Health Care Systems Evaluation - Mozambique


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Presentation for MSc Disaster Management & Sustainable Development (May 2011, Northumbria University)

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  • Mozambique and health care systemImpacts of flooding of 2000Strengths and weaknesses of the healthcare system, in terms of the themes of: political commitment, preparedness, procedures, participation, capacity building and cost effectivenessLessons and recommendations
  • Mozambique is located in south eastern AfricaArea of 799,380 km2The population of 23 million is approximately 62% rural and 38% urban.Portuguese is the official language, but other indigenous languages are also spoken.Life expectancy is just 52 years for women and 51 years for men.GDP per capita is estimated at $1000.Poverty is decreasing but remains high. Ranks 165 out of 169 countries in HDI 2010.
  • Mozambique is prone to a wide range of natural disasters, including floods, cyclones and droughts.These regularly cause major damage and set back economic growth in the disaster affected areas.High levels of vulnerability and susceptibility to climate changes has tremendous impact on Mozambique’s people, livestock, property, natural resources and physical infrastructure.Communicable diseases such as malaria and tuberculosis are also of significance, and HIV/AIDS is considered a slow onset disaster. Poverty and food shortages increase vulnerability and compound these issues, adversely affecting sustainable development and the achievement of Millennium Development Goals (Cosgrave et al. 2007). Natural disasters have the potential to overstretch, disrupt or destroy a country’s healthcare system.
  • Healthcare in Mozambique is provided by a combination of public, private and NGO agencies.The health budget is a priority for the government, but resources are scarce.In 2006/7, health expenditure was approximately 9% of total government expenditure.And in 2007/8, health expenditure was just $13 per capita.The Ministry of Health’s (MISAU) approach is based on primary healthcare (PHC), and the principle that all Mozambicans should have access to quality care at an equitable price (Access2Insulin).MISAU’s 2001-2005 Strategic Plan has as its aim for all Mozambicans to achieve health levels close to those of the rest of sub-Saharan Africa with access to basic health services and good quality through a health system that responds to its citizen's expectations. The mission to improve the health services is guided by the following principles:Efficiency and equity Flexibility and diversification Partnership and community participation Transparency and accountability Integration and coordination 70% foreign aid contribution to health sector
  • There are four levels of organisation in the public health system.The lowest level is through ‘health posts’ and ‘health centres’ offering essential primary health services.The second level includes rural hospitals, which are expected to have emergency care facilities.The third level includes provincial hospitals, and the final level includes central and specialised hospitals.There is a total of approximately 16,000 beds and 26,000 health workers.Variation between services and personnel at each level, and between districts/cities.The private sector generally works in large cities, while the non-profit sector mainly operates community health programmes.Traditional Doctors (Curandeiros) play an important role in providing healthcare to both rural and urban populations. As many people do not have access to modern medicine, Curandeiros are their only source of care.
  • Mozambique faces several challenges with regard to healthcare (Access2Insulin):Only 36% of the population have access to basic preventive and curative health services within 10km of their homes;High levels of communicable diseases exist, such as 18,000 cases of malaria per 100,000 of the population, and 11.5% of adults living with HIV/AIDS;There is a major lack of healthcare personnel, with just one ‘superior health personnel’ per 38,000 people, and just 400 Mozambican doctors;Resources are not equally allocated throughout the country: there are urban-rural and rich-poor divisions;There is a general lack of resources, from desks and paper, to medical equipment and medicines, and some facilities lack running water and electricity.
