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Changing the Face of Health Care in Mozambique
by Marc A. Snyder & Judy A. Spelman
While they waited for the pediatrics ward meeting to begin, the workers at Central Hospital of Maputo were singing. “A luta continua contra a sistema colonial.” “The struggle against the colonial system still goes on.” Although a ten-year war ended direct Portuguese rule in Mozambique, FRELIMO, the governing party, now leads a struggle against the colonial inheritance of undemocratic structures, and human and economic underdevelopment. That struggle finds expression in the twice monthly meetings of hospital workers with their conselhos do base, representative worker councils that have been developed in all workplaces as part of a program of popular democracy.
A cleaning woman led the meeting which included a discussion of the work load of the ward kitchen, the unavailability of certain items from the laundry, and the discipline of workers found to be drunk. Several nurse auxiliaries were praised by the conselho for their dedicated work and were selected for upgrading of responsibilities in patient care. Finally, a theft of measles vaccine was analyzed by a ward doctor who explained that a person who would distribute inactive vaccine for profit was an exploiter of peoples’ ignorance.
After an hour of talk, Camarada Guilhermina led a closing chant: “Long live the Mozambican people. Long live FRELIMO. Long live the hospital workers and patients.” She smiled at the unintended irony, but it is clear that since FRELIMO decided to intervene directly in the functioning of the Central Hospital in October 1976, workers’ lives are better and patients’ lives are longer.
The 1600-bed institution, with 300,000 annual outpatient visits, was notorious in colonial days for its rigid divisions of wards and services according to race and ability to pay. It began to change in July 1975, a month after Independence, when all health services were nationalized and the private practice of medicine abolished. The separation of patients by class and race was ended, as was the distinction between the elite university and the substandard public services oft he hospital.1
These measures alone could not guarantee improved medical care, because colonial attitudes still prevailed in the hospital. All but 85 of the country’s 550 doctors, the majority of whom had practiced privately in Maputo, the capital, left Mozambique after Independence. Some of them, along with others who opposed nationalization, sabotaged much of the Central Hospital diagnostic and treatment equipment. Corruption was rampant. Colonial attitudes deprecating patients continued. Nursing services were sporadic and inefficient: custodial service practically non-existent.
After repeated criticisms of the hospital were brought to the Party, FRELIMO decided to intervene. Samora Machel, President of Mozambique since Independence, himself a trained assistant nurse, described the hospital as “a center of bad treatment and of humiliation of our people. There exists in the hospital a total disinterest for the poor patient which is manifested in attitudes towards him by doctor and nurse in bad hygiene in their workplaces, in liberalism and in total absence of discipline among the workers … The hospital has been a center of theft, immorality, liberalism, confusion, anarchy, indiscipline, in sum, a center of political, ideologic and material corruption.” Why was it singled out for special treatment? “Because the Central Hospital of Maputo is our National Hospital, a unique hospital structured and organized to serve all the people. . . because (it) constitutes the major center of training and formation of health workers. . . and because the Central Hospital decisively influences, now and in the future, our fight in the field of health.”2
In 1971, when Samora Machel spoke about the hospitals established by FRELI MO in the zones of armed struggle, he characterized them as “far more than centres for dispensing medicine and cures. A patient’s stay in hospital should serve to heighten his awareness of national unity … Our nurses, our medical staff, besides having their specific tasks, are also instructors, teachers, political commissars.”3 In 1976 FRELIMO was determined to restructure the Central Hospital of Maputo along similar lines. The party appointed militant hospital workers to the hospital’s new directive body, the “Commission of Restructuring,” and it directed the setting up of conselhos on each ward and service.
A typical ward council includes the chief physician, the head nurse, and about 6-8 ward members elected by the workers. They meet weekly to discuss ward and hospital problems, have meetings twice a month with all the ward staff, and regularly with all workers and patients together. In the case of the pediatrics service, this has meant meetings with the mothers.
Conselhos often arbitrate arguments between individual workers and handle requests for work transfers. In one case a man working as the ward’s “hygienic aide” asked to transfer to the carpentry department. The conselho decided that the man could go, but only after a replacement had been found.
