Report of Tavares Madede (UEM) presented at the COHRED forum 2012 on the INCO-GHI research project

1. 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

2. Background
Parameters Value
Total Population (in million – projection based on 2007 census) 23.7
Children (population below 19 years of age) (in million – 12.3
projection 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) 138
Maternal mortality ration/100,000 live births (2007 Census) 597
HIV 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) 504
Proportion of aid by external partners in 2008 (MISAU, 2008) 73%

3. 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?

4. 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

5. What are the GHIs operating in
Health Problems/Issues
Mozambique?GHIs
Malaria US President’s Malaria Initiative
R2 & 7 GFATM
Tuberculosis
R2, 6 & 9 Stop TB Initiative
MultiCountry AIDS Programme (WB)
HIV/AIDS
Treatment Acceleration Programme (WB)
R8
Health Systems PEPFAR II US PEPFAR
strengthening
RED Clinton Foundation
Maternal and Child
Health Bill and Melinda Gates Foundation
Vaccination RED
Catalytic Initiative
GAVI

6. GFATM Support Channel
Principal Reciepients
Civil Society FDC (HIV) MISAU Prophylaxis,
Prevention and
COMMON FUND care & treatment
logistics support to (R6&7) and HSS
the NHS (from R9) World Vision Vertical fund (R8 & 9)
(malária)
Secondary sectors involved
NATIONAL
CBOs NGOs FBOs CBOs HEALTH
SYSTEM
CCM led by the government, UN family and civil society
Moved from Common funds to vertical mechanisms but reflected only at the national level

7. PEPFAR Support Channel
US Government,
Department of State
HHS/CDC USAID USG AGENCIES
EGPAF MISAU FHI JHU ICAP e.g. of SOME PRIME
PARTNERS
NATIONAL e.g. of SOME SUB-
HEALTH NGOs FBOs CBOs PARTNERS
SYSTEM
Ministry of Health mainly seen as implementing partner at the same level as CBOs/ NGOs
Off-budget, vertical support reflected on the ground

8. 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 2011
Vertical Funds 75 75 75 85 130 141 150 300 203 205 189
Common Funds 17 20 37 63 106 99 125 74 79 86 90
Government budget 70 82 96 105 104 108 127 138 126 150 133
Total Expenditure 162 177 208 253 340 348 402 512 408 441 412

9. 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
25
Vaccines 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

10. 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%
200000
Patients (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

11. 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 Y2006
AIDS seen as an emergency, partners AIDS acknowledged as a chronic
supporting with little condition… Reorganization of the NHS
control/coordination. towards sustainability.

12. What has been the influence of GHIs on
infrastructures?
• At the begining of GHI investiment on HIV

13. What has been the influence of GHIs on
infrastructures?
• Integration from 2006 (political decision by MISAU)

14. 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
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

15. 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

16. 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)

17. 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 provided
Hilde De Graeve, capacity building in this direction.
Bert Schreuder.

18. 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.