As I explored in my previous blog, the health sector and provision of health services in Mozambique is an uneven playing field. Since 1980 it has been shaped by a range of donors who have strategically positioned themselves according to their political weight and ability to contribute with ‘commodities’ and financial resources.
Although donors’ contributions are critical to guaranteeing immediate responses to unmet health needs in Mozambique, they are leading to a fragmented approach that is resulting in a health system driven by donor agendas rather than the needs of citizens, where accountability is weak and in which health inequities are reproduced.
The impact of an externally driven health agenda on health systems in Mozambique
Health interventions, from estimates of the magnitude of epidemics to the definition of health priorities, are largely defined by different donors’ and INGOs’ interests. Through elective and selective approaches, donors and INGOs establish pockets of ‘pilot tests’ and ‘excellence in packages of services’ that are occasionally appropriated and institutionalised by the Ministry of Health.
In a fragmented framework of health service provision where some illnesses and services are covered and strengthened but many others remain neglected, governmental institutions are weakened. If a donor is unsatisfied with a Ministry of Health procedures – generally related to evidence of bad management of resources, availability of audit reports, or low fulfilment of certain targets – they can simply retract their support.
In the late 90s the Mozambican Government and donor agencies established a common fund mechanism for the health sector – the Sector-wide Approach (SWAp). 12 years later, almost all donors have pulled out from the basket funding mechanism, complaining of a lack of transparency. At the same time the Mozambican government was concerned about the lack of donors’ commitment and late funds disbursements. This has left gaps in the flow of service provision, contributing to the creation and reproduction of islands of inequity and the lack of a more holistic and structured design for the national health system.
As highlighted in a recent UNICEF 2017 Health Budget Brief, the health sector receives around 7 per cent of the state budget and half of this budget ends up covering administrative costs at central level rather than meeting the health needs of citizens. The Mozambican public must advocate for the establishment and consolidation of a more holistic, cohesive and structurally consistent health system, with clear lines of accountability and long term goals. Without citizens engagement, Mozambican health system will remain vulnerable to the whims of different flows of donor programme funding and a lack of government commitment to allocate the appropriate resources to provide essential and basic health services. The discussion about health system reform and policy choices has been postponed far too long and is hampering the possibilities of delivering health services in a more equitable and sustainable manner.
The challenges around citizen engagement
Citizen rights remain at the base of the pyramid of the service provision hierarchy. The citizen receives knowledge about the health system in a vague, fragmented, concessionary process, as if it was a favour to guarantee them access to information on health. As highlighted in a 2014 Citizen Engagement Program (CEP) report, citizens have been denied any opportunity to discuss and contribute to the improvement of the health system, with the exception of election periods, when political parties visit communities with vague promises of building health centres and improving access which barely happens.
Importantly, citizen engagement projects (using community score cards and social audits methods) on related accountability issues are still new (initiated in the last seven years) and they are still far from providing substantial results or gains. What’s more, just as all of the formal health service provision system is stimulated by foreign aid, the awareness-raising movement is also catalysed and galvanised by related programmes and specific donors, with ample participation from international and national NGOs. While there are indigenous examples of citizen engagement and participation at a local level which contribute to the outlining of content and courses of action in health (such as Health Community Councils), they are quite limited and circumscribed, and the results tend to confirm the rule.
The possibility of establishing more cross-cutting efficient structures for accountability seems distant given that state-provided services, have been historically perceived as a gift, something generously provided by the goodwill of the party, government or the donor for which the citizen should be ‘appreciative’.
This is the second in a series of three blogs written by Denise Namburete based on her research for Unequal Voices. In this series, Denise delves into some of the challenges that the national health system in Mozambique faces, from the lack of a common health agenda which is mostly externally-driven and the lack of accountability of the government and of international actors, to the absence of participation by the citizen-user in the health system.