Country Profile

One swallow does not a summer make: Twenty years of challenges and achievements of family medicine in Mozambique

Yolanda Sabino, Palmira A. Francisco, Ofelia da Conceição Rambique, Leyani A. Chavez Noya, Armando J. Bucuane, Adelson G. Jantsch

Received: 14 Nov. 2021; Accepted: 02 Dec. 2021; Published: 03 Feb. 2022

Copyright: © 2022. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

After 20 years of hard work, family medicine (FM) is flourishing in Mozambique, but the challenges are immense in a context of multiple health needs. This study aimed to describe strengths, opportunities, weaknesses and threats of the current scenario that can influence the development of FM and primary health care (PHC) in Mozambique. Case study of a series of virtual world-café meetings using the World Health Organization’s Operational Framework for primary health care as a theoretical model. There is a young generation of Family Physicians (FPs) eager to improve PHC in Mozambique – a result of the reactivation of the Maputo Residency Programme and the creation of the Mozambican College of FP in 2010. The current Ministry of Health has taken this agenda forward, inviting medical societies (including FM) to jointly design plans to expand training of human resources for healthcare. This plan aims to create new training sites in five different provinces hoping that it will increase the number of FP in remote areas, fixing the unequal distribution of specialists in the country. The small number of FP practicing today and the limited financial resources of the National Government are important threats to this plan. We have many strengths already conquered and the current situation opens an opportunity for the expansion of FM in Mozambique. Hopefully, it will help PHC in our country move from verticalised and selective health programmes towards a more comprehensive, efficient and person-centred care.

Keywords: family medicine; primary health care; developing countries; Mozambique; healthcare workforce.

Introduction

Only eight family physicians (FPs) have been trained in Mozambique. Ten, if we count two Mozambicans who graduated outside the country. Given the size of our population (31.3 million in 2020), this number is extremely small and we certainly still have a long way to go before we can say that our specialty impacts the health status of our population.¹

This number could have been higher if it was not for so many difficulties experienced in the short life of family medicine (FM) in Mozambique. The first training programme in FM began in 2000 at the Hospital Geral Polana Caniço in Maputo, with the Spanish Cooperation taking care of the operations and academic management. In 2009, the programme was closed, having trained only four FPs. Only in 2015 did the programme resume its activities, with one resident starting his training that year and two more in 2016. There are currently two programmes in the country: one in Maputo and another in Nampula, which has not received any residents yet, despite having the accreditations and capacity to train new FPs.

Despite this uncertain and timid beginning, the current national scenario is very positive for the growth of FM and primary healthcare (PHC). To keep taking the right steps, we need to analyse the current political scenario and the health context in which we live. This case study is the result of a series of virtual world-café meetings amongst the authors using the World Health Organization’s Operational Framework for Primary Health Care as a theoretical model.² It aims to describe the strengths, opportunities, weaknesses and threats of the current scenario that can influence the development of FM and PHC in Mozambique.

Current context

Mozambique is a country with many social, economic and health needs. The country ranks 22nd on the Fragile States Index list³ and is experiencing an incomplete epidemiological transition scenario,⁴ where the burden of morbidity resulting from infectious diseases competes with an increasing prevalence of non-communicable chronic conditions. With just over 30 million inhabitants and a GDP per capita of US$467, we still have high maternal (289 per 100 000 live births) and infant mortality rates (74.2 per 1000 live births) and a prevalence of HIV of 11.5%, greater than most chronic non-communicable diseases. To deal with this high burden of morbidities, we have an extremely small ratio of doctors per population – just one doctor for every 10 000 inhabitants.¹

As a result of the comprehensive training, the work of the family doctor, when integrated with other professionals in the PHC team can be decisive in meeting the health needs of the population in Mozambique.⁵ Certainly, the skills developed over the four years of training makes them more capable of meeting the demands of the population. On the other hand, this same training makes local authorities see these FPs as skilled professionals who can occupy positions in the Ministry of Health (MoH) or provide managerial support in public services. Even when such duties are intermittent, the hours available for teaching and taking care of patients is reduced. In addition, professional recognition is not accompanied by financial compensation for any medical specialty in Mozambique.

Despite the quality training that we seek to offer to our residents, much of what is learned cannot be applied in clinical practice. Community health clinics lack the most basic resources and supplies for comprehensive patient care. This hinders the population’s confidence in primary care clinics, making patients and families seek care in more resourced hospital services.

