The Global Gag Rule (GGR) cuts deep into sexual and reproductive healthcare in Mozambique

A HIV test being administrated in a rural village

“They call us ‘Muhanyisse’”, it means saviour in the local language, Shangaan, says Albertina Machaieie, a nurse working with Amodefa, the Mozambican Association for Family Development.

For 19 years, Machaieie and her team of activists – volunteers who are HIV positive, have been visiting communities in the poorest suburbs of Maputo, bringing healthcare to those with HIV and raising awareness about the disease. This year they provided medical check-ups, treatment, food, and counselling, to more than a thousand families living with the virus.

But the continuation of the home care programme and other vital health services Amodefa offers in Mozambique are under threat following the reintroduction of the Global Gag Rule. The Global Gag Rule, or Mexico City Policy as it is formally known, stops US aid to all health programmes run by organisations who perform or counsel on abortion.

The decision, which will deprive Amodefa of $2 million, 60% of its budget, will have devastating consequences for the fight against HIV in Mozambique, where an estimated 12% of the country’s nearly 30 million population are living with the virus.“We estimate half million people across their HIV, tuberculosis, malaria and family planning projects will be affected,” says Santos Simione, the executive director of Amodefa, from the NGO’s headquarters in Maputo.

  • Talking about the impact of the Global Gag Rule, Executive Director of Amodefa, the Mozambican Association for Family Development, Santos Simione says, “We estimate half million people across our HIV, tuberculosis, malaria and family planning projects will be affected."
    Talking about the impact of the Global Gag Rule, Executive Director of Amodefa, the Mozambican Association for Family Development, Santos Simione says, “We estimate half million people across our HIV, tuberculosis, malaria and family planning projects will be affected."
  • A client being tested for HIV.
    A client being tested for HIV.
  •  21-year old Jenny Marcelino* and her three-year old son wait for free counselling, tests and treatment at the Amodefa clinic in Maputo.
    21-year old Jenny Marcelino* and her three-year old son wait for free counselling, tests and treatment at the Amodefa clinic in Maputo.
  • Palmira Enoque Tembe, 54, is HIV positive. She lives on the outskirts of Maputo with her two sons (also HIV positive) and four grandchildren. Amodefa volunteers visit three times a week and a nurse once a week who provide medication, food and therapy to the family.
    Palmira Enoque Tembe, 54, is HIV positive. She lives on the outskirts of Maputo with her two sons (also HIV positive) and four grandchildren. Amodefa volunteers visit three times a week and a nurse once a week who provide medication, food and therapy to the family.
  • Albertina Machaieie has been working with HIV patients for Amodefa for 38 years and is their longest serving nurse. Albertina now heads up Amodefa’s home care programme which provides medical, nutritional and emotional support to HIV positive patients living in the poorest suburbs of Maputo. longest serving nurse. “I’m going to work forever,” she says. “I like helping people, that’s why I do this job.”
    Albertina Machaieie has been working with HIV patients for Amodefa for 38 years and is their longest serving nurse. Albertina now heads up Amodefa’s home care programme which provides medical, nutritional and emotional support to HIV positive patients living in the poorest suburbs of Maputo. longest serving nurse. “I’m going to work forever,” she says. “I like helping people, that’s why I do this job.”
  • Palmira Enoque Tembe with Albertina Machaieie. “Amodefa counsels me through the difficulties in life,” Palmira says. “They help counsel me though my problems, my thoughts and worries. Sometimes I don’t know what to do when things get out of control, but Amodefa helps me through.”
    Palmira Enoque Tembe with Albertina Machaieie. “Amodefa counsels me through the difficulties in life,” Palmira says. “They help counsel me though my problems, my thoughts and worries. Sometimes I don’t know what to do when things get out of control, but Amodefa helps me through.”
  • 12 year old orphan Antonio Junior Xirindza* who is HIV positive, was almost given up as as lost cause. He has gained a new lease on life following Amodefa’s intervention. His health has improved rapidly and he is gaining weight. He is well enough now to attend school regularly and is already thinking about the future; when he grows up he wants to be a fireman. “I am happy about life here,” he says, shyly.
    12 year old orphan Antonio Junior Xirindza* who is HIV positive, was almost given up as as lost cause. He has gained a new lease on life following Amodefa’s intervention. His health has improved rapidly and he is gaining weight. He is well enough now to attend school regularly and is already thinking about the future; when he grows up he wants to be a fireman. “I am happy about life here,” he says, shyly.
