Zambia’s health profile remains bleak. The country’s health profile showcases a life expectancy of 54/56 years for male/females; a child mortality rate of 89 per 1,000 births; and 232 deaths due to HIV/AIDS per 100,000 of the population (GHO, 2013). Around 6.1% of the GDP is spent on health; and of greater concern is the loss of doctors and nurses. Zambia is identified as having a ‘human resource crisis’, with one of the worst ratios of doctors to population. In Zambia, the ratio stands at 1 to 15,000 for doctors and 1 to 1,500 for nurses (Makasa, 2008); while the WHO recommend a ratio of 1:5,000 for doctors, and 1:700 for nurses, in African nation-states. Nevertheless the human resource shortage continues to widen through Zambia’s ‘brain-drain’, with trained health professionals continuing to immigrate. The lack of trained health professionals, and Zambia’s growing population, has raised concern but it has also resulted in innovative methods in order to provide solutions. The Virtual Doctor Project (VDP) being pioneered in Zambia is a case in point. With 61% of the population, in 2011, identified as cellular subscribers the project provides a means to ensure access to health care is granted.
The project works on providing vital health care through the internet and mobile broadband. The telemedicine healthcare will connect patients and clinic staff in rural areas to medical doctors and specialists located all over the world. The networks formed provide ‘virtual doctors’ that will assist in providing precise, quick, diagnosis; and treatment for people living in remote areas. Zimbabwean medical officers work in a mobile clinic, visiting rural locations. Visited patients are screened with appropriate treatment provided. If additional information is required, or the doctors do not know the cause of the problem, patient details can be sent to a network of global medical experts for further advice. The project has three key objectives. First, broadening the scope of patients able to access treatment; secondly, reducing the need to go to distant health centres and unnecessary mortality as a result of late, or inadequate, diagnosis; and finally, improving the efficiency of patient care through knowledge transfers and faster treatment. This debate focuses on the VDP to explore whether such objectives can be fulfilled. Additionally, the project remains of interest due to the technological shift occurring within Africa. Can technology provide a means to fill Zambia’s health care gap?
Zambia’s human resource crisis in healthcare is most prominent in rural areas. Poverty remains widespread and despite Zambia’s high economic fortune as a result of copper during the 1960s it has become a heavily-indebted poor country. The World Bank (2013) classifies 76% of Zambia’s poor as residing in rural areas. With disparities in access to health prevalent, Zambia needs to train new doctors and nurses to ensure the population can access health care. The VDP is therefore tackling the issue of access within rural, and remote, areas.
Access to health is a human right, and the VDP is ensuring such rights are become a reality in rural areas and rural populations. Mortality and morbidity can be reduced as rural health workers are able to diagnose and treat a wider range of conditions.
Zambia needs to improve its health care system in general, not work on implementing a virtual programme. Physical contact is still necessary for diagnosis and treatment.
Alternative schemes are being used to meet health needs and improve the structure of Zambia’s health system. For example, the Clinton Foundation and DFID have invested in the provision of community health workers. These programmes invest in training community health workers across Zambia’s rural regions. The health workers trained are therefore physically located within the regions. This is much more important than having virtual doctors on call.
 See further readings: Clinton Foundation, 2013.
The use of ICT and creating a network of professional experts enables learning and knowledge transfer between health workers and academics. In addition to the brain-drain, whereby skilled health professionals continue to emigrate from Zambia, Zambia also shows a slow rate of training of new health workers. Therefore the VDP provides a vital learning tool. VDP provides practical skills by healthcare workers to learn from first-hand experience while having access to a field of experts, or advisers, able to answer any questions. The quality of healthcare will be improved as workers in remote locations are given access to information and correct answers for diagnosis. A global pool of skills can be drawn upon, and utilised, when required.
Although the use of virtual networks and doctors may provide solutions to share knowledge it creates other difficulties. The use of VDP as an educational tool clearly has downsides. First it is not designed for training; if it were why not use a tool specifically for training? As the VDP is not any educational benefits have to be considered secondary. Unlike with a specifically educational tool there is no way for the experts to test that the knowledge they are passing on is being learnt or that their advice is being followed.
Additionally, if the use of virtual doctors is educating medical officers on the ground does it ensure the newly trained professional will stay in Zambia? The bigger picture of what the officers do, and whether the government implement competitive labour policies, requires consideration.
The use of mobile clinics and ICT in health not only tackles issues around location accessibility to health, by travelling into remote areas, but also the flexibility provided through the clinics mobility means a larger population can be seen and treated.
