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					                                            Mozambique health aid case study

Section 1 - National health sector background
Mozambique is committed to the fight against poverty. The Government has adopted a
number of well-articulated plans for poverty reduction and growth. These include Agenda
2025 (the national long term vision), which is the basis for the Five Year Programme (2005-
2009) and the second generation of the Action Plan for the Reduction of Absolute Poverty
(PARPA II), the Mozambican PRSP II for the period 2006-2009. It has integrated the
Millennium Declaration principles and the Development Goals into its national objectives.
The government of Mozambique promotes a health policy based on principles of broad and
equitable access to basic health services. A commitment to these principles has also been
adopted in the Mozambican Constitution. For years, the Government has sought to meet its
health objectives through a sustained expansion of the primary health care system.

There remain, however, persistent obstacles to progress, particularly the number of health
professionals which, per inhabitant, is among the lowest in the world 1 with Mozambique
being one of the countries facing a critical shortage of human resources for health
care2.Additionally, the present health providers could be significantly improved with more and
better training. Moreover, administrative systems are generally inadequate with weak
financial and supply management systems undermining service delivery. There has also
been an uneven distribution of facilities, staff and other inputs among the provinces leading
to inequalities in access. Furthermore, the implementation of user fee policies has seen an
uneven application of both fees and exemptions to the detriment of the poorest sections of
the population.

With regard to access to health, it is estimated that only half of the entire population has
access to basic health services. There are large differences between the different
provinces implying significant differences in the availability and quality of health services
across the country, mostly affecting rural areas negatively3. A large number of people are
also unable to gain access to health services due to the fact that one often has to pay for
services or medicines. The implementation of user fee policies has seen an uneven
application of both fees and exemptions to the detriment of the poorest sections of the
population. The number of health workers in the country is among the lowest in the world 4
and the capacity of the limited health worker force could be significantly improved with more

  There is an overall lack of health staff especially in rural areas. More than half of the country’s 712
doctor’s work in Maputo, with an estimated doctor to patient ratio of 1:4,000 compared to 1:60,000 in
the North. 2001/2002 figures indicate that 60% of the districts’ health personnel worked in the district’s
capitals. In 2000, there were 2.4 doctors and 20.5 nurses per 100,000 populations.
  Low yearly output of medical graduates, insufficient academic level and inadequate salaries (many
practitioners combine their public sector practice with private medical work) all contribute to a general
lack of efficiency of health staff.
  Disparities still persist between provinces, urban and rural areas, and men and women. The triple
threat of HIV/AIDS, food insecurity, and the ensuing weakened governance capacity especially for
service delivery, threatens to reverse recent gains. A comprehensive decentralization approach by the
major sectors is still needed; it will help ensure effective allocations of functions, finances and human
resources for local service delivery, and therefore help improve service delivery.
  There is an overall lack of health staff especially in rural areas. More than half of the country’s 712
doctor’s work in Maputo, with an estimated doctor to patient ratio of 1:4,000 compared to 1:60,000 in
the North. 2001/2002 figures indicate that 60% of the districts’ health personnel worked in the district’s
capitals. In 2000, there were 2.4 doctors and 20.5 nurses per 100,000 populations.

                                           Mozambique health aid case study

and better training. In addition, administrative systems are generally inadequate with weak
financial and supply management systems undermining service delivery. There has also
been an uneven distribution of facilities, staff and other inputs among the different provinces
leading to inequalities in access.

Moreover, in the public sector the health is managed by different ministries with parallel
systems existing by different Ministries providing health care to different professional groups
in society.

      Institutions             Health Care                Type of Services            People Entitled
                                Providers                     Offered

  Ministry of Finance     None                        Policy and regulatory
                                                      Funding of Ministries

   Ministry of Health     National Health Service     Policy and regulatory      All the population. The
                                                      functions.                 coverage is estimated to
                                                                                 be 40%
                                                      Curative and preventive
                                                      Training and research

  Ministry of Defence     Health Care Facilities      Curative care              Soldiers and family
                                                                                 members. Approximately
                                                                                 21.000 persons.

