The sustainable and balanced socioeconomic development of a country depends, considerably, on the continuous provision of public goods and services, associated with the institutional capacity to allocate and manage resources efficiently, taking into account the prioritization and functionality of each sector for Human Development (GMD, 2018).
Access to qualitative health services has always been a challenge for the Mozambican population. It contributes to the improvement of quality of life, as well as to the generation of domestic income.
Health services are mostly provided by the public sector, and the Ministry of Health (MISAU) is responsible for the creation, planning, coordination, and control of national health policies.
Over the last few years, the National Health System (NHS) has registered remarkable advances, characterized by an increase in the response to health care, an increase in institutional childbirth, a decrease in mortality rates for children under five years of age, and a slight increase in the life expectancy of Mozambicans. Despite the advances mentioned, the country is till affected by an epidemiological profile dominated by transmissible diseases, namely: Malaria, HIV, and Tuberculosis.
The capacity to respond to these enormous challenges is still limited, since the health network covers only “half” of the population. Health services do not have adequate conditions for the provision of quality in health services, either from the point of view of human resources, as well as from the point of view of equipment, medicines and other inputs (GMD, 2018).
This document arises within the partnership between the Observatório Cidadão para Saúde (OCS) and ActionAid Mozambique, through the implementation of a project that aims to “improve Accountability in the Management of Public Resources, particularly in the provision of Health Services focused on HIV/AIDS and Sexual and Reproductive Health (SRH) for adolescents and young people.”
This project is being implemented in some other SADC countries (Malawi, Mozambique, Tanzania, Zambia and Zimbabwe), under the name “Social Accountability Monitoring (SAM)”, which contemplates the main stages of the activities of the public finance management process, from planning, resource allocation, expenditure management, performance analysis, public integrity and oversight. For each of these processes, the analysis seeks to identify the aspects that affect the quality of public service provision in the health sector.
For this study, we resorted to bibliographic research, and we analyzed the main instruments for planning and public resources’ management, namely: the Economic and Social Plan (ESP), the Balance Sheet, the Health Reports for HIV and the Five-Year Government Program (FYGP), through five processes for monitoring social accountability (Planning & Resource Allocation; Expenditure Management; Performance Management, Public Integrity Management and Oversight). However, the performance of public servants should not only be seen from the documentary perspective, but also from the citizen’s perspective in order to assess the level of satisfaction, taking into account the positive or negative scores. In this approach, the citizen’s community score card was also used, as well as semi-structured interviews and simple observation.
In this context, it becomes pertinent to analyze the budget allocation, with particular focus on Sexual and Reproductive Health and HIV/AIDS, since these diseases are visceral for Mozambican population, generating taboos associated with cultural aspects.
The document, therefore, discusses elements and problems that affect the “normal” functioning of the health sector and proposes specific recommendations or elements for advocacy in the allocation and management of public resources, in order to respond to the intentions of the Mozambican population, especially the most disadvantaged.
Analyze the evolution of Sexual and Reproductive Health (SRR) and HIV/AIDS indicators to measure the effect of allocation and execution, based on the Social Accountability Monitoring approach (2020 – 2021).
Describe the degree of planning, allocation of public resources versus priorities;
Identify the main gaps, challenges and factors that negatively impact the achievement of goals established in the national strategic plans;
Propose recommendations to improve the performance in the response to HIV/AIDS, in order to achieve the goals set out in the respective strategic plans.
3. PLANNING IN THE HEALTH SECTOR
Planning is an ongoing process that involves choices about alternative development paths and the use of available resources in order to achieve an objective within a specific time frame. For the case of Mozambique, the Ministry of Health is the central level institution responsible for the strategic management of the health sector and for designing the planning and budgeting instruments for the health sector in the systematic use of crucial instruments such as the Economic and Social Plan (PES) and the Health Sector Strategic Plan (PESS), which take into consideration the priorities contained in the Five Year Government Program (PQG), which are used for the following analysis.
3.1 Unsatisfactory Evolution of the Coverage rate of Institutional Childbirth in Relation to the Target
In the health sector planning, in the year 2020, the predicted coverage of institutional childbirthwas 89.9%, 1.10% lower than the target (91%) for the present five-year period (2020 – 2024). For the year 2021, the sector estimates to cover 2% below the five-year target and 0.9% below compared to the year 2020. The data show an unsatisfactory evolution of the coverage rate of institutional childbirthin relation to the trend of meeting the target in the operational matrix of the PQG 2020-2024.
