Mozambique

by Teresa Mendoza and Jonathan White

Our mobile clinic continues to operate successfully in Mozambique under the effective direction of our implementing partner, Friends in Global Health (FGH).

The main activities carried out during this last reporting period were related to supporting the health facilities at Macuse and Mexixine in the Namacurra district, reaching out to the community residents and families of patients gathered at these two locations.

The main services provided were HIV Prevention, Care and Treatment, Prevention and Care for TB, prevention of cervical and breast cancer, maternal and child health outreach and promotion, public education regarding the importance of adherence and proper use of condoms.

Over 800 people visited the Mobile Clinic during the activities carried out during January and February. We estimate that, if extended to the relatives (5 per person) of the direct beneficiaries, the indirect beneficiaries are approximately 4,000.

The immediate impact on the community can be seen through the results section of our full progress report which includes 620 individuals in Macuse and 190 individuals in Mexixine reached for HIV counseling and testing and trainings related to HIV prevention, care and treatment, prevention and care for TB, prevention of cervical and breast cancer, public education regarding the importance of adherence and proper use of condoms.

As usual the Mobile Clinic services include:

• Primary Healthcare and General Health Counseling and Testing
• Healthcare education
• Maternal-Child Healthcare and Health Counseling
• Vaccinations
• HIV counseling and testing
• Counseling on the importance of adherence to ART and TB medication
• Good practices for health counseling
• Evaluation of blood pressure
• Counseling on breast and cervical cancer prevention

For the detailed results of our visits to Macuse and Mexixine please see table below:

Here are the links to the galleries for the recent initiatives of RMF in Mozambique:

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Community Health Council in Nahoa

Gile, Mozambique

Inhassunge, Zambezia, Mozambique

Journey to Gile
My two-week sojourn in Gile district allowed me to observe the full-spectrum of rural health programs being run by the Ministry of Health, Friends in Global Health (FGH) and other partners. Having surveyed the clinical activities of FGH in the district during my first few days in Gile, I now needed to learn about the health outreach and education programs in the communities themselves. On June 14, I had the perfect opportunity to spend time out in the villages and observe the realities of life in rural Mozambique.

I set out from the peripheral health center in the locality of Moneia with the goal of visiting some community health councils in the surrounding communities. I was accompanied by Mr. Dambini, the district Ministry of Health supervisor, who oversees the activities of the community health councils. These councils are organized, trained and supported jointly by the Ministry of Health and World Vision, as part of a community outreach program called COACH. So far, out of 200 communities in all of Gile, currently 27 communities have set up well-organized health councils through COACH. Thus, there is definitely much more room to scale up this program which has proved to be quite successful so far.

My meeting with the health council in Nahoa proved to be the most instructive and interesting. Nahoa is a poor community of several hundred people that lies 20 km from the Moneia health center and about 40 km from Gile town. The community health council here is fairly dynamic and active. Soon after I arrived in Nahoa, we met with the council members—eleven in number—in a small open-sided mud hut in a central part of the village. After introductions, Senor Dambini explained the roles and functions of the council. The council is formed by elders and influential members of the community. It comprises activists who provide basic home-based care to AIDS patients, reproductive health counselors, influential ‘mothers’ in the community who provide nutritional counseling for children and IMCI (Integrated Management of Childhood Illness) health workers who go house-to-house to do basic pediatric evaluations. Typically, the activists and health workers are volunteers who are chosen by the council to represent them, although they sometimes receive small incentives such as t-shirts.

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Later in the day, I had the chance to accompany one of the IMCI workers as he made the rounds from house to house. At each house, the health worker looked through the child’s growth chart and made sure the vaccination record was up to date. He would examine the child and deliver nutritional counseling if he or she looked undernourished. We visited several families and in almost every instance children were malnourished. In some cases, the child had symptoms of malaria and the health worker filled out a referral slip for the case to be seen at the health center in Moneia. The IMCI health workers are instructed to refer serious childhood illnesses like persistent diarrhea, unexplained fever and suspected malaria or tuberculosis to the district health centers.

Snake Eyes Following the IMCI worker also provided me a walking tour of the village. I observed families living in mud-huts around small patches of farming land. I walked past thatched toilets with no drainage and very poor sanitation. I saw small children playing in the dirt. Older children were working in the fields. Many of them had symptoms of malnutrition; a few even had early signs of kwashiorkor. In fact, the IMCI worker told me that the two biggest problems among children in the community were acute malnutrition and malaria.

