How can healthcare be more equitable and accountable in Mozambique?

Published on 16 November 2016

Jennifer Constantine

Policy Engagement and Research Consultant

With Mozambique’s fragile economic situation and uncertain political environment, there has never been a more important time for delivering healthcare which works for all citizens in an open and transparent way. The Unequal Voices/Vozes Desiguais project, launched in Maputo by the Minister of Health, Dr Nazira Abdula and Dr Rômulo Paes de Sousa, Director of the RIO+ World Centre for Sustainable Development, will be exploring how accountability can be strengthened to ensure delivery of better health services for citizens everywhere.  

Mozambique is currently at a critical juncture, facing a severe debt crisis and ongoing conflict between its ruling party Frelimo and the main opposition, Renamo. Rapidly rising inflation and food prices are causing great uncertainty; and the fragile economic situation has severe implications for the long-term funding of government services, and the health sector in particular; given its dependence on donor support. Delivering healthcare which works for all citizens in an open and transparent way has thus never been more important.

The Unequal Voices project – Vozes Desiguais in Portuguese – examines the politics of accountability in health systems in Brazil and Mozambique, exploring how accountability can be strengthened to ensure delivery of better health services for citizens everywhere.

The International Seminar brought together researchers, practitioners and policy actors from Mozambique, Brazil, Guatemala, South Africa, Ireland and the UK, making for a large and lively audience at the Mozambique’s Eduardo Mondlane University (UEM). The Minister of Health for Mozambique, Dr Nazira Abdula and Dr Rômulo Paes de Sousa, Director of the RIO+ World Centre for Sustainable Development in Brazil and IDS Senior International Associate gave the keynote speeches, and were joined by representatives from the international community, academia, media, civil society actors and students.

The presentations covered the politics, history, and economics of accountability in health, sharing examples from Southern Africa, Latin America, China and the UK and drew on personal as well as professional experiences, which paved the way for a day of vibrant debates.

Certain themes came up repeatedly, including:

  • the need for an intersectoral approach to health
  • decentralised human and financial resources and decision-making powers
  • idening participation and access to information
  • tackling the broader social determinants of health.

The issue of health inequities resonated: speakers and participants alike expressed passion and at times indignation in discussing how to tackle inequities in access to health and other public services.

How can effective healthcare be delivered when publicly funded health systems are faced with growing financial and capacity issues?

Given the growing financial difficulties and capacity issues experienced by publicly funded health systems everywhere, delivering effective healthcare is a significant challenge. Widening participation and incorporating citizen voice into service design and delivery is essential for ensuring equity, but as was emphasised by Dr Francisco Mbofana, Mozambique’s National Director of Public Health, it is no easy task, technically or politically.

This made Minister Nazira Abdula’s speech at the event all the more significant, as she reiterated her commitment to equity as a fundamental principle in health. Dr Rachel Waterhouse, Head of Human Development and Resilience at DFID Mozambique, welcomed the Minister’s commitment to reforms, and reflected on the challenge of reducing inequalities between different groups, considering intersectionalities such as those between poverty and gender.

At a time of rapid global change and rising inequality, political commitment to equity in health systems is an essential component of tackling inequality and ensuring primary healthcare for all.

Achieving the ‘Leave no one behind’ 2030 Agenda requires the equitable (re)distribution of economic gains, through targeted public policies which are integrated across sectors, with resources mobilised and ensuing political challenges managed. Inequality is not just an issue in Mozambique, but rather a global challenge, as highlighted by Irish Ambassador William Carlos, speaking on behalf of the Health Partners Group of international donors supporting the Mozambican health sector.

Will external donors promote or hinder greater accountability to Mozambique’s citizens?

As the space available to civil society appears to be narrowing in Mozambique, the influence and power of donors in promoting or hindering efforts to secure greater accountability is a key question.

Social accountability is seen by some as a donor buzzword, and not something owned by the citizens who use public health services. Much work exists on accountability politics, but accountability in health is less familiar territory, and the discussions showed there was a real desire for a common space where such questions could be debated and where actors could learn from each other. The idea of a community of practice was welcomed by those present as a way of working together more closely to help bring about greater accountability for health equity in Mozambique.

This discussion raised a recurring question, which the project will also explore: accountability for what and to whom? Until recently, the Government of Mozambique was held accountable by donors, but arguably less so by citizens and civil society actors.

What next for citizen voice in policy making, implementation and accountability?

IDS’ Hayley MacGregor reflected on how the architecture of aid reinforces government and civil society accountability towards donors, and donors’ accountability towards their own citizens, at the expense of the citizens in the ‘recipient’ country, to whom it seemed no one was accountable. Many people asked who civil society was accountable to. When we talk about multi-level good governance, equitable resource allocation and effective and efficient service delivery, we are talking about power, which is the key determinant in the reduction of inequities.

As Denise Namburete (N’weti) said in her concluding remarks, for Mozambique, the question is how to apply this thinking to health sector reform whilst strengthening good governance, social accountability, transparency and participation. The difficult questions raised throughout the day shows the timeliness of the Unequal Voices research project, which seeks to shed light on some of the knowledge gaps discussed in Maputo.

Emerging findings from the project will be shared on the Vozes Desiguais blog, in English and Portuguese, and you can join the discussion via the blog, and on Twitter via #VozesDesiguais #UnequalVoices.

The ‘Unequal Voices’ research project was launched at the International Seminar on Accountability for Health Equity in Maputo, organised by N’weti Comunicação e Saúde, the leading Mozambican health rights NGO, and co-hosted with the Institute of Development Studies, and the DFID-, DANIDA and Irish Aid-funded Citizen Engagement Programme (CEP), Mozambique’s largest initiative working on social accountability in the health sector.

The views expressed in this opinion piece are those of the author/s and do not necessarily reflect the views or policies of IDS.

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