A special entry for the International Day of the Midwife by Barbara Bale, Save the Children Health and Nutrition Team Leader.

The birth of a baby is a magical moment, transforming human nature into a miracle of life – a time of joy. Yet it is a tragedy that women and their babies continue to die in childbirth in the 21^st century because of lack of access to midwives and other midwifery-skilled health workers.

A wealth of evidence indicates that a midwife or a health worker with midwifery competencies is crucial to reducing maternal and neonatal mortality and promoting the health of women and children. This is why the proportion of births attended by a skilled health provider is one of the two indicators for measuring progress toward MDG 5. Skilled attendance is also vital to protecting the health of newborns and achieving MDG 4: the majority of perinatal deaths occur during labour and delivery or within the first 48 hours after delivery. In Mozambique one third of children under 5 die during the neonatal period, the first month of life.

The health of women and their newborns was at the core of global development discussions in 2010, when the UN Secretary‐General launched the ‘Global Strategy for Women’s and Children’s Health’. This call for accelerated action was followed in 2011 by ‘The State of the World’s Midwifery – Delivering Health, Saving Lives’, a report produced as a result of collaboration among 30 partners, including UNICEF, UNFPA, WHO and Save the Children. It was the first comprehensive analysis of midwifery services and issues, providing new information and data gathered from 58 countries, including Mozambique. The report points to an urgent need to train more health workers with midwifery skills and ensure equitable access to their life-saving services in communities to improve the health of women and children.

The gap analysis for Mozambique shows that like many other poor countries there are inadequate numbers and inequitable coverage – in 2010 there were 2,799 midwifery personnel with a projected need for 5,559 by 2015, a doubling of the midwifery workforce to attain the performance benchmark of 6 midwives per 1000 live births per year. This severe shortage in health workers with midwifery skills holds back the scale up of maternal-newborn health initiatives. In Mozambique the number of expected obstetric and newborn complications per day is estimated at 385 with 238 occurring in rural areas where a large proportion of deliveries take place at home, perhaps with a relative or neighbour to help. Thus, Mozambique faces a triple gap – of competencies, coverage and access.

Improving the quality of care and services across the health sector is a top priority of the Ministry of Health. While training more midwives should head the list, another strategy is to improve the skills of existing midwifery personnel and other categories of health workers (see the video Birth of a Surgeon which follows Emilia Cumbane, one of a group of Mozambican midwives trained in emergency surgical obstetrics), and to develop efficient models that address both equity and the quality of care.

There are other partnership initiatives led by the Ministry of Health to improve health care delivery and bring essential services closer to rural communities, integrating key life saving practices for both the mother and baby around the time of birth. The government’s Model Maternities Initiative (MMI) trains skilled birth attendants in emergency obstetric and newborn care skills and promotes a caring environment for childbirth. In the main obstetric hospitals where MMI has been introduced with support from the Maternal-Child Health Integrated Programme (MCHIP), the number of Mozambican women who choose to give birth in a health facility is increasing. An example of a community-based approach is the training of lay health workers to increase access to and knowledge of misoprostol for use in preventing postpartum haemorrhage, the main killer of women in childbirth.

To reach pregnant women, not only where we want them to be, which is delivering in a facility with skilled attendance, but where they are now, requires courage – as Ban Ki-moon said ‘Ensuring that every woman and her newborn have access to quality midwifery services demands that we take bold steps..’

Mozambique needs more midwives – in the community, in the health facilities. May 5^th is the International Day of the Midwife – let’s celebrate the work of Mozambican midwives and step up our efforts for a health worker with midwifery skills within reach of every Mozambican woman and her newborn….because midwives save lives.

Sources:

• State of the World’s Midwifery
• Birth of a Surgeon
•  Model maternities in Mozambique
•  Preventing Postpartum haemorrhage with misoprostol

That was 2011… ©Leen Jille

A post by Leen Jille, UNICEF Procurement Consultant

It was April 2011 when Mozambican newspapers revealed the “discovery” of a MOH warehouse full with expired medicines. Some other challenges in the area of Procurement and Supply Chain Management had already surfaced earlier in 2011 so the Minister proclaimed a “medicines crisis” and established a Taskforce. As Co-Chair of the MOH-donor working group on medicines, UNICEF was part of the Taskforce and played a key role in coordinating the efforts to address the various components of the crisis situation, one of them being the warehouse with expired medicines. Senior level management in the MOH and donors agreed that a complete inventory of the expired medicines was needed prior to the disposal of the medicines.

