Photo: Phuong Tran/IRIN

Mozambique is also increasing its number of trained physicians

NAIROBI,  – The use of mid-level health workers rather than doctors to prescribe antiretroviral treatment (ART), a strategy called task-shifting, has enabled Mozambique to triple the number of facilities providing medication within six months, according to a new study.

The report, published in the in the latest edition of the Journal of Acquired Immune Deficiency Syndromes, by Kenneth Sherr from the University of Washington and officials in Mozambique’s Health Ministry, found that patients from rural and disadvantaged areas could also access quality ART services as a result of the task-shifting.

Shortly after independence in 1974, the majority of physicians – mostly Portuguese nationals – departed from Mozambique, leaving fewer than 80 physicians to care for a population of 10.6 million.

Since then the country has largely relied on ‘técnicos de medicina’ – non-physician clinicians who undergo training for 30 months – to provide the clinical and managerial tasks ordinarily carried out by doctors.

Political instability and economic structural adjustment programmes in the 1980s hit Mozambique’s health system hard, forcing the closure of up to 50 percent of public health centres. HIV prevalence reached 15 percent in 2003, yet only one percent of people had access to treatment; the government again looked to técnicos to fill the gap.

Rapid expansion

“Because the numbers of existing physicians were inadequate to cover the large number of facilities in the rapid scale-up, the national plan included a renewed effort to train new técnicos as an essential element of workforce expansion for HIV care,” the report noted.

By mid-2006, the first wave of newly graduated técnicos had been deployed at health facilities; about a year later 167 health centres covering 147 Mozambican districts and municipalities were providing treatment.

The scale-up also integrated ART into public healthcare, so physicians and técnicos would attend to all patients, not only those infected with HIV.

“Deployment of newly trained técnicos provides opportunities to staff rural and smaller urban clinics with clinical cadres that are more likely to continue to work in public healthcare. Furthermore, training, salaries, and benefits cost less for técnicos than for physicians,” the authors said.

More on Task-shifting

More training needed for task-shifting to work

Government empowers nurses to boost ARV treatment

Nurse-led model can work

Solving health worker shortages

“Supported by the integrated care approach, the number of facilities with ART tripled over a six-month period, including predominately small, rural, and peri-urban health centres, 45 percent of which were managed by a técnico de medicina.”

A continuing effort

Mozambique is also increasing its number of trained physicians; student intake at the country’s main medical school has doubled, and two new medical schools have been opened. According to the study, the quality of care provided by técnicos is equivalent to or better than that provided by medical doctors.

However, an evaluation of the técnicos’ training found that they were not sufficiently prepared for actual clinical responsibilities, especially where health system resources were inadequate, and the health workforce would have to be multiplied several-fold to achieve the United Nations Millennium Development Goals.

Nevertheless, the report concluded that “Using a mix of physicians and responsible task-shifting to non-physician providers, the Mozambique health system can maintain its momentum in ART scale-up while strengthening the wider public healthcare system.”

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Photo: Shervorn Monaghan/IRIN

The Kampala Convention could affect the global debate on “climate migrants”

JOHANNESBURG,  – An African international agreement has opened the door to a debate on the rights and protection of people displaced by natural disasters, with a nod to migration as a result of climate change.

The Kampala Convention, a ground-breaking treaty adopted by the African Union (AU), promises to protect and assist millions of Africans displaced within their own countries. Significantly, the treaty recognized natural disasters as well as conflict and generalized violence as key factors in uprooting people.

Jean Ping, chairperson of the Commission of the African Union, told IRIN that “more and more people are likely to be displaced” as Africa experiences more frequent droughts and floods brought about by climate change.

He said the inclusion of displacement by natural disasters was informed by the global debate on the need to develop a framework for the rights of “climate refugees” – people uprooted from their homes and crossing international borders – because the changing climate threatened their survival.

The reference to people displaced by natural disasters is as an interesting attempt to find… answers to the new concern about migration linked to environmental degradation

The treaty also calls on governments to set up laws and find solutions to prevent displacement caused by natural disasters, with compensation for those who were displaced. Migration expert Etienne Piguet said with the Kampala Convention the AU had “once again” tried to push the envelope.

