Health services are divided into 3 groups. The first are elective medical services that serve to correct an abnormality or a disorder that does not cause any pain or any incapability. This is provided mainly for aesthetic reasons. The second are intermediate medical services that serve to correct ailments that cause some pain and some incapability but are not life threatening. The third are emergency or critical medical services that serve to correct sicknesses that are life threatening. The hospitals in Zambia are only able to offer emergency/critical services and even this is not adequate.

The Zambian doctors' premise is that patients deserve quality health care, but the situation in our hospitals is just the opposite. Health care conditions at the moment are very harmful because even when a doctor makes a correct diagnosis the drugs are not available.

It is regrettable to note that there have been several cases of people who have died when their lives could have been saved. The hospitals the Zambian doctors work in are so rundown that the doctors helplessly watch some of their patients die of minor

diseases because the government has failed to provide basic life-saving facilities such as IV fluids or oxygen. Even surgical gloves and painkillers are rare and hospital pharmacies are dry.

The doctors bemoan the deplorable working conditions in the hospitals. There is shortage of drugs such as quinine for malaria, antibiotics, etc. There is insufficient basic equipments, e.g., suction machines, incubators, BP machines, thermometers, simple antenatal urine test machines, slides for malarial tests, etc. These are basic things which must be available in hospitals at all times and some of these are not costly.

In most hospitals in the country, there is erratic supply of insulin for diabetes. The same applies to the supply of running water and oxygen. For instance, there is no running water at the University Teaching Hospital (UTH) after 19:00 Hrs. The physical infrastructure of most

hospitals is collapsing. There are cases of hospitals having leaking roofs, wards being infested with flies, rats and cockroaches. In some of the hospitals, patients with tuberculosis are made to share the same wards with patients suffering from non-infectious diseases such as malaria.

Some hospitals do not have qualified medical personnel. There are acute shortages of both general and specialist doctors. Since the opening of the school of medicine at the University of Zambia, Ridgeway Campus, there has been on average 40 doctors graduating every year.

Zambia has produced 1,200 well-trained Zambian doctors since 1972. This includes a few Zambian doctors trained outside the country who at some point returned to serve in the country.

Though considered some of the best trained and dedicated in the Southern African region, Zambian doctors are the most underpaid (averaging US$250 per month). The conditions of service for doctors in Zambia are horrendous. For instance, some of doctors do not even have official accommodation. Those who have been accommodated are evicted now and again because the government does not pay the rentals. At UTH in Lusaka, 30 doctors share four common toilets and one bathroom in an intern's block. They have one room each in the block which some of them share with their wives and children.

No wonder that the country has been experiencing a serious brain drain. There are now only 350 Zambian doctors, including senior doctors, working in the country. It is obvious that the dismissal of the junior doctors, rather than resolving the matter amicably, is tantamount to imposing death sentence on the sick and those currently in hospitals.

The health reforms process started in 1992. The concept of health reforms in Zambia, as a principle, has widely been appreciated. The health reforms have created new divisions of responsibility between the Ministry of Health (MoH), the newly created Central Board of Health (CBoH) and the decentralised structures.

These reforms were undertaken in order to fulfil the vision of access to cost effective, quality health care as close to the family as possible. The health reforms were supposed to signify new roles for the government, communities and individuals in health care delivery. Under the reforms, clinics were supposed to be upgraded with the idea of using hospitals as referral centres only.

Thus, the Government was supposed to channel grants for health care (mainly salaries) through the CBoH, while other partners (donors/international NGOs) were supposed to disburse funds to the districts either directly or through the basket fund of pooled resources. Health services were to be decentralised so that procurement of drugs for example, were to be done at the district level.

Unfortunately, the implementation of the reforms has been problematic. Contrary to the reform principle of downsizing the administration, there has been overstaffing of the Central Board

of Health (CBoH). The reforms were characterised by innumerable seminars on capacity building to develop policies, mechanisms and capacities, which promote equity of access and utilisation of basic health services.

Instead of exposing the implementors (people at the grassroots) to the capacity building exercises, the so-called reformers (the top officials at the Ministry of Health and the Central Board of Health) were the ones attending the capacity building seminars where they earned for themselves hefty sitting allowances that saw them buy big cars, build or buy big houses, etc. Yet some of these capacity building seminars were specifically targeting the District Health Management Teams (DHMTs) to empower them to plan for and manage resources effectively for health service delivery. Only a few clinics have benefited from the health reforms as some donors and international NGOs that supported the reforms, contributed to the district basket fund. The past two years have seen partners' support to health reforms become less certain, resulting in a significant decline in finances and supplies available.

