HEALTH
JUSTICE
Mozambique
A woman and her newborn await their postnatal visit at Nhongonhane Health Center in Marracuene District
Our Journey in 2019 & 2020
Our failure to deliver decent healthcare to all people is not just a technocratic problem, relating to the way we resource and design the delivery of services. It’s also a justice problem, stemming from 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 postpartum services and HIV treatment.
Namati achieves bottom-up improvements in the health system by building a movement of people who know, use, and shape healthcare policy. The starting point of our work is the lived problems of ordinary people: a patient who is denied a private HIV test, or mothers who are neglected by nurses and have to give birth unattended. 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 challenged our grassroots legal empowerment efforts, but with appropriate personal protective equipment and safety measures we were able to persevere. In 2019 and 2020, Namati’s health advocates and the communities with whom they collaborate resolved a total of 3,220 grievances in 62 health facilities. The majority of these cases were collective in nature, improving essential services not just for specific patients but for the communities served by these facilities.
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. We draw on this information to advocate for changes to policy and practice at provincial and national levels. Since starting our health justice work in 2013, we’ve achieved significant systemic improvements using this approach: from the institution of the country’s first national anti-bribery policy to the Ministry of Health’s (MoH) formal recognition of our approach to community-led monitoring of health services.
Community members gather to share their concerns with the Director of Chicuque Rural Hospital in Inhambane province
We continued to make important progress in bringing about system-wide change in 2019 and 2020. For instance, after having collaborated with the MoH in the development of a National Strategy for the Improvement of Quality and Humanization of Health Care, which included the establishment of patients’ rights offices at every health facility, we’ve supported the MoH in bringing the policy to life. We developed a comprehensive training package and an operations manual to guide the functioning of these offices, and led training-of-trainers for MoH managers and providers at national, provincial, and district levels. Namati also collaborated with the MoH to develop a training package for health providers on human rights and ethics and co-facilitated the national and provincial training-of-trainers.
In addition to building the capacity of the Mozambican government in 2019 and 2020, Namati assisted the Global Fund to Fight HIV, TB and Malaria, one of the world’s largest public health financing mechanisms, in designing its human rights program in the country. We provided training and technical assistance to Global Fund’s implementing partners, Centro de Colaboração e Saúde (CCS) and Fundo Para o Desenvolvimento da Comunidade (FDC). Through this collaboration we supported the scale-up of nearly 300 health advocates to every province in the country and published a training manual for paralegals, health advocates, and community workers on health, human rights, and access to justice, with a focus on vulnerable groups and key populations.
In 2021 Namati will provide ongoing training and mentoring to 40 community-based organizations across five provinces to assist them in using a legal empowerment approach to improve healthcare delivery. We will also partner with the provincial director of health for Inhambane on an ambitious pilot initiative to ensure dignified bathrooms for patients and privacy in the pharmacies and consult rooms at all 144 health facilities in the province.
Our Grassroots Impact at a Glance
In 2019 and 2020, paralegals supported thousands of people to resolve breakdowns in healthcare delivery. Together, they improved life saving services for entire communities.
Maria was made to pay for a blood transfusion she received after hemorrhaging during labor.
Paying for Blood: Bribery in Mozambique’s Healthcare System
The labor pains came as no surprise. Maria* was nine months pregnant with her second child; she knew what to expect. But as she made her way to the local health center where she was to give birth, Maria began to bleed. By the time she arrived, she was hemorrhaging.
The nurse on duty quickly arranged for an ambulance to take her to Quissico District Hospital for a blood transfusion. Fortunately, Maria survived. Her baby, however, did not.
Later that night, as Maria was preparing to be discharged, a nurse approached and told her that she had to pay the equivalent of 70 USD for the blood and plasma she had received. It was a huge sum for Maria, who, like many Mozambicans, gets by on the food she farms and the small amount she makes selling some of her harvest at the market.
“I was outraged,” recalls Maria. “[But the nurse] said there’s no other way. ‘You can’t leave here until you pay. That’s the law.”
