A Look Back at Mozambique's Life-Saving Training Program

How Mozambique's Medical Officer Program Created a 'Culture of Response.'

Carrie Carnevale & Catherine Witherspoon | January 2018 

Provincial Medical Officers during the two-week training, supported by CDC and IANPHI.


A request for help may not seem like a milestone in strengthening a public health system, but when a cholera outbreak hit the Tete Province in early 2017, the request represented a significant step forward for Mozambique.

In 2016, Mozambique’s National Institute of Health (INS) held a training with the goal of improving public health through the country’s provincial health leadership’s ability to protect the health of Mozambicans. The training targeted the Provincial Medical Officers (PMOs), who are the equivalents of chief medical officers in Mozambique.

Mozambique has one PMO in each of its 11 provinces, including the city of Maputo. This provincial-level role is second only to the Provincial Health Director. The PMO is responsible for reporting public health information from the local level to the national level, coordinating public health responses at a provincial level, and implementing public health interventions. Many PMOs have only a few years of clinical experience and may have a limited understanding of public health concepts and skills critical to their role in disease surveillance.

According to INS Director Dr. Ilesh Jani, the lack of public health knowledge at the provincial level led to inaction in past outbreaks and caused an overdependence on national-level support.

Dr. Stélio Dimande, a PMO from the Inhambane Province was appointed to PMO without any prior outbreak investigation experience. “In 2008 or 2009, there was an outbreak of cholera, and at that time I did not know how to deal with the outbreak, I just heard from my colleagues what should be done,” he explained. He saw value in attending the training and subsequently put what he learned into action.

Three months after I took the course, we had a diarrhea outbreak. The team was assembled very quickly, and everything that was taught to me during the course was put into practice.

Dr. Stélio Dimande, Inhambane Province PMO Dr. Stélio Dimande

Due to Mozambique’s demographic and epidemiological shift, it’s imperative that PMOs and other health professionals are trained in early detection, outbreak management, and response utilizing epidemiological tools.

In 2016 that idea became a reality. 

Cynthia Semá Baltazar, Head of INS’s Surveillance Department, said the idea of the training was to develop a “high-level, intensive training to give [PMOs] real, practical tools for real topics,” in order to strengthen surveillance capacities, investigation, and rapid response to outbreaks and health-related emergencies at provincial and district levels. 

With support from the International Association of National Public Health Institutes (IANPHI) and the U.S. Centers for Disease Control and Prevention (CDC), INS developed the Epidemiology and Leadership course in collaboration with the Direção Nacional de Saúde Pública/National Directorate of Public Health and long-time technical assistance partner and program facilitator, the Associação Brasileira de Profissionais de Epidemiologia de Campo/Brazilian Association of Field Epidemiology Professionals

During the two-week workshop, participants learned how to think critically during an outbreak, rapid reporting, surveillance evaluation, and field investigation. They also learned about the role of laboratory, biosafety, and bio-protection during outbreaks and emergencies, health communication, leadership, and drug supply chain management.    

After the program, many PMOs noted that their previous understanding of outbreaks was incorrect. According to Baltazar, “Some of the PMOs thought they knew how the outbreak investigation worked [before the training], but during the training, they realized that they didn’t and that they weren’t reporting correctly.”

To say the training was a success is an understatement.

Three months after the training, an outbreak in the Inhambane Province demonstrated the value of the workshop. The difference following the training.

According to the Inhambane Province PMO Dr. Stélio Dimande -- the difference in response was notable. “Three months after I took the course, we had an outbreak of diarrhea,” said Dr. Dimande. “The team was assembled very quickly, and everything that was taught to me during the course was put into practice.” 

Epidemiologists from the Brazilian Association of Epidemiology Professionals (ProEpi) facilitated the training. ProEpi is a long-time partner of INS in Mozambique.

A series of cholera outbreaks in early 2017 showed further evidence of the impact of the workshop. In the Tete Province, after an outbreak risk assessment, an application was submitted to the International Coordination Group (ICG) for 709,077 doses of the oral cholera vaccine. The implementation of a vaccination campaign demonstrated an improved understand of the PMOs role in outbreak investigation, response, and intervention.

This improved confidence and public health understanding has helped provinces become more “autonomous and take more responsibility for outbreak investigation,” Dr. Jani said, “creating a culture of responding.”

Moving forward, IANPHI and CDC will help to build upon the PMO training through support for additional training at the provincial and national levels. All of this will contribute to developing a high-performing disease monitoring system, which works in collaboration with INS to detect potential health threats from the provincial level up.

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