Mozambique health care workers speak on struggle to control tuberculosis

Health care workers in Mozambique voiced concerns about the obstacles confronting them as they struggle to control tuberculosis (TB), in a study recently published in the science and medicine journal PLOS ONE.

Eighty-six nurses, medical workers, TB programme personnel, and auxiliary workers from three provinces were interviewed in 11 focus group discussions. Workers spoke of unsafe working conditions, lack of resources, and the social deprivation facing their patients.

Mozambique is one of 22 high TB-burdened countries that account for 80 percent of all tuberculosis cases, with an estimated 140,000 cases of active tuberculosis at any given time. The country’s tuberculosis epidemic is driven in large part by its generalised HIV epidemic, with 11.5 percent of the adult population HIV-positive. Tuberculosis is spread person to person via airborne respiratory fluids, such as by coughing or sneezing. Thirty percent of those co-infected with HIV develop an active tuberculosis infection.

Mozambique’s health expenditure per capita is a paltry $66, and the nation’s TB programme budget for 2014 is only $19 million (78 percent of which is unfunded), a sum not even two percent of the wealth held by any of the world’s 1,645 billionaires.

For every 100,000 people in Mozambique, there are only 70 hospital beds, 41 nurses and midwives, and four physicians. Over half of the country’s population lives in absolute poverty, on no more than $0.65 per day.

The privatisation of state-owned enterprises, particularly water, has proven catastrophic for the country’s population. Only 49.2 percent and 21 percent of Mozambicans have access to clean water and sanitation systems respectively, with huge disparities between urban and rural populations.

Health care workers interviewed complained of shortages of protective equipment, low pay, and austere working conditions. Workers often attended to tuberculosis patients outdoors because ventilation indoors was so poor. “Our physical space is small. … There are no fans, nothing,” reported a medical worker. “There is priority to give respirators to the TB programme [personnel]. … We, the others, use those of paper that do not protect at all,” added another.

Auxiliary workers, trained only in basic skills and brought in to alleviate shortages of skilled health care workers, had to bring their own boots when their health care facilities could not provide them. Irregular supplies of protective gear led to indifference toward proper usage. A TB programme worker lamented, “It should be there all the time. Because if the material is there today, but [used up] tomorrow, I am not interested, I am not protected at all…”

Health care workers expressed fears of inadvertently infecting others, particularly those in their families and communities, and reported that they had no way of protecting people outside health care facilities. “We are contracting the disease and I am going home without knowing [so]; I fall ill or infect my child,” an auxiliary worker said.

Some health care workers interviewed had colleagues who had already contracted tuberculosis. Nurses and auxiliary workers expressed concern that their lack of education in dealing with tuberculosis increased their risk of contracting and spreading the disease. Of the health care workers who participated in the study, only six of the 27 auxiliary workers (22 percent) and six of the 18 nurses (33 percent) received TBIPC (tuberculosis infection prevention and control) training.

“A lot of training is given to nurses, clinical officers, the doctors but [not to] the auxiliary staff,” an auxiliary worker explained. The nurses working at outpatient departments suggested that their risk was higher than those working at TB clinics because “those patients [going to TB clinics] are already diagnosed and on treatment.” Only 37 percent of tuberculosis cases in Mozambique are detected.

Harsh social conditions faced by patients also obstructed treatment. Mozambique has an official unemployment rate of 22 percent. A vast majority of Mozambican workers are employed in subsistence agriculture, and 68.3 percent of Mozambique’s population lives in rural areas from which it can be an hour or more by car to reach a health care facility. Public sector workers are among the lowest paid, with a minimum wage of $89 per month.

Mozambican law stipulates that TB patients are allowed two months’ leave from work to allow adherence to daily treatment, but private companies frequently do not comply. A TB programme worker recounted, “[My patient] said, ‘My job is in the private sector, if I have to remain at home two months, I’ll stay without a job. … I have to work because I cannot kill my children.’”

Health care workers also cited lack of public education on tuberculosis as an issue, with stigma and patients’ feelings of isolation impeding collaboration with health care workers. “[One] can use the respirator, but [then] the patient starts saying that [one] despises [them],” explained an auxiliary worker.

Despite being one of the world’s most impoverished nations, Mozambique is frequently hailed as a model of “progress” and “development” for Africa. Mozambique’s real annual GDP growth rate in the past four years was above seven percent. Foreign direct investment in the country exceeded $1 billion in 2010, and has since more than quintupled to $6.7 billion.

Mozambique is Africa’s second largest aluminium producer and is building what is to become the world’s second largest liquefied natural gas export site at a cost of $23 billion. The minimum wage for workers at large mining companies is just $158 per month.

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