And POTUS begat PEPFAR

“And POTUS begat PEPFAR” sounds like a passage from the Old Testament. In 2003, George W Bush (POTUS) set up the President’s emergency plan for AIDS relief (PEPFAR) to combat HIV/AIDS. This initiative has saved millions of lives by providing medication, training, supporting labs and infrastructure. But there needs to be accountability, to find out what is being done with the money. So health centres throughout Africa come together regularly to review their data.

Last week, Eastern Province held a meeting of all the health centres to discuss their performance in Quarter 1 of 2016, as compared with the last three quarters of 2015. The afternoon before the meeting, our clinic staff were in a flap because they had not completed entering the data for Q1. They were concerned because other health workers could ask searching questions about the data, revealing possible poor performance. At their request, I joined the team, helping to calculate the figures and to prepare answers to potential questions in areas where it looked as though we were not up to scratch. We finished just before 17:00.

At 7:30 the next morning, I picked up the nurse in charge and the second in command (who had never attended a meeting like this before and was being “blooded”). We arrived on time at the venue at 8am to find the meeting room empty. A couple of male nurses were at the bar, watching edited highlights of the European Cup soccer on the big TV screen above the optics. Eventually proceedings got underway 40 minutes late. Unlike Swaziland, we did not sing a hymn at the start of the meeting; we just had a prayer asking for divine guidance. I think we needed it.

The first speaker from Headquarters gave an overview of the performance of the entire province, using amalgamated data. He showed over 40 “busy” PowerPoint slides packed with detail. Instead of facing the audience, he spoke to the screen, reading directly from the slide. From the expressions on people’s faces, I could see that the audience was reeling from data overload. What did it all mean?

“Any questions?” he asked. Silence. Not a dicky bird. So I thought I’d get the ball rolling. “Thank you for an excellent detailed overview of the results of Q1. Could you pick out one or two of the most interesting points which you want to highlight?” I said.

The poor man was completely flummoxed. It was his job to present the data, not to analyse it. He had no opinion on what was important and what wasn’t. I would have to ask individual presenters about this. Fudge. I don’t think he had really contemplated what he was saying. He just read out what was on the screen without any analysis or curiosity. We moved on, but not so swiftly.

The health centre scheduled to speak first was not ready to present, so Kakumbi got the call. Our nurse in charge did well, speaking quickly and clearly. Unfortunately many of our results were in the red, meaning suboptimal. The reasons for this are complex. You can skip the next paragraph if you get bored easily.

It is not enough to count the number of attendances, positive tests, deaths and so on. Using figures projected from the last census (five years ago), health centres have “targets” to meet. For example, taking into account the national birth rate, the CSO estimates how many pregnancies and deliveries ought to be taking place according to the catchment area of the facility. If the CSO data predicts 160 deliveries per year, then every quarter there should be 40 new babies. With population growth at 4% per annum, the population is automatically increased on January 1st in Quarter 1, so if you deliver 40 babies again, you will be underperforming because there should be 42 births. The actual performance of health centres is compared with the predicted performance. There is some leeway allowing health centres to do headcounts if they feel the CSO data is inaccurate, but this is very time consuming for centres with wide catchment areas.

The lady in charge of Mother & Child Health was critical of our apparently low number of deliveries. “Why are the women not coming to the centre to deliver?” The nurse in charge said that we practised in the Game Management Area, so pregnant women starting labour were unwilling to walk to the health centre at night through the bush. The solution to this was a shelter where mothers-to-be could stay, close to the health centre until they were in established labour. But our waiting area has been crammed with building materials for the shelter for months. No work has taken place. Unfortunately, this diversionary tactic did not work.

“Ah, but the number of women coming for their first postnatal visit is still less than it should be,” exclaimed Mrs MCH. “Women who have delivered could walk to the centre in daylight.”

Nurse in charge looked downcast. I spoke up, saying that our family planning clinics were so effective that we had fewer deliveries than the planners in the Ministry of Health in Lusaka predicted. Also, quite a few women would had been referred to the district hospital for operative deliveries, and they would still be inpatients there on day six.

“But I think that it is your negative attitude towards the mothers which is causing the low attendance,” replied Mrs MCH, triumphantly. Nurse in charge agreed that midwives did criticise women who had delivered at home when they came for postnatal checks at the centre. “It is government policy for all women to deliver in a health facility and we were just pointing this out.”

