The Covid-19 pandemic has worsened that lack of quality of the National Health Services (SNS), according to a research carried out by the Observatório do Cidadão para Saúde (OCS) between June and November 2020.
The research points out that various factors contribute towards the falling quality of public services in the health sector, namely the lack of good conditions in hospital infrastructure; the deterioration of sanitation conditions, the scarcity of medicines, as well as the lack of mobile rooms for screening and clinical monitoring of new epidemiological cases.
One of the main reasons behind the falling of the quality of health services may be linked to the weak coordination between community committees and public health authorities. In other words, some communication barriers prevail between these two entities, calling into question the answers that users seek to satisfy their concerns,
Another factor that undermines the sector, according to the research, resides in the fact that the SNS depends significantly on external funding and that there is a deficit in the mobilization of internal resources. In this case, the poor collection of resources contributes to the devaluation of the quality of public health services.
Observatório do Cidadão para Saúde (OCS) – 2020 and the current (2021) year are being atypical because of the Covid-19 pandemic. Against this background, government imposed some measures that made access to many services difficult. How Covid-19 affected the health sector?
Marta Simone (MS) – Due to the restrictive measures imposed by government, we think that the workings of the national health system have been affected. We saw, for example, restrictions for users, as well as other actors that, with their activities, ensure the good functioning and care to patients. Because of these measures, for example, the number of people visiting health facilities has reduced. So, that was one of the negative aspects. Look, those members who had their family members hospitalised were affected.
Second, we were able to verify that some civil society organisations that fight for the defense of the rights and duties of the patients of the national health system, and for the human rights of citizens, saw their activities restricted. Furthermore, these measures restricted visits to communities by health activists.
The government enacted measures, but did not created conditions for, for example, provision of personal protective equipment: masks, smocks, gloves, visors, etc. It is true that it was only later that the government thought about making this material available. Before, the support that health units received came from donations from foreign countries and foreign non-governmental organisations, as well as from civil society, which provided alcohol, soap, etc.
No plan or prediction was given on what measures, based on these restrictions, government would set up towards people performing professional activities in the health sector, such as technical staff, as well as civil society organisations.
OCS – As the OCS is an organization that monitors access to health services, what was its role? What did it do?
MS – Well, seeing that many organisations and health personnel were getting affected in relation to the lack of conditions to carry out their services, the Observatório designed a project, or strategy, to be able to provide support to those organisations.
For example, we initially identified four organisations to whom we provided individual protection equipment. We distributed protective equipment to these organisations, and then we supported training campaigns for activists. With training, we wanted them to make patients, citizens aware of Covid-19.
This was one of the strategies that the Observatório outlined. In addition to this strategy, the Observatório also gave support in terms of communication and transportation so that, for example, the activist who was not in a position to travel from their home to the health facility, could communicate, do a virtual interview to find out the patient’s health situation and check if they were taking medicine, and if they were able to leave their homes to go to the health unit.
Second, transportation would be in case the activist met a patient who was not in a position to go to the health facility. The activist was able to travel to the patient’s home or community. So, we created this mechanism with the objective of continuing to provide psycho-social support, and follow-up so that the information could then be taken to the clinical management of the health units, where patients receive treatment.
OCS – But this work was based on something, wasn’t it? Some kind of evidence? For example, did you carry out any research to understand what was happening? If so, what kind of research and what were its objectives?
MS – Well, before I answer, with the support we intended, and do intend, to monitor the services in times of Covid-19. We must realise that 2020 was an atypical year in which many of us were not prepared for Covid-19 and did not know what was going to happen. The Observatório carried out this evidence-based monitoring in health facilities, as well as in communities, for chronically ill people, vulnerable people and people unable to go to health units.
The people who were undergoing their treatment – we are talking about people living with HIV, for example, who due to the restrictions imposed by Covid-19 requiring them to stay at home – thought about giving up, and many stopped their treatment. The activist did the monitoring to assess the perception that the patients had about the “stay at home”, and if the patients obeyed the preventive measures decreed by the government.
