reducing contradictions between traditional and formal healthcare systems to improve service delivery and health outcomes at community level

INTRODUCTION

To build up development from the perception of deficits and injustice as experienced by the community, and, to take local solutions and human resources as a point of departure, has become an important consideration in the conceptual frameworks of development since the 1980´s, particularly in area of health.

The need for sexual and reproductive health to be made available in the context of culture as well as in the framework of universal human rights was cemented in the Plan of Action of the International Conference on Population and Development in Cairo, 1994:

“The implementation of the recommendations contained in the PoA of ICPD is the sovereign right of each country consistent with national laws and development priorities, with full respect for the various religious and ethical values and cultural background of its people, and in conformity with universally recognized international human rights”.

Recognizing the importance of culture as a vehicle for the realization of sexual and reproductive health and rights, UNFPA, among other pioneers, developed an operational framework and instruments to integrate sexual and reproductive health, culture and human rights in programming and advocacy

The socio-cultural approach - or community development, anthropology of health, indigenous or holistic development, different terms indicating the same field of knowledge and action - is not a new approach, but one that has beenembraced by many actors, including governments of countries such as Bolivia and Ecuador. In this paper we trace the relatively recent experience in Mozambique which was first piloted in 2005 and, then, in response to its demonstrated potential in improving communities´ strategies to prevent HIV&AIDS, started in 2008 as part of the MDG-F Joint Programme on Strengthening the Cultural and Creative Industries and Inclusive Policies in Mozambique (2008-2011

This paper presents the Mozambican experience with a socio-cultural approach to sexual and reproductive health and rights (SRHR) that brings available public and traditional health services into closer alignment with the needs of potential and actual health service users. The focus on socio-cultural aspects of health services-use is motivated by the reality that despite the increasing availability and promotion of sexual and reproductive health services in Mozambique, there has been no correlating increase in the use of these services. Moreover, concerted and costly efforts invested in achieving the MDGs and in combating HIV have not yet managed to decrease or even stabilise new infections or to sufficiently reduce maternal mortality in Mozambique.

The approach presented in this paper operates on the premise that reducing contradictions and inconsistencies in, and between, the way(s) distinct community actors understand sexual and reproductive health can contribute to improving the demand, provision and use of all available services, and to enabling individual behaviour change related to SRHR.

Evidence collected from previous sexual and reproductive health (SRH) programmes show that without a proper understanding of the norms, values and beliefs that inform the SRH practices of a community, service providers have difficulties in assisting the target audience of health service recipients, and, by association, in achieving development objectives related to SRH, such as advancing HIV & AIDS prevention and treatment, improving maternal and infant health and reducing gender-based violence.

In a country as culturally diverse as Mozambique, formal health care practices are often in opposition to the directives of the cultural and traditional beliefs of the local communities. People do not easily abandon the manner in which SRH issues traditionally have been perceived and treated, nor the way rites of passage are commemorated or inscribed on the body. If a person is confronted with a conflict between what their parents, grandparents and leaders have always explicitly taught them and what a community outsider and/or formal health professional advises, it is understandable that the person chooses to stick with what they know and what is reinforced by their family unit, being the main referential, normative frame for their understanding of the material and immaterial world and their subsequent behaviour models. Acknowledging the community’s traditional health care systems is therefore a fundamental component of program design for addressing SRH issues, as is close collaboration with the traditional service providers during program design to ensure an enabling environment.

The socio-cultural approach has as its guiding principle that sustainability of community health care in poor communities in Mozambique is facilitated by systematic dialogue between service providers, service recipients and the community at large, creating a “transformational space” for collective exploration of the challenges and opportunities for achieving improved SRH, and for identifying and planning appropriate solutions for any identified obstacles.

Through dialogue, formal and traditional service providers are better able to recognise their shared objectives, and rally together to create more effective platforms for service response and improvement of SRH outcomes. As a consequence, messages communicated to community members by formal service providers (i.e. teachers, medical professionals and local government officials) and traditional service providers(e.g. community and religious leaders, initiation rite officials and traditional health practitioners) become more closely aligned, contributing to reducing the delay in decision-making processes related to seeking medical assistance.

