Mozambique
CASE STUDY
Mozambique
Since its civil war ended in 1992, Mozambique has achieved substantial reductions in maternal, under-five, and neonatal mortality rates. However, progress in these areas has been uneven and limited for people in the poorest income quintiles and for rural populations. Under the leadership of the Government of Mozambique and in collaboration with a range of partners, including the GFF, a five-year investment case was developed. The investment case prioritized high-burden districts in 10 provinces with a combination of health system strengthening activities that are needed to overcome bottlenecks in providing services in reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N).
In parallel with those activities, and despite a very challenging macroeconomic environment with pressure to reduce government expenditures, the government has begun to increase the ratio of its domestic health expenditures to its total domestic government expenditures. Data from December 2018 show significant progress on targets related to capacity building and health staffing, as well as more systematic data use. This progress has begun to translate into better results in facility and health service usage, such as increases in the use of antenatal care services, facility-based deliveries, and family planning services.
Trends in key RMNCAH-N indicators (1997–2011, DHS)
- Maternal mortality ratio:Declined from 692 to 408 deaths per100,000 live births
- Under-five mortality rate:Declined from 201 to 97 per 1,000 live births
- Neonatal mortality rate:Declined from 54 to 30 deaths per 1,000 live births
- Stunting prevalence among children under five:
Rose from 42.4% to 42.6% - Wasting prevalence among children under age five:
Declined from 10.5% to 5.9% - Age-specific fertility rate for adolescent girls (ages 15–19):
Declined from 179 to 167 live births per 1,000 women*
Country Priorities: Mozambique’s Investment Case
Mozambique’s five-year investment case was developed through an inclusive, government-led process that the GFF and a range of key actors were involved in, including historically underserved groups, such as adolescent girls. The government’s Health Sector Strategic Plan (PESS) for 2014–19, which orients all interventions in the sector, was used as the basis for establishing the priorities of the investment case. Part of this prioritization exercise involved categorizing Mozambique’s 142 districts by their needs, such as availability of resources and coverage of services, and potential for achieving results. This is illustrated in Figure 1, where dark-colored districts have the greatest potential for results and light-colored ones the least. A majority of the dark-colored districts have a hospital and both greater population density and a denser health network than the national average; they also have higher current coverage rates. At the same time, both darker and lighter districts require investments. Darker districts require investment to reinforce their role as reference districts for neonatal and maternal emergency care, while lighter districts need a stronger focus on outreach solutions, such as community health workers and mobile brigades targeting dispersed populations.
Figure 1
Mozambique districts graded by potential for achieving RMNCAH-N results (2015)
Based on this work, the investment case identified 42 lagging districts in 10 provinces in which to target investments and interventions.
The investment case defines three priorities for strengthening the National Health Service:
- Improvements in coverage, quality, and access to essential primary health care services through a combination of supply- and demand-side investments that extend to sparsely and high-burden districts, for example through the use of community health workers;
- Systems-strengthening interventions, such as efforts to improve data collection and monitoring in the civil registration and vital statistics (CRVS) system; and
- Increases in the volume, efficiency, and equity of domestic and external health financing.
GFF engagement in Mozambique has been centered on supporting the inclusive, government-led preparation, financing, and implementation of the investment case. This includes an extensive resource mapping that is directly linked with and fully finances the investment case over the 2018–2022 period (Figure 2). Mozambique was strongly committed to having a fully funded investment case, with most funding channeled through government systems.
Figure 2
Resource mapping of the Mozambique investment case (percent distribution)
The GFF’s support to Mozambique is focused on results through co-financing of the investment case through the Primary Health Care Strengthening Program. Among other things, this program promotes: (1) maintaining and eventually increasing the government’s ratio of domestic health expenditures to total domestic expenditures; (2) increasing the number, reach, and capacity of community health workers who are delivering key RMNCAH-N interventions in prioritized districts; (3) collecting and using data for decision-making; and (4) expanding the quality and coverage of RMNCAH-N services in districts that have both a high burden and high potential for results.
Results
The implementation of the Primary Health Care Strengthening Program, which is directly linked to the investment case, has exceeded most of its targets (Table 1).1 In December 2018, the Ministry of Economy and Finance reported a 9 percent ratio of domestic health expenditures to total domestic government expenditures, putting it on track to achieve the 2021 commitment of 9.5 percent. The government also committed to increasing health expenditures for the 42 prioritized districts from US$0 in 2017 to US$9 million by 2019 and US$36 million by 2021, but this target was not met the first year.
Increases in primary health care and community health staffing have also been demonstrated: the targeted number of trained and active community health workers was 3,390 in 2018, with a goal of 8,800 by 2022. The target for the first year was met, with training for 5,363 community health workers already completed. The targeted number of technical health personnel assigned to the primary health care network was 14,344 in 2018 (from a baseline of 11,970 in 2017) and has a goal of reaching 17,662 by 2022.
Efforts toward the systemic recording and use of data have also improved. To facilitate progress in tracking the implementation of the investment case, and in response to significant challenges in monitoring activities at the subnational level, the government and its partners are developing a national dashboard with jointly agreed-upon indicators. In the meantime, quality-of-care scorecards for health centers and hospitals have been piloted and will be scaled. Also, vital statistics registration, which is a key focus area of the investment case, has improved, with the share of facilities using the Data Management Module (MGDH) to record cause of death rising from 70 to 100 percent among hospitals and from 0 to 50 percent among health facilities.
Lastly, many of the RMNCAH-N indicators and targets set forth in the Primary Health Care Strengthening Program for 2018 have been achieved or exceeded (Table 1). The share of births that occurred in health facilities reached 80 percent, a number that exceeded the 2018 goals. Nutrition goals for 2018 focused mostly on training key nutrition personnel and rolling out the Nutrition Intervention Package (NIP) in the eight highest-burden provinces: these goals were also achieved. Between 2017 and December 2018, 3,609,078 additional children received basic nutrition services. To improve sexual and reproductive health outcomes, Mozambique has placed a high priority on reducing the unmet need for family planning and increasing access to modern contraceptives. To monitor utilization of this service, Mozambique uses “couple years of protection” (CYPs), and on this indicator saw a 26 percent increase in 2018 compared to the previous year, exceeding national goals.
Table 1
Selected disbursement-linked indicators from December 2017 to December 2018
| Outcome | December 2017 (baseline) | 2018 targets | December 2018 achievements |
|---|---|---|---|
| Percentage of institutional deliveries in 42 lagging districts | 66.10% | 66.80% | 80% |
| Number of couple-years of protection (CYPs) | 1,722,692 | 2,135,012 | 3,238,928 |
| Number of women and children who have received basic nutrition services | 0 | Training of health workers completed, M&E system developed | Training of health workers completed, M&E system developed |
| Number of trained and active community health workers (APEs) | 3,380 | 4,723 | 4,789 |
| Number of technical health personnel assigned to the primary health care network | 11,970 | 12,205 | 14,344 |
Conclusion
Looking forward, it is critical for Mozambique to further strengthen existing coordination structures to establish a well-functioning country platform. Areas of focus for the country platform will include monitoring the implementation of the investment case on a regular (quarterly) basis to facilitate timely and relevant course-correction. Data quality also remains a challenge; it needs to be strengthened further since it is a key input to the country platform’s functioning and data monitoring role.