ParâmetroValorPopulação total (em milhões projectada com base no Censo 2007 para 2011) (7)23.7População vivendo abaixo da linha de pobreza (%) (Relatório ODM Moçambique, 2010) (8)54%Taxa de mortalidade em menores de 5 anos /1.000 nados vivos (MICS 2008) (6)138Rácio de Mortalidade Materna/100.000 nados vivos (Censo 2007) (7)597Taxa de prevalência do HIV em adultos dos 15 aos 49 anos de idade (INSIDA, 2009) (9)11.5%Parasitémia da Malária em crianças menores de 5 anos (IIM, 07)(12)38.5%Taxa de prevalência de TB/100.000 pessoas (8)504Esperança de vida (anos)49.4Proporção de ajuda externa conferida ao país em 2010 (Portal de Governo, 2011) (15)44Proporção de ajuda externa ao sector de saúde em 2008 (14)73%
GHIs in Mozambique
INFLUENCE OF GHIs ON MOZAMBIQUE HEALTH SYSTEM GHIs in AFRICA funded by the EU 6th framework INCO-DEV program. INCO contract no. 032371 COHRED Forum 2012 – Capetown By: Baltazar Chilundo (MD, PhD) Tavares Madede (MD, Research fellow)DEPARTMENT OF COMMUNITY HEALTH, FACULTY OF MEDICINE, EDUARDO MONDLANE UNIVERSITY
BackgroundParameters ValueTotal Population (in million – projection based on 2007 census) 23.7Children (population below 19 years of age) (in million – 12.3projection based on 2007 census)People living below the poverty line (%) (Mozambique MDG 54%report, 2010)Under five mortality rate/1,000 live births (MICS 2008) 138Maternal mortality ration/100,000 live births (2007 Census) 597HIV prevalence rate among pregnant women (INSIDA, 2009) 11.5%Malaria parasitaemia among children under five (MIS, 07) 38.5%TB prevalence rate/100,000 people (WHO, 2008) 504Proportion 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 (provincial and district) levels? – Has funding/spending increased for the health systems due to GHIs? – Has the availability of services increased due to GHIs? – What has been the influence of GHIs on infrastructures? – How have GHIs affected health workers availability and performance in the public health sector, particularly at the facility level? – What is the contribution of GHIs to aid effectiveness? – What is the influence of GHIs on equity, 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) – Secondary data and 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 inHealth Problems/Issues Mozambique?GHIsMalaria US President’s Malaria Initiative R2 & 7 GFATMTuberculosis R2, 6 & 9 Stop TB Initiative MultiCountry AIDS Programme (WB)HIV/AIDS Treatment Acceleration Programme (WB) R8Health Systems PEPFAR II US PEPFARstrengthening RED Clinton FoundationMaternal and ChildHealth Bill and Melinda Gates Foundation Vaccination RED Catalytic Initiative GAVI
GFATM Support Channel Principal Reciepients Civil Society FDC (HIV) MISAU Prophylaxis, Prevention and COMMON FUND care & treatmentlogistics support to (R6&7) and HSSthe NHS (from R9) World Vision Vertical fund (R8 & 9) (malária) Secondary sectors involved NATIONAL CBOs NGOs FBOs CBOs HEALTH SYSTEMCCM led by the government, UN family and civil societyMoved from Common funds to vertical mechanisms but reflected only at the national level
PEPFAR Support Channel US Government, Department of State HHS/CDC USAID USG AGENCIESEGPAF MISAU FHI JHU ICAP e.g. of SOME PRIME PARTNERS NATIONAL e.g. of SOME SUB- HEALTH NGOs FBOs CBOs PARTNERS SYSTEMMinistry of Health mainly seen as implementing partner at the same level as CBOs/ NGOs Off-budget, vertical support reflected on the ground
Has funding/spending increased for the health systems due Decrease of both to GHIs? State budget and vertical funds Health expenditure 2001 - 2011: boost of earmarked funds 100% 600 Total Expenditire (US$ 10^6) 90% 500 80% 70% 400 60% 50% 300 40% 200 30% 20% Source: MISAU (2011) 100 10% 0% 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Vertical Funds 75 75 75 85 130 141 150 300 203 205 189Common Funds 17 20 37 63 106 99 125 74 79 86 90Government budget 70 82 96 105 104 108 127 138 126 150 133Total Expenditure 162 177 208 253 340 348 402 512 408 441 412
