- Introduction
Discussions around the performance of the health sector in Mozambique have been increasingly intense, as demographic growth is continuously recorded, which in part puts pressure on the National Health System. Several issues have been raised in the design of hospitals and health centers, taking into account 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 highlighting the chapter dedicated to the financing of the health sector, since, in all phases and cycles of the development of the National Health System, it has always deserved relevance and has accompanied the frequent circumstantial and structural variations of the sector.
The health sector is largely financed by the external sector, both for investment expenditure and for some expenditure on current goods and services. It depends 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. Therefore, there is a need to promote a rational and sustainable use of resources from these sources of funding, at the risk of becoming a burden on the sustainability of their service in the case of public debt and loss of confidence of partners, in the case of donations.
This paper presents findings from an analysis of the extent to which the health sector is performing in the provision of sexual and reproductive health (SRH) services. To this end, the research presents the trend of the sector’s expenditure over time in comparison with international commitments, inflation, demographic developments and shows the effects of these trends on selected health indicators.
- MOZAMBIQUE’S CONTEXT
Low access to health services: From 2014/15 to 2019/20, while overall access to health services increased by about 1.9pp, access to health services in rural areas, where about 67% of the population lives, decreased by 9pp, i.e. from 64.4% to 55.4%. On the other hand, in the urban area, access to health services increased from 76.7% in 2014/15 to 97.9% in 2019/20. This scenario demonstrates the disproportionality of access to health care in Mozambique between urban and rural areas, with rural areas suffering.
Figure 1: Access to healthcare total and by area of residence (2014/15 to 2019/20)
Source: IOF (2014/15 and 2019/20)
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 account for about 95% of the National Health System (SNS) workforce. In other words, the SNS has a low number of qualified staff, where doctors account for only about 5% of this staff.
Graph 2: Comparison of the Ratio of Health Professionals/ 100 000 inhab. in Mozambique in relation to WHO
Source: Ministry of Health (2018 to 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/1000 inhabitants recommended by the WHO to meet the population’s hospitalization needs.
Climate change: Over the past three decades, the country has been affected by extreme weather events such as droughts, floods and cyclones (PDNA, 2019). These events have contributed to deteriorating Mozambique’s already poor health system. For example, Cyclones Idai and Kenneth together were the most devastating natural disasters in the country’s recent history, both in terms of human and physical impacts (see Table 1) and in terms of the geographical extent of affected areas. For example, Cyclone Idai affected 51 districts in four (5) provinces, namely Sofala, Manica, Zambezia, Tete and Inhambane.
Table 1: Physical and Human Damage from Cyclones Idai and Kenneth
| Human Damage | Physical Damage | |||
Description | Total | Description | Total | |
| People Affected | 2.5 million | Number of Houses Destroyed | 223,947 | |
| Displaced People | 160.9 mil | Damaged Health Centers | 93 | |
| Number of Deaths | 603 | Damaged Classrooms | 3.504 | |
| Number of Injured People | 1641 | Crops Destroyed | 715,378 ha | |
Source: Author’s adaptations based on UNICEF (2019).
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, although the national in-hospital maternal mortality ratio is within the WHO recommended 80/100,000 LB, Maputo City has a ratio almost twice as high as the WHO recommended 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 are 28.5, which is above the global average of 18/1000 live births. Likewise, Mozambique has alarming HIV indicators, with the country being part of the 30 fast track countries with 13.2% prevalence. As a result, an average of more than 120,000 cases of new infections are reported each year.
Public Finance: Although the country has committed to allocate at least 15 per cent of its budget to the health sector, over the last 10 years (2013 to 2022), it has allocated on average only 8.9 per cent. 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.
Main Findings
Balance of Health Sector Budget vs Sector Commitments
From the point of view of the amount allocated, from 2010 to 2022, the Government never allocated the 15% of the State Budget to the health sector. In fact, in the period under review, the Government allocated an average of 9% of the State Budget to health, and in the last 5 years (2018 to 2022) this average is even lower, 8.5%. The peak weight of budget allocations to the health sector in the period under review was recorded in 2013 with 11.5%.
