The hospital vehicle was not always on the road. Several repairs and frequent maintenance were needed that could not always be done in time. The vehicle is actually old and replacement will be needed within the next two or three years. The ceiling of Female Ward I and the labour room came down as a result of old age. No patients were injured and the complete ceiling was removed but rehabilitation has not yet been done. In the theatre the only theatre lamp in use was damaged and innovative solutions had to be put in place before the lamp was repaired later in the year. Small maintenance works for equipment and assets, however, were mostly done. Two small capital projects were completed; these were the completion of the administration block (former isolation ward) and a rehabilitation of the pharmacy and general store. The pharmacy building was in a poor state with major cracks and no ventilation or windows resulting in temperatures of above 40 oC in the hot season. Cracks have been repaired, the outside painted and windows were constructed, but ventilation still remains to be improved and the space is too small. The isolation ward has been adjusted and several works have been done to complete the block. It is temporarily in use as a store but will be used as an administration wing in the year 2000. Other buildings that still require major rehabilitation (and extension) are the kitchen and laundry, were the food is still prepared on firewood and linen is washed by hand. Also the operating theatre, the labour room and female (maternity) ward do need renovation and extension, while in general the whole hospital and OPD is in need of repair and maintenance work.

In November the "water and sanitation - rehabilitation project", funded by the Royal Netherlands Embassy, started off. This project will result in, lastly, extensive new ablution blocks for Male Ward, Female Ward and OPD, rehabilitation of the ablution block for Children's ward, a new sewerage system, an underground water tank, a water pump, renewal of all water pipes, taps and sinks.

Staffing of the hospital in general remains inadequate. There were a number of changes, especially in the departments of OPD and Laboratory. The hospital continued to participate in the training activities for student clinical officers (Chainama College, Lusaka) and student doctors (University of Amsterdam, the Netherlands). It is currently sponsoring two staff members at schools in Lusaka, one for training in anesthesia and one to be trained as laboratory technician. A few staff members participated in some courses and workshops but the number remained small due to the inadequate funding.

The burden of the AIDS pandemic to the health sector is still increasing. Patients with HIV-related conditions now probably occupy an approximate of 50% of the available beds in male and female ward. For children's ward an estimate is more difficult since malnutrition and (recurrent) malaria are highly prevalent. The hospital was appointed as one of the pilot district hospitals for the 'Voluntary Counselling and Testing' (VCT) programme. The promotion of HIV-testing is now more and more done. KDH has a number of active counsellors, but the lack of a counseling room has been a constraint. The hospital is also participating in the 'Community Home Based Care' programme that started early this year. Several nurses are voluntarily visiting chronically ill patients, including AIDS and TB-patients, with volunteers from the community within the KDH catchment. Funding of this programme has been minimal and it has relied on some donations and assistance from churches, mainly the Catholic Church. Drugs have been supplied to the programme from our hospital stocks, but the amount was certainly inadequate.

3. Community and Health Status

The district health action plan and the district health annual report describe in detail the health status of the community. Population in the district consists of a mixture of tribes of which the Lozi tribe is the predominant one. Other tribes in the district are Nkoya, Luvale, Mbunda, Luchazi, Kaonde while in Kaoma Town also small numbers of Bemba, Tonga, Nyanja and others are found. Most people are subsistence farmers, growing maize and to a lesser extent cassava, rice, sorghum (millet), groundnuts and vegetables. Some people also keep cattle or goats but it is few compared to other areas in Western Province. At some places honey is collected and cutting and sale of timber does also occur in the district.

The health status of the population is poor. Life expectancy in Zambia is now about 40 years. Underfive mortality is high (203/1000; 1993), infant mortality and maternal mortality are also very high. Few people have access to safe water, of Zambia's rural population it is estimated at 28% only and 12% access to safe sanitation. HIV Prevalence estimates for Kaoma District are 24.8% for the urban population and 16.6% for the rural population (HIV/AIDS in Zambia, Dec. 1997). Also, malnutrition among underfives remains a major problem at community level with percentages in the range of 30% of all weighted children.

