Looking Back at 2021 and Ahead at 2022
Access to healthcare is not just a question of geographic proximity, improving technology and training, and abolishing user fees. It’s also about justice — about imbalances of power between people and the healthcare system, and between frontline staff and the institutions that employ them.
When people don’t understand and exercise their rights, they are vulnerable to abusive and disrespectful care: exam rooms that offer no privacy, health facilities without a functioning toilet, or health workers who demand a bribe for treatment. When these experiences accumulate, people lose faith in the health system and many opt to stay away, forgoing critical care like maternity services and HIV treatment.
Namati’s community paralegals — known locally as defensores de saúde (health advocates)— work with village health committees to raise awareness of health rights and policies and assist patients in addressing violations when they occur. They also train and support health workers to play a more proactive role in addressing barriers to care. A study published in 2019 revealed that facilities with health advocates have, on average, experienced a 43% reduction in violations.
COVID-19 continued to challenge our efforts in 2021, but despite the logistical hurdles and administrative delays, our reach and impact grew.
Namati’s health advocates collaborated with communities and health workers to resolve 4,034 grievances across 67 health facilities (see graphic below) — an increase of more than 150% from 2019 and 2020. The significant rise in the number of cases and resolutions resulted from our targeted efforts to reach individual HIV patients at the highest risk of dropping out of care and treatment.
We also brought about improvements in quality and humanization of health services through partnerships with community-based organizations (CBOs) across the country. Upon the request of PEPFAR and the Mozambique’s National AIDS Commission, we trained and mentored 39 of the CBOs they fund to use a legal empowerment approach to improve healthcare delivery. These organizations are now serving 58 additional health facilities and catchment areas across six provinces. For the first time in Mozambique’s history, CBOs are playing a key role in ensuring public health services are accountable to the communities they serve. In 2022, we will continue this effort, training and mentoring an additional 43 organizations.
In addition to supporting the scale-up of health advocates in facilities and communities across the country in 2021, Namati collaborated with the health leadership in three provinces to bring about system-wide change.
Our health advocates document every case they handle. In the aggregate, this case data provides invaluable insight into how the health system is functioning in practice. In 2021, together with village health committees, we identified common complaints related to the lack of privacy in pharmacies and during clinical consultations. In some cases the issue was linked to inadequate infrastructure, while in others it was the behavior of certain health providers. A number of patients reported that the lack of privacy prevented them from speaking openly about their symptoms and concerns. Many others reported delaying or avoiding seeking medical assistance and picking up their medications.
Village health committees, in partnership with Namati, requested a meeting with the health leadership for Maputo Province. At this meeting, several patients shared their personal experiences, the health committees presented petitions signed by community members, and we highlighted recommendations from our policy brief on realizing the right to privacy. The provincial director responded favorably, inviting us to draft an official directive requiring compliance with concrete actions to ensure privacy in all health facilities. He subsequently sent the directive to all eight district directors, who are now responsible for overseeing its application in every health facility in the province.
Together with village health committee members and patients, we then approached the health leadership of Maputo City and subsequently the Provincial Director of Health for Inhambane. Both circulated a similar directive to their district health offices, requiring them to resolve barriers to privacy in all health facilities under their mandate and providing concrete recommendations for doing so.
More than four million people stand to benefit from these system-wide changes. Over the coming year we will turn our energy towards ensuring compliance with the directives, as well as advocating for adoption of similar measures in the eight remaining provinces.
In 2021, we took another important next step in building a movement of ordinary people who know, use, and shape healthcare policy for all. In six districts, we organized district-wide advocacy groups composed of dedicated village health committee members and patients. These groups show tremendous promise in bringing patients’ voices to the forefront and reducing the prevalence of common violations across districts and provinces. By year end they had secured the construction of toilets in the five health facilities in Jangamo District that were lacking them; had wheelchair access ramps installed in the four health facilities in Maxixe District without; and improved the availability of medicines for hypertension and diabetes in the eight busiest health facilities across Matola District.
In 2022, we will support the establishment of advocacy groups in four additional districts and will focus on building the capacity of these groups to influence systemic change nationally.
Our Grassroots Impact at a Glance
In 2021, thousands of people worked to resolve breakdowns in healthcare delivery with the support of paralegals. Together, they improved life saving services for entire communities.
STORY: Paying for Blood - Bribery in the Healthcare System
After a difficult labor — one that resulted in the loss of her baby — a nurse demanded that Maria pay for the blood transfusion she received.
RESOURCE: Folheto Informativo Sobre Cobranças Ilícitas
This brochure aims to educate communities about bribery in health facilities, including how to identify and report such cases.
RESOURCE: O Direito à Informação na Saúde: O Direito de Pedir e Receber Informação
This brochure aims to educate communities about the type of information that they have a right to receive in relation to health services, patient diagnosis, and treatment.
STORY: The Importance of Toilets in Health Facilities - A Patient's Account
A patient shares his experience of visiting a health facility without a toilet and explains the implications this has — and what he did to help resolve it.
RESOURCE: Os Direitos e Deveres das Pessoas Vivendo com HIV
This brochure educates people living with HIV about their rights and responsibilities, and provides examples of common barriers to care.
RESOURCE: O Dever de Assegurar a Privacidade nas Unidades Sanitarias
This booklet provides healthcare workers with concrete strategies for ensuring privacy in health facilities.