In the this article, we invite readers to first discover the logic of the Sociocultural Approach to Sexual and Reproductive Health (I), followed by a brief section on how Mozambican anthropologists are discussing SRH issues (II). A case study of the MDG-F Pilot Initiative on SRH (IV), is summarised and analysed for readers’ consideration. A final section on opportunities for expanding the application of the Sociocultural Approach in Mozambique (V), presenting the Adolescents´ and Young Peoples´ Sexual and Reproductive Health Programme “Geraçao Biz”, concludes the document.

I. THE SOCIOCULTURAL APPROACH TO SEXUAL & REPRODUCTIVE HEALTH

Since the 1990s, governments, social movements and the donor community increasingly champion bottom-up, community-driven approaches to development programming, however, writing these concepts into policy documents does not always translate into effective practice during planning and implementation. Community dialogue not only facilitates the receptiveness of a target community to a given program, but also contributes to the effectiveness and sustainability of the objectives identified and the solutions planned, however, allowing sufficient time and flexibility to incorporate what is raised during a community consultation process is challenging and can stall implementation, which can be a deterrent for programmers looking to achieve fast results. Above and beyond “consultation”, community participation in all stages, including program design, implementation, monitoring and evaluation, ensures that programs actually respond to real community needs in a flexible and sustainable way, minimising waste or misapplication of resources in the long term.

Such bottom-up, community-driven approaches have proved particularly relevant to programs addressing SRH, as sexuality is at once universal and culturally specific – even though illnesses may have similar underpinnings from a bio-medical point of view, the explanations people devise to explain them can differ substantially from one community to the next. Without a proper understanding of the norms, values and beliefs that inform the sexual and reproductive health practices of a community, formal service providers will most likely be challenged in assisting their target service recipients. Community dialogues on SRH issues assist in cultivating participants’ understanding of the essential interconnectedness of all SRH issues, as well as creating space for traditional community and formal healthcare representatives to understand how both systems can contribute to and cooperate on addressing SRH issues.

Another key component of this approach that helps to ensure an enabling environment in the community is approaching the target community in a holistic manner. Oftentimes, a particular segment of the community is targeted, such as youth or women, victims of violence or people living with HIV&AIDS, without properly taking into consideration the impact of the perceptions and influence of the broader community upon that particular segment’s decision-making powers.

For example, equipping youth with safe sex information without equitably involving and informing the community as a whole can place a heavy burden on young people, and even invite possible backlashes, which are counterproductive to improving SRH outcomes.

The guiding principle of socio-cultural approach is therefore to plan for a broader SRHR understanding across the community, rather than isolating issues or segmenting parts of the community, making sure to engage the community’s “cultural gatekeepers” or “opinion makers” in dialogue, on the assumption that their voices carry most weight within the community and their knowledge of prevailing norms and values is the most developed. Traditional leaders can then use their clout to reinforce the harmonised SRH messages disseminated by the formal and informal health and education sectors throughout the broader community.

One key aspect of the Sociocultural Approach is that development programmers must initially reserve judgement on what they believe to be the prevalent SRH issues. By engaging key community actors and “cultural gatekeepers” in the identification of the SRH issues in the community, any gaps between what health indicators show and what key actors believe to be occurring should become apparent, helping to identify the most appropriate basis on which to contextualise problems. The facilitated debate surrounding the solutions for the identified SRH issues above can then be fed, if necessary, by relevant biomedical concepts, as facilitators, traditional and formal service providers come to understand where the conceptual divergence in explanations lies, in the interest of mitigating the inconsistencies between traditional and modern knowledge systems.

