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Nursing and Nursing Education in Mozambique from Michele August-Brady

At what levels can a person get a nursing degree in Mozambique? How many years does it take to become a nurse at each nursing degree level?

There are several levels of nursing based on the amount of education. The lowest level, elementary nurse, will gradually be phased out.

    • Elementary Nurse
      These nurses are educated to the 7th grade level and have eight months of additional training. They are 15-17 years old, they practice primarily in rural settings, in health centers or health posts (out-patient clinics). Their responsibilities are comparable to our PCAs. They bathe, dress, feed, take vital signs. Their salary is less than US $100 per month.
    • Basic Nurse
      These nurses are educated to grade 10 and apply for additional training of 18 months. The majority of nurses practice at the basic level. Salary of basic nurses is less than US $200 per month.
    • Medium Nurse
      Previously, these nurses were educated to grade 12, but the Ministry of Health reduced the education requirement to grade 10 in response to the physician and nursing shortage. These nurses have an additional two and a half years of training.  Nurses are able to specialize in their training once they are medium nurses. Their salary is US $250-260 per month. Medium nurses may become “principal” nurses after 10 years of work experience and good performance evaluations. Mozambique hopes to raise the level of nursing throughout the country to the medium level.
       
    • Superior Nurse
      These nurses are educated through grade 12, then enter university for four years to earn a baccalaureate degree. A thesis is required. An examination is given by the university and this earns the licensure as a nurse. It was started in Maputo (Instituto Superior de Ciencias Saúde) in 2004, and the first class had 28 graduates in 2008.  Their salary is US $450-500 per month. Because this is very new, the Ministry of Health has assigned each graduate to rural health area where the need for health services with more skilled and educated nurses is quite strong. Another university started offering a four-year degree in 2006, but those students have not graduated. We believe that this is Catholic University in Beira, Mozambique.  
       

Is nursing licensure required? 

 

Left to right: Dr. Lori Hoffman, two Mozambican nursing students (names unknown), Dr. Michele August-Brady, and Dr. Maria Schantz

Licensure is only required at the superior level along with an examination upon graduation. However, this is not linked to any continuing education. It is not known at the current time whether licensure renewal is built into this system, although our thinking is that it is not.  

Is there an organization or group that oversees standards for nursing practice?

There is considerable discussion in Mozambique among ANEMO (the Mozambican Nurses Association), the Ministry of Health and nurses about whose responsibility it is to be the voice of nursing and to regulate the nursing profession. This topic of discussion is likely to continue over the next year as ANEMO becomes stronger and seeks to establish itself as the professional voice of nursing in Mozambique.

In order to more thoroughly understand the educational system in Mozambique, the following information may be helpful to the readership. The Ministry of Health determines the curriculum and scope of practice for nurses. There are job responsibilities linked to each level of nursing. Students do not pay for their nursing education up to the medium level. This is provided by the government.  Education past the medium level is the responsibility of the student. Scholarships are needed for this additional education. The cost of education is free in Mozambique only up to grade 7. After this level, education costs money. Many Mozambicans are educated up to grade 7 but cannot afford additional education due to cost constraints. Nursing education is made especially attractive in that the government pays for it, and nurses are readily hired into health care positions.  

The Ministry of Health determines where the health care needs are the highest and it is responsible for assigning nurses and physicians to specific areas. It is also responsible for terminating employment. Termination of nurses is a long, bureaucratic process and may take many months.  

The medical doctor’s salary starts at US $600 per month and may increase to US $1,000. Those  physicians earning closer to US $1,000 are often the

A moment of levity with Mozambican nurses who work at the Provincial Hospital in Maputo, Mozambique. Front row from left to right: Drs. Maria Schantz, Michele August-Brady, Lori Hoffman.

central hospital specialists. Oftentimes, physicians (and nurses) have extra work in private health care settings (known in Mozambique as medical clinics) which supplements their income. They are employed by the government. There are about 600 MDs in Mozambique. The population of Mozambique is 20 million which makes the ratio one physician for 30,000 patients. Currently, physicians are leaving Mozambique and entering other African countries and other nations where the salary is higher. Because the education of physicians is in English, Mozambican physicians have greater mobility due to the language. Nurses are currently educated in Portuguese and, as a result, have less job mobility within Africa. They are unable to take advantage of educational material in English, relying on resources from various Portuguese-speaking countries such as Brazil, Angola, and Cote d’Ivoire.

The Ministry of Health developed a new health care member to help medium level nurses called an attendant.  Because of the medical and nursing personnel shortage, there is a shifting of physician responsibilities to medium nurses such as prescribing certain medications. This has resulted in a much greater nursing workload. On average, in the capitol of Maputo, one hospital-based nurse has a workload of 60 patients. The attendant is then responsible for many non-patient care activities.

How many nurses are there in Mozambique? 

There are approximately 4,000 nurses in Mozambique. Because nursing is regulated by the government, it is considered a government job, and salaries are controlled at that level. There are approximately 2,500 nurses who are members of ANEMO, but the majority of these nurses do not pay the organizational dues of US $1/month. This is one of the many issues that ANEMO is dealing with as it seeks to build itself into a viable nursing organization.

