presentation by Baltazar Chilundo and Tavares Madede

1. INFLUENCE OF GHIs ON MOZAMBIQUE
PUBLIC HEALTH SYSTEM
GHIs in AFRICA funded by the EU 6th framework
INCO-DEV program. INCO contract no. 032371
Beijing - October 31st 2012
By: Prof. Baltazar Chilundo (MD, PhD)
Dr. Tavares Madede (MD, Research fellow)
DEPARTMENT OF COMMUNITY HEALTH, FACULTY OF MEDICINE, EDUARDO MONDLANE UNIVERSITY, MOZAMBIQUE

2. Background
Parameters Value
Total Population (in million – projection based on 2007 census) 23.7
Children (population below 19 years of age) (in million – 12.3
projection based on 2007 census)
People living below the poverty line (%) (Mozambique MDG 54%
report, 2010)
Under five mortality rate/1,000 live births (MICS 2008) 138
Maternal mortality ration/100,000 live births (2007 Census) 500.1
HIV prevalence rate among pregnant women (INSIDA, 2009) 11.5%
Malaria parasitaemia among children under five (MIS, 2007) 38.5%
TB prevalence rate/100,000 people (WHO, 2008) 504
Proportion of aid by external partners in 2008 (MISAU, 2008) 73%

3. 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 levels?
– Has the availability of services increased due to
GHIs?
– How have GHIs affected health workers availability
and performance in the public health sector,
particularly at the facility level?
– What is the influence of GHIs on financial system,
HMIS and M&E?

4. 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)
– Administrative health data
– 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

5. What are the GHIs operating in
Mozambique?

6. Has the availability of services increased due to GHIs?
Trends of selected MCH indicators: PMTCT coverage (GHI funded)
compared to coverage of institutional deliveries and family planning
2007-2011
80% Coverage of new clients on Family Planning Coverage of Institutional deliveries Coverage of PMTCT
69.0% 69.0%
70%
68.0%
60% Institutional 64.0% 63.0%
deliveries 51.9%
50% 54.0% 55.1%
47.0%
40%
PMTCT
30%
20% 24.0% 24.0% 23.0%
Family Planning
10%
11.2% 10.0% 11.1%
0%
2007 2008 2009 2010 2011
Source: Administrative data_HMIS_MoH, Mozambique

7. 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

8. 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

9. HRH: Gap between needs and capacity
Ratio of health workers of specific # of new cadres graduated (basic
health areas of medicine, nursing and and medium) of specific health
MCH per 100,000 inhabitants . Source: BdPES career. Source: BdPES DRH 2012
DRH 2012
3500
250
3000
200
2500
150
2000
100
1500
50
1000
0 2009 2010 2011
2009 2010 2011
Performed 1525 2170 1688
Performed 61 63.4 67
Planned 2321 1650
Planned 60 63 65
Needs
Minimum
230 230 230 expressed in 2264 3267 3147
WHO standard
HRH plan

10. What is the influence of GHIs on
Financial system, HMIS and
M&E?
• Low capacity of MoH officials to
demonstrate accountability
• Inability of the MoH to promptly satisfy
the recommendations from financial
auditors
• Data quality remains a big issue (this was
also found by GFATM external data
auditors)
• Geo-discrepancy on service delivery and
around M&E:
– funding partners targeting specific
provinces
– Within each province an agency often
covers only one or a few districts
– PEPFAR seems to promote parallel HMIS
Source:
Hilde De Graeve, and M&E relying on their implementing
Bert Schreuder. partners’ systems

11. Final 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
• GHIs do affect HRH availability and performance
both negatively and positively
• Existing financial accountability and M&E/HMIS
are still weak and being stressed by GHIs
• 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.

12. Kudos for me: I am Becoming 40 today!
Thanks a lot
Obrigado
谢谢
A health post
from
Nampula, Moza
mbique