4. Health Policy and Health Infrastructure

Communication with the district health office is good. DHO weekly meetings are also attended by the hospital management. DHMT meetings were held every 1 or 2 months and the DHMT is the decisive body since Kaoma District Health Board was dissolved. This happened after the visit of the Minister of Health to Kaoma district in May; all over the country many Health Boards were dissolved. The Health Policy of the Zambian Government as implemented in the Health Reforms is to provide Zambians with equity of access to cost-effective, quality health care as close to the family as possible.

Basic care is supposed to be given by unpaid CHW's and tTBA's. These are chosen by their communities and trained at the district. The communities are expected to support them economically (with maize, manual work, etc). The CHW's receive a kit containing basic drugs and material for simple first-line treatment and tTBA's receive a kit containing equipment for uncomplicated deliveries. In 1998 and 1999 no training for new CHW's and tTBA's took place. The next level in the health care is the rural health centre which is ideally staffed by an EHT, a CO and a nurse or midwife. Our zone in the district has 6 RHC's. Kaoma District Hospital, then, is a first referral hospital, with Lewanika General Hospital in Mongu as nearest secondary level referral hospital and Lusaka's UTH as third level referral hospital.

5. Management

Daily management of the hospital lies with the hospital management team consisting of the heads of all departments and wards in-charges. Meetings were held every other week. There is no meeting-room and management meets in the open under a mango tree or in the MCH shelter. The management involves patient care, finances, securing medical supplies and food, maintenance of buildings the surroundings and the vehicle, reporting and planning, projects, activities and staff issues. The senior management consists of the Medical Officer in Charge, the Hospital Administrator, the Nursing Officer and Clinical Officer/OPD in Charge and meets weekly or when needed to monitor all activities and address urgent problems. The overall responsibility falls under the District Health Management Team chaired by the District Director of Health.

Other committees in the hospital are: Drugs and Therapeutic Committee, Neighbourhood Committee, Buying/Finance Committee, OPD/MCH Committee, Housing Committee. The 'Drugs and Therapeutic Committee' which is supposed to be a zonal or district committee met only twice. Rational drugs prescription, the use of clinical guidelines, general drugs issues were the main topics. The Neighbourhood Committee had been dissolved in 1998 and was re-installed in the first quarter of 1999. It consists of representatives of various government and non-government organizations included churches, business community members and community members from several nearby communities and Luena Barracks. Meetings were held monthly and main issues were medical fees, hospital projects, the relatives shelter, quality of care, the VIP latrines, income generating/supporting activities. The Buying/Finance Committee only meets immediately after a funding has been received and discusses and proposes how funding should be spent. The Housing Committee which has to look into all housing issues is a committee with members from both the hospital and the district health office. Unfortunately, no meetings took place and housing problems were handled by the hospital administrator. The OPD/MCH Committee is a new committee where activities and responsibilities of the OPD/Town clinic are discussed. The hospital management is in the process of separating the responsibilities and finances of the hospital and the OPD, which is in line with the health reforms.

The hospital has no ambulance and the only vehicle is used for all necessary purposes. These include collection of firewood and water, collection of emergencies and maternity cases from Health Centres (within the zone and those with radio-communication) as well as from within the OPD/Town Clinic catchment and the UCI outreach programme. It has been difficult to maintain the vehicle and some expensive repairs (incl. replacements) had to be done.

6. Staff

Staffing of the hospital in general remained inadequate. There were a number of changes, especially in the departments of OPD and Laboratory. Temporarily, 2 lab. assistants transferred from Luampa MH were added in 1998 to the 3 working in the laboratory. Four of them were later transferred resulting in only one, Mr. Mukumba, remaining. Staffing improved again when a lab. assistant, Mr. Akufuna, from within the district (Nkenga RHC) was transferred to KDH two months thereafter. The number of CO's deteriorated. Mr. Kopa, CO left to join ZAF, Mr. Mutuna, SCO retired and Mr. Mukwamandi, CO (Psych) was transferred to Namilangi RHC. Mr. Kalumiana, PCO and former DDH, who had been assisting in the hospital since late 1998 was appointed early 1999 as DDH for Mongu district. We were only able to appoint one general CO, Mr. Bowa, leaving the number of CO's by the end of the year at 5. Due to the shortage of CO-staff the management decided to stop having CO's on night duty (first on call). This has increased the workload of nurses on night duty and the doctor on call (MO or TAH). The hospital has one MO, Dr. Koetsier, who is also the MO in Charge. At the DHO there is one doctor as TAH, Dr. Geysels.