 What are other characteristics of nursing, like average age of the nurse, common work places, specialty areas of nursing?

Some information was not clearly discernible from this initial visit to Mozambique. At times, the same question was answered very differently. We are not certain about the average age of the nurse in Mozambique or age in reference to levels of nursing. We do know that approximately 17% of Mozambican nurses are HIV positive.

Because health care is socialized, nurses are assigned to work in one of several types of health care institutions. The following is the hierarchy beginning at the most prestigeous:

    • Central Hospital
      There are three in Mozambique (Maputo, Beira, Nampula). These offer top level of care with specialists and tertiary care system. Nurses can only get work here through referrals.
    • Provincial Hospital
    • General Hospital
      There are three general hospitals in Maputo and one in Beira.
    • Rural Hospital
    • Health Center
      There are three types depending on the number of beds.
    • Health Posts
      These are the most geographically remote.  

Elementary nurses work health centers and rural hospitals. Typically, consumers access the lowest level of health care, and as need is shown, consumers are referred up the chain. Because the need for health care services is so great in the remote areas (health posts and health centers), the Ministry of Health has assigned all 28 recently prepared baccalaureate nurses to rural posts. 

The image of nursing is often not positive. Physicians view nurses as handmaidens and tend to be authoritative. Some nurses view other nurses negatively, and there seems to be some horizontal violence between the levels of nursing practice. Society views nursing in negative terms because there is little distinction between nurses and ancillary positions. Media uses the term “nurse” for many of these ancillary positions. There seems to be some corruption and theft by these ancillary workers, but the media publishes the theft as that done by nursing when this is not the case. As a result, the public remains highly confused. All levels of health care providers wear white, including hospital directors, directors of nursing, etc. There seems to be greater gender equity in Mozambican nursing with male nurses up to 50%.

What are the current issues and challenges related to nursing and what is being done to address each of these issues?

Mozambican nurses face considerable challenges. Many of those challenges are related to poor infrastructures (no electricity, no computers, transportation challenges, etc.) and lack of resources (financial, human). Mozambique is in difficult economic times. Of 20 million Mozambicans, only 60,000 of them pay taxes. The unemployment rate is about 58%. This has improved from 30 years ago when the unemployment rate was close of 90%. Progress is slow and needs are great. 

One of the major challenges currently within nursing is the viability of the ANEMO. In order to be the professional voice for nursing in Mozambique, this organization needs to figure out a way to sustain itself, to attract members and professional dues, to offer a service to Mozambican nurses.  This challenge in part is being met with partnerships between the United States and Mozambique in the area of capacity building and program development. These partnerships have received federal funds. ANEMO is trying to determine what model might be most appropriate for them and how best to interface with the Ministry of Health. Nurses voiced their desire to connect with each other, internally within their institutions where they worked and externally with other professional nurses.

 

 

 

 


In front of the Hotel Avenida in Maputo, Mozambique. From left to right: Kim Bohince (American International Health Alliance – Twinning Center representative) with Dr. Lori Hoffman, Dr. Michele August-Brady, and Dr. Maria Schantz (St. Luke’s Hospital School of Nursing at Moravian College).

The education of nurses and the advancement of education for nurses is a major challenge. “Train the trainer” programs were initiated to educate nurses as “master trainers” who would work with those providing home care for patients with HIV/AIDS in remote rural areas of the country. There needs to be a critical mass of nurses who are able to do this.  However, this costs money which adds an additional burden for nurses who have trouble making ends meet now. 

There are four nursing schools in the country that provide education for the medium nurse. They are located in Maputo, Beira, Nampula, and Quelimane. Each of the 11 provinces has a training center. One of the greatest needs now is to update curriculum from basic level to medium level and implement it country-wide in an attempt to increase the level of nursing education that currently exists. Nurses also expressed the desire to improve access to superior nurse programs as there are so few programs and students admitted to those programs. Currently, there is no university in Mozambique that offers a masters degree in nursing.  The Catholic University in Maputo offers a four-year baccalaureate degree in nursing. As a result, nursing may lose some individuals who have recently obtained their baccalaureate degree in nursing to other disciplines offering graduate degrees. Also important to note is that to receive nursing education for advanced practice or specialization, nurses had to leave Mozambique for programs in other parts of the world. This, the nurses said, is disruptive to families and expensive to do; nurses wish to become more skilled and knowledgeable through programs in their own country.

NOTE: The information was obtained on a brief five day visit to Maputo, Mozambique. This assessment visit is part of a grant from the American International Health Alliance Twinning Center aimed at capacity building of ANEMO. The faculty members listed below participated in the initial assessment visit and may be contacted at the respective email addresses. It is anticipated that additional information will be available and these notes will be appropriately updated as this project continues. 

Michele August-Brady, RN, PhD  augustm@moravian.edu 

Lori Hoffman, RN, PhD  lorihoffman@moravian.edu         

Maria Schantz, RN, PhD  memls03@moravian.edu

 
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