  • The government established a national institute for disaster management in 2000 – INGC - took over from an earlier logistics-based structure that had delivered food and non-food assistance to those displaced by the war, and those affected by other disasters.In 2006, a new head was appointed to lead INGC, Mr Paulo Zucula, and he emphasised the coordination role of the agency over its former operational one. The INGC built a number of regional centres for managing emergency operations.The operational response to emergencies is managed by the National Emergency Operations Centre – CENOE - component of INGC. CENOE has several centres around the country which serve as the operations rooms for emergency response. In an emergency, personnel are drawn from the national level of INGC and from the governments of the affected provinces staff the CENOE.Cosgrave J, Gonçalves C, Martyris D, Polastro R, and M Sikumba-Dils
  • Heavy rain in December 1999 and January 2000 was followed by cyclones Connie and Eline hitting southern and central Mozambique respectively.This led to widespread flooding covering approximately 30,000 km2.Approximately 700 people died, 45,000 were rescued, and 500,000 had to leave their homes (Cosgrave et al. 2007). The World Bank estimated that losses, damage, and reconstruction costs from Eline were equivalent to 20% of the Mozambican gross national product (Cosgrave J, Gonçalves C, Martyris D, Polastro R, and M Sikumba-Dils)Flooding on the Zambezi has a long history, with major floods every five to ten years. Before the construction of the Kariba Dam in 1959, there was an annual flood in February or March. The new dam halted these annual floods. The lack of annual flooding encouraged encroachment on the lowlands in the lower Zambezi (Cosgrave J, Gonçalves C, Martyris D, Polastro R, and M Sikumba-Dils)
  • Political commitment: investments in EWS; MISAU and INGC well organised; EW taken seriously; leave during December and January was cancelled for key officials.Preparedness: excellent contingency plans built into disaster planning at national, provincial and district levels, but the quality of the plans varied widely: poor in affected areas. INGC organised workshops and training involving fire and police services, scouts, the Red Cross and religious bodies. Technical committees started meeting fortnightly following weather warnings from September 1999. MISAU instructed provincial health directors to prepare for the floods and cholera: medicines for distribution in early 2000 were dispatched early. Despite all the preparation, limited media coverage led to it having little impact on public awareness and action. Lack of malaria epidemic due to concerted effort of MISAU, Unicef and NGOs – promoted nets, sprayed insecticide in accommodation centres and switched drug treatment to single dose. However, continuing increase of malaria due to small ponds persisting for several years; increasing resistance and increasing AIDS.Procedures: MISAU is one the most well organised service delivery ministries. The aid dependency created by complex emergency lasting a decade proved useful as they were adept at administering aid. They prepared information guides for incoming personnel, including information about Mozambique, important illnesses and priority actions. They asked all personnel to register on arrival and to stay in contact. MISAU was anxious for recovery operations to be well coordinated through local and foreign agencies, and to follow MISAU policies. Unfortunately some agencies and personnel created tensions by marginalising local and provincial authorities, ignoring plans and preparation, rarely reporting to MISAU, and trying to replace the existing health system rather than working with it. MISAU had to publish a list of agencies authorised to work in health, and threatened to expel anyone else not cooperating. This did improve operations, but some damage had already been done. Poor relationships with some NGOs: Spanish military field hospital, European NGO with medical students; NGOs only coming for a week; inappropriate and chaotic delivery of medicine donations.The International Federation of Red Cross and Red Crescent Societies (IFRC) was quick to support the Mozambican Red Cross (CVM) and international societies helped set up regional offices. The IFRC changed policy following its poor experience during Hurricane Mitch, and encouraged bilateral cooperation. However, IFRC demanded information before issuing an appeal, and CVM felt that this hindered operations (Christie & Hanlon 2001).Participation: one of the guiding principles of MISAU, e.g. Community health volunteers, but this has not trickled down in terms of awareness and preparedness. However, the volunteers of CVM proved to be highly effective. CVM worked closely with MISAU from the beginning, participating in workshops and training exercises, and mobilising themselves. Over 600 volunteers set up health posts in accommodation centres and resettlement areas, and helped 300,000 people. Most are vulnerable themselves - some even lost everything – but they still helped. However CVM also had some lessons from 2000, the main one being that they had cut back too much on the operational side in the post-war period: they did not have enough warehouses, which hampered transport and logistics.Cost effectiveness: developing country with limited resources. The cost of the relief operation was estimated at $65 million. The health service was completely overstretched and needed substantial outside assistance (Christie & Hanlon 2001), but this is ‘situation normal’ in Mozambique, where 70% of the health sector is funded by foreign aid contributions. CVM proves cost effective, spending just $25 per volunteer per year, training them in sanitation, first aid and basic healthcare. However, they had to pay volunteers more to stop other agencies poaching them, and also spent money processing donations which arrived months after they would be useful.Capacity building: technical skills are low at MISAU and INGC, but commitment is high. They worked hard on training in the build up to the disaster. An unfortunate weakness is a ‘brain drain’ to the private sector, which discourages extensive capacity building .