A subgroup was created to develop and implement an action plan. The group was composed of pharmacists of the MOH, a pharmacist of MSF and logistics experts of PEPFAR Partner SCMS and UNICEF.

Several meetings were held to discuss the technical aspects of disposing of the expired medicines safely, and to define the planning, budget and timeline for the operation. In keeping with the recommendation of the MSF pharmaceutical expert, it was decided that the most appropriate action would be to incinerate the medicines in the furnaces of the cement factory.

On paper, the action plan looked quite straight-forward:

1) negotiate with cement factory for incineration of medicines in their furnaces;

2) obtain approval of authorities;

3) ensure availability of trucks;

4) make warehousing experts and a specialized pharmacist available to lead the inventory and disposal operation;

5) arrange a workforce to support the operation.

The assignment of tasks was also quite straight-forward: MOH would take care of the negotiations with the cement factory, obtain all the required authorisations, make trucks available, and MOH pharmacists would be overseeing the operation. MSF would be responsible for pharmaceutical waste supervision, while UNICEF would make a warehousing team from UNICEF Supply Division available to organize and supervise the logistics of the inventory, and SCMS would provide the daily labourers.

In practice the operation turned out to be quite complicated. Despite some delays, mainly in negotiations with the cement factory, the incineration capacity and the practical set up, the assignment of tasks was maintained and implemented accordingly. The inventory started towards the end of August, coordinated by the warehousing team from UNICEF, even though the incineration process itself had not been given final approval. A team of 20 workers started right away and managed to create space in the warehouse to allow for effective organization. It proved to be a complicated task, undertaken in very difficult working conditions, but by mid-October, the team had completed the job.

The results of the inventory demonstrate that international standards for volumes of expired medicines in a functioning health system were hardly exceeded; medicines had just not been properly disposed of during 5 or 6 years, and were piling up in a warehouse. Based on this experience, standard operating procedures, so called SOPs, have been updated and training is on-going at all the levels of the supply chain to ensure a proper inventory and disposal of expired products on a quarterly base.

The warehouse, that one year ago was full of expired medicines, is currently being renovated to host incoming shipments of badly needed fresh medicines.

Trying to keep the balance...©UNICEF Mozambique

March is a busy month for Ministry of Health and Partners. After a year of implementation, March is the moment of the performance evaluation. A team of consultants looks at the key indicators for the sector and comes up with a detailed analysis of progress and challenges during the previous year. Then, at one large meeting attended by the entire Ministry and all Partners, the final conclusions on the performance of the sector and the recommendations for the year ahead are presented and discussed.

Behind the scenes, on both sides, public health experts are busy crunching numbers, reviewing trendlines, assessing indicators, trying to make sense of it all, and preparing carefully crafted speeches. It is a busy and exciting moment that allows everyone to take stock of where the Mozambican health sector is going. Here are some of my personal impressions, ahead of today’s meeting, when the positions of Ministry and Partners will be officially shared and communicated to the press.

2011 has been a busy year in the health sector. It was the year of the big crises in the areas of drugs and financial management. It was the year of the vaccine derived polio outbreak in Zambezia and of the nationwide measles campaign. It was the year of the roll out of the new guidelines for PMTCT, of the universal access campaigns for bednets and of the big scale up in training for community health workers. 2011 has been a year of strong and open partnership between Ministry and Donors: despite the difficulties, or maybe, because of the many difficulties encountered, this year has greatly strengthened the spirit of collaboration between Ministry and Partners.

Undeniably, the performance evaluation shows weaknesses in the sector. They are mostly systemic in nature: the health information system is far from ideal and the reliability of administrative data is at times questionable; human resources in health, despite good progress in the year, are still well below the minimum requirements for a country like Mozambique; and the procurement and supply chain system, as well as the financial management system, persist as major bottlenecks to the development of a stronger sector.

On the service delivery side, in 2011 good progress was made on immunization and reproductive health. Lack of funding in malaria, still the biggest killer in the country, created difficulties in implementation of preventive activities. Gaps were also encountered in the TB program, where the case detection rate dropped below 2008 levels. Progress on HIV is steady, though more needs to be done to further reduce new infections and protect people infected by HIV.

In summary, this has been an eventful and difficult year characterized by systemic challenges, but supported by a transparent and constructive dialogue among health actors in the country. It is a good starting point to move into 2012, a year that will see, among other things, the results of the Demographic Health Survey, the finalization of the Health Sector Review and the preparation of the 2013-2017 Strategic Plan for the Health Sector. So, good bye 2011 and let’s take on 2012, a new exciting year of public health challenges in Mozambique!

