This analysis constitutes a result of the Government’s Five-Year Programme 2020-2024 (PQG, abbreviation in Portuguese) monitoring, taking into account the government’s promises in the health sector. This document was produced according to the analysis of the behaviour of the health sector, quoting official implementation reports of the Economic and Social Plan.
The great finding in this approach dwells in the following argument: some critical indicators of the health sector were not met and, as a result, it has been possible to assess that these results are partly linked to the fact that the health sector is operating with a budget deficit of 6.3%, as well as because it is operating with 8.7% of total public expenditure, equivalent to about 19.2 billion meticais. However, the deficit would be eliminated if the government was committed to the allocation of 15% of the State Budget, which coincides with the Abuja Declaration, of which Mozambique is a signatory. In addition, it was found that there is no compatibility between the targets established in the PQG (2020-2024), indicators foreseen in the Economic and Social Plans (PES, abbreviation in Portuguese) and PES Balance Sheets (BdPES, abbreviation in Portuguese) within the same period – which makes monitoring and evaluation an unfeasible process.
This document is a contribution of the Citizen Health Observatory (OCS) in the debate on public expenditure in the health sector. This document explores the performance of the health sector with regard to the main indicators and measures of quality of services in this sector, in response to the goals of the Strategic Plan of the Health Sector (PESS, abbreviation in Portuguese), taking into account the level of resources applied over the last few years, with emphasis on 2020, taking as reference the goals of the PQG. With this analysis, we intend to answer the following question:
• How much money does the government need to meet the promises listed in its Five-Year Plan?
Access to qualitative health services has always been the main need of Mozambican population, since it is one of the factors for the improvement of lives and generation of internal income. In Mozambique, health services are mostly provided by the public sector, and it is the responsibility of the Ministry of Health (MISAU, abbreviation in Portuguese) to create, as well as to plan, to coordinate and control national health policies.
In terms of budget allocation, data from the General State Account (GCE) show that in 2020 there was an increase in allocated resources of about 1.4% (8 billion meticais), compared to the 2019. Between 2010 and 2020, there was an average nominal growth of 16.9% of the health budget. The amount allocated to this sector was in the order of 8.7%, representing, on average, 3.1% of GDP over the period under analysis. However, the increase of resources has not always been associated to the improvement of the service’s quality.
According to the Statistical Yearbooks by the National Institute Statistics (INE, abbreviation in Portuguese), the average distance that the inhabitants travel to have access to health treatment went from 12.3 km in 2019 to 12.1 km in 2020. In other words, there was only an average reduction of 0.2 km, which means that efforts should be made to increase investment expenditure, in order to ensure the proximity of health services to the population. This can only be done by increasing investment, a component of health expenditure with lower budgetary implementation, according to its dependence on external donors, resulting from the limited capacity of domestic revenues that are consumed by operating expenditure
Regarding external dependence of the sector, it is possible to see that the budgetary analysis between 2010-2014, when MISAU was headed by Alexandre Manguele, had significant contribution of donors. The health budget was supported with about half of the internal resources and the other half was supported by external resources. In the following years, from 2015 to 2019, when MISAU was headed by Nazira Abdul, the sector was largely supported by domestic resources, at more than 80%. Currently, MISAU is headed by Armindo Tiago, and domestic resources continue to make a greater contribution to the sector’s expenditure, in the order of 79%.
As mentioned above, the trend of growth of domestic resources, in order to finance expenditure in the health sector, aims to prioritize the operating expenditure to the detriment of investment expenditure, which would allow the expansion of the health system, especially at the primary level, as well as at rural and periurban levels, ensuring its equipping (minimum health team, basic equipment, medicines and essential surgical material, water and energy), thus reducing the average distance that the inhabitants travel to have access to the health units, in a context that this indicator has not been registering significant changes in recent years.
It should be noted that the average distance that the inhabitants travel to have access to the health unit reflects the dynamics of the most important indicators, with regard to the universal coverage of health services (medical ratio per inhabitant; health professional per inhabitant; health unit per inhabitant, among others).Therefore, the poor performance of this indicator reveals the generalized inability of the National Health System (SNS) to respond to the growing population, conditioned by demographic evolution. In this context, it is worth remembering that Mozambique has one of the highest rates of population growth in the world, at about 2.6% on average.
The Government has failed to meet the PES goals for the health sector in 2020
The PES Balance Sheet (BdPES) for the health sector is a government document that should respond deeply to the issues of monitoring and qualitative evaluation of the implementation of public policies in this sector. In addition, this document makes it possible to know the circumstances of the government’s priorities in the process of PQG targets achievement.
