Strong collaboration for better health: Strengthening primary healthcare in Mozambique to address maternal mortality

Mozambique

Photo: Pedro José, Gondola, Manica Province, Mozambique Ilda Chiril leading a community lecture on cholera in Gondola, Manica Province, Mozambique

Collaborating to improve health

Mozambique has been implementing a decentralized governance model since 2019 to strengthen its primary health care (PHC) and community health initiatives. The country has achieved a significant reduction in maternal mortality ratio, dropping from 532 per 100 000 live births in 2000 to 127 in 2020.[1] However, while lower than the average of 531 deaths per 100 000 live births in the same year in the African Region, it still exceeds the Sustainable Development Goals (SDG) target of 70 deaths per 100 000 live births.[2][3] The WHO-convened Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP) agencies played a crucial role in collaboratively shaping the development of a comprehensive community health strategy, which addresses maternal mortality as a key priority. The strategy aims to reduce maternal mortality by increasing the capacity of community health workers (CHWs) for early risk identification among pregnant women and facilitate timely referrals from the community to health facilities. SDG3 GAP agencies also designed a pilot program for implementation of the strategy. This aligns with Output 4.2.1 of the 2022-2023 WHO Programme Budget “Leadership, governance and external relations enhanced to implement GPW13 and drive impact in an aligned manner at country level.”

How did Mozambique, with the support of WHO, achieve this?

The Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP) monitoring survey played a pivotal role in emphasizing better coordination among development partners, in terms of aligning more closely with national priorities in Mozambique. The contributions by SDG3 GAP partners to the community health strategy in Mozambique are a clear demonstration of their commitment to improved collaboration among themselves, behind national strategies and plans, for better health outcomes.

In 2021, WHO and the United Nations Children’s Fund (UNICEF) worked closely with the MoH to develop a comprehensive community health strategy and design a pilot program for implementation. The MoH approved the pilot program in 2022.

^{Ilda Chiril leading a community lecture on cholera in Gondola, Manica Province, Mozambique.}Photo credit: Pedro José, Gondola, Manica Province, Mozambique

WHO played a crucial role by providing technical support for the strategic process and developing essential legal documents for the community health strategy. This foundational support set the stage for effective implementation. In tandem, UNICEF contributed by providing technical support for establishing robust information systems and procuring equipment for CHWs, bolstering their capacity to deliver essential services. Financial backing from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GF), Global Financing Facility (GFF) and World Bank fortified the implementation of the community health strategy, through a disbursement-linked, indicator-based financing mechanism. Additionally, the United Nations Population Fund (UNFPA)'s focus on training and supervising CHWs in reproductive, maternal, newborn, child, and adolescent health services directly contributes to saving maternal lives.

The community health strategy aims to provide essential integrated PHC services, community leadership and coordination, and higher quality care through well-trained, consistently remunerated, and appropriately supported CHWs. WHO is supporting the MoH to develop a legal framework that allows formal recognition of CHWs and an opportunity to receive remuneration.

The SDG3 GAP partners supported the MoH in piloting the community health strategy in select provinces. One of the pilot's objectives was to test the competency-based training curricula for CHWs.

“Equipping CHWs with first aid skills and aiding in childbirth was crucial as they act as sentinels, often noticing health issues that doctors and nurses might miss due to the distance.”

- Filipe Faduco, Director of the Department of Public Health in Manica Province

Ilda João Chiril, a CHW, has received the competency-based training provided by the MoH with support from WHO in Manica Province. This training equipped her with skills in disease identification, first aid provision, community mobilization and population monitoring. Presently, she is serving the communities within the Dondo and Gondola districts.

Recalling an incident when a woman experienced contractions in the church and the nearest health center was about 20 kilometers away, Ilda assisted in relocating the woman and prepared for the birth. Eventually, with the help of other women from the church, Ilda successfully delivered the baby before the patient was transferred to the hospital. This experience is one of many that Ilda treasures as a CHW.

Maternal deaths can be prevented if women have access to quality healthcare during pregnancy, childbirth and postpartum. Ensuring that all deliveries are supervised by competent healthcare providers is especially crucial, as prompt intervention and treatment can determine the survival of both the mother and the newborn.

The distance between some communities and health units in Manica Province can extend from 80 to 100 kilometers. Like Ilda, many CHWs serve as intermediaries between these remote communities and distant hospital units. Additionally, vulnerable patients often place their trust in CHWs due to their shared community ties. CHWs play a crucial role as first responders, facilitating early referrals for pregnant women who may be at risk, thus contributing to the improvement of the maternal mortality ratio.

“I like to know that I contribute to people’s health.”

- Ilda João Chiril, Community Health Worker

The goal is to gradually cover all 11 provinces, which can save many lives and support Mozambique in getting closer to attaining WHO’s triple billion targets and health-related SDGs.

Other joint initiatives to decrease maternal mortality include the development of a Country Acceleration Plan for Ending Preventable Maternal Mortality, which integrates the “Every Newborn Action Plan” and incorporates the “Emergency Obstetric Care Network” prioritization. These initiatives are facing significant funding shortfalls, despite presenting a unique opportunity to enhance the PHC component of the health system, and thereby ensure it functions optimally and addresses the health needs at the community level.

References

World Bank, Mozambique. World Bank Gender Data Portal. World Bank Gender Data Portal for Mozambique, accessed 14 February 2024.
Maternal Mortality Regional Factsheet. Maternal Mortality Regional Factsheet, accessed 14 February 2024.
World Health Organization. SDG target 3.1 maternal mortality. SDG Target 3.1 Maternal Mortality, accessed 14 February 2024.