In Mozambique, the health sector comprises a set of institutions that are part of the Ministry of Health (MISAU) and are subordinate to it, but with their own allocations within the State Budget (SB).
Currently, the sector consists of 184 Beneficiary Management Units (UGBs), among which:
- The MOH that leads at the national level;
- 11 DPS that coordinate the sector at provincial level and
- 151 SDSMAS that coordinate the sector at district level;
The following institutions are also part of the health sector: the National Institute of Health (INS); the Central for Medicines and Medical Goods (CMAM); 4 Central Hospitals; 8 Provincial Hospitals; 5 General Hospitals; 1 Psychiatric Hospital and 1 District Hospital.
|Graph 1: Health Sector External Resources|
|Source: REO MISAU 1st Quarter 2021|
In the health sector, as well as in the other economic and social sectors, the resources available to respond to the growing needs of the population, to benefit from the goods and services that the State provides, are limited. As such, funding for the sector in general and hospitals in particular has raised crucial concerns.
In Mozambique, the health sector is financed through internal and external funds. Internal funds come from taxes, fees, duties and internal credit. For their part, external funds come from external donations and credits.
For the 2021 financial year, external resources include, specifically, External Donations for Medicines, with an allocation of 2.9 billion Meticais, which represent 28% of total External Resources. Vertical Funds have an allocation of 7.2 billion Meticais and represent 69%. External Credits with an Endowment of 0.25 billion Meticais, corresponding to 3% of the total External Resources, as shown in Graph 1.
Source of Health Sector Resources from 2011 to 2021
Health sector budget is far from achieving a balance between internal and external resources.
The Budget Execution Report (BER), of the Health sector, corresponding to 2021 first quarter shows that the mobilised resources reached the threshold of 40.1 billion Meticais, with 29.7 billion Meticais (74% of the total allocation) corresponding to internal resources and 10.3 billion Meticais (26% of the Endowment) comprising external resources.
The composition of this budget constitutes a major departure from the trend in the last decade, during which the structure was 60% and 40% of internal and external resources, respectively (see Graph 2 below).
|Graph 2: Source of health sector resources (in billion MZN and in%)|
|Source: BER MISAU 2018 – 2020, BER MISAU 2021 1st Quarter|
It is important to emphasise that the amount of internal resources and their weight in the total resources forcast for the health sector, in 2021, are the highest ever.
Far from the budget meaning an emergency in the balance between internal and external resources, the proportions for 2021 result from the significant reduction in external resources allocated to the sector in relation to the previous year. Indeed, while domestic resources saw a nominal increase of 16%, external resources saw a nominal reduction of 63%.
Health sector common fund (ProSaúde)
Donor commitments to support the ProSaúde Common Fund correspond to about 27% of the average of the last ten years
Total donor commitments to support the ProSaúde Common Fund amount to USD 15.2 million in 2021 (Graph 4). This amount corresponds to about 27% of the average of the last ten years (USD 55.5 million) and constitutes, together with the amount of 2020 (USD 14.7 million), the lowest nominal value, feeding the sector’s revenues.
The commitment for the current year represents a nominal growth of 3% in relation to the amount budgeted and executed in 2020.
Graph 3: ProSaúde Common Fund (in millions of USD)
Source: BER MISAU 2015-2020, BER MISAU 2021 1st Quarter
The proportion of donor funding has been volatile and has followed a downward trend in recent years, from USD 76.8 million (in 2011) to just USD 15.2 million (in 2021). This time around, this trend is reflected in a significant decline in foreign investment expenditure.
The ProSaúde common fund is being replaced, in part, by a new programme based on the performance of the World Bank, financed by the International Development Association (IDA); and the Global Financing Facility Trust Fund – a multi-donor trust fund for the sector in general and, in particular, for project support. The total of own revenues, reported by the Health sector, increased the annual average of about 453 million meticais (MZN) in the last 10 years. Over that period, revenues corresponded to an average of 1.2% of the budget available for the sector.
The institutions that have contributed to the revenues are: the Maputo Central Hospital (HCM), the Central of Medicines and Medical Goods (CMAM), the Regional Centre for Health Development (CRDS) and the Institute of Health Sciences (ISCISA ). However, among these institutions, only the HCM has reported collected revenues and has consistently contributed an average of about 91% of reported revenues (Graph 5).
Graph 4: Health Sector Revenues (in millions of MZN)
Source: CGE 2011-2020, BER MISAU 2021 1st Quarter
With regards to the HCM, the revenues collected over the last decade have risen to an annual average of MZN 351 million. The Special Clinic (sale of medicines) and the Special Assistance services constitute the main sources of own revenues, with an annual average contribution, in recent years, of MZN 226 million, 44.3 million MZN and 35.5 million MZN, respectively.
Graph 6: Maputo Central Hospital Revenues
Source: CGE 2011 a 2020
Health sector expenditures do not normally include financing outside the budget – which is typically high, between a quarter and a third of total sector spending. There is a consistent mismatch between budget allocations and real expenditure. They are mainly due to the difficulty of tracking donor external resources, a substantial part outside the Single Treasury Account (CUT) and even external to the budget.
Internal investment is increasingly supporting the construction of care units and the realisation of other essential expenditures, such as, for example, medicines, since external resources coming from ProSaúde and other sources, are decreasing. However, the lack of transparency in the National Health System is greatly felt, thus the need to strengthen governance, as well as accountability in the use of public resources so that the services provided are more comprehensive and robust.