“[My family and I] borrowed money and pieced together half of the amount. We explained to her that after we buried the baby we would come back with the rest. The nurse said we could go but my health card and ID card had to stay with her to ensure I’d return.”
A week after the funeral, the nurse began to call, pressuring the grieving mother to pay. Maria was at a loss as to what to do. She needed her ID and health card back, but she had borrowed all the money she could.
“I was really sad,” confesses Maria. “First I lost my child, and then they charged me this fee. It was really so much money. … That’s when I called my cousin [for advice].”
Maria’s cousin put her in touch with Cézar, a Namati health advocate, and the Quissico village health committee (VHC). They explained to Maria that paying for blood or plasma is not, as the nurse said, “the law”. In fact, requesting payment for any health services or supplies that are supposed to be provided free of charge is punishable as a crime under Mozambique’s anti-corruption law, as well as the Ministry of Health’s anti-bribery policy, which Namati helped to instate.
They assisted Maria in reporting the incident to the hospital, and when the hospital asked for a meeting, they went with her. The nurse initially denied the charge, but at a second meeting, with the hospital director present, she confessed. She asked for Maria’s forgiveness and returned her money and documents.
From left to right: the Quissico District Hospital Administrator, Cézar (Namati paralegal), two members of the village health committee, and Maria
Maria says she was both happy and “relieved” when her money was returned. “First, because I had no way to return the money I had borrowed… And [because] I am now no longer afraid to go to the hospital… I went back and told my family and my community that if ever someone asks you to pay money for care at the hospital, they are robbing you. People didn’t know this before.”
Maria’s declaration is not an exaggeration. Few Mozambicans are aware of the laws and policies that protect their rights as patients, and some healthcare workers use this to their advantage.
Quissico District Hospital was infamous for bribery and illegal fees. During the regular education sessions that Cézar and VHC held on patients’ rights, numerous people had complained that they were made to pay for treatment. Those who did not pay were reportedly denied access to essential and, in some cases, lifesaving health services.
The hospital had attempted to address the issue but the power dynamics and fractured relationship between the community and the hospital proved to be major barriers. As the hospital director, Dr. Osório Trigo, explains: “Health providers tried to raise patients’ awareness about these things in the past, [but] no one ever approached them with concerns or complaints.”
Dr.Osório recognized that “patients [and] community members feel much more comfortable speaking with the VHC and health advocate.” After Maria’s case, he asked Cézar and the VHC if they would conduct a series of educational sessions for healthcare providers and patients specifically devoted to the National Strategy to Prevent and Combat Bribery in the Health Sector. They happily obliged.
Several months later, the VHC asked patients in the hospital and community about the practice of bribery. No new cases were reported.
“We’ve seen a huge change,” affirms Dr.Osório. “When it’s the voice of the community speaking, we can no longer ignore it. When they speak up we’re obliged to respond. … The village health committee has really helped in terms of bringing the community and the hospital together.”
*name changed upon request
Sharing What We Learned
In 2019 & 2020, Namati Mozambique produced a number of training manuals, informational booklets, and studies on the impact of our approach, and was featured in external publications.
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A Practical Guide: Implementing and Scaling Up Programmes to Remove Human Rights Barriers to HIV Services
Namati's legal empowerment approach is provided as an example in this guide's section on designing programs that effectively remove human rights related barriers to HIV services.
‘We all have the same right to have health services’: a case study of Namati’s legal empowerment program in Mozambique
This paper, published in the BMC Public Health journal, explores the work and impact of community paralegals working to improve health justice in Mozambique.
The Impact of Legal Empowerment on Barriers to Healthcare
An in-depth study reveals that facilities with health advocates have, on average, experienced a 43% reduction in violations.
UNAIDS Global AIDS Update 2019: Communities at the Centre
This report includes a profile of Namati's legal empowerment approach, highlighting how it has contributed to improved health outcomes for people living with HIV/AIDS.