Since 1990, more children in Mozambique are living to celebrate their fifth birthday than ever before following sustained progress in reducing under-five mortality, thereby achieving Millennium Development Goal (MGD) 4. Yet many challenges remain, particularly regarding the stark disparities in child health outcomes between poorer provinces, such as Zambézia, as well as for the less educated and the poor, where progress has lagged behind advances enjoyed by the rest of the country. Moreover, neonatal mortality now accounts for over one third of child mortality as the reduction in both maternal and neonatal deaths has stagnated over the last decade. Malnutrition also continues to underline a significant part of child mortality. After malaria, HIV/AIDS is a significant cause of child illness and death which needs to be addressed at infancy through to adolescence. Adolescent girls are three times more likely to be infected with HIV than boys. The paradox to be addressed in this upcoming programme is the contrast between HIV/AIDS and child mortality: while young children die disproportionally in rural, poor households in the north of the country, new HIV infections are more likely in urban, relatively wealthier households in the south of the country.
For every child, health
Health situation in Mozambique
Programme priorities 2017–2020
The health component will build on the significant progress during the MDG era, when under-five mortality was reduced by 67 per cent, achieving MDG 4. Yet since nearly 1 in 12 children still die before celebrating their fifth birthday, much needs to be done to realize the global vision of eliminating preventable child mortality as part of the new Sustainable Development Goals (SDGs). UNICEF contributes towards this by focusing efforts increasingly on newborn mortality that currently represents more than one third of all child deaths and improving performance in underserved communities to ensure that all children benefit from Mozambique’s growth. To succeed, UNICEF work will focus on improving maternal, child and newborn health interventions, with Communication for Development (C4D) playing a key role in all health interventions.
The main areas of support are to:
Provide quality integrated maternal and newborn health services.
Working closely with partners – in particular, UNFPA and WHO – to improve skilled birth attendance and emergency obstetric and newborn care, health facilities will more effectively provide a package of services to mothers and newborns. This will include taking advantage of the recently-introduced Integrated Management of Newborn and Childhood Illnesses (IMNCI) for infants under 7 days old (including the assessment and classification approach for possible serious bacterial infection (PSBI); and innovations such as Chlorhexidine for newborns to prevent umbilical cord infection, which is now being provided by community workers (APEs) and will be scaled up throughout the country. Other potential life-saving interventions are being explored for expansion, such as new algorithms for preterm delivery that include the use of corticosteroids by all maternal and child health (MCH) nurses for inducing lung maturation in pre-term births, and calcium supplementation for prevention of pre-eclampsia.
Other activities are being reinforced, such as Kangaroo Mother Care (KMC), for preventing hypothermia and bonding between the baby and the mother. Mentoring programme for MCH services in Zambézia is also being implemented, capitalizing on lessons learned during antenatal care (ANC), delivery room care, postnatal care and child clinical consultations.
Better equip health workers at facility and community level to provide and stimulate demand for quality integrated child health services.
The focus will be on improving child health through community health, outreach and facility-based interventions, including prevention of neonatal sepsis with Chlorhexidine, promotion of infant and young child feeding, vitamin A supplementation and deworming, childhood vaccination, and treatment and referral of common childhood illnesses, diarrhoea, malaria and pneumonia. Another area of focus is to improve the quality of MCH service delivery at Primary Health Care (PHC) level, where most of the services occur.
Identify, enrol and treat children with severe acute malnutrition.
UNICEF will work with partners to ensure a scale-up of quality community-based screening and management of acute malnutrition, a key strategy to tackle the high level of severe acute malnutrition in some provinces like Nampula. Another crucial approach includes strengthening the quality of malnutrition management in health units.
Support health sector policy, strategy, and plans and budgets.
The focus is on providing strong evidence to build a more robust health and nutrition system, while at the same time focusing on advocacy for mobilizing resources, particularly to address the significant needs of reproductive, maternal, neonatal, child and adolescent health (RMNCAH). UNICEF will support the development of the Neonatal Action Plan, to enable the implementation of RMNCAH and Every Newborn Action Plan (ENAP).
