Too far to walk - Disaster Resilient Maternity Waiting Home in Mozambique by Tatiana Levitskaya

Disaster resilient Maternity Waiting Home in Mozambique

TOO FAR TO WALK

Politecnico di Milano Architecture and Urban Design 2021-2022

Tatiana Levitskaya - 926276 Massimiliano Piffer - 926266

Camillo Magni Isacco Rama

TOO FAR TO WALK Disaster resilient maternity waiting home in Mozambique

Master’s Degree Thesis Architecture and Urban Design 2020-2021

Candidates Tatiana Levitskaya Massimiliano Piffer

Supervisors Camillo Magni Isacco Rama

To our families

CONTENTS 8 Abstract

11 Introduction: the need for Maternity Waiting Homes 15 Methodology and essential literature 18 Glossary 20 List of acronyms and figures PART I 25 A Glance at Mozambique • Historical background • Country overview • A two speed country: urban and rural • Rural habitat

PART II 95 Framing Sofala and Manica Provinces • Provinces overview • Health structures affected by cyclones 111 Atlas of Case studies • Sofala and Manica case studies • Unpacking the MWH framework • Rural Women day schedule: daily routine at home vs life at MWH PART III

43 Of Healthcare and Maternity • Care system overview • The problem of maternal and new-born mortality

251 Too far to walk • Territorial strategy • Building habitat: design strategy and concept

59 Climate Change Effects • Vulnerability to climate change: hazards and challenges • Disaster resilience • UNHABITAT Framework: Hospital Seguro project

286 Conclusions

77 Maternity Waiting Home • A comprehensive overview • MWH strategy in Mozambique

292 Acknowledgments 294 List of figures 298 Appendix 312 Bibliography

ABSTRACT

Maternal and new-born mortality is still today a great challenge in developing countries such as Mozambique, where the health infrastructure is very vulnerable. Despite a significant improvement in recent years, the levels still remain far from the targets agreed by the 2030 agenda, especially in the most sensitive areas of the country, the rural ones. To further aggravate the situation, the recent escalation of climate change has begun to be reflected in increasingly frequent catastrophic events, causing the destruction of infrastructure such as roads, public and private buildings.

La mortalità materno-infantile risulta essere ancora oggi una grande sfida per i Paesi in via di Sviluppo come il Mozambico, in cui l’infrastruttura sanitaria è assai vulnerabile. Nonostante i dati attestino un sensibile miglioramento negli ultimi anni, i livelli rimangono ancora ben lontani dai target accordati dall’agenda 2030, soprattutto nelle aree più sensibili del Paese, quelle rurali. Ad aggravare ulteriormente la situazione, il recente intensificarsi del cambiamento climatico ha iniziato a riflettersi in eventi catastrofici sempre più frequenti, causando la distruzione di infrastrutture come strade, edifici pubblici e privati.

From these premises, the research aims to address the dynamics of maternal and child health in rural Mozambique, in particular the situation of pregnant women and their possibility of accessing care treatments. In addition to climatic threats, there are still numerous barriers that limit this capacity, including extreme poverty, geographical distance from the centers,

Da queste premesse, la ricerca si propone di affrontare la dinamica della salute materno infantile nel Mozambico rurale, in particolare la situazione delle donne gravide e la possibilità di accesso alle cure. Oltre alle minacce climatiche, sono ancora infatti numerose le barriere che limitano tale capacità tra cui povertà estrema,

lack of information, inadequate quality of structures and cultural restrictions. A key intervention to overcome these barriers are the “Maternity waiting homes”, a low-cost and sustainable dwelling to increase institutional births, bringing women closer to antenatal care and basic health education. Therefore, starting from the government strategy dating back to 2009 and relying on the PESS III reform (2014-2019 / 2023) and the UNHabitat Safer Hospital program, the research proposes to analyse an atlas of case studies in the provinces of Sofala and Manica, severely affected by cyclones Idai (2019), Chalane (2020) and Eloise (2021), investigating construction types, characteristic features and diseases widespread in MWHs. The aim of this study is therefore to address the dynamics of maternal infant mortality through the MWH strategy, aiming at raising awareness of the problem and proposing a resilient MWH pilot project. Not a model or a prototype, but a solution that can serve as a basis for further development, preserving the cultural elements and local housing techniques.

Keywords: Maternity Waiting Home, climate change, disaster resilience, Sofala and Manica, Safer Hospitals programme.

distanza geografica dai centri, mancanza di informazioni, qualità inadeguata delle strutture e restrizioni culturali. Un intervento chiave per superare tali barriere sono le “Maternity waiting homes”, una residenza a basso costo e sostenibile per incrementare i parti istituzionali, avvicinando le donne alle cure prenatali e all’educazione sanitaria base. Quindi, partendo dalla strategia governativa risalente al 2009 e appoggiandoci alla riforma PESS III (2014-2019/2023) e al programma Safer Hospital di UNHabitat, l’approfondimento progettuale si propone di analizzare un atlas di casi studio nelle province di Sofala e Manica, duramente colpite dai cicloni Idai (2019), Chalane (2020) ed Eloise (2021), investigando tipologie costruttive, tratti caratteristici e patologie diffuse nelle MWHs. Lo scopo di questo studio è dunque quello di affrontare la dinamica della mortalità materno infantile tramite la strategia della MWH, mirando ad una sensibilizzazione della problematica e alla proposta di un progetto pilota resiliente di MWH. Non un modello o un prototipo, ma una soluzione che può fungere da punto base per ulteriori sviluppi, preservando gli elementi culturali e le tecniche abitative locali.

Parole chiave: Maternity Waiting Home, cambiamenti climatici, resilienza alle catastrofi, Sofala e Manica, programma Safer Hospitals. 9

0.1 - Mothers waiting for a visit at the Inhamichindo rural Health Centre July 2021

THE NEED FOR MATERNITY WAITING HOMES: Introduction, context, scope

Approximately 303.000 women die each year from preventable causes related to pregnancy complications and childbirth. Roughly two-third of them occur in Sub-Saharan Africa, where a woman’s lifetime risk of dying during or following pregnancy remains as high as 1 in 37 - compared to 1 in 4.500 in the developed world (WHO, 2017). Maternal deaths have declined worldwide over the past two decades due to affordable, quality health care services. Not all countries, however, have benefited from advancements in technology, sanitary spaces and care. Mozambique faces high rates of maternal mortality throughout the entire country, especially in rural areas where 63% of the population lives (The World Bank, 2020). In 2017, the woman mortality rate was 289 per 100,000 live births, while the stillbirth rate was 67 per 1,000 live births (UNDP, 2017). Numerous barriers are limiting women’s ability to access care, including extreme poverty, geography/distance to medical care and subsequent delay in accessing medical care during labour and delivery, lack of information, inadequate quality of health structures, and cultural practices or restrictions. The inability to easily access timely medical care due to such factors is mostly present among women living in rural and remote communities, where 99% of all maternal deaths occur. Diseases, loss of lives and insecurity are just some of the issues related to such tragedy. In fact, maternal mortality can lead to long-term social and economic family’s vulnerability as it marks a potential increase of poverty.

Without a mother’s support, a family and the wider community itself can be left without basic supplies like food, shelter and health care. Older children who survive a mother’s death are also more likely to leave school whereas daughters tend to enter an early marriage or motherhood continuing cycles of poverty. Making pregnancy and its outcomes safer is an imperative human right beside a central goal for the development of Mozambique. It means ensuring that every woman has access to a continuum of care, including appropriate management of pregnancy, delivery and the postpartum period together with access to life-saving obstetric care when complications arise. What is lacking is the ability to bring the necessary technical skills - economic, geographic, operational, architectural - to the women in need of help. A key element of a strategy to “bridge the geographical gap” in obstetric care between rural areas, with poor access to equipped facilities, and urban areas where the services are available is the Maternity Waiting Home (MWH), or as born in ex-Portuguese colonies, “Casa de mãe-espera”. As one component of a comprehensive package of essential obstetric services, maternity waiting homes may offer a low-cost way to bring women closer to needed care and sanitary education. According to the Millennium Development Goals that placed a significant emphasis on reducing the maternal mortality ratio by 2015 (and further highlighted by the most recent Agenda 2030), in 2009 the Ministry of Health of Mozambique prioritized the set-up of maternity waiting homes as a sustainable strategy to improve institutional deliveries across the country (MISAU, 2009) but with no common guidelines to regulate the facilities or further implementation practices regarding safer design. The experiments followed the health-care standardized modules, with no specific needs assessment, community involvement or development of evaluation criteria for a proper implementation. Results show a diffuse pattern of poor, under-scaled structures that typically host overcrowded rooms, critical hygiene conditions, no clear layouts and severely damaged structures due to climate extremes. In fact, Mozambique faces different cyclic hazards. Floods of various nature, heavy storms, tropical cyclones, droughts and landslides affect thousands of people every year. Due to climate change the

number of extreme events have risen in the last decades. The last 3-years of cyclones, Idai-Kenneth-Chalane-Eloise has shown the increased severity of the hazards, leaving a trail of devastation in the whole country, with no exception for the healthcare facilities. In addition to the Disaster Risk Reduction (DRR) and Building Back Better (BBB) programs, in December 2020, the “Hospitais Seguros” project (Development of Post-Disaster (Re)construction Guidelines for Safer, Gender-Sensitive Health Facilities in Mozambique) was launched in Mozambique under the leadership of the Ministério da Saúde de Moçambique (MISAU) and Canada Government in collaboration with the United Nations Humans Settlement Program (UN-Habitat, 2020). This program aims at drafting norms and standards for the (re)construction of adequate, resilient and -sensitive to the gender issue- infrastructure in times of emergency. Among the topics related to the program, the MWH represents a crucial layer to be developed in the following phases, since so far it had no part in the (re)construction activities. Therefore, the research project investigates the construction typologies of MWH in Mozambique, more specifically in the Sofala and Manica provinces. Its aims are to raise awareness about the issue, interpret the actual trend of on-site structures highlighting the recurring deficiencies and finally propose an experimental proto-typology of resilient MWH. Not a model or a prototype, but a solution that can work as a base point to further develop. By means of guidelines embedding not only multi-hazard risk reduction and maternal security principles but also local practices and low-cost technologies, it tries to promote gender equality and a new proximity between families and health facilities. Wellfunctioning and designed MWHs have the potential to reduce maternal and stillbirth mortality ratios, fulfil policy mandates by strengthening access to facility delivery, promoting ownership of maternal infant health among community members, increasing opportunities for health education, and creating respectful, supportive care environments. The present research is proposed as a living document that should form the initial basis for mainstreaming disaster and maternal mortality risk reduction in the MWH construction and human settlements planning in Mozambique.

from above: 0.2 - Interviewing the mothers from Muda Serraçao Maternity Waiting Home August 2021; 0.3 - Measuring the maternity ward at Francisco Manyanga Health Centre August 2021; 0.4 - Interviewing the mothers from Villa Arriage de Buzi rural Hospital July 2021.

RESEARCH METHODOLOGY Learning by doing

Being aware of the complexity of the investigation, the research methodology includes both a theoretical and architectural-design framework in order to develop a critical and comprehensive awareness on the Mozambican fragile context as well as understand the role the architect should play in this scenario. Specifically, it is divided into three parts tackling at first an overview on the SubSaharan Africa and more precisely a glance at Mozambican habitat, followed by the on-site survey analysis which aims to define an architectural proposal. Therefore, the investigation started with a 3-months visit in Mozambique, more precisely in Sofala and Manica provinces. The on-site collaboration with CAM (Consórcio Associações com Moçambique) and UNHabitat Beira, made us experience plenty of social dynamics currently shaping the culture, local techniques and the way of living. The task on the field, by means of architectural surveys and structured interviews to locals deeply influenced the first research outputs, showing the huge gap between our contexts. This process has not only allowed the study of the sanitary units, making us understand the extent of damages triggered by climate extremes, but also left a clear mark into our perspectives as future professionals. The research, since the close cooperation with UNHabitat, aims to be an independent piece in the broader UNH programme named “Safer Hospital”. The project is a collaboration among the United Nations (UNHabitat), the Ministry of Health - MISAU – and the Department of Health Infrastructure and Equipment - DIEH funded by the Canadian Department of Trade and Foreign Affairs

Development – DFATD with the ultimate goal of contributing to the greater resilience of health facilities (re)built in order to protect them from climate risks, ensuring operation during crises and emergencies and providing equitable and gender-sensitive health services in the whole country. The first part opens a dialogue with a combined electronic search of a broad range of general and specialist databases, supplemented by bibliographies, reverse citation mapping of relevant studies and additional search of grey literature and precedent studies. Among these, it is important to mention “A short history of Mozambique” (Newitt, 2017), “The new scramble for Africa” (Carmody, 2016), “L’africa. Gli stati, la politica, i conflitti” (Carbone, 2005) and Felwine Sarr’s Afrotopia (Sarr, 2018) that trace the main lines of the current political environment and the potentially sustainable socio-economic development of the continent. Subsequently, given the “temporary housing” profile of the research intervention, the Mozambican urban history is analyzed by means of two previous studies, carried out in Mozambique: the first one named “Traditional informal settlements in Mozambique: from Lichinga to Maputo” (Bruschi, Lage, and Carrilho, 2004), the second “Homespace” (Jenkins, 2012). Both studies prove the importance of the on-site survey to give accurate information on the home space, giving a clear picture on the state of living: from the use of private and public space, socio-cultural traditions, to the architectural elements. In addition, two PhD dissertations were taken into consideration: “Spontaneous living Spaces” (Del Bianco, 2021) and “Gli spazi dell’istruzione primaria nei progetti della cooperazione internazionale” (Faverio, 2018) in order to broaden the support information on landscape and housing typology. Further scientific articles and papers have been analysed to address properly the fragile topic of the Maternity Waiting Home in Mozambique (“casa de mãe-espera”), a globally debated issue in developing countries. The whole literature contribution is enriched by a constant intersection with the country’s personal experience by means of reflections, hints and photo reportages. These chapters frame the research topic environment, define the scope and deal with the character of Mozambique experienced, leading the discourse to the second part, defined by the rural survey and the atlas of cases analysed.

Therefore, the second part regards the experience on site. Within the framework of environmental protection, post-cyclone reconstruction (Idai-Chalane-Eloise) and Maternal mortality reduction (Gender sensitive), 18 case-studies in the Sofala and Manica provinces were tackled. Despite it’s simple explanation, long weekly talks were needed to arrange the travel logistics and inform each district’s healthcare department about our few days’ inspections. Therefore, the total number of cases doesn’t suit our expectation but reflects a further gap into a poor communication network that mirrors the country’s vulnerability to deal with emergencies or decision making at regional level. Thus, the intervention procedure consisted of a first brief introduction with the Health unit chief followed by an interview regarding the building capacity and structural damages caused by the recent tropical storms. Subsequently, the survey shifted from the whole unit to the specific case study, where existing, since the Maternity Waiting Home dwells only in rural areas in order to bridge maternity care with the most isolated and scattered communities. The first step was an indepth interview of the users, the mothers, usually thanks to a local translator since in the countryside most of the population doesn’t know Portuguese. Secondly, a technical survey with sketches to inspect the construction typology and its materials. Sometimes, both of these phases dealt with shortages of sources, on one hand people to talk to, for example in those cases the Maternity waiting home was not hosting any mother, and on the other an appropriate amount of time to spend analyzing the building. However, a full photo reportage of the context tries to blend these gaps, framing atmospheres and construction details. Finally, a matrix of information has been developed to intersect with the resilient UNHabitat regulations. The outcomes aim to define a few guidelines for an inclusive and resilient design to apply to the further project. This comprehensive research process, all together with literature and on-site surveys, informed the resolution and its resultant design response. In fact, the third part consists of a resilient design proposal, sensitive to gender issues, aimed at promoting a culture of building a worthy and secure habitat for women.

GLOSSARY

Natural hazards A natural hazard is a geophysical, atmospheric or hydrological event (e.g. earthquake, landslide, tropical cyclone, windstorm, wave or surge, flood or drought) that has the potential to cause harm or loss.

Disaster Risk Disaster risk is a function of the characteristics and frequency of hazards experienced in a specified location, the nature of the elements at risk, and their inherent degree of vulnerability or resilience.

Vulnerability Vulnerability is the potential to suffer harm or loss, related to the capacity to anticipate a hazard, cope with it, resist it and recover from its impact. Both vulnerability and its antithesis, resilience, are determined by physical, environmental, social, economic, political, cultural and institutional factors.

Mitigation Mitigation is any structural (physical) or non-structural (e.g. land use planning, public education) measure undertaken to minimize the adverse impact of potential natural hazard events.

Disaster A disaster is the occurrence of an extreme hazard event that impacts vulnerable communities causing substantial damage, disruption and possible casualties, leaving the affected communities unable to function normally without outside assistance.

Relief, rehabilitation and reconstruction Relief, rehabilitation and reconstruction are any measures undertaken in the aftermath of a disaster to, respectively, save lives and address immediate humanitarian needs, restore normal activities, physical infrastructure and services.

Climate change Climate change is a statistically significant change in measurements of either the mean state of variability of the climate for a place or region over an extended period of time, either directly or indirectly due to the impact of human activity on the composition of the global atmosphere or due to natural variability. Urban resilience The measurable ability of any urban system, with its inhabitants, to maintain continuity through all shocks and stresses, while positively adapting and transforming toward sustainability. Safer Hospital It is a project in partnership with the Ministry of Health and its Department of Health Infrastructure and Equipment (DIEH) funded by the Canadian Department of Foreign Affairs Trade and Development (DFATD). The ultimate goal of the Safer Hospital is to contribute to the increased resiliency of health facilities (re)constructed so that they are protected from hazards, remain functional during crises and emergencies, and provide equitable gender-sensitive health services in Mozambique. A safer hospital is a healthcare building whose services and infrastructure are gender-sensitive and remain accessible at their maximum capacity, during and immediately after a destructive phenomenon of natural or anthropogenic origin.

Sub-Saharan Africa Sub-Saharan Africa is identified as the area below the Sahara transition zone. It includes forty-nine states that share a rather similar climatic, historical and political context or in any case attributable to the same original system. Maternity waiting home (MWH) or Casa de mãe-espera Maternity waiting homes are residential facilities, located near a qualified medical facility (rural health centres) that provides maternal health care services (antenatal care, skilled births attendants and emergency obstetric care). Here pregnant women can wait safely their delivery day under the supervision of midwifes and nurses. If complications arise, they can be transferred shortly to a nearby higher level medical facility (hospitals). MWHs are a key element of a strategy to “bridge the geographical gap” in obstetric care between rural areas, with poor access to equipped facilities, and urban areas where the services are available. Designed in an effort to reduce the maternal mortality rate, they are a link in a larger chain of comprehensive maternity care.

LIST OF ACRONYMS

AICS - Agenzia Italiana per la Cooperazione allo Sviluppo BBB - Building Back Better CAM - “Consorzio Associazioni con il Mozambico” onlus CS - Centro de Saude - Helth centre CUAMM - “Medici con l’Africa” DPS - Provincial Directorate of Health DEH - Department of Health infrastructure and Equipment DRR - Disaster Risk Reduction EIGSS - Inclusion Strategy of Gender in the Health Sector FRELIMO - Frente de Libertação de Moçambique HDI - Human Development Index IEC - Information Education and Communication IMF - International Monetari Found INGC - Mozambique National Institute of Disaster Management INE - Instituto Nacional de Estatistica/Statistic National Institute IOM - International Organization of Migration IPCC - Intergovernamental Panel of Climate Change MCH - Maternal and Child Health MDG - Millennium Development Goals MEF - Ministry of Economy and Finance MISAU / MoH - Ministry of Health of Mozambique

MITADER - Ministry for Land, Environment and Rural Development MOPHRH - Ministry of Public Works and Housing MSF - “Medici senza frontiere Onlus” MWH - Mternity Wating Home ND - GAIN - Notre Dame Gobal Adaption Initiative NGO - Non Governative Organization NOAA - National Oceanic and Atmospheric Administration NHS - National Health System PESS - Health Sector Strategic Plan PHC - Public Health Care RENAMO - Resistência Nacional Moçambicana SARA - Service Availability and Readiness Assessment SMI - Servico Materno-Infantil/Maternity and child Health Institute SDG - Sustainable Development Goals SDSMAS - District Service of Health and Women and Social Affairs TBA - Traditional Birth Attendant UNDP - United Nations Human Development Programme UNESCO - United Nations Educational, Scientific and Cultural Organization UNFPA - United Nations Fund for Population Activities UNICEF - United Nations International Children’s Emergency Fund UNISDR - United Nations Office for Disaster Risk Reduction UNHABITAT - United Nations Human Settlements Programme WB - The World Bank Group WHO - World Health Organization WWF - World Wildlife Fund

1.0 - Rural village in Zembe district, Manica August 2021

PART I

1.1 - A man in the hall of the Grande Hotel da Beira Paolo Ghisu Photography

A GLANCE AT MOZAMBIQUE

In the framework of sub-Saharan Africa, Mozambique is one of the youngest nations since it gained independence only in 1975. Always been part of the world linked to trade along the Indian Ocean, with Indian, Arab and Gulf merchants, in the XV century it fell under Portuguese occupation on the coast and the British missions in the interior, drastically influencing its economic, urban and political development. Historical background Origin The origin of the name Mozambique (Moçambique in Portuguese) does not yet have a clear source. According to tradition, it derives from “Musa Mbiki”, the name of a local sultan at the time of the Portuguese discovery whose pronunciation of the name gave rise to the word Mozambique defined as the overseas territories overlooking the Indian Ocean. Most of the population of Mozambique, originally from the large lakes of central Africa and coming from the Bantu groups, settled in the Mozambican territory during the III and IV centuries. The most organized states of central Mozambique were those of the “Shona” and the “Karanga” who in the XI century were reunited in the confederation of Greater Zimbabwe (current Zimbabwe). As soon as this big community showed the first signs of decline, the Kingdom of Monomotapa started to rise (south and west of present-day Tete). Dedicated to the gold trade, this kingdom soon aroused the interest of Europeans. In northern Mozambique

the populations more powerful were instead the Maravi (Malawi) and the Yao, who dedicated themselves to the ivory and slave trade, establishing also relationships with the Arab merchants. Other ethnic groups were found in north-eastern and southern Mozambique where, in the end, no centralized structures were found until the 19th century. Starting from the VII century, the Arabs settled on the Mozambican coasts by creating ports and commercial settlements. A great part of the population was converted to Islam and the region fell under the political control of the sultans. The Arabs were subsequently ousted by the Portuguese who took possession of the settlements on the coast, useful as naval stopovers during the routes to India. (Caritas Roma, 2011) Portuguese domain and the fight for freedom The Portuguese docked on the Mozambican coast in 1498. Along the shoreline, they exploited some strategic points from a geographical point of view, already identified and built by the Arabs, in order to allow greater control of the Mozambique channel and thus dominate the merchant traffic from Europe to Asia. Among these, Lorenzo Marques, today’s Maputo, Inhambane, Quelimane, Pemba, Ilha de Moçambique, and other smaller towns. Already in 1650, the slave trade started to develop in response to a demand for manpower for colonial plantations. Portugal abolished officially slavery in 1850, but in Mozambique, the “black trade” proceeded, without major interruptions, until 1910. The actual occupation of the Mozambican territory occurred only after the Berlin Conference in 1885 (where the so-called partition of Africa by the Westerner powers took place), by means of an administrative system re-organization to subdue not only economically, but also politically, the whole country. The Portuguese colonization found a great territorial resistance by the local population, resulting in a formally “pacified country” only in 1924. From this time forward, the colony established a particularly repressive regime, based on forced labour and central government imposed plantations. Later, with the Salazar regime in Portugal, in 1928, the current condition worsened further since a new restructuring campaign of colonial domains began. The emigration of Portuguese settlers to Mozambique was encouraged, aiming to impose the new colonial middle class, while the local

population came gradually expropriated its lands. To protect the interests of the “white elite”, an attempt was made to decrease the dependence of the territory from the motherland, intensifying the exploitation of local labour and strengthening the colonial administration infrastructure. The construction of railways connecting with South Africa and Rhodesia, made on behalf of several foreign companies in need of support for the extractive industry across the border, caused an important migration of the population to the two neighbouring states. Thus in the 1950s, when the other African colonies were preparing for independence, the Portuguese presence in Mozambique was consolidating. Racial discrimination constituted a very evident feature of this period: the population was divided, by law, into Portuguese and assimilados, a privileged condition (they could have been Africans who had emancipated themselves, or people who emigrated from distant lands as Arabs or Indians), almost equal to whites, and on the other hand, the local population, the indigenous, considered the lowest society and therefore devoid of any rights. In this climate of oppression, the foundations for the national liberation struggle have been forged. On the 25th of June 1962 the Frente de Libertação de Moçambique, or FRELIMO, was created from the union of Mozambican workers’ movements emigrated to neighbouring countries. With the I congress of movement, the program said aloud the will to use all means, including armed struggle, to gain independence from Portugueses. The armed struggle began on the 25th of September 1964 in the north of the country and then slowly extended towards the south. Independence and civil war 10 years later, by means of a coup d’etat (Revolução dos cravos) that put an end to the thirty years of Salazar’s fascism, the country gained independence with the FRELIMO party who, from independence to today, lead the country. The problems that the young republic was called to face were enormous: the decolonization process led to the massive exodus of the Portuguese, who deprived the country of technicians and officials, leaving it completely devoid of trained staff and with a heavily backward system. The following months were characterized by the first attempts to develop and nationalize the administrative,

educational and health system, as well as new conflicts with the Mozambican National Resistance (RENAMO), formed by former Salazarists and racist mercenaries. These fights led to decades of bloody civil war which resulted in a million deaths and the almost zeroing of infrastructures (streets, hospitals, rail lines, schools) and the national economy. The conflict, which lasted until the early 1990s, has seen opposite the Marxists of FRELIMO, financed by the Soviet Union, and the RENAMO movement, financed by neighbouring segregationist countries (South Africa and Rhodesia-Zimbabwe). In 1992, after the fall of the wall of Berlin with the dissolution of the USSR as well as the collapse of the South African apartheid regime with US support, the two movements signed the Rome General Peace Accords and started a new democratic phase of the country. In 1994, new democratic elections were held in the country, signing the FRELIMO as the first party and the RENAMO as the main opponent. After the elections, the FRELIMO politics marked a clear change of course and in 1995 Mozambique entered the Commonwealth (the only member country in never having been part of the British Empire). Several million refugees began to return to the country. Present day Despite a few episodes in 2013, since the signing of the agreements, has begun a phase of reconstruction and reconciliation, supported by massive aid from international cooperation, non-governmental organizations and religious missions. Recently, in 2018, new tensions emerged in the Cabo Delgado region, with a conflict between Islamists and the Mozambican security forces still ongoing. A former Portuguese colony for over 400 years, Mozambique is still struggling to overcome the need to be guided during the following development phases. Unwilling to engage in the economic, social and cultural growth of the colony, the Portuguese politics never tackled the primary needs of the nation, such as a common language to communicate, causing a significant delay of the Mozambican growth and a lack of responsive management infrastructure. And despite plenty of international aid, favoured by the stability of Mozambique’s politics with respect to other African countries, economic and social indicators are still among the lowest in the world.

1.2 - Celebration day at Praça de Indipendencia (Indipendence square) Beira, 25 july 2021

Country overview Mozambique is a wide territory, spanning different climates, cultures and traditions. The official language is Portuguese, even though according to the 2017 census, Portuguese is the mother tongue of only 16.6% of Mozambicans (a percentage that rises to 38.3% in urban areas) and is spoken by 47.3% of the overall population. (INE, 2017) In the great variety of local languages (about 43 languages), mostly of Bantu origin, the main ones are: Macua (26.3%), Xichangana (11.4%), Elomwe (7.9%), Cisena (7%), Echuwabo (6.3%). Population According to the latest statistical data, Mozambique is facing an important demographic growth: in 1960 it counted 7,5 million people and in 2021 are 32,5. With a current 2,94% annual growth rate, the estimates indicate that the country will reach 65 million by 2050 (The World Bank, 2020). The population structure in the country is highly pyramidal, with 65% of the inhabitants under 24 years of age (INE, 2020). Counting more than 60% of the rural population, the density per km2 varies throughout the whole country, with a mean value of 41 (World Pop review 2021). The highest values can be noticed in Maputo, with 3750 inhabitants/ km2. However, with a life expectancy of 61.3 years, 3.5 mean years of schooling (compared to 10 years expected) (UNDP, 2019), today about 54% of the population lives below the poverty line, due to inadequate infrastructure, poor and not very transparent exploitation of the numerous natural resources, low levels of education, poor quality of health services, difficulty in accessing drinking water. Governance Mozambique is divided into 10 provinces (+Maputo city-province) which are subdivided into districts (a total of 154, of which 10 are equivalent to provincial capitals), which are further divided into 419 administrative posts. In the end, the lowest scale for administrative purposes is the locations (1,052 in total). All these units are subordinate to the central government. that provincial governors are appointed by the president and monitored by the Assemblies Provincials, which have been publicly elected since 2009.

Geography Located on a large stretch of the eastern edge of the highlands of southern Africa, it overlooks the Indian Ocean to the east with a coastline of 2,800 km long and an overall surface of 799.380 km2. Bordered by Tanzania to the north, Malawi and Zambia to the northwest, Zimbabwe to the west, Swaziland and South Africa to the southwest, it gives its name to the channel that separates it from Madagascar. The Mozambican territory does not present a great variety of landscapes. From the coast to the interior, three types of reliefs can be distinguished: (i) The coastal plain, that occupies most of the territory (40%)and where the greatest concentration of population is observed; (ii) Plateaus with altitudes ranging between 200 and 1,000 meters; (iii) The large plateaus and mountains that occupy a small part of the national territory, with altitudes above 1,000 meters. However, the large extension in the north-south direction determines different weathers according to the latitude of the country. The country has generally a tropical to sub-tropical climate moderated by its topography and influenced by the movement of the Intertropical Convergence Zone resulting in heavy rainfalls, El Niño, El Niña, bringing respectively warmer and drier than average conditions or cold and wet conditions, and surface temperatures in the Indian Ocean. All of which can vary from one year to another due to variations in patterns of atmospheric and oceanic circulation. Above the 16th parallel the Alisei winds, blowing from the Indian Ocean, regulate the succession of two monsoon seasons, one warmer between October and March, with average temperatures hovering around 32-35°C and high humidity that decreases only around May, when the temperature also drops below 30 ° C. Under the 22nd parallel, the seasons are conditioned by the anticyclones of the southern hemisphere. The hot humid season, with average temperatures around 30-35°C lasts 5 months, from November to March; whereas in the rest of the year the climate is relatively cold (18-25°C). In the centre of the country the combination of the two types of climates, the Alisei winds in the north and the atmospheric depressions of the south, cause a significant increase in heavy rainfall often resulting in extensive floods. These are exacerbated by the country’s abundance in waterways: it is in fact crossed by the wide Limpopo and the

1.3 - Koppen climate classification

Tropical savanna Warm semi-arid Subtropical oceanic highland Humid subtropical Warm desert Altitude mesothermal cores Koppen climate classification

Zambezi rivers (besides the Rovuma, Massalo, Lurio, Buzi, Save, Incomati, Matola and Maputo rivers), as well as sharing with Malawi a part of Lake Nyasa. In the last decades, exacerbated by the rising of climate change, population rapid growth and environmental degradation, cyclic and dramatic episodes related to climate extremes, such as cyclones, floods, droughts are affecting the whole country. Economy With favourable environmental conditions, Mozambique is a land rich in resources, including kilometres of white beaches and coral reefs, coal, graphite and natural gas deposits, seafood and huge ports. In addition to a large potential pool of labour since the average young population, it is also strategically located, given the fact that four of the six countries it borders are landlocked, and hence dependent on Mozambique as a conduit to global markets. However, Mozambique’s local economy is mainly based on agriculture, which corresponds to approximately a quarter of GDP, followed by the manufacturing sector (about 15%) and services (10%). Only in recent years, Mozambique is undergoing a process of structural change shifting the sources of growth from agriculture to manufacture and services characterized by capital intensive activities (largely “megaprojects” in the extractive, export-oriented industries). Nevertheless, high-productivity and subsistence agriculture still employ most of the workforce (more than 70%), with the remaining divided by the second and third sectors. Therefore, with such a poorly diversified production base in which about ¾ of the economically active population are employed in agricultural activities, the industry has remained uncompetitive and the country imports most of the consumer goods it needs (The World Bank, 2020). To this must be added that Mozambique is one of the major recipients of international aid in the world, currently representing about 41% of the GDP. In fact, Mozambique today attracts international interests for large projects involving important foreign investments. In the medium term, the economy is predominantly based on the extractive sector launched at the beginning of the nineties, characterized by the reactivation of the colonial infrastructure network and the creation of new connections always based on the transport of raw materials, re-

proposing, under changed guises, the logic and mechanisms of subordination to the Western world. Thus, the enormous wealth of the subsoil is entrusted to large international investors who, on the one hand, have in fact appropriated large territorial areas excluding populations and on the other have started the territorial reorganization of the country by designing, in fact, on private purposes, the new large infrastructures exclusively for the export activity. And, as can be imagined, along these corridors, very few are left to local communities, making it clear how commercial interests override local development objectives, allowing these new settlers to “steal from the population their own roots”. (Diamantini, 2020) Development observation The above-presented phenomena, exacerbated by the recent climate emergency, have profoundly marked the territory which is struggling to rise again. Many theories are proposing valuable reasons: one lay on the belief that the former colonial rule is still the cause of underdevelopment, other blame the socialist Sovietstyle development policies established after independence, some on the civil war, and some on the global economy (Newitt, 2017). There is certainly a causal overlap, but perhaps the problem can also be traced in the development approach, still based on Western cultural matrices instead of allowing the evolution of a new and context-related development model (Del Bianco, 2021). In the end, these are also framing the reasons why the country didn’t experience yet the big urban transformations that have happened instead in other African nations. Mozambican cities are small and medium-size, with an urban development that cannot compete with the one that hit Laos City or Nairobi, characterized by fringes of modern cities, built on international language, and infinite slums at the borders, where living conditions are extreme. Maputo has a population of around 1.5 million inhabitants, while all other cities count below 500,000 units. Regardless of generous aids, economic corridors and development strategies, the rural population is still high to 65% (INE, 2020), enhancing how Mozambique is still a country with two characters, one urban, on the other profoundly rural.