By our new guest blogger, Kristine Dandanell Garn.

Have you ever heard of the importance of eating iodized salt to prevent iodine deficiency? If not, you are not alone!

Iodine deficiency is a silent plague. Only in extreme cases it will manifest itself in visible symptoms such as goitre, an enlargement of the thyroid gland. You do not feel an immediate effect on your wellbeing when you consume iodized salt. Still, globally, iodine deficiency is the single major cause of preventable mental retardation. Iodine deficiency in pregnant women causes miscarriages, stillbirths, and other complications and it prevents children from developing their full potential.

Hence, consumption of an adequate amount of iodine is essential for human development – both from the perspective of the individual and for the entire society. For this to happen, we may need to change our perspective when looking for possible solutions to this public health problem. Here is what we need to do.

Iodine is normally found in the soil and may thus be consumed via eating crops, dairy and meat. However, in many areas the iodine has been washed away, drastically reducing the levels of iodine in crops and cattle. Already in the early nineties, the Ministry of Health of Mozambique started a programme to prevent iodine deficiency disorders (IDD) and since 2000, Mozambique legally requires the iodization of all salt produced and imported for animal and human consumption. Many salt producers have been provided with iodine in the form of potassium iodate and some have received iodization equipment free of charge. Still, existing data show that two thirds of children between 6 – 12 years of age are suffering from IDD and only 25 per cent of Mozambican households consume salt with adequate iodine levels.

In order to get a better understanding of the challenges relating to the production of iodized salt, I visited several salt producers, so called salinas, in the coastal areas of Nampula province.

In Mozambique, salt is produced through a process of letting sea water into shallow basins and then leave the sun and wind to evaporate the water. The vast salt ‘fields’, desert-like landscapes where nothing grows, are often located far from the main roads. Under the mercilessly burning sun, barefooted workers continuously sweep the floor of the basins to keep the water circulating ensuring that the salt does not stick to the base but crystalize into rough grains.

Salt is a cheap product with a small profit margin. And, as could be expected, the persistent complaint that the salinas raised throughout my visit was not about the challenges in relation to ensuring proper iodization of the salt. Rather, their primary concern is the low price they get for their product. Especially, the small scale producers far from the main roads with no means of transporting or storing their salt told a tale of how they were at the mercy of the one or two retailers that would stop by their fields to buy their product.

Answering the ‘What’s in it for me’?

Now, why should we care about salt production being unprofitable for small scale salt producers in Mozambique?

Promoting iodization of salt is different from most of the work we do in UNICEF where our primary counterparts are from the public sector. Hence, a change of perspective is necessary: in order to promote the iodization of salt, we need to see the world through the eyes of a business person.

By engaging with the salinas and appreciating their concerns, we deepen our understanding of their situation and thus increase our chances of identifying solutions fitted to the local context. For instance, supporting the set up or strengthening of existing associations of salt producers may be an entry point to promote the proper iodization of salt. The associations could be supported to establish revolving funds which will allow them to procure and maintain a vehicle to transport the salt from the salt fields to a warehouse commonly owned by the producers. More importantly, the warehouse could also house equipment for iodization, as well as space for dry and cool storage which will reduce the level of evaporation of the iodine from the iodized salt. From the perspective of the profit hunting salt producers, this will allow them to wait for a retailer offering a good price for their product.

This and other models should, naturally, be developed and tested together with the salinas. The point is that iodization of salt, ideally, should be linked with supporting the business of producing salt, e.g. to promote conditions which will allow the salinas to negotiate a better price for their product. When working towards improving availability of properly iodized salt in Mozambique, we need to be able to answer the ‘what’s in it for me’ of the salt producers. Simultaneously, while stimulating the demand of iodized salt through awareness raising campaigns, the law on iodized salt should be enforced through regular inspections and punitive actions targeting the sore spot of any business person: the wallet. After all, salt production is a private business working towards improving profit margins – but it is also key in the fight against iodine deficiency in Mozambique. Let’s star t thinking business!

