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Wednesday, 6 May 2009

The politics of mobile hospitals..

A scathing attack by Lusaka Gossip on GRZ's latest plans for mobile hospitals :

"The idea for Mobile Hospitals is ill-conceived and will lead to wastage of tax payers money. As a matter of fact, the idea has all the hallmarks of someone intending to profit from whichever deal will come out of the eventual procurement of Mobile Hospitals. History has shown that rarely have Zambian politicians made decisions with the poor as the intended genuine beneficiaries. But who stands to make personal gain from the proposal? Fifty three million dollars is such a huge amount of money, for Zambian standards, that Zambians must not allow the Government to waste on cheap and transitory Mobile Hospital structures. The idea must be rescinded and all the discussions on the proposed plan to import Mobile Hospitals from China must stop with immediate effect. It is important for the leadership to start planning and constructing infrastructure that will stand the test of time."
I don't fully share the skepticism over "mobile hospitals" because we know so little about how these hospitals will work.  One of the things we have discussed in the past is that Zambia is full of isolated settlements that make it difficult to provide services.  One can certainly see the rationale for providing mobile resources (in an internet and telephone age) as way of  harnessing the economies of scale. I would be interested to hear from others where such "hospitals" have been employed.  The government needs to set out a full comprehensive case for taking this project forward. It appears the government's communication skills have not improved since I wrote Governing in difficult times


  1. And then there were the famous Chinese "Barefoot Doctors" who brought health care to rural areas:

  2. The thing is it is all about cost benefit analysis.

    And in CBA what you need is to define the "counterfactual" or comparator.

    I can see many ways in which "mobile hospitals" would be good initiatives and equally where they would be poor value for money.

    Someone surely must have done the sums. All we need to see is the evidence.

    I have dug into one or two papers that demonstrate that the concept can deliver significant savings - but until we see the detail of Zambian plan, its fumbling in the dark!

  3. Those of us that have travelled extensively to rural areas in Zambia can attest to the fact that the standard of existing rural health centers is dismal. The majority of these health centers, if not all, appear to have been exposed to the ravages of war and yet they were constructed during peace time. The only rural health center that truly bears the ravages of war, situated in Nyimba District in the Eastern Province of Zambia,was damaged by the Renamo guerrilla fighters during the struggle for independence in Mozambique. That said, the argument by the Lusaka Gossip is that Zambia's rural areas will not develop by merely importing temporary Mobile Hospitals. Infesting rural areas with mobile hospital structures will not translate into overnight and meaningful development. The question is "Should Zambia be a country of temporary structures?" Economic sense dictates that any planning authority carries out cost benefit analysis and other project selection criteria before project implementation to determine the best option. To make this idea more convincing, however, one has to make a comparison between the two options, stationary civil structures against mobile structures. In the analysis one would need to account for the quality of rural roads, the durability of both structures, operation and maintenance costs to name a few. The other argument is that mobile structures will not by themselves solve the problem of lack of development in the rural areas. What the government needs do is to put in place a phased development plan for rural areas by priorities the kind of infrastructures to be developed first. With careful planning, the US$53 million can be used to construct a good number of high quality rural health centers that will effectively give rural areas a better image than the current image of shacks.

    Rural settlements in Zambia are more scattered than clustered but the masses still commute to the existing poor quality rural health centers. The rural masses, like their counterparts in urban areas, deserve quality infrastructure. They cannot be perpetually condemned to a life of makeshift hospitals. Therefore, scattered settlements in the rural areas cannot be used as argument and justification to deny our rural people quality infrastructures.

  4. Yet another polarising issue that demands public consultation.

    The idea of mobile hospitals itself is actually good, in my opinion, if the sums add up and efficiency can be maximised. The whole concept is about sharing scarce medical resources in terms of equipment and specialist personnel, and making sure usage is kept above a certain pre-calculated optimum level.

    Otherwise, you will end up with mobile units being stuck in one place (due to vehicle maintenance problems, bad roads, etc), and in the process defeating the original idea.