Support HIV-positive pregnant and lactating women and children to adhere to HIV treatment and related services.
UNICEF will focus contributions towards achieving virtual elimination of vertical transmission of HIV (defined as less than 5 per cent transmission rate; currently the rate stands at 8.7 per cent) and universal coverage of paediatric HIV treatment. This will be achieved by addressing two major challenges: the low retention rate for Prevention of Mother-to-Child Transmission (PMTCT) of HIV and paediatric treatment, and expansion of the Early Infant Diagnosis/Point of Care (EID/POC) platform as a key link between PMTCT and paediatric HIV treatment interventions.
Community health workers save lives with the help of smartphones
When Nomsa Gonçalves, 17, returns from school, she finds her 2-year-old brother, Dionisio, sick with a high fever and struggling to breathe.
She has to act fast and alone because her mother has left to farm their plot; her younger sister, 10, who has been looking after Dionisio, is about to leave for school to attend afternoon lessons; and her father is working in South Africa.
As the nearest health facility means at least a 40-minute trek carrying Dionisio on her back, Nomsa decides against that. Instead, still dressed in her school uniform, she visits Alberto Americo, who is sitting outside his home, under the shade of a tree, with a bag of medical supplies by his side and a smartphone in his hand. She reaches him in under 10 minutes.
Although Nomsa looks anxious, Alberto’s calm and attentive manner seems to relax her. “I come to Alberto as he lives near, he gives us the treatment we need, and he never insults us and speaks to us with respect,” says Nomsa.
Alberto gets to work methodically. He feels Dionisio’s feverish forehead, and with the help of his smartphone, he counts Dionisio’s respirations; the quick respiration count suggests pneumonia. He then carries out a rapid diagnostic test (RDT) for malaria, which consists of a prick on Dionisio’s finger while Alberto distracts him.
About 10 minutes later, Alberto shows Nomsa a double red line on the slide indicating that Dionisio has tested positive for malaria. Alberto crushes tablets in a cup, adding water, and explains to Nomsa the dosage, making sure she understands.
Unfortunately, Dionisio vomits when Alberto tries to give him the mixture. Together, they try to calm Dionisio, but he vomits again. Alberto keeps his composure, playing a recorded voice on an application on his smartphone, which states that without prompt treatment, malaria can kill within 24 hours. It also stresses the importance of sleeping under an insecticide-treated net for malaria prevention. Just to be sure, Alberto translates the messages for Nomsa from Portuguese to the local language. She listens while trying to soothe Dionisio. Alberto then explains to Nomsa that he needs to refer Dionisio to the health centre, and writes a referral slip. This time Nomsa manages to hitch a ride.
I like my work as I am helping my community.
A few other people from the community have gathered, also wanting to see Alberto, who works without a break. The consultations are only meant to make up 20 per cent of Alberto’s workload, and the rest of his working hours he spends on health promotion activities, mostly house-to-house visits. Whenever possible he uses a bike, but it is of little use on sandy tracks, and he sometimes has to trek up to two hours to reach the furthest homes in Zavala, a vast, sparsely-populated and remote district about a two-hour drive from the provincial capital, Inhambane. He earns 1,200 meticais a month, about US$20. But Alberto does not complain. “I like my work as I am helping my community,” he says. He carries on attending to his clients rather than pausing to highlight his own challenges.
Alberto is a community health workers or Agente Polivalente Elementar (APE). The APE programme in Inhambane province is mostly assisted with technical support from UNICEF and heavily financed by external donors such as UKAID, USAID, World Bank and implemented by the Ministry of Health. Malaria Consortium is an important partner in Inhambane and Cabo Delgado provinces. “The programme of APEs has been put in place to overcome one of the main health barriers, notably the lack of access to essential services,” explains UNICEF Chief of Health and Nutrition, James McQuen Patterson. “About 40 per cent of Mozambique’s population live more than eight kilometres from a health facility.”
