The University Teaching Hospital (UTH), formerly known as Lusaka Hospital, stands as a cornerstone of Zambia's healthcare system. Founded in 1934 shortly after Zambia’s capital was moved from Livingstone to a little-known town called Lusaka, the Lusaka Hospital was opened to cater to the increasing number of patients in the new town.
The name Lusaka Hospital was short-lived. The newly constructed hospital was swiftly renamed University Teaching Hospital, commonly known among locals as UTH. The new name was fitting because the hospital became a practicing center for doctors, nurses, clinical officers, and other health professionals.
Today, the UTH, with a capacity of 1655 beds and a catchment population of about 2 million, is the largest hospital and main referral health institution in the country. Due to its high demand, the UTH doesn’t take every casualty and illness presented to it. In other words, one cannot, for example, go straight to UTH if they’ve got a headache or stomachache. Instead, they have to go to their local clinic and have that minor problem taken care of. Only when the doctors or nurses at a local clinic determine that they cannot handle the problem can one be referred to UTH. By ensuring that only serious casualties and major illnesses are handled, the patient population is somewhat reduced at UTH.
When it comes to training medical practitioners, the UTH is one of the nation’s greatest assets. To begin with, it acts as a repository for all the necessary equipment and specimens for a medical student to do her practicals. For engineering students, it’s easier to find old gadgets that you can use to build your model, or better still you can buy the needed spare parts. However, as a medical student, you have to practice with a real patient, and what better place to find these needed patients than at the hospital. That’s why UTH is in partnership with the University of Zambia (UNZA).
When medical students at UNZA reach their fifth year, they are moved to a new campus: Ridgeway, which happens to be near UTH so they can have access to real patients to perform their practicals.
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Because the UTH is the biggest public tertiary hospital, it’s open 24/7, benefiting both medical students and patients suffering from major injuries and serious illnesses.
Aside from helping patients get better and allowing medical students to acquire their practical training, UTH also acts as a small-scale business center. Most people in Zambia are unemployed and make their living through informal businesses such as selling fruits by the roadside. Nationalist Road, where UTH is located is populated with these small-scale, fruit-selling businesses. However it’s important to note that the prices of fruit near UTH aren’t friendly. For instance, if you decided to buy a banana or an orange there, you’d spend twice as much. To avoid these high costs, some people tend to carry with them fruits bought from elsewhere whenever they visit a patient at UTH.
It’s evident that selling fruits near UTH is good business or else vendors would’ve stopped selling there. Not all people remember to carry fruits when they visit a patient. Sometimes, a visitor would carry apples, but the patient inside would say he’d like to eat pears. The visitor then would’ve no choice but to buy from the nearby vendors. To all who give business to vendors on Nationalist Road, please continue with your generosity, for your kwachas and ngwees have a double benefit: helping patients get the needed nutrients from fruits as well as helping the vendors put food on the table.
There has been criticism about the standard of treatment people receive at UTH. Many complain that doctors don’t do much for the patients and that they can’t even give them medicines. Instead, they just write prescriptions for various medicines, which patients themselves are required to purchase elsewhere. As much as we like to complain about the sub-standard treatment at UTH, we should realize that the problem isn’t with the doctors nor is it with UTH itself. It’s bigger than that.
Doctors at UTH are well-qualified and have the heart to treat patients to the best of their abilities. The challenge is the lack of medical resources available at UTH. The hospital doesn’t have state-of-the-art equipment that would enable doctors to efficiently do their work. That’s why well-to-do citizens prefer going to private hospitals for treatment. However, many citizens aren’t well-to-do, so they have no choice but to come to UTH. This creates another problem: patient congestion. This problem is so big that it’s almost impossible to see a UTH doctor the minute your case is referred to the hospital. Instead, you’re put on the waiting list. Only those in critical condition are the ones who see the doctor immediately after being referred.
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If we depend on UTH so much, one wonders why we don’t equip the hospital with modern medical machinery. But if it’s a place where the poor get treated, then there’s very little incentive to improve the hospital. Even rich government officials never go to UTH for medical treatment. The late President Levy Mwanawasa was taken to France when he was ill in 2008. Many ministers go to South Africa for their medical treatment. Perhaps the biggest problem is that government officials - the people who are responsible for improving conditions at UTH never get their treatment there. This means they would never know how badly the hospital needs improvement and medical machinery.
