not have a specific policy on access to information for health staff, although several explicit or implicit strategies and activities are in place that could facilitate this access. In planning terms, if there is no policy in place to provide a service, it means there is no budget line for information resources and personnel. This means that the employment of qualified librarians is not possible as long as there is no budget line provided for within the expenditure provisions of the MoH. The same argument would be made for the acquisition of any library related supplies such as books or journals.
Online health information resources
As there is no connection to the Internet in the RHCs, online information resources are irrelevant at present. Until this infrastructure is in place, basic easy-to-read material should be available. In some urban health centres and hospitals there is a good potential for online resources. For the hospitals, most of the infrastructure is already available; especially access to reliable power supplies, as most hospitals have stand-by generators that automatically come on when the power supply from the main gridline is off. However, even in these places, more work is still needed to create the necessary information and communication technology infrastructure to benefit all health workers. Inadequate infrastructure is still the biggest problem hindering access to information. These infrastructure barriers have been discussed by several authors. In their analysis of Nigeria, Watts and Ibegbulam11 conclude that ‘adequate ICT infrastructure appears to be the principal reason for hindering access to online health information resources, and is clearly a more pressing problem than a lack of available information’. Edeger,12 Aronson,13 Horton14 and Smith15 all maintain that the digital divide between the developed and the developing world is a result of both structural and financial constraints.
In order to derive maximum benefit from modern information technologies, health staff also require training in electronic information retrieval and basic computer skills. This training should also address information literacy. Only then will Zambian health workers benefit from various initiatives aimed at improving health information access for health workers in developing countries such as the WHO's Health InterNetwork Access to Research Initiative (HINARI); the International Network for the Availability of Scientific Publications (INASP) Programme for the Enhancement of Research Information (PERI); the Global Review on Access to Health Information in Developing Countries; HIF-net-at-WHO: working together to improve access to reliable information for health care providers in developing and transitional countries: HIFA 2015; CHILD2015; SHARED (Scientists for Health and Research for Development; and the Ptolemy project, amongst many others. These health information initiatives are a necessary and important step towards solving the problem of access to health workers in developing countries such as Zambia. However, in the current Zambian context, these initiatives are most likely to be effective at central level (with perhaps some benefits for PHOs and DHOs). Unless there are bridging projects that can translate access to information from the central level to the rural health workers, the benefits from these information access initiatives will be limited to the central level.
Health information initiatives targeted at rural health care workers in Zambia
Several projects have targeted rural health workers in Zambia:
- • the HealthNet Project that was supported by the Boston-based SatelLife organization;
- • the Communication for Better Health (CBH) Project, funded by the Dreyfus Foundation of New York;
- • the Blue Trunk Library, funded by the WHO.
These initiatives have been successful to some extent in meeting the information needs of rural health workers. The HealthNet and CBH Project were both involved in repackaging information to make it more relevant to the needs of the health workers at local levels.
HealthNet. The HealthNet project was implemented by the University of Zambia Medical Library in the Southern Province of Zambia. It provided ‘electronic mail-based health information exchange between developed and developing countries, as well as within the developing countries themselves’.16 HealthNet was primarily used for the dissemination of literature, control of drug supply, monitoring of epidemiological data, referral consultations and communication.
Communication for Better Health. The CBH programme resulted from a partnership between the University of Zambia Medical Library and the Dreyfus Health Foundation of New York. The Dreyfus Health Foundation developed the programme ‘to improve the accessibility of relevant health information and experience in the developing world’. The programme focused on the creation of innovative, dynamic and interactive information centres, which function, not only to disseminate relevant health information, but also to collect, organize and share local regional experiences. This information was published in a locally edited and prepared digest utilizing modern information technology, such as the Internet and CD-ROM.17 The programme was implemented in several African countries—Ghana, Mali, Nigeria, Tanzania, Uganda and Zambia. In Zambia, the repackaged information was reproduced as the Zambia Health Information Digest, 2000 copies of which were then distributed to 1400 health institutions, as well as other health related organizations.
Blue True Trunk Library. This project, which is being implemented by the WHO, requires that the recipient purchases the trunk for themselves at a cost of $2000 plus shipping.18 However, such a cost is too much for health centres that can barely afford to access basic medicines. The Blue Trunk Library consists of 150 basic reference books contained in a blue trunk. So far, 20 Blue Trunk Libraries have been distributed to various institutions in the country, with the assistance of the WHO. This initiative has great potential to solve some of the information needs of health workers, but it is reliant on partnerships that can assist with the financing of Blue Trunk Libraries to the various health institutions.
The findings from this investigation show that regular access to up-to-date health related information in Zambia is very limited at all levels. RHCs were found to be the most lacking in health information resources, whilst some of the district hospitals, DHOs and PHOs had some access to information materials. The most available information materials are those provided by the MoH. These included manuals, guidelines and newsletters. Although the study concentrated on four out of nine provinces, the situation regarding access to health information in the health care system in the country is similar in the health care facilities in the rest of the country.
Despite competing priorities, access to health related information was considered by many as an essential for maintaining the motivation, knowledge and skills of staff at all levels of the health system, and therefore it should be an integral part of the health service delivery. In order for this to be achieved, more technical guidance is required along with better coordination of the various stakeholders, both within and outside the government health system. Apart from expanding and improving the current infrastructures, financial strategies and a central level policy specifically focused on improving access to information are urgently needed.
The lack of a consistent national policy on informing health workers in a systematic way is big hindrance to current access to health information in the country. Whatever health information is available to health workers is ad hoc, often from other sources. However, in order to better serve the health information needs of health workers in Zambia, the MoH should have its policy on health information provision in place to systematically address the problem.
Christine Wamunyima Kanyengo is Head of the Medical Library at the University of Zambia School of Medicine. She holds a BA from the University of Zambia, BA (Honours) and an MA from the University of Cape Town, South Africa.
Joost Hoppenbrouwer is an independent HIV/AIDS consultant who has worked with civil society organizations, governments, UN agencies and funding organizations in Africa, Asia, Latin America and Europe in policy development, project design and monitoring and evaluation systems. The issue of access to information has been a cross-cutting topic in all these areas, as it empowers people to make informed decisions, and thus take control of their own health and future.
Implications for Policy
- • Up-to-date health related information is very limited at all levels in Zambia.
- • Health information is not seen as a necessity in affecting patient care.
- • The Ministy of Health has no policy or budget for health information resources or personnel.
Implications for Practice
- • Library stock needs systematic collection, organization and updating.
- • DHOs and PHOs need to take on a proactive role in providing access to health information.
- • Health staff require training in electronic information retrieval and computer skills.