In 1969 the Convention Governing the Specific Aspects of Refugee Problems in Africa, adopted by the then Organization of African Unity, had gone a step further than the 1951 UN Refugee Convention by using a definition of “refugee” that included not only people fleeing persecution but also those fleeing war or events seriously disturbing public order.

Piguet described the reference to people displaced by natural disasters as an “interesting attempt” to find “adequate answers to the new concern about migration linked to environmental degradation”.

In 2008 climate-related natural disasters like droughts, hurricanes and floods forced 20 million people out of their homes, while 4.6 million people were internally displaced by conflicts, according to a recent joint study by the UN Office for the Coordination of Humanitarian Affairs (OCHA) and the Geneva-based Internal Displacement Monitoring Centre.

The Representative of the UN Secretary-General (RSG) on the Human Rights of the Internally Displaced Persons in a submission to the UN Framework Convention on Climate Change noted that people uprooted from their homes by natural disasters enjoyed protection under the existing human rights law and the guiding principles on internal displacement.

However, the Kampala Convention also calls on governments to “prevent or mitigate, prohibit and eliminate root causes” of displacement, and find “durable solutions” to them.

Moussa Idriss Ndele, President of the Pan-African Parliament, the legislative body of the AU, said the debate in Kampala on the rights of people displaced by natural disasters did not “quite evolve properly – we did not address the issue of climate change” because most people still believed conflict was the biggest trigger of displacement.

Can of worms

However, it was unclear which events could be linked to climate change. “More and more people are being displaced by floods, which are becoming more and more frequent and intense,” said Rachel Shebesh, chair of the African Parliamentarian Initiative for Climate Risk Reduction.

The RSG said there was a need to clarify or even develop a legal framework to help people who moved inside or outside the country because environmental degradation and slow-onset disasters – like desertification, salination of soil and groundwater – made areas uninhabitable, and if displaced persons could not return to their homes they should be considered forcibly displaced.

The Intergovernmental Panel on Climate Change (IPCC) has projected more frequent and intense floods and droughts in Africa during the next few decades, and the debate is not only set to continue, but to intensify.

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Photo: Sarah Simpson/IRIN

A market vendor in N’zérékoré (file photo)

DAKAR, 3 – Local civil society activists say Guinea’s latest political crisis has taken on an ethnic dimension in N’zérékoré – junta leader Moussa Dadis Camara’s home region – which has an ethnically mixed population and has experienced communal clashes before.

The 28 September killing of over 150 civilians by security forces in the capital Conakry triggered tension in the southeastern Forest Region.

NGOs and local authorities are trying to rein in ethnic dissension and establish dialogue among the various communities in the region.

This week the regional capital, the city of N’zérékoré, remained relatively calm but with underlying tensions, residents told IRIN. They said the days ahead would be crucial for maintaining peace.

Immediately after the Conakry killings rumours emerged in N’zérékoré that local members of the Peulh ethnic group would demonstrate against Camara and that the Guerzé, the junta leader’s ethnic group, would react violently against anyone participating.

On 10 October civil society organizations and religious and traditional leaders held a “day of dialogue”, amid what a report from the meeting called “a national crisis that compromises stability”.

“At the meeting people from the Peulh and Guerzé communities said there was no truth to the rumours,” said Béatrice Kolié, facilitator in conflict resolution with the NGO Réseau de Femmes du Mano pour la Paix (REFMAP). REFMAP and a local traditional communicators’ NGO initiated the meeting, with the support of the NGOs Faisons Ensemble and World Education.

Kolié said after the talks tensions had eased considerably. “But we don’t yet know where these rumours originated.”

The meeting report said: “It is important to note that even though the rumours were groundless they were about to set ablaze the region, and beyond that the country.”

After the events of 28 September political conflict took on an ethnic tone in N’zérékoré, Kolié said. Another observer, who requested anonymity, said there is palpable tension between Guerzé and Peulh youths. One day in mid-October some N’zérékoré neighbourhoods were strewn with flyers that read in part: “If Dadis leaves power, the Peulhs leave N’zérékoré”.

N’zérékoré is no stranger to ethnic tensions: In the past there have been clashes between Malinké and Guerzé.