  • While preparedness was good at national and agency level, community and district level programmes were limited: Increase support for community and district DRR in the ongoing development programmes (Cosgrave J, Gonçalves C, Martyris D, Polastro R, and M Sikumba-Dils). The INGC simulation exercise contributed to the quality of the response: All clusters should play a full role in the annual simulation by INGC (Cosgrave J, Gonçalves C, Martyris D, Polastro R, and M Sikumba-Dils).Planning must involve local residents: Mobilise local leaders to review and update preparations with people’s participation (C&A)Continue excellent capacity building training and exercises, but need to work on involving community members: Train teachers as flood watch monitors and escape route wardens (C&A)(Procedures) Need better coordination and control over agencies and donationsLow cost solutions must continue to be sought due to limited resources: One of the poorest countries in the world so needs methods that do not divert too many resources. Defences are expensive – evacuation should be strategy. Provide facilities for people to bring and store valuables in safety zones, including safety zones for cattle. Use radio for flood warnings. Clearly defined escape routes and safety zones, e.g. Roofs of strong buildings, perpendicular to river courses.2007 floods: clear payback from preparedness, in terms of communities and agencies. BUT, level of contingency planning of agencies varied. Those based on INGC were best. 2006 simulation exercise developed links and identified potential problems.Still to be tested to extent of 2000 floods.Government still prioritises resettlement to higher ground as DRR measure, but failed in the past due to livelihood impact.
  • Preparedness:Support district and local level planningEnsure EWS reaches communities – better media coverage; use radios; communities can determine best communication methodParticipatory:Communities involved in own planningVoluntary roles: CVM; first aid, flood watch and escape route wardens, search and rescue, health monitoring, community health volunteers – probably need some incentivesCost effective:Decentralised, communitarian – community self-careCoordinated:Better control over agenciesCapacity building:National, district and local levelsMulti-purpose, community-managed cyclone shelters. Can be used for education or community activities in ‘normal’ times. Communities can store valuables and stock medicines and supplies in preparation for emergencies.
  • Health Care Systems Evaluation - Mozambique

    2. 2. Structure of Presentation2  Mozambique and health care system  Impacts of flooding of 2000  Strengths and weaknesses of the healthcare system, in terms of the themes of: political commitment, preparedness, procedures, participation, ca pacity building and cost effectiveness  Lessons and recommendations
    3. 3. Mozambique 3  Area: 799,380 km2 (UK: 243,610 km2)  Population: 23 million (2010)  Urban population: 38% (2010)  Life expectancy: 52 years (women), 51 years (men) (2010)  GDP per capita: US$1000 (2010 est.)Sources: BBC; CIA; UN; UNDP Source: Orant Charities
    4. 4. Natural Hazard Risks in 4 Mozambique Risk Direct Impacts Indirect Impacts Flood Drowning; injuries; water Damage to health borne and vector transmitted infrastructure; food shortages disease Cyclon Injuries; trauma; asphyxiation; Water borne and vector e electrocution; drowning; transmitted disease; damage mental health effects to health infrastructure; food shortages Drough Reduced food intake; protein- Communicable diseases; lack t energy malnutrition; of water and sanitation micronutrient deficiency services; displacement  Massive impacts due to high vulnerability of population  Natural disasters set back economic growthCosgrave et al. (2007)WHO (2009)
    5. 5. Health Care System 5  Public sector complemented by private sector and NGOs1  Ministry of Health - Ministerio de Saude (MISAU) spent US $167.8 million in 2001, or 9% of total government expenditure in 2006/71  $13 per capita in 2007/81  2001-2005 Strategic Plan: all Mozambicans to achieve health levels close to rest of Sub-Saharan Africa, with access to basic, good quality health services, through a system that responds to its citizens‟ expectations2  70% foreign aid contribution to health sector21 WHO (2009)2 IIF (no date)
    6. 6. Levels of Organisation 6 Central Hospitals: 3 Psychiatric Hospitals: 2 Provincial Hospitals: 7 (3.5 million people each) Rural Hospitals: 41 (570,731 people each) Health Centres and Posts: 1224 (19,117 people each) Curandeiro sAdapted from WHO (2009)
    7. 7. Challenges 7  Only 36% of population have access to basic preventive and curative health services within 10km of their home1  High levels of communicable diseases, e.g. Malaria: over 18,000 cases per 100,0001  HIV/AIDS: 11.5% of adults (2009)2  Lack of personnel (599 superior health personnel) 1  Lack of resources: medical equipment, medicines, desks, paper, etc. 1  Unequal allocation of resources: urban-rural, rich-poor11 IIF (no date)2 CIA
