Mozambique's health system
Health and development
Since the signing of a peace agreement in 1992, Mozambique has made significant progress in recovering from its war torn past. A steadily increase of external aid, debt relief under the Heavily Indebted Poor Countries Initiative and a rapidly growing economy have led to a considerable increase of resources for the health sector.
The expenditure per capita on health has increased from US$ 4.6 in 1997 to US$ 7.5 in 2002. The publicly funded health delivery system has seen significant improvements in both health input and outputs. Extensive external aid to the health sector has been increasing allowing for the reconstruction and development of a national health system. External aid, which will amount to 73% of the total health budget in 2008, is being coordinated through a sector wide approach (SWAp) with common funds.
Despite greater availability of health resources and positive socio-economic developments inequities in health continue to persist. Absolute poverty still affects 54% of the population. Life expectancy at birth is 47.4 years. Malnutrition remains problematic with ¼ of children under the age of 5 being underweight. Adult illiteracy rate is 51.9%. Enrollment rates for primary school level are increasing but primary school completion rate in 2005 was 39%. Only 36% of the population has access to safe water and 46% access to adequate sanitation (NHS 2003).
Health status indicators
The country’s burden of disease is largely a consequence of the high levels of poverty and a result of infectious and communicable diseases. Poor access to primary health care facilities has made it difficult for government efforts to deal effectively with the health situation. According to the Mozambique Poverty Reduction Strategic Program (PARPAII), only 36% of people have access to a health facility within 30 minutes of their homes. About 30% of the population are not able to access health services and only 50% have access to an acceptable level of health care. Among the top contributors to the country’s disease burden are malaria, diarrhoea, HIV/AIDS, respiratory infections and tuberculosis. Malaria is considered the major contributor to the country’s burden of disease. 30% of the mortality rate in children 7 yrs and below is attributed to malaria. Malaria is responsible for 40% of all outpatients’ attendance and approximately 30% of all hospital deaths (Roll Back Malaria situational analysis 2001). The incidence of tuberculosis in the country is very high at 1,025 per 100,000 population (2004). The infant mortality rate has declined from 147/1000 live births in 1997 to 124/1000 live births. According to the latest figures from UNICEF the infant mortality has declined further to 100/1000 live births. The child mortality rate declined from 219/1000 births to 178/1000 births. Child mortality rates are usually considered to be a reflection of the extent and impact of prevailing poverty levels and as a proxy indicator of socio-economic development.
The high levels of poverty and the persistent nature and degree of food insecurity in the country have contributed to the poor nutrition indicators in children under the age of five years. Levels of chronic malnutrition in children under the age of 5 years are currently at 41%, with vitamin A deficiency rates at 69% and levels of anaemia at 75%. The challenge is to develop and implement viable strategies to improve food security at both the household and national levels.
The maternal mortality rate which was once considered one of the highest in the region has over the past five years declined to about 408/100,000 live births. The proportion of deliveries taking place in health institutions varies significantly by province as do most of the health indicators. According to PARPA II only 48% of deliveries take place at health facilities and the index for access to Essential Obstetric Care (EOC) is only 1.23 per 500,000.
It is estimated that more than one and half million persons are infected with HIV and the national HIV prevalence is recently estimated to be at least 16 % in people over the age of 15 years The strategic plan for the national multi-sectoral response to HIV/AIDS has been reviewed and revised to take into consideration the changing epidemiology of HIV/AIDS and the introduction of new strategies for prevention, control and treatment. Much of the effort will be directed at prevention and mitigation of the impact of HIV/AIDS at the household and national levels. Programs have been developed to scale up access to Voluntary Counselling and Testing (VCT) and Antiretroviral Therapy (ART) with a particular emphasis on access to paediatric ART.
Progress in establishing a rural primary health care network and management system has been limited by several factors, which include high rates of infectious disease and malnutrition; a growing prevalence of HIV/AIDS; inadequate access to potable water; limited numbers of trained health personnel; and inadequate funds allocated for basic health care delivery annually. Overall, the health status of the Mozambican population is lower than average for African countries and far below international standards.
