When aiming for dialogue with the community, the health sector in Mozambique refers to those on the other side of the conversation using various names: beneficiary, patient, health user, citizen. These descriptions are loaded with meanings that reflect and express the nature of the power relations between the sector and its primary discussion partner, the citizen-health user. As these descriptions change, power relations between the two also shift. This critical concept is at the centre of the policymaking cycle for health yet is seemingly ignored resulting in policy that fails to incorporate the voices of the community it seeks to serve.
Where are the citizen-users in the National Health Service?
What if the community, the individual, the citizen doesn’t participate in the health system at all? This question has unique potential to bring about significant changes to the paradigms that govern the Mozambican health sector.
The health sector is not currently giving communities a voice. It is vital that it re-articulates participation and citizenship as concepts that give these community actors the leading role. The challenge lies in each actor within the value chain of health service provision understanding and recognising the key roles they need to play in order to reach a more inclusive narrative and the consolidation of more holistic health practices. In other words, the crux of the matter is bringing these actors into the rethinking, the re-articulation and the restructuring of the health system in an holistic way.
Mozambique’s health system is limited by a hierarchical system that views citizen-users as the passive masses with no agency, instead of interested parties with the potential to contribute. It is preventing them from participating in the definition of the most basic aspects of their health. In order to considerably increase the active participation of citizens, it is necessary to think of health not as a process or a service, but as a right. To achieve results and meet globally-defined goals, it is vital that health service actors centre the citizen-health user and rethink participation as a tool to reach a holistic vision of health.
This perspective challenges us to recognise the limitations of current vertical and centralised models. It also highlights the need to come up with more practical organisational models that have horizontal narratives and that place the citizen at the centre of investment, remembering of course that the citizen is not just the user but the healthcare provider as well. There is a false dichotomy between user and provider which leads us to forget that the provider also plays a part in the chain. The Mozambican health system is quite fragmented which makes it even more difficult to consider the thought of engaging everyone in health.
Towards a more holistic health system
There are some interesting initiatives and models that focus on engaging the citizen-health user in the making and monitoring of public policy, and in the provision of health services. These have been implemented by civil society organisations with promising results. Mozambique has turned itself into a testing ground for approaches to participation, engagement and accountability, applying tools such as social audits for the health sector, budget tracking, monitoring the quality of health services for citizens, the use of the community scorecard, the citizen report card, user satisfaction surveys, public hearings among others.
In this early phase, the question is how can we generate knowledge and learning that can take these timely initiatives forward and scale them up, developing evidence that can provide a route to a more holistic health system? Although these citizen-health user engagement experiments are localised within the country, and are in their early stages, they can vocalise and capitalise on universal concepts that allow citizens to believe that they have the voice, rights, duties and the potential to participate in both the formulating and monitoring of policies, and in the provision of health services. Institutionalising these models would be one way to scale up and encourage adoption at all levels.
Constant and critical reflection on participatory practice cannot be abandoned otherwise we will continue to have a health system that leaves many people behind. However we have to recognise that the process of institutionalising participatory mechanisms may itself end up at the mercy of the power relations which characterise our health system, where the most organised are favoured and the least organised and most vulnerable are excluded.
The institutionalisation of participation also means promoting the inclusion of a series of new actors in the health debate, increasing their ability to raise grievances, and their responsibility over the definition of health-related issues. Public policies shouldn’t be initiatives reserved to policy makers only, but should be the product of discussion between social actors with a diversity of interests and needs. We need to flip the logic of the salvationist approach to health, and aim for an effective inter-sector and multi-sector understanding of health.
Denise Namburete is Executive Director of N’weti Health Communication. This is the third in a series of blogs written by Denise based on her research for Unequal Voices. In this series, Denise delves into some of the challenges that the national health system in Mozambique faces, from the lack of a common health agenda which is mostly externally-driven and the lack of accountability of international actors, to the absence of participation by the citizen-user in the health system.