A two speed country: rural and urban

Population (thousands)

70 60 50 40 30 20 10

2050

2025

2000

1975

1950

Urban

1.4 - Chart: projected urbanization profile of Mozambique, Moçambique perfil de habitação, UNHabitat, 2018

Rural

Mozambique is going through an important transition from a rural to an urban country, with a density of 39,7 people every square kilometre in 2020 (World Bank, 2021). With an urban population of 35%, which is growing every year with an increase from 3.2% to 5% it will reach its urban majority by 2050. However, the country is interesting because its majority of contemporary forms of living are rural, mapped as 65% of the total population (INE, 2020). It is also important to note that the recent urban growth is, to a large extent, associated with the natural growth of the population and not with rural-urban migration: since 2005, the average rate of change in the urban percentage is only 0,79%. Only in the latest years, the urbanization phenomenon started to rapidly increase, projecting the population residing in urban areas to 49% by 2050 (UNHabitat, 2018). Besides, among the 2/3 of the rural population, a large percentage counts alto the settlements discernible mainly in the intersections between national and provincial highways, where commerce and light industry are developed due to facilitated logistical access. They present some urban characteristics, such as greater density and an established road network, but are not considered “urban”. Nevertheless, the urbanization process in Mozambique continues to be fairly gradual relative to the pace of urbanization in other African countries. Most future urbanization is likely to occur within major cities, even though small-town populations are growing

more quickly. The long-term implications of urbanization are difficult to measure. Survey and census data reveal strong, complex production and consumption links among rural areas, towns, and cities. These economic links and structural differences will determine the national benefits and trade-offs from urbanization. They will also influence Mozambique’s choice of whether to adopt urban- or rural-oriented development strategies. Urban processes are closely linked to poverty reduction and economic growth, however, nowadays there are still large differences in poverty levels (which displays regional patterns) and wealth across urban and rural areas in the country showing how inequality during the development process can undermine both. Despite the forecasted 6.3% GDP in 2023, the Human Development Index ranks the country 180th (out of 187 countries) with over half of the population living on less than $1.50 a day. Nearly 8 out of 10 of those poor lives in rural areas. (World Bank, 2021). Moreover, Mozambique is one of the major recipients of international aid in the world. In recent decades, this has been growing steadily (in 1981, they received $158 million; in 1987, $735 million; in 1990, $1.061 billion) establishing the country as the most exemplary case of “donor doll”. One wonders where this money has gone despite to finance the state apparatus. Therefore, it is evident that Mozambique is proceeding at two different speeds. The 35% of the population residing in cities has greater economic and employment opportunities, secure and regular income (even if wages are very low), better education and health services. In rural areas, instead, life seems to have stopped. The familybased agricultural sector does not rely on any assistance, even if it constitutes the basis of the country’s economy. Away from urban centres, communications are difficult, the roads lie in a state of neglect, services are lacking, school and health facilities are insufficient and located in precarious buildings deserted by teachers and nurses. People feel forgotten by the government, engaged in other far more profitable matters and present only to moment of election campaigns. The double speed can also be seen in consumption. For the wealthy few in the cities, there

are shopping centres, boutiques, exclusive shops with imported goods. Local markets and informal trading serve the rest of the population with poor quality products. In early 2000, the government engaged a campaign to fight poverty and inequality, which was expected to culminate in 2015, the year of the Millennium Goals. However, at the 2015 deadline, the standards forecasted have not been met. Much has been done in fifteen years, but not enough, driving a new document of intent that has taken the name of “Agenda 2030 for Sustainable Development”. According to the writer Mia Couto “The greatest poverty, Mozambique is affected is the inability to produce an innovator speech. The one against poverty is a poor, repetitive discourse, based on stereotypes and populist slogans. It does not touch reality; it does not go to the bottom of the matter”. If this development is to be fruitful, it must go beyond the terminologies and container words such as “MDG (Development Goals for the Millennium), SDG” (Sustainable Development Goals). They have served to describe it, but above all to project the myth of the West on the paths of African societies. For an exit from subordination, the “tomorrow” structure will have to point in another direction, aiming at the development of endogenous socio-economic processes accompanied by a cultural enhancement and freedom of international assimilation in order to achieve a fruitful hybridization. In a context such as Mozambique’s, where few urban areas and few economic sectors are highly specialized or capital intensive but rich in cultural expression and traditional knowledge, the economic and social interaction between urban and rural areas may be the crucial component of a successful development policy to fill the gap between the two worlds, aiming to integration rather than a change. Rural habitat In the Mozambican rural territory, the physical and geographical space is extremely wide: from one village to the other grow vast areas where you can find no traces but those of nature. Only by means of settlements do men manage to build a protected habitat from the immense and indomitable forces that surround them. To

work in this context, one must be able to know how to accept the rhythms of thought and work of the locals, adapting his to theirs. The idea of imposing one’s own time and way of operating doesn’t meet the inertia of a system that is established on participation. In Mozambique, except in special cases, the production system is poorly structured and developed, especially due to the scarcity of a skilled workforce. Materials, techniques and professionals that have grown and diversified in the western world, here are in their early days. The market for many construction products, including timber beams or planks, concrete, metal plates of different types, has developed exclusively in major urban centres. Components such as blocks of concrete must be made directly on site, or fired bricks and perforated bricks are available only in some areas, manually produced since the absence of factories. Other materials such as iron, glass, nets, nails and electrical systems are not produced locally, but on the contrary, they are imported from other countries and transported to the construction site. Instead, what is widespread is the use of traditional materials such as earth, clay mixed with straw, trunks of native essences, foliage and bamboo. However, recently, very fast and parallel diffusion of galvanized metal sheets took place within urban cities. In the name of ostentatious modernism and pressing globalization, it is now the preferred element for roof construction, and sometimes even for vertical infills and coatings. In fact, despite the preponderance of rural territory compared to urban settlements, the image of the city affects life in the countryside, with the consequent demand to modify and adapt the constructions, both residential and public. Thus, the metal sheet becomes the immediate response in construction, although not always compatible with the local climate. Indeed, a house with a thatched roof and leaves ensures better internal comfort than constructions with a galvanized sheet. However, the new material is easier to assemble and has greater durability. In the same way, the houses built with concrete blocks begin to replace those with pau a pique or caniço. Rural architecture is evolving, but not always in the direction of sustainability and environmental comfort. Moreover, the lack of infrastructure and technological components makes even more

1.5 - People collecting water at the community well in Nhamatanda district August 2021

crucial a climate-adaptive design in the countryside, providing passive natural ventilation systems such as orientation with respect to the sun and prevailing winds, shading devices and a careful selection of building materials. For example, in rural areas, air conditioners are not present because of costs, maintenance and especially the lack of electricity that characterizes much of the continent’s countryside. Public and private space Cultural conditioning is the most delicate to understand and, consequently, the hardest to respect. It is difficult to comprehend the use of space, whether public or private, of a culture different. There are relationships with daily physiological needs, rituals, taboos, uses of relevant community places which the project has to take into account, besides user needs. In Mozambique, as well as in Sub-Saharan Africa more generally,

the social life of the family takes place mainly outside. The kitchen, a canopy under which meals are consumed and people rest during warm months, is located outdoors, distributed within a gated courtyard, scrupulously swept and cleaned several times over the day. The fence can be made of bamboo or by means of intertwined palm leaves. Compacted soil roads or narrow dirt paths are the main access to the settlement’s courtyard, used as outdoor living rooms. The large crowns of the trees guarantee abundant shade all year round and contribute to a pleasant microclimate during daily home activities. The indoor environments are just for sleeping and storing food as well as the family’s assets. Therefore, family life grows around this relationship between inside and outside. Rural landscape Compared to the verdant plains of Southeast Asia, rich in water and fields designed by human action, or with respect to countries of South America, strongly characterized by regions mountainous, covered with lush forests, the territory of Africa Sub-Saharan is characterized by its horizontal dimension. Large flat floodplains, painted by large and isolated trees with wide hair, host rarefied settlements on the territory, sometimes concentrated in compact cities. These horizontal directions often translate architectural elements into long bases and roofs, underlining the relationship between the building and the horizon. Of course, this condition is typical of the rural environment, where there are no built-up areas obstructing the long view of the countryside. Therefore, in this context, humans have to research a meaningful indoor space. This means building shelters capable of dealing with the infinite horizontal surfaces and the human dimensions of daily habits. Only building these “interior spaces” allows us to return to the open space and multiply the dimension that always puts people at the centre of any architectural project. Sand, earth: undoubtedly the predominant natural element of the Mozambican landscapes which is capable of determining the character of places, present into the soil, within buildings and in the dust blown by the winds. The large presence of sand, almost everywhere, gives to the landscape a bare, desert aspect,

in which the few elements present, natural or anthropic, take on an important role, becoming protagonists of silent and desolate territories. The same soil, with its red, yellow and brown tones draw the buildings by means of raw earth blocks, fired clay bricks or sandy plasters with straw and cement. The buildings seem to rise from the earth, sharing the same matter and colours. The Mozambican, and more broadly African rural landscape represents one of those places which can still be referred to as natural, in opposition to the environment of Western countries which is now totally anthropic. Here, all terrains are drawn, including the countryside with fields and terraces, result of a thousand-year-old work of man. The natural part we are used to dealing with is smaller than large artificial surfaces: streets, squares, infinite parking spaces; nature is something that exists far from cities, on high mountains or remote islands. Even urban parks represent green islands within a sea of pavements, as well as agricultural fields, which appear increasingly confined by infrastructures upon the open space. In Mozambique, on the other hand, there is an opposite situation. Streets, parking lots, paved surfaces, are artificial scraps of land which seems to grow without interruption. In Mozambique, outside the urban areas, the roads are sandy and people walk alongside cars, except closer to the larger cities where roads are covered with asphalt and paved sidewalks. In the countryside, everything that has an anthropic character is much less frequent than the entire territories dominated by the action of nature.

1.6 - A red clay road connecting Chimoio to Zembe in Manica district August 2021

1.7 - A nurse taking a break after a long hours shift at the Ponta Gea urban Health Centre, Beira June 2021

OF HEALTHCARE AND MATERNITY «O Nosso Maior Valor É A Vida» MISAU, Mozambique

The care system Background During the 60s -70s, under the basis of different types of African socialism and economic constraints related both to geopolitics and internal social affairs (Mondlane, 1969), countries as Mozambique struggled to build a comprehensive public health care system based on community health workers, health posts and centres, rural hospitals, and larger provincial hospitals. However, the Mozambican public health care system strongly incremented its infrastructure after independence, from 326 health care facilities in 1975 to 1,195 in 1985 (Magnus Lindelow, Ward, & Zorzi, 2004), thus becoming a model of PHC (Public Health Care), thriving for equity and erasing the colonial medical service that had emphasized curative and urban-based care. In fact, before 1975, the main concern of the colonial administration was to guarantee the wellbeing of Portuguese citizens, providing care just to the white urban population rather than to the largely rural native population. On top of the biased distribution of services, it is important to note that up to two-thirds of the doctors in the country were practising in the capital city, Maputo (Raisler 1984). In the 1980s and 1990s, Mozambique went through deep social, economic and political changes. In 1989, twelve years after the beginning of the civil war and after two donor strikes in 1983 and 1986, the ruling Front for the Liberation of Mozambique (FRELIMO) party formally abandoned Marxism.

Under the pressures of the International Monetary Fund (IMF) and the World Bank (WB), in 1987 Mozambique signed a structural adjustment programme (SAP), and, in 1990, a new constitution provided multiparty elections that brought the privatisation of services, reductions in government spending, and a transition to a market-oriented economy. The continued increase of foreign aid after SAP turned Mozambique into one of the major recipients of health aid in Africa nowadays (IHME, 2016) and the wide range of actors in the health sector - multilateral organizations, bilateral donors, NGOs, foundations or universities - has led to fragmentation inside the sector through uncoordinated foreign aid flows and competing donor interests. By the mid-90s, the governability of Mozambique was weak, the State budget on health was very scarce and a significant number of healthcare facilities were destroyed in the context of a civil war, mainly in the rural areas. During the following years, the big majority of Mozambicans were using a weakened public health care system (WHO, 2016) with very limited resources. The predominant rhetoric regarding public welfare, promoted in a context of scarce public funds and high international and often much-conditioned aid dependency, has placed additional hurdles on the possibility to develop a minimum comprehensive approach of the public health care system (Mackintosh, 2000). The current Constitution of Mozambique protects the right of individuals to health. However, although the population may have such right, its access remains restricted to the direct and indirect costs of accessing services, including the physical accessibility, sociocultural factors, or perceived benefits and needs (dos Anjos & Cabral, 2016; Wagenaar et al., 2016). Moreover, the health systems do not often take into account that almost half of the population sees traditional medicine as a first option to get health care. Almost 70% of the population in Mozambique seeks care in traditional medicine for physical or psychological concerns, and the estimated ratio is 1 traditional practitioner per 200 inhabitants (MISAU, 2012). Nevertheless, nowadays the situation is improving, but especially at the primary level, healthcare is characterized by a poor and not evenly spread infrastructure, scarce skilled health personnel and,

unfortunately, much more common than it is often imagined, unavailable basic requirements (an average of 34% of sanitary units) such as running water (19%), reliable power supply (12%), latrines for patients (17%) drugs, oxygen, safe transportation or diagnostic and therapeutic equipment. (SARA, 2018) Moreover, the recent climate extremes have brought the country to its knees with further damages to the national infrastructure network, destroying houses and drastically compromising the operability of basic services such as healthcare. In fact, plenty of health centres have been completely or partially destroyed, more than 50 units only in Sofala province, leading to care delays and post-disaster danger (cholera, malaria, HIV outbreaks etc.) (Post Idai assessment, 2019). Therefore, a huge need for support and reconstruction is now developing across the most affected regions (Sofala, Cabo Delgado, Manica) aiming at restoring and further improving the essential services, with healthcare as one of the key topics at the top of the list.

OMS - MISAU target

2,00 1,60 1,20 0,80

1,03

0,55

0,38

0,50

0,49

0,63

0,73

0,92

1,01

0,45

0,33

0,57

Nampula

Zambezia

Tete

Manica

Sofala

Inhambane

Gaza

Maputo Provincia

Maputo city

Total

0,00

Cabo Delgado

0,40

Niassa

Health units per 10,000 ppl.

2,40

1.8 - Rate - Health Units per 10.000 inhabitants SARA, 2018

Sanitary Unit

Urban Rural

Catchment area (CA) thousand / millions

Hc type C

Primary

10 - 25 t

Hc type B

Primary

20 - 48 t

Hc type A

Primary

40 - 100 t

Hc rural II

Primary

7 - 20 t

Area of influence Km

Location

Barrios

General / District Hospital

Rural area

Rural Hospital

Rural / General / District

8 50 indirect

Higher reference Hospital

Hc rural I

Primary

16 - 32 t

8 50 indirect

District Hospital

Secondary

50 - 250 t

near Hc CAs

Main town / roads

General Hospital

Secondary

150 - 900 t

District and borders

Main town

Rural Hospital

Secondary

150 - 900 t

District and borders

Main town / roads

Provincial Hospital

Tertiary

800 t - 3,5 M

Province and borders

Main town

Central Hospital

Quaternary

All

Province and borders

Capital of province

1.9 - Tab - description of Health care physical asset in Mozambique SARA, 2018

Service provision

Provincial / Central Hospital

Structure The current health care system in Mozambique is quite similar to the majority of Sub-Saharan African countries. Yet predominantly public, it is organized into four levels of care (primary, secondary, tertiary and quaternary) where the primary and secondary levels are oriented to the provision of Primary health care. The definition of the health facilities is based on the size of the catchment areas but ruled by an outdated Decree 127/2002 (MedicusMundi 2018). On an overall number of 1651 sanitary units, the primary level comprises 161 health posts and 1,574 health facilities (Rural Type I and II and Urban Type A, B and C) providing basic preventive and curative health services. The secondary level includes 54 basic hospitals such as rural, district and general hospitals, some of them providing also surgical services. The 7 provincial hospitals constitute the tertiary level and the 7 central hospitals constitute the quaternary level, at the top of the health pyramid. (SARA, 2018). Sanitary units 2016 - 2020 INE, 2020

1401

Health centres

1536 50

Rural / General / District Hospital 10

2016

2017

2018

2019

1600

1400

1200

1000

800

400

11 200

Central / Provincial Hospital

2020

Policies and management In Mozambique, the health sector is made up of the Ministry of Health of Mozambique (MoH), 11 Provincial Directorates of Health (DPS), 146 District Services of Health and Women and Social Affairs (SDSMAS). DPS and SDSMAS are subordinated to the MoH and the Ministry of Economy and Finance (MEF). One of the key elements in the governance is the development of health policies and the formulation of strategic plans by the MoH to design the interventions which will be implemented to achieve desirable health outcomes.

1.10 - Chart - development of Health care Units from 2016 to 2020 INE, 2020

1.11 - Tab - Prevailing policies addressing the Maternal and newborn mortality rates in Mozambique since 1978.

Since independence, healthcare has been guided by a sequence of Five-Year Development Plans. In 2002 the Government of Mozambique introduced a series of reforms in all sectors of development with the aim of starting a process of decentralization and bringing the leaderships closer to the lower levels of the State organization (Provinces and Districts). For the Municipalities was chosen a model of power delegation is currently in the process of expansion to all municipalities in the country. It is in this context that the health sector started its Strategic Plan for the Health Sector – PESS in 2000 with the aim of gradually improving the health status of populations. The current PESS is the third of its kind (PESS III 2014-2019 extended to 2023), representing a continuation of this good management practice in the country, with a view to improving access and quality of current services (Pillar 1), while at the same time continuing a series of Health Sector Reforms designed to improve the effectiveness and efficiency of overall service delivery at all levels (Pillar 2). (PESS, 2014 2019) In fact, following the main criteria are access, use, quality, equity and efficiency, the approach consist of addressing 7 strategic objectives: 1. Increase access to and use of health services; 2. Improve the quality of services provided; 3. Reduce geographic inequalities, and between population groups, in access to and use of health services; 4. Improve efficiency in service delivery and use of resources; 5. Strengthen partnerships for health on the basis of mutual respect; 6. Increase transparency and accountability in the way public goods are used; 7. Strengthen the Mozambican health system. Moreover, besides PESS, several policies exist to support the health sector in Mozambique towards achieving comprehensive health care delivery, and the more recent ones, with reference to the Sustainable Development Goals (SDGs), have been developed and are in implementation: Government Five Year Program 2014 – 2019, the Economic and Social Plan (PES), and the National Plan for the Development of Health Human Resources. Specific programs and strategies are then established for the acceleration

1978

MATERNAL AND CHILD DEPARTMENT Also known as SMI, it provides health care specifically to mothers and infants

1984

NCH PROGRAM Specific training of basic level nursing professionals (Mother and Child Health Nurses)

1987

SAFE MOTHERHOOD PROGRAM Safe Motherhood Conference in Nairobi Raising awareness about the maternal mortality problem in developing countries

1990 MM - 1390

1991

TBA Traditional Birth Attendants as skilled workers 1995 MM - 1150

2000

THE MILLENNIUM DEVELOPMENT GOALS (MDGs) MDG goal 5#: improve maternal health (reduce maternal mortality)

2001 2001 MM - 915 2005 MM - 762

PESS I (2001- 2005) First national strategy aiming at reducing MM by promoting availability, access, and use of emergency obstetric care.

2007

PESS II (2007 - 2012) Target of increasing institutional deliveries with National Strategy for Sexual and Reproductive Health. Promote access to family planning services 2010 MM - 619

2009

MATERNITY WAITING HOMES Strategy to reduce MM in rural areas

2014 > 2023 2015

THE SUSTAINABLE DEVELOPMENT GOALS (SDGs) SDG goal #3: improve overall health and well-being - reducing the global MMR to less than 70 deaths per 100,000 live births between 2016 and 2030 (with no country having a rate more than twice the global average)

2015 MM - 489

2017 MM - 289

PESS III (2014- 2019 / 2023) Improve the access, use and quality of Health sector > number and % of rural centres with MWH > From 2019 new rural health centres have to be built with a MWH (SMI)

2018

Safer Hospital (UNHABITAT - Canada - MISAU) Strategy to mitigate maternal mortality and promote gender-sensitive approaches within health centres Target SDGs - 70

of some objectives and the overall provision of health care. For example, the Family Planning and Contraception Strategy 20102015 (2020), the Inclusion Strategy of Gender in the Health Sector (EIGSS) 2018 – 2023, the Accelerated Plan for the Reduction of maternal mortality, the Accelerated Plan for the Reduction of New HIV/AIDS Infections (2013 - 2017), the Accelerated Plan for the reduction of vertical transmission (SARA, 2018) and lastly, the Safer Hospital program (2018 – ongoing) promoted by MoH, developed by UNHabitat and shortly presented in the next chapter. Besides the general objective to improve the healthcare system, a relevant point to note is that all these efforts translated into policies with health implications embody the equity and gender dimensions; central to the policies is the empowerment of women, reduction of maternal, new-born and child mortality, combating HIV/AIDS, Tuberculosis and Malaria among other priority issues and diseases (SARA, 2018). Therefore, a clear focus on the maternal/child-youth population is currently processing, in order to reduce and mitigate geographic, socioeconomic and gender inequalities. Maternity focus In 1978, soon after Mozambican independence, the MoH decided to put the primary health care of women and children as a priority, creating the maternal and child health (MCH) department, also known as SMI. Among the strategies and programs implemented across the next decades, the main evolutionary milestones can be detected in (i) the promotion of training levels oriented to managing maternal and infant health: MCH nurses; (ii) a National Comprehensive Maternal and Child Health Program/ Family Planning (1984) – with expanded program on vaccinations, schooling and adolescent health; and (iii) defining policies in order to encourage the formal education of young woman. Besides the 80s nursing training, the 90s development and promotion of the national TBA programme in 1991, only in 2001 was created a very important opportunity to strengthen and scale up the interventions in this area: the PESS I with the Maternal and Child Health as top priority intervention. The objective in this area was oriented to the reduction of maternal mortality through the expansion and utilisation of basic and comprehensive essential

obstetric care. This included preventive measures like family planning, antenatal care, and post-partum care. The present-day tells a significant improvement in the indicators of access, utilisation and maternal health outcomes in Mozambique. However, the level of income at the household level, the resources distribution within health services, the geographical distribution and availability of health-care services, and the level of education of the mother, among others, still appear to be the main limits to the national program implementation (SARA, 2018). The problem of maternal and new-born mortality Overview Approximately 303.000 women die each year from preventable causes related to pregnancy complications and childbirth. Roughly two-thirds of them occur in Sub-Saharan Africa, where a woman’s lifetime risk of dying during or following pregnancy remains as high as 1 in 37 - compared to 1 in 4.500 in the developed world (WHO, 2017). This statistic illustrates the extent of the inequality in health coverage for women still facing a wide range of problems and constraints in their daily lives (mainly originated from their lower status than men in all spheres of life – i.e. family, community, labour market, religion or politics. Moreover, large gaps exist in coverage and access to quality maternal health services between the poorest and richest households, and between rural and urban areas. In Sus-Saharan Africa only 56% of births are attended by skilled health personnel in rural areas, compared with 87% in urban areas (IS Global, 2017). Despite an overall decline in maternal mortality worldwide in the last decades (MDGs period 2000 – 2015), women continue to bear an unacceptable health burden, especially those less-educated and living in rural settlements. Though more women and adolescent girls are receiving services (e.g. delivery with a skilled birth attendant, antenatal care visits), these are often of poor quality (IS Global, 2017). The recently agreed development agenda, the Sustainable Development Goals (SDGs), includes new and ambitious targets for maternal and reproductive health including ending preventable

maternal mortality by reducing the global Maternal mortality to less than 70 per 100,000 live births by 2030. A huge challenge to undergo in the short term given the low coverage rates and unequal distribution in most Sub-Saharan countries such as Mozambique. The Republic of Mozambique currently faces high rates of maternal mortality from pregnancy and childbirth complications throughout the entire country, especially in rural areas where 65% of the population lives and the healthcare service struggle to equally spread (The World Bank, 2020). In 2017, the woman mortality rate was 289 per 100,000 live births, while the newborn mortality rate was 54.8 per 1,000 live births (UNDP, 2017). Key factors The causes of maternal mortality are well known and have been documented and classified during the last decades. Almost 3/4 of deaths are a consequence of direct obstetrics complications (eclampsia, sepsis etc.) that may be irreversible if care is not provided in time. However, the National Health Systems fails in bringing skilled attendance to pregnant women in need, because of the multiple and, most of the time, insurmountable barriers that limit access - geographical, social, cultural, educational and economic -. Therefore, maternal mortality is a combination of multiple and interrelated factors that have to be analysed to understand the context influencing Mozambican maternal mortality rates. The first set of causes are described as “direct causes”. Also named immediate medical causes, are those maternal deaths related to obstetric complications – including postpartum haemorrhage, eclampsia, infections, prolonged or obstructed labour as well as a complication following abortion. The second set of maternal mortality causes, “indirect causes”, includes factors that contribute to a mother’s risk of dying, which is exacerbated by pregnancy. The key ones are related to HIV/ AIDS, malaria, nutritional aspects (with special relevance to maternal anaemia), low access to basic health care support, and more specifically, to quality antenatal care and support. In fact, in Mozambique, only 59 % of pregnant women realized at least four antenatal visits (INE, 2020). There are several factors that have been recognized as potential causes in obtaining proper delivery care and support by a qualified practitioner: social, cultural and

1.12 - Pediatric visits at Chingussura Health Centre in Beira July 2021

economic issues, including low-income households, rural area housing, access obstructions and women’s education (including also cultural and anthropological aspects) and lack of antenatal care quality, or poor support. (SDG report 2015). Within these categories lie several explanations that clarify why access to obstetric care remains, in most cases, unachievable: basic or structural causes include relevant aspects such as health education, knowledge, inadequate maternal health practices and care-seeking, poor health facilities environments and services, and limited access to skilled health workers. These factors highlight the inability of the health national system to set up effective family planning programmes in order to increase access to qualified health care and the failure to provide obstetric care when and where it is needed. Thus, if on one hand, the patient culture-education-economic status and place of residence influences the access to quality care, on the other hand, infrastructures, services and human resources determine which level of service can be offered. Even though plenty of health centres have been built or rehabilitated and the medical universities opened to the population (for the few who can afford it or reach it), Mozambique has still an inadequate health network and coverage, along with a crisis of the health workforce. The national average ratio is less than 1 (0.57) Sanitary units and 6 health workers per 10,000 inhabitants (SARA, 2018). Transport for referral and emergency response (including public transport) is the other major factor influencing maternal mortality rates. The lack of appropriate public transport affects the entire continuum of fundamental care during the pregnancy cycle: antenatal, deliveries and post-natal consults. However, the recent infrastructure improvement made coverage more effective, at least for the facilities located near the main paved roads and corridors. Finally, we can describe “underlying causes” that prevent the utilization of potential resources as previously mentioned. Underlying factors do not affect exclusively maternal mortality rates, but interaction among them can reduce access of women to quality maternal health care. Poverty is one of the key factors that affect maternal mortality and 72.5% of the population in Mozambique is estimated multidimensionally poor, living with less than 2 $ per day (UNDP, 2020). Women tend to live in an even more negative situation, as

indicated by the Gini Index which measures inequalities between men and women. Gini Index (100 means total gender inequality and 0 perfect gender equality) in Mozambique is 54 showing a high degree of gender inequity (World Bank, 2014). Education and literacy rate are two other values that demonstrate inequality between women and men and create another barrier to care access. In fact, Mozambique has an adult literacy rate of 60.66%. While the male literacy rate is 72.6%, for females is 50.3%, showing a big gap between the genders. Globally compared, Mozambique ranks 135º on literacy rate (UNESCO, 2017). Culture and the place of residence are two interconnected values since the more secluded communities are also the ones closest to ancient values and traditions. Mozambique has a local culture still strongly dominated by rural villages, male chauvinism and vernacular care. This results in challenging access even to the infrastructure to reach the sanitary units given the condition of the roads, especially in the rainy season; a chronic mistrust in the health services, preferring to use local treatments; devoted respect for ancestral practices such as giving birth to the first child at home, with all the risks that the act involves. In conclusion, poverty, education, culture, geography and gender inequities, together with poor infrastructure quality, are primary factors that contribute to the high maternal mortality indices. Overall, addressing these inequalities is very important in efforts to improve the health status of the whole community. The three delays model As described above, numerous factors contribute to maternal mortality. However, the interval between the beginning of obstetric complications and its conclusion is one of the most critical aspects. The “Three Delays” model (Thaddeus and Deborah, 1994) proposes that pregnancy-related mortality is mainly affected by delays in: (i) delay in the decision to seek care, which means delay deciding to seek appropriate medical help for an obstetric emergency; (ii) delay in arrival at a health facility, therefore delay reaching an appropriate obstetric service and (iii) on behalf the health system, delay in the provision of adequate care when it is reached. The first delay stems from a failure to recognize danger signs. This is usually a result of the absence of skilled birth attendants. It

1st delay Delay in the decision to seek care

Community level

2nd delay Delay in reaching the health facility due to a lack of access From community to helath facility

3rd delay Delay in the provision of adequate care and referring Inside the National Healthcare System

1.13 - Three delays model Thaddeus and Deborah, 1994

may also stem from reluctance within the family or community to send (or allow) women to attend health facilities due to financial or cultural limitations. The second delay is caused by a lack of access to a health facility, a lack of available transport or a lack of knowledge of the existing services. The third delay relates to difficulties in the referral facility (including inadequate equipment or a lack of trained personnel, emergency medicines or blood). All countries that have reduced maternal mortality have done it through a dramatic increase in hospital deliveries. Therefore, maternal mortality reduction programmes should give priority to the availability, accessibility and quality of obstetric facilities (UNFPA, 2010). It can be said that the first delay is related to the procurement of services, whereas the second and the third are related to the offer of services. Strategies to improve maternal health care should contemplate both, offer and demand, due to the multiple origins of causes. However, distance and cost are major obstacles in reaching appropriate obstetric facilities. As a result, the governments of most developing countries are mainly trying to increase access and reduce the second delay. Maternity waiting homes, deeply analysed in the further chapter, are one of the strategies most recommended as they are designed to reduce the gap between the community and the health system. MHWs try to reduce delays in treatment by moving women at risk into MWHs located near hospitals, tackling the second delay of the “three delays” model. Within this context, maternity waiting homes appear like a valuable option intended to minimize the risks. In addition, MWHs appear as a cost-effective strategy in developing countries intended to increase institutional deliveries and by this intervention, reduce maternal mortality.

1.14 - Girl playing with a condom as a balloon in Manica Province August 2021

1.15 - A woman headed to the river for laundry Beira, 2021 Paolo Ghisu Photography

CLIMATE CHANGE EFFECTS “2019 was one of the three warmest years on record in Africa”. (WHO, 2020)

Climate change is one of the greatest challenges facing humanity today. It affects every country and has devastating effects on communities, economies and individuals. Together with a dramatic biodiversity loss, most of the weather patterns are changing, sea levels are rising, and catastrophic events are becoming more extreme (UNHabitat, 2018). Much of this crisis is caused by extraordinarily high levels of greenhouse gas emissions from industrialised countries where buildings contribute approximately 40% of overall global CO2 emissions, both through their construction (embodied energy) and through energy in use (operational energy) (WorldBank, 2018). However, most of the effect are detected among developing countries, particularly vulnerable to climate hazards and with a high percentage of the population living in poor structures along the river banks and wetlands or on hills and slopes exposed to landslides. Of course, the need to face up to these emergencies lies primarily with the industrialised countries of the world, but most of Africa will have to embrace policies of both adaptation and mitigation as they undergo a process of rapid urbanisation and economic growth. A holistic and resilient approach to sustainable building design is one way in which the worst consequences of these crises can be avoided. Despite the threats, climate change has not been addressed by many countries yet. The reasons include the lack of sufficient urban policies and action plans derived from a shortage of capacity and resources together with a lack of public awareness of climate instability.