Once it has been established and agreed upon that SRH issues exist and the nature of them has begun to be defined and explained by representatives from both the formal and traditional systems and a common base has been constructed, the next step includes the development of solutions to solve the identified problems, with the ensuing discussion and suggestions informing the way forward. If the process is facilitated in a conducive manner, solutions should be able to be devised that directly address those problems identified. If such an approach were to be introduced in communities where other programs were operational, the approach would not seek to compete with, but rather work to complement these programs to encourage the overall improvement of health outcomes. Indeed, coordinators of existing programs (such as youth or gender-specific programs or participative planning exercises) should also be involved in the discussion and encouraged to remain open to adapting their programs accordingly.

By approaching the sociocultural dimension of sexual and reproductive health not with the objective of “eradicating harmful traditional practices”, but with the intention of understanding them and ensuring that formal service providers understand their origins and objectives, the equally harmful practice of disjunctions between the formal and traditional systems of a community can be minimised. The reality is that many Mozambicans have first recourse to traditional medical practitioners rather than choosing to access formal health services. A refusal on the part of formal health service providers or other development partners to acknowledge and work with traditional service providers is therefore counterproductive to achieving the shared objectives of improving health outcomes and strengthening service delivery.

II. MOZAMBICAN ANTHROPOLOGICAL PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH

In Mozambique, 80% of infections are reported to result from heterosexual contact (PEN III), which makes the link between HIV, sexuality and SRH a particularly important line of enquiry. In the context of the global discussion on the sociocultural dimensions of sexual and reproductive health, Mozambican anthropologists are joining scholars worldwide in pointing to the reduced efficiency of a biomedical system of positivist interventions, which seek to cure the body as an independent entity disconnected from broader social and cultural contexts. Indeed, such research has gained momentum in Mozambique in light of the continued failure of HIV & AIDS prevention and treatment programmes (Gune 2010; Loforte 2007; Matsinhe 2007), as despite significant investments, the HIV epidemic continues to expand in ways that would indicate the need to apply a sociocultural lens.

As part of the “Women, AIDS and access to health in Sub-Saharan Africa from the perspective of the Social Sciences” publication, Mozambican author Cristiano Matsinhe’s analysis of the Mozambican health system notes that reform emphasis has mainly been on infrastructural and human resource dimensions, which while important, shift the focus away from other priorities such as combining biomedical and traditional health systems for improving access to services (Matsinhe 2007). Matsinhe shows how this perspective is consistent with the reality that prevention strategies, care and treatment for HIV & AIDS have not yet succeeded in reducing the number of new HIV infections in Mozambique, and indeed in Sub-Saharan Africa as a whole, arguing that the reason is that they have yet to acknowledge the contribution of cultural and social factors.

As an example, Matsinhe refers to interventions in the area of SRH and HIV & AIDS, such as ARV treatment, the Vertical Transmission Prevention Program (PTV), the Youth and Adolescent-Friendly Services and the Counselling and Voluntary Testing. Matinshe argues all these initiatives are approached in “positivist and almost mechanical” terms, completely ignoring the dimension of social relations and systems of meaning associated with practices. (Ibid. 24) Matsinhe concludes “the success of a project, system or mechanism for cure depends, in large part, on the existence of social networks that sustain it as credible, and that support its authority and vouch for its operative framework” (Matsinhe 2007, p.19).

In recognition of the importance of socio-cultural factors’ influence on SRH, Mozambican anthropologists are increasingly called upon to assist in understanding the sociocultural dimensions of diseases, prevention, treatment and care, in particular for the transmission and adhesion to messages that include behavioural change. The anthropological lens can be used to focus on the intrinsic relationship between sexuality, sociocultural values and the social control mechanisms that prevail in the family, for it is within the family - as the primary unit of socialisation - and within the community - as the main unit of reference in rural contexts - that children receive teachings, adopt values, rules, norms and principles. It is also within these units that accepted (and non-accepted) behaviours are defined. In this way, sexuality and sexual behaviour are integrally linked with social identities, which is where the connection can be made to the gender dimension (Loforte 2007).