The introduction of conselhos as a form of “popular democracy” has not yet changed the work attitudes of all, but for many workers it has fostered greater responsibility and pride. On several wards of the hospital, workers set up literacy classes for themselves and the patients. An elderly cook on a pediatrics ward began to take special interest in the children with tetanus. She would call the doctors when the children had convulsions or severe spasms, and call the nurses when they vomited and needed suctioning. Her efforts resulted in a precipitous fall in the death rate for these children which was displayed on a graph for all workers to see.
To deal with the problems of poor attitudes and performance, two other specific measures were instituted. One, emulacao socialista (“socialist emulation”), was introduced to increase productivity and develop a sense of responsibility among workers for the hospital and patients. Evaluation brigades, composed of workers from different wards, make surprise visits to the wards and services to assess cleanliness, charting, pharmacy, health education, linen, ordering of supplies, etc. Results are distributed, and each conselho can analyze its own strengths and weaknesses, appreciate the overall development of the hospital, and learn specific approaches to common problems that have been worked out by another ward or department. The other measure is a discipline code, which was approved by the workers and by representative neighborhood groups which periodically evaluate the hospital. A worker who hits a patient must go to a re-education camp: lateness is fined: drunkenness may result in dismissal. The conselhos on each ward will assume responsibility for administering the code.
Another mechanism by which FRELIMO has fostered a transformation of the hospital, besides the creation of democratic decision-making through the conselhos, has been the development of links between the hospital and the neighborhoods of Maputo. The local neighborhood “dinimizing groups,” one of FRELIMO’s basic units of political organization, were instructed by the Party to ascertain the quality of treatment given to patients. Neighborhood groups also come to the hospital to join clean-up campaigns. Hospital workers will be organized to go out to the neighborhoods to give talks about hygiene and health, and demonstrations about nutrition. This interaction between the hospital and community has changed worker-patient relationships. Patients who are relatively better off will help feed the sicker ones: mothers of sick children will help sew torn linen and assist in washing diapers.
In a year and a half since the party’s intervention, hospital services have improved dramatically. Wards are cleaner, auxiliary services prompter, and relationships between staff and patients have improved. The change in mentality was expressed by a nurse with twenty-six years experience at the hospital: “Before Independence, the doctors never looked at the patients: they just looked at the money. Now our hospital is in the service of the people.”
In pediatrics changes are marked. Often, mothers refused to admit their children to the hospital because of the history of insensitive, inadequate care, and because mothers were not permitted to stay with the children during their hospitalization. With the support of the Party, the chief of pediatrics and conselho were finally able to change the policy to permit mothers to “roomin.” Now the parents have regular sessions with the ward staff about child health, hygiene, and nutrition, including cooking demonstrations using traditional stoves and methods, but encouraging a more balanced diet including sources of protein that are available but underutilized. The profound changes in patient care resulted in a decrease in the death rate from 21 percent between February and May 1977 to 14 percent in the same period a year later,4 despite a 15% increase in the number of admissions, and a decline in the number of doctors from 17 to 11.
The contrast between the general pediatric ward, with mothers tending to their children, learning about nutrition and sleeping alongside the beds and cribs, albeit on mats on the floor, and the pediatric surgical service, which has not yet permitted rooming-in of mothers, and has row after row of soiled, frightened children, often inadequately suspended in orthopedic traction, emphasizes the changes that have been made as well as those that still require attention.5
In May 1978 a two-day meeting of all the conselhos of the Central Hospital, together with representatives from the Party, Ministry of Health, mass organizations of women and youth, neighborhood “dinimizing groups,” and health training schools, analyzed the results achieved since FRELIMO’s intervention in the Hospital. Frank details of progress made, and problems that remain, in organization of hospital supplies, cleanliness, food and linen services, clinical departments, social services, pharmacy, and overall planning and management, were discussed and published in a twelve-page supplement to the daily newspaper, Noticias. This form of meeting and evaluation was felt to be practical and effective and will likely be repeated every few years.
The Hospital’s director, Dr. Fernando Vaz, leader of the “Commission of Restructuring” summed up the major thrust of FRELIMO’s work in his opening remarks to this May meeting: “It is important that our hospitals have medications and surgical instruments, but the decisive factor is the health worker, whose consciousness and attitudes can make the hospital a center in which we can concretize our political line to ‘serve the masses’ and achieve our political principle that ‘the revolution liberates people’ “(authors’ translation).