We greatly regret the loss of our Nursing Officer, Mrs Sitali, in April, while she was attending a church conference in Lusaka. The Nursing Sister, Miss Kalimukwa, has been acting NO since then. Two ZEN, Mrs Lubasi and Miss Sakwiya, were transferred out while two ZEN/M, Mss Munyinda and Miss Namakando, were transferred in. One ZEN is on sick leave pending retirement on medical grounds. One RM, Mr Sulwe, two ZEM, Miss Mutoka and Mrs Chibombe, and one ZEN, Mr Simute applied and had their separation package approved. This leaving the total nursing staff to 23 ZEN's, 11 ZEM's, 2 RM's and 2 RN's.

The district health office appointed an acting administrator for the hospital. Mr. Katungu arrived in April. There were few changes in the staffing of our casual workers.

7. Finances

Kaoma District Hospital (including Kaoma OPD/Town Clinic) received K48,303,846 for 1999 (4,025,320/month), which was 41% of the approved and planned allocation (budget) for this year. Hence the financial situation of the hospital has been extremely awkward. Leaving management faced with a situation of being not able to meet the fixed monthly running costs resulting in debts only on the increase.

The finance committee met every time after receiving a grant. Since money could not be spent according to the planned budget the committee based the expenditures on an assessment of the actual situation. Major expenditures were house rentals for staff (KDH has only 6 staff houses) and food for patients, while wages, allowances and fuel accounted for a lesser extent to the expenditures. In regard to the debt situation outstanding bills (mainly Zesco and Water Affairs) amount up to almost 15 million kwacha, while allowances, house rentals and food suppliers amount up to 9 and twice 4 million kwacha respectively.

The collection of medical fees improved after they were changed in February this year. A total of K 14,971,310 was collected. This contributed to 23,7% of the total amount received in 1999 (planned was 5%). A total of 10% is returned to the DHO as per guidelines, resulting in K 13,474,179 for expenditures by the station. Most of it was spent on salaries of casual workers (59% of the total), and less on food and special committed overtime allowances for CO's, nurses and lab. assistants.

8. Hospital activities

8.1 Curative services
8.1.1 Outpatient department
Adequate staffing of the OPD with CO's was the major problem for the OPD. There were many movements of staff and leaves, some unplanned but necessary, also affected coverage. Again most CO's also have their own programme, such as TB/Leprosy, dental, psychiatry, anesthesia competing for time. The monthly eye-clinic by Mr. Chainda, CO Opthalmology, from Mangango MH continued. Mangango continued to deliver patients for the MO and X-ray weekly on Tuesday. There was a short interruption in August and September when a doctor in Mangango, Dr. Witu, was there, but still patients were seen for X-ray and theatre procedures. A specific STD-programme and a school health education programme are not in place.

The figures for outpatient attendance diminished dramatically. This is probably due to inadequate and inconsistent tallying. Until late 1998 CO's and nurses were not tallying at OPD and the outpatient register was the only source of data. This was changed by the end of 1998, but although great emphasis was given to proper tallying it is frequently forgotten. A comparison with the number of entered first attendance's in the outpatient register has shown that there is a difference of approximately 8.000 new attendance's, which is half of all tallied new attendance's (HMIS 16.649; Register app. 24.000; HMIS 1998 39.302). Recording of reattendance's is even worse with only 1.956 patients recorded compared to 47.811 last year.

In February new medical fees were implemented. This was the first time after medical fees were started in 1994. It took the hospital management almost a year to have these new fees approved by all necessary levels. Fees collection thereafter greatly improved and contributed to the running of the hospital, in particular to the employment of casual workers. Possibly the increase of fees also contributed to a reduction of outpatients.