    8. 8. Disaster Management Structures 8  National institute for disaster management established in 2000 – INGC – Instituto Nacional de Gestao de Calamidades  Paulo Zucula appointed as head in 2006 – emphasised coordination role over operational role  INGC regional centres for managing emergency operations  Operational response managed by National Emergency response Centre – CENOE – Centro Nacional Operativo de Emergencia  Component of INGC  Centres around the country that serve as operations rooms for emergency responseCosgrave et al. (2007)
    9. 9. Impact of Disaster: Floods of 2000 9  Heavy rain Dec 1999 and Jan 2000  Two cyclones in Feb 2000  Flooded area size of The Netherlands  700 people died, mostly by drowning  Some health centres destroyed or damaged  Losses of drugs, equipment and furniture  Inaccessible health centresCairncross & Alvarinho (2007) Source: Reliefweb
    10. 10. Strengths and Weaknesses 10 Theme Strengths Weaknesses Political Early Warning Systems Scarce resources commitment Taken seriously: leave cancelled Preparednes Contingency planning built into Quality of plans varied at local s disaster planning1 level1 Training and meetings following Preparation had little impact on warnings1 public awareness1 Procedures MISAU asked personnel to Poor control over NGOs: rarely register and work with health reported and tried to replace system2 health system; poor Good relations with MSF, relationships2 Unicef2 Participation CVM helped 300,000 people2 Poaching by other agencies2 Capacity Commitment and training2 Brain drain to private sector2 building1 Cairncross & Alvarinho (2007)2 Christie & Hanlon (2001)
    11. 11. Lessons: Disaster Management 11  Continue to prioritise preparedness and EWS: simulation exercises with full participation by all clusters1  Increase support for community and district DRR in development programmes1: planning must involve local people2  Better coordination and control over agencies: NGO code of conduct3  Seek cost effective solutions: evacuation over structural measures2  Link clear and simple flood warnings to previous floods2  Storage facilities for valuables and livestock2  Resettlement to higher ground is priority but impacts on1 Cosgrave et livelihoods1 al. (2007)2 Cairncross & Alvarinho (2007)3 Foley (2007)
    12. 12. Lessons: Healthcare System12 Preparednes Support local and district s planning; Ensure EWS reaches communities: better media coverage, radios Procedures Better control over agencies Source: Swiss Cooperation Participation Communities should be involved in own DM planning; Expand voluntary roles: CHVs, health monitoring, first aid, CVM, etc. Capacity At local, district and national building levels; „Train the Trainer‟ Cost “Community self care”; effectivenes Voluntary roles;
    13. 13. 13THANK YOU
    14. 14. References14  BBC, Mozambique Country Profile, Available online: (Accessed 27 March 2011)  Cairncross, S. & Alvarinho, M. J. C. The Mozambique Floods of 2000 in Matthies, F. & Few, R. (2007) Flood hazards and health : responding to present and future risks, London, Earthscan  Christie, F. & Hanlon, J. (2001) Mozambique & the great flood of 2000, Oxford, James Currey  CIA, World Factbook: Mozambique, Available online: (Accessed 16 May 2011)  Connolly, M. A. (ed.) (2005) Communicable disease control in emergencies: a field manual, WHO France  Cosgrave J, Gonçalves C, Martyris D, Polastro R, and M Sikumba-Dils (2007) Inter-agency real-time evaluation of the response to the February 2007 floods and cyclone in Mozambique, Available online: (Accessed 27 March 2011)  Foley, C. (2007) Mozambique: A case study in the role of the affected state in humanitarian action, HPG Working Paper, September 2007, Overseas Development Institute, London  GFDRR, Handbook for Reconstructing after natural disasters, Chapter 13 Institutional Options for Reconstruction Management, Available online: (Accessed 14 May 2011)  International Insulin Foundation, Available online: (Accessed 27 March 2011)  Lehmann, U., Van Damme, W., Barten, F. & Sanders, D. (2009) Task shifting: the answer to the human resources crisis in Africa? Human Resources for Health 2009, 7:49  Merlin (2009) Policy: Health and Disaster Risk Reduction, February 2009, London  Orant Charities, Map of Mozambique, Available online: (Accessed 16 May 2011)  Pfeiffer, J., Johnson, W., Fort, M., Shakow, A., Hagopian, A., Gloyd, S. & Gimbel-Sherr, K. (2008) Strengthening Health Systems in Poor Countries: A Code of Conduct for Nongovernmental Organizations, American Journal of Public Health, December 2008, 98(12), pp.2134-2140  Reliefweb (2000) Mozambique Flood Affected Population Map Feb 2000, Available online: (Accessed 2 May 2011)  Shoaf, K. I. & Rottman, S. J. (2000) Public health impact of disasters, Australian Journal of Emergency Management, Spring 2000, pp.58-63  Tekeli-Yeşil, S. (2006) Public health and natural disasters: disaster preparedness and response in health systems, Journal of Public Health, 14, pp.317–324  United Nations, UN Data: Mozambique, Available online: (Accessed 27 March 2011)