 Ministry of Education    University of Medicine      Training medical doctors   Medical students
   Ministry of Interior   Police Health Posts         Curative care
   Ministry of Justice    Prison Health Units         Curative care              Prisoners

   Ministry of Public     National Directorate of     Water and sanitation       All population
        Works             Water Programmes            programme

   Ministry of Labour     National Institute of       Social security package    Only for in-patient
                          Social Security (INSS)      for employees of private   subsidies of private firm
                                                      firms                      employees

   Grant and Credit                                   Funding of public and
      Funders                                         private institutions
                                  Source: Management Sciences for Health

                                               Mozambique health aid case study

The national health system is divided into three administrative levels: the Ministry of Health
for policy and strategy formulation, the 11 provincial offices for policy implementation and
regional coordination and the 144 health district divisions for health services provision. The
health centres provide services at the first and most peripheral level and refer to the rural and
district hospitals for medical emergencies, basic surgical and obstetrical interventions.
Provincial and central hospitals ensure specialist care. Data from 2001 gives a total of 1,141
health posts and centres and 43 hospitals.

                                       The 11 provincial offices:    According to the World
                                       1. Cabo Delgado 2. Gaza       Health    Organisation,    in
                                       3. Inhambane 4. Manica        2004,        ―out-of-pocket
                                       5. Maputo (city); 6. Maputo;  expenditure as percentage
                                       7. Nampula; 8. Niassa;        of private expenditure on
                                        9. Sofala; 10. Tete;         health” was 38.5% in
                                       11. Zambezia                  Mozambique. From the data
                                                                     currently available in the
                                 country it is not possible to determine an accurate estimate of
                                 the household expenditure in the four main provider groups:
                                 the public sector; the traditional healers; the private for profit
                                 providers; and the providers from outside of Mozambique.
                                 Data is available on the amounts of official revenues raised in
                                 public facilities but this is an underestimate of the flows of
                                 funds that actually occur. Furthermore there is no reliable data
                                 available on the financing of Mozambique’s large traditional
                                 sector which is totally dependent on household expenditures.
                                 It could be said that the proportion of household expenditures
to total health sector financing is likely to be in a range of between 20 – 50%.

According to The World Bank5, in Mozambique, corruption in health service delivery reduces
the quality and quantity of services that reach the poor. Fraudulent practices include: the
stealing of drugs and supplies6; using public facilities for private gain; requests for unofficial
payments for services that are supposed to be provided at no cost; charging bribes to
provide regular services or to speed up the provision of services; using access to patients in
public hospitals and clinics to transfer them to private clinics, and; manipulating the drug
registration and procurement process. There are weaknesses in procurement and financial
management and leakage of funds in the service delivery process.

According to the European Commission, the total annual health expenditure in Mozambique
is around US$9 per person, about 70% of which is in the public sector7. The share of
Government expenditure for health care increased considerably8. However, those
expenditure finances essentially personnel costs and other recurrent costs. The health unit
fee revenues, albeit increasing over recent years, still represents officially a minor
contribution of the governmental budget (3%).

  Promoting Shared Growth through empowerment of citizen and institutions – Mozambique country partnership
strategy 2008 – 2011 – The World Bank
 Drug availability continues to be problematic due to weaknesses in planning starting from calculations of actual
needs at the various levels of care. The national capacities for drug quality control need are still scarce.
 According to the World Health Organisation (March 2007), the country with lowest total spending per person
per year on health is Burundi (US$ 2.90).
    According to the table 5 (The World Health Organisation) the GGHE nearly doubled between 2000 and 2005.

