5150.pdf
Media
- extracted text
-
WH0/IC0/MESD.14
Original: English
“Macroeconomics,
Health and
Development” Series
Number 14
Dlatributton: Limited
The public health
sector in Mozambique:
a post-war strategy for
rehabilitation and
sustained
development
Mozambique
Country Paper
I
World Health Organization
Geneva, May 1994
05151
OSlcTO
“Macroeconomics, Health and Development” Series, No. 14
Other titles in the “Macroeconomics, Health and Development ” Series are:
I
No. 1: Macroeconomic Evolution and the Health Sector: Guinea, Country
Paper—WHO/ICO/MESD.1
No. 2: Une methodologie pour le calcul des couts des soins de sante et
leur recouvrement: Document technique, Guinee—WHO/ICO/
MESD.2
No. 3: Debt for Health Swaps: A source of additional finance for the
health system: Technical Paper—WHO/ICO/MESD.3
No. 4: Macroeconomic Adjustment and Health: A survey: Technical
Paper—WHO/ICO/MESD.4
No. 5: La place de I’aide exterieure dans le secteur medical au Tchad:
Etude de pays, Tchad—WHO/ICO/MESD.5
No. 6: L’influence de la participation financiere des populations sur la
demande de soins de sante : Une aide a la reflexion pour les pays
les plus demunis : Principes directeurs—WHO/ICO/MESD.6
No. 7: Planning and Implementing Health Insurance in Developing coun
tries: Guidelinesand Case Studies: Guiding Principles—WHO/ICO/
MESD.7
No. 8: Macroeconomic Changes in the Health Sector in Guinea-Bissau:
Country Paper—WHO/ICO/MESD.8
No. 9: Macroeconomic Development and the Health Sector in Malawi:
Country Paper—WHO/ICO/MESD.9
No. 10: Macroeconomic Adjustment and its Impact on the Health Sector in
Bolivia: Country Paper—WHO/ICO/MESD.10
No. 11 The Macroeconomy and Health Sector Financing in Nepal:
A medium-term perspective: Nepal, Country Paper—
WHO/ICO/MESD.11
No. 12 Towards a Framework for Health Insurance Development in
Hai Phong, Viet Nam: Technical Paper—WHO/ICO/MESD.12
No. 13 Guide pour la conduite d’un processus de Table ronde
sectorielle sur la sante : Principes directeurs—WHO/ICO/MESD.13
I
to
The public health sector
in Mozambique: a post-war
strategy for rehabilitation
and sustained development
by
Abdul Razak Noormahomed
National Director of Planning and Cooperation
Ministry of Health
Mozambique
and
Malcolm Segall
Consultant and Head of Health Unit
Institute of Development Studies
University of Sussex
England
9
4 .
*
I
%
The Project for the Revision of some Aspects of National Health Policy
(PRANHP) is managed by the National Directorate of Planning and Coopera
tion of the Ministry of Health with the technical assistance of the Health Unit of
Institute of Development Studies, University of Sussex, England.
The project is supported by grants from the World Health Organization, as part
of the Intensified Cooperation with Mozambique.
This document was written originally in Portuguese under the title: "O Sector
Publico de Saude em Mozambique: uma Estrategia Pos-Guerra de Reabilitaqab
e de Desenvolvimento Sustentado”. This English version was translated and
edited by Malcolm Segall.
This document is not issued to the general public, and all rights are reserved by
the World Health Organization (WHO). The document may not be reviewed,
abstracted, quoted, reproduced or translated, in part or in whole, without the prior
written permission of WHO. No part of tliis document may be stored in a retrieval
system or transmitted in any form or by any means—electronic, mechanical or
other—without the prior written permission of WHO.
r
I
The views expressed in documents by named authors are solely the responsi
bility of those authors.
>
Hg - \oo
/<
05151
/dy
Printed in &93bfwHO
V*
1
A
LIBRARY
AND
DOCUMENTATION
;
UNIT
■
i
-
CONTENTS
Page
I
PREFACE
INTRODUCTION
1
Scope of the work .
7
Structure of the document
8
METHODOLOGICAL NOTES
10
EVOLUTION AND FINANCING OF HEALTH RESOURCES SINCE 1980
14
Recurrent health resources financed from internal
sources: government and user fees
14
Expenditure in current prices
Real expenditure and resources
A
14
19
Recurrent health resources financed by international aid
25
Total recurrent health expenditure
25
Availability of real health resources
31
Drugs
Other operating items
Health personnel . .
31
33
33
Investment health expenditure
34
Total health expenditures .
37
Summary of main conclusions
37
TRENDS IN THE DISTRIBUTION OF RECURRENT HEALTH RESOURCES
42
Distribution between levels of health care
42
Distribution between urban and rural areas
45
Distribution between provinces
47
Summary of main conclusions
49
(i)
Page
POLICIES FOR THE REHABILITATION OF THE PUBLIC HEALTH SECTOR
IN THE MEDIUM TERM
51
Principles and priorities .
51
General
Rehabilitation of the health care system
Health personnel
Drugs and other operating items . . . .
Maintenance and management
International aid
Strategy for health services rehabilitation
Rural and general hospitals
Rural primary level facilities
Rural district halth management and supervision
Urban primary level units
Urban hospital services
THE REHABILITATION STRATEGY:
COSTS AND FINANCING .
51
51
55
55
55
56
59
60
65
67
68
68
70
70
Cost estimates
70
73
76
Investment costs
Recurrent costs
Drug costs . . .
Financing strategy
80
Investment costs
Recurrent costs: scenarios with and without
a social security health fund
Scenario with a social security health fund . .
Scenario without a social security health fund
Composition of international aid
80
80
81
83
86
THE NEXT STEPS
89
LIST OF TABLES 1-36
91
ACRONYMS
94
(ii)
*
PREFACE
<
has
lived
aa period
of
great
lived through
Mozambique
in
recent
years,
both
economically
and
difficulties
As
a
result
of
the
war
millions
of
people
militarily.
have had to flee from their homes; many have been forced
to live in camps or to take shelter in neighbouring
countries.
They have had to survive in very poor
conditions and their states of nutrition and health have
deteriorated as a consequence.
On top of all this, the
country has experienced recently one of the most serious
droughts of modern times.
The health services have not been immune to these
difficulties: hundreds of rural health units have been
looted, destroyed or forced to close; health workers have
been targeted for attack and have had to take refuge in
urban
areas;
urban
health
facilities
have
become
overloaded as a result of the migration of rural people
to the towns; the government health budget has decreased
radically in real terms; and the real value of health
worker salaries has fallen dramatically.
Parallel with these developments, the government has
implemented an Economic and Social Recovery Programme
with the support of the international community.
This
programme has had some positive economic impact, but it
has also added to the financial and social problems of
many of the poor. On the political front, the country is
now moving towards a multiparty system and discussions
are taking place to reach a peace agreement.
It was in this context of multiple difficulties and
change that the Project for the Revision of some Aspects
of National Health Policy (PRANHP) was initiated towards
the end of 1989 with the financial support of the World
Health Organisation.
The purpose of the project was to
review national health policies in the light of the
current social and economic realities.
In particular,
the policies were to be adapted to the economic situation
and were to form the basis of a realistic strategy for
rehabilitation of the health system after the war.
*
j
has concentrated on three main areas: an
The project
economic analysis of the Mozambican health sector and the
and
development
of
feasible
resource
projections
future
financing
strategies
for
the
medium
term
(including the roles to be played by the government and
the international donors); a 1review
-- 1_. of health personnel
and the health care delivery system, and the development
of a strategy for the rehabilitation of the health
service infrastructure; and the development of policy
towards the reemergence of private medical practice in
Mozambique.
(iii)
The project has been managed by the National Directorate
of Planning and Cooperation of the Ministry of Health
with technical assistance of the Health Unit of the
Institute of Development Studies, University of Sussex,
England. The project has had two phases. The first was
implemented by working groups of the Ministry of Health,
with the support of personnel from the Ministries of
Finance and Cooperation and international consultants.
This phase resulted in a number of working papers, the
most important of which were discussed in a national
seminar and in interministerial meetings held in Maputo
in November 1990.
One of the most important outcomes of
this phase of the project was the establishment of a set
of indicative growth projections for the different levels
of care of the Mozambican health service.
These growth
projections led to an agreement within the government,
and later with the World Bank, to aim for a real growth
of public health expenditure of 4.5 per cent per year in
the medium term.
This outcome was important because it
provided a resource framework which could be used for the
more detailed planning work of the second phase.
The project progressed slowly for a number of reasons,
including delays in funding the second phase and the
multiple demands on the time of government officials.
However, another reason was the necessity, especially in
the second phase, for the work of one area of the project
to inform that of the others, such that the various
policy and strategy formulations could become compatible
with each other.
The diffusion and interaction of ideas
among the personnel involved in the Ministries of Health,
Finance
and
Cooperation,
the
National
Planning
Commission, and some international agencies, inevitably
took time.
The various outputs of the first project phase have now
been consolidated into three documents: Revisao da
Politica Nacional
de Saude;
Estrategias e Ac§oes
Prioritarias
(’Revision of National Health Policy:
Strategies and Priority Actions') by Herculano Bata,
Leonardo Simao and Lucas Chomera Jeremias of the Ministry
of Health; Privatizagao da Medicina ('Privatisation of
Medicine’) by Leonardo Simao, Minister of Health; and the
present document.
This has itself been built on two
earlier works: Gastos, Financiamento e Afectaqao de
Recursos no Sector de Saude em Mozambique: Evolugao
Historica e Perspectivas Futuras ('Expenditure, Financing
and Resource Allocation in the Health Sector of
Mozambique:
Historical
Evolution
and
Future
Perspectives'), written by Abdul Razak Noormahomed and
Malcolm Segall on behalf of a working group of the first
phase; and Previsao das Consequencias do Firn da Guerra no
Sector da Saude ('Prediction of the Consequences of the
End of the War on the Health Sector’) by Igrejas Campos,
Vice-Minister of Health.
The present document has also
taken into account some useful reports by international
consultants and staff members of the World Bank.
(iv)
4
The three outputs of the second project phase are in the
main compatible with each other, although there are still
some minor discrepancies that have to be ironed out.
These papers should now be debated within the Ministry of
Health, with the Ministry of Finance and the National
Planning Commission, and with international agencies (in
particular the World Health Organisation, the World Bank
and the United Nations Children’s Fund).
After these
debates, the papers - amended as necessary - should be
synthesised into a single official government document.
Abdul Razak Noormahomed and Malcolm Segall
Maputo and Brighton
August 1992
(v)
INTRODUCTION
*
4
When Mozambique became independent in 1975 it was one of
the poorest countries in the world.
The economy was
backward, unbalanced and geared mainly to serve the needs
of neighbouring countries.
Large numbers of skilled
settlers left the country at a time when, as a result of
the colonial policy of discrimination, few Mozambicans
had been trained to take their place,
The vast majority
of the people lived in poverty and were illiterate.
Preventable
communicable
diseases,
nutritional
deficiencies, and maternity-related problems were rife,
and infant and child mortality rates were extremely high,
especially in the less developed provinces and the rural
areas.
The health sector was fragmented and biased
towards urban and curative services; less than 10 per
cent of the population had effective access to care.
Almost from the start, independent Mozambique suffered
armed terrorist attacks and these have escalated in
This has imposed untold
recent years to a state of war.
Millions of people have been
misery on the population,
displaced from their homes and large numbers live in
camps in a state of destitution and poor health,
dependent on international aid for survival.
Despite the difficulties of the early years - including
the effects of the application of sanctions against
(then) Rhodesia - the economy made some progress after
independence.
Then, during the first half of the 1980s,
there was a marked and sustained fall in production and
an aggravation
of
economic distortions
and fiscal
imbalances.
Between 1980 and 1985-86, exports fell by
nearly three-quarters and imports were compressed by more
than a third.
Table 1 shows that in the first half of
the decade, real growth of gross domestic product (GDP)
was negative in most years and per person was negative in
every year.
This economic downturn was the result of a
combination of
adverse world economic
events,
the
worsening security situation, and some inappropriate
government
policies.
Arrears
accumulated
in
the
servicing of external debt and inflation increased.
5
In 1987 the government launched an Economic Recovery
Programme (ERP).
In some respects the economy has
(ERP).
reacted positively,
with inflation slowing and GDP
positively,
The
growing, if more slowly in recent years (Table 1).
liberalising economic reforms have not, however, had a
positive impact on the low standard of living of the mass
of the people and have led to increasing hardship for
some
vulnerable
groups.
The
government
has
now
reaffirmed its commitment to poverty alleviation and has
recharacterised the recovery programme as a Programme of
Economic and Social Recovery.
In this programme, a high
priority is afforded to education, health, nutrition,
water and sanitation, and to the provision of a safety
Table 1
Evolution of gross domestic product and population
(’000 contos)
GDP in
constant
prices5
(‘000 contos)
1980
78 200
78 200
1981
81 500
78 365
1982
92 300
1983
Year
GDP in
current prices
Growth rate of GDP
in constant prices
Population<b>
GDP per person
in constant prices
Growth rate of GDP
per person
in constant prices
(%)
( ’000)
(Mt)
12 290
6 362
0.2
12 613
6 213
-2.3
75 656
-3.5
12 944
5 845
-5.9
91 200
66 087
-12.7
13 284
4 975
-14.9
1984
108 800
66 749
1.0
13 633
4 896
-1.6
1985
147 000
60 494
-9.4
13 992
4 324
-11.7
1986
167 000
61 570
1.8
14 361
4 287
-0.9
1987
423 300
64 429
4.6
14 740
4 371
2.0
1988
657 400
67 913
5.4
15 129
4 489
2.7
1989
966 200
71 503
5.3
15 528
4 605
2.6
1990
1 339 900
72 505
1.4
15 938
4 549
-1.2
1991<->
1 871 100
73 118
0.9
16 369
4 467
-1.8
to
Notes.
(%)
(a) Base year 1980; see Table 7 for GDP deflator.
(b) Estimates made using annual population growth rate of 2.6 per cent based on 1980 population.
(c) Provisional data.
Sources. NPC: Annual Statistical Information 1985 and 1988
Statistical Yearbook 1990
Economic and Social Plan 1992.
*
net of transfers and services to the poorest households.
The social sectors are expected to be among the main
beneficiaries of a ’peace dividend’' with the end of the
war.
4
FRELIMO health policy developed during the armed struggle
for national independence and has always given priority
to prevention and mass basic care.
On coming to power,
the FRELIMO government nationalised the. health sector and
prohibited the practice of private medicine.
It created
a national health service and adopted policies of primary
health care and essential drugs.
In the early years
after independence, these policies were pursued with
considerable success and Mozambique became renowned
internationally as one of the leading countries of SubSaharan Africa in the field of health.
Preventive
programmes were developed.
The network of primary level
health facilities was greatly expanded, especially in the
rural areas: health posts increased from 326 in 1975 to
1,195 in 1985 and health centres increased from 120 in
Nearly 10,000 health
1975 to 226 in 1990 (Table 2).
trained
or
workers
of
all
types
were
undertook
refresher/upgrading courses between 1975 and 1990.
New
categories of health personnel were created' to support
the policy of primary health care; these; categories
and
aides
(tecnicos)
assistants
medical
included
(agentes), mother and child health (MCH) nurses, and
(agentes_____
____ polivalentes
workers
health
village
Table 3 shows the increase in the
elementares) .
At
availability of some categories of health personnel,
its peak in the first half of the 1980s, the health
service reached about half of the population with
preventive programmes and about a third of the people had
reasonable access to fixed units and curative care.
Then, in the mid-1980s, the deteriorating military and
economic situation began to have serious adverse effects
on the health service.*
The war has led to the looting of equipment and material
from innumerable health facilities. Some units have been
partly or completely destroyed. The lack of security has
made the referral of patients to higher levels of care,
and the supply of drugs and materials to health units,
very difficult.
In some districts transport has only
been possible by air.
The existence of displaced
populations concentrated in areas of relative security
has obliged the health service to create a parallel
system of care, comprising mobile teams or even special
fixed units.
projects already in progress, the
Except for certain
<
network was virtually halted
the
health
expansion of
Investment
has been focused on
and
1989.
between 1985
* A large part of the description which follows has been extracted
from the document, 'Prediction of the Consequences of the End of
the War on the Health Sector', by Igrejas Campos.
3
Table 2
Evolution of health service network at the primary level
1975
1980
1985
1990
Health posts
326
629
1 195<a>
996
Health centres
120
(285)<b>
221
226
9 730
12 900
Population per post
or centre
21 300
13 230
Notes.
(a) Includes some health centres reclassified as
health posts from 1982.
(b) Includes about 74 health units designated as
rural hospitals in 1975 and subsequently
reclassified as health centres; from 1982
some smaller health centres were reclassified
as health posts (see note (a)).
Sources. MoH: Annual Statistical Information (various).
4
»
I
Table 3
Evolution of some categories of health personnel
Category
_______ 1975______
Number Population/
worker
Doctors
Medical assistants
and aides
63 000
0
1980
Population/
worker
_____
Number
1985
Population/
worker
Number
301
40 000
313
44 940
387
40 600
171
71 640
430
32 170
435
36 200
1 960<b)
5 795
2 156
5 700
2 535
5 475
3 547
4 400
MCH personnel<c=)
430<b>
26 410
475
26 400
866
15 910
1 139
13 800
Preventive health
assistants
and aides
420<b> 27 040
444<ca>
27 200
394
34 970
442
35 600
Nurses
cn
171
1990______
Population/
worker
Number
(a) Over half the doctors were expatriate.
(b) Data of 1977.
(c) Includes midwives, nurse midwives and MCH nurses.
(d) Data of 1979.