    So it has to be thought out; no shortcuts am afraid.

  5. It looks like the government does not know how these mobile clinics will otherwise the would be on the offensive on how this clinics will add value. What we need is for the government to respond comprehensively why it thinks this a better way to use our resources than building permanent structures. If we keep talking to each without putting pressure on the government we will soon have the containers called Mobile Hospitals on our doors.

  6. It looks like the does not have an idea how these mobile clinic will work. Otherwise it would be on the offensive giving a comprehensive report on why this is a better deal than building permenant building.

  7. Lusaka Gossip, Lawrence,

    That said, the argument by the Lusaka Gossip is that Zambia's rural areas will not develop by merely importing temporary Mobile Hospitals. Infesting rural areas with mobile hospital structures will not translate into overnight and meaningful development.

    These are a all stopgap measures. Mobile hospitals, NGOs, etc. are all doing what local government should be doing.

    And the reason local government is not doing them, is because they are unfunded by the national government.

    Please check out my Manifesto for Economic Transformation. It is a bit rusty, but it spells out an alternative model, to the present highly centralized form of government, which is a remnant of the One Party State, which itself was created in response to an external threat that no longer exists (apartheid in South Africa and Rhodesia), and an internal threat (national disintegration) that can be sidestepped by complete localisation and subsidiarity of government.

    According to my model, local council budgets would be doubled or tripled, and they would be held accountable for education, healthcare, policing, public utilities and administrative matters. Because those services would be directly provided and funded by local government, they would become available to every citizen in the country, no matter where they lived, or who gets elected to State House. In other words, they are taken out of the hands of political parties.

    This would take some capacity building on local government, but the result would be a government that is well funded, service oriented, and responsive to people's ideas and interests, because it would be literally located where the people live, and not in the capital.

    At the core of my idea, is that Zambia has 29 ministries, and collects 1.1 billion in revenues (plus 0.6 billion in 'donor aid', which I ignore for the sake of sustainability - in case all donor aid stopped, the plan still has to work). If half of that 1.1 billion, 550 million was directly paid out to 350 local councils of 30,000 people per council, each would receive 1.57 million in direct funding.

    (Example, the Solwezi Council, population 38,000 in 2000, has a budget of K2.1 billion or $375,000 at K5600/$. Under my model, it would receive $1.98 million ($1.57 million x [38,000/30,000]) directly from central government on top of that - allowing them to reduce local taxes while they fund services.

    The CDC (Citizens Democratic Party) and prof. Kyambalesa's Agenda For Change already have a similar interest in decentralisation, and from comments on Lusaka Times, the concept seems very popular.

    It might be too late for 2011 to create a new party and get it known nationwide, but these ideas could be adopted by an existing party, for everyone's mutual benefit.

  8. in 1999 I wrote a feature in the Daily Mail/Sunday Mail of how villagers in Chief Mpezeni's area were being trained to provide basic medical services. Unfortunately, at that time the papers were not on the internet, so one has to go to the physical archives. The point though is that the concept of Chinese barefoot doctors has been trialed in Zambia before.

  9. I have been attempting to understand the reasoning behind the creation and maintenance of mobile hospital units in the Zambian context. Certainly there can be no doubt that many Zambian communities currently lack access to adequate health care facilities, and often must travel economically difficult and medically dangerous distances to receive care. It is tempting to draw the conclusion that if the patient cannot go to the hospital, then perhaps the hospital can go to the patient. However it would seem common sense that the outfitting of a mobile hospital would be more expensive than an equivalent stationary facility. I would be curious to see a cost comparison between deployment of mobile hospitals versus augmentation and expansion of existing clinics to greater capacity.

