Health Center Staff in Mozambique Mobilize to Improve Health Services

Eleven health units in Mozambique participated in the Management and Leadership for Health Sector Support (M&L/HSS) Program between 2003-2005. The program was funded by USAID, and implemented in partnership between the Mozambican Ministry of Health (MOH) and Management Sciences for Health (MSH). Participating Mozambican health centers worked with MSH's M&L Program to enhance their leadership and management performance by initiating new methods of communication and encouraging all health center staff to participate in solving organizational challenges. The M&L/HSS Program has improved efficiency by helping health centers maximize existing resources and mobilize surrounding communities to participate in improving service delivery.

Building participation

Meconta Health Center The young director of the Meconta Health Center pointed toward the wall behind her desk as she explained, "Up there, see that? Those are our challenges that we identified months ago when we began to work with MSH and the Ministry on the Challenges part of the M&L/HSS Program. MSH staff and provincial facilitators said, 'Let's get together and talk about what you believe would make your services better.' Oh, once the staff here got going we identified so many needs! The list was huge."

To improve health services in a country with little infrastructure, the Mozambican MOH has worked with MSH on a project with a challenging proposition: improve service delivery without additional funding or resources. Health center staff were understandably skeptical at first. In a place with so little and so many needs, how were the staff to create something out of nothing?

Health centers in the Nampula Province of northern Mozambique are located in remote areas. Far from the Provincial Directorate, which supports the health centers with funding, equipment, and technical expertise, Mozambican health staff operate in isolated rural areas of striking poverty. Staff must work diligently to stretch out their resources in an environment with below-average health indicators for Sub-Saharan Africa—infant mortality is high, and the HIV/AIDS infection rate has climbed to a sobering national average of more than 13%. Directives and funding from the Central Ministry in Mozambique's capital of Maputo arrive slowly, and sometimes not at all.

Given these challenges, the Mozambican MOH and MSH have focused on achieving efficiency with existing resources through improved leadership and management practices in the rural health centers of Nampula Province. "It's about participation, more than anything else—getting people together to say honestly: what are our problems, and what can we do together to tackle them?" said the Meconta director. Health centers in Mozambique have, much like many health organizations elsewhere around the world, traditionally "attacked the consequence but not the cause of problems that are impeding service delivery," in the words of one Mozambican doctor. Where other organizations might overcome this error with money or technology, health centers in Mozambique do not have either option; inefficient allocation of resources in a place like Meconta has a dramatic effect on service delivery.

The director described how her staff appreciated the structure of the M&L/HSS Program, which began by bringing all health center staff together to voice their opinions about the center's challenges. She said that it was difficult at first for the staff to master the second step in the program: a workplan with detailed activities to deal with the problems they had articulated. In the past, the director explained, the health center managers had generated lists of problems and price tags to solve them. But under the M&L/HSS Program, all staff members at Meconta were charged with the task of step-by-step planning of the activities that would bring them to their objectives.

"We knew that the key was to identify goals we could achieve ourselves with existing funds. We knew we needed to improve the number of institutional births. We thought, how are we going to improve that? The leadership model under this program with the Ministry and MSH highlights the value of community involvement. So we went to the community. And the community responded. This is what happened." Based on information from local Meconta residents, health center staff learned that expectant mothers were not coming to the hospital to give birth because there was no assurance of a comfortable place to rest—beds at the health center are limited, and mothers-to-be were not willing to take the risk that no bed would be open for them at the center while they waited to deliver. The solution devised by center staff and the Meconta community was a maternity waiting home. With marked satisfaction at her staff's accomplishments, the director finished her story of the first successful Meconta "challenge" under the M&L/HSS Program: "Once the Meconta staff had their goals aligned with the community's health needs, they worked together to gather materials and recruit volunteers to do the building. It was a lot of work. But now we have a new maternity waiting home."