1.16 - People wade through flood waters in a rural neighborhood near Beira on March 24, 2019 Andrew Renneisen

1.17 - Idai results in the Sofala countryside 2019 International Committee of the Red Cross

Vulnerability to climate change “2019 was one of the three warmest years on record in Africa”. (WMO, 2020) According to the latest report by the Intergovernmental Panel on Climate Change (IPCC, 2021) published on August 9 2021, scientists detect changes in the Earth’s climate in every region and throughout the whole climate system. Many of these are unprecedented and some that are already underway - such as the sea level rise - will be irreversible for thousands of years. The goal is to limit global warming below an increase of 2 °C compared to pre-industrial levels by 2050. Even better, within 1.5 °, a critical threshold for limiting climate impacts. But the temperature is not the only element in play. Indeed, the main impacts of climate change will not be felt through higher temperatures but through a drastic change in the hydrological cycle. Global warming will alter ocean currents, intensifying precipitation and unevenly spreading rainfall patterns around the globe. The subtropical areas will become progressively arider and affected by chronic droughts resulting in degradation of arable land, damage to crops and loss of livestock. Tropical cyclones in coastal areas will become more intense with extreme wind speeds and greater rainfall causing a more frequent series of floods e landslides. In the last 10 years, extreme meteorological phenomena, previously considered exceptional events, have become part of everyday life revealing the growing vulnerability of each site. And the fault of these periodic scenarios of destruction is human induced. Defined as “the degree to which a system is susceptible to and unable to cope with the adverse effects of climate change”, (IPCC,2007) vulnerability is a function of the character and rate of climate change and variation to which the system is exposed, its sensitivity, and its adaptive capacity. It can be high because of high exposure, high sensitivity, or low adaptive capacity. Thus, due to geographical location or socio-economic conditions, some countries are more vulnerable to the impacts of climate change than others. Further, some countries are more ready to take on adaptation actions by leveraging public and private sector investments, through government action, community awareness, and the ability to facilitate private sector responses.

As globally known, developing countries are the regions or sectors with the highest vulnerability since they are most affected by climate change and the least able to afford its consequences. Their vulnerability - resulting in an increasing loss of lives and properties, scarcity and contamination of water, disease and malnutrition - is due to multiple factors that limit their ability to prevent and respond to the impacts of climate change. First of all, the economic importance of climate-sensitive sectors such as forestry and agriculture in combination with a low adaptive capacity; in fact, sub-Saharan Africa counts 65% of the workforce implemented in agriculture, where small changes in climate can cause large environmental changes in a fragile context. (Climate change impacts on Developing Countries EU, 2007) Secondly, the rapid population growth and urbanization density, leading to high rates of people living in slums by 2030, combined with lacking the financial capacity to respond, are likely to even intensify the climate change effects. Further crucial risk elements are poverty and socio-economic inequalities. Among the reasons behind this disparity are the inadequacy of infrastructure and the poor ability of least developed countries to invest in prevention and in disaster risk mitigation. Often the location itself and the building’s structural characteristics, as well as materials adopted, contribute to increasing threats. Finally, humans themselves frequently contribute to raising the risk of disaster or increase its severity through the destruction of natural environmental defences such as forests, coral reefs and wetlands, favouring ecosystem depletion and desertification processes. Fragile Mozambique In the Sub-Saharan panorama, Mozambique is one of the country’s most recently and seriously affected by natural extremes because of its unique geo-climatic conditions. The factors primarily linked to its vulnerability are: the influence of El Nino and La Nina phenomena on climate; the tropical cyclones developing in the Mozambique Channel, resulting in floods, chronic droughts, sea level rise and heavy rainfall patterns; and the country’s flat topography, a combination of an ancient marine morphology

(which became continent due to tectonic uplifting) and paleo-river systems that induces very large flood extent. These vulnerability factors result in a 155 ND-GAIN country rank index, underlining high vulnerability and low readiness scores. Mozambique is the 42nd most vulnerable country and the 21st least ready country, in urgent need for both investment and innovations to improve readiness and action (University of Notre Dame research, 2019). Over the past 50 years, Mozambique has suffered from an uninterrupted series of droughts and floods, with harmful impacts on social and economic development. The most severe drought periods were recorded in 1981-1984, 1991-1992 and 1994- 1995; while floods were observed in 1977-1978, 1985, 1988, 1999-2000, 2007- 2008, 2016-2017 and more recently in 2018-2019. Floods are often triggered by cyclones. Since 1970, Mozambique has been hit by more than 35 significant cyclones or tropical depressions and four subsequent major flood events in 2000, 2001, 2007 and 2008 (UN-Habitat, 2010). Lately, their intensity and frequency have been rising in the light of climate change, population rapid growth and environmental degradation as shown by cyclones Idai and Kenneth in 2019: the most devastating in recent history in terms of human and physical impact as well as geographic extent. A total of 64 districts and 19 counties were directly affected, but almost the entire country suffered from its adverse socioeconomic effects. The disaster interrupted the delivery of basic services such as water and electricity, it damaged roads and bridges (essential for commercial activity) and destroyed houses, schools, hospitals and other buildings. The cyclones, with gusty winds ranging from 180 to 220 km/h accompanied by heavy rainfall, also had a huge social impact, causing the death of more than 650 people and directly affecting about 2 million people in the provinces of Sofala, Manica, Tete, Zambézia, Inhambane, Cabo Delgado and Nampula. Although the impact of the cyclones was widespread in affected areas, there was a particular social group that demonstrated high levels of vulnerability: women. Ranking 139th out of 159 countries in the Gender Inequality Index, (UNDP, 2017) low levels of education, high maternal health risks, pressure to marry at a young age, high levels of teenage pregnancy, limited economic prospects, gender-based violence, and accepted cultural norms contribute to the precarious status of women and girls in the country. The

impact of the cyclones exacerbated these phenomena exposing them to greater distances to walk and unsafe locations, such as water collection points, severely damaged sanitation facilities and hospitals. With the destruction of health facilities, over 75,000 cyclone-affected pregnant women had limited access to safe deliveries and care, resulting in a significant increase in female poverty. Subsequently, two other cyclones hit the country respectively in 2020, Chalane and 2021 Eloise, reporting significant damages and people affected yet again in Sofala, Buzi area, Manica, the southern part of Zambezia, Inhambane, and Gaza provinces. These last storms, which struck in December and January, are a blow to efforts still ongoing to help the country recover from Cyclone Idai. Despite causing very few direct casualties, they generated impacts that were felt for long after it had passed. The threat of cholera, typhoid and malaria once more hangs over the thousands of Mozambicans displaced by these storms – and who still remain without permanent housing after earlier disasters. Moreover, humanitarian aid workers had an additional challenge – COVID-19. (WWF, 2021) The situation highlights a clear gap in terms of availability of services and, with meagre financial reserves, Mozambique – the world’s seventh poorest country – is fully dependent on international support to recover. But, despite initial disaster relief from the international community, support is proving inadequate to repair properly all the infrastructure damaged or destroyed by the cyclones. Therefore, a long road is still underway to provide earnest support in order to help people rebuild their livelihoods and ecosystems. The bitter irony, of course, is that Mozambique – in common with other PVS countries – has done almost nothing to cause the climate change that is exacerbating catastrophic weather events. However, its negative impact is a clear growing reality for the country and therefore a situation which must be considered now and into the future. Since more than 60% of the population lives in areas at high risk of natural disasters (UNDP, 2017), there is an urgent need to identify more durable solutions so that the country can adapt to climate change effects and progressively mitigate the risks. The terrible impact of 2019’s Cyclones should represent an

1.18 - Tab - Extreme events map in Mozambique: catheory, year and Province affected UNHABITAT 2010; Wikipedia 2021 1.19 - Map - Climate hazards paths and locations Tc - Tropical cyclone Ts - Tropical Storm F - Flooding NOAA 2021; NRL 2021

Climate hazard

Category - SSWS

Year

Provinces affected

Tc - “Guambe”

2021

Inhambane, Gaza

Tc - “Eloise”

2021

Sofala, Manica

Ts - “Chalane”

Storm

2020

Sofala, Manica

Tc - “Kenneth”

2019

Cabo Delgado

2019

Zambezia, Sofala, Manica

Tc - “Dineo”

2017

Inhambane, Gaza

Ts - “Chedza”

Storm

2015

Zambezia

2013

Inhambane, Gaza

Storm

2012

Inhambane (coast)

Tc - “Funso”

2012

Zambezia (coast)

Tc - “Jokwe”

2008

Nampula

F - Zambesi river

2008 - 07 - 01

Tete, Zambezia, Sofala

Tc - “Favio”

2007

Inhambane, Sofala

Tc - “Japhet”

2003

Inhambane (Vilankulo)

Tc - “Eline”

2000

Gaza

F - Save river

2000

Sofala, Manica, Inhambane

Tc - “Idai”

F - Limpopo river Ts - “Irina”

opportunity for a paradigm shift in the development model of the country towards building a culture of resilience at all levels. Climate change is definitely a pending threat on the whole of humanity but, above all, a great opportunity to create a healthier, safer environment. Change is not only possible but urgently needed, and countries as Mozambique are vivid proof. All developing nations have a unique chance to turn this crisis into an opportunity. Through implementing sustainable policy and investing in renewable energy systems and resilient buildings, they can leapfrog industrialised nations, avoiding the process of decarbonisation, and fast-track to a greener and more prosperous future. We must seize this opportunity, achieving ecological conservation and high-quality development for all, because “there is no planet B, there is no planet BLAH”. (Greta Thunberg, 2021)

Cyclones 4+ 4 cat 3 cat 2 cat T storm

CABO DELGADO

Floods

Kenneth

NIASSA Pemba

Idrography

NAMPULA Nampula

TETE

Jokwe

ZAMBEZIA

MANICA

Zambesi river

Eloise

Quelimane

SOFALA Idai

Chimoio

Chalane

Beira

Chedza Dineo

Limpopo river

Funso INHAMBANE Eline

GAZA Limpopo river MAPUTO PROV

Inhambane

Guambe

Favio

Tropic of Capricorn

Japhet Mozambique channel

Xai-Xai

Maputo

Irina

Disaster Resilience Given the common misunderstanding about the word “resilience”, a brief framework of literature is needed to draw the borders and therefore its meaning and use in a disaster context. Despite the preliminary understandings of resilience that have focused on ecological systems (Folke, 2006), the following studies focus on resilience in the context of hazards and disasters. Many authors define resilience as the activities and capacities which allow communities and societies to withstand, rebound and bounce back after disaster events (Paton & Johnston, 2006). Therefore, resilience is the relative ability of a community to absorb the effects of a hazard event and quickly return to normal, or near-normal operations. However, other scholars suggest that communities will never return to the pre-disaster state, as a disaster will lead to changes in the physical, social and psychological reality of social life (Paton, 2006). Focusing primarily on the ability to bounce back often assumes that resilient systems can reach a state of equilibrium, whereas human and natural systems are more accurately seen as unstable and non-equilibrating (Birkmann & Wisner, 2006). Paton (2006) describes resilience as “a measure of how well people and societies can adapt to a changed reality and capitalize on the new possibilities offered”. In this sense, resilience concepts incorporate a measure of individuals, groups and communities’ adaptive and transformative capacity (Folke et al., 2010). Maguire & Hagan (2007) conceptualize resilience, from these various understandings, in three different dimensions: resistance, recuperation and creativity. Before long-term impacts are experienced, resistance relates to the capacity to withstand or absorb an external pressure or disturbance. This view of resilience explores the amount of disturbance that can be absorbed by a system before changing its state (Maguire & Cartwright, 2008). The recovery approach to recuperation is the amount of time it takes for the community to ‘bounce back’ to previous levels of functioning. Therefore, the faster a community is able to return to functioning at pre-disaster levels, the more resilient the community is. While these resilience conceptualizations are common in the literature on hazards, Maguire & Cartwright (2008) argue that resistance and recuperation approaches are deterministic and do not incorporate

the complex nature of people and communities. On the other hand, the creative approach to resilience is related to the idea of increasing the community’s functionality and resilience after a disaster event. Creativity is the process of mitigating and “adapting to new circumstances and learning from the experience of the disaster” to create communities, through the recovery process, that have achieved greater resilience and functionality (Maguire & Hagan, 2007). This is also similar to the Resilience Alliance’s approach, in which resilience is understood in three dimensions: the ability to absorb, the degree of self-organization, and the capacity to learn and adapt (Kuhlicke, 2010). The idea of creative resilience contributes to an increasing body of literature that focuses not only on bringing the community back to its previous level of functionality, but also as a tool for improving general welfare conditions (Paton, 2006). Folke (2006) focuses on the positive aspects of disaster events, seeing them as having the potential to create opportunities for new things for innovation and for development. In other words, a hazardous event can be considered as a tool for learning, transformation and growth in the community (Berkes, 2007). Rather than seeing change as a source of stress from which a community needs to recover its original state, this view of resilience accepts that change is inevitable (Maguire & Cartwright, 2008). Conceptualizing resilience from a transformative perspective brings more structured and complex understanding of ‘building back better’ recovery strategies, and links to the ‘window of opportunity’ idea. In this sense, communities may use disaster events as a learning tool to facilitate a step towards improved mitigation and preparedness programs, as well as increased emphasis on resilience reducing vulnerabilities and building capacities (Birkmann, et al., 2010). This promotes the use of a conceptualization of resilience that incorporates not only the capacity to absorb and cope with hazards, but also learning, transformation and adaptation aspects. Building back better Building Back Better (BBB) is a strategy aimed at reducing the risk to the people of nations and communities in the wake of future disasters and shocks. The BBB approach integrates disaster risk reduction measures into the restoration of physical infrastructure, social systems and shelter, and the revitalization of livelihoods,

economies and the environment (UNISDR, 2020). BBB has its roots in the improvement of land use, spatial planning and construction standards through the recovery process. However, the concept has expanded to represent a broader opportunity by building greater resilience in recovery by systematically addressing the root causes of vulnerability. Since 2002, UNHabitat is working in Mozambique on Disaster Risk Reduction (DRR) and BBB by promoting the approach of “Learning how to Live with Natural Hazards”, especially in flood, cyclone, drought and seismic-prone areas. The main idea behind the proposed approach is to increase people’s resilience and increase the climate adaptation capacity (UNHabitat, 2019). However, to tackle the issue effectively, this needs to be translated into improved policies and legislation (e.g. revision of the building codes), preparation of guidelines, awareness-raising campaigns, institutional capacity building or generation of the required knowledge by mainstreaming concepts of risk reduction and resilience into the school curricula. In order to address the current condition of post-cyclones in Mozambique, UNHabitat defined a 5-year coherent and comprehensive strategy for Building Back Better (BBB) and Resilience Building in the areas affected by Cyclones. This will be done based on two inter-twined specific objectives: (i) to consolidate and scale-up the BBB approach for reducing risk which UN-Habitat started piloting over a decade ago; (ii) to pilot an integrated approach for urban resilience building at the neighbourhood, city or urban district scale, which can be replicated. Among the first pillar’s contents, one initiative is specifically designed for healthcare, the “Safer Hospital” program. Based on the Safer school methodological legacy, it embeds the idea to rehabilitate or reconstruct better, either in a rural settlement or at the level of a neighbourhood as well as in an urban area, safe public health facilities which can withstand the impact of strong winds, floods or other natural hazards, and can be used as safe havens during emergency times.

UNHABITAT FRAMEWORK: SAFER HOSPITALS PROGRAME

Introduction The health sector plays a key role to maintain the population safe. Hospitals and other health facilities are essential assets to communities on a daily basis as well during emergencies. Since the Peace Agreement in 1992, Mozambique engaged enormous efforts to accelerate the construction of health infrastructure and other basic services across the country. Despite that, the health infrastructure often was not implemented by enforced building codes, resulting in a low-performance structure with limited capacity to withstand disasters. In 2019, Cyclones Idai & Kenneth were not the exception causing vast destruction into the health sector by disrupting the services, damaging buildings, equipment, breaking stock of supplies and medicines. 95 health facilities were destroyed or partially damaged, including the major hospital at Beira city. To change this scenario, the infrastructural component of health facilities must be built in compliance with safe standard of construction to ensure continuity of services in routine conditions as well in the extreme circumstances of an emergency. Therefore, based on the experience of safer schools in Mozambique, UNHabitat through its Building Back Better (BBB) and Resilience Building Strategy in response to Idai and Kenneth cyclones, have launched the “Safer Hospital” project to ensure health facilities can withstand disasters such as cyclones, strong winds, floods and earthquakes. In partnership with the Mozambique’s Health Ministry (MIASU), the Canadian Government, INGC, Ministry of Public Works

and Housing (MOPHRH), Ministry for Land, Environment and Rural Development (MITADER) the World Health Organization (WHO), “Safer Hospitals: Post-Disaster Reconstruction and Construction Guidelines on Safer and Gender Sensitive Health Facilities in Mozambique” will provide support for ongoing reconstruction efforts in the provinces of Sofala, Cabo Delgado and Manica, in line with Building-Back-Better principles to ensure future resilience. It will also guarantee technical assistance to define rules and guidelines to (re)build resilient health infrastructures to be applied within the framework of global guidelines and contribute to a better access for women and girls to health facilities, identifying barriers and making them better-adapted and more gender-sensitive. Goals and objectives The ultimate goal of the Safer Hospitals project is to contribute to achieve resilient and gender sensitive health facilities (re) constructed more safely and protected from hazards, allowing health facilities to remain functional during crises and emergencies, and provide equitable health services to all. In order to achieve the ultimate goal, the specific objectives are: 1. Support Post-Idai and Kenneth health facilities reconstruction by supporting MISAU in conducting rapid post-disaster damage assessments and providing technical knowledge by introducing safety measures under buildingback-better principles and gender-sensitive components. 2. Awareness-raising on resilient and gender-sensitive health facilities among authorities and stakeholders, based on the results of the Risk Assessment (with a diagnosis) developed upon evidence-based knowledge. 3. Identify hospitals and health facilities as a specific target for risk reduction policy and facilitate the formulation of Reconstruction Action Plans to improve building construction standards. Gender issue Healthcare infrastructure projects are often designed and implemented as if their impact is gender neutral. Women and men use public buildings and systems in different manner. A safer and more resilient health system will allow equitable access to health

services and dedicated structures to all people, including the most vulnerable groups in communities, such as pregnant women, youth, elderly and people with disabilities in Mozambique. The project looks into what are the barriers to gender, age and disability inclusion (i.e. socio-cultural and physical) in the selected communities through the collection of gender, age and disability-sensitive data. Findings that support the improvement of accessibility and render health facilities more inclusive will be incorporated in the project implementation strategy, such as training of health professionals on gender, age and disability awareness, provision of maternity waiting homes, ramps, wider pathways, braille maps, among other specific accessibility solutions. Hence, gender will be taken into particular consideration when developing all project’s activities, that is, from the project design, assessments carried out, proposal of technical solutions, implementations, production of data, monitoring and evaluation.

1.20 - Nhaconjo urban Health Centre “Building Back Better” process completed in partnership with CAM, UNHabitat, AICS and MISAU July 2021

1.21 - Mothers having their matabicho in the MWH’S veranda of Villa Arriage rural Hospital in Buzi District July 2021

MATERNITY WAITING HOME

A comprehensive overview Several maternal health studies have shown that strengthening the continuum of care, from proper pregnancy management, antenatal care and institutional delivery to the post-partum period (with the capacity to provide life-saving obstetric care, when necessary) considerably reduces maternal mortality (UNICEF, 2008). Institutional deliveries can be defined as any delivery that takes place in a modern health facility and medically trained professionals such as medical doctors, nurses and midwife/auxiliary midwifeassisted (Nketiah-Amponsah and Sagoe-Moses, 2009). The literature shows that, in countries where maternal health is successfully improved, maternal mortality decreased if institutional deliveries increased significantly (UNFPA, 2010 - UNICEF, 2008). Three options have been therefore identified to improve access to obstetric care: (i) to establish an effective transport network in order to ensure rapid transportation of patients with complications to a qualified health facility; (ii) decentralization of health services in order to provide obstetric care by setting up health facilities near the communities and (iii) to ensure that pregnant women (with a special focus of those with high-risk conditions) wait for delivery near a health facility with obstetric care services. Most National Health Systems in developing countries have limited capacity to expand the health services network or to ensure a proper referral system based on an effective transport system; therefore, maternity waiting homes (MHW) have been

promoted as an alternative to improve maternal health, reducing the gap between communities and the National Health System. The aim of MWHs is to improve the access of pregnant women to quality and in-time maternal health care services, especially for those high-risk pregnancies or women that live in remote areas. It is assumed that MWHs contribute to increasing the proportion of institutional deliveries, and by this increase, to reducing maternal mortality. Definition and purposes A MWH is a residential accommodation located near a qualified medical facility, that provides maternal health care services (antenatal care, skilled births attendants and emergency obstetric care). Here, women defined as “high risk” can await their delivery and eventually be transferred to a nearby hospital shortly before delivery, or before complications arise. Moreover, in some cases, the facility may also offer women to improve maternal and neonatal health with sanitary education and counselling regarding pregnancy, delivery, infant care and family planning. (Lonkhuijzen et al, 2009). Thus, maternity waiting homes are considered to be a key element of a strategy to “bridge the geographical gap” in obstetric care between rural areas, with poor access to equipped facilities, and urban areas where the services are available. However, MWHs are not a stand-alone intervention. It is imperative to underline that it represents only a component of a comprehensive package of essential obstetric services, a link in a larger chain of care where all the components of which must be available and of sufficient quality to result in effective outcomes. (WHO, 1996) A framework from abroad The idea of homes for pregnant women with obstetric and social problems has a long history. For many centuries, voluntary organizations in Europe have provided shelters for single mothers in an effort to reduce abortion and infanticide. More specifically, in Northern Europe, waiting homes were built near hospitals to help women living in distant geographical areas that had limited access to obstetric care. For example, in Finland where there are remote communities with access difficulties and few obstetric services, nurses’ facilities serve as “patient hotels” with the same aim (WHO,1996).

During the second half of the 20th Century, the strategy of MWHs has been promoted in several developing countries to bring women near health facilities, in order to increase institutional deliveries and, as a result, decrease maternal mortality. While the first example has been detected in Eastern Nigeria in the 50s with highly positive results, plenty of studies can only be traced back between the 60s and 70s in Sub-Saharan Africa, South America and the Middle East. For example, Maternity huts can be found nearby the “Mnene”, a hospital in Zimbabwe, since 1915. However, the original simple huts were long ago replaced by a big brick round oval and two smaller huts. The women bring bedding, pots and food, and cook for themselves in a special kitchen. A nurse-midwife is employed at the mothers’ village as a health educator, delivering lectures on different topics (WHO,1996). In Ethiopia, the first “Tukul” (the name by which a MWH is known in this country) was built in 1976 attached to Attat Hospital. Thought as a local house by the village communities, it was hosting a total of 15 beds, with an average period of stay of 15 days (WHO, 1996; Talamanca, 1996). The Cuban experience is particularly interesting because of the comprehensive register of MWH services. Cuba’s maternity homes were founded in 1962 as part of the general movement to extend health services to the whole population in the context of the post1959 social transformations. All MWHs were built attached to a local hospital or within a reasonable distance. Moreover, national health workers were available in MWHs providing medical care, education and health promotion activities together with community-level support in management. In 1989, nearly 30 % of all deliveries used MWHs, undoubtedly contributing to raising the rate of institutional deliveries in Cuba (WHO,1996; Talamanca, 1996). In Nicaragua, the first “Casa Materna” (Maternity House) was built in 1987 as an initiative of the Nicaraguan Women’s Organization with initial support and Swedish Cooperation and the Nicaraguan Government. Besides the aim to reduce maternal and neonatal mortality, the “Casa Materna” had a special focus on women education and family planning (Talamanca, 1996). In Mongolia, the maternity rest homes - Ekhyn Amrah Bair - were

1.22 - Maternity Waiting Village, Kasungu, Kasungu District, Malawi by MASS Design Group 2015

first established in 1979, providing pregnant women with access to medical assistance for preventing complications during and after delivery of children. Moreover, training courses about nutrition, family planning, hygienic practices were offered to increase awareness and understanding of childbirth and healthy behaviours. After a first setback in the 1990s due to capitals privatization and economic crisis, the government started again to invest in MWHs to bridge the geographical gap between healthcare and remote communities or nomads, lowering the maternal mortality rate, from 199/100.000 live births to 26 in 2015. Overall, 99.6 per cent of births now take place within health facilities that thousands of women didn’t have access to in the 1990s. (PacificStandard review, 2018). The case of Tanzania is dated 1992, where a “Chigonella” house (Maternity Waiting Home) is provided at the Dodoma Regional Hospital. Initially designed to accommodate 15 women, after the implementation the house was lodging 50 to 80 pregnant women, showing an over-utilization of the services (Friederike Amani Paul, 2007). These are some of the experiences that the literature offers about MWHs around the world. Today, various forms of maternity waiting homes have been documented in 18 countries, indicating a wide variety of services currently available in different countries. Among the leading examples, the most interesting and scalable are: (i) the Maternity waiting village in Malawi, completed in 2015 by MASS Design Group. Together with the Presidential Initiative on Maternal Health and Safe Motherhood to build 130 MWHs across the country, MASS Design Group took design cues from the vernacular layout of Malawian villages, where family compounds are composed of several small buildings housing branches of an immediate family. MASS broke the large dormitory-style waiting home into similarly intimate four-bed units, a comfortable size defined in collaboration with mothers. These buildings are arranged around courtyards into ‘clusters’ of three rooms (twelve mothers). Rather than a sleeping hall’s impersonal scale, the clusters create small communities that encourage knowledge sharing between experienced and first-time mothers. Any number of these twelve-bed clusters can be assembled together, and aggregated over time as additional construction capital becomes available. In Kasungu, MASS assembled three clusters for a 36-

bed Maternity Waiting Village. And (ii) the maternity compound located at the entrance of the hospital compound of the city of Woldyia, in the northeast of Ethiopia by Vilalta studio. Completed in 2017, the project consists of a maternity ward and a MWH. The second intervention is inspired by the tukuls, the traditional Ethiopian huts and it is composed of circular volumes organised by a similar pattern. Like a big house for new mothers, it has a day area composed of an open-air living room with a kitchen and a night area with five bedrooms and toilets. A crucial point of these examples is their diversity, translated into adaptation to the local cultural environment and available resources. It should not be lost. But some guidance as to what constitutes a maternity waiting home is needed in order to properly understand the topic and its potentialities. Key elements and barriers The concept of maternity waiting homes is thriving in many ways. It does not require high technology; it relies mostly on human resources already present in many communities and it can serve as a practical way to meet the needs of pregnant women. However, as previously mentioned, MWHs are one part of the continuum of maternal care, and not just a facility that exists in a vacuum (WHO, 1996). Considering the WHO guidelines and also lessons from direct experiences, the success of maternity waiting homes depend on the following factors: 1. Careful evaluation of the context 2. Definition of risk factors and selection of women; 3. Viable community-level health service necessary for referral to occur and women’s compliance with the referral; 4. Skilled obstetric services (including the capacity to handle obstetric emergencies); 5. Community and cultural support.

1.23 - Woldyia Maternity, Ethiopia by Vilalta Studio 2017

(1) A careful evaluation starts addressing a need assessment, in order to determine “the problem”. The first threshold is the institutional delivery coverage whose values over 90-95% indicate that women are already accessing the healthcare system in that area and a MWH would remain unused (ing. Bruno Comini, MedicusMundi, 2021). Secondly, understanding the level of existing

health services and whether or not women currently use these is crucial because constraints to their use (e.g. sociocultural, financial, transportation etc.) can deeply influence the success of the maternity waiting home. Any weakness in one link will affect the strength of the entire chain and, as a result, yield little impact on maternal mortality. (2) Related to the high-risk selection there are three approaches: (i) a high-risk medical approach to identifying pregnancies likely to develop complications and refer these to a MWH; (ii) a highrisk multifactor approach that promotes a broader concept based on a combination of distance, socioeconomic and medical risk factors, and; (iii) an open-access approach that understands MWHs as a proxy for institutional deliveries. In order to define the best approach, it is indispensable to assess the capacity of the NHS to correctly identify high-risk cases and, secondly, if the health system is able to provide care to the identified women. This analysis should be locally evaluated and depending on available resources and local risk factors such as identifiable frequent conditions (medical or socioeconomic) within communities. Thus, once the definitions have been made these women need to be identified and referred to maternity waiting homes if the system is to function effectively. (3) Referring women to MWHs is another key factor, especially in developing countries. While some women may “refer themselves” (based on word of mouth or other information, education, communication (IEC) campaigns), the majority will come from referrals within the health care system. However, if antenatal care visits present a low rate and trained health professionals capable of identifying high-risk pregnancies are missing, the involvement of the community and TBAs appears as the best solution. Nevertheless, an effective primary level health service that refers to high-risk women does not guarantee that the women themselves will comply. The timing for such referrals, or however many weeks prior to the anticipated delivery date, needs to be determined by the prenatal visits depending on the prevailing conditions. Another important facet of the referral element is the need for clear and concise documentation of the woman’s prenatal

Prenatal care in remote rural areas and selection of high risk woman High-risk cases

Low-risk cases

1.24 - Chart: Mozambique “delivery” process in rural areas, starting with prenatal visits at the local health centre and referring of women according to low or high risk.

Secondary level

Maternity waiting home Primary level

Maternity waiting home with delivery at the local health centre

Normal deliveries at hospital

Planned transfer

Emergency transfer with ambulance to higher level if complications arise

Cases with anticipated complications

Tertiary or quternary level

Provincial / Central Hospital

medical and treatment history. However, with special incidence in developing countries, records are non-existent making proper assessments difficult. (4) A crucial element of effective maternity waiting home is its access to qualified obstetric services. Again, the capacity of the National Health System will be a huge determinant, though obviously skilled staff is strongly recommended. The presence of an obstetric specialist in each MWHs is strongly recommended but, in countries where human resources are scarce and no specialists are available in each facility, it is important to reinforce the visits to the MWHs, establishing, at least, periodical daily rounds in order to detect complications. (5) The final crucial element to successful maternity waiting home depend on community involvement, support, approval and cultural acceptance. In fact, in communities where the maternity waiting home purposes are shared among people, utilization and satisfaction are greater than where the maternity waiting home is

perceived as a para-hospital, where some women are persuaded to await their delivery. MWHs are the kind of health service that works better if organized directly by communities using their local resources. The credibility of the maternity waiting home is a critical factor because women and their families may not be easily convinced to move away from home before their expected delivery date due to cultural barriers. For example, in rural Mozambique where institutional delivery is still traditionally unacceptable among communities, the flow of patients only increased slowly as women returned to their villages after delivery with favourable reports about the maternity waiting home. “Word of mouth” has in fact, been shown to be the best way to increase the acceptability and use of health services. User satisfaction and women’s perceptions about maternity waiting homes will be crucial elements to the success or failure of these homes (WHO, 1996). A further element to consider is the maintenance of the MWHs since it often influences negatively the success of the strategy (Mann et al, 2006). According to the NHS capability, several options can be implemented. The most recommended involved directly the state in order to ensure long-term continuity, however, most of the time the reality involves a self-maintenance by the women-users or communities themselves. Cost of transport and food supply is another crucial barrier to access, resulting in exacerbating economic status of families who can and cannot afford the MWH stay. In some countries additional fees are requested to just access the service, limiting, even more, its potential use and benefits. Limited access to essential obstetric services continues to endanger the lives of many women. Treatable emergencies occur in environments where the necessary resources are not available. These are preventable deaths, and maternity waiting homes can be viewed as one possible option for these areas. However, given all the above key arguments and barriers, it is not an easy intervention. Only through careful needs assessment, attention to crucial links, accurate local planning and the involvement of women, communities and institutions can maternity waiting homes be successful.