OCS – What methodologies were used?
MS – First, we evaluated the face-to-face visits, in order to find out if they (activists) were properly trained and if the issue of protection against Covid-19 was respected and if the visits also took place in the communities. The visits in the health units were with the knowledge of the management or representative of the health unit. Therefore, the health sector also participated (in the research) from the moment the activists made themselves known through a credential that was approved by the management and the community leader. This was one of the methods we used as a means of making the process more transparent. It is true that the activists were already carrying out their activities in the health units, but the Observatório’s support was to add one more item to their credentials, informing the management and community leaders that the activities were about to star.
OCS – To which organisations did the activists belong?
MS – We had the participation of activists from Pfuka Uhanya, Hi Xikwanhe, Kindlimuka, and also from Amovapsa – the latter was not able to continue with us because it later became involved in other activities. In 2021, we decided to extend this monitoring because we had positive results from our first phase of implementing our support for monitoring health services and raising awareness about the care that patients should have within the scope of Covid-19. And we also extended to the provinces.
In Maputo province, we now collaborate with the Marracuene platform, located in the Marracuene district. We now also have the participation of Kutenga; we have Mahlahle, which is based in Maxixe, Inhambane; and we also have the participation of Ana Nzira, which is an association for the support and defence of human rights in Beira, Sofala province; and finally in Tete, with the Association for Social Development, which is in the district of Changara.
So, these seven organisations are the ones that have been providing an answer to what is our work on the monitoring of health services, and we always ask them to do this work based on evidence, as, for example, if they observe an illicit act in the health unit may well go to the health professional and report the act.
OCS – OCS has already published a first report. What were the main findings?
MS – I will make an observation of the activities between the 2020 and 2021. In 2021, first, one of the barriers that we noted was that the patients did not comply with the social distancing, which was one of the measures. Second, the community leaders themselves did not allow activists to carry out their activities due to lack of visors, for example. The use of visors and masks was mandatory. But what was published in the bulletin or decree did not come out clearly about the mandatory use of this personal protection equipment (visor).
Therefore, we tried to improve and as a result we had the issue of late delivery of services. We followed a case of a patient who went to a health unit and, based on her dress, the help professional did not allow the person to have access to health services because of the way she was dressed. Luckily, there were some members of the organization Pfuka Uhanya, which carries out its activities in the 1º de Maio health unit, who witnessed the situation, and only with their intervention was it possible to resolve it.
One of the cases was the situation of the toilets in some health units that were closed, or sometimes opened late, and the patients ended up urinating or defecating outside.
For 2020, we managed to solve some barriers. In some health units, we were able to verify the decrease in the number of patients, which would be the fulfillment of social distancing, the helpful service in what would be check-ups. In 2020, we saw that consultations were made in the same room, there was no privacy, there was no confidentiality, for example, in the case of a patient, they were exposed to everyone. In one of our reports we could see through what the activists reported, we could see that there was no longer this thing of violating the privacy of the patient during consultation, during an examination.
OCS – What has the impact of the report been on the discussions on access to health services in times of Covid-19?
MS – Well, we realised that one of the positive impacts in relation to this monitoring from 2020 to 2021 was that, for example, when the national vaccination plan was drawn up, this document mentioned the first groups that would be part of it. However, we realised there was the lack of inclusion of civil society organisations that work towards access to health, which, to a large extent, are the ones that have supported MISAU. In this sense, the Observatório proposed that government redraw this plan to include activists. After all, they are the first to deal directly with patients, either in the health unit, or in the community.
And in response, I believe that after two weeks the vaccination of the activists was announced and the importance of the work of the organisations was recognised, as well as the importance of the work of the activists.
OCS – The report was welcomed by MISAU?
MS – MISAU welcomed it, yes. Now what we really are not aware of is to know if the vaccination plan is being carried out fully.