8.1.2 Wards/Inpatient department
Overall the hospital suffers from congestion. Bed occupancy rate increased from 113% to 126%. Most times of the year, especially during the rainy season, there are more patients than beds in female and children's ward. Due to poor sanitary facilities (only VIP latrines) and frequent lack of water (almost every day) it was very difficult to keep the wards and surroundings clean. Almost all mattresses were in a terrible condition. An improvement was made when the hospital purchased 20 mattresses and plastic covers for all mattresses in April with donated funds. Later on the hospital received new covered mattresses and linen through Medical Stores with assistance from the MP.

Disease pattern did not change much compared to 1998. While in 1998 the hospital had a temporary measles wing in place to cope with a measles outbreak, no outbreak was recorded in 1999. There were no anthrax cases admitted this year, while the whole year round there were admissions for dysentery and meningitis. No major outbreaks occurred. At the end of the rainy season two suspected cases with cholera were admitted in isolation (using the administration wing) and a cholera awareness campaign was immediately started by the district health authorities in conjunction with the hospital. These patients had gone to the hospital immediately upon arrival in Kaoma from Lusaka and adequate measures taken prevented an outbreak in the district. There is gross underreporting of AIDS among inpatients. This is due to presentation with HIV-related conditions that are then recorded, such as EPTB and PTB, fungal infections, diarrhoea, (multiple) abscesses, malnutrition and chest infections. The number of patients admitted for trauma's remains high. Every year several road traffic accidents (RTA) along the main Lusaka - Mongu road occur. In June this year we had a major RTA with 3 deaths and many patients with complicated fractures. The difference in total in-patient deaths between HMIS data for in-patient mortality ("discharge" diagnosis) and admission (324 (208+116) vs 239) can only be explained as a result of the use of different parameters for recording in HMIS or of inconsistent reporting.

Due to the influx of refugees from Angola allocated at Mayukwayukwa refugee settlement area by the end of the year, the number of referrals from the camp increased. Although Mangango MH is their first referral hospital complicated cases are sent to KDH. Mayukwayukwa RHC has the disposal of an ambulance making the referral of patients to KDH easy.

8.1.3 Obstetrical department
The number of hospital deliveries remained the same compared to last year (760 vs 763). This is approximately 50% of the estimated number of deliveries within the OPD catchment. The number of referrals from outside the OPD catchment, that is from health centres and Mangango MH, is not known. Due to a mistake in reporting during the 2nd Quarter the HMIS data in regard to delivery care are incorrect (reported 932 deliveries and 232 complications; 1998: 763 deliveries and 59 complications). Unfortunately these data cannot be corrected since delivery registers have been misplacement. An estimated 6% of all births are stillbirths, fresh and macerated. The number of low birth weight babies remains high in the range of 20 - 25% (1998: 19%, 1999: 23% (179)). The neonatal mortality of premature babies is high, but data are not available. A total of 2 maternal deaths were recorded in HMIS. There were 2 direct maternal deaths; one due to anemia and uterine atonia immediately after Caesarian for CPD (referred from Mangango); one due to complications after ruptured ectopic (suspected pulmonary embolus). There were two indirect maternal deaths; paralytic ileus after attempted induced abortion with traditional medicine, cardiac failure immediately after delivery in a patient with RHD and anemia (own observations).

Facilities in the hospital are below acceptable standards. The hospital has no maternity wing resulting in many maternity cases admitted in the female ward. Also a waiting shelter for pregnant women with risk factors referred from health centres waiting to deliver in hospital is not there. This is a contributing factor to the high maternal and perinatal mortality and morbidity in the district and results in late referrals. The labour room is very small. There is little privacy and it is difficult to keep the room clean as a result of old assets and congestion. All 3 delivery beds are old and broken, there is no place for a proper resuscitation table and corner, there is only one postnatal bed situated in the corridor while no cots are available. The premature nursery room, situated between the labour room and female ward I, contains two 'van Hemel' incubators. This room is really too small and premature babies usually have to share. Overcrowding with sometimes more than 6 babies and mothers sleeping on the floor has resulted in the policy to discharge babies with a body weight of >= 1800 grams instead of 2500 gram (WHO recommendations).