MWH strategy in Mozambique Although there are records that prove the existence of MWHs before, the official strategy of Maternity Waiting Homes was launched by the Ministry of Health in 2009 (MISAU, 2009) as part of a greater sustainable strategy to improve safe Motherhood and institutional deliveries, especially in rural areas. This commitment was confirmed and introduced as a strategic point also in the most recent PESS III, where has been underlining the necessity of ensuring an increase in a number of health centres and maternity waiting homes to mitigate maternal, new-born mortality and promote a safe and gender equality healthcare system (PESS, 20142019/23). Moreover, as mentioned in the previous chapter, MWH concept lays also in the “Safer Hospital” program of UNHabitat as a strategy to mitigate maternal mortality and promote gendersensitive approaches within health centres (UNHabitat, Safer Hospital 2019). Casa de mãe-espera In Mozambique, MWHs, called “Casas de mãe-espera”, are small shelters mainly located near or within rural health facilities of primary (type I and type II) and secondary level (in rural hospitals). The main purpose is to facilitate access for a greater number of pregnant women to essential and emergency obstetric care, through their accommodation and permanence during the last weeks of pregnancy, thus reducing the number of maternal and perinatal deaths. Moreover, MWH is a crucial part of SMI continuous care because they aim at improving not only women’s access to healthcare but also to information and education about pregnancy, childbirth, postpartum, family planning, newborn nutrition, hygiene and care. National indicators show that 54% of Health Facilities already have a MHW implemented (SARA, 2018). However, although the emphasis of the Ministry of Health to promote the strategy, a direct survey and interviews with health workers and directors showed that knowledge concerning MWHs purpose, activities, location, characteristics, etc. are limited and in, most areas, notexistent among communities (MISAU, 2009). Thus, still in 2009, an official document specifically aimed at health professionals who promote and implement management,

1.25 - Chart: waiting home Maternity Maternity waiting homes per Province - Nr / Us province - Nr / Us - % % SARA, 2018 SARA, 2018

Cabo Delgado - 30 / 122 29%

Gaza - 75 / 146 69%

Inhambane - 96 / 138 92%

Manica - 60 /120 63%

Maputo - / Maputo Prov. - 33 / 112 42%

Nampula - 73 / 230 41%

Niassa - 25 / 192 23%

Sofala - 89 / 157 74%

Tete - 69 / 136 62%

Zambezia - 92 / 254 50%

Total - 644 / 1643 54%

assistance and community involvement activities in the area of Women and Children’s health, was shared by MoH to regulate the strategy, highlighting the following aspects. Related to construction: 1. Location of the building: inside the Health Facility area in order to ensure safe accommodation for women and supervision by the health staff. 2. Type of construction: at the primary level is provided a lowcost facility with similar characteristics to local infrastructure whereas at secondary (Rural Hospitals) its construction will follow a “type plan” 3. Responsible for construction: it must be a joint process between the District Health Board (SDSMAS), the US to which it will be annexed, the Community and Civil Society Organizations existing in the district. 4. Maintenance: a shared responsibility between community, health district Board, Health Facility and Local Governments Equipment of MWHs: 1. Bed, mattress, pillow and mosquito net should be the responsibility of the Ministry of Health (Health District Boards). 2. Tables, chairs, closets and other complementary furniture should be provided by the Provincial and district government, community or NGOs. Management and functioning responsibility: The strategy promotes a participatory process with the involvement of multiple actors, namely: Provincial Government, District Health Board, the Health Facility where the MWH is located, NGOs, community organizations, families and pregnant women. • Responsibility of the Provincial Government: advocacy and political leadership to ensure effective support to MWHs setup. • Responsibility of Health District Board: To indicate a focal point responsible for MWH management; to ensure that no illegal payments are tolerated and monitoring MWH performances • Responsibility of Health Facility: to ensure obstetric care

•

for pregnant women; to ensure available staff to attend pregnant women staying at MWHs at night (feminine staff); staff assessment regarding support to users; cleaning of MWH, bathrooms and facility surroundings; equilibrated alimentation for pregnant women; to ensure that educational health activities are performed as well as supervision and monitoring. Responsibility of the community: to indicate a focal point co-responsible of the MWHs activities: co-responsible for maintenance; to encourage pregnant women to use MWHs (especially those with high-risk or with access limitations); to establish gardens, plantations of trees and to promote Income Generation Activities to support MWHs sustainability.

Users criteria’s: • Women identified as having high-risk pregnancies (special attention to antecedents) • Women that live in remote areas or areas with access limitations. MWHs Offered services: • Maternal Health Care with a weekly antenatal visit in the health facility, and daily, health staff should visit the MWH in order to monitor and assess pregnancies. • Preventive activities: multiple informative and counselling activities should be performed regularly concerning: neonatal care, post-partum care, HIV and AIDS prevention, etc. • Recreational and productive activities such as gardening and vegetable cultivations. • Monitoring and assessment of MWHs services (including food provision to users) • Register book for all users indicating relevant aspects such as origin, the reason for coming, diagnostic, etc. • Monthly and quarterly activity reports should be elaborated by the health facility and sent to district and provincial boards. • Assessment services should be done by: (i) regular supervision visits by district and provincial boards and (ii) quarterly should be done a joint assessment by a health facility, community district and provincial board.

However, a brief assessment elaborated by the MoH in 2009 on Maternity waiting homes revealed already dramatic conditions, showing how most of the guidelines promoted by the official strategy are not being followed (MISAU, 2009). Specifically, the assessment results on 114 MWHs surveyed and 332 pregnant women interviewed highlighted that (i) 44,7% of MWH were located in peripheral health facilities, (ii) 77,5% had just a room (without additional spaces), 33% had electricity, only 38% promoted educational and health activities. Among the users, 70,83 % of women interviewed expressed that there are barriers to the MWHs use (geographical, cultural, knowledge about the existence and socio-economic), and the majority, (71,9%) was referred to the MWH by the health facility instead of by TBA (6,6%) working within communities. Moreover, it has been detected substantial differences in the characteristics of MWHs across the country have inevitably influenced the demand for the service (MISAU, 2009). Yet today, the situation regarding the casa de mae espera has not improved, on the contrary, due to climate extremes that recently hit the country, in some provinces it has even gotten worse. In fact, as further shown in the next chapter, the case of Sofala and Manica not only exposes a misinterpretation of MWH guidelines, resulting in overcrowded facilities or uninhabited houses but also how natural hazards affected the facilities, obstructing basic physical access. Among the main inconsistencies we detected by our limited site visit and interviews in the central provinces, a few points more can be added to the critical situation already emphasised by the MISAU 2009 assessment. Firstly, the responsibility of construction at the primary level is mostly a community concern, as its maintenance, resulting in poor structures. Furniture equipment, such as beds, nets or chairs are constantly missing with consequences in the quality of the stay. A critical lack of skilled workers fully available for the MWH has been detected in all facilities, exposing how the infrastructure development is not parallel with an increase of health personnel. Moreover, the inexperience of workers together with a fragile data collection (only on paper, highly vulnerable to climate deterioration) provides very little documentation regarding the patient-based records and the operability of the system. Lastly, the services offered “on paper” do not correspond to the ones

actually provided; in fact, food (which should be provided by MoH) is not guaranteed, especially for those in far peripheral areas, no vegetable garden or income-generating activity to sustain the MWH economy are in place, resulting in further barriers to afford the service. Nevertheless, given the shortlist of cases for both studies, further research is needed in order to determine the real impact of the MWHs on the institutional deliveries coverage and their mean and characteristics. Moreover, a clear definition of the barriers and limits to the service as well as introducing key variables that affect coverage (Number and training of the health staff, means of communications, geographic characteristics of the area (rivers, mountains, others), type of ethnolinguistic population, etc.) may reveal a more adherent-to-reality framework. The effectiveness of MWHs Considering the diffusion of MWHs as a strategy to improve maternal and neonatal health, the literature review shows few studies that effectively address the service. One of the reasons that could limit this type of research is the lack of registers used in most of the developing countries and the weaknesses of the health information systems. In Mozambique, for example, the MWHs official strategy was launched in 2009 and, according to the reports of the Ministry of Health (MISAU, 2009), most of MWHs until that time, had no consistent records, limiting the capacity to assess these services. In addition, registration books used in maternity services usually do not have complete or reliable information about the use of MWH making it impossible to conduct studies based on the health information system. In addition, also the evaluation of impact itself could be misleading. Since MWHs are not stand-alone interventions, maternal and child health indicators may be improving for a variety of reasons including changes in income level, general economic development and improvements due to increasing education. Cross comparison of communities with and without a maternity waiting home (conducting baseline studies in both) may be a feasible approach, even though in practice no two communities are alike. Besides, not only facility births have to be evaluated but also the home deliveries to measure the real impact on maternal mortality at a

community or population level. Thus, the evaluation of MWHs is not an easy process and requires data from a number of different sources. In Mozambique, further constraints prevent a clear reading such as (1) the absence of a territorial strategy and guidelines that standardize the MWH system; (2) a weak and low diffused healthcare infrastructure and (3) the current condition altered by the recent climate threats (flooding, tropical cyclones and sea-level rise) raging yearly on the country and therefore requiring a more resilient paradigm of intervention.

1. 26 - Maternity waiting home in Ethiopia and Zambia UNFPA, 2018 MWHA, 2017

Although there is little information on their actual effectiveness, as seen above, some currently positive examples are detected in other developing countries such as Southwest Ethiopia (UNFPA, 2018; Vilalta Studio, 2017), Malawi (MASS-design village, 2015), Congo (MAMA, 2018) and Zambia (MWHA, 2017), where quality MWHs contribute in rising the institutional deliveries, lowering perinatal mortality, supporting healthcare education and promoting gendersensitive practices. Moreover, their continuing existence indicates local sustainability. Alternatives and challenges As mentioned at the beginning, MWHs are just one of the strategies able to tackle the issue of maternal and newborn mortality. A sensible strengthening of the road infrastructure, assuring emergency transport to everyone when needed and a capillary expansion of the health system can address the rate of mortalities. In Mozambique, less than 43% of roads are paved (INE, 2020), whereas the others are simply compacted soil, highly vulnerable to erosion during rainfalls and flooding. In fact, the overall road network conditions are really poor, even the paved ones in some sections are deeply eroded, due to a lack of maintenance and the passage of heavy vehicles for commercial purposes. Another topic is emergency transport. As a reference, the Central Hospital of Beira (Quaternary level) has only two ambulances, both maintained by the Italian NGO CUAMM (CUAMM, 2021). Therefore, as can be imagined, the lower levels of service provision, such as rural hospitals or centres, lay their hopes on a much lower availability. Thus, few have a valid service and often it has to deal with a road infrastructure that doesn’t allow movements

in a short time. Therefore, MWHs seem to be a valid and low-cost option, since starting from the building phase to maintenance is a community concern (MISAU, 2009). Moreover, along with the vision of a further healthcare expansion, MWHs may represent a key intervention to tackle mortality rates among pregnant women and new-born as well as a gender-sensitive practice aligned with the governmental policies and the SDG. However, an in-depth analysis of needs, costs related to implementation, management and development are required to answer properly and later structure an effective policy to standardize the strategy across the country. Besides, Mozambique is dramatically affected by climate threats related to global warming, especially in coastal regions such as Sofala (and Manica), Inhambane and Cabo Delgado. Here, thousands of shelters, permanent structures such as schools and hospitals, road infrastructure and networks were damaged or destroyed, worsening the already serious conditions. The following chapter involves research specifically on Sofala and Manica, two provinces recently highly impacted, where the healthcare sector count hundreds of structures affected by at least 1 cyclone in the last three years. The MWHs obviously were not excluded, rather, since their poor construction details and the lack of funds for their management or repair, some observed situations show such damage that they cannot be used in any way.

2.0 - Village in Nhamatanda district (Sofala Province) August 2021

PART II

2.1 - Local storage in Jasse municipality, Nhamatanda, Sofala Province August 2021

FRAMING SOFALA AND MANICA PROVINCES

Sofala and Manica are two provinces in central Mozambique, where the current investigation has been developed. Characterized by two different landscapes, respectively large sandy floodplains and red hilly plateaus, they both deeply suffered climate change in the last years. For this reason, our focus is on analyzing the current condition of the Healthcare system and more specifically the operating MWHs service. However, an introduction regarding climate, landscape, vernacular housing materials and techniques is necessary since the starting point for any design project is an understanding of the site, the context and its microclimate, especially if buildings have to provide comfort even in extreme weather conditions. A brief overview Geography and climate Sofala Province, in central-eastern Mozambique, has an area of 68,018 km2 and a population of 2 203 762, with 32 inhab/km2 as population density (SARA, 2018). Divided in 13 districts, it is rich in waterways and large floodplains, the main rivers are the Chiveve and Pungue, passing through Beira, the Buzi river, the Save river, bordering the Inhambane province in the south and the Zambesi, defining the border with Tete and Zambezia in the north. This concentration of water and low sandy plains result in large potential flooding areas, especially during heavy rainfall periods or tropical cyclones. The climate, influenced by ocean currents, is mainly sub-tropical, with a hot rainy season and mild temperatures during the dry one.

2.2 - Climate Sofala - Beira Temperature (°C) Rainfall (mm)

40 °C

100 mm

35 °C 30 °C Rainfall

30 °C 30 °C

29 °C

27 °C

26 °C

25 °C 24 °C 23 °C 23 °C

25 °C

75 mm

17 °C

Jun

Jul

24 °C

23 °C 20 °C

19 °C

20 °C

Colder days

31 °C

27 °C

21 °C

Min temperature - av.

31 °C

30 °C 30 °C 28 °C

50 mm

21 °C

18 °C

25 mm

15 °C

Max Temperature

10 °C

Warmer days

2.3 - Climate Manica - Chimoio Temperature (°C) Rainfall (mm)

Jan

Feb

Mar

Apr

May

Aug

Sep

Oct

Nov

0 mm

Dec

40 °C

100 mm

35 °C 30 °C 27 °C

27 °C

25 °C 20 °C

20 °C

19 °C

26 °C

18 °C

28 °C 25 °C

14 °C

Jan

Feb

Mar

22 °C

Apr

May

13 °C

Jun

12 °C

Jul

75 mm

29 °C

28 °C

24 °C

17 °C

15 °C 10 °C

24 °C

29 °C

14 °C

Aug

50 mm 16 °C

Sep

20 °C

19 °C

18 °C

25 mm

Oct

Nov

0 mm

Dec

2.4 - Wind chart of Sofala and Manica - Beira and Chimoio 22 jun 24 jul 22 jun 24 28 jul aug

22 jun 24 may 22 jun 24 16may apr

28 aug 24 sep

Prevailing winds in warm season

km/h

24 sep

20 oct km/h

20 15 10 5

Jul Jan Oct

20 oct 22 nov 22 dec 22 nov 22 dec

16 apr 21 mar 13 12 11 10 9 13 12 11 10 9 15 14

20 15 161015 145 17 16 18 17 18

8 8

21 mar 23 feb 7 7

23 feb 21 jan 22 dec 21 jan 22 dec

6 6

22 NOV 22 NOV 10H10H /14H /14H ; 21 JAN ; 21 JAN 10H10H /14H /14H ; 20 OCT ; 20 OCT 10H10H /14H /14H ; 23 FEB ; 23 FEB 10H10H /14H /14H 22 DE 22CDE C 10H 10H /14H /14H 24 S 24 S EP EP O 10H 10H 20 O20 C C T 17T /14 /14 H;1723H; 23 H/1 H/1 FEBFEB 7H; 7H; 17H17H 21 M21 M 28 28 AR AR AU AU 10H 10H 22 22 G G /14 /14 DE DE 10H 10H H/1 H/1 7H 7H C C 17 17 2 2 /14H/14H H; H; 2 N 2 N ; 1 ; 1 24 24 OV OV 6 AP6 AP JU JU 17 17 R 1 R 1 0H 0H L L 10 10 H; 2 H; 2 /14 /14 H/ H/ 1 J 1 J H H A A 22 22 14H 14H N 17 N 17 H H JU JU ; 21 ; 21 N N M M 10 10 AY AY H H /1 /1 10H 10H 4H 4H /1 /1 4H 4H

Apr

Oct

Jul

Jan /Apr

2.5 - Solar chart and vertical projection of sun's rays (18°-20° parallel) km/h

km/h

20 15 10 5

H 17 R AP 7H 16 R 1 P H; 17 16 A G ; AU 7H 28 G 1 AU 28

20 15 10 5

Jul Jan Oct

Apr

Oct

Jul Jan /Apr

H AY 17 ; 21 M 17H L 17H MAY 24 JU H; 21 17 L 24 JU

22 JUN 17H 22 JUN 17H

Manica province, in central-western Mozambique, has an area of 62,272 km² and a population of 2 142 060, with 33,6inhab/km2 as population density with (SARA, 2018). Divided into 12 districts, the region shares the beginning of the Zambesi river to the North and the Save river to the South but the inland is characterized by a red hilly landscape. The main issue is represented by land erosion by means of rainfall and brutal extraction of soil for building purposes. The climate shares the same features with Sofala, subtropical with two seasons. However, given its hilly conformations, on top of plateau or low-mountains the temperatures are more rigid, especially at night. Rural housing: typology and use of space The first traces of a Mozambican house typology have been found in the country’s history of colonization, firstly by the Swahili and Bantu cultures, up to the 15th century, then by the Portuguese one, from 1505 until 1975, and finally the post-independence and modern period, from 1992 up to now. Vernacular rural habitat was, and currently is, characterized by two different types of traditional housing: in the center-south of the country the houses are mainly circular shaped huts with conical thatch roofs, called “palhotas” whereas in the north, due to the influence of the Swahili culture, they present a rectangular plan and pitched roofs. In the recent decades, the easier inner layouts organization and the aggregation possibilities, speed-up by urbanization influences, made the rectangular “Swahili” shape widely spreading across the country, especially along the bordering provinces and within informal settlements of bigger cities. The housing model is a fundamental aspect of culture to keep in mind since, unlike other contexts, the housing expansion is not given by stretching the basic module to shape a larger dwelling, but rather the addition of a further detached module, always within the same courtyard, and then connected to the others by the open spaces, which are an integral part of the house. Therefore, the expandability studies regarding housing must also take into account the possibility of enlargement inside the courtyard, which leads to a greater demand for space. Although the use of space within the house depend a lot on people

2.6 - Cylindrical type of building with conical roof in a Makonde house (Dias, 1964, p. 17). 2.7 - Makonde house, Swahili type, with rectangular plan and hipped roof (Dias, 1964, p. 18)

habits, making difficult to establish rigid rules of construction and arrangement, some general lines or tendencies can be found, widespread and imposed by culture, with repeating elements and features. The most used spaces within the living environment are those outdoors, where people spend most of their time. Outside, women cook, often under small circular canopies, make the laundry and take care of the children. Fundamental elements, often arranged in the center of the living space, are the trees, because of the cool shaded areas provided. Here it is the place for conversation and entertainment for guests. One of the most interesting architectural object is the veranda, an essential tool that provide shade on the building and space to rest or work under a roof. Typically, traditional houses with fourpitched roof have a long veranda around the entire perimeter, whereas in the case of a 2-pitched roof, it is more frequently found only along one side. Imported in the Swahili type from the circular one (“palhota”), this architectural element provides shade and protection as well as allows for the maintenance of better climatic conditions within the house. Moreover, it creates a filter between the open and the closed spaces (Bruschi, Lage, and Carrilho, 2004). In some cases, there are “machessas” who perform the function of meeting place for family and guests. They are especially present in the homes of community leaders or in public places, where a shady space is needed to gather and talk. Machessas are semi-open constructions, usually circular shaped and dwell at the center of the domestic space.

2.8 - Village in Dondo (Sofala Province) in 1891 Sousa Machado

Generally, the interior of the house is considered the most intimate space, where people spend the night or take refuge when it rains, and therefore essentially serves as a bedroom and storage room. Latrines and bathrooms are usually located in a corner of the courtyard, often in the back of the house, without a roof and spiral-shape to guarantee the needed privacy. The layout of the house depends on various factors such as access to the street and exposure to the sun, which greatly affects the temperature of the internal rooms of the house and the external shaded areas. For a cooler house, the largest walls should be the most protected from the sun, therefore the house should be oriented with the shorter walls facing east-west. However, in cyclones prone areas, a 45° inclination of the building against the main storm wind is suggested to avoid damaging and mitigate the wind effect on the volume. To orient the internal environments, it is important to take into account that, being south of the equator, a north-facing room receives more light than a south-facing cooler room. Therefore, it is recommended to place the bedrooms to the east side of the house, protected from the afternoon sun whereas the living rooms, on the other hand, are better if placed to the west. Being in a hot-humid subtropical climate, another important aspect is ventilation, which allows air circulation and therefore a greater freshness of the environment. This process can be enhanced by large windows and higher roofs, resulting in more air volumes changed during the day and the easy expulsion of hot-exhausted air from above. However, traditionally, the windows, if present,

2.9 - Survey of a rural housing in Inkaveleni Xai-Xai District, Gaza Province, 19-11-2004 Julio Pereira, Roberto João

2.10 - Mozambican stamps dedicated to traditional houses. Traditional cilindric constructions and conical roofing; squared buildings and verandas coming from Swahili tradition; cheap solutions of constructions influenced by colonial architecture Bruschi, Lage and Carrilho, 2004

100

had all small sizes as a consequence of further cost for building frames, pursuing a greater defence against thefts since the house was also storage for all possessions, and protection from ferocious animals (Facchinelli, 2010). Therefore, there is a close relationship between culture, environment, traditions of a place and the way of living. To ensure proper housing quality standards it is very important to follow some parameters concerning the orientation of the house, the arrangement of its parts, the use of appropriate local materials and the introduction of construction details that improve their quality. These aspects are usually present or otherwise known in traditional building types, born and developed over the years due to a specific climate adaptation. Precisely for this reason, particular attention is paid to the techniques and materials from traditional construction, not for a refusal of progress but for a valorisation of methods by now consolidated and born from the need to overcome specific context problems. In fact, every detail that comes from tradition is not meant to solve a single problem, but rather an elaborate method of responding to a multitude of difficulties between them interconnected, concerning society, culture, economy and locally available resources. Traditional techniques are not static but their evolution is very slow because it is based on knowledge shared by the population, handed down through generations and leading towards the definition of building typologies typical of a certain territory. And precisely these common aspects lead to the identification of the population in a community or group, which expresses itself precisely in the settlement methods and in the form of the buildings above discussed. In addition, traditional techniques have the additional advantages of taking advantage of local resources, either materials and labour, favouring a greater development of the community, a reduction of costs and a lower environmental impact. Construction typologies, techniques and materials Within the two provinces, many techniques and housing typologies have been noticed, therefore a reasonable division is between traditional and conventional constructions, here distinguished by the use of natural or industrial materials. Between these two categories, there are also the mixed constructions, those so-called

“melhoradas”, which present both elements traditional than conventional as proof of spontaneous upgrading. Traditional buildings are characterized by a capim roof and earth flooring. According to the material chosen for the walls we can distinguish different solutions, those in (i) “capim or caneço” and those in earth, further subdivided by the construction technique of “pau a pique”, “tijolo cru” or “tijolo queimado”. Conventional constructions, on the other hand, mostly consist of a zinc sheet (chapas) as roofing and walls of concrete, used as blocks, the socalled “cimento and areia” blocks, or as beams and pillars of the load-bearing structure. Mixed constructions include all possible combinations of these techniques. They, therefore, represent a transition zone between the more precarious and low-cost buildings and the more expensive conventional ones. Sometimes, especially close to urban settlements, the same houses can have walls built with different materials, showing the gradual improvement that people make from traditional dwellings. Despite the different construction typologies and external shapes, the most common traditional building technique detected on site is the wattle and daub (pau a pique) on the clay and stone platform. The walls are either made of a stone-filled construction consisting of a thick interlacement of vertical posts set into the ground with horizontal smaller branches, filled with stones, or of a construction consisting of the same posts with thicker tied mats made with wood, small sticks, or reed mats (caniço). The walls are later covered with clay paste (matope) and generally plastered on both sides. (Bruschi, Lage, and Carrilho, 2004). In Sofala, the pau a pique structures (the most frequently noticed) starts to decrease along the borders with Manica, where a change occurs due to the different Manica’s local practice: adobe bricks, called “tijolos cru” or fired bricks, known as “tijolos queimados”. Used for both circular (few) and rectangular (the most) typologies, the tijolo construction technique is for walls structures, where bricks are placed in a row with a mixture of matope as glue and subsequently covered with the same procedure used for the pau a pique, but with a thinner layer of matope. The use of concrete blocks characterizes conventional constructions which are not diffused in rural environments surveyed due to their high cost. The main structure consists of a

101

reinforced concrete frame with beams and pillars, while the blocks play the external infill function. Regarding the roofs, they are usually made of palm fronds/straw arranged on bamboo for traditional dwellings or metal galvanized sheets for the conventional/mixed. The vernacular ones show different building procedures: (i) the conical roof, independent from the walls, is built separately and assembled once the building is finished. It is made of small wooden beams converging at the top all tied by twigs positioned in a radius. The small beams are tied at the top thanks to their interlacement, or in modern constructions, they are nailed down on a circular base. The roof stands on a ring of small sticks which is also assembled separately and later erected and fastened to the extremities of the posts of the walls. All the framework joints and the joints that tie it to the walls are intertwined by plant ropes. The roof is completed with two or more layers of straw secured to horizontal laths positioned in a radius. (ii) The Swahili structure is a hipped roof, characterized by two posts that are higher than the walls to support the ridge beam. The rafters, secured at the ridge, are fanned-out being fixed on a beam that goes all around the house. As with the conical roof, the fan-shaped roof guarantees the uniform distribution of static stress on the structure. (Bruschi, Lage, and Carrilho, 2004) Within conventional and mixed constructions, metal sheets covers are the ones preferred by the inhabitants for their durability compared to those of capim and palm fronds, although their cost makes them inaccessible to a large segment of the population. Furthermore, they show many problems from a thermal and noise point of view, especially during hot seasons and rainy days. The building phase begins with the preparation of the wooden elements of the structure, the “barrotes”, which must be well dried and treated with a protective product, such as oleo queimado. The structure is then shaped by means of these elements, placed orthogonally between them with a wheelbase of about 60cm. Depending on the type of construction the beams can be simply resting on sloping walls or joined as trusses. Plenty of experiments and construction techniques improvements are present on site. Most of them involve the use of wider diameters for structural wooden beams or pillars and the addition

102

of concrete within stone infill (“pau a pique melhorado”) or inside the adobe mixture to deliver high performances bricks (“tijolos melhorados”), cement-based bedding mortar to glue them together or cement waterproof coating. Further developments regard the foundation, originally involving a simple stone bed and compacted soil, later improved with the stone-soil-cement mixture and, in a few cases, directly by means of reinforced concrete. Thus, matope, canico, bamboo, palm fronds and adobe bricks are all-natural materials sourced locally and therefore low-cost sustainable solutions. However, unsustainable alternatives such as metal sheets, reinforced concrete, wooden beams if contributing to deforestation processes, and fired bricks, if made uncontrollably and therefore emitting large quantities of CO2, already present within cities, are taking place also among rural communities. House shape, techniques and construction materials vary according to the context characteristics but, especially in rural areas, where society is still based on a subsistence economy, people use selfconstruction methodology to address all these confirmations, allowing significant savings. Usually, men take care of the loadbearing structure and roof, whereas women work on walls matope finishing and their maintenance as well as their decoration with different lands colours.

2.11 - Local construction in “pau a pique” technique, Dondo, Sofala Province July 2021

103

2.12 - Local construction in “pau a pique” technique, Siluvo, Nhamatanda, Sofala Province August 2021

104

2.13 - Local construction in “tijolos queimodos” technique Gondola, Manica Province August 2021

105

2.14 - Right chart: List of Healthcare units in Sofala and Manica provinces INE, 2020 H - Hospital Cs - Health centre Ps - Health post T - total

2.15 - Chart: overview of Sofala and Manica Total births, istitutional birth, rate of coverage and country's average INE, 2020

Healthcare network In recent years the healthcare infrastructure of both Sofala and Manica has increased in capillarity, growing within Sofala from 159 in 2016 to 170 units in 2020, and from 116 to 128 units within Manica territory (INE, 2020). Together with this expansion, also the general conditions and capacities have improved. Specifically, one of the main information considered within the research, the rate of institutional deliveries, raising from 79% (Manica) and 70% (Sofala) to respectively 90% and 83% (INE, 2020). However, according to the SARA survey, an overview on healthcare units, especially at the primary level, enhance still a significant lack of basic services. Only 58% of Sofala and 69% of Manica register the needed amount. Moreover, the overall number of healthcare units doesn’t meet still the targeted value of 2 units per 10.000 inhabitants. Sofala and Manica respectively present 0,63 and 0,73 as reference values (SARA, 2018). A focus on maternity care shows that, with the exception of basic and complete obstetric care, most health facilities have all maternal, newborn and child health services. However, the readiness index of these services is negatively influenced by the poor availability of diagnostics, norms and newly trained personnel. Furthermore, on the overall number of healthcare units surveyed, 74% in Sofala and 63% in Manica have the MWH service (SARA, 2018). Tropical cyclone Idai MWH survey - SARA 2018 n°

120.000

100.000

Istitutional births

80.000

Rate MWH % - Manica

60.000

40.000

20.000

Rate MWH % - Sofala Total births - Sofala

Total births - Manica Istitutional births Country's coverage Sofala's coverage Manica's coverage

106

2013

2014

2015

2016

2017

2018

2019

2020

2017 Healthcare type

2018

2019

2020

Beira

Buzi

Caia

Chemba

Cheringoma

Chibabava

Dondo

Gorongosa

Machanga

Maringue

Marromeu

Muanza

Nhamatanda

Total

128

161

131

161

134

166

138

170

SOFALA

65% affected by at least 1 cyclone in 2019/2021 MANICA Chimio

Barue

Gondola

Guro

Macate

Machanze

Macossa

Manica

Massourize

Sussundega

Tambara

Vanduzi

Total

104

123

128

21% affected by at least 1 cyclone in 2019/2021

107

Post-cyclones in healthcare at a glance 2.16 - Right map NOAA, Sentinal/UNITAR, INGC, 2019 - 2021 2.17 - Below chart USAID, Mozambique 2019 | IOM,2021 | UNFPA, 2021

The last three tropical extremes that swept across the provinces, named cyclone Idai-Chalane and Eloise, have deeply damaged all sectors. One of the most affected both in its infrastructure and physical asset was healthcare, further burdened by the developed epidemics (malaria and cholera) that started congesting an already fragile and severely compromised system. Both provinces counted high rates of sanitary units affected by at least one cyclone in the last years, respectively 65% in Sofala and 21% in Manica (UNHabitat, 2021). This means not only a burden in human lives and costs but also jeopardizing several achievements made by the health sector in the last decades. Moreover, the proximity of events exponentially impacted the situation, land-falling on already fragile environments such as resettlements camps and emergency shelters or temporary health tents. Unfortunately for the purpose of the research, no data are available regarding the damages at the MWHs infrastructures. Although, given the large extent of damages and the averagely poor structures characterizing the service, it can be assumed that plenty of MWHs have been affected, damaged or destroyed during the cyclones’ landfall. An on-site specific survey would be needed to assess the number of damages and properly address design strategies and reconstruction guidelines. Tropical cyclone Idai

Tropical storm Chalane

Tropical cyclone Eloise

Category (SSHWS)

Districts affected

Beira, Dondo, Muanza, Buzi, Nhamatanda, Gondola Macate

Dondo, Buzi Nhamatanda, Sussundega

Beira, Dondo, Buzi, Nhamatanda, Gondola

Effects

Strong wind, heavy rains and flooding

Strong wind, heavy rains

Strong wind, heavy rains and flooding

People affected

1.190.596 - Sofala 262.890 - Manica

26.358 - Sofala 3.270 - Manica

396.000 - Sofala, Manica

Total damage (dollars)

2.2 billion 89 partially destroyed 5 totally destroied

Health infrasctructure

108

6 million 21 partially destroyed -

10 million 82 partially destroyed 3 totally destroied

Cyclone path Unit affected Sanitaty unit Town Main city

MALAWI

Idai Storm Violent storm Hurricane Flooding

Guro

ZAMBEZIA

Tambara Chemba

Chalane Storm Caia

Eloise Storm Flooding

Maringue

Macossa

Barue Marromeu

Cheringoma

Gorongosa Vanduzi

Manica

Chimoio

Gondola Muanza

ZIMBABWE Macate Nhamatanda

Dondo

Chalane Eloise

Sussundega

Beira

Idai

Buzi

Mossurize Chibabava Machanga

Mozambique channel

Machaze

INHAMBANE GAZA

109

2.18 - A woman at the entance of the Maternity Waiting Home of Inhamichindo, Buzi, Sofala July 2021

110

ATLAS OF CASE STUDIES

Purpose Given both fragile topics of maternal mortality and disaster resilience after catastrophic phenomena, the research focuses on tackling the MWH strategy in climate-vulnerable areas, such as the provinces of Manica and Sofala, aiming at a resilient intervention to raise awareness of the issue and propose a mean to tackle it. Instead, the atlas of case studies goal is building a basic knowledge of MWHs in the provinces, collecting all the information, parameters and woman needs to frame the current MWHs postcyclones conditions. Methodology Three missions have been developed on-site together with UNHabitat, surveying health centres and MWHs in the Beira Dondo districts at first, and secondly Buzi - Namathanda districts, in Sofala; Chimoio, Gondola and Macate districts in Manica. For practical reasons (time and long distances to overcome) specific parts of these areas have been selected, giving priority to the ones closer to the main roads. The surveys resulted in 18 case studies architecturally analysed, 10 in Sofala and 8 in Manica, together with direct interviews with the users, the pregnant mothers as well as nurses for technical information. A specific MWH assessment was filled during the talks and photo reportages to frame the situations, pathologies and atmospheres following all the surveys.

111

2.19 - Mothers waiting for a visit at the Maternity Waiting Home of Savane, Dondo, Sofala June 2021

112

Outcomes The outcomes, further analysed in the next chapter, reviled high degrees of damages in the cyclones prone areas, 11 MWHs out of 18 has been deeply affected, mostly on the roofing structure (metal/zinc sheets) and the pau a pique walls, whenever detected. However, the average conditions of the not-damaged structures have been evaluated as very poor, given a significant lack of quality space, running toilets and gender respect. In fact, all the cases present a maximum of 2 rooms and no extra space for activities, 14 out of 18 had no dedicated toilet, no forms or aspects of the rural habitat is embedded to sensitize the stay and the building layouts are not thought to carefully host pregnant, vulnerable women. Therefore, both from the architectural and social point of view, the quality of MWHs surveyed is very low, resulting in precarious housing conditions and underused structures highly vulnerable to climate change. However, a further and comprehensive analysis has to be developed on-site to address the issue on a bigger scale and define more accurate guidelines, based on a large amount of data, together with the support of national stakeholders and local communities.

