Communications for Better Health Project in Zambia

by Regina Shakokata

Regina Shakokata is Medical Librarian at the University of Zambia Medical Library. She is Coordinator for the Communications for Better Health project and the National Coordinator for Healthnet. She has managed the Medical Library since 1986.

BACKGROUND AND CONTEXT OF THE PROJECT About Zambia

Zambia has an area of 752,600 square kilometers and a population of 8.09 million people ( 1990 census). It has a national average density of 10.8 per square kilometer. Children under 15 years and women of child bearing age (15-49) constitute almost 75 percent of the population in any given year.

The country has a fairly good health service infrastructure and a reasonable cadre of health professionals, at least by standards of the developing world. The health system is heavily biased in favor of curative services rather than in preventive medicine and, even then, it favors urban population over rural populations.

Health resources and status are influenced by the economic development of the country. The consequences of the economic crisis in Zambia include among others the following:
· Erosion of the health infrastructure;· A decline in the quantity and quality of access to health services;· An increase in the cases of malnutrition;· An inadequate supply of drugs; · An unsatisfactory rate of infant mortality;· Poor staff morale due to unfavorable working conditions; and· The neglect of health information provision in national programs.

The University of Zambia (UNZA)

The link between the University of Zambia and the Ministry of Health (MOM) is the School of Medicine. When the School of Medicine was established in 1970, it had a book collection which was housed at the then Oppenheimer College of Social Services. The years that followed the establishment of the Medical Library saw a steady growth of health information at the library, with a book stock of 25,000 volumes of books and 781 periodical titles on the current subscriptions list in 1985 (Stock-taking report, 1985). Although the proportion of the books and periodicals budget which was given to the Medical Library was not rationally divided, the Medical Library was able to purchase all the recommended books and to pay for the periodicals on the current subscriptions list in any given year. (See Box 1.)

The Medical Library collection was supplemented by generous donations from friends of the University of Zambia, mainly from abroad and through gifts and exchange programs within and outside Africa. The only technology that was available at the Medical library was an audio/visual collection, which was composed of slides, microfiche, microfilm, filmstrips, reel-to-reel tapes, and texts. This collection was not easily accessible because the library did not have, and still does not have, the hardware with which to view the collection. The collection was and is still only usable with the help of the equipment from the UNZA Medical Illustrations Unit of the School of Medicine.

The Medical library struggled to survive through all the economic turmoil that Zambia faced from 1985 to 1990. Health information provision at the Medical Library suffered much since 1985. The last regular subscriptions to periodicals was in 1984. The book budgets were last fulfilled at about the same time. There was near total dependency on donor support to acquire current health literature. The World Health Organization (WHO) played a major role to sustain subscriptions to critical journal titles in the Medical Library. Initially, the total number of periodicals subscribed to by WHO was 50, which was reduced to 15 in 1987 and which has remained at that level to date. The book collections were slowly becoming redundant as new acquisitions diminished in number year after year. The academic and research programs were dependent upon the ingenuity of the medical librarians and the goodwill of their partners outside the country. The host institution did not have the funding required to support the library services.

In this situation of real information poverty, genuine financial support was sought to try and alleviate or reduce the lack of information to less destructive levels. It was not possible to seek assistance in-country because the entire nation existed in an information poverty trap. Neighboring states were in no better situation either, except in the case of the University of Zimbabwe Medical Library, which survived the scourge of the rash economies of developing countries due to late independence.

The Carnegie Corporation of New York, the International Development Research Centre of Canada (IDRC), the Commonwealth of Learning, WHO, the Ford Foundation, and others have, at one time or another, sponsored meetings that brought together African medical librarians and persons working in the area of science and technology information systems and communication technologies to discuss access to information and other professional developments. Other groups also provided expert assistance and moral support. These include the American Association for the Advancement of Science (AAAS), The Health Foundation of New York (THF), SatelLife of Cambridge, Office of International Affairs of the U.S. National Research Council, and the African Regional Centre for Technology (ARCT). Most important of all resources, however, are the individuals and groups of people who initiated moves to organize these meetings.