Alicia (WHO) and Luigi (UNICEF) enjoying a One UN moment during the health partners' workshop in Quelimane © E. Capobianco

A few weeks ago I went to Zambezia for a few days to participate in a health partners’ workshop followed by a planning meeting involving Provincial and District health authorities, NGOs and UN Agencies. The three days in Quelimane were full of discussions, discoveries and adventures. I will not dwell on the 12 hours delay of the LAM flight Quelimane-Maputo, that made me arrive home when the sun was rising and the kids were awakening to go to school(!). I will instead share a couple of thoughts that I had on Zambezia and the United Nations, while waiting for the plane…

Zambezia is the province with the worst social indicators in the country. It has the highest child poverty and child mortality rates in Mozambique. Only 26% of people in Zambezia have access to safe water and only 8% have latrines. The literacy rate in women is 27%, and 22% of girls under 15 are married. Zambezia is the province where the word “development” gains the meaning often lost in big debates far from the field. Development in Zambezia means saving thousands of life from preventable diseases, providing quality education to girls and boys, and protecting children’s lives from a future of deprivations.

Zambezia is why the United Nations exist. This March, four UN agencies (UNICEF, WHO, UNFPA and WFP) are starting a new 4 years project that has the potential to build a better future for children and adolescents in Zambezia. Twenty millions dollars, generously donated by Canada, will be used to strengthen emergency obstetric care, to provide equipment for neonatal resuscitation, and to promote breastfeeding and healthy nutrition habits in every district of the province. The funds will also be used to inform girls about their rights, to support them to say no to violence and abuses, and to protect them from the threats of AIDS, early marriages and unwanted pregnancies. In Zambezia, the United Nations and their partners have the unique opportunity to change the lives of a generation: for a development worker like me, there is no greater challenge, no higher ambition.

A picture of a mother with her albino daughter on the outer wall of the Fortaleza in Maputo. © E. Capobianco

This weekend I have been to a wonderful photography exhibition at the Fortaleza in Maputo. The exhibition, called “Filhos da lua”, or “Sons of the moon”, presents stunning pictures of children and adults affected by albinism. It is a powerful reminder of the discrimination that many albino people unjustly suffer throughout Africa.

For me, this exhibition has been a great opportunity to enjoy some beautiful pictures, to learn more about the discrimination affecting albinos and to appreciate the efforts made by the local NGO ADOD (Associação Defendendo os Nossos Direitos) to explain albinism to the general public.Albinism is a congenital disease that is transmitted from parents to children when recessive genes from mother and father combine in the child’s chromosomes. Albinos are normal people: they simply lack melanin for pigmentation of the skin, hair and eyes. Their white skin is particularly vulnerable to the effects of the sun and it requires high protection to avoid painful skin lesions and cancer. The eyes of albinos are very sensitive too, particularly to strong light, and do not provide perfect vision: corrective glasses and sunglasses can greatly improve albinos’ vision.

So, albinism is a disease like many others, with no cure yet, but with treatment that can improve the quality of life of affected individuals.

However, one of the biggest side effects of albinism, particularly in Africa, is discrimination. All sorts of myths surround albinos and this exhibition defies some of the most common:

• Albinism is not contagious;
• Albinos do not disappear with thunderstorms;
• The blood of albinos or they organs are not suitable for black magic;
• When an albino dies, s/he does not vanish;
• Giving birth to an albino child is not bad luck and it does not constitute nor relate to works of darkness;
• Cursing and discriminating against albinos does not mean that one is going to bear albino children;
• There is no scientific evidence that seawater has any positive effects in treating albino skin.

“Filhos da lua” is a beautiful exhibition which will sensitize anyone who will visit it. The images are moving: there are albino kids with light and joy in their eyes, muscular strong men and graceful dancers, women with their faces damaged by the disease, children smiling at school and families united beyond the color of their skin. In those pictures, in those lives, there is love, dignity, courage, all mixed with a great deal of pain.

By all standards, this is a worthwhile exhibition, open until March 31 at the Fortaleza in Maputo. If you have a chance, don’t miss it!

Happy meal...for free! © UNICEF Mozambique

The last post focused on Mozambique’s renewed efforts to tackle undernutrition and particularly stunting. The country is committed to intervene in the first 1,000 days of life, from conception to two years, in order to reduce the stunting rate among children under 5 from 44% to 20% by 2020.

In the comments section, Barbara from Save the Children rightly pointed at breastfeeding as one of the most effective weapons to reduce undernutrition in children. Breastfeeding is indeed one of the simplest interventions to save children’s lives. Yet, many women and children in Mozambique seem to miss out on such a simple, powerful intervention.