FRELIMO intervened in Maputo’s Central Hospital not just to transform that institution, but also to create a model of change for the entire country, especially in the ways that decision-making could be democratized and workers and patients mobilized. But a central teaching and referral hospital could not be the model for delivery of primary health care services in a country like Mozambique where most of the population is widely dispersed. Consequently, decentralization of services, in the cities as well as the countryside, is another major political goal in the transformation of health care.
In Maputo, the capital city of 500,000 people, 80 percent of the population live in neighborhoods of cane huts on the edges of the concrete city center. Since October 1977, the Ministry of Health has opened eleven health centers which provide pre-natal care, routine child health supervision, and simple treatments. They have already reduced the demand on the Central Hospital’s pediatric clinic by more than a half.
The Central Hospital had consumed about a third of the national health budget before Independence. In the three years of FRELIMO leadership, the percentage of the country’s pharmaceutical budget going to the Central Hospital, for example, has declined from 40 to 10 percent, while that part of the budget has actually increased eight times.
Government health planning also calls for decentralization outside Maputo. Each of the ten provincial capitals has its own hospital and out-patient clinic services, and neighborhood health centers. Each of the 120 provincial subdivisions, or districts, has its own, smaller hospital, with ambulance transport available to the provincial hospital. Some 500 rural health centers are being developed in the smaller villages throughout the countryside. The national health scheme calls for the Central Hospital of Maputo to be the referral hospital for the entire country.
An example of this pyramidal structure can be found in Zavala district, in the central coastal province of Inhambane, with its widely dispersed population of 70,000. A Portuguese doctor had practiced in Quissico, the district capital, but the high cost of his private practice and the district hospital’s relatively long distance from the rural farms effectively denied services to most of the people. Now a young British doctor has replaced the Portuguese physician, and a nurse and two “health aides” have joined the staff of two nurses and one midwife. In addition to the 30-bed district hospital, four rural health centers, each with a midwife andjor nurse, are visited weekly by the doctor. Patients are charged seven and a half escudos, about 23 U.S. cents, for any problem, including all follow-up visits, medication, and hospitalization. A pre-natal clinic, organized a year ago, originally attracted only sick women in their final month of pregnancy; now healthy women are coming as early as their fifth month, and are receiving tetanus vaccine, anti-malarials, iron pills, and lessons in childbirth and infant care. Whereas almost all women used to deliver children in their huts, with a high incidence of sepsis and tetanus, now in-hospital deliveries have doubled in the past year.
Such a statement should not conjure up images of western hospitals with monitoring equipment and tiled, sterile surgical suites; the town of Quissico only has electricity from sundown to 10 p.m.; oxygen, forceps, suction, and incubators are not yet available, and the standard of care does not routinely include the taking of a laboring woman’s blood pressure. Still, there is no doubt that newborn and maternal mortality and morbidity have dropped as a result of the changes, even if proper statistics have not yet been compiled.
Zavala’s rural facilities, like those throughout the country, rely on nurses to provide most medical diagnosis and treatment. Efforts are underway nationally to improve their screening of patients and to standardize the treatment of the most commonly seen medical problems— malaria, schistosomiasis, anemia, tuberculosis, neonatal tetanus, measles, diarrhea, and simple trauma.
Mozambique, with its population of more than II million, has only 450 doctors now, 80 percent of them foreign cooperantes on two-year contracts. Because medical school training is long and expensive for the country, and because there are few people qualified to enter that training, the focus has been on upgrading existing health workers and educating a large number of paramedical technicians. Three training schools have been developed for this purpose in different provincial capitals. Here, nurses, some of whom have had little formal training, can advance their skills and become “medical technicians.” “Health aides” will receive two years of training and will assume responsibilities in sanitation and health education. Agentes polyvalentes (“preventive health mobilizers”), the Mozambican parallel to the Chinese “barefoot doctors,” will have six months training and will disseminate basic first aid and sanitation information to villages. Some 200, selected by their villages, will have completed courses by the end of 1978.