A sense of progress—the chance to monitor change

Carapira Health Center "We do things together here," the community leader waved his hands wildly as he described the health center's relationship with local Carapira residents. He sat in front of a large chart, tacked up in the main office of the health center, which contained several graphs labeled "Reduced Pediatric Waiting Times," "Biosecurity," and "Improved Medical Charts for Inpatients." The nurse sitting next to the excited community leader explained, "We all gathered to speak with MSH and representatives from the Provincial Health Directorate who came here to introduce this program—everyone participated: the maintenance crew, the director of the health center, and all of the nurses." She related that the group had worked together to come up with the center's "challenges," a list of shared goals for the year. "We have started to evaluate our own progress, which is gratifying—it keeps us moving forward, because these were our goals from the start, and our work carries us to them." As she spoke, she flipped through several worn charts that document the center's recent accomplishments, including proper sterilization of medical equipment, hygienic waste disposal, and success in the never-ending battle with the flies that challenge the health center's new model for cleanliness; the model, devised by center staff at the beginning of the M&L/HSS Program, prohibits the presence of flies. The nurse explained, "We have come a long way, but we are working toward 100% success with our challenges."

Managing resources and improvements

Ilha de Moçambique Hospital The hospital in Ilha de Moçambique is the oldest in the country, a relic of Portuguese colonial occupation. And though the building has struggled to maintain its dignity over the past four hundred years, its age is now an unavoidable reality for the Mozambican health staff who work within it and the Ilha residents who receive health services there. Hospital employees labor diligently in the humid island climate of Ilha to maintain standards of cleanliness—but rust creeps in from all angles, and paint peels off the walls. In such a work climate, employees struggle to cover basic sanitation requirements. Electricity is inconsistent, and staff must descend thirty feet in to the musty depths of an underground cistern to haul collected rainwater. On top of these obstacles, the Ilha de Moçambique hospital faces the same responsibilities as all health facilities—consistent service delivery, reliable monitoring and evaluation of care, and cost efficiency.

"How has this program changed our business here?" repeated Alves, the District Health Director. "It wasn't that we weren't aware of the hospital's shortcomings. They are easy to spot! When I came here, there was dust falling from the ceiling, off the walls. We could put up a net to catch the dust, yes. But if we just invest in a net, eventually that net will get old and the dust will fall again; and then we are back where we started." He continued, "You may ask why dust in the hospital in Ilha de Moçambique is linked with the leadership and management that this program promoted. I'll tell you: Good management, a sense of a process, knowing how to maintain that net and having every staff member here know what has to be done to maintain that net—that is what will keep the dust off our tables and beds. We can make improvements, yes. But it is a question of managing our improvements. That is what this program is about—having our staff agree on the process that we need to achieve our goals and maintain our success."

Seeing results, highlighting accomplishments

Lumbo Health Center The Lumbo Health Center achieved great success under the M&L/HSS Program. But this happened quite by accident. Much of the credit for Lumbo's success goes to a determined and energetic nurse named Manuela, who walked in on the wrong seminar at the district health center and was captivated by what she heard from MSH staff and program facilitators from the Provincial Directorate. After some initial confusion—she had intended to find a seminar on prevention of mother to child transmission of HIV/AIDS—Manuela eagerly began to relate her own experiences with leadership and management at the Lumbo Health Center to the other district health staff that were gathered for the workshop.

When Manuela returned to Lumbo, she was armed with new ideas about how to improve the work climate and service delivery at the health center. Ideas about what Lumbo could achieve had taken shape in her mind while she listened to other health staff relate their challenges and successes in dispensing health services to their respective communities. She met with Lumbo's director, Augusto Morgado, and explained her ideas about involving all health center staff to identify goals. Along with a program facilitator from the Provincial Directorate, Manuela and Morgado introduced the leadership and management principles of the M&L/HSS Program at the next Lumbo staff meeting. They explained that this was a chance for staff to get all of their concerns and ideas out on the table; a chance to voice their opinions about how Lumbo could improve its performance. The energy from Manuela and Morgado started things off. And the health center staff ended up with a list of over fifteen action items that they wanted to begin implementing immediately.

Manuela explained that the idea of the program was not to come up with activities that would require extra funding or resources; rather, she challenged her peers to evaluate their personal and group performance, and urged them to recognize that they already had the capacity to achieve significant improvements in the health center by themselves. "This was a new concept for us here—we usually respond to directives from the Central Ministry, and wait for funding to arrive to start our activities. We have a lot of needs, to be sure. But now we think, we are not going to wait to change what is going on here; we are going to look first at how we can change things by communicating with each other to improve our daily practices," explained Morgado.