Zambia, like any other developing country, has no time to walk - it must run to keep up with the developments of industrialized countries in all fields. In health information provision in particular, the need to focus on the 1978 Declaration of Alma Alta, which stated that primary health care was the key to attaining health-for-all and the recognition that health-for-all could not be attained without a well coordinated health information system, became critical to Zambia's aspirations to improve health information provision.

BOX 1 The UNZA Medical Library

The economic conditions that prevailed in the country due to extensive mining activities at the time of the inception of the Medical Library made it possible for the UNZA to be very well supported financially. The UNZA in turn gave 5 percent of its budget to the UNZA Library. As the local book industry was not developed and is still not developed, all required medical books and periodicals were obtained from either the United Kingdom or the United States, with less than 5 percent coming from Africa and other parts of the world (annual reports, 1970-1985).

PROJECT DESCRIPTION

The AHILA conferences (see Box 2) provided the platform for Zambia to review its performance in the provision of health information. The result was that when the first partners offered to help to solve the problems, the Medical Library took the opportunity and worked to use the resources that were extended to it to increase health information provision. There have been six major developments since 1991 offering solutions aimed at getting Zambia out of the information poverty trap:

· Installation of a HealthNet ground station at the UNZA Computer Centre in April 1991 by SatelLife and the subsequent installation of a Fidonet email point at the Medical Library.
· Installation of the CD-ROM technology by the Health Foundation in 1992.
· Establishment of a Zambia national and Africa regional African Index Medicus (AIM) data base in 1993.
· Initiation of a quarterly publication called the Zambia Health Information Digest (ZHID).
· Installation of an Internet connection at the UNZA Computer Centre and the subsequent installation of an Internet point at the Medical Library in January 1995.
· Formation of a National Aids Resource Centre (NARC) in February 1995 ( see Box 4).

All the initiatives tell one story: that Zambia wanted to solve her health information poverty problems which dated back to the 1964 pre-independence era. While I have been involved in some way in all of these initiatives and while I see them as very synergistic, for the purpose of this case study I will focus on the Communications for Better Health program, which encompasses the CD-ROM and the ZHID projects.

One initiative listed above' the African Index Medicus, is important to both me and Helga Patrikios and it has been described in detail on page 45 of this volume. Another initiative, that of bringing Internet connectivity to Zambia, is covered in detail in Neil Robinson's case study on page 191 of this volume.

BOX 2 The Value of Professional Associations

In certain instances, limitations to accessing health information from neighboring countries were caused by uncompromising political policies that were put in place by the nation towards the pre-independent Zimbabwe and South Africa. What were solvable health information problems became entangled in factors beyond the librarians' boundaries. This situation could easily have lead to professional skills redundancy had it not been checked by the existence of professional meetings at Africa regional level under the Association for Health Information and Libraries in Africa (AHILA) and the Medical Library Association (MLA).

PROJECT EXPERIENCE AND IMPLEMENTATION

CD-ROM Databases

In 1992, we made major progress in the delivery of health information by installing CD-ROM technologies. The library received a total of 12 CD-ROM databases from THF and AAAS, some of which have full text articles, on such subjects as AIDS. One CD-ROM database, called Popline, is a donation from the John Hopkins University, whereas the Infectious Diseases database was installed by the CAB International. The usage of the databases is illustrated in Tables I and 2.

Please note that even though the AIM and Infectious Diseases databases are not CD-ROM databases, their statistics have been included because they are searchable databases. The Popline database was first received after the first quarter of 1995, hence the low statistics. The statistics on the Infectious Diseases database were lower than expected because the contents of the database overlapped with those of the databases that have existed longer in the Library. The database comes with coupons for full text articles donated by the CAB International. Some of the databases were a one-time donation, whereas those that continued to be received periodically were MEDLINE, Popline and AIDS. We update the AIM database regularly.

The University of Florida Health Sciences Center Library continued to provide photocopies of full text articles. Tables 4-8 provide some statistics of the reprints that have been provided with help from THF since the project started in 1992. The statistics are disaggregated by type of request, subject, distribution by numbers, distribution by percentage, distribution by geographical location, and method of distribution. The total number of reprints received by the Medical Library by April 1995 was 1,172. Another 234 reprints were received in May 1995, bringing the total to 1,406 reprints. In terms of distribution of reprints' there were times when they were distributed multiple times, thereby pushing the statistics high.

