1. Ask students to think about facilities in their community that provide services for the public (for example, libraries, post offices, museums, community centers, schools, hospitals, etc.) Ask students to think about how their answers might differ if they lived in another part of the country or if they lived in another country. Ask students to think specifically about how far away the closest hospital is located. Ask how that might vary from one place to the next. Let students know this lesson explores access to health facilities and life-saving health services and how they vary from country to country.

2. Let students know the first country they will be exploring is Mozambique. Ask students to locate Mozambique on a map. Explain that the first video segment from the PBS program Wide Angle: Birth of a Surgeon describes the healthcare at the Hospital Rural de Manjacaze, a rural hospital in Mozambique.

3. Before showing the segment, ask students to make predictions about healthcare conditions in the rural areas of Mozambique. Ask them to write down these predictions to review later.

4. As they view the segment, have students write down similarities and differences between the Manjacaze facility and the hospital(s) in their community.

5. Play Rural Healthcare in Mozambique. After showing the segment, ask students to list some similarities between the Manjacaze facility and the hospital(s) in their community. (Possible answers: The medical staff wears uniforms. They use gloves. There is a hospital administrator. The hospital performs surgeries.) Ask students to describe how the Manjacaze hospital is different from their local hospital. (Possible answers: The only way most people get to the hospital is by walking there, even when they live very far away. Some walk for several days to get to the hospital. The hospital is very small, there are no obstetricians and the staff reuses the gloves. The power is unreliable and goes out almost every day, causing the hospital to schedule surgeries in the morning when the power is more reliable. Relatives sit outside on the ground rather than on furniture and often sleep outside when waiting for patients.)

6. Ask students to discuss how the conditions shown in the video compare with the predictions they made about healthcare conditions in the rural areas of Mozambique.

1. Discuss the role of an obstetrician in a hospital. (An obstetrician is a doctor who delivers babies and performs cesareans and other necessary procedures before, during and following childbirth.) Ask students how many obstetricians were in the Manjacaze hospital. (Zero.) Remind students that the hospital serves more than 175,000 people. Ask students what problems the lack of an obstetrician might cause. (There is no one qualified to perform necessary surgeries and deal with complications during childbirth.)

2. Let students know Mozambique is a country with a very high rate of death during childbirth and there are very few obstetricians who work outside of Maputo, the capital city. Ask students to brainstorm ways the country could solve this problem of having a shortage of qualified people to perform necessary lifesaving surgeries during childbirth. Write down the students’ responses.

3. Ask students to view the next video segment to find out how a woman’s risk of dying during pregnancy and delivery in Mozambique compares to women in developed countries (such as the US) and what Mozambique is doing to decrease the death rate.

4. Play Solving the Doctor Shortage in Mozambique. After showing the video segment, ask students what a woman’s risk of dying in pregnancy and delivery in Mozambique is compared to women in developed countries such as the US. (Women in Mozambique have a 160 times greater risk of dying from complications related to pregnancy and giving birth than women in the developed world.) Ask students to describe how Mozambique is trying to combat this problem. (The government is training midwives and nurses to perform cesareans, hysterectomies and other lifesaving surgeries.)

5. Ask students what they think about the initiative in Mozambique to train midwives and nurses to do surgeries originally performed only by doctors.

6. Let students know in the next segment they will watch Aaron Brown interview Dr. Margaret Chan, the Director-General of the World Health Organization (WHO), about the Mozambique effort. Ask students to view the next segment to find out what she thinks of this approach.

7. Play Making Women's Health a Priority. After playing the segment, ask students to summarize Dr. Chan’s view about Mozambique’s approach to solving the doctor shortage by training midwives to perform surgeries. (She thinks it is a good idea, since it is a practical way to get more people trained to handle complications which arise during childbirth. She believes it is important to try creative, “out of the box” solutions to existing problems.)

8. Ask students which populations Dr. Chan feels are the most important ones to target for improved health care and why she feels that way. (She believes it is most important to improve health care for residents of sub-Saharan Africa and women. She says sub-Saharan Africa has about 25% of the world’s disease burden, but only about 3% of the world’s health manpower and is in need of 1 million doctors. She mentions one woman dies from complications from pregnancy and childbirth every minute. She believes maternal mortality rate is a sensitive indicator for whether a country’s health system is working.)