Considerations for the near future

There is a growing movement of young FPs in Mozambique, as a result of the reactivation of the Maputo Residency Programme and the creation of the Mozambican College of FP in 2010. Despite the optimism and engagement, this group is still too small to generate political changes and modify practices in universities, health services and public administration. Fortunately, the current MoH’s agenda has been trying to fix the lack of trained human resources in our country, inviting medical societies to jointly design a plan for expanding residency training for all medical specialties with FM occupying a prominent seat at this table of negotiations.

This initiative will create new training sites in remote areas far from the capital, following successful experiences from other countries. In this way, instead of attracting young doctors from small cities to be trained in Maputo, the necessary resources will be deployed to 10 healthcare facilities in five provinces of the country, improving the quality of these services. The aim is to make future generations of FPs settle in the places where they were originally trained, increasing the number of specialists in areas that have no FP today and improving their distribution throughout the country.

This MoH initiative represents the beginning of a paradigm shift in medical education in our country, which still values tertiary hospitals and specific medical specialties as more important than the work of generalists in the community. Despite this favourable political scenario, there are major challenges to achieve this goal. Initially, the aim was to train 750 new FPs by 2025, but this number proved to be impractical because of structural and financial shortcomings. Currently, 10 health facilities in five provinces are listed as potential sites to become new residency programmes in FM. If that happens, in 2022 we will have 60 vacancies for residents spread throughout our country: 9 in Maputo province, 12 in Sofala, 12 in Zambézia, 12 in Tete and 18 in Nampula, in addition to the five vacancies in Polana Caniço.

New preceptors must be hired to teach and practice in these centers. The number of FPs about to graduate will not be enough to meet this demand. In 2022, five new FPs will graduate, but there will be no one graduating in 2023. Only in 2024 and 2025 we will have eight and seven new specialists graduating, respectively. In the short term, it is almost certain that Mozambique will need to rely on the Cuban International Cooperation to remediate this shortage of trained preceptors.⁶

In order to strengthen this initiative, it will be crucial to face another major challenge in the short term: building and validating a competency-based curriculum for FM in Mozambique. This will help us to create objective parameters to guide both the training and practice of FP and make the expansion of residency training in FM uniform amongst all six training sites.⁷

We also need to make our specialty more present and active in medical schools so that this transformation is sustainable in the long-term. Students have very little contact with FM whilst studying at medical school. Their contact with patients in the community happens under the supervision of nurses and technicians (technical professionals responsible for most of the primary care delivered in Mozambique) and takes place in health facilities where they get contact with health programmes focused on maternal and child care, HIV and AIDS, tuberculosis and vaccination. Students rarely have the opportunity to follow medical appointments during these visits and when this happens, it is not a FP running the consultation.

The Eduardo Mondlane University Health Center is the training site for residents in FM in Maputo. It serves students, university employees, employees’ families and residents of the neighborhood. Unfortunately, medical students only have contact with what we call community health. This discipline presents a simplistic view of what PHC and FM really are. Medical students and other fellow professors at the university end up discrediting the specialty, seeing it as lacking glamour and excitement.⁸

This misconception about the work of FPs needs to be ^changed and it relies on the efforts we have been making, seeking greater integration with other medical specialties and other healthcare professionals.⁹ In addition, we need to improve teaching and learning experiences in FM at the residency programme and medical school. If we succeed in this endeavour the next generations will fully experience FM and will start to see primary care as a desirable place where medicine can be taught and learnt by any healthcare student.

This new generation of FPs will have a lot of work ahead, advocating for the specialty with politicians and decision-makers. The momentum created by the resurgence of the residency programmes in 2015, the promotion of this new generation of FP and the current political scenario creates a favourable environment for the sustainable expansion of FM.⁸ Collaboration with colleagues from abroad, international internships, continuing medical education, faculty development activities and capacity building for research in PHC are key elements for FM to flourish in Mozambique.¹⁰ Finally, optimisation studies would be helpful to better plan the investment of the scarce financial resources we have.

The information described here is summarised in Table 1 presenting the strengths, opportunities, weaknesses and threats of the current scenario of FM and PHC in Mozambique, categorised according to the World Health Organization’s 14 levers for the development of PHC.

Conclusion

As the saying goes: ‘One swallow does not a summer make’. Perhaps eight swallows can, with small victories each day, make PHC in Mozambique less based on verticalised healthcare programmes and more based on comprehensive, efficient and person-centred care.

Acknowledgements

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

All authors contributed equally during the whole process.

This article followed all ethical standards for research without direct contact with human or animal subjects.

This research work received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data sharing is not applicable to this article as no new data were created or analysed in this study.

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

References