Sources. MoH: Annual Statistical Information (various)
Primary Health Care in Mozambique, Ministry of Health, Maputo, 1978.
Notes.
B
the
rehabilitation
of
existing
health
facilitiesr
particularly those which were damaged by the war.
Most
notable has been the rehabilitation of rural hospitals,
which has taken place with the support of non-government
organisations and the European Economic Community.
Material shortages have been severe and have made it very
difficult
to
keep health facilities
in
operation,
especially for inpatient care; the feeding of inpatients
has been a particular problem.
Health units which did
not suffer directly from the war have deteriorated for
lack of maintenance.
Given the fall in the purchasing power of government
salaries, many good health workers have left the public
The
service, looking for better remunerated employment,
productivity of those who have remained has declined.
Health personnel resort to ’moonlighting’ to supplement
their salaries and for many of them health service work
is no longer their main occupation.
The training programme has changed its orientation, with
a substantial
reduction in basic training of all
categories of health personnel, but particularly those of
the elementary and basic grades.
Training has focused
more on the upgrading of basic level personnel and on the
specialisation of middle level personnel.
The capacity of the higher levels of the health service
to direct, supervise and monitor the lower levels has
weakened.
This applies to the Ministry of Health in
relation to the provinces, to the provinces in relation
to the districts, and even within districts.
This
weakened health management capability has resulted in a
reduction in quality - and in some cases in coverage - of
health programmes.
Technical and administrative norms
have not been complied with properly and a degree of
The health
anarchy has crept into the health services.
information system has become unreliable in many areas,
making the management and monitoring of services even
more problematic.
During this
difficult period,
the support of the
international community for the health service has
increased substantially.
substantially.
This support has been a
lifeline that has prevented the service from sinking, but
it could have been of even greater assistance if it had
had a more appropriate form and
had fewer conditions
been attached to it.
The project PRANHP was created to contribute to the
process of formulating policies and strategies for the
rehabilitation of the Mozambican health service after the
end of the war.
This document is one product of that
project.
6
T
SCOPE OF THE WORK
The present work aims to create an overall resource
framework for the rehabilitation and development of the
public health sector in Mozambique.
To do this, it has
been necessary to review the evolution of health sector
resources during the medium term past and to project the
evolution of sectoral resources for the medium term
The framework attempts to translate the health
future.
objectives
of the government into a resource
policy
profile and to show how the resource projections can be
financed. Aspirations for the health sector which appear
to be beyond the bounds of economic feasibilty for the
time being have been excluded.
The framework thus
defines broad resource targets and limits - for the
sector as a whole and for its different components which can be used to guide and discipline more detailed
elements of the health planning process.
The resource analysis is mainly in financial terms,
because money is the only common currency that can
express all the different types of health resources and
can be used to create an overarching resource framework.
This work is thus complementary to the planning of ’real’
health resources like facilities, personnel and drugs.
In
this
document,
guidelines
are
given
for
the
rehabilitation of the health service network at the
primary and secondary levels, but more detailed planning
of the physical facilities, their location and their
modes of operation are still needed.
Criteria for the
development of the urban hospital services have also yet
to be formulated.
Apart from the definition of average
staffing patterns for primary and secondary level health
facilities, personnel planning has been beyond the scope
of this work. Aspects of personnel policy are dealt with
in the companion output of PRANHP, ’Revision of National
Health Policy: Stategies and Priority Actions’, and in
the report entitled, ’Health Manpower Development Plan
1992-2002’, by Oscar Gish and Enrico Pavignani; it should
be noted that some aspects of the personnel plan now need
revision for it to become compatible with the staffing
patterns and resource projections of the present work.
Overall drugs needs are identified, but more work is
still needed to improve
the processes of
import,
management and distribution of drugs.
a
This document addresses the public health sector in the
strict sense of the term.
It concerns the main areas of
responsibilty of the Ministry of Health and omits
consideration of the following:
- the health activities of the Ministry of Defence
7
METHODOLOGICAL NOTES
In general official data, published or supplied from a
government source, were used.
Many of the data were
derived from statistical publications of the National
Planning Commission and the Ministry of Health, and from
the accounts of various departments of the Ministry of
Health.
The data were checked for internal consistency
and plausibility and, wherever possible, cross-checked
against information from other sources; where there was
doubt, the most plausible data were used.
Estimates were
made where necessary and possible.
Footnotes to the
tables in this document give the sources of data and
explain how any estimates were made.
It should be noted that the financial analysis is in
terms of actual expenditure and not of budget estimates.
This is the first time that such an analysis has been
made for the health sector in Mozambique.
With respect
to government expenditure, most of the data were supplied
by the Directorate of Administration and Finance of the
Ministry of Health and by the National Budget Department
of the Ministry of Finance.
The figures for 1991 are
provisional.
On the advice of the Ministry of Finance,
all government expenditure data refer to the civil year.
Since 1988 some recurrent costs of health programmes have
been financed from the government investment budget.
These recurrent costs were identified and counted towards
total government recurrent health expenditure.
Other
costs of a recurrent type (e.g. salaries, operating
costs)
financed
from
the
investment
budget
were
considered to be in support of the investment projects
and as such were counted as investment expenditure.
Since 1987 user fees charged for outpatient and inpatient
care have no longer had to be transferred to the
government and could, in principle, be used by the health
facilities which collected them.
User fees from 1987
onwards were therefore considered to be a resource for
health
expenditure
over
and
above
the
financial
allocations from the government.
By contrast, fees
collected for drugs continue to be paid over to the
government and were not considered to be an additional
resource for the health sector.
Since 1990 almost all central and provincial hospitals
have provided ’special' outpatient clinics and inpatient
care of better than routine quality and at prices
considerably above the ’normal’ charges for the routine
A high proportion (that varies from hospital
services.
to hospital) of the ’special' fee income has been paid to
providing
the
care,
the
health
professionals
Nevertheless, the ’special' fees were considered to be
additional revenue for the public health service, since
10
u
they are an indirect form of support to the
salary fund and some of the fee money is
supplement the hospitals’ operating budgets.
hospital
used to
Included under expenditures on ’drugs’ are relatively
small amounts spent on related products like chemical
reagents, X-ray film, dressings and other consumable
medical items.
The expenditures include the costs of
Most
insurance, transport, customs and storage.
-- drugs
are imported for use by the national health service,r but
some go to
supply state and private retail pharmacies and
■
other outlets licensed to sell drugs to the public; from
1987 onwards, the relatively small expenditures made by
the government on drugs were for the national health
service only.
With respect to international aid, different sources of
data often give different values for the assistance
provided.
In this work, only aid actually received was
counted; items which appeared only in project budgets
were excluded.
For drugs (and related products) data
from the importing agency MEDIMOC were used.
For other
consumable items and equipment, data from the Directorate
of Supplies of the Ministry of Health were used; almost
all
donors
imported
their
products
through
this
directorate since they would otherwise have to pay import
tax and customs and storage costs.
Data on technical
assistance were supplied by the Directorate of Human
Resources of the Ministry of Health.
Estimates of the
monetary value of this assistance were made using the
methods of the Ministry of Cooperation.
Expatriate
personnel were classified into grades according to
national educational criteria.
The World Bank ’soft loan’ for the health sector was
The Swiss Government support to the
considered as aid.
was
recurrent health budget, which began in 1990,
aid category entitled ’other consumable
included in the
exclude
certain
aid data
presented
items’.
The
administrative costs paid directly by donors; (e.g. for
consultancies, project preparation, salaries of project
managers) and may not include all assistance given by
non-government organisations.
Investment costs were defined as those of construction,
equipment and other products with a durability of more
than a year.
Included in the definition of investment
expenditure werej the costs of technical assistance and
other services and goods used in support of investment
projects.
In 1991 a part of the investment health
expenditure was financed through the National Executive
Emergency Committee,
an institution created by the
government to coordinate intersectoral activities of
government
and
donor
bodies
under
the
Emergency
Programme.
Many of the financial data are presented in both current
for
and constant prices.
Various indices were used -11
deflation,
Those relating to the national economy were
obtained from official publications of the National
Planning Commission,
For imported products and foreign
technical assistance, price indices were obtained from
the International Financial Statistics Yearbook 1991 of
the International Monetary Fund,
The use of the various
indices is explained in the tables and text and the
indices are given in Table 7.
Estimates were made of the distribution of recurrent
health resources (financed
(financed from internal and external
sources) by level of health care and geographical area,
The primary level of care comprises health posts and
centres, the secondary level rural and general hospitals,
the
tertiary
level
provincial
hospitals,
and
the
quaternary level central and specialised hospitals,
The
division by level of care of salary costs and the costs
of ’other operating items’
(i.e. excluding drugs and
related products) was estimated by combining information
from the following sources of the Ministry of Health:
studies made by the National Directorate of Planning and
Cooperation on expenditures by level of care; information
on salary costs and user fees from the Directorate of
Administration and Finance and the Central Hospitals of
Maputo and Beira; various numbers of ’Annual Statistical
Information’;
data
from
the
Directorate
of
Human
Resources
on
the
location
of
technical
assistance
personnel;
a study of training costs made by the
Directorate of Human Resources; and data provided by the
With regard to drugs and
Directorate of Supplies.
related
products,
the
proportional
division
of
expenditures by level of care was obtained for 1990 from
data of the Social Fund for Drugs and Food Supplements
(see Modelo da Circulagao de Medicamentos na Republica de
Mozambique by Joaquim Durcto).
To estimate the division
of drug costs by level for 1991, the proportional
division for 1990 was applied to the total drugs imported
by MEDIMOC for the national health service in 1991. Data
for drugs supplied to the provinces were obtained from
the annual reports of the Pharmaceutical Department of
the Ministry of Health.
Data on the location of health
personnel were supplied by the Directorate of Human
Resources.
Estimates of the populations of cities and
provinces were taken from various numbers of ’Annual
Statistical Information’ of the Ministry of Health.
The above sources of information also allowed an estimate
to be made of the division of total recurrent health
expenditure into certain sectoral components for the year
1991 (Table 31A).
In the absence of a financial
information
system designed for planning purposes, this
was the greatest level of expenditure disaggregation that
could be achieved.
Despite its inadequacies, it was
sufficient to act as a basis for future projections of
recurrent health expenditure by sectoral components and
to examine the broad economic implications and feasibilty
of the rehabilitation policies and strategies.
12
4
staffing
and
recurrent
costs
of
Norms
for
the
rehabilitated health facilities at the primary and
secondary levels were defined, The unit running costs of
rehabilitated facilities were estimated in 1991 prices
from the following: average salaries of the defined
staff; estimated drug costs based on data from the
essential drugs programme, combined with information on
actual drug expenditures of selected hospitals and
estimates of future increases in drug consumption based
on urban and rural population growth rates and possible
increases in health facility utilisation; and the costs
of ’other operating items’, which were calculated as half
of salary costs as these would have been if salaries had
the same real value as in the beginning of the 1980s (a
time at which this ratio of non-drug operating costs to
salaries was empirically satisfactory) .
Norms for the
recurrent costs of central and provincial hospitals and
of training institutions could not be defined at the
time.
For the estimation of unit investment costs for the
rehabilitation or construction of various types of health
facility, the following sources of information were used:
studies by the Office for the Coordination of Investment
Projects of the National Directorate of Planning and
Cooperation, made with the support of the Danish Hospital
Institute, and the documents, ’Mozambique: Health Sector
Emergency Requirements 1992-93’ (second draft), ’Project
Proposal for Integrated Health Care Project 1992-2003 for
Manica Province, Mozambique’ (WHO-ICO 1991), and ’The
Structure of Health Sector Expenditure’ (SvJ/25.7.91/WB).
The list of health centres to be upgraded to rural
was
based
on
the
document,
hospitals
(Table
26)
produced by the
Reclassificaqao da Rede Sanitaria,
National Directorates of Health and of Planning and
Cooperation.
For the estimate of the size of a social security health
fund, the number of salaried employees in the public and
private sectors was based on the estimate of 477,000 made
by the National Institute of Social Security for the year
1989 and average salary levels were taken from the
Economic and Social Plan for 1992 published by the
National Planning Commission.
Estimates of the rural, urban and total population in the
year 2000 were taken from projections of the National
Planning Commission.
The unit of national currency is the metical (Mt) .
conto is Mt 1,000.
■t
13
One
The health expenditure as a proportion of GDP followed a
similar course,
It reached a maximum of 2.3 per cent in
1981 and 1983.
From 1984 it decreased to reach its
lowest level of 1.0 per cent in 1987, since when it has
increased gradually to attain 1.5 per cent in 1991.
Table 5 shows government health expenditure from the
recurrent budget broken down into the main categories of
its use, namely, salaries, drugs (and related products),
and ’other operating items’.
Salary costs as a percentage of the recurrent health
expenditure
increased from 50-55
per cent at the
beginning of the 1980s to reach a maximum of 73 per cent
in 1985.
This change in percentage reflects mainly the
fall in expenditure on drugs and other operating items in
the middle of the decade, as well as a slight increase in
the salary costs as such.
The proportion of recurrent
health expenditure devoted to drugs fell drastically from
more than 20 per cent at the beginning of the decade to
little more than zero in recent years.
Salary costs as
proportion of total recurrent costs have fallen again in
recent years to 50-57 per cent, but this has reflected in
part the increase of price in national currency of drugs
and other imported products.
Changes in the availability of the different elements of
health resources will be analysed in more detail when, in
later tables, expenditure is shown in constant prices and
when international aid, especially for the provision of
drugs, is taken into account. Nevertheless, it is useful
to draw attention at this point to the trend towards an
imbalance between the availability of health personnel
and that of drugs and other operating inputs (both goods
and services). This imbalance is a common consequence of
health budget constraints, when the first priority for
the use of limited funds is to pay the health workers,
leaving little money to meet operating expenses.
The
result is that health personnel receive their salaries
but lack the materials and conditions with which to work;
both the quality and efficiency of the health services
fall.
Since
1988
some
recurrent
expenditure
for
health
programmes has been financed from the investment budget.
It can
Table 6 shows the expenditures from this source,
be seen that the values are very small compared with
those that come through the normal channels of the
government recurrent budget.
In 1987 the government, in the context of the ERP,
fees
considerably
increased
outpatient
user
fees
and
increased
introduced fees for inpatient care. At the same time the
fees no longer had to be transferred to the government
and could, in principle, be utilised by the health units
which collected them.
From that year, therefore, the
user fees have been considered to be a resource for
the
financial
health
expenditure
over
and
above
(In practice the
allocation from the government budget.
16
a
Table 5
Evolution of expenditure from government recurrent health budget
by main categories of use
(Current prices:
*000 contos)
Drugs
Salaries
Year
Other operating
items
Expenditure %total
Total
Expenditure
%total
Expenditure
%total
1980
815
55
310
21
355
24
1 480
1981
930
50
475
26
445
24
1 850
1982
1 080
53
420
21
520
26
2 020
1983
1 100
52
355
17
665
31
2 120
1984
1 185
69
210
12
325
19
1 720
1985
1 320
73
250
14
230
13
1 800
1986
1 250
62
160
8
600
30
2 010
1987
2 460
55
930
21
1 070
24
4 460
1988
4 485
56
875
11
2 690
33
8 050
1989
6 580
50
1 105
8
5 765
42
13 450
1990
9 640
54
595
3
7 595
43
17 830
1991<- >15 480
57
605
2
11 275
41
27 360
(a) Provisional data.
Note.
Sources. MoH: DAF, DPh, NDPC and MEDIMOC
Bloom, G., ’Expenditure and financing of the health sector in
Mozambique', 1987
DurSo, J.R. and Pereira, R.A., Recuperagao de Gustos na Saude em
Mozambique, 1989
MoF: State Budget 1991.
17
Table 6
Evolution of total recurrent health expenditure of internal origin
(Current prices: '000 contos)
Year
From recurrent
budget(“>
1980
1 480
1 480
1.9
1981
1 850
1 850
2.3
1982
2 020
2 020
2.2
1983
2 120
2 120
2.3
1984
1 720
1 720
1.6
1985
1 800
1 800
1.2
1986
2 010
2 010
1.2
1987
4 460
195
4 655
1.1
1988
8 050
39
215
8 304
1.3
1989
13 450
285<d>
215
13 950
1.4
1990
17 830
576<d>
226
300<&>
18 932
1.4
1991
27 360
500
216
683<e>
28 759
1.5
Notes.
(a) See Table 4.
(b) Recurrent expenditure included in the investment budget for the
operation of health programmes.
(C) Estimates; see text for explanation.
(d) Estimate.
(e) Data only from the Central Hospital of Maputo in 1990 and the Central
Hospitals of Maputo and Beira in 1991.
(f) Provisional data.
Table 4
MoH: NDPC, DAF, Central Hospitals of Maputo and Beira
NPC: Statistical Yearbook 1990
MoF: State Budget 1991.
Sources
From investment
budget<b>
'Normal'
user fees<G)
18
'Special'
user fees<c>
______ Total
Expenditure % GDP
fee money is held by the provincial offices of the
Ministry of Finance and it may not always be spent by the
health units.
Nevertheless, in this work, use of the
money by the health facilities is assumed.) By contrast,
the fees collected for drugs continue to be paid over to
the government and are not considered to be an additional
resource for the health sector.
The collection of user fees has been very incomplete in
the health service and the fee rates have not been
increased since 1987. Table 6 shows estimates of the fee
revenue collected.
It can be seen that the amounts of
money generated have been extremely small compared with
government expenditure and that with inflation the
proportional contribution of fees has diminished greatly
over the years. This then is the situation with respect
to fees charged to the general public for the 'normal'
service of health facilities.
Since 1990 almost all the central and provincial
hospitals have been providing
'special'
outpatient
clinics and inpatient care of better than routine quality
and at prices considerably above the 'normal' charges for
routine services.
