By Dr Gift Risinamhodzi
Recently, I saw a heartbreaking video of a man who gave a heartfelt speech at his aunt’s funeral. He said she had died from a trivial cause that should not have been fatal. He also pointed out that we have been losing many lives to preventable and treatable conditions.
As Zimbabweans, we need to talk about what kind of health care we deserve and how to achieve it.
Now I will admit a few things. To begin with, our doctors’ training in Zimbabwe is centred more on secondary care. What that means is that a lot of work is taken to train doctors who can attend to serious illnesses and major trauma and significant disease. Doctors are also trained at major central hospitals, which means that our training is focused more on specialist care and less on primary care.
While I had some exposure to primary care in my training in medical school, it was just a small part of the training. The major focus was to train us to identify major illnesses and serious diseases, usually at a point where they could be life-threatening. Beyond that, we were trained on how to work in a hospital setting.
This kind of learning is important. However, I have come to realise that there is a major gap in the application of this knowledge when it comes to primary care. A new outlook is required, not to save life at death’s door but to prevent disease in the first place. That is the goal of primary care.
This article will explore the present situation of our health system. I will contrast it with the practices and results of other countries. I will also suggest some strategies that we, as Zimbabweans, can adopt to enhance general practice – the specialty (yes, it is a specialty and we need to appreciate its significance) – that enables people to live longer and healthier lives.
When general practice is done right, secondary care practitioners can work more smoothly and effectively. Further, the cost of health care decreases and money is saved. Our current health budget is biased towards central and provincial hospitals, but if we upgraded our primary care system, we would reduce expenses and divert them to other vital areas.
One might wonder, what aspects make up primary care?
Primary care is all the care that you get to either prevent disease completely, treat a disease early, or to identify serious disease before it becomes advanced enough to be a problem. Imagine that you have a weed that keeps sprouting on your driveway. The primary care specialist’s job is to nip it as soon as it sprouts. They yank it out or spray herbicide before it grows. If left unattended, that small sapling could become a big tree whose roots could one day crack the house.
The best primary care system adapts to the specific needs of a local population because diseases vary by location. The health challenges in Mutare may differ from those in Victoria Falls or Binga. This means that the solutions should be customised.
No country has a flawless primary healthcare system. However, we can strive to do our best to achieve the best outcomes locally. The approach to this begins with asking ourselves: What are the main causes of death in our community? What is the average lifespan of our people? What diseases are prevalent here? How can we intervene early to save resources?
In Zimbabwe, we face many challenges with access and resources. We also have issues with the structure and goals of our primary healthcare system. Most primary care in our urban or rural areas is run by local councils, which employ nurses. Sometimes a visiting doctor is attached to that clinic. They also receive support from the Ministry of Health in terms of specific programmes and resources.
While that system may have worked in the past it has a lot of weaknesses. There are solutions to these issues.
Number 1: Let’s connect our clinics
Our polyclinics are not connected. They do not share data, and the medical records of patients are either in their heads or in a tattered school exercise book that could be destroyed by rain, fire, or loss.
In healthcare, one of the most important aspects is the preservation of an accurate account of the patient’s medical history. If done right, it can save us money and effort. With good records, we would not need to repeat certain tests as they would have been done before or excluded already. By keeping a centralized, computerised database of our medical records, we ensure that we can track events and revisit them in the future.
We cannot depend on the memory of the patient because it is fickle. A patient may not be able to fully describe the details of their medical conditions. Sharing medical records and attendance nationally also helps us track prescription rates versus drug stocks. This way, we will be able to buy just what we need and not have large batches of drugs expiring in warehouses because we purchased more than we needed. It is now time to put all our health information online to track diseases and resource usage.
Number 2: Right tools for the right job
We have a shortage of doctors at the primary care level. Most general practitioners who work in primary care are in the private sector. The government never tried to attract them into the public system to improve care. This means quality service became exclusive to the wealthy.
As a basic requirement, each clinic should have at least one doctor on duty every day to provide guidance and prevent unnecessary referrals to hospitals that can be handled locally, thus relieving pressure on secondary care. Doctors are trained in the skill of diagnosis and nurses are trained to care for patients unless they are advanced care nurses or nurse practitioners, which is a different role. We are using the wrong tool for the right job.
Every clinic should have a doctor on site every time the clinic is open. This saves resources as a diagnosis can be made early and simple treatment administered.
Number 3: Invest in district hospitals
We need more district hospitals in major cities. For example, in Harare, the only options for public health care are Parirenyatwa, Harare Hospital or a local clinic. Yet, some patients may not require Pari for some conditions. We need district hospitals in Harare and Bulawayo, for instance. This will reduce the overcrowding of these tertiary centres and lead to cheaper, more accessible care.
Number 4: Proactive in care
We need to learn the art of being proactive. Often, people visit the health care centre only when they have a problem. And because it is costly, they visit only at the last minute when they cannot bear the pain anymore. They may have harboured a serious illness for years and present with an advanced form of their illness. As a result, the outcomes are poor.
We need to change as a society so that we become more health conscious. We need to focus on preventing diseases rather than just curing them. For example, type 2 diabetes is largely a lifestyle-related disease. A large proportion of patients will recover if they lose weight and exercise. A lot of cancers have early stages that are detectable and thus can be caught early.
One of our most successful preventive measures is cervical cancer screening. But the uptake among eligible women is exceptionally low. As a result, we end up having needless deaths from diseases we have the means to prevent early.
Number 5: Promoting fitness
We need to promote fitness. Generally, if you exercise daily, eat well, drink moderately, do not smoke, and do not sleep around, you could live a long life. This is, of course, assuming that you also do not drive too fast; a lot of deaths are due to road traffic accidents too.
Europe is struggling with obesity and the health issues that it brings. It is important to nip this in the bud by encouraging people to stay healthy. Statistics in the UK’s NHS show that the primary care system spends about 10% of the total NHS budget, yet it does the most work. Secondary care is expensive. Operations and large investigations are pricey, and this can be made affordable by fixing the primary care system so that it never gets to be that serious.
Number 6: Hygiene saves money
Lastly, it is time we said goodbye to the diseases of poverty, malnutrition and waterborne diarrhoeal diseases. If we invested more money in securing safe and potable water for our people, we would not need to treat as many people with diarrhoea. Again, this is an example of a preventive measure that saves money in the long run.
Learning from others
How do other countries approach general practice or primary care?
In the UK, independent general practitioners are contracted by the NHS to provide primary care services. They are then paid by the NHS for their work, and deliver high-quality care to everyone. Everyone is entitled by law to have access to a GP that they can visit free of charge. If they need to be referred to secondary care, their GP can do that.
A doctor evaluates their need. They do not just show up at a tertiary hospital and demand a hip replacement. Their GP does that assessment. This helps organise work and reduces the pressure on secondary care.
I explained earlier how we have a large cohort of general practitioners working independently in private care. We need to give them incentives to work for the public. They would get paid less than private work per patient, but then they get to see more patients. This makes it worth it for them.
We have too many unmet needs and yet plenty of resources sitting idle in other settings. It just requires leaders with a vision.
We need committed staff and resources. Having staff and no resources is pointless, all you create is health workers wasting time at work when they could be working. Healthcare systems need to be resourced. We need functional investigative tools such as laboratories, CT scanners, MRI scanners, X-ray machines, etc. We also need medication.
However, above all, we need to organise our healthcare system properly. This will save resources and make the little resources we have go further.
Dr Gift Risinamhodzi is a Zimbabwean Doctor working in the United Kingdom. His greatest passion is unleashing the full potential of Primary Care