Hmm. The previous day I had heard a complaint from a pregnant woman who said she was turned away from the health centre because she was barefoot. Nurse Zulu said that this was a misunderstanding. She had given a talk to antenatal women on appropriate footwear in pregnancy with the health message: “Do not wear high heeled shoes; you must wear flat ones.” So the woman thought she would be turned away if she wore no shoes. It is obvious that Nurse Zulu was from the paved streets of Lusaka. I have never, ever, seen a patient in Kakumbi wearing high heels. They wouldn’t last five minutes on the dusty, uneven, dirt roads. Surely she could have been discussing more important issues at the antenatal clinic?

I know that some nurses speak harshly to patients who are dirty and smelly, accusing them of being disrespectful of health workers. The atmosphere of the clinic is not as patient-centred as it is in the NHS. For example, at lunchtime, staff get very irritated if there are still patients waiting to be seen and I continue working. If I wasn’t there, I guess that the doors would close at 12:30 and the patients would have to wait until 14:00 to be seen. Maybe Mrs MCH had a valid point.

We fielded the next few questions, agreed to look into providing mobile antenatal care (a non-starter) and, with an audible sigh of relief, nurse in charge came back to her seat.

Now it was another health centre’s turn to run the gauntlet. Their data looked fantastic. Immunisation coverage 246%. How could this be? “Oh, we vaccinated a few villages outside our catchment area.” But 246%?” “Yes, it is very high so we did a head count. This showed we were just overperforming by 130%.” I tried to stifle a laugh, making it into a cough. No one asked any further questions about this, probably because no one knew the answers.

I felt sorry for the medical officer in charge of the district hospital as he was unwell and had to present his data sitting down. When he finished, he said, “Thank you for not asking any questions.” But we did. “At the beginning of the year there were 78 new HIV positive patients taking anti-retroviral drugs, but at the end of the year, there were just 70. What happened to the eight?”

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The medical officer in charge said he didn’t know. “Had they died?” “Did you transfer them to other units?” He could not offer an explanation, so the discussion ended. There was no suggestion that he should look into this, that it was a glaring omission. He had presented the data, that was his job. If it wasn’t recorded in the dataset, he knew nothing about it.

I don’t think that many health workers analyse their data critically and try to find out what happened. They see their job is to collect the data, without any detailed examination of the results. That is done by the people with desk jobs at headquarters.

The day wore on. More people presented excellent results, 100% for good indicators, 0% for bad indicators. Several people were happy to say that they had exceeded their targets, well over 100% in some cases. The number of people diagnosed with an STI equalled the exact number of contact tracing slips issued. It looked too good to be true. Doubts started to creep into my mind about the veracity of the data.

This reminded me of a similar situation of a few years ago in Swaziland. Every centre was reporting almost perfect results. This was not credible, so instead of allowing health centres to submit their data, the Ministry of Health Monitoring and Evaluation SWAT team would descend unannounced on health centres, scoop up their ledgers and prepare the data themselves. No more Mr 100%.

Lunch was also over 100%. There was no shortage of nshima (Zambian polenta). My meal was a whole fish which filled the plate. I ate the flesh and put down my knife and fork, to the astonishment of my fellow diners. “Eh, Dr Ian, you are not a Zambian,” said one. “I always start with the eyes. Then the head. It is the tastiest part.” I said he was welcome to pick the skeleton I had left on the plate, but he declined.

After lunch, the atmosphere in the meeting became torpid. One sleeping health worker was delegated to take the minutes, but he declined, saying that there was a secretary to do this. People were stifling yawns. Some people were fiddling with their smart phones beneath the table. I tried to keep awake by guiltily doing some work on my laptop.

At the end of the meeting, everyone felt exhausted. More than a few seemed demoralised. We must have heard a dozen virtually identical presentations. The questions had petered out. It was time to go home. Did anyone have anything else to say?

I stood up and said, “I appreciated being invited to attend. The meeting was very interesting and we ought not to lose sight of some important facts. No women had died in labour in the province in the last quarter. Immunisation rates were well ahead of those in UK. No drugs had been allowed to go out of date. The incidence of HIV appeared to be half of what it was two years ago. Only a handful of children had malnutrition. We ought to congratulate ourselves on the good work we are doing and look more closely at the indicators next quarter to see how we can improve further.” Cue dramatic applause and time for prayers. Phew. Clinical work had never seemed more enticing.

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