    There seem to be some other possible assumptions involved with the decision to deploy mobile hospitals. The first that occurs to me is that there are skilled medical professionals who are otherwise idle when deployed to stationary facilities, and thus require mobility in order to have access to enough patients that they can achieve cost effective rates of productivity. Given the current ratios of health care professionals within the general population, this strikes me as unlikely, especially given the time and expense of actually moving the facility, during which it and its personnel are presumably idle.

    Another possibility is that there are patients requiring surgery or other medical procedures who cannot safely be moved by ambulance to a stationary facility and thus will not receive proper treatment unless availed of a mobile facility. This reasoning strikes me as also unlikely, since patients in such remote locations are unlikely to be reachable by the quality of road a mobile hospital would require. It seems common sense that an ambulance service would be able to more rapidly reach and transport patients than waiting for the provincial mobile hospital to arrive from its last destination.

    A third possibility is that the services provided by a mobile facility will be specific enough, infrequent enough, and demand for them clustered enough both geographically and temporally to enable such a facility to effectively rotate through a province providing services and moving on according to a set schedule. Certainly there have been positive experiences in many countries using mobile facilities for provision of non-emergency primary procedures such as immunizations, dental care or screenings for pre-existing conditions such as cancer or HIV/AIDS. However such procedures generally do not require the full services of a hospital per se, and are usually quite adequate when provided at a properly outfitted primary care clinic (whether mobile or stationary). Fully equipped mobile surgeries (complete with x-ray rooms, blood warmers, oxygen generators, etc.) on the other hand are generally only deployed in disaster or war zones where there has been an overwhelming volume of emergency cases and/or interruption in the normal functions of the civilian health care infrastructure. Thus it is likely that these specific mobile facilities would be better termed "clinics" rather than "hospitals" in public discourse to avoid confusion as to their capabilities.

    This last impression is defied however by the reputed price tag associated with the deployment of these nine mobile facilities (US$53M for all is approx. US$5.9M per unit). My review of costs for clinic-sized mobile units appears to be significantly lower (e.g. US$250,000 to US$300,000 each based on f.y. 2009 prices for a variety of US and German made dental clinic "trailer" models, excluding costs for actual dental equipment (US$25,000-60,000 depending on single or double occupancy, x-ray equipment, etc.), electric generators, or towing vehicles). This leads me to think that these nine proposed units must in fact be more along the lines of 20-50 bed "transportable hospitals" intended for medium to long term deployment in any given location, which seems to defy the need for mobility outside of disaster or war zones.

    This 2004 article from indicates that central government contributions to investment in the deployment of thousands of mobile primary care clinics to rural areas amounts to only tens of thousands of US$/unit rather than millions, however no specifics are given on the level of investment being contributed by local authorities or individual patients. I remain confused as to the exact nature and intent of the "mobile hospital" plan currently producing controversy in Zambian media, and would welcome any clarifications if anyone can provide some.


  11. I personally think that the Mobile Hospital Units are important to the people of the republic of Zambia.

    Specialized medical facilities tend to be concentrated in medical centers in metropolitan areas, which results in unavailability of adequate medical care to large portions of our population.

    I would wish to introduce to you readily available Field Medical Units from CueMed Consultants Ltd.

    CueMED Mobile Field Hospital is envisioned as a unit capable of assisting a damaged hospital or adding capacity to a functioning hospital, following a dieses outbreak, natural disaster or act of terrorism.

    The units are designed and equipped to provide a wide range of healthcare services, including emergency surgery, orthopedic stabilization, wound repair, burn treatment, cardiovascular and pulmonary care, invasive and noninvasive advanced life support for cardiac arrest, comprehensive asthma care, and dental procedures.

    The Vehicle Hospital Units has total body dimensions of up to 8.0 meters, exterior width 2.5 meters and interior height 2.0 meters of space.

    The Medical Tents have up to a capacity of 12 beds. They are designed with an air-conditioning system, drainage outlets and are well ventilated.

    For more information please visit;

    Mike N.
    CueMed Ltd

  12. MikeN,

    Thanks for this info about mobile hospitals.

    How much is the outfit you linked to cost?


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