Breastfeeding is natural, essential to strengthen the baby’s immune system, and to reduce the risk of infections. It is important for bonding, and it also has beneficial long term health effects for the mothers (e.g. less breast and ovarian cancer). In the video at the end of this post, UNICEF Deputy Representative, Roberto De Bernardi adds the important economic benefits of breastfeeding. It is completely free: an enormous additional advantage for poor people in low income countries, like Mozambique.

Despite all benefits of breastfeeding, data from the 2008 MICS in Mozambique indicate that less than half of the children 0-3 months are exclusively breastfed. The percentage of children benefiting from the precious “leite do peito” further decreases with age: at 5 months, only 16% of children are exclusively breastfed. There are many reasons behind this refusal. Some are cultural (For example many women believe that the first milk expressed, the highly nutritious colostrum, is not good for children. Many others believe that little children need water of solid food.) Some reasons are linked to low capacity for support by care providers, in communities or hospitals. Lastly, breastmilk is in a fierce competition with formula. For decades the powder milk industries have irresponsibly putting children’s lives at risk by placing their products in markets where knowledge about the benefits of breastfeeding is low.

It was therefore very refreshing to see the video below aired by the Mozambican National Television on February 14. Valentine’s Day is all about nurturing, protecting and building a future with your loved ones. By those standards, breastfeeding may possibly be the greatest act of love.

PS: If you like to know more about knowledge, beliefs and practices about breastfeeding in Mozambique, please check out this article by UNICEF Nutrition Specialist, Maaike Arts.

http://www.youtube.com/watch?v=liWusH5hxK8

Preparing a meal ©UNICEF Mozambique

Last week, UNICEF Executive Director Tony Lake wrote a brief, yet powerful Op-Ed on the less known type of malnutrition called “stunting”. Stunting is the irreversible outcome of chronic nutritional deficiency during the first 1,000 days of a child’s life, i.e. from conception up to their second birthday. Stunted children look like “normal” children, but they are shorter than children of the same age. They are five times more likely to die from diarrhoea; and their brain development is impaired: the neurons of a stunted child are in fact fewer and smaller. The physical and cognitive damage caused by not receiving enough of the right type of nutrients in the first 1,000 days of life is permanent. It cannot be treated. But it can be prevented in these first 1,000 days– and at relatively little cost. A cost that is far below the economic and social benefits of its prevention.

Worldwide there are 180 million stunted children: 1.7 million live in Mozambique, in poor and richer households. In this country, stunting affects 44% of children under five and, surprisingly, prevalence does not vary much across wealth quintiles. These data threaten the future of Mozambique: a generation of children stifled in their cognitive development will translate into an adult population with lower productivity, and lower wages. The end result will be lower GDP growth, and perpetuation of poverty.

This dark prospect can be avoided and Mozambique is moving in the right direction to ensure a brighter future to the nation. Effective interventions are cheap and at hand: vitamin A and therapeutic zinc supplementation; deworming; fortification of food staples with essential micronutrients – iodized salt and iron-; prevention and treatment of malaria; community based nutrition promotion, particularly on breastfeeding and complementary feeding.  The challenge ahead is to rapidly scale up all these interventions throughout the country. In September 2010, the Council of Ministers approved a Multisectoral Action Plan for the reduction of Chronic Undernutrition, which aims to reduce stunting from 44% to 20% by 2020. The goal is ambitious but the future of a nation lies on it. There is no bigger incentive to translate the plan into simple, yet vital interventions that should reach young children and pregnant women in every Mozambican household.

"Rociadores" in Marracuene, resting after spraying a house against mosquitoes ©E. Capobianco

In the past ten days I have been travelling a lot across Mozambique. I have been in Gaza Province to take a look at the APEs program and to quickly assess the impact of the cyclone Dondo. I have been to Marracuene, in Maputo Province, to check Indoor Residual Spraying against malaria and to see more training of APEs. I am now in Zambezia, to discuss with the Provincial Director and his Team how to plan for the implementation of a USD20 million CIDA-funded project that the United Nations will implement in the next 4 years.

These days looking at UNICEF work and interacting with people in the field have been priceless. They showed me the distance between paperwork and reality, between dry statistics and people with faces and feelings. I have seen a lot, I have listened as much as possible and I have tried to put myself in the shoes of the people I have met. Above all, I have learnt some lessons that cannot be easily learnt staying in an office behind a computer.