                                                      Mozambique health aid case study

                National Expenditure on Health Source: The World Health Organisation – 2008
A. Selected ratio indicators for            1996     1997     1998     1999     2000     2001     2002     2003     2004     2005
expenditures on health
1. Expenditure ratios
Total expenditure on health (THE) as %         3.8     4.1      4.0      4.5      5.5      4.6      4.7      4.2      4.0         4.0
of GDP
Financing Agents measurement
General government expenditure on            51.8     56.4     58.8     65.2     69.7     68.9     72.2     69.2     68.4     68.5
health (GGHE) as % of THE
Private sector expenditure on health         48.2     43.6     41.2     34.8     30.3     31.1     27.8     30.8     31.6     31.5
(PvtHE) as % of THE
General government expenditure on            10.0      9.6     11.0     12.1     12.9     10.7     11.5     10.9      9.1         9.1
health as % of GGE
Social security funds as % of GGHE            0.0      0.0      0.0      0.0      0.0      0.0      0.0      0.0      0.0      0.0
Private households’ out-of-pocket            41.6     41.4     40.8     40.5     40.8     39.6     38.8     38.7     38.5     38.5
payment as % of PvtHE
Prepaid and risk-pooling plan as % of          0.6     0.6      0.6      0.6      0.6      0.6      0.6      0.6      0.6         0.6
Financing Sources measurement
External resources on health as % of         39.3     43.6     41.8     41.6     35.0     37.8     38.0     50.9     55.9     69.5
Resource Costs measurement
Compensation of government health              n/a     n/a      n/a      n/a      n/a      n/a      n/a      n/a      n/a         n/a
employees as % of GGHE
Total expenditure on pharmaceuticals as        n/a     n/a      n/a      n/a      n/a      n/a      n/a      n/a      n/a         n/a
% of THE
Private expenditure on pharmaceuticals         n/a     n/a      n/a      n/a      n/a      n/a      n/a      n/a      n/a         n/a
as % of PvtHE
Provider measurement
Total expenditure on hospitals as % of         n/a     n/a      n/a      n/a      n/a      n/a      n/a      n/a      n/a         n/a
Functions measurement
Total expenditure on inpatient care as %       n/a     n/a      n/a      n/a      n/a      n/a      n/a      n/a      n/a         n/a
of THE
Prevention and public health services as       n/a     n/a      n/a      n/a      n/a      n/a      n/a      n/a      n/a         n/a
% of THE
II. Selected per capita indicators for
expenditures on health
Total expenditure on health/capita at           7        8        9       11       11        9       10       11       12         14
exchange rate
Total expenditure on health/capita at          21       24       27       32       40       38       42       41       42         46
international dollar rate
General government expenditure on               4        5        5        7        8        6        7        7        8         10
health cap x-rate
General government expenditure on              11       14       16       21       28       26       30       28       29         31
health/cap int. $ rate

            these ratios and per capita levels are automatically derived using the aggregate figures in Section B. (following)

                                              Mozambique health aid case study

Section 2 – Other stakeholders in the health sector
Mozambique is one of the most aid-dependent countries in the world9.There are nearly 50
donors present in the country and the amount of external aid is, on average, 15% of GDP
(five-year average according to the Conta Geral do Estado, excluding off-budget funds).
Although the long-term objective of the Government is to reduce its dependence on aid, an
increase in the volume of external aid for the PARPA II period (2006-2009) is a likely
scenario, particularly for achieving the MDGs and fighting poverty. Principal donors active in
Mozambique include the European Commission, the World Bank, Danida, DFID, UNDP,
Sweden, The Netherlands and USAID.

The Mozambican health sector involves a large and well established donor community,
which finances it using different mechanisms (through NGOs, direct budget support and
directly implemented programs). All these mechanisms show strengths and weaknesses in
terms of supporting government policies and financial management. The European
Commission/European Development Fund (EDF) is the second top donor in the health
sector and accounts for 11% of the total.

The overall objectives of the EDF support to health are to promote and to preserve the state
of health of the Mozambican population, by means of equitable expansion of quality
health services, and to reduce the burden of HIV/AIDS on the Mozambican population.
The purpose of the programme is to support the Ministry of Health, both financially and
technically, to implement its Health Sector Strategic Plan (PESS) and to assist the National
AIDS Council (CNCS) with achieving its goals and coordination in keeping with its national
strategic plan.10

The EC has a strong presence in the health sector in Mozambique. In terms of policy
dialogue, for the last year and a half, the EC became a focal partner of all partners in the
health sector, contributing to the Government’s policy discussions in the framework of a
SWAp in the health sector (PROSAUDE). The Terms of Reference of the SWAp were signed
on April 2007. The health SWAp is opened to and inclusive of key stakeholders such as the
National AIDS Council, bilateral and multilateral agencies, global initiatives such as the
Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis and the Global Alliance for
Vaccination and Immunisation, civil society organizations such as the International HIV/AIDS
Alliance, the private sector, medical associations and academic institutions. Similarly, the
large EDF contribution to multi-donor general budget support in Mozambique,
particularly due to the fact that performance in the health sector is one of the
determinants of the amounts of the variable tranches, which allows closer sector
policy dialogue with the Government that complements EC’s direct support in this

Other Stakeholders:
The Global Fund for AIDS, Tuberculosis and Malaria has awarded four grants to
Mozambique, with a combined commitment of US$51 million over two years. The total five
year value of these grants is US$ 153 million. The National AIDS Council is the Principal
Recipient of the Global Fund.