8.1.4 X-ray and U/S department
The X-ray department is run by one X-ray technician. KDH uses the X-ray machine of Mangango MH that was loaned to us when Mangango MH was left without a doctor about 5 years ago. An oxygen concentrator was exchanged for an X-ray machine with Senanga District Hospital in July. It was expected that the Mangango machine had to be returned upon arrival of a doctor there. Unfortunately the machine from Senanga does not function well and needs to be fully examined with the X-ray technician of Senanga. Due to old intensifying screens the quality of the X-rays has gone down but is still of good standard.

A portable ultrasound machine was received from the Netherlands by April and has been functioning well. Mr. Sichimwi, the X-ray technician, was sent for a two week in-service training by an ex-pat. radiologist in Lukulu District Hospital.

8.1.5 Laboratory department
The laboratory department was faced with a lot of changes in staffing. Four assistants left on transfer and one assistant was transferred in from within the district, resulting in two laboratory assistants running the lab. A medical assistant from Luena Barracks and a casual worker are assisting. Workload somehow increased when the VCT programme started. A comparison with last year could not be made due to inadequate recording of data.

Lack of laboratory supplies and tests was a problem. RPR tests (syphilis) were out of stock during the first half year. Blood bank supplies from Central Blood bank were inadequate and tests had to be bought from private suppliers (RPR tests, Hep. B tests, anti-sera, blood packs). Destilled water for ZN-stain and other tests had to be bought. Only one microscope was in use, the others being not repairable. During the first few months of the year the laboratory had to rely a lot on the small hospital generator in order to continue services. Power supply was poor as result of frequent breakdown of the ZESCO generator. After this improved by April when a new generator was installed, again later supply became infrequent when diesel was in shortage all over the country. Waiting time before getting results, especially for inpatients, is still unacceptably long and needs further improvement.

8.1.6 Theatre department
The theatre department is staffed by one theatre nurse and one assistant nurse. Our PCO is also CO anesthesia and gives the anesthesia during major operations. He went on vacational leave in October. During the year it was difficult to maintain an assistant nurse in the theatre department and we relied on a medical assistant from Luena Barracks. The last few months we had to rely on the assistance of Mr. Nkandu, RN and in-charge of children's ward, while Miss Mooya, ZEM and theatre nurse fell sick.

Generally, the number of major and minor operations remained the same as last year. For about a month and a half no elective surgery was performed due to the broken theatre lamp. Emergency surgery continued during this period by improvising with headlamps. We had also some problems with the suction machine and had to rely on the only other suction machine from the labour room. Only ketamine for general anesthesia and lidocaine for local or regional anesthesia has been used. Spinal anesthesia was not used due to lack of iv-fluids the whole year round.

With assistance from a VSO volunteer from Lukulu the main autoclave, which had not been in use since its installation some years back, was repaired. Until so far we had to rely on a small autoclave (cooking pot model) placed on the floor in the theatre. The theatre is in need of renovation. It has several cracks in the walls, loose and broken tiles, broken windows and no paint on the walls. There is no functioning sluice and no proper corridor while the entrance doors are in a state of collapse. Surgical equipment is basic and old.

8.1.7 Dental department
During the first months of the year the dental department of the hospital was in disarray and not functioning. It was only by late March that management decided to collect the CO from Namilangi on a weekly basis to start performing dental extractions. The department was taken over by the new CO, J. Bowa, in July and has been running more or less regular since then. A total of 222 (153 up till July; 69 up till December) patients for extraction were treated.
8.1.8 Tuberculosis and Leprosy
Tuberculosis still remains a major health problem due to the HIV pandemic. During the year under review four hundred (400) TB patients were diagnosed, out of it 105 were sputum-positive (26,25%) and 175 were sputum-negative, while 88 were EPTB. Thirty-two (32) cases were diagnosed as relapsed, 13 were sputum-positive (3,25%) and 19 were sputum-negative (4.75%). During data analysis it was noted that the number of sputum-positive cases is too low.

The chest clinic is manned by Mr. Pumulo, clinical officer with special training in both TB and leprosy control programme. A ZEN, Mrs. Kabika, who has also some experience in both diseases assists him. Activities carried out are defaulter tracing, participation in Home Based Care, DOTS monitoring (if possible), notification of diseases, compiling of quarterly reports, supervision of RHC's, CHW's and other institutions. Kaoma DH has no TB-ward in place, the originally constructed TB-ward is in use as Children's ward, therefore the chest clinic is located at the duty room of the Children's ward. No changes in staffing took place.