LESSON #1: SOCIAL COMMUNICATION IS NEVER ENOUGH

During our visit to the team of “rociadores” who were spraying villages with DDT, one house at a time, we saw that the rate of refusal was very high: up to 30% of households were refusing to have their walls sprayed, thus considerably increasing their risk of contracting malaria. It always amazes me to see people refusing a lifesaving intervention. Yet, I just need to stop to a McDonald’s or in a smokers’corner in the West to realize that human beings are not always rational in their behaviours. In Marracuene, people were refusing spraying because “it would create cockroaches”. Indeed the spraying kills the mosquitoes but not the cockroaches that emerge from their hidings when houses are fumigated. We spoke to the social mobilizer in the team and he seemed quite comfortable with the reasons put forward by the villagers. He was not ready to challenge the opposition to the spraying and somehow he was not protecting his villagers from the threat of the biggest killer in Mozambique. This encounter made me once again realize how easy it is to forget the importance of social communication for the success of public health interventions. There’s little hope without it!

LESSON #2: ROAD SAFETY, A FORGOTTEN PRIORITY

On our way to Guija’ we saw branches in the middle of the street, the unmistakable African sign of an accident ahead. A damaged car had just parked on the side of the road and a woman was lying in the middle of the street. The UNICEF driver stopped the car. My colleague Barbara from Save the Children and I jumped down to assist the poor woman who had been hit while crossing the road. We tried to take her pulse but she had already passed away. We left her there, curled in a foetal position in the middle of the street, her eyes wide open and her purse still lying on her side. That accident was a stark reminder that Mozambique has one of the highest road fatality rates in the world. And that road safety has still to climb up as a top public health priority in many African countries.  

LESSON #3: NEVER UNDERSTIMATE THE POWER OF THE BELLY

In a meeting with the trainees of the APEs program in Guija’, one student raised her hand, stood up and looking at us said: “Alegria vem da barriga!” (Happiness comes from the belly). Virginia was complaining about the low stipend for the trainees and about the poor quality/quantity of the food being served during the four months long training. She said her words with a large smile on her face and made everybody laugh (NB: Her “barriga” was pretty big, sign of a certainly happy woman!). Even when they are angry and complaining, Mozambicans are of a wonderful nature.

A CHW in Guija checks a baby for pneumonia by counting the number of breaths per minute ©E. Capobianco

Jeffrey Sachs recently wrote an interesting article titled “Breakthrough in Saving Lives in Rural Africa”. The article is about the new wave of community health workers (CHWs) that is rapidly moving across Africa, saving thousands of lives in many countries. CHWs come from rural communities, have local knowledge and can reach vulnerable individuals and marginalized groups providing life saving interventions. Sachs calls for a scale up of mass training and deployment of CHWs and makes the argument that the Global Fund and leading pharmaceutical companies should finance CHWs’ deployment across the continent.

On January 19, Luigi, two colleagues from Save the Children, and I travelled to Guija’, in Gaza Province, to review how the CHWs Program in Mozambique(called the APEs program) is functioning. We saw a training center where 20 new APEs were being formed and we spent time observing and talking to one APE operating in a remote village. The visit strengthened my conviction that Mozambican APEs are a major weapon to reduce child mortality due to malaria, diarrhea and pneumonia. It also made me think of what needs to be done to make this program truly successful in Mozambique. Here are my thoughts.  

APEs are not new in the country. They were first introduced in communities back in 1979. They were severely affected by the war, but they were re-instated in 1989 under a program sponsored by the Swiss Development Cooperation. APEs were also trained by the Red Cross and known as “socoristas”.

In 2010 the Ministry of Health launched a new strategy to revitalize the program and since then more than 1,200 new APEs have been trained. More than 200 are already operating and the rest will complete their training in the next few months. The expansion plan includes training of additional 1,300 in the next couple of years.

This progress is incredibly positive, but there are challenges ahead. The first one is maintaining and further strengthening the political support for the program. The APEs have the potential to change Mozambique forever: the open support by the Prime Minister or the President would be very important at this critical stage.

Second, international partners financing the program need to commit to support APEs for the medium/long term, securing resources for the next five years. Five years are needed to produce tangible results and progressively built sustainability into the program. Closing the tap now or next year would be detrimental for a young program, that requires time to grow.

Third, the Ministry of Health and technical partners need to work together to get the program right on the technical details: ensuring that drug kits are delivered on time; maintaining a high level of supervision for APEs; and further improving training tools are all essential components for a successful program.

If all of the above will happen, I am convinced Mozambique will indeed be a leader of the revolution that the CHWs have initiated all over Africa.