Initiation rites serve to educate boys and girls on certain behavioural codes, specifically in relation to sexuality, necessary for adult life in a community. Colonial institutions, prolonged war, socialist ideals of “the new man” and development aid have each tried to eradicate, change or replace these ritual practices, and although some have, in fact, changed, eroded or disappeared, initiation rites are still widely practiced (UNESCO/UNAIDS 2002; Arnfred, 2011).

Ethnographic research demonstrates how in Macua society, the cultural category of “adult women” is produced by means of the initiation rites. It is the experience of initiation that irrevocably defines the appropriate cultural age for marriage, reproductive roles and motherhood, and not the girl´s chronological age (Arnfred 2012), a view that is in obvious contradiction with bio-medical and legal definitions of adulthood. Community dialogue could produce a higher degree of consensus on what needs to be accomplished for a girl to successfully transit from childhood to adulthood in the contemporary social environment, placing traditions, such as early marriage and motherhood, in the broader Human Rights context.

On the other hand, in populations in which initiation rites have disappeared, a void arises with regard to sexuality education. Where previously, traditional mentors, rather than members of the primary family unit, were responsible for providing continuing SRH education to girls in and after initiation, a breakdown in social cohesion of many traditional communities in Mozambique has meant these mentors are often no longer available, with parents the only remaining counsellors. However, as it is traditionally considered a taboo for parents to speak about sex and reproductive health to their children, the transmission of values and knowledge about sexuality are left to agents outside the core affective and cultural frames of reference of the young person, leaving the young person without support for decision-making on these important issues. For girls, whose limited window from childhood to puberty – when a girl is traditionally considered ready for procreation and marriage – socially and culturally relevant SRHR information is arguably even more important, particularly given that more than half of the Mozambican female population are married before they turn 18 (Arthur 2010).

This overview of anthropological studies of aspects of sexuality and health in Mozambican communities confirms that ethnographic information in these areas is generally available. However, the occasions that an anthropologist, or an anthropological analysis, is systematically included in a development intervention - beyond a brief diagnostic of the social aspects of the community executed by an consultant - are rare. Moreover, in spite of the fact that these studies underline the importance of the inclusion of the members of the community and their worldview(s) in programming, even more rare are interventions that facilitate the community to articulate their common analysis of the effectiveness and justice of their ways of dealing with complex issues like health or early marriage, and, shape interventions in accordance with their worldview ánd a changing environment.

III. THE MDG-F PILOT INITIATIVE ON SEXUAL AND REPRODUCTIVE HEALTH (2008-2011), UNESCO/UNFPA

The case study of the “Sociocultural Approach” looks at the MDG-F Pilot Initiative on SRH, implemented by UNESCO and UNFPA in Mozambique and based on pilot projects conducted by UNESCO in the provinces of Zambezia and Sofala for the promotion of socio-cultural approaches to HIV and AIDS prevention. On the strength of the pilot exercises, and in order to further explore the role of sociocultural factors in the health sector and in the fight against HIV & AIDS, the Sociocultural Approach methodology was included in the design of the MDG-F Joint Programme on Strengthening the Cultural and Creative Industries and Inclusive Policies in Mozambique (2008-2011). In the spirit of Delivering as One, UNESCO and UNFPA cooperated on program planning, implementation, monitoring and evaluation for this component in order to achieve the UN objective of assisting those who are most disadvantaged in obtaining access to their right to development, particularly health. UNESCO’s mandate on inclusive education, intercultural dialogue and cultural diversity, as well as leadership in applying sociocultural approaches to HIV and AIDS prevention and sexual education, was complemented by UNFPA’s mandate on reproductive health, HIV & AIDS, women and youth.

The MDG-F Joint Programme’s component on SRH focused on taking sociocultural practices, norms and beliefs into consideration in sexual and reproductive health and education programs at district level. For the international consultancy firm who conducted the Final Evaluation of the MDG-F Joint Program, the SRH pilot initiative was “almost unanimously considered the one representing the biggest success of the Joint Programme, based on both process and results” with “enough momentum to continue and spread to other districts” (EUROSIS, 2012). This sentiment was echoed by a Mozambican consultancy firm, who undertook a complementary evaluation, and declared the initiative “an innovation presenting a new path for the development programming process, with individuals and the community placed at the centre of a dialogue about the problems that afflict them and the concrete ways to address these problems” (KULA, 2011).