Drug shortages were experienced especially during the fourth quarter. Rifinah (rifampicin and INH) and Pyrazinamide got both out of stock. This dangerous situation resulted in many patients not starting their TB treatment. Targets for the year 2000 are to increase sputum-positivity from 26% to 40%; to reduce defaulter rate from 9% to 5%; to supervise CHW's (and HBC-volunteers) once per quarter.

With the implementation of MDT in 1983 the number of new cases had dropped down. During the year six (6) paucibacillary cases were diagnosed while two (2) multibacillary cases were diagnosed. It is assumed that some leprosy cases are hidden in communities due to lack of health education and fear of social stigma. We also experienced a shortage of leprosy drugs during the fourth quarter.

8.1.9 Pharmacy department
The hospital and OPD depend fully on drug supply through Medical Stores Ltd. The district budget allows a 4% to be spent on emergency drugs and medical supplies for the whole district. Although hospital funding was greatly inadequate it was sometimes as well used to purchase drugs. Drug supply throughout the year had its ups and downs. Deliveries by Medical Stores improved, they were regular according to schedule each month but amounts were not sufficient enough to reach our demands. IV-fluids were not available throughout the year, while certain drugs such as quinine inj., diazepam inj. and oxytocin inj. had to be purchased. However the hospital vehicle was not anymore sent out to Lusaka and purchase of drugs was done by sending the acting pharmacist or by the doctors. In the first quarter the hospital received a donation of drugs and supplies from the Netherlands (Stichting Medisch Comitee Kaoma) which relieved us from the drug shortage that started late 1998. Health Centre Kit supplies improved when numbers almost doubled. Also the three hospitals were supplied with a number of kits for their OPD's in the 2nd and 3rd quarter. No kits were received in the fourth quarter but stocks at the district were still sufficient to provide HC's. A pre-fabricated pharmacy store was received from Medical Stores for storage of RHC kits and supplementary drugs/supplies.

Staffing of the department was a problem. The pharmacy is run by one ZEN both for the store keeping as well as the dispensary. Proper balancing and stock control and checks could not always be done accurately. Part of the year the medical assistant from Luena Barracks in the theatre department also assisted at the dispensary. A dispenser was later on appointed. There is a need for further training of these people. The pharmacy store was renovated.

8.2 Preventive and Promotive services
8.2.1 Mother and Child Healthcare
This department is run by 4 nurses, of which 2 are FHN/ZEN/ZEM and 2 are ZEN/M. One nurse left on voluntary separation within the first 6 months of the year and another nurse left during the last half of the year. Activities carried out are pertaining safe motherhood, e.g. early detection of abnormalities and/or complications that may hinder a progressive healthy pregnancy and labour including postnatal care. In regard to child health activities are the usual immunization programmes (EPI), growth monitoring of underfives and treatment of growth faltering and malnourished children, participation in national immunization days, NIDS (Polio) and Vitamin A supplement campaigns (Child Survival Week). Lastly, family planning services are provided, including child spacing and counseling in child bearing. Health education is given on the dangers of constant pregnancies and deliveries and the problems of caring for a big family.

The department managed to carry out its activities despite the shortage of members of staff. It uses the "supermarket" model, which means that all services are provided on a daily basis. Only the first antenatal attendances are seen once in a week. The UCI outreach programme was successfully resumed in October 1999, after a standstill for almost a year. Main problem for the MCH is that the room is far too small to carry out the activities. Also the place is congested with the district officers' items as they occupy about 1/3 of the place, while the roof leaks and the walls are cracked. Growth monitoring, health education and other activities are therefore carried out in the open, under a Mango tree. There are only 3 wooden benches. Especially during the rainy season it is very difficult to facilitate all services. With increasing population in the district there is an urgent need to improve our safe-motherhood and underfive services. A new and more extensive MCH-unit is required.