For the cervical cancer screening rate, there is a contrary scenario with planned increase in screening of women aged 25 – 54 years; in Family Planning consultation by 1% from 25% in 2020 to 26% in 2021. The sector estimates to cover 4% below the five-year target of 30%.
The forecast of increasing this target by only 1% is quite timid, looking at the impact that this has at the national level, as the Government recognizes that Family Planning is a right by itself, and it is crucial for reducing maternal mortality and empowering women. As it is widely documented, the benefits in this sector include improved health scenario, education, and economic prospects at both the individual and domestic levels.
Chart 1– targets of FYGP 2024 VS ESP 2020 and 2021
The indicators related to the number of children and adults benefiting from antiretroviral treatment (ART) show a satisfactory evolution in absolute terms, but do not allow us to measure the HIV/AIDS infections.
In the year 2020, the plan envisaged benefiting 130,455 children with ART treatment. For the 2021 plan, the number rose to 135,805. According to 2020 data, 2,100,000 people were living with HIV in Mozambique (1,900,000 are adults and 130,000 are children under 15 years of age). This indicator will be satisfactory if the number of new recipients gets greater than the average number of new infections.
Chart 2 – targets of FYGP 2024 VS ESP 2020 and 2021
Within the efforts that the health executive has imposed for training and awareness process of adolescents and young people on matters of Sexual and Reproductive Health, HIV, nutrition, alcohol consumption and other drugs, the planned number of trained activists has grown by 14% from 1,740 to 1,980, while the expected growth of trained activists is far from the number of adolescents and young people that are intended to be sensitized. The target grew by only 4%, from 1.1 million to 1.2 million (see chart 3 below).
This scenario highlights two points: The first is the deficiency in planning and the second is the weak capacity to achieve results, with the addition of human resources for the work to be implemented, associated with a low efficiency and rationalization of existing resources, with particular focus on financial resources.
Chart 3 – Training and Awareness Plan for Adolescents and Youth on SRH, HIV, Nutrition and Drugs
4. ANALYSIS OF FINANCING, MANAGEMENT AND PERFORMANCE
Funding in the health sector in Mozambique is largely dependent on international donors who, historically, have contributed considerably with resources to address HIV.
The Government, on an ongoing basis, allocates funds to address HIV, although much of these resources come from international donors, mainly from the Global Fund in the order of USD 249 million between 2018 and 2020, and PEPFAR in the order of USD 395 million. These two partners’ contributions reach about 92% of HIV expenditure (Chart 4).
Chart 4 – Evolution of HIV Financing (Million USD)
In 2018, government expenditures accounted for USD 9.7 million of costs by programmatic area (not including salaries and benefits to HIV/AIDS service providers, pharmacists, laboratory technicians, and other health professionals), approximately 3% of total HIV expenditure .
Table 1 – HIV Expenditure by programmatic area in 2018
One hundred percent of the ARTs, during the GFATM 2018- 2020 implementation period, were mobilized by donors, mainly by GFATM (74%) and PEPFAR (26%). The country also relies substantially on donors, particularly on U.S. Government for the procurement of other products for the HIV program, such as reagents (viral load and Early Childhood Diagnostics (ECD). Government commitments for the next two years will not significantly change this scenario, exacerbating an existing funding gap (especially for ART) of over US$100 million.
Programmatic decisions, regarding the elimination of new diseases, must prioritize long-term funding (including the domestic contribution) as a priority.
According to the National Plan for the Triple Elimination of the Vertical Transmission of HIV, Syphilis and Hepatitis B in Mozambique 2020-2024, access to prenatal consultations, as well as access to institutional deliveries and other maternal child health indicators are strongly associated with school level, socioeconomic status, and place of residence. From the point of view of targets achieved semi-annually and annually in relation to the FYGP in 2020 and in the first half of 2021, the health sector shows acceptable performance for indicators linked to the coverage rate of institutional childbirth in the order of 98% and 40%, respectively.