113

Sofala case studies

The following cases are inspected specifically in four districts: Beira, Dondo, Nhamatanda and Buzi

Nhangau cs rural I 2

Tica cs rural I 7

Villa Arriage Hospital rural 3

Lamego cs rural II 8

Guara-Guara cs rural II

Vinho cs rural II

Inhamicindo cs rural II

Savane cs rural II

114

Siluvo cs rural II

Jasse cs rural II

08 Cs

SOFALA

10 Cs

MANICA

07 Cs

09 Cs Nhamatanda

05 Cs

06 Cs

Dondo

01 Cs

04 Cs Buzi

03 Cs

03 Hr

Beira

Water City Province border Primary road Secondary road N1 N6

Highways

Health centre

Rural Hospital

115

NHANGAU

Location Sofala province Beira district Nhangau locality Data primary level rural type I Referral hospital Beira’s Central Hospital 26km 5h25min / walk 0h59min / car MWH construction re-built in: 2020 by: MISAU - USAID

116

A long dirt road guarded by baboons leads to the town of Nhangau, in the midst of which the construction site of the Health Centre rumbles over the noise of the market and the roar of the running motorcycles. New buildings, recently repainted, without furniture and surrounded by workers, do not allow to identify at first sight the casa de mae espera in Nhangau. There are no fires or bellied mothers wrapped in capulans guarding the entrance. The structure in conventional materials, concrete and sheet metal is divided in half: on one side of the veranda some patients wait to step on the scale and talk to the doctor, on the other, an open door overlooks what should be the room dedicated to mothers where, instead, there is a desk full of documents and registers. The only mothers are in the maternity ward, to rest on the beds for the 24 hours allowed by the centre before preparing to return to their homes with the newborn in their arms.

Shrubs Grass Soil Compacted soil A

MWH

Maternity

Latrinas

Water pump

-19.71608 , 35.00927

117

+0.00

+4.40

+3.40

+2.77

+0.30 +0.00

1.20 0.82

1.20 0.82 5.1

1.20 0.82

Bedroom

5.1

4.8 2.8 2.1

+0.35

0.83 1.95

7.1 2.1

+0.30

2.0

Veranda 10 m2

2.0

Veranda

Bedroom Storage 27 m2

0.90 1.95

1.20 0.82

0.90 1.95

Layout (currently unused)

5.1

+0.00

Kitchen outdoor Resting area outdoor

Rampa - 5%

Latrine not present 5.3

118

3.7 9.1

+4.40

+0.30 +0.00

Material Walls “blocos” - concrete blocks 130x180x400mm concrete pillars 130x30 Roof metal sheet wooden structure Basement concrete

+4.40

+3.40

+2.77

+0.30 +0.00

1.20 0.82

1.20 0.82 5.1

1.20 0.82

5.1

4.8 2.8 2.1

+0.35

0.83 1.95

7.1 2.1

5.1

+0.00

0.90 1.95

1.20 0.82

0.90 1.95 +0.30

2.0

119

VILLA ARRIAGE DE BUZI

Location Sofala province Buzi district Villa Arriage locality Data secondary level rural type A Referral hospital Beira’s Central Hospital 151km 30h00min / walk 3h14min / car MWH construction built in: unknown by: MISAU

120

A casa de mae-espera in the rural hospital can accommodate up to 50 expectant mothers. In the labyrinth between the pavilions for patient visits, vaccinations and training courses, the building of the Casa di Buzi stands out. Three rooms packed with bags, backpacks and big sacks of rice covered by large blue mosquito nets connect a small bathroom, one edge, adapted to a bedroom, to a large veranda on the other, where mothers from all over the district share berries, sitting on their mats. The access ramp studded with colourful slippers and yellow water tanks delimits the "kitchen" area: an expanse of small stoves made of bricks and wood on which some mothers are bent, mixing white polenta, baby food and milk. Spread over the verandas of the administrative buildings at the back of the house, other mothers rest, in the shade, away from the chatter of roommates.

D C

A B

Shrubs Grass Soil Water Compacted soil A

MWH

Maternity

Latrinas

Water pump

- 19.52588 , 34.35339

121

+2.66 +2.45

+1.30

+0.30

+0.00

0.75 2.10

0.75 2.10 1.2

1.3

1.4

3.3 14.1

14.1

0.90 1.10

Extra Bedroom

2.5 2.0

0.90 1.10

1.3

Bedroom Storage 2.6 83 m2

2.5

2.0

3.3

4.0

1.4

3.8

1.6

0.90 1.10 0.90 1.10

1.3

Bedroom

4.0

1.2

0.90 1.10

Layout

4.0

0.90 1.10

3.8 1.6

4.0

0.90 1.10

0.75 2.10

0.90 1.10

5.0 1.3

0.75 2.10

0.90 1.10

5.0

1.2

0.75 2.10

0.90 1.10

0.75 2.10

1.2

0.65 1.37

0.75 2.10

0.90 2.10

+2.66 +2.45

0.90 2.10

+3.50

0.90 2.10

+3.50

0.90 2.10

+4.60 +4.40

0.90 1.10

+4.60 +4.40

Veranda 33 m2 Kitchen outdoor Resting area outdoor/ Veranda

Kitchen

Latrine present 16.8

16.8

122

0.90 1.10

0.90 1.10 4.0

6.4

3.3

Bedroom

Veranda

3.3

0.90 2.10

4.6

+0.38 0.90 1.10

0.90 1.10

0.85 2.10

0.75 2.10

+0.30

Rampa - 8%

+0.00

6.6 23.4

123

124

125

Rampa - 8%

+0.00

Material Walls “blocos” - concrete blocks 180x200x500mm concrete pillars 150x50

+2.60

Latrine 3.7

Roof metal sheet wooden structure Basement concrete

1.6

1.3 +0.00 2.6

+2.60

3.7

+0.00

126

Patologies Walls Not damaged Roof Not damaged Basement Not damaged Others Shortage of bedrooms

127

Mothers cooking matabicho; Rural hob system: 3 bricks with a burning wood in between them July 2021

128

Mothers resting and napping in the shaddow after the matabicho July 2021

129

GUARA-GUARA

Location Sofala province Buzi district Guara-Guara resettlement Data primary level rural type II Referral hospital Hospital Rural de Buzi 16.6km 3h20min / walk 0h33min / car MWH construction built in: 2020 by: ComuSanas

130

The Guara Guara Center is located in the middle of an intricate path through the streets of the informal camp; the inhabitants themselves do not know how to orient to get to the hospital. It is evening, the health center is now empty, music can be heard in the distance and the smell of embers immediately draws attention to the casa de mae espera. The structure appears apparently new, in concrete blocks and a large roof in corrugated metal sheet. The central flap folded like an origami on one side shows the uncovered interior of the house; rolled-up mats, bags of rice and dried fish are stored neatly along the indoor edges. Under a small Maçinhas tree, illuminated by the setting sun, four mothers wash the dishes and close the leftovers of the meal in bundles of capulana. A mother sits on the edge of a brick canopy, the youngest child who could not leave home, hides her bare feet in the sand that surrounds the structure.

Shrubs Grass Soil Compacted soil A

MWH

Maternity

Latrinas

Water pump

-19.87716 , 34.46864

131

+4.70

+2.24

+0.00

3.8

4.9 1.00 1.00

Bedroom

3.7

1.00 1.00

10.2 7.7

Layout Bedroom Storage 64 m2

Storage

3.8

+0.30

4.9

1.00 1.00

0.90 2.15

1.00 1.00

Veranda 40 m2

Kitchen

Kitchen Veranda

+0.00

8.0

Resting area 13 m2 / Veranda Latrine present

10.2

+3.00

+1.80

132

R2.3

+0.00

Material Walls “blocos” - concrete blocks 180x200x500mm concrete pillars 150x50 Roof metal sheet wooden structure Basement concrete

133

+0.00

10.2

7.7 8.0 10.2

3.8

+0.30

+3.00 4.9

1.00 1.00

Resting area

0.90 2.15

Walls concrete - concrete pillars 150x50mm

+1.80

1.00 1.00

Material

R2.3

+0.00

Roof wooden structure metal sheet

8.0 10.2

+3.00

Basement concrete +2.30

+1.80

2.5

+0.00 +0.00 2.9

+2.30

2.5

+0.00

134

Patologies Walls Partially damaged Broken bricks > Cyclone / bad construction Roof Heavily damaged The metal sheet is overall up-lifted and not adherent > Strong wind Basement Not damaged

135

Entrance at Guara-Guara MWH July 2021

136

Mothers washing their dishes after dinner July 2021

137

INHAMICHINDO

Location Sofala province Buzi district Inhamichindo municipality Data primary level rural type II Referral hospital Hospital Rural de Buzi 57km 11h13min / walk 2h5min / car MWH construction built in: unknown by: local community

138

The path to get to the Inhamicindo Health Center is winding and irregular, easier to do by foot than by car. There are no signs and it’s out of the maps, you just suddenly find yourself there. The main building is managed by one doctor and two nurses, dozens of patients crowd under the veranda and at the entrance, moving following the shadow cast on the large unfenced open space. Inhamichindo’s Casa-de-Espera, built in mixed materials, concrete base, earth walls and metal sheet roof, welcomes some patients in a row for maternity seated between the “pillars” of the structure. The peeling walls show the “basket” of poles and bamboo to which the earth was attached and a large branch protruding from one of the slopes. At the back, from a small wooden hut, the smoke of some embers rises and between the twigs of the roof, a future mother mixes the papinha in her tin pot.

A C

Shrubs Grass Soil Compacted soil A

MWH

Maternity

Latrinas

Water pump

- 19.47194 , 34.11042

139

+4.06

+2.25

+1.40

+0.30 +0.00

+0.00

0.80 0.77

0.95 1.90

0.80 0.77

2.8

Bedroom / Storage +0.30

2.9

6.3

8.5

1.2

2.9

2.3

Layout Bedroom

Bedroom Storage 44 m2

3.4

3.2

0.80 0.77

2.8

0.90 2.00

Veranda 30 m2

Bedroom 3.2

+0.20

Kitchen 3.7 m2

6.7

Resting area outdoor/ Veranda

8.7

Latrine not present 2.0

140

+2.25

2.4

Material Walls “pau a pique” 200mm Roof metal sheet raw wooden structure Basement concrete

141

6.7 8.7

Material Walls raw wooden structure twigs intertwined

2.0

Roof raw wooden structure straws +2.25

Basement -

+0.00

142

Kitchen

Patologies Walls Heavily damaged Matope coating digregation and wooden structure deterioration > Rainfall / flooding Roof Partially damaged The metal sheet is overall up-lifted and not adherent > Strong wind Basement Partially damaged Disgregation of the concrete surface and collapse of of the base > Rainfall / flooding

143

Mãe Rita cooking chima below the canopy, Inhamichindo MWH June 2021

144

A mother waiting for pediatric visit, Inhamichindo MWH June 2021

145

SAVANE

Location Sofala province Dondo district Savane locality Data primary level rural type II Referral hospital Beira’s Central Hospital 28km 5h40min / walk 0h58min / car MWH construction built in: by: MISAU

146

Divided in half by the path that connects the community to the water pump, the Savane Health Center hides in the shade of tall trees. The casa de mae espera, set against a small cornfield, is filled with women chatting and children playing, all queuing for a visit. But they are not guests of the house. The four beds in the main room have been empty for days, medical equipment, chairs, cane mats, remain stacked in a corner. Every now and then, for half an hour, new mothers come in for a group course. A broken table under the weight of hundreds of registers and the room where the service agent lives complete the house, but no mother stays there to sleep. Children run by, pulling a kite made of twigs and plastic, they just stop to take a sip of water from the pump.

A C B D

Shrubs Grass Soil Compacted soil A

MWH

Maternity

Latrinas

Water pump

- 19.38785 , 34.70708

147

+0.00

+4.30

+3.45

+2.55

+0.50 +0.00

3.8

1.00 1.00

0.56 0.56

0.90 2.00

1.00 1.00

h. 1.44

1.7

2.8

0.90 2.00

6.2

5.8

Bedroom

2.2 0.90 2.00 1.00 1.00

2.8

1.30 2.00

3.0 +0.50 3.3

1.00 1.00

5.8

H 2.05

+0.00

3.7

2.2

6.3 12.3

Layout Bedroom Storage 73 m2 Veranda 6 m2

148

Kitchen outdoor Resting area outdoor / Veranda Latrine not present

+4.45

+3.45

+2.20

+0.00

Material Walls “blocos” - concrete blocks 200x200x500mm concrete pillars 200x200

+4.30

+3.45

+2.55

Roof metal sheet wooden structure Basement concrete

+0.50 +0.00

3.8

1.00 1.00

0.56 0.56

0.90 2.00

1.00 1.00

h. 1.44

1.7

2.8

0.90 2.00

6.2

5.8 2.2 0.90 2.00

2.8

1.30 2.00

3.0 +0.50 3.3

1.00 1.00

5.8

1.00 1.00

H 2.05

149 +0.00

3.7

2.2

6.3 12.3

Right: Empty beds in Savane’s MWH June 2021 Below: A health care operator drying the harvested wheat for her own use July 2021

150

Patologies Walls Not damaged Roof Not damaged Basement Not damaged Others Too close to the urban settlement

151

TICA

Location Sofala province Nhamatanda district Tica locality Data primary level rural type I Referral hospital Nhamatanda Rural Hospital 29km 5h49min / walk 0h35min / car MWH construction built in: 2019 by: MSF - USAID

152

A few tens of meters from the N6, one of the main roads of the Province of Sofala, stands the new health centre of Tica. Recently built, it has numerous health pavilions, which have been properly rebuilt. The casa de mae espera, located just outside the centre, near the community water pump, also seems to have been recently built: the structure in pillars and concrete ring beam is coated by rows of red bricks, united in the classic square shape, inspired by the casa de mae built by the community. A few steps from the main building an open but covered canopy serves as a kitchen and at the back, the latrine overlooks the community gardens. 20 mothers are housed in this facility, attracted not only by the condition of the building, new and comfortable but also by the good service offered by the health centre and the direct connection on the asphalted road to the reference hospital.

C D

Shrubs Grass Soil Asphalt Compacted soil A

MWH

Maternity

Latrinas

Water pump

- 19.40456 , 34.43615

153

+4.70

+2.40

+2.40 +0.45 +0.00

+0.45 +0.00

4.9

1.00 1.00

Bedroom

3.9

4.0 4.9

1.00 1.00

Bedroom

3.6 1.00 1.00

3.9

10.0

4.0

Layout

Bedroom / Storage

3.6

+0.45 10.0 3.8 4.7

4.7

154

+0.25

+0.15 8.0 10.1

8.0 10.1

Veranda

+0.10 1.00 1.00

Resting area outdoor/ Veranda Latrine present

+0.15 7.7 1.95 0.75

+0.25 1.00 1.00

Kitchen 13 m2

3.8

1.95 0.75

Veranda 35 m2

1.00 1.00

7.7 +0.45 1.00 1.00

Bedroom Storage 65 m2

2.4

+0.10

2.4

Material Walls “tijolo queimado” - adobe bricks 80x75x230mm concrete pillars 200x200 Roof metal sheet wooden structure Basement concrete

155

Material (kitchen) Walls “blocos” - concrete blocks 180x200x500mm concrete pillars 150x50 Roof metal sheet wooden structure Basement concrete

Kitchen

1.00 1.00

3.6

+2.90

+2.20 +1.75 +0.45

+0.00

1.95 0.75

1.00 1.00

7.7

+0.15

+0.10

0.80 1.90

2.4

8.0 10.1

2.9

1.00 1.00

3.6

+2.20

+0.45

+0.00

+0.15

1.00 1.00

156

1.95 0.75

7.7

+0.10

+0.00

Walls “blocos” - concrete blocks 180x200x500mm concrete pillars 150x50

Latrine

+0.10

Roof metal sheet wooden structure

0.80 1.90

2.4

Material (bathroom)

Basement concrete

2.9

+2.20

+0.00

+0.10

0.80 1.90

2.4

2.9

157

Above: Mothers resting under the veranda Top right: A woman collecting water from the well Below right: Mothers gathering and getting the dinner ready August 2021

158

Patologies Not present, given the recent reconstruction

159

LAMEGO

Location Sofala province Nhamatanda district Lamego locality Data primary level rural type II Referral hospital Nhamatanda Rural Hospital 14km 2h55min / walk 0h21min / car MWH construction not built as MWH

160

The Lamego area, full of small rural houses, does not have a real casa de mae espera. The health centre appears to have been recently rebuilt, with a large veranda extended over long concrete benches. Curious children throng outside the fence and in the open space outside the residences of health workers, a nurse holds a health education course for young people from Lamego. The recent cyclones have taken away the structure used to house the mothers and now they have to wait inside old storage, converted into a home, closed by a simple plastic sheet. The structure is made of concrete blocks and a metal roof, but the space available, though minimal, should accommodate up to 8 mothers. Unrealistic.

Shrubs Grass Soil Compacted soil A

MWH

Maternity

Latrinas

Water pump

-19.33465 , 34.31461

161

+1.94

Layout Bedroom Storage 6 m2

+0.00

+0.05

2.2

Bedroom 0.75 1.75

Veranda +0.00

Kitchen -

2.6

Resting area -

+0.05

2.2 +1.94

0.75 1.75

Latrine not present

+0.00

2.6

+0.05

0.75 1.75

2.2

+0.00

2.6 MWH site before Idai

Material Walls “Blocos” concrete blocks 120x180x300 mm Roof wooden structure metal sheet Basement concrete

162

Patologies Structure not built for the MWH purpose

163

VINHO

Location Sofala province Nhamatanda district Vinho locality Data primary level rural type II Referral hospital Nhamatanda Rural Hospital 38km 7h47min / walk 1h30min / car MWH construction built in: by: ComuSanas

164

Located on the path that connects Gorongosa National Park to the bike ride in the local community beyond the Pungue river, Vinho health is surrounded by a fence and high vegetation. Besides the presence of a maternity ward, an unused casa de mae espera stands from the backyard. Despite being in a very rural area and with a very low rate of institutional births, the structure, built some time ago in traditional materials by the community, is not in the right conditions to house mothers. After the tropical cyclone Idai, the area of Vinho remained completely flooded for days by the waters of the river which gradually consumed the matope of the bottom of the house, flooding the interiors and damaging the load-bearing structure. In recent years, no mother has been able to use the house and the community has never re-activated to rebuild it.

A C B D

Shrubs Grass Compacted soil

MWH

Maternity

Latrinas

Water pump

-19.00358, 34.34457

165

+0.20 +0.00

+4.00

+2.15

+0.20 +0.00

2.8

0.77 0.77

0.75 0.75

Bedroom

Bedroom 2.9

Bedroom / Storage

Veranda 30 m2 Kitchen outdoor Resting area outdoor Latrine not present

166

2.8

0.90 2.00

Bedroom (currently unavailable) Storage 44 m2

0.75 0.75

Layout (currently unused)

+0.20

+0.00

6.7 8.7

0.75 0.75

8.5

Veranda

+4.00

+2.15

+0.20 +0.00

Material +4.00

Walls “pau a pique” - 180mm Roof metal sheet raw wooden structure

+2.15

Basement concrete

+0.20 +0.00

2.8

0.77 0.77

0.75 0.75

0.90 2.00

2.8

+0.20

+0.00

0.75 0.75

2.9

0.75 0.75

8.5

167

Top: View of the entrance at the MWH Top right: Detail of the building footing showing the pau a pique deterioration Bottom right: View of the indoor conditions June 2021

168

Patologies Walls Heavily damaged Lost earth infill > Cyclone / raw construction / flood Roof Partially damaged The metal sheet is perforated sheet metal, rusty areas > Strong wind / strong rain Basement Heavily damaged > Flood

169

SILUVO

Location Sofala province Nhamatanda district Siluvo locality Data primary level rural type II Referral hospital Nhamatanda Rural Hospital 21km 4h11min / walk 0h23min / car MWH construction built in: by: local community

170

The casa de mae espera in Siluvo is made of traditional local material, built for the mothers by the community. The “pau a pique” walls have lost their matope layer in some places, revealing the wooden skeleton of the house. In some places, the drawings of ComuSanas, the association that supports communities in the construction of homes for expectant mothers, are still visible, essential for being able to recognize the structure and activate the “word of mouth” among women. The metal sheet roof shows some signs of sagging. A managing mother (the reference figure inside the house who supports the new arrivals and helps the SMI nurse manage the facility and her guests) chats with some friends sitting on the veranda. Other mothers take advantage of the last hours of daylight to go to the market and the youngest, the latest arrival, rests in the darkness of one of the rooms, hidden under a mosquito net.

Shrubs Grass Soil Asphalt Compacted soil A

MWH

Maternity

Latrinas

Water pump

-19.24104 , 34.02808

171

+0.10 +0.00

Layout Bedroom Storage 41 m2

+4.10

Veranda 25 m2 Kitchen outdoor / Veranda

+1.70

Resting area outdoor / Veranda +0.10

0.60 0.60

+0.00

0.60 0.60

Latrine not present

2.7

2.9

Bedroom 3.0

8.1

Bedroom 3.0

2.7

3.1

Bedroom / Storage

Walls “tijolo” - adobe bricks 80x75x230mm concrete pillars 200x200 Roof metal sheet wooden structure Basement concrete

172

+0.10

6.4 8.1 +0.00

0.60 0.60

Kitchen

0.75 0.75

2.6

0.60 0.60

6.1

Material

Patologies Walls Heavily damaged Matope coating digregation and wooden structure deterioration > Rainfall / flooding

+4.10

Roof Partially damaged The metal sheet is overall up-lifted and not adherent > Strong wind

+2.30 +1.70

Basement Partially damaged Disgregation of the concrete surface and collapse of of the base > Rainfall / flooding

+0.10 +0.00

+4.10

+1.70

+0.10

0.60 0.60

2.7

0.60 0.60

+0.00

2.9

3.0

2.7

3.1

173 0.60 0.60

2.6

0.75 0.75

6.1

0.60 0.60

8.1

3.0

Top: One of the windows restored with cheap solutions; some drawings survived the rains; Bottom: The back of the building, damaged by strong winds and rains; Right: One of the bedrooms in the MWH composed by a simple bed covered by the mosquito net. August 2021

174

175

JASSE MAINGUENA

Location Sofala province Nhamatanda district Jasse Mainguena locality Data primary level rural type II Referral hospital Beira’s Central Hospital 24km 4h47min / walk 0h45min / car MWH construction built in: by: local community

176

The Jasse Mainguena health centre is deeply immersed in the rural area of Nhamatanda. On the long winding road, many barefoot mothers are walking, carrying a bundle of wood on their heads and the youngest of the family tied to their backs. “It is not far away,” they say to those who ask for directions. The main structure of the centre is severely damaged, there is no roofing or frames, the casa de mae espera is totally missing. In its place there is just the beginning of a hut in pau a pique, 12 thin and irregular trunks are gathered in a circle, held together by an intertwining of branches. A few branches are missing, it must have been used to make a fire. The few mothers of Jasse, who have no choice but this skeletal hut, await the moment to give birth under a roof of wooden beams and sky or try to walk further to another health centre.

B A C

Shrubs Grass Compacted soil

MWH

Maternity

Latrinas

Water pump

- 19.2892 , 33.9874

177

Layout (currently unused) Bedroom Storage 8 m2 Veranda Kitchen Resting area Latrine not present

+3.20

+1.69 +1.24

+0.00

Bedroom

Material 0.7

Walls raw wooden structure twigs intertwined Roof raw wooden structure straws Basement -

178

1.6

3.1

+0.00

Patologies Unfinished structure

179

Manica case studies

The following cases are inspected specifically in three districts: Chimoio, Macate and Gondola

Inchope cs rural I 12

F. Manyanga cs rural II 17

Muda Serracao cs rural II 13

Macate cs rural I

Zembe cs rural II

Chissui cs rural II

180

Chipindaumue cs rural II

Amatonga cs rural II

Gondola 17 Cs 18 Cs

Chimoio 15 Cs

16 Cs

14 Cs

Macate

11 Cs 12 Cs

13 Cs

Water City Province border Primary road Secondary road N1 N6 Cs

Highways Health centre

Hr 181

INCHOPE

Location Manica province Gondola district Inchope locality Data primary level rural type II Referral hospital Gondola Rural Hospital 44km 8h20min / walk 1h11min / car MWH construction built in: by: MISAU JOIN KUBATSIRANA Assotiation

182

Along the paved road to Gondola, the Inchope health centre is accessed directly from the N6. The centre is large, three pavilions house health services whereas two containers are used for verbal visits with specialized doctors. The casa de mae espera is located on the sidelines, close to the residences of health workers. The structure was built with the collaboration of an American NGO and it is in good condition. The adobe bricks and reinforced concrete pillars are painted in yellow and red, the roof made of wooden beams and metal sheets is firmly embedded in the loadbearing parts of the building. The interior is divided into two big rooms without beds. The veranda, located in front of the building, is used more as a waiting area and for short educational courses run by local activists rather than a kitchen. In fact, mothers cook on one side of the building, under the shade of a large tree. The husbands usually come by to visit them.

A D B

Shrubs Grass Soil Asphalt Compacted soil A

MWH

Maternity

Latrinas

Water pump

-19.20284, 33.92582

183

+3.20 +2.72

+0.00

1.7

3.9

3.0

2.7

Bedroom / Storage

4.7

+0.20

Storage

2.7

2.6

Veranda

3.7 +0.00

Layout

2.6

+0.20

2.9

2.4 5.6

Bedroom Storage 33 m2 Veranda 20 m2 Kitchen outdoor

11.0

+2.90

Resting area +2.32 outdoor / Veranda Latrine not present

184

+1.05

+0.00

0.77 1.96

1.09 0.77

0.77 1.96

0.73 0.77

Kitchen

2.7

Material Walls “tijolo queimado” adobe bricks 130x90x260 mm concrete pillars 130x130 mm Roof fiber cement sheet wooden structure Basement concrete Patologies Not damaged

185

Panoramic view on the MWH. Women gather under the only shade available, a tree's one Inchope August 2021

186

Mothers under the veranda, waiting after a quick chatting with their husbands August 2021

187

MUDA SERRAÇAO

Location Manica province Gondola district Moda Serraçao locality Data primary level rural type II Referral hospital Gondola Rural Hospital 78,4km 11h40min / walk 1h31min / car MWH construction built in: unknown by: MISAU Local community

188

Muda's casa de mae espera, as the health centre, overlooks the paved road that leads to Gondola district. Very close to a river bed, the entire complex of buildings and emergency tents is raised above street level. The casa de mae espera is separated from the centre by a metal fence and consists of a two-room building that can accommodate up to 15 mothers at a time. The building does not have a veranda, the mothers cook in the back, squatting on three bricks that hold a saucepan and spend the rest of the day lying on mats and capulane in the shade of the large mango tree that grows next to the house. A few meters away there is the enclosure of the incinerator of the health centre. On that fence, the mothers hang their laundry to dry.

A C

Shrubs Grass Water Asphalt Compacted soil A

MWH

Maternity

Latrinas

Water pump

-19.3284, 33.83369

189

+3.23 +2.80

+0.00

Kitchen

1.6

4.0

3.0

4.5

3.3

Bedroom / Storage

2.7

+0.20

Storage

0.70 0.70

0.75 1.63

0.70 0.70

0.75 1.63

0.70 0.70

0.35 0.35

10.0 11.0 +0.00

Layout Bedroom Storage 30 m2 Veranda -

+2.40 +2.00

4.0 1.4

Kitchen outdoor Resting area outdoor under a tree Latrine present

190

1.1

+0.00 2.3

Material (home) Walls “tijolo queimado” adobe bricks 120x80x230 mm Roof metal sheet wooden structure Basement concrete

191

10.0 11.0 +0.00

Material (bathroom) Walls “tijolo queimado” adobe bricks 120x80x230 mm

4.0

3.0

4.5

2.7

+0.20

+2.40 0.75 1.63

0.70 0.70

1.4

0.75 1.63

4.0

0.70 0.70

+2.00 0.35 0.35

Roof metal sheet wooden structure

1.6

1.1

Basement concrete

10.0 11.0

+0.00

+0.00 2.3

+2.40 +2.00

+0.00

192

4.0

Patologies (home) Walls Partially damaged Peeling finish, absent in the upper part of the building > Weathering, bad construction, unfinished work Roof Heavily damaged Missing half of the roof > Cyclone Basement Not damaged

193

The outdoor “kitchen” and few mothers resting under the shadow of a big tree August 2021

194

Food and personal items stored on the floor or hanging from the wall August 2021

195

MACATE

Location Manica province Chimoio district Macate locality Data primary level rural type II Referral hospital Chimoio Rural Hospital 38,7km 7h46min / walk 0h57min / car MWH construction built in: unknown by: MISAU, Local community

196

The Macate Health centre’s plot is dense with buildings, dangerously lower than the street level, it offers many services to the community. The casa de mae espera is incorporated into this complex of buildings. Between the maternity ward and the pediatric building, stands a traditional single-room brick house, plastered in matope and covered by metal sheets. The small side openings overlook the kitchen, an external veranda in raw wood structure, covered and surrounded by pieces of corrugated metal sheet leftovers. At its centre stands a block of bricks and concrete that serves as a hob for the guests of the house. Mothers spend their days outdoors, sitting on the base of the maternity building, watching the patients of the centre wander from one pavilion to another.

C A

Shrubs Grass Soil Compacted soil A

MWH

Maternity

Latrinas

Water pump

-19.41506, 33.51295

197

+3.60

+2.85

+0.40 +0.20 +0.00

3.4

4.1

3.4

Bedroom / Storage

0.90 1.00

Bedroom / Storage

+0.50

Layout 0.62 0.70

0.90 2.08

Bedroom Storage 30 m2

0.4

Veranda 8 m2

7.3 +0.00

Kitchen outdoor / Veranda +2.44

Resting area outdoor / Maternity basement Latrine not present +0.00

198 1.8

2.0

0.9

0.90 1.00

Material (home) Walls “tijolo queimado” adobe bricks 140x90x290 mm Roof metal sheet wooden structure Basement concrete

199

3.4

Material (kitchen)

4.1

0.90 1.00+0.00

3.4

0.9

2.0

0.4

Kitchen

7.3

+0.00

Basement concrete and bricks Stove iron corners bricks and concrete

1.8

4.0

+2.44

+0.00

1.8

2.0

0.9

4.0

200

0.62 0.70

0.90 2.08

Walls raw wooden structure metal sheet Roof raw wooden structure metal sheet

0.90 1.00

+0.50

Patologies (kitchen) Walls Partially damaged Old metal sheets, rust spots, holes and sagging > Weathering, bad construction Roof Partially damaged Old metal sheets, rust spots, holes and sagging > Weathering, bad construction Basement Not damaged

201

Kitchen table under the sepatared veranda; August 2021

202

Three mothers resting under the sun August 2021

203

ZEMBE

Location Manica province district locality Data primary level rural type II Referral hospital Provincial hospital Chimoio 24 km 4h50min / walk 0h24min / car MWH construction built in: by: local community (exbank building adapted as MWH)

204

The only way to reach the health centre of Zembe is through an impervious dirt road. The community takes action periodically to cover the holes dug by the water, making the centre more accessible. The rural centre is very small, surrounded by fields and cattle pens which at times invade the sanitary lot. The casa de mae espera, built-in brick and roof in rough wood and metal sheet, was originally a bank, as can be seen from the buffered shapes of a door and windows facing the access to the centre. To date, the entrance of the house is facing the health centre, covered by a poorly constructed veranda. The interior is completely blackened by the smoke of many fires. The municipality of Zembe is colder in the evening and mothers are forced to cook indoors in the only room dedicated to them. However, no mothers were housed at the moment of the survey.

B C

Shrubs Grass Soil Compacted soil A

MWH

Maternity

Latrinas

Water pump

-19.26458, 33.38774

205

+2.40 +2.10

+0.90

+0.00

+2.40 +2.10

+0.90

Bedroom / Storage +0.00

Layout Bedroom Storage 14 m2

0.40 0.40

Kitchen indoor

5.6

0.78 1.80

Veranda 8,5 m2

3.5

+0.00 2.2

Resting area outdoor / Veranda Latrine not present

206

4.2

Material Walls “tijolo queimado” adobe bricks 120x80x230 mm Roof and veranda metal sheet raw wooden structure Basement absent

207

Patologies (home) Walls Partially damaged Peeling finish, missing both in front and back wall; interior part burned (due to cooking fires) > Weathering, bad construction Roof Partially damaged Old metal sheets, rust spots, holes and sagging > Weathering, bad construction

208

The back of the building showing the old entrance and openings today closed with bricks; A pig hanging around the water pump in the Health Centre August 2021

209

CHISSUI

Location Manica province Chimoio district Chissui locality Data primary level rural type I Referral hospital Chimoio Rural Hospital 7km 0h20min / walk 1h20min / car MWH construction built in: by: MISAU

210

A few minutes from the urban area of Chimoio, immersed in agriculture fields, the health centre of Chissui is the closest satellite to the provincial hospital of Chimoio. Therefore, given the recent years of urban expansion, the casa de mae espera has lost its function. To date, the internal space of the block, originally dedicated to the rooms, is divided into two parts by two fabric sheets hanging from the wooden beams of the roof and intended for visits for adults. Built-in local adobe bricks, it shows the typical rectangular conformation with a front veranda and a single-slope roof of metal sheet. The damages caused by the cyclone are limited to the windows and the basement corroded by water.