It was observed that a few isolated cases of DPT injections developed some abscesses in the middle of the year. Upon realizing this old needles were removed and replaced by new ones. There was incomplete recording in the books/registers due to lack of manpower. Cooperation between the nutrition officer of the district and the MCH staff needs improvement.

The percentage of fully immunized under 1 yr children increased from 75% to 80% (980). All immunization scores improved. However it must be noted that coverage is above 100% for BCG, DPT III and OPV III. These are 112%, 165% and 165% respectively. It can only be concluded that our estimated population of under 1s and under 5s is much higher and/or that immunization services provided by the nearby Health Centres is poor. Nutritional status of underfives did not change (32% vs 34% below lower line). The number of first antenatal attendances went down (from 1,464 (99%) in 1998 to 1,394 (90%) in 1999) while the reattendances went up (from 3.1 average visits to 4.0 average visits). Post delivery mothers do not come back for postnatal examinations even when they have been advised to do so, the coverage diminished from 49% to 17%. There was a slight increase in new acceptors for family planning compared to last year while the numbers of revisits remained equal. The total preventive contacts increased from 18,913 in 1998 to 20,748 this year.

8.2.2 Other Preventive and Promotive activities
There are 13 CHW's in our catchment of which 10 are active. The number of kits received was 48. Naliele PHC unit did not receive any kits since the community rejected the CHW and chose a tTBA to undergo a CHW training. The number of tTBA's is 16, but 14 are not active. The two tTBA's who are active need tTBA kits. Three PHC units have no CHW or tTBA but are very active. The chairman and village health committee members man them. The fully participate in programmes as NIDS, UCI, Vitamin A campaign and report on disease outbreaks in their area. A selection of 5 CHW's and 4 TBA's to be trained was done by various village health committees in their respective areas. Unfortunately no funds were available at district level to organize the training. We hope that this training will take place in the year 2000 as well as a refresher course for the active CHW's and tTBA's.

A total of 14 outreach stations are visited, making 15 UCI stations together with our static MCH department. There are six trips made per month, combining some of the stations on one day. The programme was restarted after September.

Outbreaks that were recorded included 25 cases of meningitis with 6 deaths, 11 cases of dysentery with 4 deaths (gross underreporting) and two non-confirmed cases of cholera with no deaths. Notification of outbreaks to the DHO was done by the EHT. Vaccinations and treatment of contacts (in meningitis) were done according to protocols. Most dysentery death cases were from Kaoma Prison, in addition there was an increased number of deaths of prisoners due to malnutrition. The problem was reported to the DHO and an investigation was made. One suspected case of polio (AFP) was admitted. Stool examinations were negative, follow-up of the case was done but the child had died at home. The two cases of cholera were residents of Kaoma Township and Kasabi (HC-staff), which had travelled to Lusaka and Copperbelt area respectively when major outbreaks were reported in those areas of the country.

The public health department of the hospital is staffed by one senior EHT. Tasks include control of communicable diseases with notification and vaccination; inspection of food stuff, sanitation and water sources; supervision of CHW's and tTBA's; UCI programme coordination; spraying and malaria control; routine inspections of hospital premises and coordination of maintenance of hospital buildings.

The shortage of manpower to keep the hospital surrounding clean was a problem. Although a group of prisoners come twice a week, they are emaciated, frail and weak due to starvation. Also, there is an inadequate amount of cleaning materials like hoes, rakes etc. The non-completion of the existing male and female ablution blocks caused a stir. The VIP latrines (PIT) were overfull and created an unsafe and unhealthy environment. Due to the fact that allowances could not be paid the UCI and epidemic programmes were initially brought to a standstill. The EHT could not be replaced during leaves. The 6 staff houses were not renovated due to poor funding. The condition of the houses is really deteriorating. Some electrical fittings and appliances at the MCH shelter and a refuse disposal bin were stolen. The wire fence at the front of the hospital has many holes and needs to be replaced. Also a big gap in the wall fence between the hospital and the staff houses compound makes security of the premises difficult to control.