Democratization of the medical structures, as well as decentralization, is a central political goal in the countryside. In Inhambane’s provincial capital hospital of 235 beds, as in others throughout the country, conselhos have been created. In Quissico, all the hospital workers get together weekly to discuss problems, and there have even been open meetings with patients mobilized by FRELIMO to present criticisms of the staff. As a result of one of these meetings, a midwife who treated patients roughly now has a more gentle approach.
A striking example of the efforts to democratize and decentralize can be seen in the recent decision of the Ministry of Health to send all national proposals for health policy and budget to the provinces and districts for evaluation and criticism before they are adopted.
Although the process of socialist transformation has begun in Mozambique and will continue, it is still beset with very serious problems, some of which will take years, even generations, to overcome.
The country still suffers the effects of the exodus of medical personnel and the class of technically and administratively trained Portuguese who had managed the commercial and governmental sectors. Some factories and stores closed, transportation was sabotaged, import/export services were rendered inoperable.
This collapse of the infrastructure is still felt in the health sector in many ways. Rural health centers like those in Zavala often have shortages of antibiotics and aspirin. Some district hospitals do without proper suture material and have limited equipment for obstetrical care. The maternity hospital in Beira, the country’s second largest city, has only one functioning oxygen apparatus which must be shared bv women in lauor and babies in incubators. In Maputo’s Central Hospital there are a few respirators, but no trained personnel to operate them. There is a multi-channel blood chemistry analyzer, but not enough reagents to keep it working. In Quissico, the ancient jeep-ambulance frequents the garage almost as much as the health centers because spare parts are difficult to obtain. The chief pediatrician in Maputo, a British cooperante, wanted to encourage a hygienic measure, like handwashing between diaper changes and feeding of children, “but with no sinks on wards and no soap or towels in the bathrooms, it’s not easy to do.”
A major problem inherited from colonial times is that of a cumbersome bureaucracy. Official transactions require the purchase of special forms in one place, revenue stamps in another, and waiting in lines at a third place where the transaction will hopefully be completed. The Mozambicans who have taken over work in the government offices had been delegated very little responsibility under Portuguese management and often find it difficult to exercise authority. Consequently, today even decisions as routine as vacation schedules need to be brought to the Ministers’ desks for approval. On the district and provincial levels of bureaucracy, programs often experience long delays because of the unwillingness of local officials to make decisions and their desire for direction from higher levels in Maputo. Authoritarian attitudes still persist. In some places there is a rule that hospital workers should rise to attention when a doctor or head nurse enters a room.
One of the most basic struggles is that against illiteracy. At the time of Independence, an estimated 90- 95 percent of the population could not read or write. There are 20 different tribal languages, most without written tradition; and only about half of the people, mostly men who have had contact with the colonial administration, can speak Portuguese. Frequently, the problems of a patient have to be translated by a couple of intermediaries before communication is established. A Maconde-speaking woman visiting the Quissico hospital had to be translated into Chopi and then into Portuguese.
Myths about health and nutntwn abound, and many have proved harmful. Many women believe that they will become sterile if they use latrines and consequently contaminate soil and water with their wastes, contributing to the spread of communicable diseases. Bleeding following urination, caused by shistosomiasis, is believed by many to be normal. When it appears in teenage boys, for example, it is considered the male equivalent of menstruation, and no treatment is sought. It is commonly thought that eggs make children bald and that women should stop breast-feeding if they become pregnant. These myths contribute to the serious problem of malnutrition.
FRELIMO is taking a creative role in relation to harmful beliefs and practices. When a group of mothers took their sick children out of Maputo Central Hospital because they feared the “spirit” of a child that had died there recently, FRELIMO asked the neighborhood “dinimizing groups” to find the mothers and encourage them to return to the hospital, and they directed a lengthy radio appeal against the harm caused by traditional beliefs about “spirits.”
FRELIMO and the Ministry of Health recognize and intend to incorporate positive aspects of traditional knowledge, but the process is not simple and is complicated by the fact that these “curandeiros,” “herbalistas,” and “fetishistas” as they are called, are practicing privately and for profit in a country that is committed to developing socialist health care.