  • 18 year old Yuran Nhaquila* gets a HIV test at the Amodefa clinic in Maputo.
    18 year old Yuran Nhaquila* gets a HIV test at the Amodefa clinic in Maputo.
  • Nurse Julia Suzette Mulambo* administers hormonal contraceptive injection to Eleria Horacio Mabucule.
    Nurse Julia Suzette Mulambo* administers hormonal contraceptive injection to Eleria Horacio Mabucule.
  • Aida Carlos Cossa, 17, is a student at the Armando Emilio Guebuza secondary school in Maputo. She has come to Amodefa’s clinic for free counselling at the “Tua Cena” at Armando Emilio Guebuza School in Maputo. “This is better than a hospital – it’s close, it’s private, I feel comfortable,” says Aida Carlos Cossa.
    Aida Carlos Cossa, 17, is a student at the Armando Emilio Guebuza secondary school in Maputo. She has come to Amodefa’s clinic for free counselling at the “Tua Cena” at Armando Emilio Guebuza School in Maputo. “This is better than a hospital – it’s close, it’s private, I feel comfortable,” says Aida Carlos Cossa.
  • A fresh delivery of bikes for staff and volunteers to use to reach local communities sit piled in a store room. The programmes that use these to deliver services will cease to operate as the funding stops.
    A fresh delivery of bikes for staff and volunteers to use to reach local communities sit piled in a store room. The programmes that use these to deliver services will cease to operate as the funding stops.
  • Nurse Julia Suzette Mulambo* gives family planning counselling and treatment to 16-year old student Eleria Horacio Mabucule, at the Amodefa clinic in Boane, in southern Mozambique.
    Nurse Julia Suzette Mulambo* gives family planning counselling and treatment to 16-year old student Eleria Horacio Mabucule, at the Amodefa clinic in Boane, in southern Mozambique.
  • At the Armando Emilio Guebuza secondary school in Maputo Amodefa has set up a sexual and reproductive health clinic to provide access to services including contraception. Known locally as the 'Tua Cena' project, the clinic aims to increase access to quality services and information on safe abortion, STIs and HIV, relationships.
    At the Armando Emilio Guebuza secondary school in Maputo Amodefa has set up a sexual and reproductive health clinic to provide access to services including contraception. Known locally as the 'Tua Cena' project, the clinic aims to increase access to quality services and information on safe abortion, STIs and HIV, relationships.
  • Cacilda Antonio Nimaco, is responsible for transporting HIV and TB tests from the local communities to the lab. Amodefa's TB programme is under threat; the programme, which has been running just over a year, identifies and treats patients with tuberculosis, some living more than 80 km from the nearest health centres. “I like the programme because it helps a lot of families,” she says. “There are lots of families who are sick, but can’t reach healthcare – people who can’t leave their homes.”
    Cacilda Antonio Nimaco, is responsible for transporting HIV and TB tests from the local communities to the lab. Amodefa's TB programme is under threat; the programme, which has been running just over a year, identifies and treats patients with tuberculosis, some living more than 80 km from the nearest health centres. “I like the programme because it helps a lot of families,” she says. “There are lots of families who are sick, but can’t reach healthcare – people who can’t leave their homes.”
  • Cacilda Antonio Nimaco picks up a TB sample in rural Ribaue District, Nampula Province, Mozambique.
    Cacilda Antonio Nimaco picks up a TB sample in rural Ribaue District, Nampula Province, Mozambique.
  • A free HIV test is administered in a village that has just registered eight new cases of TB. TB is prevalent in Mozambique with an estimated 12.5% infection rate. Communities will be abandoned just as the success of the treatments, and the effects of educating communities about HIV and TB, is breaking fear and stigma around the diseases.
    A free HIV test is administered in a village that has just registered eight new cases of TB. TB is prevalent in Mozambique with an estimated 12.5% infection rate. Communities will be abandoned just as the success of the treatments, and the effects of educating communities about HIV and TB, is breaking fear and stigma around the diseases.
  • Amodefa staff work late into the evening in Nampula’s local communities. Maria Teresa de Fátima and her team have been testing for HIV and TB. “If the US cuts this off, it’s going to implode. This is finished, you can’t imagine what will happen. If we could bring Trump here to come and see this, if he could see the work we are doing, maybe he would change his mind.”
    Amodefa staff work late into the evening in Nampula’s local communities. Maria Teresa de Fátima and her team have been testing for HIV and TB. “If the US cuts this off, it’s going to implode. This is finished, you can’t imagine what will happen. If we could bring Trump here to come and see this, if he could see the work we are doing, maybe he would change his mind.”