Before I left Nahoa, I was invited to observe a drama put on by the health council relating to malaria. This was the highlight of my day in the communities. The council often organizes participatory health-related theatre pieces for the benefit of the community members. The drama started out with one of the health workers—playing a malaria patient— lying prone on the floor, shivering as if with chills. One of the ‘mothers’ in the council played the role of the frantic mother of the patient. A traditional healer was summoned and quickly pronounced that the patient was possessed by demons that needed to be exorcised. Following an unsuccessful exorcism, featuring a rattle and medicinal water, an IMCI agent arrived and counseled the mother to take the patient to the health center. After a lot of convincing, the patient was finally picked up and carried to the hospital where he received anti-malarial medication. Eventually, after home care involving the regular administration of medicines and blankets and a theatrically contrived convalescence, the patient recovered fully. A joyous mood overtook the audience as they clapped and celebrated the banishing of malaria.

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Afterwards, Mr. Dambini giving a debriefing session on the performance. He emphasized that mosquitoes—and not evil spirits—were the causative agent of malaria and highlighted the importance of expediting suspected cases to the health center without delay. On a different note, Dambini also lectured on the negative consequences of not receiving childhood vaccinations. The whole production was then wrapped up with the activistas leading a chant about the benefits of vaccinations for children. Here and there, mothers from the community would be prompted to join in, initiating a form of collective participatory learning.

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As I observed the theatre and participatory learning activities, I realized that the community health council was enacting a real grass-roots mobilization for health education. What I saw in Nahoa was a well run community program—one which provided health education, entertainment and self-actualization for the community. No program to combat something as complex as AIDS can survive on testing and treatment alone. I realized then that the community health council would be a great forum for the mobile clinic to integrate outreach and education activities into its program. This week, after many discussions with FGH staff, Mr. Dambini and Dr. Kizito, the District Director of Health, I have formulated a plan to do this. Although the plan is in its conceptual stages, the idea is not only to generate publicity and referrals to the mobile clinic through the community health council but also to film their activities, demonstrations (eg nutritional demonstration to prepare enriched foods) and dramas and project them on a screen attached to the mobile clinic. There is a local traveling cinema group in Mozambique called CinemArena that is showing educational movies for HIV and we can adapt their model to our mobile clinic project. In this way, we can amplify the impact of the health council while incorporating health education into the mobile clinic activities, making it an integrated treatment, testing and education platform for the community. Mr Dambini has already agreed to be our liaison to the health councils for this purpose. The next steps will be to learn more about CinemArena and consult with them to help us implement this combined mobile clinic/cinema idea.

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On June 9, I packed my bags and departed for a two week survey of Gile district. Gile is a mountainous area in the north-east of Zambezia province, easily one of the most isolated and challenging regions in rural Mozambique. Considering the highly dispersed population and tremendous need for basic healthcare—let alone HIV/AIDS services—in Gile, it had been suggested by Friends in Global Health (FGH) as an ideal place to pilot the mobile clinic. Accordingly, I undertook the 400 km journey to Gile from Quelimane on a clear Monday morning with Dr. Emilio Valverde, FGH’s clinical adviser for the region.

Having endured 8 hours on a treacherous and jagged dirt road, I was thankful to finally enter the environs of Gile as the evening merged into nightfall. We ascended a sloping road and crossed a rough log bridge into Gile town, in the heart of the district. The journey had already done much to convince me that we should indeed launch Real Medicine’s mobile clinic project in Gile. On the way there, I had encountered a striking landscape with verdant hills and statuesque mountains. But I had also seen numerous families living in great poverty and scores of patently malnourished children lining the road as we rolled past.

The next few days reinforced my initial impressions about the acute lack of development in Gile. The vast majority of the district has no electricity, cell phone reception or paved roads. The mountainous terrain and make-shift bridges over the numerous rivulets make it very difficult for people—particularly sick people— to travel even short distances. Indeed, the terrain poses a challenge to all but the most sturdily built vehicles. In some places, the bridges are only wide enough to permit the passage of a vehicle the width of a land-cruiser. As I traveled through Gile, I noted these logistical constraints which certainly have obvious implications for the design of the mobile clinic but in a way also underscore the need to bring mobile health services to isolated communities.