Ethnic dimension

Guinea’s ethnic makeup consists of Peulh (a majority at about 40 percent), Malinké, Soussou, and several smaller groups from the Forest Region. From independence in 1958 to the 2008 coup bringing Camara to power, the country had two presidents – one Malinké and one Soussou. Observers say many Peulh think it is “their turn”. Meanwhile Camara supporters are seen as playing on the exclusion of Forest Region ethnic groups, according to International Crisis Group (ICG).

“No matter how you look at it, in Guinea the ethnic dimension constitutes a very prominent element in every socio-political aspect,” Mohamed Jalloh, Guinea expert with ICG, told IRIN.

One man who said he was beaten by soldiers on 28 September in Conakry told IRIN every soldier he came in contact with asked him his ethnicity. Youths in Conakry said in the following days soldiers harassed and threatened Peulh people. The current defence minister, Sekouba Konaté, has links with rebel and militia groups from Guinea’s and neighbouring Liberia’s recent past, according to ICG, who says in its latest report that the junta is training militias in the southeast.

Kola nuts and caravans

In opening the 10 October meeting in N’zérékoré – after a moment of silence for the 28 September victims – a sage presented 10 kola nuts each to community representatives as a sign of welcome and brotherhood.

Members of several ethnic groups discussed the situation, with traditional and religious leaders reminding participants that they are all part of one Guinea and if the nation suffers, all suffer.

A Peulh Islamic leader at the meeting, who has lived in the region for more than 40 years – “in perfect harmony with my Guerzé hosts” – urged participants to work for national unity.

One of the recommendations from the meeting was that citizens and authorities go after rumour-mongers. “Identify, denounce and interrogate those propagating rumours,” the report recommends, adding: “This assumes the effective involvement of the authorities, defence and security forces and the judiciary.”

The participants also recommend using local radio to defuse rumours, reviving local structures aimed at preventing conflict, holding more dialogue days, organizing youth prayer days, and forming interethnic and religious committees.

In another initiative local civil society groups conducted a “peace caravan” in which people gathered and visited representatives of various ethnic communities, to shake hands and talk.

“This was to reinforce national unity,” said Auguste Impérial Théa of a N’zérékoré peace and development coalition; he helped organize the caravan. “There was a serious tear in the social fabric and that is dangerous.”

He added: “We plan to expand the caravan to the rest of the region. This is giving people a chance to talk about the fear that is in their hearts.”

Intra-ethnic threats

One Guerzé man who requested anonymity said ongoing peace-building efforts must immediately be concentrated on the youth, claiming that young Guerzé reject – often violently – the slightest criticism of junta leader Camara. He said he knows a woman market vendor who was recently beaten by some youths for selling goods to Peulhs.

Photo: Nancy Palus/IRIN

Road to the airport in N’zérékoré

One day he heard a group of Guerzé youths alleging that the international media were paid by the Peulh to spread bad information about Guinea. “When I spoke up and simply asked them if they could say that Dadis’s actions up to now have really been noble, they roughed me up and threatened me with a knife, calling me a traitor and a bastard – saying that I must not be a true Guerzé. I was completely taken aback.”

When he went to a lawyer about the confrontation the lawyer said that given the current conditions in Guinea it was best to keep quiet. “The lawyer told me, ‘Otherwise you’ll give up your life for nothing.’”

ICG in its report expresses concern over inter-communal violence in the region, noting that a top junta official recently on a visit to N’zerekore declared, “Dadis or death”.

The Guerzé man told IRIN on another occasion he was threatened again when he tried to ease hate talk against the Peulh.

“I heard a group of Guerzé youth saying they would have to eliminate some Peulhs to diminish their number in Guinea. After the initial incident I had vowed I would keep quiet, but this disturbed me so much; I just had to say something.” He said he told the youths that hurting or killing Peulh would solve nothing.

“Later that night the group – with a few additional people – came to my home… two people in the group who have known me for a long time urged the others not to harm me.”

He added: “But I live in fear. Every day I fear they could come to my home and attack me.”

Conflict resolution worker Kolié said communities must continue to meet and talk. “In conflict prevention we cannot say, `we’ve done this and that and now we’re finished’. It must be ongoing.”

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