INFLUENCE OF GHIs ON MOZAMBIQUE HEALTH SYSTEM

GHIs in AFRICA funded by the EU 6th frameworkINCO-DEV program. INCO contract no. 032371

COHRED Forum 2012 – Capetown By: Baltazar Chilundo (MD, PhD)

Tavares Madede (MD, Research fellow)

DEPARTMENT OF COMMUNITY HEALTH, FACULTY OF MEDICINE, EDUARDO MONDLANE UNIVERSITY

BackgroundParameters Value

Total Population (in million – projection based on 2007 census) 23.7

Children (population below 19 years of age) (in million – projection based on 2007 census)

12.3

People living below the poverty line (%) (Mozambique MDG report, 2010)

54%

Under five mortality rate/1,000 live births (MICS 2008) 138

Maternal mortality ration/100,000 live births (2007 Census) 597

HIV prevalence rate among pregnant women (INSIDA, 2009) 11.5%

Malaria parasitaemia among children under five (MIS, 07) 38.5%

TB prevalence rate/100,000 people (WHO, 2008) 504

Proportion of aid by external partners in 2008 (MISAU, 2008) 73%

Research Questions• What are the GHIs operating in Mozambique?• What are the current implications of selected GHIs on

health systems strengthening at both national and sub-national (provincial and district) levels?– Has funding/spending increased for the health systems due

to GHIs?– Has the availability of services increased due to GHIs?– What has been the influence of GHIs on infrastructures?– How have GHIs affected health workers availability and

performance in the public health sector, particularly at the facility level?

– What is the contribution of GHIs to aid effectiveness?– What is the influence of GHIs on equity, HMIS and M&E?

Research Methods• Qualitative at the national level (2008 - 2010)

– Documents review– 22 interviews with key informants (MISAU authorities

and managers, partners’ representatives, NGOs…) • Qualitative and quantitative at the Sub-national

level (2010 - 2011)– Secondary data and 66 interviews to provincial,

district and health unit authorities and NGO representatives

• Nampula (Nampula & Nacala-porto) - Northern• Zambézia (Mocuba & Quelimane) - Central• Gaza (Xai-Xai & Chókwe) - Southern

What are the GHIs operating in Mozambique?

Ma la r ia

T ube rcu lo sis

HIV/AID S

Vaccina tion

US Pre siden t’s Ma la r ia In itia tive

G F AT M

Mu ltiC oun try AID S Prog ramme (W B)

C a ta ly tic In itia tive

Hea lth Prob lems/Issues G HIs

Stop T B In itia tive

T rea tmen t Acce le ra tio n Prog ra mme (W B)

US PEPF AR

Bill and Me linda G a tes F oun da tionMa te rn a l and C h ild Hea lth

C lin ton F ound a tion

Hea lth Syste msstre ng then in g

G AVI

R 2 & 7

R 2 , 6 & 9

R 8

R ED

R ED

PEPF AR II

M I S A U C O M M O N F U N D

( R 6 & 7 )V ert ical fu n d (R 8 & 9 )W o r ld Vis io n

( m alár ia )

N G O s F BO s C BO sN A T IO N A L

H E A L T HS Y S T E M

CBO s

P r in c ip a l R ec iep ien ts

S ec o n d ar y s ec to r s in v o lv ed

G F A T M S u pport C ha nnel

CCM led by the governm ent, UN fam ily and civil socie tyM oved from Com m on funds to ve rtica l m echan ism s bu t re flected on ly a t the na tiona l leve l

F D C ( HI V)Civ

il Soci

etyPrev ention and

logis tic s s upport tothe N HS (from R 9)

Prophy lax is,care & trea tment

and H SS

US G o v er n m en t,D ep ar tm en t o f S ta te

HHS /C D C US AI D US G AG E N C I E S

M I S AU F HI J HU e.g . o f S O M E P R I M EP AR T N E R S

N G O s F BO s C BO sN A T IO N A L

H E A L T HS Y S T E M

I C AP

P E P F A R S u pport C ha nnel

e .g . o f S O M E S UB-P AR T N E R S

M in istry o f Hea lth m a in ly seen as im p lem enting partner a t the sam e leve l as CBO s/ NG O s O ff-budget, ve rtica l support re flected on the g round

E G P AF

Has funding/spending increased for the health systems due to GHIs?

Decrease of both State budget and

vertical funds

Maj

ority

of

verti

cal f

unds

av

aila

ble

for H

IV

& A

IDS,

TB

and

Mal

aria

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Government budget

70 82 96 105 104 108 127 138 126.04813306177

9

149.65193482688

4

133.03672776646

3

Common Funds

17 20 37 63 106 99 125 74 79.416123557365

9

86.234012219959

3

90.172674813306

2

Vertical Funds

75 75 75 85 130 141 150 300 202.87786829599

5

205.37260692464

4

189.22257298031

2

Total Expenditure

162 177 208 253 340 348 402 512 408.34212491513

9

441.25855397148

7

412.43197556008

1

5%

15%

25%

35%

45%

55%

65%

75%

85%

95%

50

150

250

350

450

550

Health expenditure 2001 - 2011: boost of earmarked funds

To

tal

Ex

pe

nd

itire

(U

S$

10

^6

)

Sour

ce: M

ISAU

(201

1)

Has the availability of services increased due to GHIs?