The hospital managed to spray all wards at least once in the year. Several maintenance activities could be done through external funding (Stichting Medisch Comitee Kaoma). Basically most small maintenance work was done and the administration block was completed. The mortuary fridge, the incinerator and other electrical appliances (e.g. cooking pot, autoclave, switch box, theatre lamp, suction machine, oxygen concentrator, small generator) were repaired. The pharmacy was renovated, painted and windows were installed. Routine inspections were carried out, rat infestation in the kitchen and food store was reduced.

9. Training

The hospital has two staff members in training; Mr. Chiswamo at Evelyn Hone College for training as laboratory technician and Mrs. Lubasi, CO, at UTH for anesthesia training. Various other staff members attended short courses or workshops. Mrs. Liyoka, ZEN, emergency and first aid medicine; Mr. Daka, ZEN, home based care and counseling; Mrs. Mundia, ZEN, and Mrs. Namakulo, ZEM, Reproductive Health workshop (organized by the district); Mr. Sichimwi, X-ray techn., Ultrasound techniques. Two staff members, Mr. Nkandu, RN and Mrs. Milupi, ZEM, together with the MO attended the ICASA XI conference on AIDS and STD's in September in Lusaka. Mrs. Simakumba, ZEN, attended a workshop on Living Positively with AIDS in Mongu, Mr. Nkandu (EN) and Mr. Daka attended locally organized workshops in Home Based Care. Mr. Mukumba and Mr. Akufuna had further training in HIV-testing. Mr. Mundia (SCO psych.) attended a course on mental health rehabilitation.

Participation in the training programmes of Chainama College and the Medical Faculty of the University of Amsterdam continued. KDH trained 2 (originally supposed to be 4 but 1 intake in Chainama College was delayed) student clinical officers for a 6 month period. This practical training in a district setting is the last and final part of their 3 years training. The students participated actively in all departments and were very motivated. The programme started in 1997. Accommodation is provided by the hospital, costs for living come from Chainama College. Students have their own books from the College in the absence of a library at KDH. In the coming year the training at district level will be extended to a 9 months period. Two student doctors from Amsterdam stayed for 4 months (March - June) with us. KDH is recognized as an affiliation of the Medical Faculty for the training "Internship in Developing Countries". Costs for training materials, housing etc. are all covered by the University of Amsterdam. A house for students was on rent the whole year and was also used by the student clinical officers. Starting from 1995 KDH received student doctors from the University of Amsterdam, but only in 1997 an official agreement for two students per year was made. For 2000 it has been agreed to extend the programme so that KDH will train a student doctor every 4 months.

Weekly clinical lessons did not regularly take place as planned. This was due to poor attendance last year and failure to have several staff members presenting a topic. The clinical lessons that took place were mostly presented by student clinical officers and student doctors. On a monthly basis slide presentations were given by the MO in the evenings. Also, since November monthly clinical lessons have started for volunteers of the home based care programme.

The planned training of CHW's and tTBA's for this year did not take place due to lack of funds at district level. Attempts to find external funding for the training also failed. However, a 3 week training in reproductive health for health centre and hospital staff took place in December. Several staff members of the hospital participated in the teaching and two of our nurses, Mrs. Mundia (ZEN) and Mrs. Namakulo (ZEM) were trained.

10. Planning for the year 2000

The planning for the year 2000 is fully described in the approved 'Action Plan - 2000' for Kaoma District Health Board. The budget for Kaoma District Hospital is K90,326,110 (19.2% of total; 49.7% of allocated 38% for first referral hospitals) and K30,579,152 for Kaoma OPD as Health Centre Level (6.5% of total; 16.6% of 45% for HC-level). The total district allocation is K470,448,488 with 10% for capital, 4% for emergency drugs, 12% for DHO, 38% for 1st referral hospitals, 45% for health centres and 5% community level activities.

11. Epilogue

The year 1999 was a very difficult year for the hospital. Only through the commitment and effort that was made by our staff we were able to work under the difficult circumstances. Sincere thanks go to all who assisted the hospital in one way or another. The visits of several supervising and evaluating teams (district, region, central, bloodbank, VCT) are appreciated. Continued medical support and advice is needed. We would also like to thank those generous donors that are supporting various projects/activities: The Royal Netherlands Embassy, Stichting Medisch Comitee Kaoma, 't Lange Land Ziekenhuis, Medical Faculty AMC.