As part of the program, an ethnographic study on “Cultural and community practices for promoting Sexual and Reproductive Health (KULA, 2010) was conducted, for the purpose of identifying whether gaps existed between reproductive health and education practices espoused by formal and traditional systems. This study was conducted in selected communities in four districts from three provinces in Mozambique: one northern province (Nampula), one southern province (Inhambane) and one from the central region (Sofala). The study was intended as an advocacy tool to guarantee the full engagement of the health and education counterparts in the programme.

The research noted that health professionals tended to adopt a superior stance regarding knowledge and the capacity to intervene on SRH issues. Despite the common target group – youth – of the various entities and actors involved in sexual education at community level, no effort was made to harmonise content or develop common teaching methods between the traditional community and formal knowledge systems. While parents and traditionally appointed educators distrusted the formal school system, teachers and health professionals accused communities of practices that were contrary to “modernity”. The study clearly pointed to the gaps that occur as a result of systems founded on conflicting principles not communicating with each other, which have the consequence of confusing service recipients as to the best course of action when illnesses are discovered, thus delaying response time in their seeking medical assistance.

On the basis of these findings, the Sociocultural Approach to Sexual and Reproductive Health was applied in three focal districts: Mossuril and Mozambique Island (Nampula Province) and Zavala (Inhambane Province). The approach centred around the direct involvement of influential community members (the so-called “cultural gatekeepers” or “opinion makers”) in all the decisive phases of the program, namely problem identification and prioritization, activity plan design, implementation and monitoring. Members identified as influential included religious leaders, traditional health practitioners and midwives, Alephs, Sheiks, Halifas, masculine and feminine initiation rite leaders and advice/support givers, formal health and education service providers and government representatives.

Initial community dialogue sessions were undertaken for traditional and biomedical concepts of sexual and reproductive health to be clarified, debated and new levels of understanding and agreement to be reached by participating community members. The process followed with the identification and prioritisation of SRH problems to be addressed by all actors, including a clear distribution of roles and responsibilities for each relevant group of actors in both the traditional and formal settings. Thus, a transformative “space” was created for the development of greater synergies between health professionals and traditional medical practitioners, and between traditionally appointed education figures and teachers, and a common language developed to discuss SRH.

The subsequent selection of ten people per district who showed special leadership and/or pedagogical potential established cross-sector “district task forces”, with an equal number of representatives from each of the education and health sectors, and from the traditional and formal community systems. These district task forces were then involved in an action-training process resulting in the development of work plans with activities designed to respond to the specific SRH problems identified. Some of those activities were: extra information sessions on biomedical and public health issues for leaders, development of radio programs to complement community sensitization programmes and developing easy-to-read and local language brochures on relevant legal frameworks and sexual reproductive education.

As per the work plans developed in each of the three districts, the first activities consisted in training all participating community members on basic SRH concepts and related legal frameworks (family law, gender-based violence and sexual abuse), with 80 members trained per district, and a total of 240 people trained between 2008 and 2011. Using the knowledge produced, the key community leaders then facilitated community sensitisation sessions on SRH and HIV & AIDS, using communication media such as radio debates and seminars, and working with their colleagues and counterparts, ensuring that the wider community receive the same type of messages regarding SRH from all sectors.

Based on the ethnographic study findings and the initial community dialogue sessions, a functional literacy tool was also developed in cooperation with the Ministry of Health (MISAU) for traditional leaders - the “Conversations with the Community trainingmanual - to assist the traditional leaders in communicating SRH information to their constituents. In the same vein, a training manual for teachers called “Knowledge, capacities and attitudes on Sexual and Reproductive Health and HIV & AIDS[6]” developed in conjunction with the National Institute for Educational Development (INDE) for the reinforcement of teachers’ capacities in Teacher Training Institutes (UNESCO 2009), was distributed in the focal districts to aid formal sector teachers in sensitising young people on SRH issues.