Although a high proportion (that
varies from hospital to hospital) of the 'special' fee
income has been paid to the health personnel directly
involved in providing the services,
the fees are
considered to be additional revenue for the public health
service, because they are an indirect form of support to
the hospital salary fund and some of the fee money is
used to supplement the hospitals' operating budgets.
Table 6 shows that the amount of 'special' fee revenue
collected has been relatively high, especially as the
data refer only to the Central Hospitals of Maputo and
Beira.
The final column of Table 6 shows total recurrent health
expenditure of ’internal origin', that is to say,
expenditure financed from within the country, either by
the government or by user fees.
It is clear that,
despite the existence of the other sources of finance,
the vast bulk of national recurrent health expenditure is
financed through the normal channel of the government
recurrent budget.
Real Expenditure and Resources
Table 7 shows the five indices that have been used for
the deflation of nominal expenditure.
Their use is
explained in the text and notes to the tables which
follow.
The evolution of recurrent health expenditure of internal
origin is shown in constant prices (base year 1980) in
Table 8.
It is clear that, in real terms, the health
sector suffered serious expenditure cuts during the
course of the 1980s.
In prices of 1980, the recurrent
expenditure was over Mt 1,500 million at the beginning
of the decade and it decreased to about a half of this
19
Table 7
Indices of exchange rate and deflators
(Base year 1980)
International
products
Exchange rate
(Mt = $1)
Rate
Index
1980
32,04
100
100
1981
35.35
111
110
1982
37.37
118
118
1983
40.18
124
125
1984
42.44
131
130
1985
43.18
133
136
1986
40.43
125
139
1987
289.44
893
143
1988
528.58
1 631
147
1989
747.06
2 305
153
1990
929.09
2 867
161
1991<~) 1 391.45
4 294
168
Gross
domestic
product<b>
Public
consumption
items
Private
consumption
items<b>
1980
100
100
100
1981
104
104
104
1982
122
122
122
1983
138
137
138
1984
163
157
163
1985
243
232
243
1986
248
261
271
1987
616
719
657
1988
978
1 114
968
1989
1 478
1 559
1 351
1990
2 034
2 134
1 848
1991<a>
2 842
3 035
2 559
(a) Provisional indices.
(b) Deflators are more reliable from 1987.
NPC:
Annual Statistical Information 1975-84 and 1988
Sources.
Annual Economic Information 1989
Statistical Yearbook 1990
Economic and Social Plan 1992
IMF: International Financial Statistics Yearbook 1991»
Notes.
20
Table 8
Evolution of recurrent health esqsenditure
of internal origin in constant prices<a>
(Base year 1980:
’000 contos)
*
Constant prices
Expenditure Per person
(Mt)
Year
Current
prices
1980
1 480
1 480
120
1981
1 850
1 779
141
1982
2 020
1 656
128
1983
2 120
1 536
116
1984
1 720
1 055
77
1985
1 800
741
53
1986
2 010
811
57
1987
4 655
756
51
1988
8 304
849
56
1989
13 950
944
61
1990
18 932
931
58
1991<fa)
28 759
1 012
62
(a) Deflation with public consumption index
(Table 7).
(b) Provisional data.
Source: Table 6.
Notes:
21
value in 1985-87.
Then, over the next few years, during
the course of the ERP, it increased gradually to around
Mt 1,000 million at the beginning of the 1990s.
In terms of recurrent health costs per person, national
expenditure fell in 1980 prices from a maximum of Mt 141
in 1981 to a minimum of Mt 51 in 1987,
increasing
gradually after that to reach Mt 62 in 1991.
The trends in recurrent health expenditure shown in Table
8 are expressed in terms of the general prices of the
economy.
However these values do not represent the
’real' health resources that could be acquired with these
expenditures.
This is because, on the one hand, health
worker salaries did not keep up with the general price
inflation and, on the other hand, the prices in national
currency of drugs and other imported products were
subject to a rate of inflation greater than that of the
national economy in general.
These differential price
effects are shown in the following tables, which refer
only to health expenditure from the government recurrent
budget.
Tables 9A and 9B show the evolution of the availability
of health personnel, drugs and other operating items
(that is, the changing availability of ’real* health
service inputs) financed. from the government recurrent
budget.
Table 9A shows that the number of health workers
increased from a little over 12,000 in 1980 to nearly
17,000 in recent years.
This was despite a dramatic
decrease in real total salary costs between 1981 and 1987
(since when there has been a gradual rise).
A reduced
salary fund supporting a rising number of personnel was
possible only by virtue of a fall in health worker real
salaries from an average of - in 1980 prices - 66.5
contos in 1980 to 21.1 contos in 1988, after which there
was a gradual increase to 30.5 contos in 1991.
Thus although the number of health personnel increased
during this period, it is likely that their motivation
and productivity fell as a consequence of the serious
reduction in their purchasing power, as well as of a lack
of drugs and other operating inputs with which they could
work (see below).
Table 9B indicates the availability of operating inputs
necessary for the proper functioning of the health
services financed from the government recurrent budget.
Since drugs are almost entirely imported to Mozambique,
changes in the volume of government imports have been
estimated by deflating current expenditures using the
product of the international price
and exchange rate
budgetary
the
indices
(Table
7).
In line with
constraints of the mid-1980s, government expenditure on
drugs decreased in 1980 prices from Mt 310 million in
1980 to Mt 92 million in 1986. Then with the massive and
22
*
Table 9A
Evolution of ’real* health resources(H) financed by government recurrent budget
(Base year 1980)
A: Health personnel
to
co
Total salary costs ('000 contos)
Current prices
Constant prices (
Average annual salary(5
in constant prices<c>
(contos)
Year
Number of health
workers
1980
12 261
815
815
66.5
1981
12 830
930
894
69.7
1982
13 669
1 080
885
64.8
1983
14 513
1 100
803
55.3
1984
14 691
1 185
755
51.4
1985
15 321
1 320
569
37.1
1986
15 171
1 250
479
31.2
1987
16 208
2 460
342
31.6
1988
15 874
4 485
403
21.1
1989
16 852
6 580
422
25.0
1990
16 096
9 640
452
28.1
1991<d>
16 740
15 480
510
30.5
(a) This means the availability of actual health personnel, drugs, and other medical and
non-medical operating items necessary for the functioning of the health service.
(b) Crude estimate made by the simple division of the total salary costs by the total number
of health workers. This does not take into account changes in the relative weight of the
different categories of health personnel. Such changes were not however substantial.
(c) Deflation with private consumption index (Table 7).
(d) Provisional data.
Sources. MoH: Annual Statistical Information (various)
Table 5.
Notes.
Table 9B
Evolution of ’real' health resources(a>
financed by government recurrent budget
(Base year 1980: '000 contos)
B. Drugs and other operating items
Year
_____ Drugs
Current
Constant
prices
prices<to>
Other operating items
Current
Constant
prices
prices<G5
1980
310
310
355
355
1981
475
389
445
429
1982
420
302
520
435
1983
355
229
665
486
1984
210
123
325
207
1985
250
138
230
99
1986
160
92
600
230
1987
930
73
1 070
149
1988
875
37
2 690
242
1989
1 105
31
5 765
370
1990
595
13
7 595
356
1991<d>
605
8
11 275
372
Notes:
(a) See note (a) in Table 9A.
(b) Deflation using the product of the exchange
rate and international price indices (Table 7),
Deflation
with private consumption index
(c)
(Table 7), which is appropriate for the products
and services bought locally for the health
service.
(d) Provisional data.
Source: Table 5.
24
4
progressive devaluation of the metical from 1987 (Table
7), drug prices in national currency increased enormously
and government imports plummeted in 1980 prices to less
than Mt 10 million in 1991.
The effects of this
reduction on the health service will be discussed later
when the provision of drugs through international aid is
taken into account.
By contrast, real expenditure on 'other operating items’
also suffered a big reduction in the middle of the 1980s,
but afterwards made a reasonable recovery.
This can be
explained partly by the fact that, given the lack of
foreign exchange and an increase in drug imports through
aid, there was a shift towards the end of the 1980s in
the use of the government budget away from drugs to the
local purchase of items for general operating purposes
(see Table 5).
RECURRENT HEALTH RESOURCES FINANCED BY INTERNATIONAL AID
The evolution of recurrent health expenditure financed by
foreign assistance is shown in current US dollars and the
equivalent in local currency in Table 10.
Aid
expenditure increased rapidly from 1986-87, particularly
for drugs and
’other consumable items’;
technical
assistance costs also increased but more gradually.
In
total the assistance increased from over $5 million in
1983 to nearly $33 million in the early 1990s. Although
it is not shown in the table, Jbetween 1983 and 1989 the
proportion of total expenditurej on imported products and
technical assistance financed by aid increased from 39 to
In recent years, aid for recurrent costs
93 per cent.
has been about 50 per cent for drugs,, 40 per cent for
’ other
technical assistance and 10 per <cent for
consumable items’.
Table 11 shows the number and broad categories of
personnel
employed
through
health
expatriate
It should be noted that
international aid since 1986.
the great expenditure on technical assistance has
resulted in the employment of only some 350-400 health
workers per
year.
About
three-quarters
of
the
recruitment has been at the higher level.
TOTAL RECURRENT HEALTH EXPENDITURE
In Table 12 an attempt is made . to estimate total
from
both
recurrent
health
expenditures,
financed
This
estimate
internal sources and by international aid.
gives a broad idea of the total volume of health care
activities in the country. The table shows national and
international expenditures in local currency at current
prices and their respective proportions of the total.
25
Table 10
Evolution of recurrent health expenditure financed by international aid:<n>
imported products and technical assistance
(Current prices)
Year
to
cr>
________ Drugs(° >
$'000
Expenditure %total
'000
contos
Other consumable items<d>
$'000
'000
Expenditure %total contos
Technical assistance(>
$'000
'000
Expenditure %total contos
_____ Total
$'000 ’000 contos
1980
NA
NA
NA
NA
NA
NA
NA
NA
1981
NA
NA
NA
NA
NA
NA
NA
NA
1982
NA
NA
NA
NA
NA
NA
NA
NA
1983
1 000
18
40
747
14
30
3 783
68
152
5 530
222
1984
1 296
NA
55
NA
NA
NA
NA
NA
NA
NA
NA
1985
926
NA
40
NA
NA
NA
NA
NA
NA
NA
NA
1986
8 781
57
355
742
5
30
5 936
38
240
15 459
625
1987
9 639
51
2 790
1 728
9
500
7 487
40
2 167
18 854
5 457
1988<fJ
15 438
50
8 160
6 395
21
3 380
8 829
29
4 667
30 662
16 207
1989
10 727
45
8 095
1 740
7
1 300
11 603
48
8 669
24 070
18 064
1990
16 981
51
15 777
3 875
12
3 600
12 048
37
11 194
32 904
30 571
1991<«>
16 169
49
22 498
3 285
10
4 571
13 490
41
18 771
32 944 .
45 840
(a) This table includes almost all aid actually received by the Ministry of Health. The expenditure is shown in
US dollars and the equivalent in local currency.
(b) For calculation of value of aid in local currency, official exchange rates were used (see Table 7).
(c) Aid for drug purchases was insignificant in the early years of the 1980s.
(d) Excludes equipment which is considered as investment. The data for 1983 are estimates. For the years 1990 and
1991, the figures include provisional data for the budget support of the Swiss Government.
(e) Excludes expatriate health personnel paid by the Ministry of Health; the figures are estimates.
(f) The high values for imported products in 1988 appear to be due to delays in the arrival of some aid agreed in
previous years and/or to misattribution in accounting.
(g) Provisional data.
Sources. MoH: DPh, DS, DHR, NDPC and MEDIMOC.
Notes.
Table 11
Evolution of numbers of expatriate health personnel
employed through technical assistance<a)
Year
Higher level
Middle level
Basic level
Total
1986
301
64
42
407
1987
292
54
41
387
1988
306
60
30
396
1989
272
63
14
349
1990
270
68
15
353
1991<b>
260
99
31
390
(a) Includes personnel paid totally or partly from international
aid.
(b) Provisional data.
Source. MoH: DHR.
Notes.
27
Table 12
Evolution of total recurrent health expenditure <“>
(Current prices: '000 contos)
Year
Internal origin
Expenditure %total
International aid
Expenditure %total
______ Total
Expenditure
%GDP
1980
1 480
NA
NA
NA
NA
NA
1981
1 850
NA
NA
NA
NA
NA
1982
2 020
NA
NA
NA
NA
NA
1983
2 120
91
222
9
2 342
2.5
1984
1 720
NA
NA
NA
NA
NA
1985
1 800
NA
NA
NA
NA
NA
1986
2 010
76
625
24
2 635
1.6
1987
4 655
46
5 457
54
10 112
2.4
1988
8 304
34
16 207
66
24 472
3.7
1989
13 950
43
18 064
57
31 729
3.3
1990
18 932
38
30 571
62
49 503
3.7
1991<b> 28 759
39
45 840
61
74 599
4.0
(a) Includes expenditure financed from internal sources and
through international aid.
(b) Provisional data.
Sources: Tables 6 and 10.
Notes.
28
Since the mid-1980s, and especially from 1987, the
contribution of aid has increased greatly, from 9 per
cent of total recurrent health expenditure in 1983 to 5766 per cent in recent years.
The table
also
shows
that total recurrent health
expenditure in relation to GDP fell from 2.5 per cent in
1983 to 1.6 per cent in 1986 and then, largely as a
result of the increase in aid, rose to 4.0 per cent in
1991 (compare with Table 6 for internally financed
expenditure only).
However, a better■ idea of the changing availability of
health resources is given by Table 13, which shows the
evolution of total recurrent health expenditure in
Real
expenditures
financed from
constant prices.
To
internal sources have been shown already in Table 8.
arrive at an estimate of the real value of international
aid during the last several years, it was necessary to
use a realistic exchange rate.
The rate for 1991 was
chosen; this was the last year of the present time series
and by then the metical was effectively floating.
The
aid expenditures in US dollars for the years under study
were inflated to 1991 prices using the international
price index (Table 7) and then converted to national
currency using the 1991 exchange rate.
For the purposes
of comparability with other constant price time series in
this work, the aid expenditures in 1991 metical prices
were deflated to the prices of 1980 using the public
consumption index (Table 7).
The aid expenditures in
prices of both 1991 and 1980 are shown in Table 13,
together with the expenditures of internal origin and the
total recurrent health expenditures from all sources.
The table shows that, in 1980 prices, total recurrent
per person was Mt 143 in 1983,
health expenditure
<
with
Mt
144-170
between 1988 and 1991.
compared
It is also possible to make a comparison between these
Total recurrent
years in a slightly different way.
health expenditure in relation to GDP was, in 1980
prices, 2.9 per cent in 1983 compared with 3.6 per cent
in 1991, a year in which the real GDP was greater (see
Table 1).
The Mozambican health services need more funds to improve
the quality and coverage of care and all efforts should
be made to increase the available health resources.
Nevertheless, contrary to what has been commonly thought,
recurrent health expenditures in real terms have not been
lower in recent years than at the beginning of the 1980s
and probably they have been somewhat higher.
It is
useful to remember that 1983 was one of the better years
of the Mozambican health service:
in 1991 prices,
recurrent health expenditure per person was equivalent to
$2.9 in 1983 compared with $3.2 in 1991.
29
Table 13
Evolution of total recurrent health expenditure in constant prices
('000 contos)
Year
Internal origin
Prices of 1980
Expenditure % total
___________International aid_________
Prices of 1991
Prices of 1980
Expenditure(a5 Expenditure(5 % total
Total_____
_____Prices of 1980____
Expenditure Per person
(Mt)
1980
1 480
NA
NA
NA
NA
NA
NA
1981
1 779
NA
NA
NA
NA
NA
NA
1982
1 656
NA
NA
NA
NA
NA
NA
1983
1 536
81
10 338
364
19
1 900
143
1984
1 055
NA
NA
NA
NA
NA
NA
1985
741
NA
NA
NA
NA
NA
NA
1986
811
47
25 998
916
53
1 727
120
1987
756
41
30 821
1 084
59
1 840
125
1988
849
33
48 758
1 716
67
2 565
170
1989
944
42
36 776
1 294
58
2 238
144
1990
931
36
47 775
1 681
64
2 612
164
1 012
39
45 840
1 613
61
2 625
160
GO
O
1991<c>
Notes:
(a) To use a realistic exchange rate, the aid expenditures in current US dollars were
inflated to 1991 prices (using the international price index) and converted to
local currency using the exchange rate of that year (Table 7).
(b) For comparability with the other time series of expenditures in constant prices
in this work, the aid expenditures in 1991 prices were deflated to 1980 prices
using the public consumption index (Table 7).
(c) Provisional data.
Sources: Tables 8 and 10.
It seems that the current impression of an acute lack of
health resources is related, not so much to absolute
shortage, but to problems in:
- the composition of resources
the distribution of resources
- efficiency in the use of resources
- external dependency.
To begin to address these problems, an analysis follows
of how the total recurrent expenditures are translated
into the availability of ’real' health resources, that
is, the availability of drugs, of other operating items,
and of health personnel.
AVAILABILITY OF REAL HEALTH RESOURCES
Drugs
From the data presented in Tables 5 and 10, it can be
calculated that the total expenditure on the import of
drugs (and related products) in 1991 amounted to $16.6
million, which represented an average value of $1.0 per
person.
To put this level of drug provision in
perspective. Table 14 shows the evolution of the
The table shows
availability of drugs since 1980.
drugs
in constant
government and aid expenditures on
prices (base year 1980) in US dollars and the equivalent
in local currency.
As was already seen in Table 9B, government expenditure
on drugs fell markedly in real terms from the middle of
the 1980s to reach very low values in the early years of
the 1990s.