  In 2000, donors contributed to as much as 68.5% of the total health expenditures. In per capita terms, health
spending has grown from USD 4.9 in 1997 to USD 7.4 in 2000. There are no clear guidelines on the allocation
of funds to provinces.
     Mozambique European Community Country Strategy Paper 2008-2013
     Mozambique European Community Country Strategy Paper 2008-2013

                                          Mozambique health aid case study

The National AIDS Council was created in 2000 by a ministerial decree, with responsibility
to coordinate the national multisectoral response. The Board is chaired by the Prime
Minister, with the Minister of Health as Vice Chair. The Second National Strategic Plan
(2005-2009) was approved in December 2004. AIDS has been integrated into the
Government’s five-year plan for 2005-2009, into the second action plan for the reduction of
absolute poverty (2006-2009) and the 2006 economic and social plan. Activities being
implemented by the National AIDS Council are financed by the Common Fund, supported
by five external donors, the World Bank and the Global Fund for AIDS, Tuberculosis and

Section 3 - Health sector analysis
For the most important indicators in health, Mozambique is currently ranked lower than its
neighbouring countries South Africa, Malawi, Tanzania, Zambia and Swaziland. It still has
among the highest maternal and infant mortality in sub-Saharan Africa. According to recent
figures of the WHO, 15% of all children die before reaching the age of five years, the most
common cause of death being Malaria, and 1 out of 16 women die as a direct result of their
reproductive role during their fertile period of life. Life expectancy at birth is 46 for males and
45 for females.12 By far the biggest challenge is posed by the HIV/AIDS epidemic with an
incidence of at least 16%. The HIV prevalence in pregnant women (15-49 years) rose from
11% in 2000 to 16% in 2004.13 Youth aged 15-24 are most heavily affected and account for
60% of new HIV infections. Also striking is the gender disparity. Within the 20-24 age group,
young women living with HIV out number men by four to one. By the year 2010, it is
expected that nearly half of the 1 million maternal orphans in Mozambique will be orphaned
due to HIV and AIDS. The scale of the national response remains weak. In 2006, only 17%
of those in need had access to Anti Retroviral treatment. 14

However, substantial improvements were made over the last ten years in the Mozambican
health sector. For instance, infant mortality was reduced by 32% between 1997 and 2003
and it has gone further down since then. The same development can be seen in all major
health indicators. Regarding HIV/AIDS, ARV-treatment provided by the public health sector
started in 2002 and by June 2006 approximately 27.000 persons received treatment.

The Millennium Development Goals in Mozambique

While progress is evident in the achievement of some of the MDGs, the situation in relation
to others is not improving or is not improving fast enough. The second national poverty
reduction strategy developed by the Government of Mozambique, known by its Portuguese
acronym as PARPA II (2006-2009), (Mozambique’s PRSP), sets time-bound targets in line
with the Millennium Development Goals (MDGs). Mozambique is also grappling with the
rapidly evolving aid environment, with increased alignment of donor activity centred on the
PARPA and a move towards direct budget support and sector-wide approaches, with all
significant funding for a given sector supporting one policy and expenditure programme
across the sector. However it is not at all certain that the delivery of the PARPA, and for
health the implementation of PROSAUDE, will be effective enough to deliver these targets.
This is because the adoption of these policies has not addressed the fundamental problems
of low capacity in the sector, either in terms of frontline staff or administrative support.

   Conselho de Combate National ao HIV/SIDA, 2006
   DFID Mozambique CAP 2008-2012

                                            Mozambique health aid case study

According to the European Commission for instance, in the case of MDG 1 (eradicating
extreme poverty and hunger), Mozambique is on course to halve the proportion of people
living in extreme poverty by 2015 but is unlikely to halve the proportion of those suffering
from hunger, because of drought, floods and other natural calamity -related constraints.
Similarly, while MDGs 4 and 5 concerning child mortality and maternal health are ―on track‖,
it is unlikely that the objectives of universal primary education (MDG 2), gender equality
(MDG 3), halting the spread of HIV/AIDS (MDG 6), and ensuring environmental sustainability
(MDG 7) will be met by the target year of 2015. Please refer to table 8 in Annex 7: MDGs
Progresses by goals (current status in accordance with national Government reporting).
Moreover the assertion that child mortality and maternal health targets will be met rests the
assumption that the PARPA and PORSUAD will be entirely effective which is far from certain
given the capacity limitations Mozambique faces.