TABLE 1 Literature Search Statistics (1994)

Database	Yearly Total
MEDLINE	273
British Medical Journal	21
Lancet	15
New England Journal of Medicine	21
AIDS	30
Paediatrics	17
Morbidity and Mortality Weekly Report	1
Viral Hepatitis	2
Year Books	1
American Journal of Public Health	12
Family Physician	2
AIM	5
TOTAL ANNUAL STATISTICS	400

TABLE 2 Literature Search Statistics (January-June 1995)

Database	6 Months Statistics
MEDLINE	714
British Medical Journal	88
Lancet	69
New England Journal of Medicine	7
AIDS	95
Paediatrics	13
Morbidity and Mortality Weekly Report	12
Viral Hepatitis	45
Year Books	11
American Journal of Public Health	34
Family Physician	26
AIM	67
POPLINE	36
Infectious Diseases	48

TABLE 3 Categories of Reprints for Medical Library (September 1992-April 1995)

Category of Reprints	Number of Reprints
Topic requests from UNZA Med. Lib.	66
Special requests from UNZA Med. Lib.	159
Clinical information file, UNZA Med. Lib.	947

TABLE 4 Reprints by Broad Subject Category

Subject	Number of Reprints
Cancer	66
Cholera	62
Diabetes	53
Diarrhea	82
Hepatitis	63
HIV/AIDS	35
Hypertension	91
Malaria	36
Maternal & child health/nutrition	43
Measles	85
Meningitis	52
Ophthalmology	42
Sexually transmitted diseases	53
Trauma/wounds	39
Tuberculosis	92

TABLE 5 Distribution of Reprints

User category	Number of Reprints
University of Zambia	586
University Teaching Hospital	703
Health practitioners	762

TABLE 6 Percentage Distribution of Reprints

User category	Percentage distribution
University of Zambia	50%
University Teaching Hospital	60%
Health practitioners	65%

TABLE 7 Health Practitioners Distribution of Reprints

Geographical location	Number of reprints
Within Lusaka	410
Outside Lusaka	352

TABLE 8 Method of Reprint Distribution outside of Lusaka

Method	Number of reprints
Print	176
Email	176

The email provided an avenue to request and transmit literature search requests. Furthermore, both the email and post were used to distribute reprints to users outside Lusaka. Our vision is to provide access to the CD-ROM databases to health care workers outside the university by using a leased line. The greatest need for this service is at the periphery health facilities and yet most, if not all, of the databases cannot be networked over a wide area because of the copyright rules that govern them. Serious thought should be given to waiving some copyright regulations to third world countries if information is to be shared equally among all health care workers.

Zambia Health Information Digest (ZHID)

The ZHID is a creation of the Medical Library and the Ministry of Health (MOH), with a grant from THF and IBM International Foundation. It is an offspring of the CD-ROM technology component of the Communications for Better Health Project. The first issue was launched on 1 February 1995 at a ceremony held at the Medical Library. Its contents include appropriate and relevant health information designed for all levels of health care workers (presented in the form of abstracts culled from the Ovid MEDLINE and AIM databases), articles on the management of common medical conditions, feature articles on other medical conditions, and institutional profiles.

The digest is produced quarterly and circulated to 1200 health facilities and institutions throughout the country. The MOH plays an important role in the distribution of the digest. The digest is also distributed on the Internet using the ZAMNET gopher. It is our intention to distribute it locally using the local Fidonet email system as well. The launching issue of the digest attracted positive comments from the local readers and from as far away places as Brazzaville, Columbia University and Geneva. The hardware on which the digest is being produced came from a cooperative grant between THF and IBM International Foundation. The launching attracted dignitaries from Zambia, the United States, the Republic of South Africa and received positive media attention.

The University of Florida Health Sciences Center Library provides full text articles of the Ovid MEDLINE abstracts that are included in each issue of the digest. The provision of the full text articles by the University of Florida is a continuation of the aid which is being given to the UNZA Medical Library.