From the point of view of executed expenditure, in general, the execution weight is relatively lower than the allocation weight, with emphasis on the years between 2016 and 2019, meaning that in addition to the budget allocation intentions (average of 9% from 2010 to 2022) being below the Abuja Declaration (15%), the average weight of expenditure actually spent in the health sector is 8.7%.
The negative difference in the share of expenditure executed compared with the share initially planned means that, if the availability of resources planned for a given year is reduced, the health sector’s budget allocation is one of those sacrificed, just as, if total public expenditure increases, the health sector is one of those that benefits least.
Chart 3: Health Sector Weight vs Abuja Declaration (2010 to 2021)
Source: Authors’ calculations based on GCE (2018 to 2021), PESOE (2023) and WHO (2010).
Budget Allocated to Health Sector vs Population Growth (2010 to 2022)
According to the MDG/ODS, each country should apply USD 60.00 per capita to ensure access to health services for all. Chart 4 indicates that from 2010 to 2022, Mozambique did not reach even half of the MDG recommended amount (USD 60.00), peaking in 2013, where it allocated USD 28.69 per capita. Likewise, per capita health sector expenditure in Mozambique is below the Africa average of USD 32.00. This means that health expenditure is not keeping pace with the population growth trend, which may jeopardize the improvement in the provision of SRH and HIV/AIDS goods and services, for example.
Graph 4: Health Sector Expenditure (in US$ per capita)
Comparison of plan and expenditure execution
Table 2 shows that from 2010 to 2022, the government implemented on average 87% of the Health Sector expenditure. The lowest and highest execution were in 2017 and 2022 at 77 per cent and 92 per cent respectively. The low execution, coupled with the fact that the allocated budget (9%) is below the Abuja Declaration (15%) jeopardizes the objective of progressively improving the services provided by the SNS in the long term.
Table 2: Comparison between Plan and Realization of Health Sector Expenditure (2018 to 2022) MZN Billion
| Description | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | 2021 | 2022 |
| Plan | 10,2 | 10,7 | 17,3 | 22,7 | 18,9 | 20,3 | 25,2 | 23,4 | 27,4 | 26,1 | 34,8 | 34,3 | 43,3 |
| Execution | 8,1 | 9,4 | 15,6 | 20,9 | 17,3 | 18,3 | 19,5 | 18,8 | 23,1 | 22,7 | 32,2 | 30,8 | 39,9 |
| Execution | 79% | 88% | 90% | 92% | 91% | 90% | 77% | 80% | 84% | 87% | 92% | 90% | 92% |
Source: Author’s calculations based on CGE (2010 to 2021) and BdPESOE (2022).
Effects of health sector expenditure execution on sexual and reproductive health (SRH)
While HIV expenditure realization increased almost threefold from 2019 to 2020, from USD 64.3 million to USD 173.4 million respectively, there was a downward trend in both nominal and real terms in the later years, 2021 and 2022. In fact, the realization of actual HIV expenditure in 2022 represents a reduction of more than half of the 2020 expenditure. This reduction contrasts with the fact that Mozambique presents alarming HIV indicators.
Graph 5: Evolution of HIV Expenditure Realization (2019 to 2022) in USD Millions
Source: Authors’ adaptations based on the FSB (2019 to 2020).
Comparison of expenditure plan and execution
Although the realization of SRH expenditure has increased in real terms from USD 5.0 million in 2019 to USD 112.9 million in 2020 overall. This increase has not been constant over the years. For example, from 2020 to 2021, there was a reduction from USD 11.9 Million to USD 7.0 Million, i.e. a reduction of USD 4.9 Million. This scenario affects the capacity to provide SRH goods and services over time.
Graph 6: Evolution of SRH Expenditure Realization (2019 to 2022) in USD Millions
Source: Authors’ adaptations based on REO (2019 to 2020).