In 2006, the United Nations and the Government launched a Millennium Villages programme
to accelerate the achievement of the MDGs at grass-roots level. This endeavour is being
supported under a United Nations Joint Programme, with the proactive involvement of

Promotion of gender perspectives
On December 9, 2003, the National Assembly of Mozambique passed a new Family Law,
securing a broad range of rights previously denied to Mozambican women. The new law
raises the minimum age of marriage from 14 to 18, allows women to inherit property in the
case of divorce, and legally recognizes traditional marriages, which constitute the great
majority of marriages in Mozambique. This progressive legislation, drafted by an Oxfam-
supported women's coalition, marks a huge step forward for the women of Mozambique, who
have long suffered profound discrimination. What's more, lawyers speculate that the Family
Law will serve as a precedent on which future gains in gender legal reform can be built. Both
legal systems—common and customary—contain legislation and practices that disadvantage
women. This example was provided in order to show that little by little, the women’s right is
improving in Mozambique. In the health sector and in the framework of the fight against
HIV/AIDS, donors and health stakeholders finances activities assuring promotion of gender
equality, women’s empowerment and the reproductive rights of men, women and
adolescents. This is extremely important because for physiological, social and economic
reasons, women face a greater risk of HIV infection than men do. In Mozambique, like in
other African countries, girls in the 15-19 year age group are five times more likely to be
infected than are boys in that age group.

Civil society involvement

The development of a strong, autonomous and politically articulate civil society is still in its
early stages in Mozambique. The majority of the civil society organisations see themselves
more in the role of service providers aiming to bridge the gap left by the Government’s
lack of capacity to deliver basic services. The authorities have progressively opened up
space for monitoring and evaluation by civil society, in particular in the framework of the
poverty reduction plan. According to the European Commission, during the programming
process of the Country Strategy Plan/paper Civil Society Organisations were involved to a
limited extent.15

     Mozambique European Community Country Strategy Paper 2008-2013

                                          Mozambique health aid case study

Section 4 - Aid effectiveness
Being an ―Aid darling‖, managing the donors well is a key challenge for the Government of
Mozambique. The 1990s saw the emergence of new aid approaches as general budget
support (GBS), sectoral budget support (SBS) and pool fund arrangements under the Sector-
Wide approach (Swap) – along with the Poverty Reduction Strategy Papers (PRSP) as an
attempt to improve aid effectiveness by increasing predictability of aid flows, promoting
ownership, decreasing transaction costs and strengthening institutional capacity and
domestic accountability of recipient countries.

In Mozambique, there have been significant improvements in donor performance and aid
management. In general, donors are committed to the Paris Agenda. A donor working group
on sector alignment and on implementation of the 2005 Paris Declaration was constituted in
2005 to define the optimum planning and budgetary cycles, to identify where sector
cooperation is out of alignment, to analyse the possible obstacles to further alignment and
the level of predictability of aid flows in the different sectors. The significant increase in the
use of budget support in Mozambique enabled the Government budget to grow by
36% between 2000 and 2004, with budget support due to deliver 15% of the budget in
2007. This has allowed budgeting and planning to begin to be driven by Mozambique and the
proportion of public expenditure that is subject to parliamentary scrutiny and debate has
significantly increased. This is delivering a much stronger platform for accountability.16

A group of 19 donors, known as G-19, currently provide budget support to Mozambique,
accounting for about 25% of the G-19 donor’s total aid to Mozambique. It is premised on
support for poverty eradication by building a partnership based on frank and open dialogue
on the content and progress of Mozambique’s poverty reduction strategy, and by providing
financing for poverty reduction, clearly and transparently linked to performance. Alongside
general budget support are large common funds to health, education, HIV/AIDS, agriculture
and smaller common funds supporting, for example, public financial management. Between
10% and 15% of their flows can be identified as sector budget support.17 There are also large
amounts of off-budget resources, especially for HIV/AIDS. The coming together of 19 budget
support donors behind one coordinated framework has led to a step change in the
relationship between government and donors. The donors are working within one
performance framework, are having one coordinated policy dialogue with the
Government and have delivered a significant improvement in the predictability of
short term financing.