By way of compensation, aid in drugs became
significant in the middle of the 1980s and increased
greatly from 1986.
In 1985 international assistance
financed only 14 per cent of the cost of drug imports,
while by 1990 that proportion had risen to 97 per cent.
With respect to total availability, expenditure on drugs
fell in 1980 prices from some $10 million per year at the
beginning of the 1980s to less than $5 million per year
Then
in
in the middle of the decade.
T1-- with the
_1__ 1increase
------ i__
international support, total drug expenditure rose such
that in 1991 it was again some $10 million in 1980
____ . However, because of the increase in population,
prices
this value represented a drug expenditure per person (in
1980 prices) of $0.62 compared with $0.78 per person in
1980. Thus the availability of drugs per person in 1991
was about four-fifths of that at the beginning of the
1980s.
The recent situation has therefore been much
better than in mid-decade, but it is still necessary to
import more drugs only to reach the level of drug
31
He
0515C
wq i
(of
|°(
)
$
Table 14
Evolution of availability of drugs
(Drug expenditure in constant prices:<a>
Year
__________ Government
_______ $’000______ ’000
Expenditure %total contos
base year 1980)
____ International aid
*000
_______ $'000______
Expenditure %total contos
$’000
Total_________
'000
Per person
contos
$
Mt
1980
9 640
100<b>
310
9 640
310
0.78
25
1981
10 773
lOO^^
389
10 733
389
0.85
31
1982
7 390
100<b)
302
7 390
302
0.57
23
1983
5 376
87
229
800
13
26
6 176
255
0.46
19
1984
3 488
78
123
997
22
32
4 485
155
0.33
11
1985
4 253
86
138
681
14
22
4 934
160
0.35
11
1986
1 964
24
92
6 317
76
204
8 281
296
0.58
21
1987
1 937
22
73
6 741
78
219
8 678
292
0.59
20
1988
933
8
37
10 502
92
340
11 435
377
0.76
25
1989
956
12
31
7 011
88
230
7 967
261
0.51
17
1990
344
3
13
10 547
97
342
10 891
355
0.68
22
1991<c>
509
5
8
9 624
95
312
10 133
320
0.62
20
CJ
to
(a) Expenditure is shown in US dollars and the equivalent in local currency. Dollar costs
were deflated using the international price index; costs in local currency were deflated
using the product of the exchange rate and international price indices (Table 7).
(b) Aid for drug purchases was insignificant in the early years of the 1980s.
(c) Provisional data.
Sources: Tables 5 and 10.
Notes.
provision per person that prevailed more than a decade
ago.
Other Operating Items
Expenditure on fother operating items' (that is, on items
other than salaries and drugs) is presented in Tables 5,
9B and 10.
In the early years of the 1980s, when prices were fairly
stable, about half the recurrent health expenditure was
devoted to salary costs and the other half was shared
about equally between drugs and other operating items
(Table 5).
At this time the health services were
Also these proportions were
functioning relatively well.
similar to"those found in the health services of a number
of African countries before the advent of the economic
crisis of the 1980s.
Although these are crude criteria
for appraisal,
it seems that the Mozambican health
service began the 1980s with a reasonable balance in the
use of recurrent resources.
From this base, real government expenditure on 'other
operating items' was relatively well maintained in many
of the years under study, including in recent years
(Table 9B).
In addition,
addition. as Table 10 shows, there has
been external support for ’other consumable items’.
The Mozambican health service doubtless needs more
operating funds to improve the quality and efficiency of
care.
But the total funds available for general
operating inputs do not appear to be one of the main
limiting factors in the functioning of the health care
system.
This global assessment does not of course
exclude problems in the distribution and use of these
inputs.
Health Personnel
Issues in the distribution, management and training of
health personnel are addressed later in this document and
in more detail elsewhere (see 'Scope of the Work’).
At
this point, however, it is useful to draw attention again
to Table 9A, which shows the increase in the total number
of health workers during the 1980s, despite the economic
difficulties that the country was experiencing.
For at
least some personnel categories, this increase in numbers
represented an improvement in population to health
personnel ratios (see Table 23).
On the other hand, it
is necessary to emphasise again that health workers
suffered a great fall in their purchasing power during
the 1980s, even though in recent years there has been a
slight improvement (Table 9A) .
As has been mentioned
already, this fall in real salaries has resulted, in the
practice of 'moonlighting' and a loss of guality and
productivity in health work.
Hence the approach at this
point in time to increasing the effective availability of
health personnel should be, not so much to increase their
numbers, but to remotivate health workers by improving
33
their living standards and to promote increased service
outputs from salary inputs.
In addition to the thousands of national health workers,
the country has benefited each year from the support of
about 400 expatriate health personnel (see Table 11).
Many of these foreign workers have filled important
staffing vacancies in the health service, especially of
doctors and other specialised personnel, and have ensured
the functioning of many of the countryTs hospitals.
Nevertheless, it is appropriate to draw attention again
to the high costs of this technical assistance,
Table 10
shows that this relatively small number of expatriate
health personnel represented in 1991 over $13 million or
about 40 per cent of the total aid support.
The
promotion
of
cost-effectiveness
in
this
technical
assistance will be discussed later in this document in
the context of proposed policies
for
the use of
international aid.
INVESTMENT HEALTH EXPENDITURE
As is usually the case, investment costs in the health
sector are much less than those for recurrent activities.
However, given the amount of reconstruction that is
needed now in Mozambique, the mobilisation of sufficient
investment resources will be a critical factor in the
success of the sectoral rehabilitation strategy.
Table 15 shows the health expenditure from the government
investment budget
in relation to total
government
investment expenditure since 1980.
The proportion of
total investment costs allocated to health decreased from
1.7 per cent at the beginning of the 1980s to 0.3 per
cent in 1987-88, after which it increased to 0.6-0.9 per
During this period, government
cent in recent years.
investment health expenditure as a proportion of GDP
remained at 0.1 - 0.3 per cent.
It was pointed out earlier (see Table 6) that since 1988
expenditures from the government investment budget have
included some recurrent costs of health programmes.
Table 16 separates out true government investment costs
for health and, from 1986 onwards, shows aid expenditures
for health investment, thus allowing the calculation of
total investment health costs.
Since 1986 aid has
per
cent
of
total
health sector
contributed 74-91
investment costs, a degree of dependency that has become
quite common for countries of Sub-Saharan Africa in
recent times.
In general data do not exist for the distribution of
investment expenditure by levels of health care.
It is
the case, however, given the insecurity prevailing in
many rural areas and particularly in the more remote
places, that there has been an emphasis in recent years
on the rehabilitation of urban and rural hospitals
hospitals..
34
T
Table 15
Evolution of expenditure from government investment
budget: total and health
(Current prices: *000 contos)
Year
Total
expenditure
Health
expenditure
Health as %
of total
expenditure
Health
expenditure
as % GDP
1980
9 916
168
1.7
0.2
1981
13 962
240
1.7
0.3
1982
14 255
226
1.6
0.3
1983
17 099
168
1.0
0.2
1984
10 600
206
1.9
0.2
1985
6 655
207
3.1
0.1
1986
9 263
87
1.0
0.1
1987
68 000
192
0.3
0.1
1988
139 700
357
0.3
0.1
1989
214 300
1 878
0.9
0.2
1990
324 300
2 515
0.8
0.2
464 900
2 566
0.6
0.1
(a) Provisional data.
Note.
Sources. NPC: Annual Statistical Information 1975-85 and 1988
Statistical Yearbook 1990
Economic and Social Plan 1992.
35
Table 16
Evolution of total investment health expenditure <a>
(Current prices: '000 contos)
Year
Government
International
investment budget
__________aid<b>
Investment
Recurrent
Expenditure
% total
expenditure(c> expenditure(d J
investment
expenditure
Total
investment
expenditure
1980
168
NA
NA
1981
240
NA
NA
1982
226
NA
NA
1983
168
NA
NA
1984
206
NA
NA
1985
207
NA
NA
1986
87
244
74
331
1987
192
1 619
89
1 811
1988
39
318
1 831
85
2 149
1989
285
1 593
4 425
74
6 018
1990
576
1 939
7 706
80
9 645
1991<«>
500
2 066
20 067
91
22 133
Notes.
(a) For definition, see methodological notes.
(b) Estimates based on information from donors; in general, the
expenditure excludes certain costs paid directly by the donors
(e.g. for consultancies, project preparation, salaries of project
managers).
(c) See Table 6 and methodological notes.
(d) Estimates; for the years 1984-86, the investment expenditures of
the health and education sectors were accounted together; the
portion of the combined expenditure allocated to health was
estimated by applying to the joint costs the average proportion
of combined health and education expenditures allocated to health
in the preceding four years.
(e) Provisional data; includes expenditure financed through the
National Executive Emergency Committee.
Sources. MoH: DAF, NDPC and DS
MoF: State Budget 1991
NPC: Annual Statistical Information 1985 and 1988
World Bank: Working paper SvJ/25.7.91/WB.
36
*
Indeed, in contrast to the situation with hospitals,
funds budgeted for the rehabilitation of rural health
posts and centres could often not be completely spent.
Nevertheless, the government health policy of giving
priority to primary level and rural services is shown in
the Three Year Public Investment Plan 1991-93 (Table 17).
In this plan 47 per cent of the investment health budget
is allocated to the primary and secondary levels of care,
mostly in the rural areas.
TOTAL HEALTH EXPENDITURES
From the data of the previous tables, it is possible to
compile estimates of total health expenditures, that is,
recurrent
plus
investment
expenditures,
and
costs
financed from both internal and external sources.
First Table 18 shows the evolution of total (recurrent
plus investment) health expenditure of internal origin
since 1980.
Given that the recurrent costs are much
greater than the investment costs, the trends shown in
this table are similar to those for internal recurrent
health expenditure alone (see Tables 6 and 8).
When in Table 19 grand totals of health expenditure
(recurrent plus investment, internal plus external) are
rapid increase
-----------compiled it can be seen that there was a 1^11
of total health expenditure in relation to GDP from 1.8
Of the
CI
J— total
per cent in 1986 to 5.2 per cent in 1991.
health costs in recent years, some two-thirds were
financed by international aid.
In 1991 total health
For the
expenditure per person was equivalent to $4.2.
in
1980
purposes of comparison. Table 19 shows that,
increased
prices, total health expenditure per person
from Mt 148 in 1986 to Mt 208 in 1991, an increase of 40
per cent.
SUMMARY OF MAIN CONCLUSIONS
recurrent
health
costs,
real
1. With
respect
to
“i financed from internal sources
expenditure per person
decreased in the middle of the 1980s to less than half
of what it had been at the beginning of the decade,
rising again gradually in recent years.
International
aid increased to compensate for this fall.
In the
last few years, more than half of recurrent health
expenditure has been financed by external assistance.
--- prices
'
t total recurrent costs per
As a result, in 1991
$3.2
in 1991 compared with
person were equivalent to
concluded
that the current
$2.9 in 1983.
It is
lack
of
health
resources is
impression of an acute
an
absolute
shortage,
but to
related, not so much to
problems in:
- the composition of resources
37
Table 17
Three Year Public Investment Plan for Health Sector 1991-93
(1991 prices: *000 contos)
Sub-sector
1991-93
% total
Institutional support
4 400
7
Training
4 600
7
Health posts
9 800
15
Health centres
12 200
19
General and rural hospitals
8 600
13
Provincial hospitals
5 200
8
Central hospitals
4 800
7
General support services
16 500
25
Total
66 100
100
(a) Includes costs to be financed by the government
and international aid.
Source. NPC: Plano Trianual de Investimento Publico de Saude 1991-93.
Note.
38
«
c
r
Table 18
Evolution of total health expenditure of internal origin
(’000 contos)
Investment
expenditure
Total
Expenditure % GDP
Investment
expenditure
in constant
pricesJ
Total in constant prices<a)
Expenditure
Per person
(Mt)
Year
Recurrent
expenditure
1980
1 480
168
1 648
2.1
168
1 648
134
1981
1 850
240
2 090
2.6
231
2 010
159
1982
2 020
226
2 246
2.4
185
1 841
142
1983
2 120
168
2 288
2.5
122
1 658
125
1984
1 720
206
1 926
1.8
126
1 182
87
1985
1 800
207
2 007
1.4
85
826
59
1986
2 010
87
2 097
1.3
35
846
59
1987
4 655
192
4 847
1.2
31
787
53
1988
8 304
318
8 622
1.3
33
882
58
1989
13 950
1 593
15 543
1.6
108
1 052
68
1990
18 932
1 939
20 871
1.6
95
1 026
64
1991<b>
28 759
2 066
30 825
1.6
73
1 085
66
ID
(a) Base year 1980; deflation with public consumption index (Table 7).
expenditure in constant prices is given in Table 8.
(b) Provisional data.
Sources: Tables 6, 8 and 16.
Notes.
Recurrent health
TABLE 19
Evolution of total health expenditure of internal origin and from international aid
(’000 contos)
Year
4^
O
Recurrent expenditure
Internal origin
Aid
Investment expenditure
Government
Aid
Expenditure
Total
% GDP
% financed
by aid
Total in constant prices<£a)
Expenditure
Per person
(Mt)
1980
1 480
NA
168
NA
NA
NA
1981
1 850
NA
240
NA
NA
NA
1982
2 020
NA
226
NA
NA
NA
1983
2 120
222
168
NA
NA
NA
1984
1 720
NA
206
NA
NA
NA
1985
1 800
NA
207
NA
NA
NA
1986
2 010
625
87
244
2 966
1.8
29
2 123
148
1987
4 655
5 457
192
1 619
11 923
2.8
59
2 202
149
1988
8 304
16 207
318
1 831
26 660
4.1
68
2 792
185
1989
13 950
18 064
1 593
4 425
38 032
3.9
59
2 664
172
1990
18 932
30 571
1 939
7 706
59 148
4.4
65
3 131
196
1991<fc>>
28 759
45 840
2 066
20 067
96 732
5.2
68
3 404
208
Notes.
(a) Base year 1980; aid expenditure was deflated by the method explained in Table 13, notes (a) and (b);
expenditure of internal origin in constant prices is given in Table 18.
(b) Provisional data.
Sources: Tables 6, 10, 16 and 18.
the distribution of resources
- efficiency in the use of resources
A
*
- external dependency.
2. Despite the economic difficulties of thej sector, the
number of health workers increased considerably during
the 1980s.
This increase facilitated the delivery of
health care, but accentuated the decline in the real
salaries of health workers: the average health worker
salary in 1988 had one-third of the value in real
terms as it had in 1980. Despite a slight improvement
in salary levels in recent years, this fall in
purchasing power has resulted in demotivation and the
practice of ’moonlighting’ by health personnel, and a
reduction of the productivity of health work.
A high
priority should be given in the medium term to the
improvement of the real salaries and of the conditions
of life and work of health personnel.
3. In recent years technical assistance has comprised 2948 per cent of total aid expenditure, but the high
costs have translated themselves into the employment
of only about 400 expatriate health workers per year.
The policy and procedures for the recruitment of
technical assistance personnel should be reviewed from
the standpoint of cost-effectiveness and stricter
criteria applied in the recruitment process in the
future.
4. The purchase of drugs by the government decreased
drastically during the 1980s.
However, this fall was
compensated by international aid, such that in 1991
drug imports were worth $1.0 per person, which
represented an availability of drugs per person about
four-fifths of that at the beginning of the 1980s.
More drugs must be imported only to reach the level of
drug provision per person of more than a decade ago.
5. In recent years 74-91 per cent of investment health
costs have been financed by international aid.
In
1991, the grand total of health expenditure per person
(financed from
internal
sources
and
through
international aid, and for recurrent and investment
costs) reached 5.2 per cent of GDP; 68 per cent of the
total expenditure was financed by external assistance.
Total health expenditure per person was $4.2, which
was 40 per cent higher in real terms than in 1986.
It
is evident
that this
expanded - and hopefully
expanding - volume of health resources must be well
planned and managed.
That subject is addressed in
later sections of this document.
41
TRENDS IN THE DISTRIBUTION OF RECURRENT HEALTH RESOURCES
This
section analyses
the distribution of
health
resources in the country. Information is given about the
latest year for which data are available and, where
possible, trends in resource distribution over previous
years are shown.
Data are presented for recurrent
expenditure, for some categories of health personnel, and
for drugs.
In all cases the resources include those
financed from internal sources and through international
aid.
Distribution of resources is analysed by level of
health care, by urban/rural areas, and by province.
*
DISTRIBUTION BETWEEN LEVELS OF HEALTH CARE
Table 20 shows the percentage distribution of total
recurrent health expenditure, salary expenditure and drug
expenditure by levels of care for the year 1991.
(The
definitions of the levels of care are given in the
methodological notes.)
In general, the primary level
absorbed about a fifth to a third of the expenditures,
the secondary level about an eight of the expenditures,
and the tertiary and quaternary levels combined about a
half
to
two-thirds
of
the
expenditures.
The
concentration of resources in the two highest levels was
most marked in the case of salary expenditure; 67 per
cent of total salary costs were absorbed by these levels.
Thus the 12 provincial, central and specialised hospitals
consumed more than half of all three types of recurrent
expenditure.
The share of the secondary level was
particularly low and reflects the historical weakness of
the rural hospital network in Mozambique.
Table 21 shows trends in the distribution of some
categories of health personnel during the 1980s. Doctors
have been concentrated heavily at the tertiary and
quaternary levels and this concentration increased during
the decade; the proportion of doctors at these levels
rose from 66 per cent in 1980 to 76 per cent in 1989, at
the cost of the other levels.
