The discussion and relevance of the performance of the health sector in Mozambique has been increasingly intense, as demographic growth is registered, which in part puts the national health system under pressure. Several aspects have been the subject of reference in the design of hospitals and health centers, from the forms of construction, geographical distribution and population density. Therefore, it would not be possible to write the history of the evolution of the health sector in Mozambique without reserving a chapter dedicated to the financing of the health sector, since in all phases and cycles it has been of relevance and has accompanied the frequent circumstantial and structural variations of the sector.
The health sector is largely financed by the external sector, both in the realisation of investment expenditure as well as for some expenditure on current goods and services. Depending to a “large extent” on grants and loans from international partners, despite the fact that external capital, in the form of direct investment or loans to the health sector, has played various roles since the early days of the Mozambican economy, there is a need to promote a rational and sustainable use of resources from these sources of financing, at the risk of becoming a burden on the sustainability of its service in the case of public debt and loss of confidence of partners in the case of grants.
This document presents findings from analyzing the degree of performance of the health sector in the provision of sexual and reproductive health (SRH) services. To this end, the research presents the degree of achievement in the provision of Sexual and Reproductive Health Services and shows the effects of this achievement on the attainment of the key targets of the Government’s Five-Year Programme 2020-2024.
- CONTEXT OF HEALTH SERVICE PROVISION IN MOZAMBIQUE
Low access to health services: From 2014/15 to 2019/20, although overall access to health services increased by about 1.9pp, in the rural area, where about 67% of the population resides, it decreased by 9pp, i.e. from 64.4% to 55.4%. In urban areas, on the other hand, access to health services increased from 76.7% in 2014/15 to 97.9% in 2019/20. This scenario denounces the disproportionality in access to health between urban and rural areas, the latter being the most disadvantaged.
Shortage of health professionals: Mozambique’s health professional ratio (1.7 per 1000 inhab.) is 0.6 below the WHO recommendation, and is mainly composed of health technicians and nurses who together correspond to about 95% of the SNS workforce. In other words, the SNS has a low number of qualified professionals, with doctors accounting for only about 5%.
Chart 1: Access to health care total and by area of residence (2014/15 to 2019/20)
Source: IOF (2014/15 and 2019/20)
Lack of health professionals: The ratio of health professionals in Mozambique (1.7 per 1000 inhab.) is 0.6 below the WHO recommendation, and is mainly composed of health technicians and nurses who together account for about 95% of the SNS workforce. In other words, the SNS has a low number of qualified professionals, with doctors accounting for only about 5%.
Graph 2: Comparison of the Ratio of Health Professionals/ 100 000 inhab. in Mozambique in relation to WHO
Source: MISAU (2018 a 2021)
Low access to facilities: for example, the country has 0.7 beds/1,000 inhabitants (World Bank). This ratio is about 4 times lower than the 3 to 5 beds/1,000 inhabitants recommended by the WHO to meet the inpatient needs of the population.
Sexual and Reproductive Health: According to the Global Financing Facility (GFF), Mozambique has achieved substantial reductions in maternal, under-five and neonatal mortality rates. However, progress has been uneven and limited for the poorest populations in rural areas.
Overall, while the national in-hospital maternal mortality ratio is within the WHO recommendations of 80/100,000 LB, Maputo City has a ratio almost twice as high as the WHO recommendation at 145/100,000 LB. In addition, the provinces of Gaza and Sofala are in the red line with 82/100,000 LB and 80/100,000 LB, respectively. Furthermore, neonatal mortality/1000 live births is 28.5, which is above the global average of 18/1000 live births. Likewise, Mozambique has alarming HIV indicators, being part of the 30 fast track countries with 13.2% prevalence. Therefore, more than 120,000 cases of new infections are reported on average per year.
Public Finance: Although the country has committed to allocate at least 15% of its budget to the health sector, over the last 10 years (2013 to 2022), the country has allocated on average only 8.9%. Similarly, over the last 5 years (2018 to 2022), the majority of health sector expenditure, 79%, has been allocated to operating expenditure, with only 21% being applied to investment expenditure. The country also has a strong external dependency for the financing of investment expenditure. In fact, over the last 5 years, about 79% of capital expenditure has been financed by external sources.
EVOLUTION OF KEY HEALTH INDICATORS (2022 TO 2023)
- Percentage or number of institutional deliveries. From 2022 to 2023, there was an increase of the targets by 6pp. That is, from 1,209,315 institutional deliveries in 2022, to 1,327,589 in 2023, there was an increase of 118,274 institutional deliveries. Notwithstanding the increase in institutional delivery coverage targets to 90.6% in 2023, the targets of Zambézia (88.6%), Tete (87.0%), Inhambane (89.5%) Maputo Province (62.0%) and Maputo City (70.0%) provinces have coverage below the national average.
- Number of children fully vaccinated. Between 2022 and 2023, the target for this indicator had a slight variation from 1,039,446 to 1,060,171, respectively, an increase of 20,725.
- Percentage of children with acute malnutrition cured. From 2022 to 2023, the target of children with cured chronic malnutrition remained unchanged at 80%.
- Number of adults living with HIV on ART. The target for this indicator increased from 1,697,217 in 2022 to 1,774,804 in 2023, an increase of 77,587.