9. Discuss what Dr. Chan says needs to happen in order for health care to improve. (She says governments need to be held accountable for providing services and that W.H.O- the World Health Organization- cannot replace the government. She believes the government must be supported with technical know-how and capacity building and resources to improve the health of women.)

10. Ask students what they think about Dr. Chan’s view that it is important to focus on improving women’s health care in order to better the health conditions for everyone.

1. Remind students about what Dr. Chan said in the previous video about governments’ roles in providing for the health of their citizens:

“The government should be held accountable for providing services. W.H.O (the World Health Organization) cannot replace the government. Not at all. The government must be made aware of their situation. They must be supported with technical know-how, with capacity building and with the resources to improve the health of women.”

2. Explain that the Universal Declaration of Human Rights, adopted by the United Nations in 1948, states everyone has the right to medical care. It states (Article 25): “(1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.” (View the Universal Declaration of Human Rights)

3. Let students know about the Declaration of Alma-Ata (1978), created by the International Conference on Primary Health Care (in what is now Almaty, Kazakhstan), which states governments have a responsibility for the health of their people. The Declaration states: “Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice.”

4. Ask students to brainstorm things governments could do to improve the health of their citizens. Write down all answers.

5. Let students know they will select a country for their final project and research efforts its government has taken within the past 200 years to improve the health of its citizens. Ask each student or small group of students to pick one country to research and write about. Instruct students to write reports, which include the following:

• The name of the country
• The health problem(s) it was facing
• The actions the government took to improve the situation
• The role of non-profit organizations or other non-governmental organizations to help in this effort
• The results/impact of those actions

Here are some possible countries for students to research:

• Costa Rica
• New Zealand
• Oman
• People’s Republic of China (“Barefoot Doctors”)
• Sri-Lanka
• Sweden
• Tanzania
• Venezuela

6. Ask students to present the findings of their research, highlighting how government actions have impacted the country’s health. Possible topics to include in the discussion:

• Costa Rica: Costa Rica’s 1949 constitution abolished its national army, which made it possible for increased  funding and attention to go towards education, health and other social programs. As a result of the General Health Law of 1973, all health treatment services became controlled by the national social security program. (For more details, see the link above.)
• New Zealand: New Zealand was one of the first countries to provide universal health care. Its hospitals are public and treat citizens and permanent residents free of charge.
• Oman: The Ministry of Health provides universal healthcare automatically to all citizens and to expatriates working in the public sector. The life expectancy in Oman as of 2007 was 71.6 and an infant mortality rate of 9 per 1000 live births. (For more details, go to: Wikipedia: Health Care System)
• People’s Republic of China: In 1965 the Chinese government began training thousands of young farmers to provide basic health care in rural areas. These medical workers, known as “barefoot doctors,” spent half the working day providing health care and the rest of the time farming. By the 1970s, over one million people had been trained as “barefoot doctors.” Private medicine has now replaced the barefoot doctors. For more information go to: Explore the Against the Odds online exhibit.
• Sri Lanka: Sri Lanka reduced maternal deaths from 500 to 600 maternal deaths per 100,000 live births in 1950 to 60 per 100,000 in 2007. For more details, go to: Give Well: Reducing Infant Mortality in Developing Countries.
• Sweden: A national effort to train midwives to use medical instruments and work independently of doctors was launched in Sweden in the 19th Century. The trained midwives played a critical role in decreasing maternal mortality in the country. Sweden is now one of the safest countries in the world for women to give birth. For more details, view The Decline in Maternal Morality in Sweden.

  The producer and director of Birth of a Surgeon (both from Sweden) discuss their reasons for creating the film and compare the history of combating maternal mortality in Sweden with the current situation in Mozambique at Birth of a Surgeon: Video Filmmaker Notes.

• Tanzania: Between 1999 and 2007 access to health services improved in Tanzania (especially among the poorest Tanzanians) and infant mortality dropped from 99 deaths per 1000 live births to 58 and under-five mortality dropped from 146 deaths per 1000 live births to 91. For more details, see: Learning from Maternal and Child Health Success in Africa.
• Venezuela: Healthcare in Venezuela improved dramatically between 1940 and 1990, due in large part to government efforts. Life expectancy increased from 43 years to 70 years and the death rate decreased sharply. (For more information, go to Healthcare in Venezuela)

7. Lead a discussion about how governments’ decisions impact the health of their people. Ask students to reflect upon what they have learned from the international examples.

8. Optional: Ask students to find out more about health care and access to health care in the US and to compare it to the international examples discussed during the lesson.