Although it is not shown
in the table, between 1980 and 1985 the number of doctors
in Maputo Central Hospital increased from 92 to 117, that
is, from 31 to 41 per cent of the total doctors in the
country.
This concentration of doctors in Maputo began
before the intensification of the war during the 1980s
and has been most evident in the case of Mozambican
doctors.
In 1990, owing mainly to the increase in the
number of doctors in other hospitals, the proportion of
total doctors in Maputo Central Hospital decreased to 27
per cent.
The concentration of doctors in the higher levels of care
has been compensated up to a point by the distribution of
medical assistants and aides.
Taking these three
42
f
♦
Table 20
Percentage distribution of health expenditure
by level of care 1991
Recurrent
expenditure
Salary
expenditure
Drug
expenditure
Tertiary/
quaternary
58
67
51
Secondary
15
13
12
Primary
27
20
37
Level<b>
(a) Includes expenditure financed from internal
sources and by international aid; includes
expenditure on health programmes, but excludes
the salary costs of personnel in the MoH
headquarters, provincial and district health
directorates, and training and other institutions
not concerned directly with health care
delivery.
(b) For definition of levels of care, see methodological
notes.
Sources. MoH: NDPC, DAF, DS and MEDIMOC.
Notes.
I
43
Table 21
Trends in percentage distribution of some categories of health personnel J
by level of care
Level5
Doctors plus medical
assistants and aides
Doctors
1980 1985 1989
4^
Nurses
Midwives and
MCH nurses
Preventive health
assistants and aides
1980
1985
1988
1980 1985 1989
1980
1985 1989
1980
1985
1989
Tertiary/ 66
quaternary
78
76
43
34
34
45
43
39
36
39
16
NA
1
2
Secondary
18
10
15
19
10
19
14
14
18
20
19
19
NA
15
18
Primary
16
12
9
38
56
47
41
42
43
44
42
65
NA
84
80
Notes.
(a) Includes personnel paid by the government and through technical assistance, but excludes
staff not engaged in direct health care delivery (see note (a) in Table 20).
(b) For definition of levels of care, see methodological notes.
Sources. MoH: Annual Statistical Information (various).
Ih
1
i ■■ un
<
categories of health workers together, the proportion at
the
primary
level
increased,
and
that
at
the
tertiary/quarternary levels decreased, during the 1980s.
In 1988, 47 per cent of these personnel combined were
working at the primary level.
With respect to nurses,
a slight increase in the
proportion working at the secondary level can be seen by
the end of the 1980s, at the cost of the higher levels of
care, while throughout the period more than 40 per cent
of the nurses were located at the primary level.
Large
numbers of MCH nurses were trained during the 1980s and
they were deployed mainly in the rural areas and mainly
at the primary level.
This training and deployment
policy is reflected in Table 21, which shows that the
proportion of midwives and MCH nurses at the primary
level increased from 44 per cent in 1980 to 65 per cent
in 1989.
The table also shows that most preventive
health personnel were deployed at the primary level
during the decade.
In general,
therefore,
it
can be
said that the
distribution of the elementary and basic grades of health
personnel has reflected well the policy of giving
However,
priority to primary level health services.
attention should be drawn again to the concentration of
doctors in the main city hospitals, which absorbed 76 per
cent of the total in the country in 1989.
DISTRIBUTION BETWEEN URBAN AND RURAL AREAS
Table 22 shows trends in population to
health worker
ratios during the 1980s for the main categories of health
personnel and for three types of area: the City of
Maputo, other cities, and the rest of the country.
The problem of the concentration of doctors in the large
cities is once again clear.
The table shows that the
population to doctor ratio in the City of Maputo stayed
more or less constant during this period, while the
ratios in the other parts of the country deteriorated
from the middle of the decade, In 1988, there were 5,500
people per doctor in the City of Maputo, 18,300 people
per doctor in the other cities, and as many as 501,700
people per doctor in the rest of the country.
The table shows again that, considering doctors and
medical assistants and aides together, the situation is
Even
less unbalanced and has been somewhat more stable.
so, the urban population has been much better served by
this group of medical workers than the rural population.
The urban/rural distribution of nurses stayed more or
less constant during the 1980s.
Nevertheless, the
population of the cities was 5-6 times better served by
nurses than that of the rural areas. Only in the case of
45
Table 22
Trends in population to health worker ratios for some categories of personnel<a>
by urban/rural areas
(Population '000)
Maputo
City
1980
Other
cities
Rest of
country
Maputo
City
1984
Other
cities
Rest of
country
Maputo
City
1988
Other
cities
Rest of
country
5.2
6.5
249.0
5.8
6.1
234.6
5.5
18.3
501.7
Doctors plus
4.7
medical assistants
and aides
5.1
65.3
5.2
4.0
39.4
4.4
9.3
60.2
Nurses
1.2
1.9
9.5
1.6
0.9
14.5
1.8
1.7
10.3
Midwives and
MCH nurses
5.4
7.0
52.3
5.8
5.1
28.8
3.7
5.4
24.7
Doctors
(a) Includes personnel paid by the government and through technical assistance, but excludes
staff not engaged in direct health care delivery (see note (a) in Table 20).
Sources. MoH: Annual Statistical Information (various).
Note.
i
MCH personnel was there an improvement during the 1980s
in the relative position of the rural areas, as a result
of the training and deployment of MCH nurses.
DISTRIBUTION BETWEEN PROVINCES
r
Table 23 shows trends in population to health worker
ratios for the main categories of health personnel.
nationally and by province.
At the national level, the reduction in the availability
of doctors relative to the population can be seen in the
deterioration in the ratio of 38,100 people per doctor in
1979 to 45,500 people per doctor in 1990.
It is clear
that doctors are a very scarce resource in Mozambique and
for this reason they should be distributed strictly in
accordance with the health needs of the people.
By
contrast, the table shows an improvement in national
population to worker ratios for medical assistants and
aides, nurses, and MCH personnel.
There was, however, a
deterioration in the number of preventive health workers
relative to the population during this period, as a
result of a slowing in the training programme of this
personnel category.
With respect to provincial distribution, Table 23 shows
‘ : the City of Maputo and the
that two provinces stand out:
For all the categories of health
Province of Zambezia.
personnel presented. the City of Maputo is always the
best served and Zambezia Province is (almost) always the
least served.
1
While most of the provinces experienced a considerable
deterioration in the availability of doctors during the
1980s, the City of Maputo was not only much better served
than the other provinces, but the population to doctor
ratio actually improved during the decade.
In 1979,
there were 3 4 times more people per doctor in Zambezia
than in Maputo City and by 1990 this advantage had
increased to 73 times.
Taking doctors and medical
assistants and aides together, the availability of these
health personnel relative to the population improved
during the decade in almost all the provinces, although
in 1990 Zambezia had 17 times more people per worker of
this medical group than Maputo City.
There was an improvement in the availability of nurses
during the 1980s in nine out of the 11 provinces.
Nevertheless in 1990, the number of people per nurse was
nine times higher in Zambezia than in the City of Maputo.
The availability of MCH personnel improved considerably
in all the provinces during the decade, although in 1990
Maputo City was still 11 times better served than
Zambezia.
47
Table 23
Trends in population to health worker ratios for some categories of personnel ca* by province
(Population *000)
1979
1985
1990
Midwives and
MCH nurses
1979
1985
1990
Nurses
Preventive health
assistants and aides
1979 1985
1990
Province
1979
1985
1990
Doctors, medical
assistants and aides
1979 1985
1990
Niassa
47.7
73.0
95.2
20.8
13.0
18.0
4.5
4.2
4.4
31.8
13.3
13.9
15.4
24.4
24.7
Cabo Delgado
105.4
59.3
101.7
52.7
21.8
23.0
8.8
6.6
5.7
41.3
50.9
21.8
22.6
42.7
53.0
Nampula
77.5
136.5
158.9
54.6
31.0
40.2
7.3
9.7
6.0
38.1
29.1
30.0
34.3
44.1
45.4
Zambezia
183.4
202.8
270.2
80.2
33.4
52.3
14.3
9.9
9.0
85.6
24.5
31.8
47.5
49.0
56.9
Tete
45.1
78.6
51.3
31.2
23.0
23.4
5.3
5.6
5.6
32.5
18.2
17.1
15.3
27.0
43.1
Manica
68.2
121.5
63.9
30.7
24.3
20.3
6.0
6.0
5.0
40.9
17.0
12.6
29.2
34.7
30.8
Sofala
27.8
48.4
65.8
20.2
19.2
20.3
4.4
4.1
3.1
27.8
18.9
12.1
25.3
34.6
34.5
Inhambane
110.6
70.8
61.6
39.8
22.2
24.0
6.6
5.9
5.5
19.2
14.2
12.2
26.9
33.3
32.3
Gaza
64.1
86.5
142.7
34.3
21.6
25.2
7.3
5.9
5.1
22.9
12.2
13.2
32.0
34.1
31.3
Maputo
Province
Maputo City
67.8
93.0
79.7
}
}6.5
19.2
22.5
11.9
4.4
}
13.6
9.7
30.2
5.7
3.7
}
4.8
3.0
1.4
1.0
}6.7
}
3.9
2.9
}
}18.9
}
23.2
4.7
}
}1.3
}
20.9
12.1
Mozambique
38.1
48.0
45.5
26.7
18.5
20.3
5.2
5.5
4.5
26.5
15.9
13.8
27.2
35.0
35.9
Doctors
03
(a) Includes personnel paid by the government and through technical assistance, but excludes staff not engaged in
direct health care delivery (see note (a) in Table 20).
Source. MoH: Annual Statistical Information (various).
Note:
4
By contrast, there was a marked deterioration in the
ratios of population to preventive health personnel in
almost all the provinces during the 1980s; only Maputo
City showed a considerable improvement.
Available data allow for the analysis of the provincial
distribution of one other type of health resource, namely
drugs.
Table 24 shows drug expenditures per person by
province for the years 1979 and 1990 and the ratios of
this expenditure in the better supplied provinces to that
in the least supplied province.
It can be seen that in
1979 the variation in this ratio was quite small: the
City and Province of Maputo together were 3.6 times
better provided with drugs per person than the least
supplied province (Manica).
On the other hand in 1990,
the inequality in the distribution of drugs was much
greater: the City and Province of Maputo together were
14.2 times better provided with drugs than the least
The City of Maputo alone
supplied province (Zambezia).
was \21.4 times better supplied than Zambezia in 1990.
Although not shown in this table, the drug expenditure of
Maputo Central Hospital increased from 10 per cent of the
total drug expenditure in the country in 1979 to 25 per
cent in 1988 and 30 per cent in 1990.
SUMMARY OF MAIN CONCLUSIONS
At the time of independence, Mozambique inherited an
unbalanced health care system,. biased towards large
hospitals and the urban areas, especially the City of
It was thanks to the post-independence national
Maputo.
health service and the policy of primary health care that
a considerable expansion in primary level health services
took place, above all in the rural areas, although the
rural hospital network has remained weak.
However, since the beginning of the 1980s, there has been
a
tendency
towards
the
reconcentration
of
health
resources, especially in Maputo City and in Maputo
Central Hospital.
This tendency has been most marked in
the case of doctors (particularly Mozambicans) and drugs
- both crucial categories of health resource.
The
imbalance in the health system in favour of urban areas
and large hospitals thus remains a problem.
Although the insecurity in the countryside has been one
of the causes of this shift of resources to urban health
facilities, it has not been the only one, because the
process began before the war intensified in the middle of
the 1980s.
With the coming of peace, it will be
necessary to apply specific policies to attract health
personnel (including Mozambican doctors) to work in the
rural areas, in the least served provinces, and at the
lower levels of health care.
Such policies are discussed
in the next section.
49
Table 24
Trend in distribution of drug expenditure<Q5 per person by province
(Current prices: meticals)
Province
_______ 1979
Expenditure/
person
Ratio<fa)
1990
Expenditure/
person
Ratio
Niassa
33
1.3
492
2.4
Cabo Delgado
29
1.1
386
1.9
Nampula
30
1.2
245
1.2
Zambezia
27
1.0
208
1.0
Tete
34
1.3
272
1.3
Manica
26
1.0
343
1.7
Sofala
41
1.6
1 824
8.8
Inhambane
35
1.4
467
2.3
Gaza
34
1.3
730
3.5
92
3.6
Maputo Province}
Maputo City
Mozambique
}
}
654}
}2 958
4 458}
3.1}
}14.2
21.4}
741
37
Notes.
(a) Expenditure on drugs supplied to provinces.
(b) The ratio of expenditure per person in better supplied provinces
to that in the least supplied province.
Source. MoH: DPh.
50
POLICIES FOR THE REHABILITATION
OF THE PUBLIC HEALTH SECTOR IN THE MEDIUM TERM
PRINCIPLES AND PRIORITIES
The strategy to be described for the rehabilitation and
development of the public health sector in Mozambique is
based on certain health system principles and priorities.
Since many of these principles and priorities are already
aspects of Ministry of Health policy and/or are accepted
elements
of
international
health
policy,
their
presentation here is mainly in summary form.
General
1.
From its inception, the national health service of
Mozambique has been based on the policies of primary
health care and the use of essential drugs, and these
policies will continue to guide the development of
the public health service in the future. The aim is
to extend essential health care progressively to the
entire population, with priorities set on the basis
of relative health need.
2.
A high priority will continue to be given to health
promotion and disease prevention, through programmes
like those for mother and child health, immunisation,
Units like health
and communicable disease control,
posts, which have been exclusively curative, will
assume also preventive
and promotive
come
to
In addition,
functions.
addition. greater emphasis will be
placed on measuring the impact of health programmes.
Indicators will be developed and used to monitor more
systematically
the
effectiveness
and
cost
effectiveness of programme activities.
3.
During the colonial period. the health services for
the majority of the Mozambican people were derisory.
In the early years after independence, great efforts
health
care
rapidly to
were made
to extend
underserved populations, especially in the rural
was
understandable
and
areas.
This
policy
however
,
to
more
attention
commendable.
It led, however,
being paid to the quantity of health services than to
their quality and efficiency.
While every effort
will be made in the medium term to restore the health
service quantitatively to the level it attained in
the early 1980s, more emphasis than before will be
placed on the improving the quality of care and the
efficiency of services.
Rehabilitation of the Health Care System
4.
All levels of the health care system are in serious
need of rehabilitation, from rural health posts to
central hospitals.
Despite the priority to be given
51
Hehoo
05151 0
A/
to primary level care in the rehabilitation process,
hospitals must also be included:
they provide
essential curative services and are - or should
become - centres for referral of patients and support
for lower levels of the health system.
Rural
secondary care has always been weak in Mozambique and
a high priority will be afforded to the upgrading and
expansion of the rural hospital network.
In
particular, rural hospitals must become capable of
offering emergency surgical and obstetric services.
Nevertheless,
in general in the rehabilitation
process, priority will be given to the primary level
of care.
5.
Priority will also be given to rehabilitating the
health services in the rural areas, where the level
of care is currently so low.
The upgrading of rural
health services will be the contribution of the
health sector to the restoration of normal life in
the countryside, such that it may be more attractive
for rural migrants to the towns to return to their
home areas.
The location of rural health facilities
will take account of the new agglomerations of people
which are the inheritance of the camps for the
displaced population.
Some priority will also be
given to the upgrading of health services in the
periurban areas which have become swollen with rural
migrants, not all of whom will return to the
countryside.
6.
therefore, first
In the rehabilitation process,
priorities will be afforded to rural primary level
and
rural
hospitals
and,
where
facilities
appropriate, to primary level units in periurban
areas.
'This means that, given the scarcity of
resources,
it will be necessary to limit the
allocationL Of additional resources to the urban
health services, especially to the larger hospitals.
In these urban services, which are relatively well
developed,
there
are
ample
opportunities
for
improving efficiency: it should be possible to raise
the quality and increase the volume of service
without entailing a proportionate increase in the
consumption of resources.
7.
Rural health centres in Mozambique have been looked
upon as relatively big units, with quite large
numbers of personnel, and have been correspondingly
expensive to run.
However, they have often operated
inefficiently.
This is partly because larger units
are more difficult to manage and partly because the
numbers of the people living in the immediate
vicinity of the centres have not always justified the
number of health workers on the staff; given the
difficulties of rural transport, a catchment area
with a radius of more than a few kilometres is often
mainly theoretical. In future, physical accessibilty
and density of the population will be more important
criteria in determining the size and location of
52
rural health facilities.
In general fewer, if any,
big health centres will be built and more reliance
will be placed on the provision of a larger number of
small facilities situated closer to people’s homes.
These
health
facilities
will
have
preventive,
Such
promotive
and curative
functions.
small
curative plus preventive units have been termed in
However
the past ’developed health posts’.
However,, since
they should have in effect health centre functions,
they are referred to in this work as ’mini health
centres’, a term which emphasises their preventive
and outreach responsibilities. Existing health posts
in both rural and urban areas will be gradually
upgraded to mini health centres.
8.
The not-for-profit non-government organisations will
play an increasingly important role in the provision
of health services in Mozambique, especially in the
rural areas. Rural health facilities which are owned
and run by these organisations are strictly part of
the private sector.
Nevertheless, their work should
be integrated with that of the rest of the district
health system and the strategy presented in this
document includes voluntary health services with the
public sector for planning purposes.
Health Personnel
9.