 

Albertina’s team of 60 volunteers has already had to be halved. She says some of her volunteers will continue to visit families, but without funds to cover transport many patients will no longer receive the treatment or counselling they need.

For women like Palmira Enoque Tembe, who lives with her two sons who are also HIV positive, and four grandchildren, stopping these visits would sever a vital lifeline. Tembe says she was terrified when she found out she had HIV: “I didn’t want to do anything, just sit in my room and cry.” But the anti-retroviral therapy and counselling Amodefa provides have given her a new lease on life. She is well enough to start subsistence farming again, “and I am making plans for the future. I know now to get ill is not to die,” she says.

By the end of October 14 of Amodefa’s 20 sexual and reproductive health clinics across three provinces in southern Mozambique will also have to close. Nurses at the clinics see around 300 patients a day, mostly girls seeking family planning advice, but also people looking for testing and counselling for HIV and other STDs.

“Outside of these service centres young people have little to no access to this information,” says Nalia Chambal, the head of the Tua Cena programme, which is operated through these clinics. With the closures, “we’ll see a rise in unwanted pregnancies, early child marriage, HIV and STD transmission,” she says - which will mean more girls will drop out of school, and there will be more unsafe abortions.

Amodefa works closely with the Ministry of Health to ensure the family planning services it offers, as with its HIV, tuberculosis and malaria programmes, complement and support the government’s own health services. “When we stop, there will be a huge pressure on government facilities,” says Simione. “It will tough on all the country.”

But it will be the poorest and most vulnerable that will be most affected, such as those living in rural Nampula, one of Mozambique’s largest and most impoverished provinces, where Amodefa’s ChallengeTB programme is under threat. The programme, which has been running just over a year, identifies and treats patients with tuberculosis, some living more than 80 km from the nearest health centres.

As the team of volunteers and staff on bicycles and motorbikes bring awareness and testing to ever more remote communities, the true scope of the disease is beginning to be understood – in the first quarter of this year 1,318 people were tested for TB in the eight districts where Amodefa works; in the second quarter, 2,106 were tested; and in the third quarter, the number reached 3,154. More than half of these people were diagnosed to be carrying TB.

“We’ve done a lot but there’s a lot more to do,” says Maria Teresa de Fátima, head of monitoring and evaluation for the project. She expects the number of cases will continue to rise over the next two years, before they start to drop off.

Particularly at risk are the roughly 2000 patients currently taking medication. TB treatment must be taken daily for six months, and those who stop because they can no longer access healthcare may develop a multi-resistant form of the virus which is much harder to treat. Mario Vilanque, a volunteer working with communities in Naha in Morrupula district, where 5 new people have just started treatment, said his patients, are “very confident” in Amodefa; “They have seen 10 people cured – now they have great faith.”

It wasn’t always this way. When Machaieie started the HIV homecare programme in Maputo, she had to hide her car and go into communities anonymously. “People feared HIV so they feared me coming to them,” she says.

It has taken 19 years to change attitudes and break taboos in Mozambique. Now, just as hope is overcoming this fear, global gag rule threatens to force the work of Amodefa and the lives of its patients back into the shadows.

Read more about AMODEFA's tireless work in Mozambique