President Michael Sata had diagnosed this problem too. He was famously against government officials flying to South Africa for medical treatment. He argued that if these government officials didn’t think they’d get better treatment at UTH, then they needed to make sure that conditions at the hospital were improved. President Sata went so far as to say that if he were ill, he’d spend his time in UTH rather than wasting government money flying out of the country.
We’ve all had a connection with UTH. If you’ve never been admitted there, you probably have a family member or friend who was admitted there.
UTH plays a critical role in nurturing Zambia's future healthcare professionals. Over the years, UTH has been home to distinguished physicians and faculty members who have made significant contributions to Zambian healthcare.
UTH's unwavering commitment to exceptional patient care, medical education, and fostering distinguished healthcare professionals cements its position as a cornerstone of Zambia's healthcare system.
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Like the Supreme Court, which is the last court of appeal for all things legal, the University Teaching Hospital is the last resort for all things medical.
Global Health Exchange Program
Since 2015, the University Teaching Hospitals (UTH) of Lusaka and the University of Maryland, Baltimore (UMB) have jointly conducted a global health exchange program. Such exchanges have increased in popularity; over 200 American universities now offer a global health experience [1]. Of 154 allopathic medical schools in the United States, 140 offered international electives between 2016-2017 [2].
As trainees and facilitators of this exchange program, we describe our experiences working in Lusaka and Baltimore, and strengths and challenges of the partnership. Since 2015, we have facilitated rotations for 71 UMB trainees, who spent four weeks on the Infectious Disease (ID) team at UTH. Since 2019 with funding from UMB, nine UTH ID trainee physicians spent up to six weeks each rotating on various ID consult services at University of Maryland Medical Center (UMMC).
Challenges and Mitigation Strategies
Challenges in global health rotations can include inadequate preparation or inappropriate expectations among high-income country trainees, low-value experiences for low- and middle-income country trainees, lack of appropriate mentorship at sites, and power imbalances in research collaborations. International medical experiences whereby learners from high-income countries (HICs) travel to low- and middle-income countries (LMICs) can be inequitable, potentially resulting in exploitation and harm [3]. Traditional colonialism was characterized by exploitation of knowledge, materials, and both natural and human resources from LMICs; in contrast, inequitable medical exchanges may promote neocolonization of global health, characterized by extraction of experiences, education, and research data [4,5].
Trainees from HICs often travel to LMICs with minimal understanding of the cultural, medical, and socio-economic environment, potentially resulting in interactions with domineering or colonizing connotations. Trainees may have an appropriate approach to clinical management, but lack contextual understanding: an American doctor in Zambia might insist on a lumbar puncture, not understanding local cultural taboos against spinal procedures [7].
Training experiences provided to LMIC trainees in HICs may offer limited educational value due to mismatches between HIC resources and local environments. HIC training opportunities may also contribute to ‘brain drain’ by providing incentives and opportunities to remain in HICs. Though many LMIC clinicians and researchers wish to stay in their own country [8], some migrate due to limited resources, lack of training and research opportunities in LMICs, or higher employment, salary, and perceived increased quality of life in HICs [9,10].
Zambia’s healthcare system transformation . The Levy Teaching hospital.
Finally, HIC-LMIC joint research has historically been inequitable to LMIC collaborators: LMIC authors are often under-represented on scientific publications, with articles on Africa having only 44% LMIC authorship [13]. Barriers to research and publication in LMICs include lack of funding opportunities, training resources, research management, technology, infrastructure, and access to scientific literature [14,15]. ‘High-impact’ studies are often conducted by HIC researchers in LMICs but rarely led by LMIC researchers [16]. This further causes LMICs to abandon innovation, instead settling for less costly, ‘lower-impact’ studies such as epidemiologic studies and case reports.
We try to mitigate these issues by ensuring pre-departure and on-site orientation for UMB trainees, cross-cultural mentored experiences for all trainees, and intentional sharing of authorship and credit on scientific collaborations. To ensure UMB trainees are prepared for their time in Zambia, all aspiring participants meet with UMB faculty in Baltimore prior to acceptance. We discourage participation for the purposes of resume enhancement, interview talking points, or simply vacation, which have all been cited as motivations for global health rotations [25]. Upon arrival, trainees receive orientation from UMB faculty regarding Zambian history, culture, and medical norms, including respectful patient and interprofessional interactions. The orientation invokes Abimbola’s ‘principle of subsidiarity’ in global health: proximate actors at ground level hold the most knowledge about their domain and decisions should take place at that level, i.e., ‘default to the local gaze,’ with ensuing practical and moral benefits [26].