Health services are only as good as their health
workers, who are the most valuable resource of any
In Mozambique, it is; necessary to
health system,
raise the productivity of health personnel and
Among the
improve the quality of their care,
measures to be taken to achieve this will be the
following:
- training institutions will be rehabilitated and
equipped, and their teaching staff strengthened;
courses <and curricula will be reviewed and revised
stricter educational criteria will be applied
the selection of candidates for basic training
in
more emphasis will be placed on refresher and
upgrading courses for existing health personnel
including
between
grades,
will
be
- promotion,
facilitated and will be based on more objective
criteria, so that personnel will have professional
and material incentives to perform well
- support to existing personnel will be increased by
in-service
training,
establishing
systems
of
regular supervision and the flow of professional
information
- the decline of real salaries during the 1980s has
had a demotivating effect on health workers and has
obliged many of them to ’moonlight’ in order to
53
support their families; every effort will be made
to increase the real income of health personnel to
the extent that the economy allows; in the present
work, a projection has been made for an increase in
the average real salary of health personnel by the
year 2000 to a point midway between the present
level and that which obtained at the beginning of
the 1980s.
10. During the 1980s, many health workers moved from
rural to urban areas and from working at lower levels
of care to higher levels. This applied particularly
to personnel, like doctors and nurses, who were
capable of working in hospitals. With the end of the
war, special attention will be paid to encouraging
health personnel to work in the rural areas and in
underserved provinces where they are greatly needed,
and to rewarding them for doing so.
Among the
measures to be taken will be the following:
- more people will be recruited for health worker
training from underprivileged provinces and areas,
since they will be more prepared to work in these
places after graduation
- priority for post-basic training and promotion will
be given to personnel who have served in priority
areas
- decent housing will be provided for health
personnel and their families
- a system of allowances will be instituted to
compensate personnel for hardship postings and for
lost opportunities to earn additional income
- clearer regulations about the obligation to serve
in rural and other priority areas will be made.
11. The government health budget will be constrained for
the foreseeable future.
If the real salaries of
public health workers are to increase, a limit must
be placed on the number of health personnel that the
government employs.
The Ministries of Health and
Finance have agreed that in the medium term the total
number of employees of the national health service
should remain effectively at the present level.
In
this work, it has been assumed that the number of
health service employees in the year 2000 will not
exceed 17,000. However, the numbers of qualified and
more highly trained professionals will be increased
by the following means:
some support staff will be upgraded to become, or
health
will
be
substituted
by,
professional
personnel; the ratio of trained to untrained
employees in the health service will be increased
from the present 1:1 to 2:1
54
♦
- the proportion of health workers in the middle and
higher grades will be increased; this will be
achieved by post-basic training and promotion of
personnel from lower grades and by expansion of
recruitment for the basic training of middle and
higher grades.
12. The key categories of the basic grade will the
medical aides, preventive health aides, and MCH
nurses. These workers will be the main personnel for
the new mini health centres and the backbone of the
primary level services.
They will be trained in
sufficient numbers to staff the rehabilitated and
expanded rural health infrastructure.
The cadre of
’basic nurses’ has not fulfilled satisfactorily its
anticipated role in primary health care and these
workers will be regarded primarily as nurses in the
ordinary sense of the term; in the meantime, however,
they will
substitute
for medical
aides until
sufficient of these personnel have been trained.
Drugs and Other Operating Items
13. A major cause of low productivity of health personnel
in Mozambique is a lack of drugs, equipment and other
operating items which they need to carry out their
work.
Every effort will be made to keep health
personnel supplied with essential operating inputs.
In this work, an attempt has been made to calculate
the needs of the primary and secondary levels of the
health service for drugs and other operating items.
The projection is made to reattain by the year 2000
the level of drug provision per person that prevailed
at the beginning of the 1980s. Given the shortage of
foreign exchange and rate of population growth, this
will not be an easy goal to achieve.
Maintenance and Management
14. Too often capital investments are made in health
facilities, equipment and vehicles without adequate
provision being made for maintenance. The result is
that the capital goods deteriorate rapidly and have
to be replaced prematurely:
much of the original
investment is wasted.
In the cost projections of
this work, estimated recurrent expenditures include a
provision for maintenance.
But adequate systems of
maintenance
and
especially
of
preventive
maintenance - still have to be developed.
15. Reference has been made already to the need to
improve the quality, effectiveness and efficiency of
health services and programmes.
This implies the
Two areas
need to improve health system management,
will be given special attention:
- hospitals, especially the central and provincial
hospitals, are responsible for a high proportion of
the country’s health expenditure, but there is
55
ample scope for improving the quality of their care
and increasing the efficiency with which they use
resources; professional hospital management will be
strengthened or
introduced and a system of
performance indicators will be developed to monitor
progress in the areas of quality and efficiency
- an integrated health system based on primary health
care demands effective planning and management at
ministry, provincial and district levels, and
efforts will be made to increase the number of
personnel trained to perform these functions;
particular attention will be paid to the district
level, which is the basic unit of health service
delivery in the rural areas; training of personnel
of the district health directorates in planning,
management,
programme
development
and
implementation, and support and supervision of
primary level services, will be a high priority;
the main responsibility for support and supervision
of rural primary services will pass to a trained
mobile team based at the district level; a system
of indicators will be established to monitor
progress in district health system development.
16. The use of resource allocation as a means of
implementing government health policy implies reform
of the present system of financial management.
Procedures must be developed to strengthen the links:
between
health planning and administrative systems
(for example, by making budget categories correspond
to planning categories like levels of health care);
between the investment and recurrent budgets; between
departments of the Ministry of Health; between the
different administrative levels of the national
health service; between the Ministries of Health and
Finance and the National Planning Commission; and so
on.
Such reform will not be easy, but it is
the
essential
if
health
policy
including
is
rehabilitation strategy developed in this work
to be translated into reality.
The next phase of
PRANHP will study the need for reforms in financial
management in the short, medium and long term.
17. The health information system is also in need of
rationalisation.
Necessary data should be collected
and analysed in as simple a form as possible and be
channelled expeditiously to those who will use it including the people who generated the data in the
first place, Conversely, information without a clear
Work will
use should be eliminated from the system,
continue on the development of a functional health
information system.
International Aid
18. Support from the international community has been
crucial for the survival of the Mozambican health
service in the last several years and will remain so
56
The
strategy
for
to
come.
for
some
years
rehabilitation of the service presented in this
continuation
of
this
the
on
document
depends
There
is,
however
,
solidarity,
international
associated with this level of support a serious
The
strategy
external
dependency.
problem of
attempts to address this problem and begins to move
the health system in the direction of national
sustainability in the long run.
19. The main problem of dependency arises when donors
finance a high proportion of recurrent costs, such
that the routine operation of the health service
depends on the continuation of international support.
In the strategy to be presented, an increasing
proportion of donor assistance is projected to be in
the form of support for investment costs - the
traditional area for external aid. Donor support for
recurrent costs is also projected to increase, but
more slowly than the financing from internal sources,
so that the proportion of external financing of
recurrent costs will gradually fall.
20. The need to increase the availabilty of drugs in
Since almost all
Mozambique has been shown above.
international aid will
drugs must be imported r
continue to be the main source of finance for drug
purchases.
It is projected that an increasing
proportion of donor support for recurrent costs will
be used for drug imports.
21. Technical assistance will continue to be an important
component of international aid.
Expatriate health
workers have filled important staffing vacancies in
the health service, especially for doctors and other
have
ensured
the
and
specialised
personnel,
country's
hospitals,
functioning of many of the
pointed
out
already,
a
However,
as
has
been
relatively small number of foreign professionals has
been employed at a very high cost and technical
assistance comprises a high proportion of total
health aid.
There are other causes of concern with
the technical assistance programme: not all the
' '
expatriate
personnel have had appropriate skills;
of
them
have been recruited on excessively short
some i— —
and
sometimes foreign professionals have
contracts;
been imposed on the health service through aid
it has
been difficult
for local
projects and
In the
officials to control their activities.
strategy developed in this work, it is projected that
technical assistance will constitute a <decreasing
■ - ,
The
proportion of donor support for recurrent costs.
application of stricter <criteria
in
—
1- 1
— the -recruitment
process should make it possible to select good
cost.
quality cadres at a reasonable cost.
This policy
could be realised more easily if the Ministry of
Health were permitted to undertake the foreign
recruitment directly, allowing
allowina national officials a
greater say in the selection, terms of contract and
57
cost of individuals, as well as a greater control on
the mix of personnel recruited (for example, in
future less middle level personnel will be needed and
greater emphasis will be placed on the recruitment of
more highly qualified professionals).
22. The Ministry of Health benefits from a large number
of foreign aid projects: there were 116 separate
projects
in 1989.
As mentioned above,
above,
this
assistance is vital to the survival of the Mozambican
health service. However, the form of the cooperation
leaves room for improvement.
The large number of
distinct projects, some of them quite small, makes it
virtually
impossible
for
the
national
health
authorities to manage them all properly.
Funds are
spent
on
studies
and
consultancies,
and
on
administration, which do not have a great bearing on
the development of services.
The pattern of
assistance has also sometimes been at variance with
national health policy.
For example, support for
health programmes in a vertical form has weakened the
Ministry’s policy of integrated primary health care.
In addition, much of the aid is tied and this has
limited the ability of the government to 'shop
around’ in the world market and obtain good ’value
for money’ .
In the case of drugs, for example,
Mozambique
has
considerable
experience
in
the
purchase of products of good quality at reasonable
prices, but a substantial portion of aided drug
imports by-passes this national capacity, which is
weakened as a consequence.
Thus the present
procurement mechanisms of international assistance
lack cost-effectiveness. The Ministry of Health will
try to convince donors that their cooperation would
be of greater value if more of their aid came in the
form of untied budget support. This would allow the
health authorities to integrate the assistance more
effectively into the Mozambican health service and
national structures would be stengthened in the
process.
It is understood that the Ministry would
have to account fully to the donors for the use of
aid in this form.
This approach to international
cooperation would also reduce the number of separate
projects; those that remained would be larger, better
defined and better managed.
23. The Ministry of Health will attempt to increase its
capacity to plan and manage foreign assistance and to
negotiate constructively and creatively with donors.
The present exercise of reformulating national health
policy should result in a coherent strategy for the
rehabilitation of the Mozambican health service in
the medium term.
This strategy will be translated
into detailed plans,
which will be presented
proactively to donors for funding.
58
STRATEGY FOR HEALTH SERVICE REHABILITATION
The strategy developed for the rehabilitation of the
public health service follows from the principles and
priorities just described.
More details concerning the
strategy may be found in the companion document of
PRANHP, ’Revision of National Health Policy: Strategies
and Priority Actions’
by Bata,
Simao and Chomera
Jeremias.
Here some key aspects of the strategy are
presented and given a quantified form.
It should be emphasised that the strategy does not
constitute a detailed health development plan. More work
is still needed at the micro-level to determine which
health facilities will be rehabilitated in a given area
in a given year,
the exact specifications of the
rehabilitation, the location of new primary level units,
the phasing of the intakes of training institutions, and
so on. The strategy traces the broad lines to be adopted
for health sector development in the medium term, costs
them, and identifies feasible financing mechanisms.
The project PRANHP has concentrated so far on the primary
strategy. and
and secondary levels of health care.
The strategy,
the resources needed, to rehabilitate and run the health
service network at these priority levels have been
These levels will be given
identified with some care.
the first priority in the resource allocation process,
To a large extent, growth in spending by city hospitals
has had to be treated for the time being as a residual
within the overall ceiling projected for the growth of
public health expenditure.
More detailed work on a
development strategy for the urban hospital services will
be undertaken in the near future.
Staffing patterns are presented for the different types
of primary and secondary level health facilities.
These
personnel establishments are a compromise between various
existing proposals.
It is understood that in practice
the staffing of individual health facilities will vary
according
to
particular
circumstances,
notably
the
availabilty of personnel at the time and the number of
people a unit serves.
The teams shown indicate the
’average’ staffing patterns to be aimed for in the medium
term and are used in this work mainly to calculate the
unit recurrent costs of rehabilitated health facilities.
Within the general parameters of these costs, therefore,
more refined definitions of staffing patterns can be
made.
In this strategy, rehabilitation or construction of
primary and secondary level facilities includes the
provision of equipment and furniture, means of transport
for outreach activities, and staff housing.
For the
operation of rehabilitated or new facilities, financial
adeguate supplies of drugs and
provision is made for adequate
59
other operating inputs,
including
outreach work and maintenance.
those
needed
for
The description of the rehabilitation strategy will begin
with rural hospitals, because of their key place in the
rural health infrastructure and because their number will
determine the number of rural health centres to be
rehabilitated.
Urban general hospitals will be dealt
with at the same time.
Rural and General Hospitals
Rural secondary care has always been weak in Mozambique
and the need to strengthen this component of the health
The essential
care network has been mentioned already,
service that these hospitals must provide is emergency
it is this service which
surgical and obstetric care;
distinguishes a rural hospital from a rural health
centre.
The hospitals will provide the four basic
surgery. obstetrics
specialities of internal medicine, surgery,
and paediatrics.
In addition to their strictly hospital role, rural
hospitals will undertake the primary preventive and
curative activities of a rural health centre.
These
primary level services will normally be provided in a
separate health centre wing of the hospital although, for
the purposes of economy, this wing will share many common
services
(like the pharmacy,
laboratories,
laundry,
kitchen) with the rest of the facility.
There will also
normally be a rotation of staff between the wards and the
health centre wing, so the hospital staff can keep in
touch with both inpatient and primary health care work
and see the connection between them.
Rural hospitals
will be responsible for providing mobile services and for
supporting and supervising the primary level facilities
in the district.
All relevant staff will be mobilised
for this outreach work, including hospital clinical
personnel, who can play a valuable role in upgrading the
quality of curative care offered at the primary level.
In
the
rehabilitation
strategy,
two
vehicles
are
allocated to each rural hospital for outreach activities.
The typical staffing pattern of a rural hospital is shown
in Table 25.
The team includes the personnel necessary
for the hospital, health centre and mobile/supervisory
functions. The policy that rural hospitals should become
centres of emergency surgery and obstetrics implies that
senior medical students and young doctors will have to
have more - and more practical - training in surgical
techniques.
Adequate numbers of surgical assistants and
nurses specialised in anaesthetics, theatre work and
midwifery must also be trained.
Most new
Existing rural hospitals will be rehabilitated.
rural hospitals will be developed by upgrading existing
rural health centres located in district administrative
centres.
The number of new hospitals that can be
60
Table 25
Average staffing patterns of rehabilitated health facilities at the
primary and secondary levels<a>
District rural health centres <b>
medical assistant
1
medical aide
1
preventive health aides
2
dental aide
1
basic nurses
2
MCH nurses
2
0,5 pharmacy aide
0,5 laboratory aide
1
administrative aide
0,5 pharmacy auxiliary
0,5 microscopist
elementary nurse
1
support workers
4
Rural hospitals
doctors
2
surgical assistant
1
medical assistant
1
preventive health assistant
1
laboratory assistant
1
0,5 dental assistant
pharmacy assistant
1
general or specialised nurses
4
nurse midwife
1
medical aides
3
preventive health aides
2
pharmacy aide
1
laboratory aides
2
radiology aide
1
dental aide
1
basic nurses
14
MCH nurses
5
administrative aide
1
support workers
10
Other rural health centres
medical assistant or aide
1
preventive health aide
1
basic nurse
1
MCH nurse
1
pharmacy auxiliary
1
microscopist
1
elementary nurse
1
elementary midwife
1
support workers
3
General hospitals
doctors
4
surgical assistant
1
medical assistant
1
preventive health assistant
1
laboratory assistant
1
dental
assistant
1
radiology
assistant
1
pharmacy
assistant
1
administrative assistant
1
general or specialised nurses
6
nurse midwives
2
medical aides
3
preventive health aides
2
pharmacy aide
1
laboratory aides
2
radiology aide
1
dental aides
2
basic nurses
14
MCH nurses
5
administrative aides
2
support workers
10
Mini health centres: rural or urban
medical aide or basic nurse
1
preventive health aide
1
MCH nurse or elementary midwife
1
support worker
1
Village health post
village health worker or
1
first aid worker or
elementary nurse
Urban health centres
medical assistant
1
general nurse
1
nurse midwife
1
medical
aide
1
preventive
health aide
1
laboratory aide
1
dental aide
1
pharmacy aide
1
basic nurses
3
MCH nurses
3
administrative aide
1
support workers.
5
~
Notes. (a) The number 0.5
of” ai health worker means that only one in two
of the type of health facility will have this cadre.
(b) Some facilities of this type may have a doctor.
61
developed in the medium term is limited, not so much by
financial constraints, but by the lack of staff to run
them and the limited building capacity in the rural
areas. The selection of districts for new hospitals will
be made on criteria of population size, transport links,
and economic importance; all of the government’s defined
priority districts whose population lacks reasonable
access to hospital services (either in their own or in a
neighbouring district) will be included.
A provincial list of hospitals to be rehabilitated or
built in the medium term is shown in Table 26.
Fourteen
rural hospitals in priority districts and eight in non
priority districts are identified for rehabilitation
(work is already in progress in several hospitals). New
rural hospitals are projected for six priority districts
and nine non-priority districts (in some cases, the exact
selection has still to be made). Thus by the end of the
rehabilitation period, the number of rural hospitals will
have increased from 22 to 37.
The effect of this strategy on the distribution of rural
hospitals by province is illustrated in Table 27.
This
shows the changes in rural population to rural hospital
ratios
that
would
result
if
the
rehabilitation/construction works were completed by the
year 2000.
Nationally there would be a decrease from
611,000 to 475,000 rural people per hospital. The table
shows that the strategy would narrow the difference
between the provinces in the number of people served per
hospital; the ratio of the number in the least served
province (Zambezia) to that in the best served province
(Gaza) would decrease from 5.2 in 1990 to 2.2 in 2000.
Table 26 also shows that the four general hospitals of
the City of Maputo are due for rehabilitation (work is
already in progress in two). A general hospital has been
foreseen for Nacala for some time and that hospital is
included in the table.
The city has more than 100,000
people and an important economic role in the context of
the Nacala corridor.
