SUMMARY
Prepared under the Project Strengthening Social Accountability and Supervision in the areas of Health and Agriculture – PSA, implemented by ActionAid Mozambique in partnership with the Observatório Cidadão para Saúde, this position paper analyses budget dynamics in the health sector, with focus on Sexual and Reproductive Health Rights (SRHR) and HIV and AIDS. The analysis shows that the State Budget, allocated and executed in the health sector, has never reached the Abuja commitment (15%), even after the coronavirus outbreak in 2020. The increase in the health budget over time does not mean greater capacity to provide health goods and services, in general, and SRHR and HIV and AIDS, in particular, as it does not follow the general rise in prices (inflation) and population growth. As a result, there is a trend of decline in SRHR and HIV and AIDS indicators, aggravated by the Covid-19 pandemic. Therefore, greater allocation of resources for the health sector, in general, and SRHR and HIV, in particular, is recommended, which may be through the exploration of idle fiscal spaces without increasing the cost of access to health services for the population.
1 .INTRODUCTION
Health is one of the common development challenges among African countries. A report by the World Health Organization (WHO) estimates that around 630 million lives were lost in 2015 due to diseases that affect the population of its Member States in Africa. This represents a loss of more than US$2.4 billion, of the region’s annual Gross Domestic Product (GDP) value (WHO, 2019).
In Mozambique, health is one of the priority sectors, among the strategic development objectives, defined in the main long-term government policies, which, in principle, should be aligned with regional and international development commitments.
Thus, it is understood that understanding government actions in improving the provision of quality and inclusive health services is possible, among other ways, through the analysis of the achievement of short-term goals, defined in the Economic and Social Plan (PES) and the respective execution of the State Budget (OE). Thus, this document is the result of the analysis of the health sector budget dynamics, with a focus on gender that directly influences Sexual and Reproductive Health (SRSR) and HIV and AIDS, with a view to contributing to the improvement of allocation and management of public resources in the health sector and, ultimately, improving the provision of health services to populations.
Graph 1: Comparison between the Health Sector Weighting and the Abuja Declaration for the period 2010-2020 (in Percentage of Total Spending)
2.MAIN FINDINGS
a)From 2010 to 2020, the government did not prioritise the health sector taking into account the Abuja commitment (15%). During this period, the average weight of health expenditure in the OE was 9%. In light of this commitment, government stopped investing about MZN 146.81 billion in the health sector. Despite the Covid-19 pandemic that has direct implications for the health sector, a share of 14% is expected in 2021, still below the Abuja commitment.
Source: Authors’ calculation based on the CGE (2010 – 2020); OE (2021) and OMS (2011)
In real terms, the expenditure of the Health Sector has been decreasing since 2013, which means a deterioration in the purchasing power of the health sector with consequences on the coverage and quality of health services, with the exception of 2021, where real growth in the order of 10.7% is expected.
Graph 2: Comparison of Resource Allocation for the Health Sector in Nominal and Real Terms (in MZN Billion)
Source: Authors’ calculation based on the CGE (2010 – 2020), IPC (2010 a 2021) and OE (2021)
b) The actual expenditure on SRHR actions reduced by 92.8% from 2018 to 2020.
Graph 3: Comparison of Resource Allocation for Sexual and Reproductive Health in Nominal and Real Terms (in MZN Millions)
Source: Authors’ calculation based on the CGE (2010 – 2020), IPC (2010 to 2021)
c) Spending on actions to combat HIV and AIDS increased, at the central level, by about 59.7%, while at the provincial level they decreased by 42%, contrary to the ongoing decentralization process in the country.
Graph 4: Nominal and actual expenditure on HIV and AIDS in Central and Provincial Levels (in MZN Millions)
Source: Authors’ calculation based on the CGE (2010 – 2020), IPC (2010 to 2021)
d) Health expenditure is not following the population growth trend, which may compromise the improvement of the provision of SRHR and HIV and AIDS goods and services, for example. This is because, in per capita terms, the expenditure of the health sector tends to reduce since 2013, from US$ 28.69 to US$ 15.41, in 2020. The amount for 2020 represents a quarter of what would be needed for the SDGs ($60.00) and corresponds to only 6% of what is needed to achieve the SDGs by 2030 ($271.00). It should be noted that the same value (US$ 15.41) is also below the average for Africa (US$ 32.00 per capita).
Graph 5: Health Sector Expenditure (in US$ per capita)
Source: Authors’ calculation based on the CGE (2010 a 2020) and INE (2021)
e) The level of execution of the health expenditure has been less than 100%, in part, due to the low execution of investment expenditures that depend mostly (70%) on external sources, which are subject to constraints and uncertainties in disbursements.
Graph 6: Execution of Health Sector Expenditure 2010 to 2020
Source: Authors’ calculation based on the CGE (2010 – 2020)
The HIV and AIDS indicators have had a low performance, and from 2019 to 2020, the percentage of patients with TB/HIV on ART decreased from 97% to 94%. Likewise, the increase in people living with HIV and AIDS on ART (41,429 people) was lower than the number of new infections (131,536 people) in the same period. With regard to SRHR, the country managed to maintain coverage of hospital births at 87%. However, the scope of sensitisation of young people about HIV and AIDS and SRHR has reduced from 1.7 million to 1.2 million, in contradiction with the growth statistics of the young population in Mozambique.
Table 1: SHRH and HIV and AIDS indicators
Source: Authors’ calculation based on PES balance (2019 e 2020)
3.RECOMMENDATIONS
The following points constitute the study’s recommendations:
- Re-examining budget priorities in line with Health commitments – this implies increasing the health sector’s share of resource allocation to at least 15%;
- Aumentar as alocações de recursos para o sector de saúde, no geral, e SSR e HIV/SIDA, em particular, tendo em conta o aumento dos preços e o crescimento da população em Moçambique.
- Reduce the level of external dependence on the financing of investment expenditure in the health sector to address the trend of reduction in external aid and associated constraints, as well as reduce disbursement uncertainties and, thus, improve expenditure execution. This can be done by exploring existing fiscal spaces in the health sector, without increasing the cost of access to health services for the citizen. For example, the recovery of health expenses not reflective of insurance costs; increase the tax on goods harmful to health (alcohol and tobacco consumption) and direct these revenues to the health sector.
- Prioritise prevention actions (SRHR) with a view to reducing, in the long term, the costs inherent to the treatment (HIV and AIDS) and to improve the indicators of access to treatment for SRHR and HIV and AIDS.
- Improvement aimed at equipping health units and preferential care services for women, girls and children.