The CD-ROM project did not start in a vacuum rather, it built upon the HealthNet project that had just been introduced to the UNZA Medical Library. Part of the technology (a 286 Olystar Computer) had already been installed by SatelLife. THF added on a CD-ROM player, providing one work station for CD-ROM activities. This took place in July, 1992. The pressure on the one computer, which was used for both email and CD-ROM activities, mounted as more and more people became aware of the improved health information services being provided by the UNZA Medical Library.

Efforts to get more equipment from donors met with some hitches as we failed to provide convincing justification for the acquisition of additional equipment. This did not surprise us because statistics maintenance was poor at that time. After a lengthy two years of negotiating with donors, THF working in collaboration with the IBM International Foundation, donated two 486 IBM file servers, each with a 540 megabyte hard disk; one laser printer; one dot matrix printer and color monitors.

With the availability of this equipment, we ventured into publishing the ZHID. This project went on smoothly because all that was required to be done was a few lessons in the use of Wordperfect 6.0 and how to use the graphics, both programs that we had acquired with the arrival of the file servers. The project proved a great success and is still running strong. The cooperation from the Ministry of Heath, THF, and the IBM International Foundation motivated us to such an extent that we aimed to do everything as correctly as possible.

THE RESULTS, IMPACT, AND BENEFITS OF THE PROJECT

The reaction of the clientele to both the CD-ROM and the ZHID projects was amazing. Initially the Library staff took advantage of the visit of Dr. Leonard Rhine, Medical Librarian at the University of Florida Health Sciences Center Library1, to market the CD-ROM services. In October 1992, he conducted three half-day seminars on Automated literature searching at the Library. The participants in the seminars were drawn from among medical students, the University Teaching Hospital (UTH) health care workers, and research and teaching staff from both the School of Medicine and the University's Great East Campus. The UNZA Medical Library and Main Library staff were also active participants in the seminars.

The publicity leaflets for the seminars were put up before the arrival of Dr. Rhine. From that time onwards, most of the Medical Library clientele became aware of the new technology in the library. They were booked for thirty minutes each to do literature searches, but they complained that time was too short. The time allocation provided for a maximum of 15 searches a day. Some requests for literature searches arrived by email from the periphery hospitals - even though the technology was not adequately marketed outside of Lusaka. However, my involvement in the evaluation of the HealthNet project provided an opportunity to introduce the CD-ROM activities in the Southern Province of Zambia.

The comments from the readers of the digest both from the printed copy and from the Internet were full of praise for the initiative taken and for the quality and usefulness of the publication in promoting health information provision. (See Box 3.) Some comments were made against the UNZA Medical Library for excluding some departments of the MOH and other health institutions. Another indicator of the success of the digest was reflected by the number of local and international researchers who brought their reports to be published in the digest. The impact of the digest on the Medical Journal of Zambia is that the editors have been motivated by the progress made on the digest to such an extent that they have regrouped and are working out new strategies for reactivating the publication.

Publicity of the ZHID was done in grand style with the Deputy Minister of Health, Dr. Katele Kalumba, officiating at the launching ceremony of the digest. The occasion attracted media coverage that lasted more than one week. The launching was followed by a workshop on Problem Solving For Better Health (PSBH), which took place in Ndola, the Copperbelt Provincial capital. The participants in the workshop came from all over the country, thereby giving an opportunity for the digest to be introduced across the country. The method of disseminating the digest to all health facilities, using the MOH, provided yet another form of publicity. In short, the digest was self-selling.

It has not been easy to measure the impact of the CD-ROM services in the absence of carrying out an impact assessment survey addressed from the point of view of the student performance from the time of the introduction of the service. The other way of measuring impact would be to find out the increase in medical research and publishing activities among health care professionals in the School of Medicine and the UTH. However, the Post Basic Nursing student projects have greatly improved in quality in the past two years. The 1994 projects were even applauded by the Research and Ethics Committee of the School of Medicine after a seminar at which they were presented to the School. As the UNZA Medical Librarian, I give yearly lectures to the Post Basic Nursing students on library services and literature search strategies. Recently, I started to do the same for the School of Nursing students at the UTH.

