3.1. Worker Rights, State Responsibilities, Workers’ Compensation in Mozambique
We analysed specific provisions of legal documents establishing rights and obligations relevant to occupational TB and health workers. Table 2
provides excerpts of provisions that are binding upon the government (i.e., employer).
At the apex of the legal system is the Mozambique Constitution adopted in 2004 [55
]. It formally establishes worker rights, freedoms, and guarantees (Table 2
, row 1). This includes the right to workplace health and safety and the freedom to form trade unions. As a rule, any law which contradicts constitutional provisions can be considered unconstitutional and regarded as invalid. However, the exercise of worker rights and freedoms depends on enabling legislation that establishes responsibilities and steps for implementation.
The Mozambican Congress passed two pieces of enabling legislation giving effect to rights and freedoms of workers. Specifically, in 2014, Congress passed enabling legislation that determined the steps for unionization in the public sector, namely the Trade Unions Act [56
], which reaffirms workers’ constitutional rights to form and to join trade unions, as well as to collective bargaining for the protection of their work-related interests. Relevant to occupational TB, the Trade Unions Act
provides for worker participation in the elaboration of working conditions and workplace safety (Table 2
, row 2). The legislation provides for collective bargaining at facility and all government levels. However, the legislation provides no specific elements and mechanisms for public servants’ participation in any existing governmental Occupational Safety and Health Committee.
In Mozambique, public sector workers fall under the Ministry of Public Administration and Public Service and under the Public Servants and Public Agents Act 10/2017
, which regulates relations in the public sector [57
]. (Employment relations within the private sector fall under the Employment Act 23/2007
] and industry specific laws; employment relations in the private sector are beyond the scope of our study). The Public Servants Act
] reaffirms workers’ constitutional rights to unionization as above, and to workplace health and safety to be exercised under specific legislation (Table 2
, row 3). The Act charges the federal government with the promotion of continuing education and engagement of workers in “collective methods of work management” and requires the government to develop specific frameworks that define further responsibilities and steps for implementation.
With regard to regulation, the National List of Occupational Diseases
for compensation is relevant [59
]. TB is not included in the national list, and TB in health workers exposed to patients with TB is therefore not presumptively considered a compensable occupational disease in Mozambique. Under the country’s legal regime, compensation may be payable for work-related diseases not listed in the occupational diseases schedule provided that the worker proves the link between the disease and the workplace (Table 2
, row 4) [60
]. As such, this shifts the onus of proof onto the worker and involves a burdensome process.
It is worth noting that while the private sector is subject to the same compensation regime as the public sector (Table 2
, row 4), the legislation regulating employment in the private sector is more comprehensive, establishing, inter alia, thorough responsibility and accountability frameworks [58
]. In addition, the private sector legislation provides that the statutory interpretation of its provisions should be in accordance with international human rights principles and best practices in the field [59
]. In theory, this would allow the recognition of TB as an occupational disease in healthcare settings in the private sector. This interpretation standard is not part of the Public Servants Act
3.2. International Treaties
According to the Mozambican Constitution [55
], international and regional treaties come into full force once ratified by Congress, whereupon the government must ensure that all laws, policies, and programs in the country conform with international agreement, including adopting required legislation. Mozambique has signed, ratified, or acceded to several international and regional treaties relevant to the protection of workers, with emphasis on the Universal Declaration of Human Rights [61
] (Arts. 23.1, 23.4), the International Covenant on Civil and Political Rights [62
] (s. 22.1), and the African Charter on Human and Peoples’ Rights [63
] (ss. 10, 15). These treaties require the Mozambican government to adopt comprehensive legislation and practice that enable, inter alia, the enjoyment of safe working conditions and freedom of association.