Although the government, for the reason of wanting to ensure continued donor support, might not want to admit that the health reforms have failed, the health indicators that have been obtaining since the inception of the reforms speak for themselves. According to Demographic Health Surveys by the Ministry of Health, infant mortality rate (IMR) has persistently remained high.

Between 1990 and 1998, it has moved from 90 to 112 per 1,000 live births. Under five mortality rate (UNR) increased from average 192 per 1,000 live births from 1990 to 197 deaths per 1,000 live births in 1998. In 1996 Maternal Mortality Rate (MMR) was 649 deaths per 100,000 live births. The Global Human Development Report for 1998 confirms the MMR at 940.

The 1990 census puts the average life expectancy in the country at 46.9 years. It is estimated to have fallen to about 43 years. Because of the HIV/AIDS pandemic the country's life expectancy in 2002 is estimated at 37. All these indicators graphically illustrate the population's poor access to basic health services.

In the 1999 Government Republic of Zambia (GRZ) Budget, the government allocated to the whole health sector only 40 percent of what was proposed to the Central Board of Health as required to meet basic needs in the health sector for a year. The budget requirements per month of the different major hospitals in the country are K1.2 billion for UTH, K400 million for Kitwe Central Hospital, K450 million for Ndola Central hospital, and K80 million for Arthur Davison Hospital.

In the 1999 GRZ Budget, K22.94 billion was allocated to the District Health Boards, where as K40.02 billion was allocated to the hospital boards, including UTH. This means that a total of K65.96 billion was allocated to the health sector in 1999. In the 2000 GRZ budget K50.63 billion has been

allocated to the whole health sector. The comparison of the two budgets shows that the government's commitment to the health sector has exceedingly been reduced not only in real terms but also in nominal terms.

One questions government's priorities when you look at other allocations and disbursements in the GRZ budget. For instance, last year the government spent K100 billion on vehicles, K50 billion on servicing cell phones and K120 billion for fuel and running cars of senior government officials. The 2000 GRZ budget has allocated a huge sum of money for the president's discretionary fund.

Whereas the government is in the process of downsizing through the public service reform programme, President Chiluba is busy creating new public service posts, the district administrators. He has recently appointed 72 district administrators with the staff of 15 for each district administrator. In the 2000 GRZ budget the district administrators have been allocated K12 billion. Each of the administrators will be allocated a big house, a big car and other fringe benefits.

The government of President Chiluba is aware of this pitiful state of the health sector. So rather than risk their lives in the country's hospitals (locally dubbed "mortuaries"), all senior government officials and their families fly abroad (particularly to South Africa) for better but more expensive treatment at the state's expense. The money that is spent ferrying VIPs abroad for treatment could have been spent on bringing drugs and equipment, and to improve salaries of local doctors.

Immediately after having sacked the Zambian doctors, the government recruited new doctors from abroad, particularly from Cuba. Ironically the imported doctors are being paid tenfold what domestic doctors get. By looking at how the government is spending money on things like cell phones, fuel, cars, president's discretionary fund, district administrators and all that goes with such an appointment, medical treatment of VIPs abroad, recruitment of expatriate doctors, etc., at the expense of neglecting provision of essential services, it becomes very clear that the government is not people-centred.

Economics teaches us that resources are always scarce. Precisely because of the scarcity of resources, the government is required by law to prioritise the usage of its limited resources for the benefit of its people and not for the benefit of the head of state and top government officials. The government of President Chiluba has unscrupulously been spending heavily on non-essentials, with insufficient funding on essential services, i.e., health and education. This questions not only the government's priorities but also its capability and legitimacy to govern.

The doctors' strike, though said to be illegal, is based not on selfishness but on a serious desire for professional service to the nation. Going on strike is always considered the last resort after negotiations have failed. In the case of the medical doctors in Zambia, there are a number of structural inhibitions that have made negotiations fruitless, thereby forcing the doctors to go on strike.

The doctors in Zambia are affiliated to a number of professional bodies. The first body is the Resident Doctors Association of Zambia (RDAZ), whose aim is to uphold professionalism. This body has recently been forced to take up the role of negotiating for improved working conditions in the hospitals and improved conditions of service for doctors. The Medical Council of Zambia (MCZ), which is supposed to negotiate for the improved working conditions in the hospitals, has abrogated its responsibilities.