BOX 3 Some Comments on the Inaugural Issue of ZHID

The introduction of the ZHID is highly welcome and commended in that it will not only keep health workers abreast with new developments in health but will also instill the spirit to do some research. (Clinical Officer in Kasama)

I wish to congratulate you for the introduction of ZHID. Surely it will go a long way in changing some attitudes and methods in the manner clients are treated and thereby improve the health standards of Zambian citizens. (Health worker in Samfya)

I wish to congratulate you most warmly on the first issue of ZHID. it is most impressive and I particularly like the variety of information included: the institutional profile is an excellent idea, which I hope will be picked up by other countries. (WHO Librarian, Geneva)

I was so impressed with your educative material, especially for health workers in remote health centers of the country. Please keep it up. (Environmental Health Technician, Nakonde)

ANALYSIS OF LESSONS LEARNED

The main constraints we faced in implementing the project were the poor staffing levels at the professional ranks and the lack of appropriately trained persons to manage the projects. I, as coordinator of the project, had to learn computer skills as a matter of urgency in order to get going with the activities. In addition, the support staff were requested to work with me to move the projects forward. This on the job training worked for our library but I would suggest that it is better to start with the training before implementing the projects.

One lesson learned from this experience is that it pays to include support staff in traditionally professional projects. We found that many of the medical library staff had a natural instinct for the technology. For instance, the fastest learner we had was a library attendant. Once this person was trained, she then went on to train others, including the library users, to do their own CD-ROM searches.

If I were to start this project again, I would probably not do it much differently. The idea that intrigued me most was the need to be able to build on the existing projects instead of re-inventing the wheel. (See Box 4.) The other thing that I found useful was the use of relatively low budgets in implementing all the projects. In some cases, the projects were parasitic in the sense that they had no budgets at all, but relied totally on the existence of the other projects. An example of this is the AIM project which has no budget of its own and is dependent on the CD-ROM project for sustainability.

We were also able to build on the electronic communications initiatives of the University's Computer Center. In 1991, through the Computer Centre, we got hooked to a Fidonet system and installed a HealthNet satellite ground station. We started using electronic communications for the following purposes:

Library Partnership Program

The first use we made of email was to request literature searches. To do this, we found a partner in the United States - the University of Florida Health Sciences Center Library - to carry out the searches on our behalf. SatelLife facilitated the partnership. In June 1991 the first request (for information on meningitis) was sent to Florida late one afternoon. By the following morning, we had received a long list of citations, complete with abstracts. Dean Kopano Mukelabai of the School of Medicine at the University of Zambia acknowledged this giant breakthrough in the provision of health information by inviting me to address a meeting of the Eastern and Southern African Chairmen of Paediatrics Departments, in August 1991.

HealthNet News

SatelLife introduced an electronic newsletter that we disseminated to health care workers linked to the Fidonet system. A snap survey on the impact of the HealthNet News in 1993 showed that it was not widely read by users largely because of the busy schedules of the health care workers at whom the publication was targeted.

Literature Searches

We used the HealthNet communication system to receive and transmit literature search requests from the health care workers within the country. This aspect of SatelLife's information services was slow to be fully used because the health care workers were not fully aware of the information facilities that were at the Library. By 1994, SatelLife paid for a Grateful Med account to the National Library of Medicine with access to Toxinet, Cancerlit, AIDS, and Alert.

The HealthNet Communication Service

At the national level, the Library was linked to the Fidonet system but, at global level, communication was limited by Healthsat to those collaborators who were hooked to the HealthNet communications system. Most of the communication was centered on literature searches and to a lesser extent on other non-specific consultations with health care workers and medical librarians.

In January 1995, we received an Internet account from ZAMNET (see Neil Robinson's case study in this volume.) This development further enhanced access to and provision of our health information services. Some of the things we are able to do with the Internet are listed below:

Access to Health Information Databases

Through the Internet, the Library can access many unrestricted databases, such as the WHO Library database in Geneva. Because a subscription is needed to access some databases, the Medical Library still needs some assistance to support these charges.

Access to the ZAMNET Gopher

We have installed the AIDS Bibliography on the ZAMNET gopher. A pointer to ZHID was opened on the Zambia's Worldwide Web homepage in November 1995, and it is accessible to all Internet users around the world. We have plans to have more health information on the Internet as more is generated.