Achievement of SRH Targets Achievement of SRH Targets
Coverage of new users in family planning consultations. From 2019 to 2021, there was a reduction in the coverage of family planning consultations from 41% to 32% at national level, respectively.
Institutional Deliveries Coverage. The coverage of institutional deliveries remained unchanged between 2019 and 2020, at 85%.
Number of Maternal Deaths and Maternal Mortality Ratio (MMR). From 2019 to 2021, the number of maternal deaths decreased from 861 to 801 respectively. Likewise, the MMR per 100,000 inhab. reduced from 77 to 65.6 in the same period, respectively. Compared to WHO international standards (80/100,000 Live Births), at the national level, Mozambique’s situation is not worrying. However, when disaggregated by province, Maputo City has a ratio almost twice as high as the WHO recommended 145/100,000 LB.
Coverage rate of HIV+ children receiving ART
Coverage rate of HIV+ children receiving ART increased by 28pp from 2019 to 2022.
Similarly, the Coverage Rate of HIV+ Adults receiving ART has seen an increase of 33pp, i.e. from 66% in 2019 to 94% in 2022. However, it is important to highlight that there is a provincial disproportionality regarding the evolution of the coverage rate of HIV+ receiving ART. In fact, according to the statistical yearbook, from 2019 to 2021, on average, only 4 of the 11 provinces reached 100% of the targets for this indicator. Prevention of mother-to-child transmission (PMTCT) of HIV+ pregnant women. There was a slight progress of 1,458 from 2019 to 2021.
Table 3: Evolution of SRH Indicators (2019 to 2022)
| Indicators | 2019 | 2020 | 2021 | 2022 | Varies. |
| Coverage of new clients in family planning consultations | 41% | 32% | 32% | N/A | -9% |
| Coverage of Institutional Births | 85% | 85% | 89% | 85% | 0% |
| Number of Maternal Deaths | 861 | 858 | 801 | N/A | -60 |
| Maternal Mortality Ratio /100,000 LB | 77 | 75 | 65,6 | N/A | -11,4 |
| Coverage rate of HIV+ adults who received ART | 59% | 69% | 81% | 92% | 33% |
| Coverage rate of HIV+ children receiving ART | 66% | 64% | 79% | 94% | 28% |
| Prevention of Vertical Transmission (PMTCT) of HIV+ pregnant women | 112.282 | 107.533 | 113.740 | N/A | 1.458 |
Source: Authors’ adaptations based on BdPES (2019 to 2022).
- Improve the prioritization of the health sector to at least 15%, in line with the Abuja Commitment. The health sector can capture resources in other fiscal spaces (car insurance, harmful products, etc.) that create uncompensated costs to the public sector health system.
- Ensure that the health sector budget is at least maintained at the level initially foreseen.
- Increase health sector resources in line with population growth trends and the parameters necessary to ensure access to health services for all.
- Ensure the effective realization of health sector expenditure, at least in the terms established in the State Budget.
- Improve the allocation funds for expenditure investment on HIV prevention and treatment actions in Mozambique.
- Improve the allocation of realization of expenditure on SRH-related actions in Mozambique. Early action on prevention (e.g. sexual education for young people) can save large resources that would otherwise be allocated to treating new HIV/AIDS cases.
- Strengthen the coverage of new users in family planning consultations in all provinces, with emphasis on Maputo City and Sofala and Nampula Provinces.
- Accelerate efforts for the coverage of institutional deliveries in order to reach the PQG target of 96%.
- Improve actions to combat Maternal Mortality, with emphasis on Maputo City, Gaza and Sofala provinces, which are above the WHO recommended MMR.
- Ensure access to ART in all provinces of the country.
- Continue to develop PMTCT actions for HIV+ pregnant women.
Read the full report here:https://www.observatoriodesaude.org/download/analise-do-balanco-do-plano-economico-e-social-na-componente-da-saude-sexual-e-reprodutiva-dos-adolescentes-em-mocambique-2010-2022/