A CRITICAL EVALUATION

*
*Provision
of quality and safe health services that meet the needs of the people through a network of health facilities organized to function on the basis of increasing levels of sophistication. level of care is expected to provide a package of well defined services provided by appropriately trained health professionals.
Diploma Radiography (Diagnostic) - 2012

*Each

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* Mission clinics * Rural health clinics * Various organisation staff clinics * Ante- natal and post- natal clinics * Family planning clinics * Others

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*
* Environmental Health technician * Two nurses * Community based distributor * Midwives * Village health workers

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* There is about 50% staffing in all rural health clinics. * Only less than 46% of rural households have access to

worker. * Village health workers are no longer receiving supplies. * Only fewer midwives available as a result of lack of trained professionals who are supposed to train midwives (issues of brain-drain). * The current staffing status of 2 nurses per clinic is no longer adequate due to increased workload. * Few Environmental Health Technicians with the vacancy rate reaching 50%. * The 2007-2008 drastic economic decline rendered rural health clinics dysfunctional thereby losing credibility in the social circles. This is still causing patients to by-pass them thereby impairing the referral system.-75% of patients attended to by Central Hospitals are self referring. * Large distances that patients/ expectant mothers have to travel to reach rural health clinics ( No transport or ambulances) * Poor connectivity and communication systems.
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a village health

*
District Hospitals Mission Hospitals that have been designated as District Hospitals Various missionary, private, and company facilities may also provide the same emergency and general health services as district hospitals. (The government intends that each District Hospital serve a catchment area of 140 000 people)

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*
* Nurses * Doctors (this is the lowest level where patients can be treated
by doctors)

* For specialty health services, or more difficult health issues than

the district health staff can treat, district facilities may refer patients to the tertiary facilities. health committee.

* District hospitals are administered by a hospital and district * DHOs supervise the district hospitals, and in turn are supervised
by the PMD.

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*
SHC Facility

No. of Facilities

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*
* Most
District hospitals are facing challenges that involve dilapidation of infrastructure and lack of fund to revamp the situation.

* Shortage of doctors and nurses (a result of brain drain). * Shortages of pharmaceuticals. * Shortage of equipment especially in the Imaging Department. * Lack of technological advancement leading to generally
processes.

slow

* Recent shortages of Anti-retroviral drugs.

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*
* This
consists of 7 Provincial hospitals which are situated in every Province with the exception of Harare and Bulawayo.

*Provincial

hospitals receive referral patients from district hospitals and tend to have specialists on staff to deal with more difficult health issues. However, various unique and difficult cases are referred to the six central hospitals that receive patients from all provinces of Zimbabwe.
located in Zimbabwes largest cities, though many of the private clinics tend to be too expensive for most Zimbabweans.

*Tertiary care is also available at some private clinics/hospitals

Health Personnel Involved

*Specialist Doctors.
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*
*Quaternary/central
care consists of six central hospitals in Bulawayo, Harare, and Chitungwiza. *There are currently 6 of these and they have the most advanced equipment, staff, and pharmaceuticals for dealing with the most severe cases. *The central hospitals have the largest staff of consultant specialists and clinicians and act as the highest level for health referrals. *Central hospitals report directly to the MOHCW. Similar to tertiary care facilities, Zimbabweans with high incomes tend to forego quaternary care in favor of treatment outside of the country.
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*
Challenges

* Disregard of the referral chain- despite this, and disappointingly, the

central hospitals are in most ways unable to cater for the needs of these patients since the standard has also gone down.

* Brain drain of health professionals.

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The Role
of

Imaging
in Primary Health Care

*Background & Statistics

Historically; of the myriad of global health care efforts, very few involved radiologists or radiographers. The role of diagnostic imaging in global health has been underrepresented, likely due to the perception that radiology requires expensive imaging equipment, not available/accessible in developing countries. However, as the gap between technology and production costs closes, the role of radiology in global health work has grown. Simple diagnostic X-ray installations have a valuable role to play (orthopaedics, congenital and infectious diseases). Modern technology, new modalities and diagnostic techniques are making it more and more feasible and cheaper to produce quality radiographs and other forms of diagnostic images.
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*Background Contd.

Statistics indicate that less than 1 third of the word population have accesses to diagnostic x-ray radiography, let alone other modalities. In Africa, the statistics indicate that there is 1 machine for more than 50 000 people. As compared to developed countries (<1000 per machine). The majority of health problems in rural populations and grassroots community levels are due to trauma and infectious diseases (TB, Pneumonia etc.). The treatment of 80% of these conditions can be facilitated with accurate radiological diagnosis. * Availability and accessibility of radiological imaging facilities in primary heathcare in Zimbabwe still a major challenge due to the prevailing socioeconomic climate
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* X-ray - 1895 (Wilhelm Conrad Roentgen) * First Chest X-Ray 1896 (F H Williams, Using AgBr coated plates) * Collimator 1903 (E.A.O. Pasche) * Gamma Rays - Baqurel * Grid, Vacuum Hot-Cathode Tube 1913 (Gustav Bucky, William D.

Coolidge) * Tomography 1930-1931 * CT - 1972 (Godfrey N. Hounsfield) * Improvements in X-ray (digital, fluoroscopy), CT. PET, Angiography (dual modalities, 3D reconstructions). DSR * Developments in MRI, Ultra Sound * Health Concerns: Radiation Protection
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* Imaging In Primary Health-Care

* Some
clinical conditions in primary care are common and appear to be easily diagnosed clinically requiring no more therapy than reassurance and proprietary OTC medicines available in pharmacies.