Access to Other Databases

The world of information both related and unrelated to health opened to the Medical Library users with the installation of our Internet node. We have access to multidisciplinary information through the Internet.

BOX 4 National AIDS Resource Centre (NARC)

This latest project is still in its infancy. In spite of the fact that the proposal is still under consideration by donors, some local HIV/AIDS literature was pulled from the UNZA Medical Library and UNICEF databases and put on the ZAMNET gopher. The Tropical Disease Research Centre (TDRC) Library has also prepared some abstracts that are still to be installed. The NARC coordinating center is the UNZA Medical Library and the TDRC Library is a satellite center. The participating centers are the HIV/AIDS information producing institutions which are on the email. Data collection will be done by email, whereas the AIDS database will be resident at the UNZA Medical Library. The ZAMNET gopher will be updated regularly.

CONCLUSIONS AND RECOMMENDATIONS

Good programs have been brought to the Medical Library and implemented to the best of our ability. What we have been doing is just the beginning of a long road to providing health information for problem solving. Although HealthNet became a household name in health information transmission, the project failed because it failed to attract funding after the pilot phase. There is no more health information being transmitted by Healthsat because the ground station was moved from Zambia to a more needy site.

In another vein, the Fidonet system which spread all over the country is, in some cases, being replaced by the interactive Internet. Progress and technology are playing a major role in the development of a better health information system. Neil Robinson's case study describes this progression from Fidonet to Internet and explains how ZAMNET is providing service to all levels of users in Zambia.

Although CD-ROM usage statistics have shown a steady increase since 1992, the use of the databases outside Lusaka has not improved much. The most frequently used databases continue to attract more and more users, while the less popular databases continue to be underused. The Popline database is proving to be very popular.

The AIM database is regularly consulted, too. The collection of data outside the School of Medicine and the UTH has proved to be slow because of the time and personnel factors. The first NARC HIV/AIDS bibliographies were culled from the AIM database. Since the database is accessible on the Internet, it has a wide circulation, but we have not yet devised a method to monitor usage at the national level. The only statistics available are collected from users who use the database from the library. On average, there are eleven clients who use the AIM database per week, and seven of these requests are made by readers of the digest.

Although only two issues of the digest have been released, the feedback from the readers in form of comments and requests for full text articles has been good. The usage and comments on the usefulness of the digest will be monitored continuously through a feedback mechanism built into the publication.

The Medical Library will continue to need support from partners to develop these programs that improve information provision to health care workers. The devastating effects of the structural adjustment program on the development of health information and literature can only be alleviated through the sort of assistance we have received and hopefully will continue to receive until the national economy strengthens. In view of the above concerns, I suggest the following:

· We need to network the CD-ROM for greater accessibility to databases by health care workers who cannot easily come to the library.· We need to subscribe to key CD-ROM databases not only for the Medical Library clientele but for other health care workers who depend on us for information services.· There are eight other health sciences libraries in Zambia that should be linked to Zambia's Internet service.· We need to market CD-ROM databases and other health information services outside Lusaka.· We need to purchase a portable CD-ROM workstation that we can use for demonstrations.· In order to confer on issues relating to health information provision, Zambian medical librarians should meet at least once a year.· We need to continue to improve the coverage and frequency of publication of the ZHID. · We need to send medical librarians to all AHILA meetings where much of the professional sharing takes place.· We need to subscribe to more databases on the Internet, for example, MEDLINE.

The issues that haunt the UNZA Medical Library hinge on whether health information and literature provision will develop at the same pace as health provision - which is attracting reasonable funding from both the government and donors. Or will these efforts collapse soon after the current crop of Library staff disappear from the institution?

I would like to wrap up this story with the following: partnership, intelligent use of available resources, marketing of health information, and willingness not to give up are very important factors in the provision of health information. Better health information leads to better health care. Lastly, our philosophy has been to access information - not to OWN it. Collaboration with others, regardless of geographical or political boundaries, and acceptance of the changing information and communication technologies is the way forward.

NOTE

1. The Florida Health Sciences Library has a twinning arrangement with the University of Zambia Medical Library.