Furthermore, Mozambique has been a member State of the International Labour Organization (ILO) since 1976 [64
]. The country has ratified a number of conventions [65
], including all eight fundamental conventions and three (out of four) governance priority conventions [66
]. Two conventions are particularly relevant to protect health workers from occupational TB, namely C19—Equality of Treatment
], and C144
(International Labour Standards
Ratification includes an undertaking to adopt and ensure that new and revised legislation complies with and enables tripartite consultation for implementing international labour standards within the country (i.e., C144). It also includes an undertaking to report on the application of the conventions regularly. The last country report on C144 dates back to September 2018 and reported overall developments on regular tripartite dialogue throughout the country without, however, providing specific content and outcomes [69
Another barrier to holding the government accountable for deficiencies in occupational safety and health among health workers is that Mozambique is yet to ratify the C155—Occupational Safety and Health Convention, 1981 (N. 155)
] providing an international standard for safety and health at the workplace. Under the ILO’s Constitution, Mozambique, as a member State, is still required to report on measures undertaken toward implementation of any provision of a non-ratified Convention [70
] (s. 19.7.b.iv). The same applies to steps undertaken to include TB in the Mozambican national schedule of occupational diseases as per ILO’s Resolution No. 194—List of Occupational Diseases Recommendation
that classifies TB as an occupational disease [17
] (s. 1.3.5).
3.3. TB Control Policies
In 1979, the Mozambican government created the National TB Control Program with centralized management at the federal level and decentralized services at provincial and district levels. At the federal level, the Health Ministry is responsible for setting national priorities, developing regulations and policies, resource allocation, and partnership coordination. At the provincial level, provincial health authorities are responsible for coordinating and overseeing implementation, resource distribution, and providing technical and logistical support to district governments. At the district level, local authorities are responsible for service delivery (The two hospitals and healthcare center analyzed in this study are service providers under district administration, but also report to the federal government).
In 2013, the Health Ministry launched the National TB Program Plan
to provide strategic and operational directions to all health authority levels in respect of the essential components of TB prevention and control [33
]. Following international standards and guidelines [16
], the Plan [33
] establishes the respect for human rights as guiding principles for implementation (p. 36), although without elaborating on what those efforts entail in relation to IPC at healthcare facilities. Ambitious targets for healthcare facilities were established: a 75% implementation by 2016, and 100% implementation by 2018 [33
] (p. 87). However, limited resources were allocated in the TB Plan to achieve such targets, namely 2.2% of the total health budget [33
] (p. 92).
The Health Ministry also published the National Infection Control Policy for Congregate Spaces
that sets out the overarching policy context for the national TB response in healthcare settings [50
], addressing its responsibility for surveillance and data management; program monitoring and evaluation; community-based awareness; stakeholder engagement and cooperation; budget planning and allocation; and provision of technical assistance, training, and capacity building. In recognition of the increased risk of TB infection at the healthcare workplace, the policy sets out actions to protect health workers in healthcare settings, including supporting cross-governmental collaboration, engaging in targeted research, and conducting TB surveillance in health workers. Healthcare facilities are responsible for IPC implementation, including management, administrative, environmental, and personal controls, with administrative measures detailed in a written TB infection and prevention control plan to achieve accelerated laboratory diagnosis and TB treatment for health workers. The policy, however, provides a generic framework for IPC controls in healthcare settings for the protection of workers, patients, and the public, without defining specific employer responsibilities to create and maintain a safe and health workplace for health workers.
3.4. Key Informants’ Perceptions of Worker Rights and Barriers to Implementation
Despite the existence of the national policy described above, we identified major legal gaps as perceived by workshop and policy discussion group participants as barriers to effective realization of health workers’ rights to be protected from TB at their workplace. Four inter-related themes emerged: legal classification of occupational TB; self-disclosure, privacy work-related stigma and discrimination; unionization; and limited state resources. First, all participants agreed that not having TB officially recognized as an occupational disease was a substantial barrier. The general view was that government acted in such cases only when compelled by law, with one manager explaining, “codification is the only way that governments get things done in this country.” There was therefore “the need to amend the National List of Occupational Diseases” (issued in 1957), which does not include occupational TB. Under Mozambique’s compensation regimen, the addition of TB to the list would entail the presumption that the disease in health workers exposed to patients with TB was occupational and hence would create a legal obligation upon the state to compensate workers who were infected on the job. Such presumptive compensation would also exert pressure upon governments to implement and maintain the health and safety of the workplace “in order to not have to pay compensation.”
