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%
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
Influence of GHIs on Mozambique public health system
INFLUENCE OF GHIs ON MOZAMBIQUE PUBLIC HEALTH SYSTEM GHIs in AFRICA funded by the EU 6th framework INCO-DEV program. INCO contract no. 032371 Beijing - October 31st 2012 By: Prof. Baltazar Chilundo (MD, PhD) Dr. Tavares Madede (MD, Research fellow)DEPARTMENT OF COMMUNITY HEALTH, FACULTY OF MEDICINE, EDUARDO MONDLANE UNIVERSITY, MOZAMBIQUE
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) 500.1HIV 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) 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 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
Has the availability of services increased due to GHIs? Trends of selected MCH indicators: PMTCT coverage (GHI funded) compared to coverage of institutional deliveries and family planning 2007-201180% Coverage of new clients on Family Planning Coverage of Institutional deliveries Coverage of PMTCT 69.0% 69.0%70% 68.0%60% Institutional 64.0% 63.0% deliveries 51.9%50% 54.0% 55.1% 47.0%40% PMTCT30%20% 24.0% 24.0% 23.0% Family Planning10% 11.2% 10.0% 11.1%0% 2007 2008 2009 2010 2011 Source: Administrative data_HMIS_MoH, Mozambique
How have GHIs affected health workeravailability 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 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
HRH: Gap between needs and capacity Ratio of health workers of specific # of new cadres graduated (basic health areas of medicine, nursing and and medium) of specific health MCH per 100,000 inhabitants . Source: BdPES career. Source: BdPES DRH 2012 DRH 2012 3500 250 3000 200 2500 150 2000 100 1500 50 1000 0 2009 2010 2011 2009 2010 2011 Performed 1525 2170 1688 Performed 61 63.4 67 Planned 2321 1650 Planned 60 63 65 Needs Minimum 230 230 230 expressed in 2264 3267 3147 WHO standard HRH plan
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 Source:Hilde De Graeve, and M&E relying on their implementing Bert Schreuder. 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 postfromNampula, Mozambique