There is no space to upgrade the
present health centre to a general hospital and
construction of a hospital on a new site is already
included in the development plan for the city.
In the rehabilitation strategy, two new elements are
added to the specification of a general hospital: these
are an accident and emergency service (which in Maputo
will take the pressure off the Central Hospital) and a
maternity service for the referral of local women with
high risk pregnancies. The average staffing pattern of a
general hospital is shown in Table 25.
In addition to
work within the hospital, the staff will be responsible
(as in the case of rural hospitals) for supporting and
supervising primary level facilities in its area.
Among
other elements of such support, doctors from the hospital
will make regular supervisory visits to local health
centres and will conduct outpatient sessions there.
62
*
Table 26
Rural and general hospitals for rehabilitation or construction in the medium term<“>
Construction
(in most cases by upgrading
rural health centres)
Rehabilitation
Priority
districts<b>
Non-priority
districts
Priority
districts<fa>
Non-priority
districts
RH Cuamba <<= >
RH Mocimboa da Praia < <= >
RH Nametil (Mogovolas)
RH Alto-Molocue
RH Mueda
RH Angoche <C)
RH Catandica (Barue) <<=>
RH Maganja da Costa
RH Montepuez <<=>
RH Songo
(Cabora Bassa)
RH Homofne or RH Panda
or RH Massinga
RH Mutarara or
RH Changara
RH Monapo
RH Vilankulo
RH Moamba
RH Espungabera
(Mossurize)
RH Namapa
RH Marromeu
RH Luabo (Chinde) <a >
RH Marrupa
RH Ribaue
RH Chicuque
(Maxixe)<G)
RH Pebane or RH Milange
RH Inhaminga < a> or
RH Chibabava
RH Mocuba
RH Chicumbane
(Xai-xai)<c>
GH Nacala
RH Moma or RH Malema
or RH Murrupula
RH Gurue < <= >
RH Xinavane
RH Macomia
RH Ulongue
(Angonia) < «= >
GH Mavalane <<=>
RH Chicualacuala or
RH Massingir
RH Nhamatanda
GH Jose Macamo
RH Buzi
GH Chamanculo
RH Chokwe c <= >
GH Machava
RH Chibuto
RH Mandlakaze <C>
Notes. (a) The list of hospitals is provisional. The target is to complete this rehabilitation
by the year 2000.
(b) Priority districts defined by the government; in those not included in this list,
the population has reasonable access to hospitals in neighbouring districts or to
provincial hospitals.
(c) Rehabilitation or construction in progress.
(d) Facility in need of complete reconstruction.
(e) Rehabilitation already complete.
63
Projection of rural population to rural hospital ratios by province
resulting from the rehabilitation strategy<e* >
Table 27
Ratio<0>
Number of
rural
hospitals
2000<b>
Rural
population
(’000)
per hospital
604
2.0
2
394
1.3
3
385
1.3
4
376
1.2
Nampula
4
705
2.4
6
613
2.0
Zambezia
2
1 548
5.2
6
673
2.2
Tete
2
491
1.6
3
442
1.4
Manica
0
2
473
1.5
Sofala
3
362
1.2
4
354
1.1
Inhambane
2
623
2.1
3
542
1.7
Gaza
4
299
1.0
5
312
1.0
Maputo Province<c3>
1
539
1.8
2
351
1.1
Mozambique
22
611
37
475
Number of
rural
hospitals
1990
Rural
population
(’000)
per hospital
Niassa
1
Cabo Delgado
Province
<T>
4^
Notes.
Ratio*
(a) See Table 26.
(b) Projection based on the scenario that the rehabilitation will be completed by the year 2000;
population projection taken from the National Planning Commission.
(c) The ratios of the rural population per rural hospital in the less served provinces to that
in the best served province (Gaza).
(d) Includes the population of Matola.
t
5
Rural Primary Level Facilities
In this strategy, four types of rural primary facilities
are recognised: district rural health centres (located in
district administrative centres), other rural health
centres, rural mini health centres, and village health
posts (Table 28).
This classification is somewhat
28) .
different from that which has been used the past and has
been made for the following reasons (discussed already
above):
the need to bring health centre functions closer to
rural people’s homes
- problems
centres
in
the
efficiency
of
larger
rural
health
- the assigning of the main responsibilty for support and
supervision of rural primary level facilities to
specialist mobile teams based at the district level.
The strategy envisages that the primary level network
will be rebuilt in the medium term to the maximum
strength that existed in the 1980s (that is, a total of
1,421 units) minus the 15 rural health centres in
district administrative centres which will be upgraded to
rural hospitals.
Table 28 shows that 1,284 of the
projected 1,406 primary level facilities are planned for
the rural areas.
The table shows that 92 district rural health centres
of
existing
rehabilitation
by
will
be
developed
include
the
rehabilitation will
facilities.
The
provision of maternity facilities. The staffing pattern
(Table 25) of this type of unit provides for the
additional personnel needed to take part in district
As in the case of rural
mobile supervisory teams.
hospitals, two vehicles will be allocated to these health
centres for outreach activities.
In the rehabilitation
1..
process, priority will be given to these health centres
in district administrative centres, especially in the few
priority districts that will not have rural hospitals.
Outside the district administrative centres, rural health
facilities should be located according to criteria of
population density,
transport
links,
and economic
importance.
Even
units
identified
here
for
’rehabilitation’ may sometimes be reconstructed elsewhere
if circumstances dictate it (the difference in building
costs between rehabilitation and construction y1.11. not be
great where - as is usually the case - facilities are
seriously damaged or deteriorated) .
The location of
units will take into account any new agglomerations of
people which have resulted from the camps for the
displaced population.
Non-district rural health centres
will
be
located
preferentially
in
subdistrict
administrative centres.
65
Table 28
Rehabilitation of the health service network at the primary level in the medium term<Q>
___________________ Rural areas______
Health centresMini health
District
Other
centres
Average number of
personnel per faciLity<c=>
17
11
92
81
4
Village
health
posts
_____ Urban areas_____
Health
Mini health
centres
centres
1
20
450
38
4
Number of facilities:
cn
to be rehabilitated
- to be upgraded from
a health post
509
48
to be built from new
152
36
Total
92
81
661
450
38
84
Notes. (a) The target is to complete this rehabilitation by the year 2000. Some work is already in progress.
(b) Priority will be given to the rehabilitation of district health centres, especially those in
government priority districts.
(c) See Table 25.
The
strategy
allows
for
the
rehabilitation
(or
reconstruction) of 81 rural health centres outside
district administrative centres (Table 28). This is the
number of such facilities currently and, in the medium
term, it should provide for reasonable coverage of rural
areas with high population density, The staffing pattern
of this type of health centre is shown in Table 25. The
rehabilitation will include the provision of maternity
facilities and a vehicle for outreach activities in the
catchment area.
The policy of transforming health posts into mini health
On average, a mini centre
centres has been explained.
will have three professional staff (Table 25) to deal
respectively with curative care, preventive/promotive
The unit will have
work, and mother and child health.
maternity facilities and 2-4 general observation beds.
Like other health centres, it will be responsible for a
defined catchment area and the unit will be provided with
motorbicycles (or bicycles) for outreach activities in
the community.
Table 28 shows that 509 rural health
posts will be upgraded to mini health centres.
In addition to health posts serving residential areas,
the national health service has operated 188 posts
attached to work places. These work-related health posts
are in the process of being transferred out of the public
service to the ownership of the respective enterprises
and it is expected that this process will be completed in
the near future.
In order for the national health
service to stay with the same number of primary level
units as before, the strategy allows for the construction
of 188 new mini health centres. Table 28 shows that 152
of these new mini centres have been allocated to the
rural areas, making a total target of 661 rural mini
health centres for the rehabilitation period.
Available data indicate that there are about 450 village
health posts.
The strategy allocates some government
funds to support the rehabilitation of these posts.
They will be operated typically by one health worker of
the elementary grade (Table 25).
Rural District Health Management and Supervision
It has been stated already that the district is the basic
unit of health service delivery in the rural areas and
that it will be necessary to increase the skills of
personnel at the district level in planning, management,
programme development and implementation, and support and
supervision of primary level facilities.
The main
responsibilty for support/supervision of rural primary
services will pass to a specialised mobile team based at
the district level. The personnel and vehicles for such
a team have been included in the resources allocated to
the rural hospitals and health centres located in the
district administrative centres (see above), but it will
67
be up to the district health directorate to decide to
what extent the team remains attached to the district
health facility or works more directly under the control
of the directorate itself.
Other rural health centres
will continue to supervise health posts/mini health
centres in their respective catchment areas.
Instruments will be developed to support district health
management including job descriptions, working routines,
programme norms, supervisory checklists, and indicators
to monitor progress in the functioning of the district
health system.
Urban Primary Level Units
Given the constraints on the growth of public health
expenditure, it will not be possible to expand the urban
health services greatly in the medium term, even at the
primary level. However, as has been mentioned, there are
opportunities for increasing the efficiency of urban
services, so that the quality of care can be raised and
the volume of service increased without there being a
proportionate increase in the consumption of resources.
For example: primary level units are often underutilised
in the afternoons and, with better organisation, the
second half of the day could be used to provide
additional outpatient sessions and/or outreach services
in the community; a high proportion of adult urban
patients suffer from chronic degenerative disorders and
the development and use of diagnostic and therapeutic
norms for these conditions would result in better and
more cost-effective care.
Table 28 shows that the 38 existing urban health centres
will be rehabilitated. This rehabilitation will include
the provision of maternity facilities for all centres.
The average staffing pattern of urban health centres is
shown in Table 25.
For the reasons discussed already,
the 48 urban health posts will transformed into mini
health centres; these will have the same facilities and
staffing pattern as the rural mini centres. In addition,
the urban areas will benefit from 36 of the new mini
health centres to be built in substitution for the
enterprise health posts; these new mini centres will be
located mainly in periurban areas where the population
has expanded with rural migrants.
By the end of the
rehabilitation period, therefore, there should be a total
of 38 urban health centres and 84 urban mini health
centres.
If this were achieved by the year 2000, there
would be one health centre or four mini health centres
per 50,000 urban people.
Urban Hospital Services
The strategy allows for the physical rehabilitation of
the existing urban hospitals, including the general
hospitals of the City of Maputo (see above) and the
larger provincial, central and specialised hospitals.
68
Beyond that, however, there is not yet a policy for the
development of the urban hospital services.
Staffing
patterns and norms for the consumption of drugs and other
operating items have not yet been defined for the
different types of hospital in the context of efficiency
considerations and economic feasibility.
For this
reason, in the expenditure projections which follow, the
growth of recurrent costs of the urban hospitals has been
left as a residual: that is, as (most of) the difference
between the combined expenditure growth of the rural
hospitals and the primary level of care, and the
projected growth of public recurrent health expenditure
as a whole.
Much more work is needed, therefore, to
arrive at a costed and feasible strategy for hospital
development in Mozambique, including ways to increase and
monitor the efficiency of hospital resource use. Such a
strategy is needed both to improve the country’s hospital
services and to prevent the uncontrolled growth of urban
hospital costs, which would undermine the development of
priority services in the rural areas and at the primary
level.
69
THE REHABILITATION STRATEGY: COSTS AND FINANCING
In this section the cost implications of the proposed
rehabilitation strategy are examined.
The investment
costs of rehabilitating the public health system, and the
recurrent costs of the system when it will function with
the defined level of resources, are estimated.
The
potential contributions of different sources of finance
are quantified and changes in the composition of
international aid are proposed.
COST ESTIMATES
I
Sources and methods for estimating unit investment and
recurrent costs are given in the methodological notes and
more information is given in the footnotes to the tables
which follow, The investment costs of facilities include
provision for equipment and furniture and, for primary
and secondary level units, means of transport for
outreach activities and staff housing.
The recurrent
costs of rehabilitated primary and secondary level units
cover the salaries of the defined staff and an adequate
supply of drugs and other operating inputs, including
those needed for outreach work and maintanance.
The
investment expenditures are expressed in US dollars,
since it is expected that the major part of these costs
will be financed by international aid.
On the other
hand, the recurrent expenditures are expressed in local
currency, since the intention is to finance a growing
proportion of these costs from national sources.
All
cost estimates are in prices of 1991.
Investment Costs
Table 29 refers to the rehabilitation of the health
service network at the primary and secondary levels of
care. It shows the different types of health facility
defined in the rehabilitation strategy, the numbers of
facilities identified for rehabilitation or construction,
the estimated unit costs of investment, and the total
investment costs involved.
For these levels of care
combined, the total estimated investment cost amounts to
$210.4 million.
To
complete
the
estimate
of
investment
costs
for
the
public health system as a whole. Table 30 summarises the
costs of the primary and secondary levels shown in Table
29 and adds those for rehabilitating provincial, central
and specialised hospitals and training institutions.
The total cost of rehabilitating the public health sector
in the medium term is estimated to be $278.9 million. If
this rehabilitation were to be completed by the year
2000, the total would represent an average investment of
70
Table 29
Estimates of investment and recurrent costs for the rehabilitation of the health service
network at the primary and secondary levels in the medium term<“>
(1991 prices)
Investment costs*13’
________ ($ million)
Total
Unit costs
Annual recurrent costs<b>
Unit costs*c>
Total
('000 contos)
(million
contos)
Type of health
facility
Number
Rural hospital
37
1.35<a>
50.0
292.6
10.83
Rural health centre
173
0.41
70.3
63.4
10.97
Mini rural health centre
661
0.10<r>
66.1
18.6
12.32
Village health post
450
<0.01
1.0
0.9
0.42
General hospital
5
1.40<a>
7.0
461.7
2.31
Urban health centre
38
0.20<h>
7.6
118.1
4.49
Mini urban health centre
84
0.10
8.4
28.0
2.35
Total
1 448
210.4
43.69
Notes. (a) The target is to complete this rehabilitation by the year 2000.
(b) Investment costs are expressed in US dollars because most of this expenditure will be
financed by aid, while recurrent costs are expressed in local currency because an increasing
proportion of that expenditure should be financed from national sources.
(c) Unit recurrent costs include provision for maintenance and outreach support and supervisory
activities.
(d) Unit cost based on the rehabilitation of 20 existing hospitals at $1 million per unit and
17 hospitals for construction (in most cases by upgrading existing rural health centres) at
$2 million per unit. The cost includes provision for equipment and furniture estimated at
25 per cent of building costs; two vehicles at $30,000 each (including 22 per cent of cost
for spare parts and maintenance); and staff housing.
(e) The unit cost includes provision for equipment and furniture estimated at 20 per cent of
rehabilitation cost; two vehicles (see note (d)) for each of the 92 district health centres
and one vehicle for each of the 81 other rural health centres; and staff housing.
(f) The unit cost includes provision for equipment and furniture estimated at 15 per cent of
upgrading/construction cost; two motorbicycles (including 15 per cent of cost for spare
parts); and staff housing.
(g) Unit cost based on the rehabilitation of four existing hospitals at $0.5 million per unit
provision for
equipment
and furniture
and one new hospital at $5 million. The cost
--- includes
’ ’
"
. .
estimated at 25 per cent of building cost and staff housing.
(h) The unit cost includes provision for equipment and furniture estimated at 20 per cent of
rehabilitation cost and staff housing.
Table 30
Estimates of investment costs for the rehabilitation of the
health service network and training institutions in the medium
term<“>
(1991 prices: $ million)
Level/area/institution
Investment costs
% total
Rural primary
137.4
49
Rural secondary <b)
50.0
18
Urban primary
16.0
6
Urban secondary
7.0
2
Provincial hospitals (7)
35.0<c)
13
Central and specialised
hospitals (5)
25.0<c)
9
Training institutions (10)
8.5<c)
3
Total
Notes.
278.9
100
(a) The target is to complete this rehabilitation by the year 2000.
Some work is already in progress.
(b) See Table 29.
(c) Includes costs for equipment and furniture estimated at
25 per cent of rehabilitation costs.
72
$31.0 million per year.
To put that figure in
perspective, the investment health expenditure in 1991
was some $16 million.
Thus to achieve by the end of the
century the relatively modest level of rehabilitation
involved in this strategy would imply a doubling in the
availability of investment funds and an ability to absorb
such funds at twice the present annual rate - in both
cases a very considerable challenge.
Table 30 shows that 49 per cent of the projected
investment costs are for the rehabilitation of rural
primary level facilities and 18 per cent for rural
The primary and secondary levels of care in
hospitals.
both rural and urban areas are projected to receive 75
of
the
total
investment
costs.
These
per cent
allocations are thus in line with the stated priorities
for the health sector.
Recurrent Costs
Table 29 also presents the estimated recurrent costs of
the primary and secondary level facilities when fully
rehabilitated and shows that the total recurrent costs of
these two levels
combined will amount to some 43.69
million contos per year.
To put this figure in perspective, it is necessary to
compare it with the existing expenditure on these levels
and relate the difference to the possible evolution of
public recurrent health expenditure as a whole.
An
attempt to do this is made in Table 31A.
For the purposes of illustration, the table presents a
scenario for the growth of public recurrent health
expenditure based on two assumptions: that the present
task of medium term rehabilitation will be completed by
the year 2000; and that total recurrent health costs will
grow in real terms at a rate of 4.5 per cent per year,
which is the target agreed already between the government
and the World Bank (see Preface).
As explained in the methodological notes,
existing
recurrent health expenditure could be disaggregated only
incompletely and it has not been possible to divide
existing expenditures exactly into the categories of
levels of care and rural/urban areas used in the
rehabilitation strategy (Tables 29 and 30).
Instead
Table 31A divides the public health sector. into eight
components, which were determined by the available data.
These
components
correspond
approximately
to
the
categories of the rehabilitation strategy and they are
adequate for the present purposes of examining the broad
economic
implications
and
feasibility
of
the
rehabilitation policies and strategy.