Has the availability of services increased due to GHIs? PMTCT coverage sharp increase as a result of GHIs (HIV) compared to a steady/stagnant status of other MCH programs 2003-2008 80 35 PMTCT & Contraceptive coverage (%) 70 30 70 71 67 67.5 60 63 62 25Vaccines coverage (%) 61 60 59 58 50 Contraceptive Coverage 20 40 18.2 17.8 17.4 17 16.6 16.2 15 30 10 20 10 5 0 0 2003 2004 2005 2006 2007 2008 Source: Mozambique MDG report, 2010
Access, need and coverage of anti-retroviral treatment of patients over 15 years of age 350000 in Mozambique, 2003-2010 325053 100% 296207 90% 300000 269124 80% 244774 250000 70% 223055 % Adult Coverage 202169 60% 200000Patients (N) 181298 160639 156688 201596 50% 150000 40% 118937 100000 30% 82001 20% 50000 40684 17325 10% 4% 30322% 6779 9% 18% 34% 44% 53% 62% 0 0% 2003 2004 2005 2006 2007 2008 2009 2010 14/05/12 Coverage Over 15Y receiving ART 10 Total people in need Source: MISAU-CCS 2011
What has been the influence of GHIs on infrastructures? HEALTH UNIT Lab/ HEALTH UNIT Pharmacy Lab/ Outpatient Inpatient Pharmacy Other ATS services Outpatient Inpatient(VCT) Other Day services Hospital TB HIV Lab & Pharmacy Service Now, all services are fully integrated (ART) including management of HRH, but still weak ATS (VCT) FIGURES OF FRAGMENTATION FIGURES OF INTEGRATION F BEFORE Y2006 ROM Y2006AIDS seen as an emergency, partners AIDS acknowledged as a chronicsupporting with little condition… Reorganization of the NHScontrol/coordination. towards sustainability.
What has been the influence of GHIs on infrastructures?• At the begining of GHI investiment on HIV
What has been the influence of GHIs on infrastructures?• Integration from 2006 (political decision by MISAU)
How have GHIs affected health workeravailability and performance in the public health sector?Health partners funded by PEPFAR/GFATM tend to be moreattractive in terms of incentives and are hiring the mostexperienced 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 HealthStill recently NGOs (e.g. ITECH funded by PEPFAR) areproviding support to MISAU for in-service and pre-servicetraining mainly oriented to the areas of their interest So, NGOs are seen as acting in a double-edged fashion: while contributing to low-level staff retention, through support of training and payment of some incentives, they are also held responsible for recruiting the best public sector cadres
HRH – Remarks from the national and subnational interviewsThe latest health sector human resource development plan(2008‐2015) clearly lays out strategies that can be used tostrengthen the workforce in terms ofmotivation, retention, availability and so, for betterperformance…but it demands funding that could come from GHIsThe rapid "scale up" of ART services had negative effect on thequality of services provided by the health system due to workoverload as the level of HRH availability did not change at all
What is the contribution of GHIs on aid effectiveness?• A significant proportion of health, especially HIV/AIDS related, USG aid, is still channeled according to donor defined priorities and through NGOs“well we want to diversify the risk. We don’t want to put all our eggs in one basket” - Partner representative• Unpredictability of disbursements (e.g. GFATM)
What is the influence of GHIs on equity, HMIS and M&E? • Geo-discrepancy on service delivery and around M&E: – Multiple programs being simultaneously implemented. – funding partners targeting specific provinces – Within each province an agency often covers only one or a few districts – Separate evaluations and inefficient – Inability to compare results given differences on objectives, approaches and indicators – PEPFAR seems to promote parallel HMIS and M&E relying on their implementing partners’ systems – GFATM fights to improve the HMIS and Source: M&E systems and so, has providedHilde De Graeve, capacity building in this direction. Bert Schreuder.
Partial 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• The vertical nature of GHIs stresses the ongoing efforts of harmonization and alignment• GHIs do affect HRH availability and performance both negatively and positively• 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.