B D

Shrubs Grass Soil Compacted soil A

MWH

Maternity

Latrinas

Water pump

-19.1431, 33.4478

211

+3.00 +2.60 +2.40

+1.00

+0.00

6.9

Bedroom 3.7

3.4

5.2

0.70 0.90

0.70 2.00

0.70 0.90

6.9 1.5

1.4

+0.15

Veranda

7.2

+0.00

Layout (currently unused) Bedroom Storage 27 m2 Veranda 10,8 m2

+2.25 +2.07 +1.76 2.8

Kitchen Resting area outdoor / Veranda Latrine present

212

+0.00

2.5

Material Walls “tijolo queimado” adobe bricks 130x90x260 mm concrete pillars 130x130 mm Roof fiber cement sheet wooden structure Basement concrete

213

7.2 3.7

3.4

1.5

1.4

+0.00

5.2

0.70 0.90

0.70 2.00

0.70 0.90

6.9 +2.25 +2.07 +1.76

+0.15

Latrine 2.8

7.2

+0.00

2.5

+2.25 +2.07 +1.76 2.8

+0.00

2.5

Material Walls “tijolo queimados” adobe bricks 130x90x260 mm Roof fiber cement sheet wooden structure Basement concrete

214

Patologies Walls Partially damaged Peeling on the plaster > Weathering Roof Not damaged Basement Not damaged Other Too close to urban settlement - heavily damaged windows

215

FRANCISCO MANYANGA

Location Manica province Gondola district Francisco Manyanga locality Data primary level rural type II Referral hospital xx Rural Hospital 00km 0h00min / walk 0h00min / car MWH construction built in: by: xx

216

The construction of the Francisco Manyanga health centre dates back to 2014. The facility is connected to the ministerial water service (FIPAG) but it still has no electricity. According to the pharmacist, this seems to be the reason why neither the maternity ward nor the casa de mae espera service has been active since then. Despite the passage of cyclones, there does not seem to have been any significant damage to the windows or roofs. The house is built in concrete blocks and clad in cement plaster, the roof with wooden beams and metal roofing is single-pitched, wedged in the extension of the higher walls. The external veranda, protected by room locks and firmly anchored by means of two pillars and a load-bearing wall. Only mothers are missing in this health centre, both in the delivery room and in the casa de mae espera.

D B

Shrubs Grass Compacted soil

MWH

Maternity

Latrinas

Water pump

-19.10817, 33.63453

217

+4.05 +4.05 +3.15 +3.15

+0.00 +0.00

Bedroom / Storage

5.6

+0.45

5.6

+0.45 1.00 1.00

1.00 1.00

0.95 1.90

1.00 1.00

0.95 1.90 8.6 +0.00

Layout (currently unused)

8.6 +0.00

Bedroom Storage 48 m2 +3.40

Veranda . Kitchen 13 m2

+3.40 +2.65 +2.65 3.1 3.1

Resting area outdoor Latrine not present

Kitchen / Veranda +0.30 +0.30

+0.00 +0.00

4.1 4.1

218

Material Walls “Blocos” - cooncrete bricks 130x90x260 mm Roof fiber cement sheet wooden structure Basement concrete Patologies Not damaged

219

CHIPINDAUMUE

Location Manica province Gondola district Chipindaumue locality Data primary level rural type II Referral hospital Gondola Rural Hospital 21km 4h13min / walk 1h30min / car MWH construction built in: by: local community

220

An uphill road leads to the Chipindaumue health centre. Like many health centres in the Macate district, it suffered from cyclones Idai, Chalane and Eloise, losing the entire roof, remaining without electricity and, due to lack of funds at the provincial level, it still shows these effects. The same casa de mae espera, made up of two blocks, one for the night and a veranda for cooking, is badly damaged. Originally the structure was built with a traditional brick and metal roof. The bedroom is today without roofing and frames, with a floor covered with pieces of metal sheet and broken beams, resulting in overnight sleeping in the maternity ward; the kitchen, however, is still used. A single mother, the only guest of the structure, spends her days sitting on the ground waiting for the moment of birth.

Shrubs Grass Compacted soil

MWH

Maternity

Latrinas

Water pump

-19.05232, 33.78508

221

+2.50

+3.20 +0.00 +2.50

3.0

3.3

+0.00

0.90

4.5

1.4

2.0 +0.20

3.0

3.3

0.60 0.60

+3.20

+2.50

Bedroom +2.10

0.87 1.82

0.75 0.90

+2.00

+1.77

+1.70

6.3

+0.00

+2.10

+2.00

+1.77

+1.70

Layout (currently moved to the maternity ward) +0.00

Latrine

3.0

3.3

3.0

+0.00

3.2

0.90

Bedroom (currently unavailable) Storage 20 m2

3.8

0.8 2.5

Veranda -

3.0

3.2

Kitchen 12 m2 Resting area outdoor Latrine present

2.9 +2.10

+2.00

+1.77

+1.70

0.8 2.5

4.0 +0.00

+0.00

222 3.0

3.2

Material Walls “tijolo queimado” adobe bricks 130x90x260 mm Roof fiber cement sheet wooden structure Basement concrete

223

+0.00

4.5

3.8

Material

+0.20

3.0

3.3

3.0

2.9 0.87 1.82

0.75 0.90

Roof fiber cement sheet wooden structure

6.3

0.8 2.5

2.0

Kitchen

3.2 0.75 0.90

Walls “tijolo queimado” adobe bricks 130x90x260 mm

Basement concrete

1.4

+0.00 4.0

+2.10

+2.00 +1.70

+1.77

+0.00

3.8

3.0

3.2

2.9

0.8 2.5

224

4.0

0.60 0.60

Patologies Walls Partially damaged Has peeling on the finish > Weathering Roof Heavily damaged Main roof absent > Cyclone / strong wind Basement Partially damaged Eroded concrete at ground level > Flood

225

The only mother at Chipindaumue MWH waiting for the daily visit August 2021

226

Bricks and pots under the kitchen-veranda August 2021

227

AMATONGA

Location Manica province Gondola district Amatonga locality Data primary level rural type I Referral hospital Gondola Rural Hospital 23km 4h40min / walk 0h55min / car MWH construction built in: colonial period by: private

228

The history of the casa de mae espera in Amatonga dates back to the colonial period. Back then, it was only a temporary residence, four guest rooms directly facing a shared veranda, with large windows. In recent years, with the construction of the Health Centre, the structure has been adapted to casa de mae espera, but not reinforced according to the climate change standards. Unfortunately, the recent cyclones took away the roof and damaged part of the openings and the MWH function was moved to an abandoned activist's house, built of traditional local bricks, which the guest mothers of the centre used as a kitchen during the day, since the night is spent in the maternity ward. On average, four or five mothers have to adapt to this system, in order to be close enough to the centre to give birth safely.

A C

B D

Shrubs Grass Soil Asphalt Compacted soil A

MWH

Maternity

Latrinas

Water pump

-19.10013, 33.81

229

+2.85

+2.25

+0.00 - 0.25

+2.85

+2.25

1.28 0.59

+0.00

Layout (currently moved to the kitchen building) 3.2

Bedroom

4.4

1.3

Kitchen 19 m2 extra building

8.2

Resting area outdoor 5.2

Latrine not present

1.4

230 3.9

+0.50

2.1

0.65 1.14

2.50 0.70

0.65 1.14

Veranda

+0.10

+0.00

1.9 2.50 0.70

1.7 2.50 0.70

1.9 0.65 1.14

Veranda 20 m2

0.65 1.14

2.0 2.50 0.70

Bedroom Storage 36 m2

Bedroom

Material Walls “tijolo queimado” adobe bricks 130x90x260 mm concrete pillars 180x180 mm Roof fiber cement sheet wooden structure Basement concrete

231

8.2

+0.00

Material

5.2

Walls “tijolo queimado” adobe bricks 130x90x260 mm concrete pillars 180x180 mm

1.4

3.9

Roof metal sheet wooden structure

Kitchen +0.50

Basement concrete

2.1

+0.00

+3.00

+2.25

+0.50 +0.00

232

Storage

2.7

2.1

Patologies Walls Partially damaged Plaster erosion Has peeling on the finish > Cyclone Roof Heavily damaged Main roof absent > Cyclone / strong wind Basement Partially damaged > Heavy raing and flooding

233

Unpacking the MWH framework

In order to define a clear framework, the survey inputs have been separated into 8 categories: location, typology, layout, dimensions, infrastructure, materials, pathologies and builder. However, due to practical reasons, on some occasions, a couple of case studies have not been considered during the outcomes due to their different original purposes or nature. As a location the analysis takes into account the actual position of the MWH within the health centre (since by regulation it has to be inside the health centre enclosure), distinguishing in “isolated” when the MWH is built on the side-lines separated from the main health centre fluxes, or “not isolated” when it is clustered between buildings and facing the main open space. Typologies refer to the main conformations detected during the surveys, which vary from squared to rectangular with or without verandas and additional external canopies. The layout category describes the use of spaces and services provided by the MWH. Specific care has been placed for the basic hygienic and nutrition services, such as private toilets and kitchen, and the mean number of bedrooms. Dimension, coming from the technical surveys, aims at scaling the object, searching for common dimensional patterns within the main elements such as the closed space (bedrooms) and the open but covered (verandas and canopies). 3 thresholds each has been identified to categorize the case studies. The infrastructure, not useful for the research’s designing purposes, play a crucial part in the establishing and operability of MWHs. First of all, has been classified the road materials (and therefore conditions) to access the health centre, varying from coated (asphalt) to natural (clay, sandstone…). Secondly, the distance (km) timing (hours) needed for emergency transfer to higher levels of care by car or on foot.

234

The materials category takes into consideration the building techniques and is further divided into 3 subcategories, (i) walls, ranging from pau a pique, adobe bricks and cement blocks; (ii) roof, mainly constituted by metal sheets; and (iii) Basement, whenever present, composed by a stone-cement infill. Due to climate hazards and dysfunctional layouts, the surveyed highlighted the most frequent pathologies encountered on site. These have been directly associated with the previous category in order to underline the vulnerabilities of specific materials and solutions. The main ones detected regards the roof, up-lifted or destroyed by wind, and the pau a pique walls, too fragile in contexts of heavy rains, wind and flooding. Finally, the builder means the stakeholder involved in the construction. Among the cases surveyed 3 main options have been detected, (i) local community, sometimes supported by local associations; (ii) the MoH directly, with a construction company; and (iii) NGOs in partnership with the MoH. All the previous cases presented are summarized in two matrixes of features, the 8 categories, divided between Sofala and Manica. By means of these, collected in the appendix n°2, a clear process of "Unpacking" guided us towards the main design opportutities and constrains.

235

Vila Arriage

Jasse

Lamego

Zembe

Amatonga

Unpacking parameters Location

Isolated / Not isolated The distinction depends on the location of the CME, defined as isolated when set in the background, separated from the main functions of the center or outside the fence. Not isolated is when the location is clustered among buildings facing the main space.

Typology

Squared with perimetral veranda - and canopy Stecca simple / with veranda / with canopy The distinction depends on the building typology detected on site and the further presence of verandas or canopy

Layout

Toilet / Kitchen / Rooms The layout describes the spaces and services provided by the CME. In particular the presence of a private toilet, an open but covered space for cooking and the mean number of rooms provided.

Dimensions

Squared meters _ closed / open-covered The maximum and minimum dimensions have been categorized by the mean dimensions detected.

Infrastructure

The analysis of the distances of the case studies from the higher level hospitals of reference does not lead to the definition of design patterns. However, the roads materials such as asphalt, clay and, in some places, sandstone, greatly affect the use of CMEs. The CS of Tica and Inchope for example, being directly on the N6 (asphalted) generally host many more mothers than the average of the rural CS visited.

Closed 1. x < 29 2. 30 < x < 59 3. x > 60

Open-covered 1. x < 14 2. 15 < x < 30 3. x > 31

Walls / Roof / Basement Materials and patologies The research analyzed the different building techniques and materials.

Pau a pique: Intertwined wooden structure with a stone or adobe fill and matope coating Tijolos: Fired (sometimes sun-dried) adobe bricks Blocos: Sun dried concrete bricks Damages The research analyzed the different patologies (due to climate hazards) and are directly associated to the previous cathegory in order to underline the vulnerability of materials

Builders

236

Local community / MISAU / MISAU+NGO The list allows us to understand the main stakeholders and builders of the CME service

nb: From the typological point of view, the research rates 5 out of 18 case studies not always consistant with the analysis. In particular: - Hospital rural di Buzi, as a secondary level structure offers different services, therefore it hosts within the CME, built on the model of a “typical plan” defined by MISAU. Typology, infrastructure and numbers are clearly out of the standard cases taken into account; - the structures of Lamego, Zembe and Amatonga are used as CME but not built with this purpose; - the Jasse structure does not meet any of the requirements set by the MISAU guidelines and does not present itself as a livable habitat.

10 / Isolated

06 / Not isolated

05 / Squared

11 / 16Stecca

14 / 16* Are provided by an open-covered space for services (kitchen, resting space)

05 / 16 Private latrine

2 Mean number of rooms

+ 10 / 16 Canopy - kitchen

Closed 08 / 15 - 30 < x < 60 Open-covered mean value 07 / 15 - 15 mq mean value Walls - pau a pique - tijolos / cls structure - tijolos - blocos / cls structure

3 4 4 4

Damaged walls: - pau a pique 3\3 - tijolos + cement 0\4 - tijolos 2\4 - blocos +cement 0\4 Bottom wall - Openings Coating disruption and adobe bricks damaging

Roofs: - Metal sheet

Basement: - Concrete

Damaged roof: - Metal sheet 7\15

Damaged basement: - concrete 2\15

Veranda and roofing Pitch disruption and wooden beams + indoor damaging

Foundations+Basement Bad foundation construction and low mantainance

10 / 16 Local community (3 of which supported by local association ComuSanas) Current conditions: Severe damaged 03 / 16 MISAU Current conditions: Good, but out of service because too close to large urban areas

03 / 16 MISAU + NGOs Current conditions: Good and fully operational

237

Context considerations

Location

Expansion pattern of health centers The upgade from a rural center type II to type I depends on the population included in the c.a. Its feasibility lays on the current pavilions-conformation that allows further buildings to rise in the masterplan, clustering the center with new healthcare functions aligned to the increased number of patients.

Typology

CME typologies The CME service at the primary level (rural health centers type I-II) has not been regulated yet. Therefore the typology mirrors local needs, materials and low-cost construction technologies.

Layout

Use of space The CME inner layout is mainly thought as a combination of 1/2 bedrooms and a larger common space as storage. However, the lack of space has changed the storage into a further bedroom, increasing the the number of spots available. Traditional habitat The rural families spend most of their time outside, in direct contact with nature. Therefore, the buildings are devoted only to sleeping and storing food / tools. Verandas or canpies are an in-between space that host cooking, resting and meetings.

Dimensions

CME dimensions The CME service at the primary level (rural health centers type I-II) has not been regulated yet. Therefore the dimensions are not standardized or based on the actual need on site. Only at secondary level (Rural hospitals) exist a “standard plan”and dimensions to address the CME needs.

Infrastructure

Local materials The main available materials on site are: adobe, wood and matope for coating. Foreign materials Plenty of new industrial materials have been imported in the last century: concrete for bricks and reinforced structures, steel bars and nets, corrugated metal sheets for roofing, steel / iron connectors, plastic layering etc.

Materials and patologies

Climate patologies Most of the damages come from tropical storms, flooding and heavy rainfall patterns. However, wrong details and connections between foundation - walls /walls - roof made damaging more severe, highlighting the fragile current condition.

Builders

Proximity to urban areas According to the cases detected, rural health centers closer than 30-40 km to the city, do not need a CME because of the high rates of istitutional births, the proximity to higher levels of attendance and the presence of an operational infrastructure for emergency trasportation. Type of builder Since no regulations have been taken for the CME infrastructure, the ones built by local communities are based on low budgets and poor materials resulting in fagile structures. MISAU and NGOs interventions are often characterized by higher budgeting and long-lasting quality material (however not always sustainable).

238

Analysis outcomes According to MISAU strategy regarding the upgrading of Health Centers from type II to type I, the location of the Casa de Mae-Espera within the masterplan is crucial for two reasons: 1. Privacy / Proximity 2. Cs stretching and expansion There is no prevailing vernacular typologies beside a reiteration of a building pattern used within health centers or in the settlements near by. However, an interesting care is dedicated to domestic habits, providing specifically built extension to the open space by means of verandas or canopies.

The analysis highlightes how services such as cooking and bathing are placed outside, under a roof (veranda / canopy) or in the openair. Enclosed spaces are only for very private activities such as sleeping and storing personal belongings. - Private and closed > Bedrooms and storages - Flexibility Storage > Bedroom - Outside services > Kitchen and Resting areas Mean dimensions: - Closed space _ 0 < x < 40 mq - Open-covered space _ 15 mq - Mq / woman detected _ 3 mq

Primary level (rural health centers)

Secondary level (rural hospitals)

The infrastructure is a key element in determining the success of the CME. The closest the CME to the main road the more mothers may reach the structure. - Asphalt road > High accessibility - Clay / Soil / Sandy road > Low accessibility (especially during the rainy season)

- Pau a pique >Local and sustainable construction technique; High vulnerability to rainy weather and flooding, damaging specifically the wooden primary structure and the matope coating. - Tijolos (+ concrete structure) >Local and sustainable construction technique; Concrete addition to reinforce the structure - Low sustainability; Medium-high coating vulnerability to rainy weather. - Blocos (+ concrete structure) >Local / imported construction technique; concrete addition to reinforce the structure - Low sustainability; Low vulnerability to rainy weather. - Corrugated metal sheets >Local / imported construction technique; Low sustainability; High vulnerability to wind and tropical storms /especially due to bad construction details) . - Basement >Local / imported construction technique; Low sustainability; Medium vulnerability to flooding due to bad construction. 1. Local community: poor structure; sustainable materials 2. MISAU: High-resistance structure; No sustainable materials 3. MISAU + NGOs: High-resistance structure; Mix

239

Resilient guidelines UNHabitat Finally, the outcomes have been intersected with the guidelines of UNHabitat Mozambique for disaster-resilient reconstruction. For each category, specific norms and precautions are underlined leading to the following design phase with an overview not only on the current condition, local building practices, layouts, dimensions but also on construction norms to implement into the design of a resilient MWH for cyclone-prone areas.

Location

Potential landslide area

Building 100

+ Spring

Circolar

Compact and simmetric shape

Potential flooding area

Latrine

Squared

Rectangolar

Roof detachment

Veranda (roof attached or separated)

Veranda detachment

Angled to the main winds (45°)

Openings (Absent or front / opposite direction of strong winds) Dimensions (45°)

240

River

max 3x

h/2

Distance from trees

h/2

Vulnerable connections

Stakeholders and process

02 04

01 05

MISAU (Government partner) + NGO / UN (Implementation partner) + UNHABITAT (Technical partner) + LOCAL COMMUNITY (Focus groups)

SITE SELECTION 01 Wall / Roof structure connection

- Strengthen the connection with the reinforced concrete ring beam - Trusses with diagonals

02 Primary / secondary roof structure connections

- Metal connectors or hurricane clips between the layers

03 Wall / beams connection

- Fixing the beams with a reinforced diagonal concrete beam

04 Metal pitch / Secontary beams connections 05 Veranda / walls connection 06 Openings protection

- At least 0.6 mm metal sheet - “J” bolts and srews - 2-3 overlap waves

PROTOTYPE APPLICATION

WORKSHOPS (teaching resilient construction rules)

LOCAL COMMUNITY (Builders) + UN/NGO (Technical supervision)

- Separation between main roof and Veranda - Reinforcing with pillars - Doors and windows with metal bar locks and lids

241

2.20 - Women daily activities in Grand Hotel Beira and in Dondo countryside 2020 - 2021 Paolo Ghisu Photography

242

RURAL WOMEN DAY SCHEDULE: DAILY ROUTINE AT HOME VS LIFE AT MWH

Within the traditional rural family, whereas the man leaves the house for working, the woman is the figure who lives and manages it, beside taking care of children. Cleaning, laundry, re-organizing inner space layout and small house repairs are important tasks to ensure the home as a clean and safe space. She spends plenty of time outdoors, within the courtyard defined by the “palhotas” and vegetation, a place where daily life develops and children can play safely. Some activities, such as collecting water, going to the market, working on vegetable gardens and harvesting food or wood for fires, that brings her out of the house enclosure, giving her the occasion to meet friends or other family members. Despite the absence of a gender sensitive approach, the woman is also the main user of healthcare, mainly due to ordinary visits when someone is sick, prenatal visits when pregnant and paediatric care for children. In fact, the maternal and child sector is the one most diffused across the country, giving the high need of care in rural areas, where plenty of diseases (malnutrition, cholera, malaria, HIV, tuberculosis, etc.) are still widespread.

2.21 - Women daily activities at home and at MWH - comparison Social activities and spaces to promote a new MWH paradigm

Addressing the MWH concept means understanding the woman's condition, all her facets and details of everyday life. Therefore, the daily schedule of women represents a key aspect to understand their role within the family as well as an element to start from in order to define a familiar space, sized on her necessities. Thus, the following scheme proposes a comparison between the daily home schedule and the one provided at the MWH service, at least the ones we had the chance to survey.

243

- River - Water-well - Tank

Water collecting

5:00 wake-up

6:00 Housekeeping Health center check-ups

Machamba

- Dish and dust cleaning

- Prenatal visits - Consultations - Health checks

The man is present only for sowing and harvesting

Xima

According to the amount of patients waiting time can vary

Beans

Firewood Laundry Market

10:00 Matabicho

Dishes House cleaning Family care

15:00 Lunch Resting

18:00 Dinner

19:00 / 20:00 Sleep 244

The presence of artificail lights can stretch the after-dinner time

Inhamichindo

Water provision Within the health center drinking water is provided

6:00 wake-up Maternity ward

Maternity daily visit

Maternity visits space within the MWH > Clinic

Local market Church

- Secure a daily visit - Avoiding emergency delays - Promoting the MWH use

10:00 Matabicho

Shared kitchen with dining space - Building community

Prenatal classes Activity space for health education, nutrition baby care and vegetable garden > covered space > open courtyard Shared kitchen with dining space - Building community

- Family care - Stimulate community sense - Promoting the woman education - V. garden for the next guest

15:00 Lunch

Vegeteble garden Courses Training Pottery Weaving

Promoting income generation activities > Veranda > Activity space > Open courtyard - Exploit the waiting time to generate a source of income - Foster educational and cultural development

19:00 / 20:00 Sleep

18:00 Dinner

Shared kitchen with dining space

Resting

- Building community

The presence of artificail lights can stretch the after-dinner time

245

The only consistent activities detected are the moments of foodshopping at the market (for those who can afford it), going to church on Sunday (only few cases allow these practices) and family members visiting (mostly husbands bringing food to their wifes). The rest of the day is spent without any activity, everything is characterized by a constant waiting.

2.22 - The only woman in Chipindaumue wainting ceaselessly the delivery day Chipindaumue, Gondola Manica August 2021

246

Therefore, the comparison scheme proceeds towards the potential answer of architecture and social engagement to this state of constant waiting. By means of the interviews with pregnant mothers, nurses and an accurate observation we identified specific moments of the day translatable into spaces that offer open and covered solutions for extra activities to implement at MWH. The idea is to create not only a place to wait for delivery but also a chance of health practices, education, training, income generation and women empowerment in order to support their future as mothers and workers. However, the first barrier is the lack of knowledge regarding the system, therefore a first step aims at moving the prenatal visits within the MWH compound in order to speed the “word of mouth” among communities. Furthermore, the accommodation is studied to provide extra spaces to extend the capacity for emergency reasons or to host companions.

247

3.0 - A “capulana” dress hanging from the MWH’s window in Siluvo, Nhamatanda, Sofala August 2021

PART III

3.1 - A pregnant mother waiting on a large bench-basement in Macate health centre Macate, Manica 2021

250

TOO FAR TO WALK Disaster resilient Maternity waiting home in rural Mozambique

“L’ingrediente principale del mio lavoro è la libertà. Per progettare ho bisogno di tre tipi di libertà: quella che mi concede il cliente, quella che mi concede l’autorità e quella che io concedo a me stesso. Lavorando in Africa ho potuto beneficiare delle tre libertà ed essere pienamente responsabile (nel bene e nel male) delle mie opere. Un’altra componente indispensabile è il rispetto: rispetto per coloro che usufruiranno della mia architettura. Il rispetto mi impedisce di abusare della libertà” (Fabrizio Caròla) The context which this research tries to address in Mozambique is complex and constantly changing. Indirectly, it covers a broad scenario of vulnerable situations and sectors, ranging from natural disaster’s emergency to social discomfort and marginalization of women, from contexts of limited resources, social and economic crisis, to the lack of primary needs. Maternal and newborn mortality in rural areas falls into all these areas and can be tackled in different ways. The government took a lead in 2009, promoting the MWH program as a strategy to bridge remote areas to national healthcare and improve the number the institutional, and therefore safer, deliveries. However, several barriers didn’t’ allow the system to spread correctly, further damaged by the recent wheatear extremes. Thus, the research project aims at taking advantage of the current country’s policies regarding safe childhood and motherhood,

251

addressing specifically the vulnerability of the MWH system induced by climate change. The field of experimentation lands in the limited areas of Sofala and Manica by means of a piloting intervention to raise awareness of the topic, approach the gender issue and resilient construction metodology, trigger local development as well as finally propose a worthy habitat for women. In fact, the architecture projects in these areas should act as a “tool”, not an “end”, becoming an opportunity to contribute to development. The use of “appropriate and appropriable technologies” (H. Massuh) highlights the will to influence local communities and production systems from below. The purpose, in other words, is not the construction, but the promotion of development in the belief that architecture can be a tool (not the only one, not the first) to improve the living conditions of local communities. Only in this way, can be achieved a transition from an architecture intended in a productive sense that aims at the optimization of the building for sale, to a procedural architecture interested in social, environmental, and economic ecosystems, which it is proposed to interact and interfere with. This bottom-up approach is an effective way to improve sustainable hardware and software, building local capacity through the process of design and construction to instigate social change and empowerment through sharing knowledge and skills on-site. Participatory design, meant as a respectful attempt to actively involve all stakeholders (students, families, teachers, local community, local authorities, etc.) through all project stages, to help ensure that the end result meets their necessities, always results in locally fabricated, low-carbon, long-lasting buildings that, inspired by traditional construction methods, effectively fulfill the needs of users and enhance lives in the local community. These low-tech and bottom approaches are key elements and have not to be mistaken as a return to the past. The process fully represents contemporaneity, it manages complexity and chooses the minimum terms to do so, demonstrating the ability to deal with an idea of tradition that explores the global to give it a local interpretation, hybridizing the local never ordinary, never for its own sake.

252

Territorial strategy The MWH strategy is only one part of a comprehensive continuum of obstetric care. Therefore, a territorial strategy has to take into consideration a parallel development and spread of the rural healthcare units, equipped with maternity wards. According to PESS III, both the expansion of rural healthcare centres and MWH service are part of the national program. Thus, a definition of site proposals for future sanitary units has been suggested, starting from the main parameters to consider before establishing an MWH: (i) provincial/district and local institutional deliveries coverage, (ii) analysis of current population and growth trends, and the proximity of national infrastructure and scattered settlements. A further parameter to consider is the vulnerability of the area to climate extremes, given their high impact on the country’s infrastructure. Moreover, a needs assessment at the local level has to be implemented to understand the potential barriers (cultural, economic, geographic, etc.) and gain the support of the community in the acceptance of the system, to spread the “Word of mouth”, build and maintain the structure. Unfortunately, few recent data regarding institutional deliveries are available at the local level, therefore the research used the most recent value (2020) but at the higher level (provincial). The population density, as well as the settlements, roads, and cities positions, come from an MSF post-Idai assessment dated 2020. The climate extremes area instead is from a UNHabitat survey to address the Safer School program in 2015.

253

xxx x x x

x x xx x

x x

90%

xx x

x x x

+ 1

Institutional births (Province level) - INE 2020 -

x x x

x x

x x xx x xxx x

x xx x x x

x xxx x

x x

x x xx

x x

xx x x

x x

xx x x x xx x xx x x xx x x x x x xx

x x

xx x x x x

x x xx

xxxxxx x xx x xx x x x x xxx x x

x xxx

x x

xxx

x x

x xx

x x

x xx xx xx

x x x

x xx

x x x xx

xx x

x x

xx xx xx xx xx xx x x x x xxx x x

x xxx

x x

xx xx x

x x xx

x x

xxxx xx x

x x x

x x

x xx

xx x x x x

x x x x xxx x x

x x

xx x x

x x

x x xxx

x xx

x x

x x x x

x x

x x x x xx x xx

x xxxx x xx xx xx x xx x x x x xx x x x xx x x x

x x x xx xxx x xx xx xxxx xx x x xx xx x x x xx xx x xx xx x x x x x x x x xx x x x x x x x x xx x x xxx xx x x x xxxxx x xx x x xxxx x x x x x xx x x x xx x x x xx x x x x x x x x x x x x x xx x xx x x x x xxx xx xxxxx x xxx xx x x x xx xxx x x x x x xx xx x xxx x xx x x xxxx xx xx xx xxxx x xx xx xx xx x x x xxx x x xx x xx x x x xxx x x x xx x xx xx x x x xx x x x xxx x x x x xxxxx xx x x x x xx x xxxx xxxx x x xx x xx x x x x x xxx xx xxx xx xxxx xx x x x xx x xxxx x x xx x xxx x x x x x x x x xx x x x x x x xx x xx x x x x x xx x xx x xx x x xx xxxx x xx xx x xx xxxx xx x x xx xx x x x x x x xx x x x x xxx xxx x x x x x xx xx x xx x x xxx x x x x x x x x x xxxx x x xx x x x xxxx x x x x xx x x x x xx xx x x x x x xxx xx x xx x xx x xx x x x x x x xx x xxx x x x x xx x x x x x xx x x xx x x xx xxx x x x x xx x xxx x x x x x xxx x xxx x xx x x x x x xx x x x x x x x x xx x xx x x xxx xx x x x x xx x x x x x x xx x x x xx x xx x x x xx xx x xx xxx xxx xx xx x xx x xx x xxx x x xx xx xx x x xx x xx x x xxx x x x x x xxxxxxxx x xx xx xx x x x xx x x xx x xx xxx x x x xx x x x x x x xx xx x x x x x xx x x x x x x xx x x x xxx xx xxxxx x x x x xx x x xxx x x xx xx x xxx x x x xxx x xx xxxxxx xx xxxx x xx xx x x x xx x xx x x xx x x xxx xx x x xx x x x xxxxx xxxxxxxx x xxxxxxx x x x xxxx x x x x x x x x x x x xx xx x x x xxx xx xx x x x xxxx xx x xx x x x xxxxx x x x x xx xx xx x xx x x x xx x xxx x x xx xx xxxx x xx x x xxx xx xx x x x xx x x x xxx xxx x xxx x xx xxxxx x xx x xx x xxx x x xx x xx xxxx xx xxxxxxx xx xx xxxx x x x xx x x x x xx x x xx xx x x xx x x x x x xx x xx xx x xxxx xxxxxx xxxx x xx x xxxxx xx xx xxx x x x xxx x x x xx xx xx x x xxxxx x xx x x x x x x xx x xxx xx x xx x xx xxx x x x xxx xx xxxxxxxxxx xx xxx xxxx x x xx xx xxx xxx xx x x xx xx x x x x xxxx x xx x x xx xxxx x xx xxxx x x x xx xx xx xx xx x x xxxxx x x xx xx x xx xx xxxxxx x xxxx xxx x x x xx x xx xxx x x x x xx x xxxxx x xxx xxxx x x x xxxx x xxxx x x x x x x x x xx xxx xxxxxx x x x x x x xxx xxx x x xx x x x xxx xx xxxx x x xx x x x xx xx x xx x xx x x xx x xx xxx x x xxx x xx x x x x x x xxx xxx xx x xxx x x x xxx x x xx x xx xxxx xxxx x x x x xx xx xx x xx xx xx x x x x x x x x x x x x x x x x x x x x x x x x x x x xx xx xx xx x x x xx x x x x xxxxx xx x x xx xx x x xxxxx xx x x x x xx xxxxxxx x x xx x x xx xxxxx x x xx xxx xx xx xx x x xx xx x x x x xxxx x x x x x xx x x x x x xx x xxx x xx x xx x x x xx xx x x xxxxxxx xx x x x xx x x xx x xx x x xx xxxxxxxxxx x x xx x x x xx xxxxxx xxxxxxxxx xx xx x x x xx xx xx x x xxxx x xxx x x x x xx x x xx x x x xx xx xx x xx x x x x x x x x x x x xx x x xxx xxx x xxx x xx xxx x xxx x xxx x x xx x xx x xxx x xx x xx x x xxxxxxx xxx x xx x x xxxxx xx xxx x x x x xx xx x xx xx xx xx xx x xx xx xxx x x x x x x x x x x x x x x x xx x x xx x xxx xxxxx xx xx x xxx x x x xxxxxxx xx xx x x x xx xxx xx x x x x x xx x x xx xxx xxxxxx xx xx x x x xxxx x x xx x xx x x x x x xxxx x x x x xxxx xxxxxxxxxxx xxxxx xxx x x xx xx x xx x xx x xxxx xxxxxx x xx x xxx x xx x xx x xxxx x x xx x xx x xx xx x x x x xx

83%

xx x

x xx x x xx

x xx

x x

x x xx

xx xx x x xx x

x x x

x x xx x x x x x xx x x x x x x x xx

xxxx x

x x

x x x

x x

xx x xx x x x x x

x x x x x x

xx x

x x

xx xx xxx x x x

x xxx xx xx x x

xx xx xx x

x x

x x x

xx xx x

xxx xx

x x

xx x

xxx xxx x

x x xx x x x xxx x x x x x x

x x

x x x

x x

x xx xxx x xx xxx xx x x x xx xx x xx x xxx xxxx xx xx xx x x

x xx x

xx xxx

+ 2

Infrastructure and settlements development - INE 2020 -

Zone I

+ 3

3.2 - Parameters to take into account before establishing a MWH

254

Demography trends - WorldPop 2020 -

+ 4

Disaster risk: vulnerability to tropical cyclones - UNHabitat 2019 -

x xxxxx xx

x x xx

x x x xx

x x xx

x x x x

3.3 - Barriers to detect before establishing a MWH: Cultural Geographic Economic Political / Management Climatic

Cultural (Family constrains)

Geographic / Economic (low diffusion and poor infrastructure)

Political / Management (No policies, poor structures)

Climatic (extreme hazards)

3.4 - Strategic operational plan: Parameters and Barriers assessment > Action

Tropical cyclone prone area: zone I

Health centre + MWH

Remote areas

MWH

Resilient proposal

opt-3 opt-2 opt-1

Resilient recovery Monitoring

Hospital

Methodology

Actors

Development

Direct MWHsurvey - Not present - Destroied - Damaged - Operational

MISAU Local community External partners

Improve diffusion of MWHs, rural Healthcentres and infrastructure network

Flexibility Future adaptability: maternity extension HC shared kitchen or worker’s accomodation 255

x x

x xx

Marker / Point of interest

xx x

x xx x x x x

x x

xxx x x x

Capillarity / diffusion

x x

x x xx

xx x

x x xx x

Infrastructure development

x x x

x x

x x x

x x x x x xx

xx x xx x x x x x x

xx xx

x x xx

x x x x xx

x xx x xx x x x x x x x x xx x x x x xx x x

xx x

x x

x x xx x x x x x x x x x x x x x x x x x x x x x x xx x x x x xx x x x x x x x x x x x x x x xx x x x x x x x x x xx x x xx x x x x x xx x x x xx xx x xx x x xx x xx

x x x x

x xxx x

x x

x x x x xx x x x xx x x x x x x x x x xx xx x x xx xx x x x x x x x x xx x x

To bridge the geographical gap between rural communities and health care units. The access to maternity care even in remote areas allows to formalize more births and overcome the current barriers to the service.