The priority of the PQG (2020-2024), in the context of the Development of Human and Social Capital, the following actions are defined for the health sector: expanding access and improving the quality of the health service; reduce maternal and child mortality; reduce morbidity and mortality from chronic malnutrition, malaria, tuberculosis, HIV, non- infectious diseases and preventable diseases.
In 2020, the Government intended to reach the target of 89.9% of institutional childbirth, 4% below the target set in PQG 2020-2024. In the case of coverage of children under 5 years old fully vaccinated, the government intended to reach the target of 95%, 1% below of what is established in the PQG. Concerning to the number of children receiving Antiretroviral Treatment, the target was 130,000 children out of the 141,000 expected in PQG 2020-2024.
The PQG does not foresee the indicator “Number of professionals allocated to the Health System”, but, on the other hand, it foresees an unusual ratio in planning, represented by the density ratio of professionals with a special national health system, as well as foreigners per 100,000 inhabitants of 118, 30% below the target anticipated in the PQG 2020 – 2024.
Table 1 – PES Health Indicators 2020-2024
Comparing with the commitments made in the PQG 2020-2024, which appear on page 07 of resolution number 15/2020 approving the PQG of the 15 indicators of the PQG, in the balance sheet report, 04 highlighted indicators can be extracted in the execution of the actions planned for the health sector.
From the analysis, it can be seen that the BdPES does not present all the indicators according to PQG. It can be seen in the same document that the establishment of goals has been annual, without any basis for comparison that makes reference to the PQG.
However, in general, some critical indicators for the health sector were not met. One is the No. of children receiving Antiretroviral Treatment. For this indicator, the 2020 data point to a very low level of achievement corresponding to 62% of what was programmed. The failure to meet this target has been obvious since 2013.
Chart 1 – No. of children receiving Antiretroviral
For the indicator ratio of density of national and foreign special health professionals per 100,000 inhabitants, the level of achievement is around 93%. As a result, the country, in 2020, was able to train and hire a considerable number of health professionals, but 7% below the plan. Raising the level of training and hiring health professionals can significantly contribute to the quality of services provided to citizens, improving the quality of human capital in the country.
Chart 2 – Indicator of health professionals allocated to the Health System
Source: OCS based on 2011-2020 BdPES
Some actions represented a positive evolution, namely: the coverage rate of institutional childbirth and child vaccination.
Looking at the goals set in the PQG 2020-2024, three years before the end of the term office, the current government has yet to meet the commitment regarding the coverage of the number of children receiving antiretroviral. The government has also to improve the ratio of health professionals per inhabitant. Looking at the effort of the previous years, in terms of achievement, what would be the possibility of meeting the goals?
In order for the government to meet the targets set in the indicators it spent, on average, 8.7% (19.2 billion meticais) of the total expenditure, which means that the health sector operated with a deficit of about 6.3% of the required expenditure, corresponding to 20.9 billion meticais in 2020. Therefore, we believe that the government should have spent at least 15%, corresponding to 53.1 billion meticais of the total expenditure in 2020, ensuring compliance of the planned goals until the end of its mandate in 2024.
Table 2 – PQG indicators in the health sector 2020-2024
This analysis was performed as part of the monitoring of the goals of the PQG 2020 – 2024, focusing on the first year of implementation, 2020. This report on the performance of the health sector was carried out through the use of the 2020-2024 PQG, BdPES from several years, resolutions, official statistics, among other reports.
Observing the unsatisfactory evolution of the health sector indicators, especially the average distance travelled by the population to reach the health units, we defend the continuous need for greater efforts to improve the National Health System.
The minimums required in the Abuja declaration recommend the allocation of at least 15% of the state budgets for health development. However, Mozambique has never reached this goal, having reached only half of it, in 8.7%. Evidently, this situation justifies the weak response capacity of the sector, in a context in which the social needs of health services are increasing, due to the high demographic growth rate, according to the PES balance in the last years, including 2020.
There is a weak link between the targets set in the PQG (2020 – 2024) and the indicators provided in the Economic and Social Plans (PES) and the PES Balance Sheets (BdPES) of the same period, which makes it difficult to monitor compliance of the implementation of the goals. In general, some critical indicators for the health sector were not met.
For the government to meet the internationally acceptable minimum conditions in the health sector, it would need to spend at least 113 billion meticais, corresponding to 32% of the total expenditure, the triple of 2020 expenditures.
There are factors related to the Government’s planning instruments that do not allow an effective assessment of the achievement of the targets. On the one hand, the CGE reports only the budgetary-financial component, and on the other, the last published PQG balance report (the PES 2020 Balance Sheet) is a document of intentions, without resource envelope.