McQuen Patterson continues, “although maternal and child mortality has reduced in Mozambique, stark disparities in child health outcomes persist. Still, overall, nearly 1 in 12 children die before celebrating their fifth birthday. The community health programme is one of the key ways that the Government and its partners are addressing this. The aim is to scale up the APE programme to around 7,200 APEs who will cover the country’s most deprived communities. Moreover, the use of smart phones improves the prevention, diagnosis and treatment of childhood illnesses, and also improves case monitoring and evaluation.”
To enrol on the APE programme, the individual has to be able to read and write and be elected by the community. They receive a five-month course of basic training in health promotion as well as diagnosis and treatment of common preventable and treatable illnesses, including the three main child killers: malaria, pneumonia and diarrhoea. The training also includes maternal and child health care, such as the use of Chlorhexidine gel for umbilical cord care, promotion of infant and young child feeding, supplementation of vitamin A, screening of acute malnutrition, use of Misoprostol to prevent and treat postpartum haemorrhage if a woman gives birth away from a health facility, and default tracing and referral for antiretroviral treatment and tuberculosis. In Inhambane, one additional week courses have been added to the training, focused on using upSCALE, a smart phone application.
Following this training, each month the APEs give Misoprostol tablets to traditional midwives in their area, who are now instructed to accompany a pregnant woman to the health facility rather than deliver the baby themselves.
Ecelina Alfredo, who had been a traditional midwife since 1986, accepts her role has changed, and now works under Alberto and without pay. “I don’t receive anything, but I am accustomed to working,” she says. “I work well with Alberto. Whenever I have a problem, I consult him.”
Ecelina remembers how soon after her recent training, which she did with Alberto, she had to put what she had learnt into practice. “I was accompanying a woman in labour to the health facility, but she could not wait. So, we went into the bush for privacy and I helped her deliver, and then I gave her the three tablets of Misoprostol that Alberto had given me to stop any bleeding.”
With this expanded APE package, which includes post-partum and postnatal home care as well as health promotion, many causes of neonatal, maternal and child deaths and illness can be prevented.
McQuen Patterson adds, “With this expanded APE package, which includes post-partum and postnatal home care as well as health promotion, many causes of neonatal, maternal and child deaths and illness can be prevented.”
Likewise, Eastacio Armando, the coordinator of the 26 APEs (nine men and 17 women) in Zavala in the province of Inhambane, believes the APE programme make a significant difference. “The numbers of cases of diarrhoea and malaria have reduced in the district, and I’m sure some of this must be due to the work of the APEs.” He adds that the upScale programme has also helped with case management as it enables him and other health workers to monitor activities in real-time, including drug stock status, as well as allowing them to send feedback reports on performance. Armando adds that he is impressed how quickly the APEs have learnt to use the phone app. “I think about half of the APEs are using the app easily, without any difficulty, although some need a little more practice as they haven’t used a touch phone before.” Moreover, he is encouraged that no APEs have dropped out in the district in recent years.
Adolfo Guambe, the public health officer and coordinator of the APEs at Inhambane provincial level responsible for monitoring their performance, is also impressed with their work. Regarding Alberto, he says, “he works well, he uses the phone applications with ease, and you can see his dedication in the way he works with the community.”
The following day, Alberto visits Dionisio to see whether Dionisio is recovering and to ensure that the family are giving him the medication prescribed. Satisfied, Alberto returns again three days later, and is pleased to report that Dionisio is “no longer showing any signs of illness”.
Health in Mozambique at a glance
|Under-five mortality||71 per 1,000 live births*|
|Infant mortality||53 per 1,000 live births*|
|Neonatal mortality||27 per 1,000 live births*|
|Maternal mortality||489 per 100,000 live births**|
|HIV prevalence among general population||13,2% ***|
|Mothers enrolled in PMTCT services who are retained at 12 months||67%****|
|Children living with HIV||200.000*****|
|Estimated children under 15 living with HIV who are on treatment||38%*****|
|Rate of vertical transmission of HIV||11%|
* UN inter-agency group for child mortality estimation, 2016
** UN inter-agency group for maternal mortality estimation, 2015
*** IMASIDA, 2015
**** PEPFAR 2017
***** UNAIDS, 2017