256

x x x x x x x x x x x x x x x x xx xxx xx x x x

“The big picture”. A number of new structures and roads to allow an incremental rural development over time, strenghtening the existing connections and lowering delay in maternity care.

x x xx xx xxx xx xx xx xx x

x x

x x x x x x xx

x x x

x x

x x x

xx x

xx xx x

xxx

Area of impact

Highlighting specific zones that shows high rates of population density, low i.b. and shortage of health units. Future economic hubs may as well trigger a further implementation of strategic plans.

x x xx x x x

x x

The framed areas mark the proposed primary field of application/impact. The current research focuses on tropical storm’s affected areas in Sofala and Manica provinces.

x xx

3.5 - Territorial strategy

xxxxx

x x

x x x

x x

x x x x x x xx

x x x

x xx x

x x x

x xxx

x x xxx

x x x x x

+ x

xx x x

xx x x x x xxxx x x x

x x x x x xx xx x xx x xx x xx x x x x x xx x x x x x xx xx xx x xx x xxx x x xxxx x x x x x x x x x x xxx xx xxx x x xxx xx xx xx x xxx x x x xx x xx xx xx x xx xx x xx x x x x x x x x x xx x xx xx x x x x xxxx x x x x

x x x x x

x x

xx xx x x x

x x x

xxx x

x x

xx x x x

x xxx

xx x xx xx

xx xx x

x x x x

x xx x x x x

x Infrastructure strenghtening

x x

Infrastructure on-going -2021Future hotspot New resilient MWH needed

x x

x x x

x x xx

x x

x xx x

xxx x x x xxx xx x

x x

Zone I

xx x

x xx

xxx xx

x xx

x x

x xx x

xx x x xx x

x x

xx x

x x

xx x

xxx xx x xx x x xx x x x xx xx x x x xx xx x N6 x x xx x x x

x x x x

x xx xx x x x

x x

xx x

x x

+ +

Partial resilient restoration needed xx x x x xx x x x

CS affected Settlements Hospital Rural - Provincial - Central

Rural health center type I - II + Catchment area (8km) Influence area (30km)

257

Building habitat: idea and concept

UNHabitat Unpacking

3.6 - The concept strategy have been studied according to the unpacking process and the resilient guidelines of UNHabitat Mozambique 2021

max 3x x

+ +

Compact shape and ration Key spaces: between the 2 sides - Open court - Bedroom - Kitchen - Veranda - Activity area

UNHabitat

01 THE VILLAGE central space

max 3x x

Toilet 8.5mq

Bedroom 47mq

Activity 31mq Compact shape and ration between the 2 sides

Orientation and ventilation Kitchen - SE, 45° tropical storm wind 18mq

258 - Openings (Absent or front Court

Veranda /opposite 37mq direction of strong winds) 70mq

Kitchen and toilet

In Mozambique countryside, the living conditions and opportunities are very poor, resulting in spontaneous form of shelters made of “pau a pique” or adobe bricks according to the regional resources. The vernacular typologies shift from a rectangular shape in the north (due to Arabic influences) to rounded dwellings called “palhota” to the south. However, in the last decades, the rectangular form is wide-spreading due to its easy building character and urban conformation. In both cases, the rural house is defined by a series of buildings, where different functions are allocated: the home-bedroom for sleeping and storing food beside personal belongings, the canopy to cook outside, and a veranda to welcome the guests or rest after work. The open space plays a crucial role in this conformation, tying together all these elements. The features of the Maternity waiting homes surveyed are very similar, although poorer, showing the intention of local communities to use the native technologies to dwell the pregnant mothers within health centres. Besides, these practices are the only ones they know, handed down from one generation to the other. However, most cases present only one building storing all the functions, a precarious shelter as kitchen (when provided), and no personal toilets. Building costs are still a huge barrier for rural communities, given that the MoH has dumped on them the responsibility and construction expenses. This situation has been dramatically exacerbated by climate extremes, resulting in structures’ damages or destruction. Moreover, since most rural houses have been destroyed, shifting the community engagement on personal dwellings, a further lack of maintenance or noreconstruction only worsens the conditions. Given the state of the art, the design idea roots into the village pavilion configuration and the value rural population lay on the open space, considered a crucial environment where they spend most of the time. Our intervention, not specifically designated to the one only site, tries to embed this value starting the design from the central collective space lately surrounded by modular pavilions not only brings up the vernacular settlements’ suggestion but also allows a future expansion by the addition of further modules in

UNHabitat UNHabitat

spaces intentionally left empty (as already in place within health centre). Moreover, the compact solution is highly advised as a resilient UNHabitat strategy, indicated as one of the most windresistant shapes.

max 3x x Roof detachment

Compact shape and ration between the 2 sides Veranda detachment

UNHabitat

Veranda configuration

+ +

max 3x x

UNHabitat

02 ROOFED CONNECTION Veranda as a link among spacesCompact and indoor/outdoor filter shape and ration between the 2 sides Bedroom 47mq Toilet 8.5mq Activity 31mq

Kitchen 18mq

Court 37mq

Veranda 70mq

+ +

Kitchen and toilet fumes Bedroom

Orientation and ventilation 47mq Toilet - SE, 45° tropical storm wind 8.5mq - Openings (Absent or front /opposite direction winds) 03of strongActivity HIERARCHY 31mq Private and “public” spaces within the MWH UNHabitat

Therefore, it is always “the open” that generate and influences the closed space, in constant relation through small passages, seats, cozy courts, large openings (whenever possible), and filter spaces as verandas. As shown in the “unpacking” process, architectural elements like the veranda are spread and act as key domestic components, where open but covered spaces meet, and plenty of activities can be performed protected in all seasons. Moreover, it plays an important role as a temperature regulator in a tropical climate, avoiding the sun’s rays to reach and overheat the main facades of buildings, guaranteeing a cool indoor environment. In our intervention, besides being a space of stay and climate control, it takes over another function: connection. Many cases surveyed had a veranda but either too small to host activities or poorly built and detached, highlighting a potential barrier in rainy seasons and an untapped opportunity to create gathering. Thus, with trusses spanning almost 3 meters, it puts in communication all the closed spaces and, bending on one side, it also enhances the central collective space. Given its conformation, it further works as a rainwater collector, harvesting into a water tank dedicated to sanitary uses. This alternation of open, closed, and open but covered spaces generates different levels of privacy ranging from the most private bedroom and storage for belongings pavilion, to the most public activity building, facing the central space with large windows and hosting a small clinic for check-ups. A third building, widely open to the central court, allocates the moment of cooking and eating. Personal toilets are provided in the back, separated by a small court to do the laundry and dry clothes Appropriate wall partitions and light wooden additions reinforce this concept, allowing the mothers to enjoy moments of pause or be involved in collective practices. Specifically, the idea to close the veranda in front of the bedroom aims at generating a background for the central space, protecting bedrooms from the sun in the hot hours, and creating a moment of privacy close to the bedroom building.

Kitchen 18mq18 17

13 12 11 10 9 15 14

Court 37mq

7 6

Veranda 259 70mq

Kitchen and Hot toiletseason wind fumes

+ UNHabitat

Compact shape and ration between the 2 sides

Bedroom max 3x47mq

Toilet 8.5mqx

Activity 31mq

Compact shape and ration between the 2 sides Kitchen 18mq Court Veranda 37mq 70mq

Kitchen and toilet fumes UNHabitat

04 SIZING According to the function allocated, woman needs and daily habits

UNHabitat

13 12 11 10 9 15 14

7 6

Hot season wind ESE Tropical storm wind SSE

+ Orientation and ventilation - SE, 45° tropical storm wind - Openings (Absent or front /opposite direction of strong winds)

260

The pavilion’s dimensions are sized on the functions they host, starting from the central court of 37 m2 and the back one for services of 24 m2. The veranda, despite the average 30-40 m2 detected, has been doubled to 70 m2. The pavilions respectively measure (i) 47 m2 (30 of storage) the bedroom, (ii) 18 m2 the kitchen, (iii) 31 m2 (7 of the clinic) the activity pavilion, and (iv) 8,5 m2 the bathroom. It is significant to note that the conformation chosen brings also a high rate of flexibility, especially in the activity pavilion which can work as an extra bedroom in emergency cases or host relatives if mothers come together with a family helper. In fact, one of the important factors within the village and African communities is not so much the function of the building itself but rather its ability to adapt to different situations. Our idea indeed aims at flexibility also at that level, thinking the MWH as a further extension of the maternity ward for prenatal visits (bringing also awareness of the service through the word of mouth), a shared kitchen for the whole health centre, or extra accommodation for sanitary workers. Climate has been constantly taken into account in all these steps, shaping and directing most of the choices given the objective to design a dwelling resistant to weather extremes. Specifically, from the shape, already mentioned, to the main wind and sun orientation. In fact, the stronger and compact building, the bedroom, has an N-S orientation, with a 45° inclination against tropical cyclones wind, as defined by UNHabitat guidelines. Simultaneously, the openings and small holes are placed in the direction of the summer breeze to ventilate the indoor space and blow out the exhausted air. The activity pavilion follows the same principle, breaking the wind at the southern edge and letting the wind vent from the openings on the opposite side to the entrance. The kitchen instead, is well protected by the bedroom, however, being mostly open due to cooking fumes, acts like the veranda, letting the wind blow away. Furthermore, the building rotation according to prevailing winds allows to turn away the toilet and kitchen fumes. The open spaces are studied to be highly illuminated by sun rays almost in all seasons especially the colder ones, allowing mothers to pick the warm atmosphere outside or to stay under the cool veranda. This choice is crucial to keep the front space vibrant,

UNHabitat

Kitchen 18mq

Aware that the presented project is only a first step to address the issue at the general level, it tries to take into consideration all the strategic features for a worthy and climate-adaptive design sized on the country’s weather and its users, pregnant women. Further and crucial steps of stakeholders’ engagement, such as focus groups with the local community and the MoH as well as technical partners to instruct the workers, have to check the studies and verify its adaptability to the site-specific constraints. Technologies and materials The technologies proposed are taking inspiration from the past, employing local materials to foster new building processes, which are affordable and easy to reproduce. In fact, the aim is to support the local economy by teaching people (self-made construction) how to make the most out of the easily available materials, so that they can apply the same construction techniques for their own houses in the future besides starting new income generation businesses. In particular, the project’s walls are constructed of Compressed Stabilized Earth Blocks (CSEBs) as an alternative to traditional fired brick, which uses large quantities of wood in the firing process. Moreover, they represent a higher durable solution than “pau a pique” construction, extremely vulnerable to rains and flooding. However, to increase durability and define checkpoints for maintenance, the idea involves the use of a pigmented matope plaster, engaging a further actor in the participation process: women, who usually contribute to private dwellings using earth

Kitchen and toilet fumes

Compact shape and ration between the 2 sides

13 12 11 10 9 15 14

7 6

Hot season wind ESE Tropical storm wind SSE

+ 05 ORIENTATION According to prevailing winds and sun path UNHabitat

the vegetable garden productive and the backcourt dried since most of the humidity is collected there due to the presence of a bathroom. Finally, another prevention for climate extremes suggested by UNHabitat is to raise the building on a large platform to protect the indoor spaces from flooding. This element was studied to raise the MWH by 45 cm, creating perimetral extra seats, that shrinks and enlarge according to the collective spaces, and a resistant basement against soil erosion. The access is guaranteed by steps in the front and a ramp in the back, close to the bedroom, for disabled people and emergency transfers.

Court Veranda 37mq max 3x 70mq

+ Orientation and ventilation - SE, 45° tropical storm wind - Openings (Absent or front /opposite direction of strong winds)

261

3.7 - Abacus of Materials, mostly sourced locally

coating and painting. Moreover, the painting activity is culturally well spread across the country not only for aesthetic reasons but also as function indications (for example, some MWHs displayed walls drawing to show the function allocated inside to guarantee an easy identification and address also illiterate people) and detector element for needed maintenance since specific paints dissolve at water excessive contact and humidity. The foundation and raised platform detail take advantage of the local practice of a mixture of mud, field stones, and cement to create the plinths, further surmounted by a ring beam of reinforced concrete to stabilize the ground detail. The above pavement uses the same technology starting from a stone field and earth base, with addition of stabilized earth/sand and a plastic sheet to avoid rising damp. Subsequently, the reinforced concrete pavement by means of a bamboo net of 10x10 cm. Bamboo is a locally sourced material, low-cost, extremely flexible and resistant. Even though wide-diameter structural bamboo is not present in central Mozambique, medium dimensions, appropriately cut and assembled, can cover large areas and assure resistance. The roofing structure uses the well-studied UNHabitat technology of wooden trusses, appropriately connected with metal joints and hurricane clips for secondary structure. Specifically, the connection between walls and roof structure is designed as a reinforced ring beam and the overhangs don’t go over 60 cm to prevent the strong tropical wind rip. The covering layer implements fibercement sheets, heavier than metal sheets, more durable and lower in costs. Moreover, this choice has been driven by the presence of a local business in Dondo (Sofala) “Mozalite” that produces the panels. A false ceiling of self cast-in-place concrete panels further isolate and protect the bedroom pavilion from potential jumps in temperature, assuring a high quality thermal comfort. The inner roofing layer is then covered by intertwined straw mats, widely present in the Mozambican tradition, to offer indoor thermal and acoustic insulation, especially during heavy rains. This solution, besides providing a cozy and isolated indoor environment, engages again the women’s expertise in the production of long mats connected to the lower part of the wooden structure on the roof.

262

MATERIAL ABACUS

REINFORCED CONCRETE 300 x 300 mm

CSEB SUN-DRIED BRICKS 280x 140 x 100 mm Dry soil + sand + 5/8% cement + water Curing for 10-20 days

TIMBER BOARDS 150 x 50 x A mm 75 x 50 x B mm

Locally produced Sustainable Low-cost Sound/Fire/Bugs proof Thermal inertia Humidity regulators

Natural material Locally sourced Low-cost Recyclable

WALLS

ROOF STRUCTURE WINDOW FRAMES

FIELDSTONES variable dimensions

BAMBOO 10 mm / 10x10 mm

Durable Low-maintenance High compressive strenght Fire and water resistent

Locally sourced Natural material Low-cost Durable

Locally sourced Natural material Low-cost

FOUNDATIONS RING BEAMS FALSE CEILING

FOUNDATIONS INFILL PAVING

FOUNDATION NET WINDOW FRAMES BRISE-SOLEIL

FIBER CEMENT SHEET 1500 x 920 x 6 mm

STRAW MATS 150 mm

METAL CONNECTORS

Durable Locally sourced Low-cost

Locally sourced Natural material Low-cost Thermal properties Sound proof

Durable Fire and weather resistent

ROOF COVER

ROOF INSULATION

WOODEN STRUCTURE CONNECTIONS

263

FLEXIBILITY - Further bedroom for emergency periods - Maternity ward estension

3.8 - Functioning: - Spaces hierarchy - Rainwater harvesting - Waste management - Climate response

BACK COURT Laundry area Drying surfaces

BEDROOM Sleeping area Storage

VERANDA Meeting sapce Resting area

ACTIVITY PAVILION Clinic for daily visits Educational

3.9 - Right: Planview

BATHROOM FLEXIBILITY 2 latrines - Further bedroom for emergency periods - Maternity ward estension

BEDROOM Sleeping area Storage

VERANDA Meeting sapce Resting area

KITCHEN Cooking hob Dining area

ACTIVITY PAVILION Clinic for daily visits Educational

KITCHEN Cooking hob Dining area

HARVESTING > DRINKING WATER The water harvested from the pavilion is treated with special filters to obtain drinking water

HARVESTING For laundries and personal hygiene

VERANDA Act as a water collector

ECO VENTILATED LATRINE Fumes expulsion Manual removal of residue recycled as fertilizer for vegetable garden

TROPICAL STORM WIND From south/southeast

GROUND rainy season ngs the water another tank ed to harvest

HARVESTING > DRINKING WATER The water harvested from the pavilion is treated with special filters to obtain drinking water

HARVESTING For laundries and personal hygiene

264

O VENTILATED LATRINE mes expulsion nual removal of residue recycled ertilizer for vegetable garden

VERANDA Act as a water collector

RAISED BASEMENT Against flooding

HA >D Th the spe dri

HARVESTING VERANDA For laundries Act as a wate andTROPICAL personal hygiene STORM WIND From south/southeast

OPEN COURT Educational space Outdoor dining Vegetable garden Meeting with relatives

TO THE GROUND Given the intense rainy season this slope brings the water away - If needed another tank can be installed to harvest

OPEN COURT Educational space Outdoor dining Vegetable garden Meeting with relatives

TO THE GROUND Given the intense rainy season this slope brings the water away - If needed another tank can be installed to harvest

ECO VENTILATED LATRINE Fumes expulsion Manual removal of residue recycled as fertilizer for vegetable garden

RAISED BASEMENT Against flooding

Water tank (drinking water) Daily visit room 8 m2

Ramp 6%

Entrance / Storage 18 m2

Educational training room 23 m2

Veranda 70 m2

Public activities veranda

Resting area Soneca da tarde

Outdoor common space 40 m2

Main entrance

Extra space for temporary guests

Bedroom (6 mothers) 28 m2

Back court Laundry/drying 21 m2 C

Housekeeping area

B’

Kitchen and covered dining space 27 m2

MWH vegetable garden C’

Eco ventilated latrine Latrine 2 m2 Sink room 3,7 m2

Water tank (sanitary/kitchen use)

D A’ 1 0

3 5

265

3.10 - MWH uses 3.11 - Right: Front - E

Planeamento familiar

nutrição

Vamos jantar juntos ?

Palestra!

Daily meals | Kitchen-Courtyard Matabicho, lunch, dinner

Activities | Pavilion-Veranda-Courtyard Helath education, trainings, courses and collective meetings Mãe, como você está?

As capulanas estão secas!

Tenho dolor de barriga

Chego!

Personal hygiene | Toilet-Backcourt Laundry, drying, showering

Bom descanso!

Resting | Bedroom-Veranda Soneca da tarde, night sleep

266

Clinic service | Room-Waiting hall Daily check-ups and prenatal visits

Estamos bem, e em casa?

Relatives visits | Courtyard-Veranda Family reunification

Rita! Como estás? e o bebê?

1 0

3 5

267

3.13 Collage 01 - A tarde Visual relation between the activity pavilion and the kitchen through the open courtyard 3.14 - Right: Section A - Fluidity Relation among the Kitchen, the open courtyard, the veranda and the activity pavilion

268

269

Stove Kitchen

Back-court Laundry

Dining area Indoor / Roofed Kitchen

Washbasins Cleaning area

Caniço mat Ceiling

Open courtyard Outdoor Meeting space

Bamboo frames Sun / privacy shading

Veranda Roofed Common space

Activity room and clinic Indoor

Drainage system

3.15 Collage 02: meiodia The veranda 3.16 - Right: Section B - Privacy Relation among the bedroom pavilion, the veranda and the open courtyard

270

Wind Hot season wind direction

Back-courtyard Outdoor Laundry and personal cleaning Pre-cast panels

Pot Ventilation

Veranda Roofed Common space

Ceiling

Kitchen Indoor / Roofed Cooking and dining space

Vegetable garden Outdoor

Wind Hot season wind direction

Bedroom Indoor Sleeping area and storage

Veranda Roofed Common space

Open courtyard Outdoor Meeting space

Water tank For sanitary uses Ventilation shaft Eco ventilated latrine

Cutting bricks Ventilation and fumes expulsion

1 0

3 5

271

3.17 Collage 03 - Matabicho Back court view 3.18 Right: Section C - Front|Back connection Relation among the back courtyard, the veranda and the kitchen Front D - Lateral view of the services pavilions: toilets and kitchen

272

Wind Hot season wind direction

Back-courtyard Outdoor Laundry and personal cleaning

Veranda Roofed Common space

Kitchen Indoor / Roofed Cooking and dining space

Vegetable garden Outdoor

Water tank For sanitary uses Ventilation shaft Eco ventilated latrine

Cutting bricks Ventilation and fumes expulsion

1 0

3 5

273

CSEB adobe bricks 280x140x100 mm

3.19 - Production chain - Foundations - Walls - Roof

Pavement Sand cement screed 25 mm Concrete paving 75 mm Bamboo fiber net 100x100mm D.P.M membrane Filed stone paving 125 mm Compacted sand 75 mm Hardcore 250 mm

Mansonry infill CSEB adobe bricks

Ring-beam Reinforced concrete 12Ømm

Wooden frames Pavilions: Wood/glass Veranda: horizontal Bamboo infill

Eco ventilated latrine Load bearing walls CSEB adobe bricks 280x140x100 mm

Foundation Lean concrete 100mm D.P.M membrane Reinforced concrete, field-stone plinth 1000x900 mm Ring beam - x500 mm

Pavement Sand cement screed 25 mm Concrete paving 75 mm Bamboo fiber net 100x100mm D.P.M membrane Filed stone paving 125 mm Compacted sand 75 mm Hardcore DESIGN STRATEGY 250 mm

Eco ventilated latrine 274

Soil tests: 1 smell/nibble/touch/wash - 2 sedimentation - 3 dry strenght - 4 ball drop

Pavement

Formwork

Layers

Steel

Bamboo

Fieldstone

Cement

Foundation

Soil

PRODUCTION CHAIN

TOO FAR TO WALK 275

10 Ø 200x200 mm

Mansonry infill CSEB adobe bricks

Ring-beam Reinforced concrete 12Ømm

Wooden frames Pavilions: Wood/glass Veranda: horizontal Bamboo infill

Load bearing walls CSEB adobe bricks 280x140x100 mm

Pavement Sand cement screed 25 mm Concrete paving 75 mm Bamboo fiber net 100x100mm D.P.M membrane Filed stone paving 125 mm Compacted sand 75 mm Hardcore 250 mm

276

Eco ventilated

Metal connectors Cement pouring

Pre-cast on site concrete predalles and reinforced beams

Curing time 15 - 28 days

Earth-cement mortar Matope plaster

Primary structure assembly

Wall - bricks

Water

Cement - 5/8%

CSEB Bricks production

Soil + sand

Soil tests: 1 smell/nibble/touch/wash - 2 sedimentation - 3 dry strenght - 4 ball drop

Pavement

Formwork

Layers 277

structure Wooden beams 75x50 mm Roof primary structure Primary wooden trusses, 150x50 mm Roof secondary cover Roof - Mozalite structure Fiber cement panels Wooden beams 150x92x65 75x50 mm mm

Caniço Pre-castand ceiling bamboo Predalles mats Ceiling, 20 mm 1000x1700x80, Roof cover - Mozalite Fiber cement panels 150x92x65 mm Caniço and bamboo mats Ceiling, 20 mm Roof secondary structure Wooden beams 75x50 mm Roof primary structure Primary wooden trusses, 150x50 mm Roof secondary structure Wooden beams 75x50 mm Caniço and bamboo mats Ceiling, 20 mm Pre-cast ceiling Predalles 1000x1700x80, 10 Ø 200x200 mm

278

Roof primary Caniço and structuremats bamboo Mansonry infill Primary 20 wooden Ceiling, mm CSEB bricks trusses,adobe 150x50 mm

10 Ø 200x200 mm

Mansonry infill CSEB adobe bricks Roof primary structure Primary wooden trusses, 150x50 mm

Ring-beam Reinforced concrete 12Ømm Pre-cast ceiling Predalles 1000x1700x80, 10 Ø 200x200 mm Wooden frames Pavilions: Wood/glass Veranda: horizontal Bamboo infill Mansonry infill CSEB adobe bricks

Load bearing walls CSEB adobe bricks 280x140x100 mm Ring-beam Reinforced concrete Pavement 12Ømm Sand cement screed

- Lateral overlapping 1 wave

Caniço and bamboo mats

Caniço

Mats production

Bamboo

Steel reinforcement Formwork Metal connectors Cement pouring

Pre-cast on site concrete predalles and reinforced beams

Ring beams and predalles ceiling

Primary structure assembly 279

Roof secondary structure Wooden beams 75x50 mm

Roof cover - Mozalite Fiber cement panels 150x92x65 mm Caniço and bamboo mats Ceiling, 20 mm

Roof primary structure Primary wooden trusses, 150x50 mm

Roof cover - Mozalite Fiber cement panels 150x92x65 mm

Roof secondary structure Wooden beams 75x50 mm

Pre-cast ceiling Predalles 1000x1700x80, 10 Ø 200x200 mm

280

Caniço and bamboo mats Mansonry infill Ceiling, 20 mm CSEB adobe bricks

Roof secondary structure Wooden beams 75x50 mm

ment

tation alite industry

acing

erlapping

3 1

230 mm

1 wave 170 mm

verlapping

Fiber cement panels

nd mats

Caniço

Wooden truss assembly

281

3.20 - Detail - section B 04 - Ring beam, 280x300mm, 12Ømm - Matope plaster - Embedded “U” metal plate, 5mm - Metal loop, 25 Ømm 05 - (4) Reinforced concrete beam, 150x100mm, 12 Ømm - (15) Cast-in-place concrete panels, 100x170, 12 Ømm 06 - Clay pot for ventilation, 200/400 Ø mm

07 - Ventilation holes (removing adobe bricks)

05 04

282

08 (from below) - Primary wooden truss (pao preto/ferro), 150x50mm - Bamboo and strawmats intertwined, 20mm - Secondary wooden beams, 75x50mm - Hurricane clip, 6 Ø mm - Fiber cement panels, 150x92mm - Metal clip - grampo -

09 - Wooden frame with single layer glass, 1660x570mm 10 - Wooden frame (pao preto/ ferro) with 2 gradients bamboo shading system, 20/30 Ø mm, 20mm - 100mm

283

3.21 - Detail 01 - Lean concrete, 100 mm - D.P.M (Damp Proof Membrane) - Reinforced stone-filed foundation, 900 mm, 12/16 Ømm - Ring beam, 500 mmx300 mm, 12/16 Ømm 02 - Hardcore, compacted earth, 250 mm - Compacted sand bedding, 75 mm - Filed stone paving, 125 mm - D.P.M - Bamboo fiber net, 100x100 mm, 20/40 Ømm - Concrete paving, 75mm - Sand cement screed, 25 mm 03 (from indoor) - Matope plaster, 10mm (earth-straw-cement-clay powder) - Load bearing adobe CSEB brick, 280x140x100mm - Matope plaster, 10mm (earth-straw-clay powder)

284

285

CONCLUSIONS

Maternal mortality is one of the most challenging health problems in the majority of developing countries. Several strategies have been launched within the safe motherhood policies to reduce the current high mortality rates. In this context, Maternity Waiting Homes have been promoted in several countries, including Mozambique, as a potential answer to the issue. According to the recent literature and the empirical examples obtained from different countries, health facilities with MWH have a better institutional deliveries coverage than those without this service, suggesting that MWHs are contributing to increased coverage and therefore contributing to a maternal/new-born mortality rate reduction. However, due to globalization in health policies, numerous experiences have shown that some strategies are not completely replicable in different contexts or national health systems, leading to the logical recommendation to study and assess their real impact in the Mozambican context before promoting a major expansion of the MWH strategy. In fact, a further improvement of the road network’s level, reaching also the remote areas (with high impact at the landscape level as a drawback), an increase in vehicles for emergency transports (that goes together with the infrastructure development, otherwise some areas will remain out of range anyway) and the healthcare centres spread could already address positively the maternal and new-born mortality. MWHs are a link in a larger chain of comprehensive maternity care between communities and the Health System, therefore

286

depending on a large variety of health parameters and social/ economic conditions. According to the surveys in the area of study in Mozambique, these obstacles are exacerbated by the wide range of MWH types, location, quality and services offered (mostly poor), contributing to the complexity of an impact assessment process. Moreover, the recent evolution of weather extremes has raised a further complication, resulting in a dramatic need for a Climate-adaptive resilient design, able to deal with such dynamics and build back better. Designing in disaster-prone areas requires a straightforward approach to the technical part, dealing with low budgets and resources. Unfortunately, this method often leads to a lack of time and assets to deepen the research for a worthy human-scaled living space. Thus, the project proposal, aware of being only a first step to address the issue, tries to tackle these factors from an architectural and social point of view, aiming to promote awareness about maternal conditions in Mozambique and design a scalable highquality service, with special consideration for the gender issue, to enable future studies with fewer confounders. In fact, architecture can be a powerful tool (not the only one, not the first) to improve the living conditions of pregnant women in rural areas and positively influence local communities’ economies and development. A crucial step within the research to understand the issue of maternal mortality in a climate hazard context was surely the on-site experience. A remote knowledge is not sufficient to comprehend the necessities and the cultural potentialities of a country like Mozambique. Touching by hand and talking to people, in a culture where “oral knowledge” and self-constructions are the community’s pillars, were the most vibrant and interesting moments to catch their real values and ideas. The surveys discussed within part II are clear examples of how poor architectural base conditions and natural hazards have profoundly hit the country in the Sofala and Manica provinces. And MWHs are always the last facility to be considered. The recent government policies and strategies are pointing towards an improvement of the MWH service but the evidence is still lacking and most of the houses on site are not respecting any standards.