The shift in aid modalities in Mozambique has underpinned a significant improvement in
service delivery and outcomes. For example, health service units and health
personnel grew annually by 3.7% and 7% respectively between 2001 and 2004.18

However, the weight of project aid is still huge and dominant and in some sectors
(including health), it is increasing.19

Division of Labour: The general trend in Mozambique has been for donors to specialise on
limited priority sectors. According to the 2005 data (donor matrix prepared by the EC
Delegation) and taking into account the four focal sectors and the first non-focal sector

   DFID Mozambique CAP 2008-2012
   DFID Mozambique CAP 2008-2012
   DFID Mozambique CAP 2008-2012
   AFRODAD, a Critical Assessment of Aid Management and Donor Harmonisation, the Case of Mozambique,

                                            Mozambique health aid case study

(health) in the Country Strategy Paper, the EC/EDF is among the top three donors to
macroeconomic, financial and trade policies (18 major donors), where it provides 22% of the
total aid, to agriculture and rural development (16 major donors) where it contributes around
29% of the total to the sector, and to transport infrastructure (5 major donors), where it
accounts for approximately 39% of the total. In health (18 major donors), the EC/EDF is
the second top donor and accounts for 11% of the total.

The European Commission’s support in the focal sectors is complementary in areas
traditionally covered by EU Member States and other development partners in Mozambique.
The methods of aid delivery determine the approach to coordination and complementarity of
external aid. In the context of non-targeted budget support, the Government decides the
allocation of external funds, and the concept of complementarity may therefore be
understood as support for continuous policy dialogue at high political level. Regarding sector
budget support, the concept should be defined as coordination of the sector group and
support for policy dialogue at sectoral level. Where aid is delivered in the form of projects,
greater complementarity can be ensured either sectorally or geographically. In 1997,
the decision was adopted that each EU Member State was to focus on a particular province,
in close consultation with the provincial government, and this has led to a stronger presence
of EU Member States in specific provinces.20

     Mozambique European Community Country Strategy Paper 2008-2013

                                               Mozambique health aid case study

     Field of   Health    Agriculture     Water     Good        Macro    Education   Energy   Env.   Transport
development                and rural              governance   support
Austria                      X             X          X
Denmark          X           X                        X          X          X          X
Finland          X           X                                              X
France           X           X             X                                X
Germany          X           X                                              X          X                  X
Ireland          X           X                        X          X          X
Italy            X           X             X          X                     X
Netherlands      X                         X          X          X          X                  X
Portugal                     X                        X                     X
Spain            X           X                        X                     X
Sweden                       X                        X          X          X          X                  X
U.K.             X           X                        X          X          X                             X
Source: The European Commission – 2008.

International Health Partnership: As part of a Global Campaign for the Health MDGs, the
UK in collaboration with 14 governments of developing and developed countries and the
heads of the major UN agencies involved in improving health have committed to work
together in the new ―International Health Partnership (IHP), created to build sustainable
health systems and improve health outcomes in low and middle income countries. The IHP
is a key step in putting the Paris Declaration into practice in the health sector and
builds on recommendations of recent commitments on health, such as the High Level Forum
on the Health MDGs, the G8, the 2006 UN General Assembly declaration on AIDS, the
recommendations of the Global Task Team on improving AIDS Coordination among policies
particularly those related to ―MDG Contracts‖ and other ongoing work of the European
Commission on harmonisation and aid coordination among EU Member States etc.
Mozambique is one of the first seven developing countries that signed up to the IHP. In
Mozambique, IHP partners have identified tackling the shortage of nurses and doctors
as one of their key priorities. In recognition of this, DFID has supported the plan of a health
human resources strategy and provided funds to help implement the plan. The intention of
the strategy is to secure long term, predictable funding over the coming years to support an
ambitious increase in the number of trained health professionals in Mozambique.

Integration of the Global Fund into the health SWAp: The integration of the Global Fund
into both the health SWAp and the health common fund in Mozambique in 2004 represents a
pioneering example of how a targeted, disease specific funding model adapts itself to better
fit with country systems whilst simultaneously strengthening broader health sector

The existence of a Country Coordinating Mechanism solely for developing and overseeing
Global Fund proposals and grants has always been a contentious issues in Mozambique.
Given the existence of the SWAp, a key health sector coordinating mechanism, the Ministry
of Health and development partners questioned the necessity of another coordination
mechanism, although they recognized that neither the SWAp Forum that meets monthly nor
the working groups linked to it could substitute for the very specific responsibilities assigned
to the CCM, or at least not without a substantial adaptation of the SWAp-related

A solution was agreed in August 2006 to subsume the role and function of the CCM within
the broader SWAp forum. Under this arrangement all the CCM members would become de
facto members of the SWAp, but would continue to perform their specific CCM tasks as
when required. The decision coincided with the nomination of a new chair and vice chair of

                                               Mozambique health aid case study

the CCM, which also resolved the issue of conflict of interest that had arisen when the
Ministry of Health was both the Chair of the CCM and the Principal Recipients of the grants.