The second emergent theme was reluctance among health workers to disclose a TB diagnosis owing to fear of stigma and workplace discrimination. One participant explained that Mozambique has a law requiring TB case-reporting to health authorities, but there was no law mandating TB case-reporting to employers. In fact, one manager noted that in her experience, workers typically do not disclose TB diagnosis to management, although noting, “if a worker misses more than a few days of work it is likely that everyone will guess what is happening.” The general sense was that the lack of privacy enabled pervasive "gossip" at the workplace. One health worker explained: “people will even think that the person on sick leave [when TB is guessed, but not disclosed] is also HIV positive, because of the connection between TB and HIV.” Another participant concluded, “... there are no specific rules for disclosure or for workers’ privacy, only a lot of gossip ... something needs to be done about the gossip.”
Particularly problematic from the perspective of managers was that if a worker who is sick with TB does not disclose the diagnosis, the "health worker zero" transmission goes unidentified, and the infection is not promptly addressed. This is especially challenging, as a manager explained, “... workers usually seek TB treatment elsewhere. Employers are not notified that the worker is being treated for TB. We guess, but it could be treatment for any other disease, really. TB then goes unaddressed in our unit.” Whether, and especially how, employment disclosure should be achieved raised a heated debate among participants. On the one hand, managers were of the opinion that special legal attention should be given to a mechanism for mandatory disclosure and testing. On the other hand, health workers were reluctant to accept mandatory disclosure of a TB diagnosis. Workers were emphatic about the need for legal attention to where treatment could be sought, reporting a strong preference for healthcare facilities other than their own workplace. Managers, however, vehemently disagreed with an option of sick workers seeking treatment outside their own workplace, with one manager stating, “... if we allow that [non-disclosure and treatment in other hospitals], we will never combat occupational TB and address TB-related stigma in our hospital. We all lose.”
The prevailing opinion was that while greater professional confidentiality was needed, this should be supported by regulation setting out the rules of privacy, notification requirements, and responsibilities for the implementation of education and awareness campaigns.
The third theme was the lack of trade unions for public servants associated with “an opportunity to be heard”. Participants generally agreed that trade unions created important spaces for action. A few participants complained about the lack of opportunities to pressure government to improve health and safety at work, and to lobby for insurance coverage for occupational health. There was, however, an incorrect perception that there was no enabling legislation providing for the formation of trade unions. One participant reported the existence of a nurses’ association, explaining that the role of the association was mainly to assist its members with grievance procedures rather than exerting pressure over decision-making. Participants were also unaware of any mechanism to monitor law, policy, or regulation reform in the country and of any training to strengthen knowledge and awareness about laws and policies, including in relation to workplace health and safety other than a few pamphlets hanging on walls.
With respect to “an opportunity to be heard”, informants showed some interest in the status of Mozambique’s Treaty ratification after the presentation of the International Labour Organization (ILO)’s representative (e.g., C144—Tripartite Consultation (International Labour Standards) Convention, 1976
], and Convention C155—Occupational Safety and Health Convention, 1981
]). However, there was no engagement with what such conventions would mean in practice in relation to tripartite labour management toward influencing better working conditions. The discussion about unionization also brought to the fore considerations about the regulatory disparity between the public and private healthcare sectors. For example, one participant in the discussion group showed a binder with a compilation of laws regulating occupational health in the private sector, highlighting the regulatory gaps in the public sector, “…we [public servants] are very disadvantaged with respect to occupational health and organized labour in relation to the private workers. There is little to nothing about this for us.” One participant noted, however, that Mozambique’s private healthcare sector is small and incipient, with insufficient legislation and poor unionization.
The fourth theme was one of limited resources in the public sector, with one health worker noting, “we cannot compare the public and the private sector ... the private has money, the public has not.” This discussion turned into debates about implementation challenges owing to resource constraints, with one government official elaborating, “…the public budget is in deficit ... that is why we have problems in Mozambique ... donors cut external resources and the state faces challenges to implement national health plans. So, there is no resource to do many things.” However, different views were expressed, e.g., “‘we don’t have money’ is the classic answer when Mozambique’s governments want to justify omission.” Another manager reiterated that implementation challenges were due to a lack of legislation rather than resource constraints, and that “… what we need is for occupational TB to become law… then the State [employer] has to come up with resources and ways to address stigma.”