Immunisation in Mozambique: meeting the challenge
Running a health system with Mozambique’s staggering level of disease burden would challenge even the world’s richest nations. An estimated 13% of under-five deaths are caused by pneumonia, there are very high levels of malaria, and HIV creates another crushing burden with prevalence rates of more than 30 percent in some areas with resultant tuberculosis epidemics.
Yet Mozambique is not only one of the world’s poorest countries. Its poverty is compounded by the lasting impact of a 16-year civil war (1977-92) that severely disrupted health services, and recurrent floods that continue to undermine a fragile network of health centres.
This makes the Health Ministry’s efforts to put in place an effective and efficient immunisation system even more remarkable. During a recent three-day visit, I witnessed evidence of the Ministry’s success: from orderly vaccination sessions and the rigorous registration of immunisation cards at Manhiça district hospital, 70km from Maputo, to the well-trained personnel and cold chain system operating at the nearby Maragra health centre.
All of the clinics (albeit in a relatively high functioning area) that I visited took advantage of vaccination sessions to provide maternal and child health check-ups – a best practice long observed in developed countries. Far from having to convince mothers to vaccinate their children, I saw that immunisation is considered an important social occasion, with mothers dressing-up for a visit to the local clinic.
With the Health Ministry poised to introduce pneumococcal vaccine using GAVI support, there can be no room for complacency. Yet my visit also revealed some clear and present danger signs.
The Expanded Programme for Immunisation (EPI) group in Maputo confirmed that immunisation coverage rates for Mozambique dropped in 2010. This is borne out by an inability to lift pentavalent vaccine coverage to high-levels and an increase in measles outbreaks. Data shows that Mozambique is close to a full birth cohort of measles susceptibles; if there is a large outbreak, it will spread very quickly. Polio immunisation rates are disturbingly low which also means if there is a reintroduction, there is risk of a sizeable outbreak.
On the ground, local health centres explained to me the difficulties in running mobile immunisation clinics; essential to reach Mozambique’s often widely dispersed villages. In Manhiça district, the vehicle used for delivering vaccines to remote communities usually doubles-up as an ambulance – in emergencies, the mobile clinics can be cancelled at the last moment. There are also shortages of fuel and spare parts. And in more remote districts particularly in the North, this takes on a more concerning note: more than 40% of Mozambique’s citizens are not served by fixed based facilities, so for many, outreach is the norm.
Reassuringly, Mozambique’s Prime Minister Aires Ali told me that the national immunisation programme is a priority for his Government. Vice Health Minister Naira Abdula revealed her ambitious plans and that she has invited Mozambique’s Head of State to attend the launch of the pneumococcal vaccine, scheduled within the next two years.
There is also interest from the Health Ministry and GAVI’s in-country partners WHO and UNICEF in using GAVI’s health system strengthening support to meet the challenge of building a more sustainable vaccine delivery system.
The role of CSO’s in helping to solve these challenging problems has also been demonstrated. We observed Village Reach operating in Manhiça district, an NGO of which I am very familiar as I was a former board member. Village Reach has worked on vaccine delivery logistics in Mozambique for a number of years. They provide 4×4 vehicles to ensure there is no vaccine stock-out at local health centres, help to provide support for the cold chain as well as training health workers. You can learn more about this particular experience by visiting our website .
The challenge will be extending these kinds of collaborative solutions to Mozambique’s 127 other districts. Two decades after the end of the civil war, facilities and trained personnel remain in very short supply especially in the northern rural areas.
One of the most encouraging signs for Mozambique’s future is the full integration into the national health system of the Manhiça Foundation research facility. The centre is perhaps best known as one of 11 centres spread across seven African countries currently involved in phase III trials of the RTSS malaria vaccine candidate. However, the research facility is also doing trials of a new TB vaccine candidate and preparing for potential HIV vaccine trials. Moreover, their work goes far beyond vaccine trials. By following a large demographic cohort of >90,000 persons in the district (some of which dates back to 1996), they are providing real-time information on local disease burden and the on-going impact of public health interventions.
Furthermore, the Foundation is grooming a cadre of highly trained Mozambican scientists dedicated to improving people’s health in their country. Dr. Betuel Sigavque is one such example. Educated at Maputo’s medical school, Betuel joined the Manhiça Foundation in 2001, trained in Pediatrics and tropical medicine, and took his PHD in public health in Barcelona, Spain. Today, he doubles up as the Foundation’s director of research for pneumococcal vaccine research and for potential future HIV vaccine trails, and as the Chief Medical Officer at the Manhiça District hospital.
Thanks to the likes of Betuel and his many well trained colleagues at the Manhiça Foundation, as well as the Government’s vote of confidence in vaccines, I left Maputo with the sense that Mozambique’s immunisation system is likely to have a bright future. I and my colleagues at GAVI look forward to assisting Mozambique in any way that we can with this vision.