Progress towards Millennium Development Goals
|Children 1 year old immunized against measles||59%*||61%||71%||77%|
|Infant Mortality rate/ 1 000 live births||158*||145||122||100|
|Under five mortality rate/1 000 live births||235*||178||145|
|Contraceptive Prevalence Rate (modern methods)||5.10%||11.80%|
|Births attended by skilled health personnel||47.70%||48%|
|Maternal Mortality rate/100 000 live births||1 500*||1 000||408**|
|Prevalence of tuberculosis/100 000 population||296*||520||580||597|
|Tuberculosis detection rate under DOTS||46%||44.40%||48.70%|
|Tuberculosis death rate/100 000 population||33.7||77.9||115||123.8|
|HIV Prevalence in 15-49 age group||16.2%*|
|Source: Database: MDG Info.2007.mdb; (08-02-2008)|
|* Other sources, MOH data.|
|** According to the Maternal Death UN report2005, the estimate for Mozambique is 520, ranging 360-680 maternal deaths/100000 live birth.|
Progress towards attaining the health MDGs has been slow mainly as a result of the following reasons:
- Weaknesses in linkages between: strategic plans and annual operating plans;
- Weaknesses in linkages between the health sector and broader development processes;
- Difficulties in coordinating international initiatives;
- Staffing and systems limitations,
- Inadequate monitoring systems for resource flows, progress and outcomes;
- Limited progress in transferring global commitments into concrete action at country level (e.g., the provision of predictable, long-term financing);
- The lack of a multi-sectoral approach to achieving health outcomes.
National Health Policy
The health policy framework for Mozambique is articulated in several documents, including the Five Year Government Plan (2005 – 2009), the Poverty Reduction Strategy Paper (PARPA II), the Economic and Social Plan (PES), the Three Year Public Investment Plan (PTIP), the Medium Term Expenditure Framework (CDFMP, or MTEF) and the Health Sector Strategic Plan (2007-2012 (PESS), Stated cornerstones of the policy are primary health care, equity and better quality of care. These six documents provide a framework for national planning and programming. The main document in this hierarchy is the Government Five Year Plan 2005- 2009 which sets its main objectives as, reducing the levels of absolute poverty, rapid and sustainable economic growth, consolidation of peace, national unity, justice, democracy and national awareness, as indispensable conditions for the harmonious development of the country and the fight against corruption, crime and red tape.
The Poverty Reduction Strategy Paper II (PARPA II) is the operational plan for the government’s Five Year Program (2005–09) which includes a strategic matrix of key indicators, a joint effort by the government, development partners and civil society. These indicators are fully integrated into and monitored through the annual instruments of the Economic and Social Plan (PES). The human capital pillar provides, inter alia, for the development of good health and hygiene and a reduction in the incidence of diseases that affect the most vulnerable population groups, focusing particularly on the battle against malaria, tuberculosis and HIV-Aids. Health contributes to human development, and directly and indirectly to a reduction in poverty.
The objectives for the health sector are laid down in the Health Sector Strategic Plan (PESS 2007-2012) and the PARPA II. The Health Sector Strategic Plan also takes into consideration regional health initiatives within the SADC and global initiatives such as the Millennium Development Goals. Success factors addressed include the mobilization and efficient use of resources, increasingly harmonized planning and budgeting processes, improved management, the availability of competent professional staff, the availability of essential supplies and community participation/collaboration with various stakeholders in health development.
The PESS ensures that the plans are tools to serve the sector, tools to indicate direction, objectives and strategies and, at provincial and district levels, to articulate the means by which these objectives and strategies can be achieved. The plans also serve as tools for monitoring the achievement of targets and indicators. Expected outcomes from the PESS include:
- Increased access to health services
- Consolidation of the PHC approach and integrated service delivery
- Strengthened referral system and continuity of care
- Improved quality of services delivered at all levels
- Improved functioning and performance of health care facilities at all levels of care
- Guaranteed, adequate and early response to Emergencies and Epidemics
- Strengthened Community Participation approach
- Promotion of a collaborative approach with other health providers
- Improved inter-sectoral collaboration