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Mozambique – Human Rights Approach During Emergencies
Malaria represents a significant health problem in Mozambique. Since the late 1990s UNICEF-Mozambique has developed a new strategy to fight malaria through a methodology combining human rights-based approach to programming and community capacity development.
Mozambique is a low-income, predominantly agricultural country prone to natural disasters—particularly flooding—due to its extensive, low-lying coastline. The population also suffers from a high incidence of malaria; more children are hospitalized from malaria than from any other single illness or disease, and more than a quarter of them die. In some parts of the country as many as 90% of children have malaria parasites. Pregnant women who contract malaria are prone to developing particularly severe symptoms, as well as anemia, contributing to Mozambique’s already high maternal mortality rate (408 per 100,000 births). Moreover, their children are often born underweight, affecting their subsequent physical development.
In the late 1990s UNICEF-Mozambique determined that malaria poses an especially significant threat to the survival, health, and development of the country’s children, and that identifying an effective way to combat the disease was necessary. A first step was to carry out surveys to learn why malaria is so problematic; the surveys revealed that most rural Mozambicans did not know either that mosquitoes spread malaria or that it affects children and pregnant women most severely.
Because it takes a human rights approach to development programming, UNICEF is convinced that people can and should play a key role in demanding and achieving their own rights. UNICEF believes that people are capable of making informed decisions and taking actions to protect their rights and those of their children—when and if they receive adequate support. In the case of malaria, this meant that Mozambique’s rural communities needed two key inputs: knowledge about malaria (how it is transmitted, who is primarily at risk, and how to protect against the disease); and improved access to means of protection. Most prevention work at the time involved spraying in urban and peri-urban areas. Thus UNICEF also had to convince government authorities of the importance of trying new ways to combat malaria—in this case, insecticide treated bed-nets (ITNs), which are relatively inexpensive and can easily be used in rural settings.
To carry out its programme, Unicef-Mozambique selected a strategy of participatory “community capacity development” (CCD). The idea was to stimulate within communities a dialogue in which residents would be involved in identifying the problems that affect them, analysing the causes of those problems, and ultimately designing actions and strategies to address them. The office created a set of simple tools, mostly drawings, that tell the story of malaria: depicting the mosquito that spreads the disease, its symptoms and treatment, and how communities can act in the area of prevention—such as environmental sanitation and ridding villages of standing water where mosquitoes can breed.
The original idea was to begin in one province with particularly high malaria rates. UNICEF would work with local health authorities, a nonprofit organization with extensive experience in rural communities, and a Mozambican training institution that could train health workers in both the participatory approach being employed and the use of bed-nets to prevent malaria.
The Flood Emergency
Just as these plans were nearing completion, in February 2000 a flood emergency took place in a different province, sending thousands of families to emergency camps. The Ministry of Health and UNICEF were concerned that when families returned to their homes the risk of malaria would be sharply heightened by the presence of large quantities of standing water. So a decision was made to launch an emergency participatory CCD effort to prevent a major outbreak of malaria in Gaza Province.
Mozambican health authorities agreed to distribute ITNs free to affected families in Gaza, while UNICEF and its partners carried out participatory activities to promote understanding of malaria prevention and treatment, emphasizing the special vulnerability of children and pregnant women. People in the emergency camps would be introduced—through drawings and discussions led by trainers—to the signs and symptoms of malaria, how to treat it, and how to take action at the community level to prevent it.
Between October and December 2000 about 189,000 people participated in capacity-development activities and more than 200,000 ITNs were distributed. Ten months later UNICEF and its partners carried out a follow-up activity to gauge the success of the CCD program. The results were very impressive:
• 100% of those interviewed knew what malaria was, and 91% understood that it is transmitted by mosquitoes (compared to only 30% in the earlier survey).
• 98.1% still had and were using their nets.
• Of ITNs observed, 93.8% were still in good condition.
• Over 95% of those who received a net reported sleeping under it, and 87.1% said their children were sleeping under the net.
• Finally, children were identified as a high-risk group by 85%-89% of respondents. Although only 57% identified pregnant women as a risk group, this was significant, since not a single respondent had done so during earlier surveys.
Another important indicator of the success of the Gaza CCD work was communities’ increased understanding of their own ability to take measures to fight malaria: for example, 93% of respondents in Gaza stated that it is possible to protect against the disease by using ITNs. These results clearly indicate that community capacity to assess, analyse, and take action on a pressing problem can be strengthened by involving people directly in participatory techniques. Another group that had been introduced to malaria prevention through a drama—which they watched but did not participate in—displayed a far weaker grasp of malaria treatment and prevention.
The Gaza experience also demonstrates that a human rights approach—that seeks both to improve the capacity of ordinary people to protect their rights and to influence decision-makers at the highest level—can work during an emergency. Had the government merely decided to spray in the affected areas, or handed out bed-nets without the accompanying discussion among community members, no knowledge or understanding would have been passed on to rural Mozambicans, and thus no sustainable progress would have been made in the larger effort to reduce the heavy toll of malaria on children.