* However,
* These

some conditions may be diagnosed or strongly suggested clinically but require imaging to confirm the diagnosis and to assess the extent of the changes.
are then treated appropriately and follow up examinations may be required to confirm or assess the degree of resolution. a confirmed diagnosis but resolution is slow or has failed and imaging is required to exclude or define complications.

* Sometimes the primary care clinician may be treating a patient with

* Finally,

imaging may be undertaken for more complex cases that require specialist referral but prior investigations is undertaken to ensure that the referral is to the correct specialist and that the consultation is productive.
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* Primary Health-Care Radiography

*A
primary care radiological facility involves a complete X-ray system that will provide basic radiography at all public health centres and hospitals. * This allows trauma conditions and pathologies to be diagnosed more accurately e.g. accurate diagnosis is made between simple pneumonia and tuberculosis, as compared to using a simple stethoscope. * In some countries the access to diagnostic imaging services is limited to basic conventional examinations. * Ideally, the types of investigation available to primary care clinicians should be based on relevance to the clinical problem and patient management and not only on the cost or complexity of the imaging procedure. * Developments in CT, MRI and US have resulted in these modalities also being used extensively and should be essential services to be provided in Primary Care. * There should obviously be competent radiology personnel and physicians able to image and interpret the radiographs. * If interpreting is done by junior doctors there is risk of adopting falsepositive results in many cases. (Zimbabwe situation)
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*Pathologies
Of the diversity of pathologies that are prevalent at primary level, the majority can be diagnosed with radiological imaging. However, because patients have limited access to health care, many diseases are imaged in advanced stages. A brief list of conditions that can be usefully examined by primary care radiology are as follows:

* Trauma: All limbs fractures, spinal injuries, skull injuries, ribs * Chest: Pneumonia and all acute lung infections * Tuberculosis, Tuberculosis pericarditis and all chronic lung infections * Pneumothorax (traumatic and spontaneous) * Pleural effusions * Effusions due to cardiac failure * Lung infections (fungal, abscesses) * Asthma and emphysema * Carcinoma of the lung Diploma Radiography (Diagnostic) - 2012

*Pathologies Contd.
Abdomen * Acute obstruction, * Renal or bladder infections and calcifications * Liver abscess * Splenic abscesses * Chronic pancreatitis, calcification Other * Congenital * Arthritis * Dietary deficiency (e.g. rickets)
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*Diagnostic Yield
* The
diagnostic yield of radiographic imaging depends much on the pathological/medical condition of the patient and the modality used. film X-ray images are very useful and economic in many skeletal conditions (especially trauma) symptomatic conditions (chest, abdomen) can be assessed fairly effectively with plain film radiography. modalities in order to come up with accurate diagnosis.

* Plain

* Other

* However, many conditions require core complex and more expensive * For
example, research has revealed that routine chest radiography has low diagnostic yield in asymptomatic primary care patients.

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*Diagnostic Yield Contd.

* Nevertheless,
of patients. chest radiology is one of the most widely used diagnostic imaging techniques.

* It has been reported to change patient management by the GP in 60%

* This
has substantially reduced the number of referrals and initiated or changed therapy.

* It has also been shown to be cost effective. * Joint disease is also an important reason for consultation in primary
health practice.

* Although

clinical history and examination can assist in the diagnosis of osteoarthritis radiographic demonstration may be required and the x-ray features have been shown to affect management regardless of the clinical picture.

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* Screening, Invasive Procedures & New Technologies

* Radiological imaging has made it possible for certain conditions to be
to be assessed more comprehensively and with much accuracy and certainty e.g. alimentary canal (barium contrast procedures), tumour development, size etc. * Fluoroscopy has also made it possible for many sensitive surgical operations to be done more efficiently with improved outcomes. * It has played a key role in orthopaedic insertion, removal and monitoring of intramedullary rods, plates, screws, fistula, foreign bodies. * Likewise, Ultra Sound has played a critical role in obstetrics. * Some conditions managed by primary care physicians are acute and require rapid investigation. * The technological advances in radiological imaging (mobile radiography, digital radiography etc.) has allowed timely intervention in such scenarios.
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* Medical Imaging In Zimbabwe

Trends and current status

* The

public health sector has a well established medical imaging system that is available in all district, provincial and central hospitals. due to the shortage of spare parts.

* However, most of the equipment is either obsolete or non-functional * Because

of the need for specialist services, most facilities are centralized in Harare and Bulawayo. (MRI, CT, PET etc.) has increased training of imaging professionals at Parirenyatwa, UZ and NUST. since

* Government

* X-ray operators were also trained in provincial hospitals. * However, the public health sector has no single radiologist
these are trained outside the country.
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* Trends & Current Status Contd.

* Due to the shortage of radiologist in the healthcare system, most of * On-going * In
the interpretation of radiographic images is being done by junior doctors and this is negatively impacting on outcomes. research on the red-dot system is being done (to assist doctors in interpreting radiographs) line with their objective to strengthen imaging services, the government has also made commitments to scale up training and retention of radiology staff and specialists also look forward to revamp the facilities in BYO, Harare, provincial and districts hospitals.

* They

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*References:
* Madzorera
H Dr. 2009: The National Health Strategy for Zimbabwe. Ministry of Health & Child Welfare. Harare chest radiography in a primary care setting. National Library of Medicine National Institutes of Health. Atlanta

* Palmer P, 1978: Radiology and Primary Care. WHO. New York * Tigges S, Roberts DL, Vydareny KH, Schulman DA. 2004: Routine

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