Some results from the MDG-F pilot include reference systems created for referring patients of traditional medical practitioners to formal health services, and vice versa. In the district of Mossuril, for example, circumcision began to involve health professionals, with other components of the ritual administered by local leaders, and in Zavala district, traditional midwives have begun to be invited to participate in deliveries inside the health clinics.

In Zavala, secondary schools have begun forging links with the health clinics – once a month, a health service provider has been offering seminars for the students. Where previously SRH was only dealt with by teaching the male and female reproductive systems, now it has broadened to include the prevention of STIs including HIV, how to use condoms, personal bodily hygiene, the menstrual cycle and the constitution and functioning of reproductive systems, the rights and duties of children, positive behaviour for good SRH practices, the consequences of early marriage and adolescent pregnancy, amongst other issues. On the basis of this experience, all schoolteachers involved in the activities began addressing SRH with their students, where previously only the Biology teacher covered this material.

IV. OPPORTUNITIES FOR EXPANSION

The UNESCO/UNFPA pilot experiences with the Sociocultural Approach and the general need for a more systematic approach to mainstreaming crosscutting issues in development programming in Mozambique culminated in 2010 in the Integrated Approach to Mainstreaming Culture, Gender and Human Rights[7].  qBy articulating a vision for ensuring culture and gender-responsive programs that are consistent with a human rights-based approach, the CGHR Integrated Approach aims to assist those who are most disadvantaged in obtaining access to their right to development, involving them in people-centred formal planning processes. Conceptualised by UNESCO, UNFPA, UN Women and UNICEF, in collaboration with key Mozambican development partners, including central and local government, academia, civil society, community leaders and traditional health practitioners, the CGHR Integrated Approach expands the conceptual underpinnings of the Sociocultural Approach, broadening its application to other sectors of development beyond health and HIV & AIDS prevention.

In order to continue broadening and strengthening the CGHR Integrated Approach as a vision for development programming in Mozambique, it would be necessary to recognise and maximise the opportunities for expanding the Sociocultural Approach to Sexual and Reproductive Health, as the pioneering and most successful operationalisation of this vision. This final section demonstrates that the Sociocultural Approach is consistent with how the Government of Mozambique is communicating its strategy on SRH, and in particular on HIV & AIDS, positioning the approach as a useful mechanism for translating national-level policies into local-level action.

The Government of Mozambique’s Second National Plan of Action to Combat HIV & AIDS (PEN II, 2005-2009) recognises the sociocultural dimension of sexuality, and the PEN III (2010-2014) goes on to advocate for the identification of sociocultural factors associated with sexuality that can contribute to the risk of infection, such as a lack of communication and negotiation between partners on SRH issues, widow cleansing rites, treatments that involve unprotected sex and the use of vaginal products to dry out the vagina for greater friction during the sexual act(Gune 2010; MDG-F, KULA 2008).

The PEN III recommends:

“Implementation of communication strategies that are attentive to the characteristics of the epidemic, and to the social and cultural contexts that the Mozambican population live in. The content of the communication approaches that address HIV & AIDS must be structured, systematized and attentive to gender dynamics, and implemented in a continuous and dialogical fashion, making use of the multiple existing media and communication channels available at national, community, family and interpersonal levels” (CNCS 2010: 17).

Consistent with the PEN III’s recommendations, the Sociocultural Approach revolves around the direct involvement of influential community actors in all important program stages: identifying problems, designing activity plans, implementing and monitoring activities, enabling the development of SRH communication strategies that are both scientifically accurate and culturally sensitive, inciting sustainable change in knowledge, attitudes/values and practices in sexuality, sexual education and SRH.

UNFPA’s Geração Biz Program (PGB) was designed to address these issues, equipping young “activists” with evidence-based SRH information to distribute to their peers. The program has been widely and enthusiastically appropriated by the government, though some program elements show room for improvement in order to maximise effectiveness.