Lumbo staff set their own priorities for improving the health center. From their wish list of fifteen challenges, they settled on two goals to start—improve hygiene and biosecurity. The staff compiled a list of activities to achieve these goals. The charts they created now hang on the walls in each ward of the health center. A graph in Morgado's office displays the progress the center has made with cleanliness and hygiene over the past several months—all staff work together to monitor their activities and ensure they are all in compliance with agreed-upon standards to keep the health center clean and safe. "Here we can see our progress, all staff are aware that their ideas and actions have had a direct impact on our business here," said Morgado, "and the community has taken note—they tell us they are impressed with our conduct."

After having achieved success through teamwork, Morgado decided to take the Lumbo's success to the next level. Armed with an action plan from his staff about how to improve their center facilities, as well as statistics on improved cleanliness from the center's first "challenge," Morgado approached a local NGO about funding. "They liked what they saw—it was clear that we had a plan, a vision, and we had already produced results on our own." Morgado and his staff received the funding they desired. Thanks to collaboration with the local NGO, the Lumbo Health Center now stands with a fresh coat of paint over all surfaces of its maternity ward, in-take center, administrative offices, and client kitchen.

"We are putting plans together now for a new well," said Morgado, "and we will present our plans to the donor and begin construction quite soon. There is so much to be done here, but working in a team as we have been recently produced good results."

Adjusting the approach and moving forward

Mossuril Health Center Staff at the Mossuril Health Center conduct their work twenty-one kilometers off the main highway, down a deeply rutted red dirt road. Upon arrival in Mossuril, a doctor from the Provincial Directorate congratulated Mossuril's director on his work at the health center under the M&L/HSS Program. "You mean the team's work!" corrected the center's director, Calisto Maria Sampo, with a smile as he shook the doctor's hand.

The Mossuril Health Center's quality results were tacked neatly on the walls in Sampo's office. "Defining the root of our problems got us over the idea that we needed money for everything," explained Albino Marcoa, the chief General Nurse and Deputy Director of the Health Center. "Don't misunderstand, there is plenty that we could do with more resources here. But this program helped the Mossuril staff focus their energies on problems they could change by working together." Marcoa continued, "Now we mobilize when we identify new problems. We involve the community as much as we can, and we stretch our money out."

Sampo reported that he had witnessed an impact in his staff's personal lives, as well. One of the Mossuril lab techs was trying to build a house, Sampo related, and this man had firmly in his mind that he needed more money. But after participation in the M&L/HSS Program and seeing what the Mossuril staff had all been able to accomplish in the absence of money, he applied the program's management and communication techniques of the program to his personal life. "He started to collect materials by talking to his neighbors about what he needed. And eventually he built that house, and he invited me over!" said Sampo.

"Before we worked with the MOH and M&L on leadership and management principles, this health center didn't look so together. We still have a long way to go, but this process helped us get the nurses together with the maintenance crew to talk about how to deal with cleanliness," said Sampo, "This program prompted us to chart our results, and we see our progress." He grinned, "It has turned us into—what's the word? Egotists!"

Sampo sobered when he began to talk about the health center's next challenges, which are considerable. Mossuril needs a new kitchen to provide their sick clients with adequate nutrition during their hospital stays. And the health center still does not have funds for basic equipment that would allow staff to identify and treat common illnesses that cause suffering among the vast population that Mussoril serves. Staff have only been able to achieve compliance with less than half of the 160 basic quality standards set by the central ministry, because the health center lacks staff and basic resources. "But this program has been a process of gaining self-confidence for all of the staff here," Sampo concluded seriously, "and together we are going to move forward to work over our next obstacles."

Sampo and other health center managers in Nampula are realistic when they speak about Mozambique's substantial health challenges. But these managers also report that the M&L/HSS Program's approach of improving management and leadership capacity has promoted the efficient use of critical resources and, most importantly, empowered staff to make a difference in their local areas.

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