The inclusion of Global Fund resources into Prosaude has not helped to solve or lessen
existing problems between the Ministry of Health and NGOs for the delivery of public
services, particularly in the field of HIV/AIDS. Problems such as the lack of legal mechanisms
within the Ministry of Health for contracting out services or for channeling government
resources to NGOs have been brought into sharper focus and exacerbated by the Ministry’s
powerful position as Principal Recipient of Global Fund grants until August 2006.

However, the Global Fund’s entry into the SWAp and Prosaude has definitely helped broader
civil society and NGO participation in SWAp policy-making processes, and assisted intra-
NGO communication and coherence. 21 It has also been a mutually reinforcing process, with
the Global Fund acting as a more harmonized development partner and the SWAp process
gaining from the Global Fund’s sharper focus on technical and clinical priorities and use of
more rigorous indicators as evidence of results. 22

     HLSP Institute, The Global Fund operating in a SWAp through a common fund, January 2007
     HLSP Institute, The Global Fund operating in a SWAp through a common fund, January 2007

                                           Mozambique health aid case study

Section 5 – Lessons learned and conclusions
Whereas the shift in aid modalities in Mozambique has underpinned a significant
improvement in service delivery and outcomes, health sector resources, both human and
financial, are still clearly insufficient and only cover selected groups of the
Mozambican population. It is clear that substantial further progress is needed in both the
coverage and quality of these services in order to attain the MDGs. One reason for this is
that the domestic public financing of equitable health services is still very low to face these
challenges. Additional external support for the health sector, in a predictable and
aligned manner, is critical in order to move towards MDGs 4, 5 and 6.23

Despite strong improvements in the way donors work together in Mozambique, budget
support is still only about a quarter of total aid and some donors are increasing project
support faster than budget support. According to DFID, this is creating a very fractured
and complex portfolio for many sectors, which makes the coordination processes still too
burdensome to the Mozambican Government and is muddling lines of accountability to civil
society.24 Civil society involvement remains extremely low.

The process of the division of labour in Mozambique is still limited. There continues to be a
large number of donors in the health sector, which is a major obstacle to increased aid
The review of the health sector conducted by the IHP donors concluded that progress
towards attaining the health MDGs has been slow and that most of the constraints are
systemic, such as unequal access to services and outcomes. These issues are the result of
weaknesses in linkages between the health sector and broader development processes;
insufficiently coordinated international initiatives; staffing and systems limitations, inadequate
monitoring systems for resource flows, progress and outcomes; limited progress in
transferring global commitments into concrete action at country level (eg., the provision of
predictable, long-term financing) and the lack of a multisectoral approach to achieving health
outcomes. 25

   European Community Country Strategy Paper and National Indicative Programme 2008-2013
   DFID Mozambique CAP, 2008-2012
   IHP bi-weekly update, issue no 4, 18 December 2007

                                      Mozambique health aid case study

Action for Global Health’s conclusions of this case study are similar to the findings of
assessments made by donors (such as the IHP donors and UK DFID) and NGO networks
(such as AFRODAD):

   o   Budget support should be based on national government-owned results-based
       planning, budgeting and monitoring systems.

   o   The capacity of civil society should be strengthened to hold the government to
       account, which will, in turn, foster greater accountability around health service

   o   Any aid modality targeting health system strengthening should be accompanied by
       responsive pro-poor policies that make sure the hardest to reach can access services
       (for example by continuing to support the government to abolish user fees in health).

   o   Significant improvements in aid effectiveness at are needed at the sector level.
       Efforts to improve aid effectiveness should be equally applied to sectors receiving
       large amounts of off-budget resources.

   o   The focus of the political dialogue should be shifted to the monitoring of health
       service delivery outcomes to ensure a stronger focus on results and impact.

   o   Direct financial support across the social sectors in addition to budget support is
       essential if the social sectors are to scale up successfully.

   o   Financial allocations between sectors should not be determined by donor
       preferences, the division of labour should be domestically owned.

   o   Greater complementary should not only be ensured by sector, but also geographically
       (across provinces).


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Description: Executive summary grassroots clinics1