By Rosalind McCollum, 27 September 2013
As a relative newcomer to REACHOUT, working in Maputo with the team from Universidad Eduardo Mondlane has been a great experience for me. The last two weeks have given me the chance to understand more about the role of ‘close-to-community’ (CTC) providers, known as Agente Polivalente Elementar (APE), some of the strengths of the programme and the challenges APEs face in carrying out their daily activities.
It is estimated that only 30% to 50% of the population have access to healthcare services in Mozambique. Mozambique first introduced the community health worker programme in 1977 as a strategic attempt to reduce poor access to healthcare services in the rural population. The APE programme was revitalised in 2010, with the intention that each APE provides health promotion and disease prevention along with curative services through household visits. This includes basic first aid for all and diagnosis and treatment for pneumonia, diarrhoea and malaria for children who are less than five years old.
“An excellent opportunity to make the most of the research programme’s initial research data in preparation for the intervention phase of REACHOUT.” Dean of the Medical Faculty and REACHOUT Principal Investigator Dr Mohsin Sidat
During a week long workshop held from the 16th- 20th September, we spent time as a team discussing the process for data collection which occurred across two districts (Manhiça and Moamba in Maputo Province), reading and discussing interview and focus group discussion transcripts, and starting to analyse the data collected for the contextual analysis process. The Programme Manager for the APE within Ministry of Health and the USAID advisor for the APE joined the team to share initial findings from the Ministry’s APE baseline study and from routine data collection by APEs. We felt privileged to hear these data, which have only just been made available, and it was encouraging to see the commitment of the staff in the Community Health Unit to the programme and exciting to see that over 2,000 APEs have been trained (2010-2013). Meanwhile, the baseline data, involving over 1,000 APEs, showed that over 3 million Mozambicans have been beneficiaries of APE services in an 18 month period.
One of the recurring themes that started to emerge during our discussions was the commitment that APEs felt to carrying out their work. One APE explained, “working for health is equal to a pastor who works for God. Working [as an APE] for people and working for God is all encompassing”. Another theme related to the difficulties faced by APEs in carrying out formal instructions to use 20% of time for curative and 80% of their time for health prevention and promotion activities. Difficulties in striking the right balance are compounded by the community, many of whom seem to prefer curative over health promotion activities. In addition, there was the continuously returning issue of the distance which APEs need to travel to carry out their work. This challenge was vividly brought to life when we visited Cesaltina, an APE in Calanga community, Manhiça district.
Our trip to visit Cesaltina (see photo below) reinforced many of the issues which came up in the workshop. To reach the community where Cesaltina lives and works was no easy task, as the sandy ‘road’ gave way beneath our sturdy 4x4 car. During our journey we saw two tractors which were stuck in the sand and making the journey on a bicycle (the only means of transport of APEs apart from walking) would be impossible. Once we reached our destination (thanks to a superb job negotiating the sands by co-researcher turned driver Mr Sozinho Ndima), we were struck by just how geographically isolated Cesaltina is in her work and the difficulties that something as simple as collecting supplies from her nearest health facility can be.
The photo of Cesaltina demonstrates how she transports typical monthly kit supply. It took two people to lift the box onto her head. Despite the challenges that they face, the APEs in Manhiça district appear to be very appreciated by health facility staff. One nurse we visited told us, “the APE is like a third arm for our work here.”
The week has provided plenty of further insights into the APE programme and already ideas are starting to emerge for potential interventions during the next REACHOUT quality improvement (intervention) stage. There are some exciting opportunities to improve the working lives of APEs like Cesaltina and I am looking forward to working together with the Mozambique team as they develop a research agenda which meets their needs.
This project is funded by the European Union.