- Number of children living with HIV on ART. The target for this indicator remained almost unchanged, with an expected increase of only 1 child living with HIV on ART from 2022 to 2023.
- Number of adults living with HIV on ART. The target for this indicator increased from 1,697,217 in 2022 to 1,774,804 in 2023, an increase of 77,587. PESOE 2023 presents some indicators not foreseen in 2022, with emphasis on number of HIV+ people tested, number of pregnant women on ART and number of patients reintegrated on ART.
Table 2: Evolution of key health indicators (2022 to 2023)
| Indicador | Goal | Variation | ||||
| 2022 | 2023 | |||||
| % or number of institutional deliveries performed | 85% | 90,6% | 6pp | |||
| Number of children fully immunized | 1.039.446 | 1.060.171 | 20.725 | |||
| % of children with acute malnutrition cured | 80% | 80% | 0pp | |||
| Number of adults living with HIV on ART | 1.697.217 | 1.774.804 | 77.587 | |||
| Number of children living with HIV on ART | 141.153 | 141.154 | 1 | |||
| Number of people tested HIV+ | ND | 71.500 | NA | |||
| % of pregnant women on ART | ND | 4 | NA | |||
| Number of patients reintegrated | ND | 32.500 | NA | |||
Source: Authors’ adaptations based on PESOE (2022 and 2023).
Health Sector Budget Prioritization Trends
From 2022 to 2023, the budget allocation for the health sector in relation to total expenditure was below the 15% commitment made by the Government of Mozambique, averaging 8.3%. From 2022 to 2023, there was a reduction from 9.1% to 7.6%.
Chart 3: Share of Allocated Health Sector Expenditure vs Abuja Commitment (2022 to 2023)
Source: BdPESOE (2022) e PESOE (2023)
Analysis of the Possibility of Meeting the Targets Set for 2023 under the PQG 2020-2024
The sexual reproductive health indicators with target information in the PQG show slower progress in the first 3 years (2020, 2021, 2022), with greater pressure concentrated in the last 2 years (2023 and 2024).
Looking at some of the indicators we have the following data:
- For the percentage of children fully vaccinated, the baseline was 94% in 2019 and the target for 2024 was 96%. However, this percentage decreased from 91% in 2020 to 85% in 2022. This raises questions about how the health sector can reverse the trend to the point of reaching the 96% target in 2024.
- In the case of the percentage of institutional deliveries, there is also a regression from the 2019 baseline (87%) to 85% in 2022, with the last 2 years being responsible for reaching the 96% target.
- For the number of children receiving ART, the baseline scenario was 95,000 children in 2019. This number reduced to 80,000 children in 2020 and increased to 99,000 in 2021. However, the target of 141,000 in 2024 has been challenging for the past 2 years.
Assessment of the Main Changes in the Approved PESOE Proposal and their Implications for the Achievement of Targets
With the exception of the percentage or number of institutional deliveries performed, the number of specialized doctors in the SNS and the number of men aged 45 screened for prostate cancer, the other indicators remained unchanged between the PESOE proposal and the approved PESOE.
Table 4: Changes between the PESOE Proposal and the Approved PESOE (2023)
| PESOE 2023 | Variation | ||
Indicator | Proposal | Approved | |
| % or number of institutional deliveries performed | 340 | 1,327,589 | 1,327,249 |
| Number of children fully vaccinated | 1,060,171 | 1,060,171 | 0 |
| Number of patients on ART with suppressed viral load results | 719,000 | 719,00 | 0 |
| Number of women screened for cervical cancer | 1,432,568 | 1,432,568 | 0 |
| Número de adultos vivendo com HIV em TARV | 1,774,804 | 1,774,804 | 0 |
| Number of children living with HIV on ART | 141,154 | 141,154 | 0 |
| Number of people tested HIV+ | 71,500 | 71,500 | 0 |
| % of pregnant women on ART | 4% | 4% | 0 |
| Number of reintegrated patients | 32,500 | 32,500 | 0 |
| Number of reclassified general and district hospitals | 1 | 1 | 0 |
| Number of specialist Medical Doctors in the National Health System | 741 | 437 | 304 |
| % of children with acute malnutrition cured | 80 | 80 | 0 |
| Number of 45-year-old men screened for prostate cancer | 0 | 13,000 | 13,000 |
Source: PESOE Proposal (2023) and PESOE Approved (2023)
- Recommendations
- Improve the distribution of annual indicator progress targets towards the achievement of the PQG targets, reducing the overload of indicator progress in the last 2 years (2023 and 2024);
- Maintain consistency of planning and resource allocation with country targets and commitments, specifically the Abuja Declaration.
- Continue with the realisation of the Integrated Planning Meeting of the Ministry of Health and Partners in order to reduce discrepancies in indicators between provinces;
- It is always necessary to ensure a progressive scenario of improvement of sexual reproductive health indicators in view of the greater demand caused by the pressure of population increase;
- Ensure that relevant SRH indicators are included in the planning to better monitor efforts and progress towards the achievement of the recommended targets;
- Ensure greater consistency between the different planning and public management instruments in the health sector, including consistency between the IC targets and the PESOE.
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