The UMMC rotation for Zambian MMed ID registrars strives to be beneficial and impactful. While in Baltimore, MMed trainees are mentored by UMB ID faculty that work in Zambia or other sub-Saharan African countries; this creates a shared baseline for focused and impactful learning. The UMB rotation is timed to coincide with UMB Zambia-based faculty attending at UMMC, to preserve continuity of mentorship and education. Infectious disease rotations are structured to reinforce key concepts in ID (i.e., principles of antibiotic therapy, antibiotic stewardship, and microbiology) that strengthen the trainees’ ID expertise. Finally, the UMB rotation is used to launch collaborative research, with connections to mentors and projects.
To build equity in scientific collaboration, we developed a shared authorship model for collaborative research projects. In doing so, we aim to mitigate against parachute or parasitic research [28], imbalanced power dynamics [4,6], and to ‘amplify the voices of the health workers and researchers in LMICs for whom the notion of “global health” is but an everyday reality of their working lives’ [16]. All collaborative UTH-UMB manuscripts have either a UTH first or last author, to ensure that ‘local people [are] writing about local issues for a local audience’ [26].
The MMed ID Program
The collaboration between UMB and UTH has a longstanding history and has evolved into an equitable medical education partnership [17]. In 2005, the Zambian Government requested assistance from UMB to develop Zambian capacity to address the growing HIV/AIDS epidemic.
The Masters of Medicine in Infectious Diseases (MMed ID) represents a novel ID specialist training program that emphasizes equitable and collaborative models to improve healthcare training [18]. The program began as a Masters of Science in HIV (MSc HIV) in 2009 via a UMB, UTH, University of Zambia, and MOH partnership; in 2014, it then evolved into MMed training and by 2018 fully transitioned to local leadership. Candidates complete five years of postgraduate training in ID and internal medicine. The program is led by Zambian MMed ID physicians, with support from two Zambia-based UMB ID faculty physicians and a UMB Global Health Fellow.
The MMed ID program contributes to global health equity by transferring skills and developing local training capacity. MMed ID graduates have the training to practice in any global setting while continuing to develop a cadre of health professionals.
To complement opportunities in the MMed ID program, UMB and UTH trainees have participated in bidirectional exchanges since 2015. UMB trainees, including medical students, residents, pharmacy trainees, and ID fellows, visit UTH for a four-week structured rotation. Trainees round with the inpatient ID consultation service and see patients at the HIV clinic. All rotations are supervised by a Zambian MMed ID senior trainee or graduate and UMB faculty. UMB trainees participate in medical education with UTH MMed ID registrars and contribute to didactic sessions by presenting lectures or case conferences.
UTH MMed ID registrars spend up to six weeks rotating at the University of Maryland Medical Center (UMMC) in Baltimore. The MMed ID registrars round with UMMC consultation services in carefully selected ID sub-specialties not available in Zambia, such as transplant, surgical, and oncology ID, which both reinforce core ID concepts and enhance understanding of novel diagnostic and therapeutic modalities. MMed ID trainees attend didactic sessions, including core curriculum lectures, case presentations at ID grand rounds, microbiology rounds, journal clubs, and morbidity and mortality conferences.
Research and Publications
The UTH-UMB exchange has created opportunities for both institutions to partner in research. Over the past eight years, the collaboration published 10 abstracts at international scientific conferences, nine peer-reviewed manuscripts, three more manuscripts under review, as well as clinical antibiotic stewardship guidelines for UTH [20]. All publications include trainees and faculty from both institutions.
For the first three years, the collaboration did not have independent funding and trainees paid their own way or applied for small grants. Since 2019, the University of Maryland School of Medicine, via the Center for International Health, Education, and Biosecurity (Ciheb) at the Institute of Human Virology and the President’s Global Impact Fund (PGIF), via the UMB Center for Global Engagement (CGE), supported the UTH-UMB Global Health Collaboration. Funds are equally applied to each institution; to date, nine UTH and 15 UMB trainees have been supported.
