Introduction
The Health Sector in Mozambique presents chronic challenges that include, among others, low access to and quality of health services due to insufficient infrastructure, poorly equipped (equipment and materials), lack of qualified human resources and inefficient public financial management. In fact, according to the IOF 2019/20, about 45% of the population in rural areas (where about 67% of the population lives) does not have access to health services.
In summary, the following indicators provide a snapshot of the challenges of the National Health System (NHS): i) a ratio of 17,419 inhabitants/health unit, i.e., 7,419 inhabitants more than recommended by the WHO, ii) the current ratio of 0.7 beds/1000 inhabitants (inhab.) is about 3 times lower than that recommended by the World Health Organization (WHO). iii) about 95% of health professionals are composed of health technicians and nurses and only 5% are physicians. The ratio of health professionals per 1000 inhabitants (1.7 health professionals/1000 inhabitants) is below that recommended by the WHO to ensure primary health care coverage for the population (Annual Report on the Health Sector Balance, 2021).
Based on this scenario, the discussion and relevance of the performance of the health sector in Mozambique have been increasingly intense, as there is demographic growth, which in part puts pressure on the national health system. 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.
This document presents findings resulting from the analysis of the Proposal for the Economic and Social Plan 2024 with a view to assessing the level of inclusion of adolescent sexual and reproductive health services, taking into account the investment case and the Government’s Five-Year Programme 2019 – 2024. To this end, the survey presents the degree of achievement in the provision of Sexual and Reproductive Health Services and shows the effects of this achievement on the achievement of the main goals of the Government’s Five-Year Program 2020-2024.
- FINDINGS
- 1. Evolution of the Main Health Indicators (2022 to 2023):
- or number of institutional deliveries. From 2023 to 2024, the target for this indication increased by 0.4pp. That is, from 1,327,589 institutional births in 2023 to 1,361,359 in 2024, an increase of 33,770 institutional births. Notwithstanding the increase in institutional birth coverage targets to 91% in 2024, the targets for the provinces of Tete (87%), Maputo Province (63%) and Maputo City (70%) have coverage below the national average.
- Number of children fully vaccinated. The target for this indicator changed positively by 3.1% between 2023 and 2024, i.e., it increased from 1,060,171 in 2023 to 1,093,139 in 2024.
- Number of adults living with HIV on ART. Between 2023 and 2024, the target for this indicator increased from 1,774,804 in 2023 to 2,100,353 in 2024, an increase of approximately 18.3%.
- Number of children living with HIV on ART. The target for this indicator remained unchanged between 2023 and 2024.
- It is noteworthy that the PESOE 2024 proposal does not present some indicators foreseen in 2023, such as the % of children with acute malnutrition cured, the number of children living with HIV on ART, the number of people tested HIV+, the % of pregnant women on ART and the number of patients reintegrated.
- There is a lack of consistency in the balance sheet documents, this scenario raises great concerns, as it compromises transparency in the public financial management process and raises questions about the real scenario of provision of these services to the populations in Mozambique.
Table 1: Evolution of key health indicators (2023 to 2024)
Source: Authors’ adaptations based on PESOE (2023) and PESOE’s proposal (2024)
- 2. Link of Health Indicators with Investment Case
- Most of the indicators of the Investment Case (IC) are not reflected in the PESOE 2024 proposal. Of the 24 IC indicators, only 2 are reflected in the PESOE 2024 proposal, namely, the coverage rate of institutional births and the % of children fully vaccinated.
- The targets for the coverage rate of institutional births and the % of fully vaccinated children of the PESOE 2024 proposal are above the IC 2021-2022 targets, 91% and 96% compared to 80% and 10-15%, respectively.
Table 2: Alignment of the indicators of the PESOE 2024 Proposal with the IC goals (2021-2023)
| Indicator | PESOE 2024 Proposed Target | CI Target 2021-2022 |
| Coverage rate of institutional births | 91% | 80% |
| % of children fully vaccinated | 96% | 10%-15% |
Source: Authors’ adaptations based on Mozambique IC Annexes and PESOE (2023)
- The fact that important IC indicators are not reflected in the PESOE 2024 proposal compromises the public financial management process, as it becomes ineffective to monitor the developments associated with the respective indicators, which may culminate in the poor quality of the provision of health services at the community level.