287

For the above reasons, our proposal starts from an understanding of the women’s daily schedule, their habits, and needs within the health sector. Observation and communication were the main tools we used to carefully translate the needs into spaces and moments, giving high relevance to the open spaces as centripetal generators of life. Therefore, building the root into local technologies and UNHabitat resilience guidelines, we used this opportunity to rethink together the spatial hierarchy of MWHs in Mozambique and UN disaster standards, enhancing the value and use of collective roofed spaces. The low-cost/tech approach is based on self-made construction, cast-in-place elements, and a new interpretation of traditional techniques such as the CSEB bricks. This technology has not only greater thermic and resistant properties but also avoids firing procedures, lowering deforestation practices. Moreover, it can foster local industry, standardizing innovative building processes. The multi-scalar dialogue with the subjects the project approaches, the economic and environmental sustainability deriving from supporting “the local”, accurate observation of the context and cultural substrates of a people, especially in these frameworks, are cornerstones of good architectural practice. Besides the MWH objectives, the relevance of this project is the embedment of the first step towards a broader awareness of the role of the architect in this context. “Beautiful” architecture has the duty to respect standards, the opportunity to work as a tool to foster development but it is firstly for people. Staying in a clean, well-kept, harmonious, even creative place is a kind of right. It is not a question of costs but culture (Raul Pantaleo). Design in disaster risk areas has to do with the future, and it must be imagined better than the present, it would make no sense to think otherwise. Therefore, resilient and high-quality MWHs are an indispensable facility in rural areas not only to bridge pregnant mothers with the health centers to give birth safely (resulting in maternal mortality rate reduction) but also to promote dignity and beauty within health structures, usually the place where people are most vulnerable. Moreover, this approach can more address the broader topic of

288

women, contributing to family education/promotion of health practices and the idea of gender care in developing countries. Our project proposal was useful to activate a process of understanding the context and its bases – aiming to provide dignity to a place that has struggled to recover for years. In the Mozambican fragility, we saw the resilience of a part of the world that struggles to restart because it is forced to take care of its survival, a part of humanity repressed for decades, whose culture in the most remote areas still bears a colonial heritage and which today finds itself chasing after the same goals as the Western world. However, for Western architects, it is easy to fall into the prejudice of the “colonizing white man” whose task is to teach through the project the right way to build in an environment he has studied but often not fully experienced and understood. Therefore, the vision that must accompany the birth of new projects is the involvement of the local community and users as an essential center within a broader frame that emphasizes the sense of community, local traditions, and construction types. Keeping distance from the term “participated” as a validating element of the project from which the various rhetoric of a social architecture branch off, opening the doors to “white elephants”, projects of which intentions have not achieved the objective. As suggested by Emilio Caravatti during a remote conversation, the architecture definition already embeds participation, sustainability, and socio-cultural adherence to the place. The approach must be shared and functional to create a common narrative that allows a profound identification of the community in the project. Not only aesthetics but above all adaptability and use. The building itself provides an element of representation of the society that over time will form and change its functions based on the social assets and dynamics that will be created around it. The greater the interest and respect of the community, the greater the possibility that the elusive white elephant will turn into a “grey one”. Ultimately, given the extremely vast and heterogeneous panorama, the system the European architect has to deal with is outlined by

289

fragmentation of subjects, conditions, and environments which from time to time, concerning the specific context, generate characteristic effects that require deep study and a spirit of observation. The challenge consists in articulating a thought that faces the destiny of the Mozambican and more generally sub-Saharan continent by observing its politics, economy, social, symbolic, artistic creativity, and all those places from which new practices and discourses talk about the Africa of tomorrow. We need to interpret the current dynamics, collect the rise of radical innovation, think about the content of possible societies, analyse the role of culture in these changes and make a perspective reflection. Conceiving a “beautiful” habitat that puts man, dignity, and the natural environment at the center of its concerns by proposing an idea of a society that responds to the material, cultural and spiritual needs of individuals, in balance with the territory. Building spaces that make sense for those who live there.

290

3.22 - The grey elephant of Gorongosa National Park Gorongosa, Sofala 2021

291

ACKNOWLEDGMENTS

This work would not have been possible without the countless amounts of help we received from different people and institutions. First and foremost, we are grateful for all the support our families and friends gave us in the pursuit of this degree. Sharing suggestions, doubts and experiences helped us lead our interest in this research topic. We are particularly indebted to Isacco Rama and CAM Trentino team, who dedicated their time and expertise to give us the necessary guidance that made the journey in Mozambique possible. In the same vein, we would like to thank our supervisor, Camillo Magni, who patiently supported this 1-year resilient thesis development at all its stages and all our colleagues at UNHABITAT Beira with whom we shared moments and information with. In particular, arch. Fernando Ferreiro, arch. Silvia Tscholl, arch. Ludovica Sodomaco and ing. Avelino Sabonete, who made all the surveys possible, even the farer ones. A special thought goes to ing. Manuel Evaristo Paulo, who has always driven us with enthusiasm around the city of Beira, among construction sites and the Carrizo do Carmo’s projects. Furthermore, we would also like to thank all the professionals and experts whose works and studies made it possible for us to gain an insight about working in Mozambique: especially Ana Tostões, Paul Jenkins of the University of the Witwatersrand, Corinna del Bianco of Politecnico di Milano, Corrado Diamantini of

292

University of Trento, arch. Luca Faverio, arch. Filippo Cavallari of CUAMM, dr. Alberto Papaleo of MSF, dr. Muanda Pinho of MISAU. Among the external contributions, we need to count the precious meetings with arch. Emilio Caravatti of Caravatti_ studio, arch. Alessio Battistella of Arcò, ing. Bruno Comini of MedicusMundi and dr. Gianpaolo Rama of CUAMM. A warm hug to all our expat friends we shared nice journeys and experiences with. Among them, our heartfelt thanks to Marica Maramieri and Federico Berghi of CAM for supporting us, in duty and pleasure, during our stay in Mozambique. A particular mention is necessary for Paolo Ghisu, a friend that made us discover the effervescent Grand Hotel Beira community and borrowed to this work some of his personal pictures. Among the people who contributed to keeping our spirits up during the whole design process, we have to thank Giovanni Wegher, who called and visited us almost every week. Our sincere gratitude goes to our great friends Alice Bassi, Alessandro Chojwa and Flavia Brajon for helping us in small but crucial interventions besides their unwavering support and belief in us. A kind hug goes to Tati’s sister, who traveled from home few days in advance to help us with the finishing touches. Thanks also to the wonderful mothers and health workers of the Sofala and Manica provinces who, despite hardships and language barriers, sat with us to talk during the interviews, telling us glimpses of daily life and reminding, with their amused smiles, that for us twenty-eight guys “o tempo vai embora!”. Lastly, thanks to all the Mozambican friends who made us understand the value of “waiting” as a space of cultural respect and realize that a 3-months visit is not enough to experience Mozambique but certainly plenty of time to be fascinated by.

293

LIST OF FIGURES

Pictures The pictures collected within the research are coming from the personal photo reportage shooted during the journey. Massimiliano Piffer Photography External photgraphic contributions Paolo Ghisu Photography INTRODUCTION Figure 0.1 - Mothers waiting for a visit at the Inhamichindo rural Health Centre Source: Authors, 2021 Figure 0.2 - Interviewing the mothers from Muda Serraçao Maternity Waiting Home Source: Authors, 2021 Figure 0.3 - Measuring the maternity ward at Francisco Manyanga Health Centre Source: Authors, 2021 Figure 0.4 - Interviewing the mothers from Villa Arriage de Buzi rural Hospital Source: Authors, 2021

294

PART I Figure 1.0 - Rural village in Zembe district, Manica province Source: Authors, 2021 Figure 1.1 - A man in the hall of the Grande Hotel da Beira Source: Paolo Ghisu Photography Figure 1.2 - Celebration day at Praça de Indipendencia (Indipendence square) Beira, 25 july 2021 Source: Authors, 2021 Figure 1.3 - Koppen climate classification - WEATHER BASE Source: Authors design, 2021 Figure 1.4 - projected urbanization profile of Mozambique, Moçambique - perfil de habitação, UNHabitat, 2018 Source: Authors design, 2021 Figure 1.5 - People collecting water at the community well in Nhamatanda district Source: Authors, 2021 Figure 1.6 - A red clay road connecting Chimoio to Zembe in Manica district Source: Authors, 2021 Figure 1.7 - A nurse taking a break after a long hours shift at the Ponta Gea urban Health Centre, Beira

Source: Authors, 2021 Figure 1.8 - Rate - Health Units per 10.000 inhabitants - SARA, 2018 Source: Authors design, 2021 Figure 1.9 - Tab - description of Health care physical asset in Mozambique SARA, 2018 Source: Authors design, 2021 Figure 1.10 - Chart - development of Health care Units from 2016 to 2020 INE, 2020 Source: Authors design, 2021 Figure 1.11 - Tab -Prevailing policies addressing the Maternal and newborn mortality rates in Mozambique since 1978.Source: Authors design, 2021 Figure 1.12 - Pediatric visits at Chingussura Health Centre in Beira Source: Authors, 2021 Figure 1.13 - Three delays model Thaddeus and Deborah, 1994 Source: Authors design, 2021 Figure 1.14 - Girl playing with a condom as a balloon in Manica Province Source: Authors, 2021 Figure 1.15 - A woman headed to the river for laundry. Beira, 2021 Source: Paolo Ghisu Photography Figure 1.16 - People wade through flood waters in a rural neighborhood near Beira on March 24, 2019 Source: Andrew Renneisen Figure 1.17 - Idai results in the Sofala countryside 2019 Source: International Committee of the Red Cross Figure 1.18 - Tab - extreme events map in Mozambique: catheory, year and Province affected - UNHabitat 2010; Wikipedia 2021

Source: Authors design, 2021 Figure 1.19 - Map - Climate hazards paths and locations, NOAA 2021; NRL 2021 Source: Authors design, 2021 Figure 1.20 - Nhaconjo urban Health Centre “Building Back Better” process completed in partnership with CAM, UNHabitat, AICS and MISAU Source: Authors, 2021 Figure 1.21 - Mothers having their matabicho in the MWH’S veranda of Villa Arriage rural Hospital in Buzi District Source: Authors, 2021 Figure 1.22 - Maternity Waiting Village, Kasungu, Kasungu District, Malawi by MASS Design Group 2015 Source: Achdaily Figure 1.23 - Woldyia Maternity, Ethiopia by Vilalta Studio, 2017 Source: Vilalta studio Figure 1.24 - Chart - Mozambique “delivery” process in rural areas, starting with prenatal visits at the local health centre and referring of women according to low or high risk. Source: Authors design, 2021 Figure 1.25 - Chart - Maternity waiting homes per province - Nr / Us - % SARA, 2018 Source: Authors design, 2021 Figure 1.26 - Maternity waiting home in Ethiopia and Zambia, UNFPA, 2018 MWHA, 2017 Source: Authors, 2021 PART II Figure 2.0 - Village in Nhamatanda district, Sofala Source: Authors, 2021

295

Figure 2.1 - Local storage in Jasse municipality, Nhamatanda, Sofala Source: Authors, 2021 Figure 2.2 - Climate Sofala - Beira Bluemeteo.com Source: Authors design, 2021 Figure 2.3 - Climate Manica - Chimoio Bluemeteo.com Source: Authors design, 2021 Figure 2.4 - Wind chart of Sofala and Manica - Beira and Chimoio Source: Authors design, 2021 Figure 2.5 - Solar chart and vertical projection of sun’s rays (18°-20° parallel) Source: Authors design, 2021 Figure 2.6 - Cylindrical type of building with conical roof in a Makonde house (Dias, 1964, p. 17) Figure 2.7 - Makonde house, Swahili type, with rectangular plan and hipped roof (Dias, 1964, p. 18) Figure 2.8 - Village in Dondo (Sofala Province) in 1891 Source: Sousa Machado Figure 2.9 - Survey of a rural housing in Inkaveleni Xai-Xai District, Gaza Province, 19-11-2004 Source: Julio Pereira, Roberto João Figure 2.10 - Mozambican stamps dedicated to traditional houses. Traditional cilindric constructions and conical roofing; squared buildings and verandas coming from Swahili tradition; cheap solutions of constructions influenced by colonial architecture Source: Bruschi, Lage and Carrilho, 2004 Figure 2.11 - Local construction in “pau a pique” technique, Dondo, Sofala Province Source: Authors, 2021

296

Figure 2.12 - Local construction in “pau a pique” technique, Siluvo, Nhamatanda, Sofala Province Source: Authors, 2021 Figure 2.13 - Local construction in “tijolos queimodos” technique Gondola, Manica Province Source: Authors, 2021 Figure 2.14 - Chart - list of Healthcare units in Sofala and Manica provinces. INE, 2020 Source: Authors design, 2021 Figure 2.15 - Chart - overview of Sofala and Manica: Total births, istitutional birth, rate of coverage and country’s average INE, 2020 Source: Authors design, 2021 Figure 2.16 - Cyclone effects map NOAA, Sentinal/UNITAR, INGC, 2019 - 2021 Source: Authors design, 2021 Figure 2.17 - chart - Cyclones description USAID, Mozambique 2019 | IOM,2021 | UNFPA, 2021 Source: Authors design, 2021 Figure 2.18 - A woman at the entance of the Maternity Waiting Home of Inhamichindo, Buzi, Sofala Source: Authors, 2021 Figure 2.19 - Mothers waiting for a visit at the Maternity Waiting Home of Savane, Dondo, Sofala Source: Authors, 2021 CASE STUDIES REPORTAGE Within this ection all contributions, technical drawings and pictures are part of the author’s personal photoreportage Source: Authors, 2021 Figure 2.20 - Women daily activities

in Grand Hotel Beira and in Dondo countryside 2020 - 2021 Source: Paolo Ghisu Photography Figure 2.21 - Women daily activities at home and at MWH - comparison Social activities and spaces to promote a new MWH paradigm Source: Authors design, 2021 Figure 2.23 - The only woman in Chipindaumue wainting ceaselessly the delivery day in Chipindaumue, Gondola Manica Source: Authors, 2021 PART III Figure 3.0 - A “capulana” dress hanging from the MWH’s window in Siluvo, Nhamatanda, Sofala Source: Authors, 2021 Figure 3.1 - A pregnant mother waiting on a large bench-basement in Macate health centre, Manica Source: Authors, 2021 Figure 3.2 - Parameters to take into account before establishing a MWH Source: Authors design, 2021 Figure 3.3 - Barriers to detect before establishing a MWH Source: Authors design, 2021 Figure 3.4 - Strategic operational plan: Parameters and Barriers assessment > Action Source: Authors design, 2021 Figure 3.5 - Territorial strategy Source: Authors design, 2021 Figure 3.6 -The concept strategy have been studied according to the unpacking process and the resilient guidelines of UNHabitat Mozambique

Source: Authors design, 2021 Figure 3.7 - Abacus of Materials, mostly sourced locally Source: Authors design, 2021 Figure 3.8 - Functioning scheme Source: Authors design, 2021 Figure 3.9 - Planview Source: Authors design, 2021 Figure 3.10 - Planview Source: Authors design, 2021 Figure 3.11 - MWH uses Source: Authors design, 2021 Figure 3.12 - Front E Source: Authors design, 2021 Figure 3.13 - Collage 01 - A tarde Source: Authors design, 2021 Figure 3.14 - Section AA’ Source: Authors design, 2021 Figure 3.15 - Collage 02 - Meiodia Source: Authors design, 2021 Figure 3.16 - Section BB’ Source: Authors design, 2021 Figure 3.17 - Collage 03 - Matabicho Source: Authors design, 2021 Figure 3.18 - Section BB’ / Front D Source: Authors design, 2021 Figure 3.19 - Production chain Source: Authors design, 2021 Figure 3.20 - Detail 1:10 section B - roof Source: Authors design, 2021 Figure 3.21 - Detail 1:10 section B - base Source: Authors design, 2021 Figure 3.22 - The grey elephant of Gorongosa National Park, Sofala Source: Authors, 2021 Figure 3.23 - A woman headed to “Machamba” in Zembe, Manica Source: Authors, 2021

297

APPENDIX

1. Ficha de levantamento tecnico - Technical survey module 2. Matrix of case studies: Location, typology, Layout, Dimensions, Infrastructure, Materials, Patologies, Builder 3. Maquette 1:50 - shooting - Axonometric view - Section 01 -Section 02 - Back court - Kitchen - Veranda - Activity pavilion entrance

CASA DE MÃE-ESPERA – FORMULÀRIO DE LEVANTAMENTO TÈCNICO N° ficha

Fare clic o toccare qui per immettere una data.

Data

1. Dados do operador: Equipe: nome 1

função

contacto

função

contacto

2 3 Pessoa entrevistada: nome 1 2 3 2. Dados gerais da unidade sanitária: Nome da Unidade Sanitaria Nìvel Area Tipo

☐ primàrio ☐ urbana ☐ A ☐ B

☐ secondàrio

☐ terciàrio ☐ rural ☐ I ☐ II

☐ C

☐ quaternàrio

3. Localização geográfica: Coordenadas

Lat.

Long.

Provincia Distrito Localidade 4. Acessibilidade: Tipo de estrada de acesso: ☐ Asfalto

Condições de transitabilidade:

☐ Terra batida

☐ Arenoso

☐ Boa

☐ Condicionado pela chuva

☐ Mà

Struttura sanitaria di riferimento: Nome

298

Distância

Tempo de resposta

Horas de carro

Horas a pé

5. Dados gerais casa de mãe-espera: n° partos Durata ospedalizzazione Serviços

Limites para não usar a casa de mãeespera

Istitucional:

Casa de mãe-espera:

Pre-parto:

Post-parto:

☐ Consultar pré e pós-parto ☐ Maternidade ☐ Sala de parto ☐ Palestra coletiva ☐ Palestra individual ☐ Pediatria ☐ PAV ☐ Não podem deixar seus filhos sozinhos ☐ Falta de autorização (marido, sogra) ☐ Desinformação ☐ Qualidade do serviço de saúde ☐ Estado da estrutura (danificada, falta de espaço) ☐ Distância \ transporte ☐ Falta de serviço de alimentação ☐ Outro (especifique):

n° locais

Disponìvel:

Equipe envolvida na gestão de CME

Medicos

Efetivo (ocupação máxima): Enfermeiras

Agentes de serviço

Mãe-gestora

Outro

6. Dados estruturais casa de mãe-espera: Construção: ☐ Comunidade

☐ Ministério

☐ Outro (espec.) -

Ciclone:

Construção:

Descrição do status de dano:

☐ Idai ☐ Chalane ☐ Eloise Técnica de construção

☐ convencional

☐ local

☐ mista

Estrutura Fundações Cobertura Layout interno Layout externo

CASA DE MÃE-ESPERA – ENTREVISTAS COM MÃES

Idade

Nome

n° filhos

Local de nascimento dos filhos

Residência

Meios de transporte

Fonte de informação sobre CME

299

Nhangau | CS rural I

Villa Arriage | HR

Guara-Guara | CS rural II

“Stecca” + v

Squared + pv + c

Location

Typology

Layout

S V

K B

B S K

Dimensions

27 mq Veranda - 10 mq

83 mq Veranda - 33 mq

64 mq Veranda - 40 mq Resting space - 13 mq

Infrastructure

HC Beira (Sofala)

HC Buzi (Sofala)

Materials

walk

5.25

car

0.59

Walls “Blocos” Concrete blocks 130x180x400mm Concrete pillars 130x30mm

Roof Metal sheet

Basement Concrete

walk

151

car

153 3.14

Walls “Blocos” Concrete blocks 180x200x500mm Concrete pillars 150x50mm

Roof Metal sheet

Basement Concrete

walk

16.6 3.20

car

16.6 0.33

Walls “Blocos” Concrete blocks 150x200x400mm Concrete pillars 150x50mm

Roof Metal sheet

Basement Concrete

Patologies

To close to the city

Shortage of bedrooms

Roof - Walls

and Builders

MISAU - US Aid

MISAU (planta tipo)

ComuSana -post Eloise-

300

Inhamicindo | CS rural II

Savane |CS rural II

Tica | CS rural I

note

Squared + pv + c

“Stecca”

Squared + pv + c

v - veranda pv - perimetral veranda c - canopy

V B B

B - bedroom K - kitchen V - veranda T - toilet O - other S - storage

B B

O R

V K

44 mq Veranda - 30 mq Kitchen - 3,7 mq

76 mq

65 mq Veranda - 35 mq Kitchen - 13 mq

HC Buzi (Sofala)

HC Beira (Sofala)

HC Nhamatanda (Sofala)

walk

57 11.13

walk

61 12.28

walk

5.49

car

0.35

Walls “Pau a pique” 200mm

2.05

Roof Metal sheet

Basement Concrete

Roof - Walls Openings - Basement Local community

Walls “Blocos” Concrete blocks 200x200x500mm Concrete pillars 200x200mm

1.45

Roof Metal sheet

Basement Concrete

Walls “Tijolos” Adobe blocks 80x75x230mm Concrete pillars 200x200mm

Too close to the city

MISAU

MSF - US Aid

asphalt dirty road (soil, sand...)

Roof Metal sheet

Basement Concrete

301

Lamego | CS rural II

Vinho | CS rural II

Siluvo | CS rural II

n.d.

Squared + pv

Location

Typology

Layout B

B B K

B K

B V

Dimensions

6 mq

44 mq Veranda - 30 mq

41 mq Veranda - 25 mq

Infrastructure

HR Nhamatanda (Sofala)

Materials

walk

2.55

car

0.21

Walls “Blocos” Concrete blocks 120x180x800mm

Roof Metal sheet

walk

7.47

car

1.30

Walls “Pau a pique” 180mm

Basement Concrete

Patologies

Not built as a MWH

and Builders

Private (was previously a private storage)

302

Roof Metal sheet

Basement Concrete

walk

4.11

car

0.23

Walls “Pau a pique” 180mm

Roof Metal sheet

Basement Concrete

Walls - Floor Openings - Basement

Roof - Walls Openings - Basement

ComuSanas

Local community

Jasse Mainguena | CS rural II Inchope |CS rural I

Muda Serraçcão| CS rural II

note

Squared + pv + c

“Stecca”

v - veranda pv - perimetral veranda c - canopy

“Stecca” + c

B V

8 mq

33 mq Veranda - 20 mq

30 mq

HR Nhamatanda (Sofala)

HR Gondola (Manica)

walk

4.47

car

0.45

Walls “Pau a pique” wooden structure only

Roof Wooden beams Basement Soil

asphalt

walk

8.20

walk

78.4 11.40

car

1.11

car

78.4 1.31

Walls “Tijolo queimado” Adobe blocks 130x90x260mm Concrete pillars 130x130mm

B - bedroom K - kitchen V - veranda T - toilet O - other S - storage

Roof Metal sheet

Walls Roof “Tijolo queimados” Metal sheet Adobe blocks 120x80x230mm

Basement Concrete

Roof - Walls - Floor

Roof - Walls

ComuSanas - never restored -

MISAU - JOIN KUBATSIRANA

MISAU - Local community (roof replacement Idai)

dirty road (soil, sand...)

303

Macate | CS rural I

Zembe | CS rural II

Chissui | CS rural II

“Stecca” + v

Squared + pv + c

Location

Typology

Layout K B

Dimensions

30 mq Kitchen - 8 mq

14 mq Veranda - 8,5 mq

27 mq Veranda - 10,8 mq

Infrastructure

HP Chimoio (Manica)

Materials

walk

38.7 7.46

walk

4.50

walk

1.20

car

38.7 0.57

car

0.24

car

0.20

Walls Roof “Tijolo queimado” Metal sheet Adobe bricks 140x90x290mm

Roof Walls “Tijolo queimado” Metal sheet Adobe bricks 120x80x230mm

Basement Concrete

Walls “Tijolo queimado” Adobe bricks 130x90x260mm Concrete pillars 130x130mm

Patologies

Roof - Walls - Openings

Openings

and Builders

MISAU - Local community

Local community (ex-bank, adapted to MWH)

MISAU

304

Roof Metal sheet

Basement Concrete

Francisco M | CS rural II

Chipindaumue |CS rural II

Amatonga | CS rural I

note

Squared + pv + c

“Stecca”

Squared + pv + c

v - veranda pv - perimetral veranda c - canopy

B - bedroom K - kitchen V - veranda T - toilet O - other S - storage

T B B B B K

V S S

48 mq Kitchen - 13 mq

20 mq Kitchen - 12 mq

36 mq Kitchen - 20 mq

HR Gondola (Manica)

walk

3.4

0.28

car

15.7 0.44

Walls “Blocos” Concrete blocks 180x200x400mm Concrete pillars 180x180mm

Roof Metal sheet

Basement Concrete

walk

4.13

car

1.30

Walls “Tijolo queimado” Adobe bricks 130x90x260mm Concrete pillars 180x180mm

Roof Metal sheet

Basement Concrete

asphalt

walk

4.40

car

0.55

Walls “Tijolos” Adobe blocks 130x90x260mm Concrete pillars 180x180mm

dirty road (soil, sand...)

Roof Metal sheet

Basement Concrete

Roof - Walls - Openings

Roof - Walls

MISAU

Local community - never restored post-Idai -

Private - ex-colonial building -

305

306

307

308

309

310

311

BIBLIOGRAPHY

Books • •

•

312

AA.VV., Safer House Construction Guidelines, Bureau TNM, Milano, 2015 AA.VV., Mozambique, Cities Without Slums, Analysis of the Situation & Proposal of Intervention Strategies, National directorate of Planning and Territorial Development (DINAPOT) Ministry for the Coordination of the Environmental Action (MICOA), Maputo, 2006 Africa architecture culture identity, exhibition catalogue (AFRICA. Architecture, Culture, Identity Louisiana, 25 June - 25 October 2015) curated by Kjeld Kjeldsen, Mathias Ussing Seeberg, Louisiana: Louisiana Museum of Modern Art, 2015. Arecchi A., Abitare in Africa. Architetture, villaggi e città nell’Africa subsahariana dal passato al presente. Milano: Mimesis, 1999. Bruschi, S., Lage, L., and Carrilho, J. Era Uma Vez Uma Palhota. Maputo: FAPF-UEM, Centro de Estudos e Desenvolvimento do Habitat, 2005

•

• •

• • • • •

Bruschi, S., Lage, L., Menezes C., and Carrilho, J. Traditional informal settlements in Mozambique: from Lichinga to Maputo. Maputo: FAPF. Faculdade de Arquitectura e Planeamento Físico-UEM, Centro de Estudos e Desenvolvimento do Habitat, 2004. Bruschi, S., Lage L., O desenho das cidades. Moçambique até o Século XXI, FAPF, Maputo, 2005 Burdett M., Urban land use patterns and models. 2018 https:// geographycasestudysite.wordpress. com/urban-landuseCabral J., Mocambique, XYZ Books, Lisbon, 2017 Carbone G., L’africa. Gli stati, la politica, i conflitti, Bologna: il Mulino, 2005 Carola F., Vivendo, pensando, facendo, Intra Moenia, Napoli, 2004 Guedes Correia M. et al., Arquitectura sustentável em Moçambique: manual de boas praticas, Maputo, 2009 Kuchena J.C., Usiri P., Low cost construction technologies and materials Case study Mozambuique., Nocmat, Bath (UK) 2009

• • • • •

• • • • • • •

•

Jenkins P., Home space: Maputo, Maputo, 2012 Leipik A., Afritecture: Building in Africa, Ostfildern: Hatje Cantz, 2014 Negrao J., Cem anos de economia da familia rural africana, Maputo, 2006 Newitt, M., A Short History of Mozambique. London: C. Hurst & Co. Ltd., 2017 Noorloos van F., Kloosterboer M., Africa’s new cities: The contested future of urbanisation, Urban Studies Journal, Vol. 55, n.6, 2018. Pallasmaa J., Mallgrave H., Robinson S., Gallese V., Architecture and empathy, Espoo- Finland, 2015 Pantaleo R., Made in Africa, Eleuthera, Milano, 2016 Pantaleo R., La sporca bellezza, Eleuthera, Milano, 2007 Sarr F., Afrotopia, Bologna: Edizioni dell’asino, 2018 Sennett R., Cities Without Care or Connection, New Statesman, 2000 Tostões A., Modern Architecture in Africa: Angola and Mozambique, Lisbon: ICIST, Técnico, 2013 Tostões A., How to Love Modern PostColonial Architecture: Rethinking Memory in Angola and Mozambique Cities, Architectural Theory Review, 2016 Veras O., Urbanisation in sub-Saharan Africa: City master plans, 2018 https:// www.howwemadeitinafrica.com/ urbanisation-in-sub-saharan-africacity-master-plans/61241/ Chavane L., Gonçalves C., Inequalities in Maternal and Child Health in Mozambique: A Historical Overview, Brighton, 2019

PhDs and Master thesis • •

• • •

•

Del Bianco C., Pemba: Spontaneous living spaces, Routledge 2021 Faverio L., Gli spazi dell’istruzione primaria nei progetti della cooperazione internazionale: le scuole dei paesi in via di sviluppo: il caso del Mozambico, DastuPolitecnico di Milano, 2018 Galli J., Tropical Toolbox. Fry and Drew and the search for an African modernity. Lettera Ventidue, 2019 Facchinelli P., Studio di soluzioni appropriate per costruzioni a basso costo in un contesto in via di sviluppo, Trento, 2010 Romano E., Futurafrica: sperimentare la tradizione nel contemporaneo, il caso di Mali e Burkina Faso in Area Subsaharina, Roma, 2018 Polat U., AN-OTHER WAY - Disaster Resilient Housing In Bairro dos Pescadores, Maputo, Mozambique, Milano, 2020

Documents • • • •

•

AA.VV.(2017) Diébédo Francis Kéré, Building as Education – Oris 108, 2017 AA.VV., IPCC 2021- Climate change, The Physical Science Basis, 2021 Berkes F., Understanding uncertainty and reducing vulnerability: lessons from resilience thinking, 2007 Birkmann, J., & Wisner, B. Measuring the Un-Measurable: The Challenge of Vulnerability. Bonn: United Nations University: Institute for Environment and Human Security, 2006 Clegg Bradley Studio, A Manifesto for climate responsive design, Enabel, 2019 313

• •

•

• •

•

• • • • • •

314

CNAPPC, LO SPAZIO MORALE: Assistenza umanitaria e cooperazione allo sviluppo, Milano, 2019 Folke C., Resilience: The emergence of a perspective for social-ecological systems analysis. Global Environmental Change, 2006 Gironés A., Belvis F., JuliaM., Benach J., Health care inequalities in Mozambique: needs, access, barriers and quality of care: Technical Report, Barcelona, 2018 INE, IV recenseamento geral da população e habitação 2017, Maputo, 2019 Kuhlicke C. Resilience: a capacity and a myth: findings from an in-depth case study in disaster management research. Natural Hazards, 2010 Maguire B., & Cartwright S., Assessing a community’s capacity to manage change: A resilience approach to social assessment. Australian Government: Bureau of Rural Sciences, 2008 Maguire B., & Hagan P., Disasters and communities: understanding social resilience. Australian Journal of Emergency Management, 22, 16-20, 2007 MISAU, DPC,DIS, “Anuário estatístico de saúde 2020”, Maputo, 2020 MISAU, Estratégia de Casas de Espera para Mulheres Grávidas, Maputo 2009 MISAU, Inventário nacional de infraestruturas de saúde, serviços e recursos, Maputo 2020 MISAU, “Plano Estratégico do Sector da Saúde PESS 2014-2019”, Maputo, 2013 MISAU, OMS, INS Moçambique, Canada, SARA 2018 – Inventario nacional, Maputo, 2020 MISAU, UNHABITAT, Reconstructing gender sensitive, safe and resilient health

• •

•

• • •

facilities in Mozambique (Safer Hospitals), Beira, 2020 MISAU, Mozambique Cyclone Idai – Post Disaster Needs Assessment, Beira, 2019 Paton D., Disaster Resilience: Building Capacity to Co-Exist with Natural Hazards. In D. Paton, & D. Johnston (Eds.), Disaster Resilience: An Integrated Approach. Springfield, Illinois, 2006 Talamanca I., Maternal mortality and the problem of accessibility to obstetric care; the strategy of maternity waiting homes. Soc. Sci.Med, 1996 Shrestha SD., RAjendra Pk. and Shrestha, Feasibility study on establishing Maternity Waiting Homes in remote areas of Nepal. Regional Health Forum, 2007 UNFPA, Maternity Waiting Homes in Tanzania. Chingonella: “Waiting for delivery”, 2007 UN-HABITAT, Focus on Mozambique, Maputo, 2012 UN-HABITAT, UNDP, RED CROSS, MISAU, Construir com os Ventos – Guião de Construção para Zonas de Risco de Ciclone, Maputo, 2007 UN-HABITAT, Moçambique perfil do sector urbano: Maputo, 2008 WHO, Maternity waiting homes: a review of experiences, Geneva, 1996 WORLD BANK GROUP, GFDRR, Disaster risk profile Mozambique, Washington D.C., 2019

Sites • • • • • • • • • • • • • • • • • • • • • • • • •

AlbertFaus Architecture Architectureindevelopment.org ASF Italia BBC - Mozambique Casa Melhorada CRAterre.org CUAMM – Mozambique FAREStudio.it Humanitarianlibrary.org INE – Mozambique Kerè Architecture LOADroject MASSdesign Group Meteoblue.com Minha Casa MSF – GIS maps NOAA ResearchGate The Guardian The World Bank Group - Mozambique UNDP – Mozambique UNFPA – Mozambique UNICEF - Mozambique UNHABITAT - Mozambique USAID – Mozambique

315

3.23 - A woman headed to “Machamba” in Zembe Manica 2021

Sand and earth are undoubtedly the predominant natural element characterizing Mozambican landscapes. Blown ceaselessly by the wind, they give to the landscape a bare, desert aspect, where the few elements standing, natural or anthropic, play an important role, becoming the protagonists of silent and remote territories. Here, the soil, with its red, yellow, and brown tones hand-draws the buildings by means of raw earth blocks, clay bricks, or sandy plasters with natural fibers. Thereby these architectures seem to rise from the earth, sharing the same matter and colours.