When analysing the PGB, evaluators identified that sociocultural aspects were being taken into account when training activists, in parent sensitization sessions, and in the development of didactic materials. Deficiencies were identified, however, such as 1) the lack of effective strategies to mobilise sustained support of influential community figures (ex: traditional leaders) in the program and 2) the use of the same messages and approaches across localities which effectively ignores the differences in conceptions of sexuality. It was argued that any inconsistencies between local knowledge (especially messages which are transmitted during initiation rites) and those communicated by the program might actually contribute to the vulnerability of adolescents and young people. A solution proposed was to adapt the program to each implementation context in a socio-culturally appropriate way and systematically involve authority-figures in the community in the process (UNFPA 2010: 45-46).

One of the main challenges for this approach is the fact that results are not always precisely measurable in the short-term. In the case of the MDG-F SRH pilot, the number of institutional births increased 6% and 12% in Mozambique Island and Mossuril in the year of the pilots’ implementation (2011), however causality between these significant gains and the pilot is difficult to establish. The most demonstrable result was the synergies developed between the different intervening entities at the local level where the program existed.

In conclusion, we could argue that understanding the sociocultural reality of the location where a program or project is to be implemented means acknowledging the cultural specificities of the target group, their values and norms. This enables greater sensitivity in allowing better contextualisation of the planning and implementation stages of priority actions and helps identify true situations of vulnerability. In this article we have demonstrated that the Sociocultural Approach, which is a community-driven, bottom-up approach, is particularly beneficial for addressing the SRH issues of disadvantaged populations in districts with unfavorable SRH indicators, and where sociocultural issues are likely to be barriers for better use of locally available health resources. The approach’s characteristic of unlocking the potential of existing (traditional and formal) health services makes it a valuable strategy towards the achievement of MDGs 4, 5 and 6 amongst those populations who are the most difficult to reach, and in the effective improvement of community health service delivery and health outcomes across Mozambique.

List of Acronyms

AERMO Mozambican Association of Herbalists

AMETRAMO Association of Traditional Healers

ARV Anti-Retroviral Treatment

ARPAC Archive of Cultural Heritage/Institute for Sociocultural Investigation

AVEMETRAMO Association for Retailers of Traditional Medicines of Mozambique

CBO Community-Based Organizations

CGHR Culture, Gender and Human Rights

DAA Department of Archaeology and Anthropology, University Eduardo Mondlane (UEM)

GDP Gross Domestic Product

GoM Government of Mozambique

IEC Information, Education & Communication

INE National Institute of Statistics

INJAD National Inquiry on Sexual & Reproductive Health and Behaviour of Young People and Adolescents

MDG Millennium Development Goals

MDG-F Millennium Development Goals Achievement Fund

M&E Monitoring and Evaluation

MEC Ministry of Education and Culture (now defunct)

MICULT Ministry of Culture

MINED Ministry of Education

MISAU Ministry of Health

MJD Ministry of Youth and Sports

PARPA II Action Plan for the Reduction of Absolute Poverty, 2006-2009

PEEC Strategic Plan for Education and Culture, 2006-2011

PEN II National Plan of Action to Combat HIV/AIDS, 2005-2009

PEN III National Plan of Action to Combat HIV/AIDS, 2010-2014

PGB Geração Biz Program

PQG Five-Year Government Plan

PROMETRA Association for the Promotion of Traditional Medicine – Mozambique

PTV Vertical Transmission Program

SRH Sexual & Reproductive Health

STI Sexually-transmitted illness

UNAIDS United Nations Joint Programme on HIV & AIDS

UNCT United Nations Country Team

UNDAF United Nations Development Assistance Framework

UNESCO United Nations Educational Scientific and Cultural Organization

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

UN Women United Nations Development Fund for Women (formerly UNIFEM)

VLIR University Development Cooperation of the Flemish Interuniversity Council