2003 2004 2005 2006 2007 20080

10

20

30

40

50

60

70

80

0

5

10

15

20

25

30

35

63 62 61 60 59 58

6767.5

70 71

18.2 17.8 17.4 17 16.6 16.2

PMTCT coverage sharp increase as a result of GHIs (HIV) compared to a steady/stagnant status of other MCH pro-

grams 2003-2008

Vacc

ines

cov

erag

e (%

)

PMTC

T &

Con

trac

eptiv

e co

vera

ge (%

)

PMT

CT

C

over

age

Contraceptive Coverage

1 year old immunized against measles

0-12 month immunized against DPT3/HepB

Source: Mozambique MDG report, 2010

April 13, 2023 10

2003 2004 2005 2006 2007 2008 2009 20100

50000

100000

150000

200000

250000

300000

350000

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2% 4%9% 18% 34% 44% 53% 62%3032 6779

17325

40684

82001

118937

156688 201596160639

181298

202169

223055

244774

269124

296207

325053

Access, need and coverage of anti-retroviral treatment of patients over 15 years of agein Mozambique, 2003-2010

Coverage Over 15Y receiving ARTTotal people in need

Patie

nts

(N)

% A

dult

Cove

rage

Source: MISAU-CCS 2011

What has been the influence of GHIs on infrastructures?

HEALTH UNIT

FIGURES OF FRAGMENTATIONBEFORE Y2006

Day Hospital

(ART)

ATS (VCT)

TB Service

HEALTH UNIT

Now, all services are fully integrated including management of HRH, but

still weak

FIGURES OF INTEGRATION FROM Y2006

Outpatient Inpatient

Lab/ Pharmacy

Other services

Outpatient Inpatient

Lab/ Pharmacy

Other services

HIV Lab & Pharmacy

ATS (VCT)

AIDS seen as an emergency, partners supporting with little control/coordination.

AIDS acknowledged as a chronic condition… Reorganization of the NHS towards sustainability.

What has been the influence of GHIs on infrastructures?

• At the begining of GHI investiment on HIV

What has been the influence of GHIs on infrastructures?

• Integration from 2006 (political decision by MISAU)

How have GHIs affected health worker availability and performance in the public health

sector?

Health partners funded by PEPFAR/GFATM tend to be more attractive in terms of incentives and are hiring the most experienced qualified staff coming from the public sector• Official figures from MISAU headquarters (2010) say 56.5% (14/23) of

MD with Master or PhD moved to outside the public system, with 71.4% (10/14) from the National Directorate of Public Health

Still recently NGOs (e.g. ITECH funded by PEPFAR) are providing support to MISAU for in-service and pre-service training mainly oriented to the areas of their interest

So, NGOs are seen as acting in a double-edged fashion: while contributing to low-level staff retention, through support of training and payment of some incentives, they are also held responsible for recruiting the best public sector cadres

HRH – Remarks from the national and subnational interviews

The latest health sector human resource development plan (2008 2015) clearly lays out strategies that can be used to ‐strengthen the workforce in terms of motivation, retention, availability and so, for better performance…but it demands funding that could come from GHIs

The rapid "scale up" of ART services had negative effect on the quality of services provided by the health system due to work overload as the level of HRH availability did not change at all

What is the contribution of GHIs on aid effectiveness?

• A significant proportion of health, especially HIV/AIDS related, USG aid, is still channeled according to donor defined priorities and through NGOs

“well we want to diversify the risk. We don’t want to put all our eggs in one basket” - Partner representative

• Unpredictability of disbursements (e.g. GFATM)

Source: Hilde De Graeve,

Bert Schreuder.

What is the influence of GHIs on equity, HMIS and M&E?

• Geo-discrepancy on service delivery and around M&E:– Multiple programs being simultaneously

implemented.– funding partners targeting specific

provinces– Within each province an agency often

covers only one or a few districts– Separate evaluations and inefficient– Inability to compare results given

differences on objectives, approaches and indicators

– PEPFAR seems to promote parallel HMIS and M&E relying on their implementing partners’ systems

– GFATM fights to improve the HMIS and M&E systems and so, has provided capacity building in this direction.

Partial Remarks• GHIs increased services scale up for the specific health

programs (HIV+++, Malaria++ and TB+)

• No evidence of GHI interventions negatively affecting other health related services

• The vertical nature of GHIs stresses the ongoing efforts of harmonization and alignment

• GHIs do affect HRH availability and performance both negatively and positively

• The collective efforts of GHIs would have resulted in better health outcomes if they had targeted the health system as a whole in a coherent manner.