6 Not the patient’s real name. A pseudonym has been used.
The right to the highest attainable standard of health is universally recognized, enshrined in the Universal Declaration of Human Rights and stipulated in laws and policies. But those commitments do not always translate into practice, and the right to health is not enjoyed equally.
Surveys and studies regularly record service problems at health facilities, including denial of services, violations of confidentiality and privacy, negligent or stigmatizing care, coerced procedures (including sterilization) and corruption. Communities that are subjected to multiple forms of discrimination and inequality are often most affected.
Accountability and oversight mechanisms help realize people’s right to health and ensure that breaches of those rights are remedied. A programme in
Mozambique is showing how community-based action can efficiently and effectively safeguard health rights within a low-income country grappling with one of the world’s largest HIV epidemics and many other public health challenges. The country’s health system faces major pressures, including severe poverty, unequal access to services, and profound shortages of health facilities and health-care providers (35).
Namati Moçambique (Namati), a legal empowerment nongovernmental organization, deploys grass-roots health advocates—known locally as “defensores de saúde”—to identify and solve health service problems by working with both community members and health workers. They inform residents of their rights, raise awareness about basic health policies and support community efforts to achieve fairer, better health services (36).
Namati began working in two rural districts in southern Mozambique in March 2013. It now has health advocates at more than 60 health facilities in the capital city, Maputo, as well as in Inhambane, Maputo and Zambezia provinces. Each advocate is responsible for between one and three health facilities and receives back-up support from programme officers and a small technical team that monitors and assists with the cases.
The health advocates speak to patients waiting at clinics and address local cooperatives, HIV associations and women’s groups, informing them about the health policies and protocols that affect their lives. They also arrange meetings between communities and health-care staff to identify and deal with barriers to health-care. When problems do arise, Namati uses dialogue to solve them.
Sometimes, however, a forthright approach is required. When Marizinha,6 a woman living with HIV in Inhambane province, filled her antiretroviral prescription at the local clinic pharmacy, she discovered she had been handed only 30 of the 60 prescribed pills. “[The pharmacist] acted like he had given me all of them,” she recalled, pointing to the
“certo” (“OK”) check mark on the pill container (37).
Marizinha alerted the local health advocate, Davide da Conceição Saúte, who summoned members of the village health committee. Together, they approached the facility pharmacist, who claimed that he had been trying to ration antiretroviral medicines because of a warning of an imminent stock-out. But further enquiries revealed that it had not been an isolated incident.
There also was suspicion that the withheld medicines were being sold on the black market. After the conversation, the pharmacist apologized and handed Marizinha the remainder of her pills.
Since then, the health advocate and committee members have been sporadically interviewing patients as they leave the pharmacy. “We try to find out whether they are getting the right amount of medicine, and also whether they are getting all the necessary information about how to take their medicines and about side-effects,” Davide explained. In the subsequent months, no similar problems were reported at the health facility.
Namati’s health advocates have addressed more than 5400 concerns at health facilities since 2013, three quarters of which were successfully resolved (38). The complaints have been related to a variety of issues, including staff absenteeism, disrespectful treatment, unlawful charges and fees, breaches of privacy and confidentiality, inadequate infrastructure, and poor or incorrect counselling about diagnoses and health care (Figure 6.10).
135 Changes include improved observance of health
protocols—for example, immediate initiation of antiretroviral therapy following HIV diagnosis, and provision of tuberculosis prevention therapy for seropositive children and adults—as well as increased respect for patient dignity. Health advocates have also successfully lobbied district-level authorities to renovate unused structures, repair toilet facilities and install privacy screens at pharmacy windows.
At Chicuque Rural Hospital, the second-largest health facility in Inhambane province, lack of privacy was a problem, with staff often attending to a patient in the same room where others were waiting for care. The health advocate and health committee raised the problem at various levels of the hospital hierarchy before discussing it with the hospital director, who proposed renovating an unused space for patient consultations.
9
0 200 400 600 800 1000 1200
Ambulance used for unrelated activities Theft or sale of public goods Refusal of care (outside catchment) Expired medicines Lack of informed consent Precarious buildings Other (medicine) Lack of access for physically disabled Lack of porches, shade, benches Distance between commun. & health services Lack of ambulance/fuel Discrimination Violation of confidentiality Facility does not have water Facility does not have bathrooms Lack of mosquito nets Facility does not have electricity Lack of rapid response to urgent case Failure to fast-track specific populations (elderly, disabled, HIV) Illicit charge / bribery Insufficient dispensing of medicines Lack of hygiene in the health facility Lack of machines/machines broken Lack of information regarding health services Lack of sufficient beds/matresses Other (equipment and medical supplies) Violation of privacy Other (provider behavior) Lack of medicines Lack of medical/surgical supplies Clinical negligence Lack of info re patient's health…
Other (infrastructure) Staff absenteeism/tardiness Disrespectful treatment
Resolved cases Cases in process
FIGURE 6.10 Patient grievances, by issue, 52 health facilities in Mozambique, March 2013–May 2019
Resolved cases Cases in process
Source: Programme data from the Moçambique Right to Health Program, March 2013–May 2019, provided to UNAIDS on 11 June 2019.
Distance between community and health services Lack of information regarding patient's health
(eg., diagnosis, treatment, test results)
Other (provider behaviour)
Lack of suffi cient beds/mattresses
llicit charge/bribery Failure to fast-track specifi c populations
(elderly, disabled, those living with HIV)
CONFRONTING STIGMA AND DISCRIMINATION
“Almost every day, we were receiving complaints about privacy,” said committee member Maria Francesco.
“When the director said that we had another room for consultations, it was such a relief for us” (37).
Many problems take time to sort through. Medicine stock-outs, for example, often require more complicated changes to logistics and supply chain management systems. Namati estimates that grievances related to infrastructure and equipment require about three months to resolve on average, while those related to provider performance, supplies or medicines take between 45 and 60 days. The vast majority of cases tend to be resolved at the level of the health facility supervisor.
One of Namati’s biggest achievements has been strengthening village health committees. These were set up to act as liaisons between communities and formal health services, but when the Namati programme began operating in 2013, it found that many committees were not functioning. Health advocates have been working with local health and community leadership to revitalize these committees, ensuring that they include representation from groups that often are marginalized.
Namati provides training and technical support (e.g., on the patient bill of rights, key health protocols and conflict resolution methods), working with health committees to resolve barriers to care and treatment.
Together, they carry out twice-yearly assessments of local facilities that draw on feedback from community members and health workers.
“Problems always existed, but no one reported them,”
reflects a nurse at the Morrumbene Health Centre in Inhambane province. “But now people’s concerns are heard by the health advocate and the village health committee. . . . With the existence of the committee, they get a prompt response, and the health providers change immediately” (39).
As village health committees become active again, it allows the health advocates to step back and assist other health facilities and communities, making it a highly sustainable approach. Mozambique’s Ministry of Health has formally approved this partnering approach and has incorporated it into its new five-year strategy—recognition of the power of community-based action (39).
Lúcia Levene attends a village health committee meeting.
Village health committees in Mozambique act as liaisons between communities and formal health services. Namati health advocates have been helping to revitalize these committees and ensure that they include representation from groups that often are marginalized.
Credit: Namati Mozambique
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