The second body is the Medical Council of Zambia (MCZ). This body issues practising licences and is also supposed to regulate medical practice, inspect medical facilities, i.e., physical infrastructures in the hospitals, equipments, etc., recommend improvement of the medical facilities, and close down hospitals if they prove to be below the required standard. In spite of the excessive deplorable conditions in the public hospitals, MCZ has never closed down a public hospital, but has never hesitated to close down private hospitals.

The third body is relatively new and is not yet a statutory body. This is the Zambia Medical Association (ZMA). This is a new mother body for all the doctors in both public and private institutions in Zambia.

The doctors' cause for improved working environment for health personnel and improved provision of drugs, laboratory and medico-surgical supplies should have been the MCZ's cause,

going by the MCZ's terms of reference and objectives. The MCZ is supposed to take up the negotiating role with the hospital management boards and the government on behalf of the doctors.

Since the MCZ has abrogated its responsibilities, the doctors are left with no effective structures of negotiation. It is because of this and on the basis of a number of statutes that the junior doctors went on strike in December.

Some of the statutes for the doctors' withdrawal of labour are as follows: First, the Constitution of Zambia - articles 110 and 112 /d which state that the state shall provide adequate medical facilities and take measures to improve such facilities and amenities. Second, Medical and Allied Professions Act, 1998 Clause 3 - item U which states that a medical worker, working under deplorable conditions, constitutes infamous conduct.

Third, Hippocratic Oath, which states that the doctor should abstain from committing deleterious acts. It further states that the doctor will follow that system of regiment which according to one's ability and judgement one considers for the benefit of his/her patient and abstain from whatever is deleterious and mischievous.

It also states that into whatever houses a doctor enters he/she will go into them for the benefit of the sick and will abstain from every voluntary act of mischief and corruption. If doctors continue working in the hospitals in the state in which they are, it would tantamount to voluntary mischief and corruption.

The Hippocratic Oath further states that while the doctor continues with this oath and not violate it, may it be granted to him/her to enjoy life and practice of the art respected by all in all times. Whereas doctors should commit themselves to serving the patients, they should enjoy the act (the profession) and not endure it.

Fourth, African Charter on Human and People's Rights (to which the Zambian government is a signatory) - Article 15 of the Charter states that every individual shall have the right to work under equitable and satisfactory conditions, and shall receive equal pay for equal work. Article 16/2 states that parties to the present Charter shall take the necessary measures to protect the health of their people and to ensure that they receive medical attention when they are sick.

Many Zambians, although against the strike, sympathise and back the doctors' demands. In their communiqué after their plenary meeting in Lusaka on 28 January, the Zambia Episcopal Conference (ZEC) expressed concern with the on-going doctors' strike and the stand-off with government. The Bishops of Zambia said:

We add our voice to those of many others in supporting the doctors' stand which is not based on selfishness, but on a serious desire for professional service to the nation. We deplore the loss of many lives as a result of this scenario. We, therefore, call upon the government to lead the way in resolving this impasse.

In mid - February, the Parliament debated on the private member's motion urging the government to unconditionally reinstate all the sacked junior doctors and immediately re-open dialogue with them. The motion also called for the provision of a conducive working environment for health personnel and improvement in the provision of medical drugs, laboratory and medico-surgical supplies.

This motion stimulated a very highly charged debate in the Parliament. Following the debate on doctors in the Parliament, the Medical Council meted out punishment to the resident doctors. Over 70 striking doctors from UTH were fined US$200 each and their practising licences suspended for one year. The MCZ also censured the doctors for unprofessional conduct. The penalties come after a complaint by the UTH management against the resident doctors who went on an illegal strike.

Soon after the MCZ meted out punishment to the resident doctors, President Chiluba offered to meet the fired junior doctors. The meeting took place and it is alleged that there was an agreement after the meeting for government and the medical practitioners to start working together. It is yet to be seen if the junior doctors are going to be reinstated and the conditions in the hospitals improved.

The doctors said in the interview that they do not intend to emigrate in spite of being treated harshly by their management, the council and the government. The doctors said that the brain drain on the continent has done enough harm already. Zambian doctors were trained at a great expense by Zambian people.

"It is an act of betrayal and omission to leave the country and serve other people. We would like to stay and serve our own people. Emigration does not solve the problem. We would like to stay and solve our own problems." The doctors went on to say that the medical profession is a calling from God. The fact that they have stayed on is because they are responding to that call. Their Christian conscience urges them to continue speaking out against evil and to continue seeking solution to their problems.

One wonders what crime the junior doctors have committed by asking for the improved medical environment in the hospitals. Even if ethically and morally doctors should not abandon the patients, the crisis in the health sector in Zambia shows that the government should be more responsible to the needs of the people instead of waiting until things get out of hand.