Mozambique's health system

Partners in health development

The Ministry of Health of Mozambique receives considerable support from a large number of international development partners. In 2007, foreign aid contributes to 70% of the health sector’s budget and will increase to 73% in 2008.

Mozambique has adopted a “Sector Wide Approach” (SWAp) to the health sector in 2000. The introduction of the Health SWAp aims at improving the performance of the sector, strengthening government leadership, putting greater emphasis on policy and strategy development and lowering the transaction costs of foreign assistance.

Currently, a total of 26 partners use the Health SWAP structure to enhance strategic dialogue among partners and between the Ministry of Health and partners on sector policies, priorities and performance in the context of Absolute Poverty Reduction Plan of Action (PARPA) and delivery of the sector strategic plan (PESS). 30% of external funding is channelled through a Common Fund Mechanism (Prosaude).

The dynamics of the Health SWAp are evolving and new challenges present, such as the incorporation of global vertical health financing initiatives. Significant and continuous efforts are being made to improve the efficiency and the effectiveness of the Health SWAP in harmonizing and aligning partners to government systems, strategies and plans, in line with the Paris Declaration on Aid Effectiveness.

Health development partners

Mozambique has several development partners supporting the health sectors and they include multilaterals such as:

  • WHO – World Health Organization
  • UNFPA – United Nations Population Agency
  • UNAIDS – Joint United Nations Program for HIV/AIDS
  • UNICEF – United Nations Children’s Fund,
  • WB - World Bank
  • UNDP – United Nations Development Program
  • ADB – African Development Bank,
  • EU- European Union,
  • OECD - Organization for Economic Cooperation and Development
  • Global Fund

On the bilateral list of partners are:

  • DFID, the UK Department for International Development
  • JICA, the Japanese International Cooperation Agency, and the
  • Japanese Ministry of Foreign Affairs;
  • NORAD, the Norwegian Agency for Development Cooperation;
  • EC, the European Commission;
  • IA, Irish Aid;
  • DANIDA, the Danish International Development Agency;
  • The Direzione Generale Cooperazione Allo Sviluppo, Italian Ministry of Foreign Affairs;
  • USAID, the US Agency for International Development;
  • GTZ, BMZ, the German Ministry for Economic Cooperation.
  • The Netherlands
  • France
  • Flemish Cooperation
  • SDC
  • Several NGOs

Overview of Sector Wide Structure (SWAp)

The trend to operate through projects led to increased fragmentation of the country’s national health system. As a result the Mozambique SWAp was established within the above context. The SWAp initially emphasized an incremental and progressive process, focusing on developing an open, inclusive arrangement where the MOH and its development partners share a set of common principles, objectives and working arrangements, which characteristically include:

  • A health sector strategic plan (PESS), endorsed by all development partners with a set of agreed indicators to evaluate policy implementation and health sector progress
  • A code of conduct signed in 2000 (revised in 2003) which sets the basic rules of engagement between the MOH and its partners;
  • SWAp Terms of Reference (ToRs)
  • Working arrangements that enable structured dialogue and consensus building between the MOH and development partners
    • The Sector Coordination Committee (CCS): which meets twice in a year, is chaired by the health minister and comprises his/her cabinet, selected provincial health directors (on a rotating basis) and the representatives from development partners active in health. The forum endorses key reports and recommendations (such as those emerging from the joint annual reviews of the Strategic Plan), informs development partners of significant issues or decisions relating to health sector policy, especially focusing on MOH Annual Operation Plans for the following year
    • The Joint Coordinating Committee (CCC): replaced the former SWAP MOH-Partners Working Group, provides a good opportunity for a small group of representatives from MOH and the community of external partners to deal with some critical issues in a more informal manner.
    • SWAP-related thematic working groups: Working groups (and ad-hoc task groups) which provide an opportunity for development partners and the MOH to jointly review or oversee specific areas of health policy where a more in-depth analysis is required prior to their adoption or consideration by the broader SWAP Forum. All of these have their own jointly agreed ToRs
  • A sector financing framework (MTEF) which:
    • Forms part of the health strategic plan, the MoU, and the code of conduct
    • Highlights the expectations of the Government in relation to aid modalities and financial instruments to be used by development partners in the health sector
    • Points to the need to increase the government health expenditure,
    • Points towards donors increasingly placing development assistance for health into common funding and budget support mechanisms;
    • Needs to be improved as an instrument as well as in its content
  • The Performance Assessment Framework (PAF) has been developed to serve as the basis both for monitoring progress of the PARPA, and to inform future developments within the General Budget Support (GBS) programme. Other objectives identified for the PAF include:
    • Greater transparency and predictability in the link between policy, implementation, and the level and timing of GBS flows, thereby facilitating improved planning and management;
    • Reduced transaction costs through increasing harmonization of donor conditions.

The PAF indicators enable PARPA monitoring to be explicitly linked to budget instruments reviewed by Parliament, thereby increasing accountability parliament and the population, and of donors to the people of Mozambique. At the 2003 Consultative Group meeting, partners, including the World Bank, pledged to link their long-term commitments to release GBS to achievement of PAF indicators.

  • A set of review mechanisms to evaluate health sector progress and commitment to the objectives of the strategic plan,
    • Operationalized through a joint annual reviews and biannual meetings of the Sector Coordination Committee (CCS).

Achievements in implementing the SWAp

  • Funds flow through a Common Fund and use a harmonized financial management and accounting system
  • The depth and breath of participation has meant that most key stakeholders are well informed and involved.
  • There is high level support an engagement within the Ministry of Health
  • There is regular and committed involvement from external partners
  • There are opportunities for cross fertilization and harmonization across Ministry of Health Departments and within the external partner group
  • New MoU and the amalgamation of three common funds into one, using GoM
  • PFM rules and regulations, and aligned with the state planning and evaluation cycle.
  • A PAF (Performance Assessment Framework) of 40 jointly agreed indicators and targets across the continuum of the sector
  • The health partners have agreed on a HPG (Health Partner Group) ToRs that define the modus operandi of collaboration in a harmonized partnership

Challenges in implementing the SWAp

  • To ensure that all partners are on board the SWAp.
  • To get all partners in the SWAp to abide by the rules set in the MOU.
  • To allow space for the government (MOH) to exercise its leadership role without over burdening it.

The role of WHO in Health SWAp

  • Bring technical expertise and set international norms and standards
  • Function as an impartial broker between national government and partners
  • As co-focal partner ensure health priorities are addressed and consensually agreed initiatives implemented.
  • Be a visible, strong representative in the SWAP working Groups
  • Strengthen position of multilaterals in SWAp by sharing its comparative advantages