However, the reduction of maternal and neonatal mortality was slow, since both are associated with the quality of care in childbirth and postpartum, and it has been identified as the main challenge of maternal and child health services in the country, despite the increase in the number of institutional childbirths.
By 2020, the cervical cancer screening rate reached an achievement of 91% and the number of adolescents and young people sensitized on issues of Sexual Reproductive Health, HIV, nutrition, alcohol and drug consumption reached 101% (table 1). The goals for the first half of 2021 show a less encouraging scenario, looking at the same indicators.
Mozambique is among the countries with the highest number of new HIV infections in children (about 16,000 in 2018 alone), with most infections resulting from vertical transmission, a result of poor use of prevention methods by men and women. According to the latest UNAIDS report, Mozambique is one of the sub-Saharan African countries with the lowest reported condom use. Data from IMASIDA 2015 indicate that only 28% of women, with multiple partners in the previous year, used a condom at last intercourse. Among men, that percentage is even lower (24%).
The goals achieved in relation to the FYGP, in the first half of this year, show that the number of adolescents and young people sensitized on matters of Sexual Reproductive Health, HIV, nutrition, alcohol consumption and drugs had a low achievement of 46%. The same scenario is observed in the plan designed for cervical cancer screening, which reached an accomplishment of 39%.
The health sector does not show a good performance in the efforts that the executive has imposed, both for the training and sensitization of adolescents and young people in matters of Sexual Reproductive Health, HIV, nutrition, detachment from the consumption of alcohol and other drugs. The planned number of trained activists has grown by 14% from 1,740 to 1,980, while the expected growth in trained activists is far from the number of adolescents and young people that are intended to be sensitized.
Chart 5 – Achievement Rate Compared to the FYGP
Some actions presented favorable evolution, especially the coverage rate of institutional childbirth. However, in general, some critical indicators for the health sector were not met. As the current government is three years away from the end of its presidency, the coverage of the number of children receiving ART and the number of cervical cancer screening actions and the number of trained activists should be improved so that the number of adolescents and young people covered by awareness campaigns can grow and reduce the pressure that the national health system has been facing with the increase of HIV cases.
Since one of the main challenges faced by NHS is the poor maintenance of patients on ART and the lack of domestic resources – with seriously inadequate investment in Prevention – Mozambique would first need to increase investment in SRH and HIV prevention and treatment; improve the overall management of HIV+ adolescents and young people at the health facility level; increase viral load testing to monitor response to ART; streamline recommendations and practices that can contribute to HIV treatment maintenance; and finally, rethink the factors underlying the current situation and propose strategies and activities to put the country “on track” for HIV case reduction.
5. CONCLUSIONS AND RECOMMENDATIONS
The resource envelope allocated to the health sector for SRH and HIV in Mozambique dependent heavily on international donors who have historically contributed significantly with resources used in the response to HIV. Thus, it is necessary to highlight that Mozambican executive needs to prioritize the domestic contribution.
Programmatic decisions regarding the control of new diseases must take into account the prioritization of long-term funding (including the domestic contribution) as a priority.
In general, the Health Sector faces challenges in terms of resource allocation and execution. As such, high attention is required from the State in materializing the Goals advocated in the FTGP 2020-2024 and meeting global commitments. The government’s allocation of funds has not risen significantly in the last three years and the discussion on financing the sector with domestic funds has just begun.
The Ministry does not get budget allocation for the activities planned for multi-sectorial response. In other words, the planned activities are not followed with a specific budget line, and it is extremely dependent on international donors.
Taking into account this argumentation, it is recommended that the Government make fair allocations and comply with the Abuja commitment to allocate 15% of the State Budget to improve the health conditions of Mozambicans. Specifically, the additional resources needed could be useful to:
Increase the investment to prevent and treat issues related to SRH and HIV;
Improve the overall management of HIV+ adolescents and young people at the health facility level and increase viral load testing to monitor response to ART;
Amplify recommendations and practices that may affect HIV treatment maintenance;
Rethink the factors underlying the current situation and propose strategies and activities to put the country “on the path” to HIV case elimination;
Increase the number of Community Health Agents and Multipurpose Agents and increase their incentives for better performance;
Hold awareness sessions regarding the importance of screening for MIR in the community (health talks on community radios).
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