The Director of International Relations writes from Mozambique, the first destination of a mission that will take him to Ecuador, Bolivia and Bosnia in the follow-up and execution of our public health interventions. The reflection on health as a right and health as a result of both national and international politics and decisions are the focus of these comparative, global and critical notebooks.

“Thinking about public health from justice shows us […] that we must give solutions to complex issues such as freedom in a society dominated by interests and power relations that make it unfair.” – Fernando Peñaranda.

Bulletin No. 132 of the Republic of Mozambique published on July 10, 2019, signed by the Minister of Economy and Finance, Adriano Afonso Malelane, updates the “Ajudas de Custo”, allowances for state officials and agents. Despite the current date and the fact that it already circulates in a digital format even by WhatsApp, the document seems taken from another era: in black and white, typed, with the official shield of the country, in a  seventies-style, post-colonial, austere, with state authority. If it were not for the serious repercussions, a grey document, one more piece in the bureaucratic gear of a country that lives between two worlds could go unnoticed, with a brief past of a state of socialist nature and a present of wild neoliberalism.

But this page and a half of information is a real treasure to understand (or rather to lose yourself permanently in the attempt) many things about this young country and its relationship with the world. In summary, the decree indicates that a state worker who participates in a “service mission” to any area of the country will get paid six thousand Mozambican metical per day of “Ajudas de Custo”. At the official exchange rate of the Bank of Mozambique, that value corresponds to approximately ninety Euros.

There are different reasons to perform “service missions”, but the most common in the case of health officials is continuous and ongoing training. In a country that has the worst indicators of health workers in the entire Southern African region (in both quantity and quality), this strategy is presented as something indispensable and relevant for those professionals who are already attending patients to improve their diagnostic capability.

Well, translated into the language of the people I hope to read these lines and fleeing the rhetoric of the “language of help and cooperation”, what this means is the following:

Imagine a health centre that is located in the middle of the African savannah, perhaps about 120 or 130 km from the nearest city, what is here called the district headquarters (an absolutely usual situation in Mozambique). In that health centre works, let’s put an example, Nila, who did a training course of twenty-four months to work as a nurse. Nila is alone in the centre and attends all kinds of consultations, from malarial cases, HIV cases, births, small surgeries, etc. She is a hero, fights against all the inclemencies, difficulties, sterilizes her medical equipment in a coal autoclave, attends births with candlelight, fights the poison of cobra bites. She feels lonely and often frustrated because she has no medications, they don’t reach her and she is hopeless. A letter from his superiors reaches her: the Ministry of Health determines that there is a new treatment for malaria and wants to train its workers in that new protocol. This is a training of five days to be held at the district headquarters. Nila “should” go to that formation, of course.

We are facing what, in the language of development cooperation would be called “a felt need” (every day I hate this jargon more…). But it is at this time, in this obvious logic of what “must” be done to have better trained nurses and therefore healthier population, that one begins to wonder and consider many things: Nila’s monthly salary is 12,470 meticals, that is about 184 euros per month and 5 days of training will generate 450 Euros. Well, it is certainly an “incentive” for her. We can go a little further, maybe Nila begins to consider that it is better to go to training than being in the health centre, I think we would all think the same, right? Remember that Nila works alone in the centre, which means that if she leaves the centre, the population she attends is left unattended for five days. Remember that Nila lives in conditions of extreme hardness in the community. And of course, remember that Nila wants to know that new treatment (although internally she wonders if the medicines will ever reach her to be able to apply it…).

Who pays her training? In a country where the vast majority of the money invested in health is still in the hands of international donors (in recent years, large NGOs, UN agencies, the World Bank, etc … have handled more than 70% of the investment in health), many of the formations are assumed by external aid. At the same time, the International Monetary Fund (IMF) “suggests” to the Government of Mozambique to, in exchange for credits, freeze the salaries of state officials, but inflation in the country is skyrocketing and the cost of living is very high. Nila does not get her salary for a week … How do we improve the salary of a large number of the country’s workers? With stimuli to be formed, a large part of which is paid for outside help. And watch out, that external help has a brutal responsibility in this perverse system, because, with the supreme purpose of complying with the indicators of the projects, almost three decades ago, it was thought that it was appropriate to define a model of incentives, at first food and a juice, then a small diet, and now we are already at the level of almost paying one hundred euros per person and per day (in a country where the minimum monthly salary does not reach seventy euros) to go to a training, this means that to train twenty nurses in a new malaria protocol, more than ten thousand euros are needed…

Would it not have been easier, from the beginning, to pressure repeatedly the state to pay decent wages to its workers than to have these unsustainable pyramid systems? Wasn’t it necessary to stop the international financial organizations that with their structural adjustment measures denigrated the lives of thousands of professionals who over the years have lost faith in the public health system in which they work? Many entities understood years ago that this was not their role, that they “did not get into politics”, that “they wanted to save lives” … I feel that this naive, almost messianic vision of aid has done a lot of damage and also confuses everyone, especially the citizens of the north who, with very good intentions, have been concerned for countries like this. I feel that in recent decades, the role of politicians throughout the world has been to strive to make saying “I am apolitical” to be considered something positive.

Would it not have been easier, from the beginning, to pressure repeatedly the state to pay decent wages to its workers?

Wasn’t it necessary to stop the international financial organizations that with their structural adjustment measures denigrated the lives of thousands of professionals who over the years have lost faith in the public health system in which they work?

Patch on patch is weaving this dress with African body and international sleeves.

We all want to save lives, the issue is how that end is reached.

Patch on patch is weaving this dress with African body and international sleeves. Health as a right is not among the political priorities of a government obsessed in emptying the bowels of land that it believes is its own. Health as a right is not the end of the vast majority of organizations that operate in this country. We all want to save lives, the issue is how that end is reached.

Some believe that there will be no choice but to pay for health, others believe that if that is the way, hundreds of thousands of Mozambicans will be once again excluded. Be that as it may, it is in this context of absolute absence of logic in which we have to execute projects and try to open a path to justice, not from charity, loaded with the contradictions of a wild model that increasingly copies closer to the nearest savanna around us.

Iván Zahínos Ruiz

International Relations Coordinator

medicusmundi Mediterrània

*Translate from Spanish into English by Susanna Pujol Clivillé