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Currently, healthcare operations in Gile originate from the district hospital in Gile town. The hospital functions as the nerve center for all clinical and outreach activities in the district. It lies in a central part of Gile town and is equipped with a maternity wing, general wards for men, women and children with 6-8 beds each, several consultation and emergency rooms, a pharmacy, a lab, a database room, a counseling and testing area and administrative offices. It is staffed with several medical technicians (technico de medicina), preventive medicine technicians (technico de medicina preventiva), maternity nurses, mid-wives, lab agents, pharmacists and database managers. In addition, there is an ambulance and a driver. FGH also pays for two social assistants that coordinate the community outreach activities such as peer educators for HIV/AIDS and the ‘bushkativa’ work of activistas (community activists) which involves going into the community to track down patients who have abandoned anti-retroviral treatment.

The Clan of the Cave Bear divx However, the hospital does not have a surgical facility or staff. Thus, surgical emergencies (such as C-sections) can only be handled at the rural hospital in the neighboring districts of Alto Molocue or Nampula, each of which is half a day’s travel by car. This means that many patients—mostly women experiencing complicated pregnancies—die before they ever receive surgical care.

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Dr. Emilio and Dr. Kizito, the District Director of Health, are based at the Gile district hospital. A few times a week, however, they set out for one of the peripheral health units distributed about the district, each meant to serve the population of a single locality. These health posts largely function as satellite clinics with HIV testing and treatment occurring when the Dr. Kizito or Dr. Emilio go out there with a clinical team. However, since only 5 out of 14 localities in Gile are covered in this manner, nearly two-thirds of the population still has no access to health services of any kind.

The Ministry of Health in Gile is prevented from expanding their services not only by a major lack of funds but also by a dearth of medical professionals in Mozambique. Before Dr. Emilio from FGH started working in Gile, there was only one physician for the entire district, a population of 170,589 people.

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The lack of healthcare resources is deeply disturbing when one considers the swelling epidemic of HIV in Gile. An estimated 14% of the population or 23,883 people are thought to be infected with the virus. Right now, 40-50 new cases are being found each month and the numbers are growing. In fact, since FGH started working in Gile last November, more than 600 people have already tested positive. Approximately, 10% of these patients are already dead.

Perhaps the biggest tragedy, though, is the situation of children amidst the growing HIV/AIDS crisis. Within the family structure, children can often be the lowest priority when it comes to healthcare. Due to the great difficulty of accessing medical services, parents will not make the effort to bring an HIV-positive child regularly to a health center to receive treatment. Instead, they resign themselves to the likelihood that the child will not survive, investing their hopes in having other children who might be healthy. At the satellite clinic in the locality of Moneia, I saw this dynamic playing out. A child who had tested positive was not brought back to the health center for CD4 counts the following week. Dr. Emilio told me that this was a common occurrence in Gile—after being tested, many HIV-positive children were never seen at the health center again.

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Not surprisingly, given the context of a virtually non-existent healthcare infrastructure, Friends in Global Health and the Ministry of Health have only begun to address these tremendous challenges posed by the HIV epidemic in Gile. However, valuable progress has already been made in some areas, particularly Gile town and the locality of Moneia. At this point, nearly 160 patients in total—including 10 children—have been started on anti-retroviral treatment, most of whom remain adherent to treatment. The next step will involve expanding to more localities in Gile which are in urgent need of care. For this purpose, mobile clinics are a perfect solution to accessing scattered rural populations in remote areas of Gile. Eventually, mobile clinics can become part of a highly decentralized and effective network of satellite and mobile units that will deploy resources according to local needs. Both PEPFAR and WHO—through its Commission for Macroeconomics and Health—have called for just such a dispersed and close-to-client network of clinics to combat HIV in rural sub-Saharan Africa.

The mission of the Real Medicine Foundation over the next several weeks is to prepare the groundwork necessary to realize this vision of efficient, decentralized health care. During my time in Gile, I will collaborate with Friends in Global Health to complete a field survey of communities in the district, including an assessment of the roads, logistical barriers and distances to existing healthcare centers. This will not only inform the design concept for the mobile clinic but will also allow us to map out remote population centers that we can target with the mobile clinic. The long-term plan is to test drive the mobile clinic in Gile before expanding to other sites in Zambezia province in the long run. Consequently, careful planning and implementation along with a good monitoring and evaluation program is needed at this stage to ensure the project’s success in the future.

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Real Medicine Foundation is preparing to establish a clinic in the refugee camps in northern Mozambique (150,000 refugees after the floods in the Zambezi River Basin and the impact of Cyclone Favio) in cooperation with The Sole of Africa (www.thesoleofafrica.org

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Surgeries will be provided by Operation of Hope and the RMF team at Pemba Hospital.