INFLUENCE OF GHIs ON MOZAMBIQUE PUBLIC HEALTH SYSTEM

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

Beijing - October 31st 2012By: Prof. Baltazar Chilundo (MD, PhD)

Dr. Tavares Madede (MD, Research fellow)

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

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) 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%

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?

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

What are the GHIs operating in Mozambique?

Malaria

Tuberculosis

HIV/AIDS

Vaccination

US President’s Malaria Initiative

GFATM

MultiCountry AIDS Programme (WB)

Catalytic Initiative

Health Problems/Issues GHIs

Stop TB Initiative

Treatment Acceleration Programme (WB)

US PEPFAR

Bill and Melinda Gates FoundationMaternal and Child Health

Clinton Foundation

Health Systemsstrengthening

GAVI

R2 & 7

R2, 6 & 9

R8

RED

RED

PEPFAR II

Has the availability of services increased due to GHIs?

Source: Administrative data_HMIS_MoH, Mozambique

2007 2008 2009 2010 20110%

10%

20%

30%

40%

50%

60%

70%

80%

11.2% 10.0% 11.1%

24.0% 23.0%

54.0%

51.9%55.1%

64.0% 63.0%

24.0%

47.0%

68.0%

69.0% 69.0%

Trends of selected MCH indicators: PMTCT coverage (GHI funded) compared to coverage of institutional deliveries and family planning

2007-2011Coverage of new clients on Family Planning Coverage of Institutional deliveries

PMTCT

Institutional de-liveries

Family Planning

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

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

2009 2010 2011

Performed 61 63.4 67

Planned 60 63 65

Minimum WHO standard 230 230 230

25

75

125

175

225

Ratio of health workers of specific health areas of medicine, nursing and MCH per 100,000 inhabitants . Source: BdPES DRH

2012

2009 2010 2011

Performed 1525 2170 1688

Planned NaN 2321 1650

Needs expressed in HRH plan

2263.745 3266.7525 3146.5

1250

1750

2250

2750

3250

# of new cadres graduated (basic and medium) of specific health

career. Source: BdPES DRH 2012

HRH: Gap between needs and capacity

Source: Hilde De Graeve,

Bert Schreuder.

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

and M&E relying on their implementing partners’ systems

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.

Kudos for me: I am Becoming 40 today!Thanks a lot

Obrigado谢谢

A health post from Nampula, Mozambique