- 3. Health Sector Budget Prioritization Trend
- According to African Arguments, by 2011, ten years after the declaration, 27 African countries had increased the share of the health sector in relation to total expenditure. However, only two countries, Rwanda and South Africa, had reached the 15% target, but seven countries had gone in the opposite direction, reducing the burden of health budget allocations. By 2016, the situation had deteriorated, with 19 African countries spending less on health relative to total spending than in the early 2000s, before the Abuja Declaration.
- As can be seen in Graph 4, the level of prioritization of the health sector in the State Budget from 2022 to 2024 is below the 15% commitment made by the Government of Mozambique (representing an annual average of 8.4%), with 2023 being the period in which the lowest allocation (7.6%) of the series was verified, which corresponds to almost half of the 15% assumed. For the 2024 financial year, the Government foresees a budget allocation of 8.5%, which corresponds to a growth of around 0.9pp compared to 2023.
- The expenditure allocated to the sector in the last 2 years represents, on average, almost half of the 15% assumed.
Graph 4: Weight of Health Sector Expenditure Allocated vs Abuja Commitment (2022 to 2024)
Source: BdPESOE (2022), PESOE (2023) and PESOE Proposal (2024)
- 4. Analysis of the Possibility of Meeting the Targets Defined for 2023 within the Scope of Compliance with the 2020-2024 PQG, with a focus on the indicators of sexual and reproductive health of young people and adolescents
- Regarding the percentage of fully vaccinated children, the baseline scenario was 94% in 2019, and the target set by the PQG for 2024 is to increase it to 96%. However, analysing the trajectory, it is noted that, from 2019 to 2020, this indicator reduced by 3pp, that is, the percentage of fully vaccinated children was 91% in 2020. The following year, in 2021, there was an increase to 92%. However, in 2022 the indicator evolved negatively, i.e., it decreased to 84%. By the third quarter of 2023, the degree of achievement for this indicator was 71.1%, which is 24.9pp away from the target (96%). For the rest, the scenario is heading towards greater pressure in 2024.
- Regarding the percentage of institutional births, there is a significant increase compared to the baseline scenario, from 87% in 2019 to 91% in 2022. However, it is worth noting that the degree of achievement of this indicator in the first half of 2023 was 74%, which represents a difference of 17pp in relation to the target (91%). It should also be noted that the published data on the level of achievement until the III Quarter of 2023 (695.3%) are doubtful since they even exceed the target set in PESOE 2023 (90.6%), which ends up compromising the monitoring of the dynamics of the indicator itself, in particular, and the activities of the Government, as a whole. Finally, the health sector expects that the target of the percentage of institutional births (91%) will be reached in 2024, as stated in the PESOE 2024 proposal (91%).
- For the number of children benefiting from ART, the baseline scenario was 95,080 children in 2019, this number reduced to 80 thousand children in 2020, having increased to 99 thousand in 2021. Although the target of 141,153 was reached in 2022 and the degree of achievement was 117,499, by the third quarter of 2023, data on this indicator are not reflected in the PESOE 2024 proposal.
Table 3: PESOE targets in relation to PQG, with a focus on SRH indicators for young people and adolescents
Source: Authors’ adaptations based on the Statistical Health Yearbook (2020-2021), PESOE (2023) PQG (2020-2024)
2. RECOMMENDATIONS
- Improve the distribution of the annual targets of the progress of the indicators towards the achievement of the FPG targets, reducing the burden of the progress of the indicators in the last 2 years (2023 and 2024);
- Maintain consistency in the planning and allocation of resources with the goals and commitments assumed by the country, specifically the Abuja Declaration;
- Continue with the Integrated Planning Meeting of the Ministry of Health and Partners with a view to reducing the discrepancies in indicators between provinces;
- It is necessary to ensure the consistency of planning, to ensure the continuous monitoring of sexual and reproductive health indicators, especially in those whose demand increases due to the pressure of population growth;
- Reflect in the planning the relevant SRH indicators to better monitor the efforts and progress of these indicators towards the achievement of the recommended targets;
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