The rotations at UMB and UTH include a co-developed curriculum that covers medical knowledge, practices, and culture encompassing Eichbaum’s paradigm shift of global health: patient safety, fair trade, co-developed curricula, power dynamics, and equalization of access and opportunity [4].
Challenges and Future Directions
The greatest challenge faced by the collaboration is funding. Initially, UMB trainees paid their own way or were supported by independent scholarships; there was no support for Zambians to travel to Maryland. Because trainees were self-funded, this inherently selected for people of means with a potential sense of entitlement.
Until 2018, the two Zambia-based UMB faculty were funded in part via PEPFAR to support medical education; when this grant ended, they continued their work pro bono and developed a funding proposal for UMB. In 2019, Ciheb and CGE provided internal funding for the UTH-UMB collaboration, which supports travel and lodging for all trainees, small stipends for Zambians while in Baltimore, and salary support for the Zambia-based UMB faculty.
Another hurdle is the extensive bureaucratic requirements faced by Zambian trainees when coming to UMMC, which American trainees do not face going to UTH; these include USA visa applications and extensive hospital paperwork. The hospital rules for observers at UMMC also limit access to electronic records and hands-on physical examination of patients. Lack of pre-established understanding on authorship distribution caused challenges during our first forays into collaborative research. Collaborators from UTH and UMB had to have difficult conversations to determine author order and credit.
The COVID-19 pandemic imposed hurdles due to international travel restrictions. When exchanges were paused in April 2020, we began weekly virtual case discussions and journal clubs, which maintained both academic learning and professional relationships.
Scientific ideas from LMICs in research, clinical management, and innovation should be brought to scale and visibility. Unstated standards or norms in global health education govern transfer of ideas generated in the HICs to LMICs; science is often produced with ‘the foreign gaze’ in mind [26]. To develop equity in global health education, we need a paradigm shift so that impactful innovations generated from LMICs can play a key role in HICs [4,6].
Intersectionality assesses relationships and interactions between factors rather than examining individual factors themselves; it allows for assessment at multiple levels in society to determine how health is shaped across population groups and geographical context [29]. One of the great inequalities in medical education and global health is the lack of access to resources and tools available for fostering research in LMICs. As data becomes more available, resources to strengthen research output would improve scientific productivity for LMIC researchers.
The UTH-UMB global health collaboration is intended to promote reciprocal exchange with commitment to equitable training and professional development. The structure of these rotations enhances healthcare capacity building, transfer of knowledge, and contextual cultural learning to advance global health equity.
Building global health equity requires developing medical education aligned with the needs of LMICs. We advocate for global health exchanges with targeted education centered on perspectives of medical education and cultures, including dialogue around neocolonialism and decolonization of global health. There are significant and complex barriers to these proposed exchanges, including resource limitations.
Challenges of Medical Records Interoperability
Lack of a SNOMED CT E.H.R System in surgery departments causes inefficient scheduling of surgical procedures, insufficient and inaccurate pertinent patient historical information, misconceptions and error arising from ambiguities in terminology usage. The result is unhealthy clinician working environment leading to high death rates among patients.
Baseline Survey was conducted using questionnaire to establish the major drawbacks of the current manual system in use at the department. Record inspection was done followed by roundtable discussion with stakeholder. Convenient sampling was used, out of 40 respondents 72.5% had computers in their section, 27.5% did not have, 60% were using partial electronic records and paper based, 37.5% were using manual system, 2.5% reported that they were using electronic record system. The result reviewed more than 50% of the medical practitioner ranging from nurses to surgeon reported to be dissatisfied with the current system.
In addition, record inspection was conducted by going to each section of the department to understand the business process and the form and format of data storage; this exercise reviewed redundancy in the capture, storage and management of patient records due to the fact that in every section where a patient pass, while undergoing diagnosis procedure, basic details are collected afresh for the same patient. This situation has brought about unnecessary duplication of work. The other drawback is the storage of patient records arising from lack of storage space. Record which are ten years old are destroyed to create space for new ones. This destruction of records robs researchers of the much-needed data for trends analysis and patient disease history.
The following table summarizes the findings of the baseline survey regarding the use of electronic and manual systems in the surgery departments:
| System Type | Percentage of Respondents |
|---|---|
| Computers in Section | 72.5% |
| Partial Electronic Records and Paper Based | 60% |
| Manual System | 37.5% |
| Electronic Record System | 2.5% |
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