Virtual doctors are flexible; one doctor can be providing his or her expertise through numerous local doctors and nurses at any time. They can help staff with much less training make the correct decisions. By using mobile clinics the location is flexible - and can be altered depending on variations in social need and seasons -, and the time individuals can access the clinic is flexible. Mobile clinics are more responsive to demand.
Mobility remains a key issue across Africa. The WDR (2009) identifies three key sources for effective integration: institutions, infrastructure, and interventions. Infrastructure includes systems that facilitate the geographical movement of goods, services, people, and ideas - such as roads. The reality of a mobile clinic therefore relies heavily on having the infrastructure to support flexibility, mobility, and frequent movement.
Mobile clinics still won’t be able to reach all patients that need their help; public investment is required into infrastructure such as roads and railways first. The project can only work if mobile clinics are able to be mobile. Further, even if they are mobile it doesn’t necessarily ensure people become ill when the medical officer happens to be visiting.
Each mobile clinic will be equipped with vital tools and equipment, and staffed with a medical assistant, a midwife/nurse, and project officer. Furthermore, the presence of a medical staff team means a number of services can be provided for women, men, and children. The team are able to carry out tests on the ground, and if required refer the patient to a hospital. Referrals are made by the staff, with all required information passed on to the hospital and an appropriate appointment made.
The VDP makes each actor within the referral and treatment process aware of their position and role. The VDP appropriately delegates jobs; thus improving the system of hospital referrals and minimising unnecessary costs from inappropriate referrals.
A study carried out by Masiye (2007) indicates only around 40% of Zambia’s hospitals can be defined as efficient. There remains a significant problem of resource wastage in Zambia’s hospitals and the hospitals are technically inefficient in producing, and delivering, services. Health goals cannot be achieved in Zambia if hospitals continue to function inefficiently. This raises concern as to how the hospitals cope once referrals are sent? Is the wider health system adequate?
Outsourcing of medical professions into rural areas, and making improvements in the speed and quality of referrals does not resolve the issue of hospital quality. Although VDP’s can act to significantly reduce the number of inappropriate referrals investment, training, and improved management, is still required within Zambia’s hospital system. Additionally, improved access to drugs is needed. Drug shortages have been reported due to corruption scandals - funding provided to supply drugs in the health sector have previously gone missing. Generic drugs are in short-supply, and high demand. Without doctors being able to access vital drugs, whether they are located in hospitals or remote areas, treatment cannot be provided.
 See further readings: IRIN, 2011.
Not only does VDP improve access to primary health care but the networks developed between different health advisers mean changing health demands can be met. Across Africa there is now a shift in the type of diseases prevalent. Increasing rates of non-communicable disease are being recorded - for which advisers can provide ongoing support. Additionally, there remains a need to improve understanding and treatment of mental health issues within rural areas in particular. Concern with mental health requires greater recognition across Africa. Finally, data can be collected on health issues affecting rural areas for targeted intervention.
Can the VDP go beyond basic needs and rights when the scale, and scope, of basic need is so large? Figures show a negative image not only of physical health, also the environment in which people live in. The maternal mortality ratio is calculated at around 590 per 100,000 and infant mortality (under 1) stands at 53 per 1,000 live births. However, only 61% of the population have access to improved drinking water; and 48% are able to access improved sanitation facilities (UNICEF, 2013).
Can we rely on NGO’s providing the VDP to fulfil basic needs when the challenges are so large?
A key issue that needs to be raised is funding. Currently the VDP is funded by a range of corporate partners - including Microsoft and Google. However, for the project to be sustainable in the long-run investment is required from a wider range of bodies, and further partnerships need to be formed with the public sector. The government needs to be included as a funder and supporter. The neglect, and exclusion, of the government within discussion on health projects - such as VDP - only acts to remove their responsibility and obligation to tackle the social dilemma. Healthcare is the responsibility of government, not the NGOs and private firms that are providing VDP.
Today the inclusion of private stakeholders in providing access to health is proving to be a sustainable approach. To achieve developmental impact the public sector is no longer the key source or actor. Although increased support by the government - both financial and political - may be required in the future it is not fundamental for the implementation stage. The VDP can continue to grow and be sustainable through the work of private organisations and funders. The state can later step in and expand the system nationwide when it is fully demonstrated. Private partnerships are changing how health-care is provided and its sustainability.
To what extent does the VDP resolve the lack of health service professionals in Zambia? Two caveats emerge.
