Decentralized nurse training in rural Zambia – triplicating the output of trained nurses.

Author(s) Martina Weber1, Toddy Sinkamba2, Klaus Thieme3.
Affiliation(s) Zambia, SolidarMed, Chongwe, Zambia, 2 St. Luke's School of Nursing, Mpanshya, Zambia, 3 SolidarMed, Chongwe, Zambia.
Country - ies of focus Zambia
Relevant to the conference tracks Health Workforce
Summary The SolidarMed pilot project decentralized practical nurse training in rural Zambia started in 2012 with St. Luke’s School of Nursing in Mpanshya. The project aims at providing nurses for rural districts of Zambia by triplicating the annual student intake, and by delivering quality theoretical and decentralised practical training to meet quality standards. It is a pilot project presented as a valuable model for nurse training in Zambia to the Ministry of Health and other interested stakeholders. The project is based on the recommendations of WHO Global Policy Recommendations (2010) on Improving access to health workers in remote and rural areas through improved retention.
What challenges does your project address and why is it of importance? Zambia, like many other low income countries in the region, faces considerable challenges in providing sufficient human resources for health. In Zambia only about half of the health facility workforce are trained. Nurses and midwives are crucial in an already struggling health system, and not having enough key staff like nurses weakens the health system. Zambia has a shortfall of 9’000 nurses which is approximately 60% of its requirement. Rural hospitals particularly illustrate a drastic gap between the planned medical staff and the actual staffing situation. Historically, Zambia has not invested enough in its health training institutions. The under-funding of health institutions, poor training and accommodation facilities, inadequate equipment and study materials, as well as inadequate teaching staff have resulted in high attrition rates from pre-service training (like nursing), fewer graduates and an overall deterioration in the quality of outputs.
How have you addressed these challenges? Do you see a solution? The SolidarMed pilot project tries to target all these recommendations in the partnership with St. Luke’s School of Nursing at St. Luke’s Mission Hospital in rural Mpanshya / Zambia. The school had 30 students in 2009. The project target is to double the output of students by decentralisation of practical training. The first external practical training site is Sacred Heart Mission Hospital in Katondwe – a small hospital in a very rural and remote part of the Province. Experiencing clinical practice is essential for the student nurses to understand their professional future. Nurses are likely to find themselves as one of the few health professionals within a rural health institution. If they have never experienced the reality of rural practice and learnt to deal and adapt to its challenges, the outlook for their retention in the rural areas is not good. Given the limitations of a rural posting, where there is likely to be staff and equipment shortages as well as crumbling infrastructure, nurses need to be trained for this. And this kind of training is only possible if you actually train within a rural, peripheral context. The second external practical training site will be Chongwe District Hospital. This Level 1 District hospital is quite close to Lusaka, in the District capital of Chongwe and here nursing students supplement their experience of clinical practice in a remote rural area with practical training in a more urban hospital. Patient numbers are high, which is also valuable preparation for their professional future. In addition, being based in Chongwe allows nursing students easier access to Chainama Hills Hospital where they complete a practical rotation in mental health. Two clinical instructors are placed at all three practical training sites. The combination of learning and experience available at these three quite different hospitals provides a balanced mix of exposures to various professional settings. This allows nursing students to experience as many aspects of their practical work as possible, and thus gives them the best possible training for their future career.
How do you know whether you have made a difference? The project is on-going. The overall goal is to improve the provision of nurses for rural health care in rural districts of Zambia. In order to achieve this goal, SolidarMed invested in infrastructure and equipment at the decentralised training sites by building a student hostel and staff houses for the clinical instructors at Sacred Heart Mission Hospital in Katondwe and at Chongwe District Hospital, as well as staff houses for the clinical instructors at St. Luke’s School of Nursing in Mpanshya. Additionally, teaching and learning equipment is constantly upgraded. Furthermore, SolidarMed is supporting the training of one nurse tutor and six clinical instructors, incentivising the latter and supporting St. Luke’s Nursing School by placing them on the payroll of the individual practical training sites. To ensure cooperation between the Nursing School and the decentralised sites works smoothly, a comprehensive Framework Agreement is drawn up to define roles and responsibilities. The relevant Ministry of Health and Ministry of Community Development, Mother, Child Health are very interested in both the negative and positive outcomes of this pilot project. It is seen as a way of increasing the output of trained nurses in a relatively cost effective way with the additional benefits for the participating decentralised practical hospitals. Since the start of the project the intake of nurse students has been increased to 103 in 2013. This triples the number of students since the Nursing School started.
Have you or the project mobilized others and if so, who, why and how? This project is a pilot project for the Zambian training system for medical personnel. As well as the training institution, St. Luke’s School of Nursing and its Hospital involved other parties at the decentralized training sites at Katondwe Sacred Heart Mission Hospital and Chongwe District Hospital. All lessons learnt are shared with all stakeholders – e.g. the General Nursing Council of Zambia, the Ministry of Health and the Ministry of Community Development and Mother & Child Health and all other training institutes interested in scaling up their output. The involvement of the General Nursing Council is crucial for the success of this pilot project. This professional body registers nurses and midwives and regulates their professional conduct and education while also registering nursing and midwifery schools. It also has an advisory role in the Ministry of Health on matters relating to nurses and midwives. With regard to nursing and midwifery schools, the General Nursing Council sets the monitoring and evaluation standards, decides whether facilities are suitable for training, conducts supportive supervision visits and evaluates the training programmes offered at individual institutions. Furthermore, the General Nursing Council also develops and reviews curricula, teaching and learning materials, evaluates the implementation of these curricula and conducts knowledge and skills updates for teaching and clinical staff. The lessons learnt could be applicable for other job training institutions in Zambia that focus on topics other than health.
When your donor funding runs out how will your idea continue to live? The design of the SolidarMed project is that the decentralized nurse training can continue after funding runs out. The nursing school benefits from investment in its infrastructure and faculty and will be strengthened in the area of quality assurance. SolidarMed experienced that the practical training sites hosting the students benefited from their participation in nursing training. Nurses in training are a form of additional manpower in the context of a human resource crisis. SolidarMed has not created separate cadres of health professionals or designed its own brand of training, but rather supports Zambian training programmes, tailored to Zambian requirements. The project supports local ownership of human resource for health strategies. So it is fully consistent with Zambia’s national health priorities and strategies as defined in the Government of the Republic of Zambia’s Fifth National Development Plan 2006 -2010 as well as the Ministry of Health’s National Health Strategic Plan 2006 -2010, and the Human Resources for Health Strategic Plan 2011-2015. Preliminary drafts of the Sixth National Development Plan 2011-2015 suggest that this project is in line with Zambia’s future national health priorities and strategies. Local ownership is key to sustainability. SolidarMed supports Zambian solutions to Zambian problems, and this project is fully in line with this strategy. In doing so, SolidarMed recognises that a home-grown solution is more likely to be effective in addressing context-specific challenges, and more efficient and affordable. SolidarMed seeks out local knowledge and expertise to achieve its aims and contributes its own experience to build capacities and strengthen its partners.

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