Eulalia Laichela caressed her six-year-old son, Leosio, who lay on the pavement, coughing from beneath a blanket. They had been waiting in the park outside José Macamo, one of the largest hospitals in Mozambique's capital Maputo, since early morning.
Laichela hoped her sister-in-law, who works at the hospital, would help find a doctor to attend to Leosio before the end of the day. Waiting in the queue at the hospital's reception area was not an option, she said.
"If you don't have extra money to pay the doctor, there is no point in doing that. There are many people outside waiting, and they sit there hour after hour without being attended to," she told IRIN.
Ansina was among the patients waiting in the queue. She feared she had malaria but lacked family connections or money for a bribe. "Something is wrong. I have number 142, and they are calling 188. I have been waiting here since this morning," she complained to the man next to her. He told her that it is patients’ money that determines who goes first, not their medical conditions.
"That´s why we are still here," he said. Ansina agreed.
Corruption is rife in Mozambique's public health sector. According to a 2006 study by the Centre for Public Integrity (CIP) in Maputo, corruption is present at all levels in the system: from the reception to the laboratory, during appointments with doctors, and even at the morgue.
A 2011 regional household survey by Transparency International found that nearly 40 percent of Mozambican respondents had paid bribes for medical services in the past year - the highest such figure in the region. In Mozambique, it was second only to the percentage that had paid bribes to the police.
The CIP study identified low salaries as one of the main causes of health sector corruption. A doctor identified as Cossa*, who has worked at hospitals in Maputo over the last 18 years, agreed. Doctors earn between US$700 and $1,000 per month, and the lowest paid nurses earn just over $100 - no more than a domestic worker.
Cossa maintained that most bribes are paid to the nurses and other workers who see patients before they reach a doctor. But he added that doctors earn additional income in other ways. For example, most public-sector doctors also work at private clinics; according to the CIP study, this makes them chronically tired. The study links the deterioration of public sector health care to a 1998 government decision to allow public-sector doctors to also work in the private sector.
Cossa noted that by 10am, the majority of doctors have already left the city's public hospitals for their private-sector jobs.
|We chose this profession in the first place because we like to help people who are ill, but our government does not prioritize health care|
"This is a well-known fact, but the ministry has chosen to look the other way," he told IRIN. "They cannot punish the doctors or demand that they be present at the hospitals full time if they don´t provide them with decent salaries and decent working conditions."
Cossa recently stopped practising medicine to take a better paid NGO job. He estimated that around 30 percent of doctors in the country now work for NGOs.
"If the ministry gave us better conditions, I am sure that almost all of us would return," he said. "We chose this profession in the first place because we like to help people who are ill, but our government does not prioritize health care. If you work at the customs, you earn five times more than a doctor."
The CIP study also highlighted the widespread theft of medication and equipment from public hospitals for use in private clinics. The theft is often well organized, with the clinics contracting public-sector employees as suppliers. Stolen or illegally purchased medicine is also sold in food stores and markets throughout the country.
Toward a solution
Ana de Lurdes Cala is the director of the Department of Quality and Humanism, a new unit at the Ministry of Health that opened two years ago to improve patient care at hospitals and health posts.
"The most common complaints we receive are bad treatment, illicit charges and long waits in the queues," said Cala.
|Of course a doctor should never accept a bribe ... but that is a common human error|
The department is tasked with establishing committees of civil society, local and religious leaders as well as patients to address these issues. The department also arranges workshops at hospitals where the rights and obligations of employees are discussed.
"Our first annual follow-up meeting showed that bribes are diminishing, but you must remember that this is not a problem you can change overnight, it is a long process," she told IRIN. "Our goal is to put an end to illicit charges, not only to diminish them."
One of the difficulties, according to Cala, is that patients are often reluctant to identify those who have requested bribes. Health workers caught taking bribes could face public denouncement and salary deductions while employees caught stealing or selling medicine could lose their jobs. However, they are not reported to the police.
"It is not our role to report these cases to the police; our role is to work with the attitudes of our staff," said Cala. "Many times the patients don´t help when they pay doctors to get better treatment and then say that the doctors claim bribes. Of course a doctor should never accept a bribe ... but that is a common human error."
*not his real name