Firstly, the project shows how intervention from international organisations can work against trade union demands and employment issues. The project is introducing a model of outsourcing. The medical staff do not need to be based in hospitals so reducing government costs and decentralising employees. Recent strikes by nurses shows dissatisfaction with work conditions and overwork. It raises concern over the motives of the VDP. Is the VDP encouraging social protection and an ethical work environment for all medical professionals? Or is the VDP an escape mechanism to keep wages low and neglect demands made by working nurses? A majority of the expert ‘virtual doctors’ employed are volunteers. Ultimately then the government might consider the VDP a good excuse not to invest in training Zambian doctors.
Secondly, does the VDP resolve the issue of brain drain? Improved incentives and increased salaries are required for trained medical professionals, to motivate them to stay. The VDP may help educated doctors but it does not provide them with reasons to remain in Zambia, rather it gives them contacts with outside healthcare systems where their skills will be much better rewarded.
 See further readings: Kunda, 2013.
The VDP is providing a number a solution to the lack of human resources within Zambia’s health sector. VDP is enabling the growth of local jobs, for Zambian nationals. Although there are no current figures to estimate the amount of jobs that will be provided within the health sector, the VDP has currently been rolled out into six sites and continues to expand. New clinics will be set-up across Zambia, as well as Tanzania, Malawi and Kenya. A growing body of health workers will be required to maintain the VDP network; reducing the doctor to population disparity in Zambia.
ICT is providing innovative solutions to resolve many social problems across Africa. However, is there now a dangerous reliance on technology? Not everyone has access to mobiles and signal remains precarious. When answers, diagnosis, and treatment, are reliant on using technology in the field it needs to be ensured that the service fitted in mobile clinics will remain reliable for field health workers. Additionally, it needs to be ensured that the network of global professionals frequently check messages for updates and respond as quickly as possible. The quality of health service cannot be improved if the response time remains low due to insufficient technology or connectivity. The scheme requires partnerships to telephone and information technology companies.
The reliance on technology is also danger when we consider what information the technology used is actually providing. The VDP will mainly involve text-based emails and messages to provide patient information. Expanding to use images and videos - such as through Skype - will ensure the virtual doctor is more involved in the process, reducing error.
Technology will only be required within the mobile clinics, to enable the VDP networks to be used. It is a key component, but not the only foundation of which the VDP is based on. This means that the clinics can carry equipment to ensure access to the internet remains – such as a satellite connection. Furthermore, significant developments have been made in Zambia’s technological revolution. Internet connectivity has improved in rural areas; and pioneering movements across rural areas - such as the implementation of solar-powered internet - means connectivity is spreading into rural, remote, Zambia.
Even if VDPs do improve access to health services we cannot assume the health services will be used. The use of traditional healers, and practices, remains popular across rural Zambia. If the population is unwilling to use modern medicine then providing better access to that medicine will be of little benefit. If formally trained doctors and medicines are not accepted, or trusted, by communities then the resources being spent on VDPs would be much better spent on education to encourage people to make better use of the facilities they already have than introducing new technology based solutions that will simply be more likely to be rejected.
 See further readings: Bansal, 2012.
Figures showcasing the popular use of traditional practices, and medicine, do not show the reasons behind use. It fails to recognise the degree of choice and the nature of treatment provided. If people don’t have access to modern medicine then they will go to that which is available. The answer then is to increase access to modern medicine to provide the alternative.
Chibuye, M., Interrogating Urban Poverty Lines: The Case of Zambia, Human Settlements Working Paper Series: Poverty Reduction in Urban Areas, 30, IIED (International Institute of Environment and Development), London, 2011, http://pubs.iied.org/10592IIED.html
GHO (Global Health Observatory), Zambia Country Profile, 2013, http://apps.who.int/gho/data/node.country.country-ZMB
Makasa, E., ‘The Human Resource Crisis in the Zambian Health Sector: A Discussion Paper’, Medical Journal of Zambia, 35, 3, 2008, http://www.ajol.info/index.php/mjz/article/view/46522
Masiye, F., ‘Investigating Health System Performance: An Application of Data Envelopment Analysis to Zambian Hospitals’, BMC Health Services Research, 7, 58, 2007, http://www.biomedcentral.com/1472-6963/7/58
UNICEF, Zambia: Statistics, 2013, http://www.unicef.org/infobycountry/zambia_statistics.html
World Bank, Zambia: Poverty Assessment, 2013, http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/EXTPA/0,,contentMDK:20204786~menuPK:435735~pagePK:148956~piPK:216618~theSitePK:430367,00.html
WDR (World Development Report), Reshaping Economic Geography, World Bank, 2009, http://web.worldbank.org/WBSITE/EXTERNAL/EXTDEC/EXTRESEARCH/EXTWDRS/0,,contentMDK:23080183~pagePK:478093~piPK:477627~theSitePK:477624,00.html