FRELIMO also must confront the myths and bad practices of “modern” medical treatment styles inherited from colonial times, especially the misuse of drugs. Before Independence, 13,000 pharmaceuticals were sold, all but a few available without prescription. The new Ministry of Health has reduced this to about 2,000 and has created a national formulary of about 600 drugs, listed by generic name only, which are available at nominal charge by prescription only, from state pharmacies. The process of change, however, has only been underway for a short time. There are still many private pharmacies selling non-formulary drugs at high prices and without prescription. There are a few “detail men,” working as propaganda agents for international drug companies like CIBA-GEIGY, who encourage doctors to use expensive and dangerous drugs that can only be purchased from the private pharmacies. One such detail man told doctors that a certain anti-inflammatory drug, not on the national formulary, which has restricted use in the United States, should be used to treat all abscesses—a gross misrepresentation of the drug’s qualities.
In addition to a national formulary, the Ministry of Health has developed standard treatment regimens for common illnesses. This process has cut back on the use of rifampicin, a very expensive anti-tuberculous drug, to those cases resistant to the first-line, less expensive, medication. The misuse of anti-diarrheal agents, common in colonial times, has been analyzed and discouraged; and health workers are instructed that penicillin should not be prescribed for every cough. Plans are underway to develop a small drug industry to help Mozambique become less dependent on multi-national drug companies which would like to extract more of the limited foreign exchange.
But despite the shortage of personnel and supplies, a cumbersome inherited bureaucracy, an illiterate population, and negative aspects of traditional and modern medicine, FRELIMO has had remarkable success in implementing its goals in a socialist transformation of health care. And the changes have occurred in only three years since a guerilla army took over leadership of the government. “Maputo’s Central Hospital was an awful place when I came two years ago,” according to an Australian infectious diseases specialist. “Now, although there are still a lot of problems, there are democratic structures that get things done.”
The changes have occurred because FRELIMO identified health problems in political terms. The Minister of Health, Dr. Helder Martins, said that “Health structures are reflections of society, so political structures are our best instruments to develop a program of health care.”6 This political approach has meant nationalization of curative health services, but more importantly, a focus on preventive medicine.
FRELIMO has mobilized people to build latrines, establish water systems, combat illiteracy, and improve agricultural production. It also organized a mass vaccination campaign against tetanus, smallpox, measles, and tuberculosis that reached four million people by August 1977 and will reach over 90 percent of the population by the end of 1978—a spectacular achievement that has been verified and acclaimed by the World Health Organization.
Health care, although perhaps lower on the scale of national priorities than defense and agricultural production, has been given an increasing share of the national budget, from 4.1 percent in 1974 to 12.8 percent in 1977. That amounts to U.S. $3.70 per capita, or 3.5 percent of the gross national product, a figure which compares favorably with most “less-developed” countries.
Dr. Martins told a Dag Hammarskjold Foundation Seminar last year that “the aim of our revolution was to free man and establish social justice. The most elementary measure was to place all on an equal footing when faced with misfortune and stop disease from being a motive for exploitation.”7 Mozambique has clearly gone beyond the elementary measures in health care. Through its emphasis on health education, decentralization of health services, and worker and patient involvement in the decisions of their health system, it may well serve in some ways as a model for countries that have been labelled more developed.
Marc A. Snyder is a physician in family practice and emergency room medicine. Judy Spelman is a nurse in an intensive care unit. They are active in South Africa support work and health care politics in the Bay Area. They were in Mozambique in June-July 1978.
- The fusion of the Hospital da Universidade and Hospital Miguel Bombarda had taken place in October 1974 during the year of transition preceding Independence.
- Authors’ translation.
- “Our health services’ role in the revolution,” speech at the beginning of a course for health care, November 1971. in Mozambique: So wing the Seeds of Revolution.
- The probability that this change could be explained as a random fluctuation is less than 1%.
- Since the original draft of this article in June !978, the pediatric surgical service has planned to permit “rooming-in.”
- Quoted in Watts, G., “What to do when the doctors leave,” World Medicine, Jan. 26, 1977, p. 17-22.
- Speech to Dag Hammarskjold Foundation Seminar, Uppsala, 12-16June 1977.