The components
have been given titles which reflect the main types of
health facilities represented.
73
Table 31A
A scenario for the evolution of public recurrent health expenditure to the year 2000
(1991 prices)
A. Expenditure projections
Sectoral
components <to)
1991____________
Expenditure/ Expenditure %total
person
(million
(contos)
contos)
2000____________
Average annual
Expenditure/
growth rate
person
(contos)
(%)
Expenditure
(million
contos)
%total
’Rural primary'
14.3
19
27.2
25
7.4
’Rural secondary'
6.5
9
11.3
10
6.3
Maputo City primary
2.8
4
3.4
3
2.2
Maputo City secondary
4}
}
34}
}
}
15} 69
}
}
3}
}
13}
69.0<<3>
62
3.4
Other*a>
2.7}
}
25.5}
}
}
10.9} 51.0
}
}
2.2}
}
9.7}
Total
74.6
100
110.9
100
Tertiary/quaternary
(excluding CHM)
Central Hospital
of Maputo
Training institutions
Increase in real salaries
of health workers
Grand total
4.6
5.3
4.5
9.4<“>
120.3
5.8
Notes. (a) Includes expenditure financed from all sources and includes costs of health programmes. The
projections are based on two assumptions: that total public recurrent health expenditure will grow
in real terms at an average rate of 4.5 per cent per year; and that the rehabilitation of the
primary and secondary levels of the health network will be completed by the year 2000.
(b) See text for definition of components.
(c) Calculated as a 'residual'; see text for explanation.
(d) Includes MoH headquarters, provincial and district health directorates, maintenance and supply
centres. National Institute of Health, central laboratories and other institutions.
(e) The figure shows the financial implication of an increase in the average real salary of health
workers to a point midway between the present level and that which obtained at the beginning of
the 1980s, assuming 17,000 health personnel in the year 2000.
The component 'rural primary' is composed mainly by rural
health centres and posts, but includes also urban primary
level facilities other than those in the City of Maputo.
In the scenario presented, the rehabilitation strategy
would result in an increase in the recurrent costs of
this component from 14.3 million contos in 1991 to 27.2
million contos (in 1991 prices) in the year 2000, which
would represent an average rate of real growth of 7.4 per
cent per year.
The share of this component of total
recurrent costs would increase from 19 per cent in 1991
to 25 per cent in 2000, so the strategy would effect a
shift in the distribution of health sector expenditure in
favour of the primary level and the rural areas.
The component 'rural secondary' comprises mainly rural
hospitals, but includes also the new general hospital for
Nacala.
The strategy would increase the recurrent costs
of this component from 6.5 million contos in 1991 to 11.3
million contos (in 1991 prices) in the year 2000, which
would represent an average real growth rate of 6.3 per
cent per year.
The share of this component of total
recurrent expenditure would increase from 9 to 10 per
cent, which would again be a change in expenditure
distribution in line with stated health policies.
The costs of the component comprised by primary level
facilities of the City of Maputo would increase according
to the scenario from 2.8 million contos in 1991 to 3.4
million contos (in 1991 prices) in 2000, an average real
expenditure growth of 2.2 per cent per year. This would
result in a fall in the share of this component in total
recurrent costs from 4 to 3 per cent (while the absolute
increase in expenditure would allow for a reasonable
improvement in the city's primary level services, as
described above).
It was explained earlier that unit recurrent costs of
rehabilitated tertiary and quaternary level hospitals
have not yet been defined, and nor have they for training
and other institutions or for general administration. It
has therefore not been possible to make cost projections
for these components of the health sector in the same way
as for the primary and secondary levels.
By way of a
provisional resolution of this problem.
Table 31A
aggregates the components for urban hospitals, training
and 'other'
institutions and treats their combined
expenditure growth as a residual: that is, as the
difference between the projected growth in costs of the
primary and secondary components (described above) and
the projection for the growth of public recurrent health
expenditure as a whole.
The result is that the real
expenditure of this 'residual', which is comprised mainly
by the large city hospitals, would grow at an average
rate of 3.4 per cent per year.
This growth rate would
result in a decline in the residual's share of total
recurrent expenditure from 69 per cent in 1991 to 62 per
cent in 2000, reflecting the shift in balance of
75
expenditure towards the lower levels of the care and the
rural areas.
Despite the relatively low expenditure growth rate
projected for the large urban hospitals. Table 31B shows
that in the scenario the ’residual’ (and therefore the
hospitals) would consume nearly a half of the total
growth of expenditure between 1991 and 2000; this is
because the low growth rate is applied to high baseline
By contrast, the component ’rural primary’ would
costs.
benefit from 36 per cent of the total growth money and
Thus
’rural secondary’ from 13 per cent of the total.
the providers and beneficiaries of the urban hospital
services would have no cause to complain that the
strategy neglects the need to improve the quality of
urban hospital care.
The final result of this scenario is that total recurrent
health costs would grow from 74.6 million contos in 1991
to 110.9 million contos (in 1991 prices) in the year
2000, which would be the consequence of applying the
planned average growth rate of 4.5 per cent per year
(Table 31A).
This growth would represent an increase in
recurrent health costs per person from 4.6 contos in 1991
to 5.3 contos (in 1991 prices) in 2000.
The scenario also foresees the possibility of an increase
Table 31A
in the real salaries of health personnel.
illustrates the case of an increase in the average real
salary by the year 2000 to a point midway between the
present level and that which obtained at the beginning of
the 1980s (see Table 9A) .
The calculation is based on
the assumption that the total number of health personnel
This increase in real salaries
in 2000 will be 17,000.
would imply an additional expenditure of 9.4 million
If this
contos (in 1991 prices) in the year 2000.
made,
the
result
would
be
additional expenditure were
total recurrent health costs of 120.3 million contos (in
represent
1991
prices)
in
2000,
which
would
an
expenditure per person of 5.8 contos.
Drug Costs
Given the importance of medicines in health care and the
need to import almost all drugs in use in Mozambique, it
is useful to identify separately the drug costs foreseen
in the rehabilitation strategy.
Table 32 gives an
estimate of such costs in US dollars at 1991 prices, for
the different elements of the health service network and
the retail pharmacy outlets.
First, with respect to total drug consumption, it was
shown earlier that in 1991 total drug costs amounted to
an expenditure of $1.0 per person, which represented an
availability of drugs per person about four-fifths of
The
that which prevailed at the beginning of the 1980s.
rehabilitation strategy sets the target of closing that
If this were to be
availability gap in the medium term.
76
Table 3IB
A scenario for the evolution of public recurrent health
expenditure to the year 2000
(1991 prices: million contos)
B. Division of growth in expenditure
% total
expenditure
growth
Sectoral
component
1991
Expenditure____
2000
Growth
'Rural primary'
14.3
27.2
12.9
36
'Rural secondary'
6.5
11.3
4.8
13
Maputo City primary
2.8
3.4
0.6
2
Rest
51.0
69.0
18.0
49
Total
74.6
110.9
36.3
100
(a) See notes to Table 31A.
Note:
Source: Table 31A.
77
Table 32
Estimates of annual drug costs of the rehabilitated health service
network and retail pharmacy outlets in the medium term(Q>
*
(1991 prices)
Type of health
facility
Number
Unit costs
($’000)
Total costs
($ million)
% total
costs
Rural hospital
37
67.42
2.49
9
Rural health centre
173
21.62
3.74
13
Rural mini health
centre
661
6.75
4.46
16
Village health post
450
0.36
0.16
1
General hospital
5
134.00
0.67
2
Urban health centre
38
44.21
1.68
6
Urban mini health
centre
84
13.45
1.13
4
Provincial/central/
specialised hospitals
12
NA
11.04<b>
39
Retail pharmacy outlets
2.82<c=>
10
Total
28.19<a>
100
Notes.
(a) The target is to achieve this level of drug expenditure by the year
2000.
Calculated
by difference; see text for explanation.
(b)
Estimated
as
10 per cent of the total.
(c)
This
level
of
drug costs in the year 2000 would represent the same
(d)
real drug expenditure per person as prevailed at the beginning of
the 1980s.
78
achieved in the time frame of the above expenditure
scenario, this would mean that in the year 2000 real drug
expenditure per person would be the same as that of two
decades earlier.
Table 32 shows that this apparently
modest goal requires an expenditure on drugs in 2000 of
$28.19 million (in 1991 prices) which, for the population
projected for that year, would represent the expenditure
of $1.36 per person (for comparison with Table 14, this
value is equivalent to $0.80 per person in prices of
1980).
Considering that the absolute figure of $28.19
million compares with that of $16.6 million spent on
drugs in 1991, the seemingly modest goal for total drug
consumption will not be an easy one to achieve.
The estimates of the drug costs of rehabilitated
facilities at the primary and secondary levels (Table 32)
were made as described in the methodological notes.
For the purpose of this calculation, a figure of 10 per
cent of total drug expenditure (based on past experience)
has been estimated for the costs of retail pharmacy
outlets.
Then, in the absence of norms for drug consumption of the
large hospitals, their drug costs have been calculated as
the difference between the estimated costs of the primary
and secondary level facilitites plus the retail outlets
and the total projected drug expenditure. The result is
that the drug consumption of the tertiary and quaternary
level hospitals is estimated at $11.04 million.
Given
that in 1991 the drug costs of these hospitals were $6.67
million (not shown in the table), the scenario of
completing the rehabilitation process by the year 2000
would result in a real growth of drug expenditure by the
major hospitals of 5.8 per cent per year, which is above
Thus
the estimated growth rate of the urban population,
an
again
the
rehabilitation
strategy
allows
for
improvement in the quality of care by the urban
hospitals.
Table 32 shows that in the strategy the rehabilitated
primary and secondary level facilities are projected to
consume 51 per cent of the total value of drug
consumption, whereas the major hospitals are estimated to
absorb some 39 per cent of the total value. Although the
latter is still a considerable percentage, it represents
a lesser concentration of drug consumption than at
present: excluding the retail outlets for comparison with
Table 20, the major hospitals are projected to be
responsible for 44 per cent of drug expenditure by the
health service compared with 51 per cent in 1991.
79
FINANCING STRATEGY
Investment Costs
As stated already, international aid should be devoted as
rather than
far as possible to support for investment
recurrent - costs,
costs, to minimise the degree to which the
routine functioning of the health service is dependent on
It may be remembered that in 1991
external assistance.
by
the
proportion
of
investment
costs
financed
In
international aid reached 91 per cent (see Table 16).
the financing strategy presented here, it is assumed that
aid will fund 90 per cent of the investment costs of the
rehabilitation programme.
The government will be
responsible for the remaining 10 per cent.
Recurrent Costs: Scenarios
Security Health Fund
with
and without
a
Social
In many respects, it is more problematic to finance
recurrent costs than investment expenditure.
Unlike the
latter, the former costs are - as their name states recurrent and any increments to the volume or quality of
health
services
are
reflected
in
additional
and
cumulative costs.
The adequate funding of recurrent
expenditure is essential for the achievement of quality
and
efficiency
in
health
services.
Yet,
for
sustainability, this funding should be as far as possible
national in origin.
The financing strategy must identify the means of funding
the recurrent costs resulting from the rehabilitation
process. According to the projections of the expenditure
scenario (Table 31A), the task is to finance a total of
110.9 million contos (in 1991 prices) in the year 2000,
which would represent an average real growth of costs of
4.5 per cent per year from the baseline expenditure of
1991.
Four possible sources of finance for the recurrent costs
are identified here:
- government
user fees
a social security health fund
international aid.
scenarios
Two
financing
includes, and one which
health fund.
80
which
presented,
one
are
excludes, a social security
Scenario with a social security health fund
This scenario is shown in Table 33A. In it the estimate
of finance to be raised by a social security health fund
is based on the following assumptions (see methodological
notes): a number of salaried employees in the public and
private sectors of 500,000 in the year 2000 (which is
probably an underestimate); an average monthly salary of
these employees of 49.3 contos (in 1991 prices); and a
contribution to the fund of 2 per cent of salary by both
the employees and their employers.
On this basis the
table shows that a social security health fund could
finance 11 per cent of the total recurrent health costs
projected for the year 2000.
In this scenario with such a fund, government recurrent
health expenditure would grow in real terms at an average
annual rate of 4.5 per cent, which is the rate agreed
indicatively by the government and the World Bank for the
growth of public recurrent health expenditure.
In this
case, the proportion of total recurrent costs financed by
the government would be the same in the year 2000 as in
1991, namely, 37 per cent.
Given the level of poverty in Mozambique, the scenario
assumes that the maximum revenue to be expected from
direct user fees would be 5 per cent of government
recurrent health costs,* which would constitute 2 per
cent of the total recurrent costs.
To finance the rest of the expenditure, international aid
for recurrent costs would have to grow in real terms at
an average rate of 2.2 per cent per year. In this case,
the contribution of external assistance to recurrent cost
finance would decrease from 62 per cent of the total in
1991 to 50 per cent in the year 2000.
In this way the
external dependency of health service activities would
decrease in relative terms.
Employment-related insurance is a source of health
finance that a growing number of developing countries are
turning to, including in Africa, given the constraints on
government health budgets. There are advantages in this
scenario with a social security health fund.
As Table
33A illustrates, such a fund can bring significant
amounts of money into the health sector and take pressure
off the government budget.
Also, in contrast to the
regressive nature of user fees, a social insurance fund
is normally raised by payments which are at least
proportional to salaries and it usually requires a
contribution also from employers.
A social security
health fund does not exist presently in Mozambique, but
it is a possibility that should be studied in the near
* This percentage is in accordance with experiences elsewhere in SubSaharan Africa (see 'User Charges for Health Care: a Review of
Recent Experience' by A.L. Creese, WHO/SHS/CC/90.1, WHO, Geneva,
1990).
81
Table 33A
Financing the growth of public recurrent health expenditure to the year 2000
(1991 prices: million contos)
A. A scenario including a social security health fund
Year
Total expenditure>
Expenditure Average
annual
growth
rate
Social security fund
Expenditure
%total
(%)
_________________ Sources of finance___________
Government______
User fees
Expenditure Average %total Expenditure %total
annual
growth
rate
_____________ (%)
0
0
27.9
11.8<b>
11
41.5
1991
74.6
2000
110.9
Notes.
(a) See Table 31A.
(b) See text for explanation of estimate.
_____ International aid
Expenditure Average %total
annual
growth
rate
(%)
37
0.9
1
45.8
37
2.1<b>
2
55.5
62
00
4.5
4.5
2.2
50
future. It could be integrated with the broader fund of
the National Institute of Social Security, which would
and reduce
facilitate the
collection of payments
administrative expenses.
Scenario without a social security health fund
The contributions
This scenario is shown in Table 33B.
of user fees and international aid are essentially the
same as in the previous scenario, since it is doubtful if
significantly more income can be raised from user fees
and the reduction of dependency on external assistance
for recurrent costs is a priority.
To compensate for the lack of a social security health
fund, government recurrent expenditure in this scenario
has to grow in real terms at a rate of 7.3 per cent per
year and the government contribution to total recurrent
health costs would increase from 37 per cent in 1991 to
47 per cent in the year 2000.
As before, the
contribution of international aid to the total costs
would decrease from 62 to 50 per cent.
It is clear that this second scenario puts more pressure
on the government budget.
Even so, it is not an
impossible financing strategy.
An estimate of real
growth of GDP of 4 per cent per year in the post-war
On this
period would not be unreasonable (see Table 1).
assumption. Table 34 shows that,
in the scenario
including a social security health fund, government
recurrent health expenditure in the year 2000 would
constitute 1.6 per cent of GDP, a proportion similar to
that in 1991 (see Table 4).
On the other hand, in the
scenario without a social security fund, government
recurrent health costs in 2000 would be 2.0 per cent of
GDP; although higher than in the first scenario, this
proportion is still only half way towards the percentage
(2.3 per cent) that obtained in 1981 (Table 4). In other
words, the allocation of 2.0 per cent of GDP to recurrent
health expenditure would not be without precedent and
might well be accommodated by a ’peace dividend’ after
the war.
This level of government health expenditure can be looked
at another way.
Following the above assumption of GDP
growth, it can be assumed that total government recurrent
expenditure would also grow in real terms at 4 per cent
per year.
Then in the financing scenario with a social
security fund, government recurrent health costs in the
year 2000 would constitute 6.4 per cent of total
government
recurrent
costs
(Table
34),
which
is
a
proportion similar to that in 1991 (Table 4).
On the
other hand, in the scenario without a social security
fund, the recurrent health costs in 2000 would be 8.1 per
cent of total recurrent costs (Table 34); again, although
higher than in the first scenario, this proportion is
still only half way towards that (10.7 per cent) which
obtained in 1981 (Table 4).
83
Table 33B
Financing the growth of public recurrent health expenditure to the year 2000
(1991 prices: million contos)
B: A scenario without a social security health fund
Year
Total expenditure<
Expenditure Average
annual
growth
rate
(%)
1991
74.6
2000
110.9
Sources of finance___
_________ Government______ ____ User fees____
Expenditure Average %total Expenditure %total
annual
growth
rate
(%)
27.9
_____ International aid
Expenditure Average %total
annual
growth
rate
(%)
37
0.9
1
45.8
47
2.8
3
55.5
62
00
4.5
Note. (a) See Table 31A.
52.6
7.3
2.2
50
Table 34
Comparison of government contribution to public recurrent health expenditure
in the year 2000 according to the scenarios with and without a social
security health fund<a>
(1991 prices)
Government
recurrent health
expenditure
(million contos)
Average annual
growth rate
from 1991
(%)
% GDP<b>
% total
government
recurrent
expenditure^)
With
41.5
4.5
1.6<c>
6.4<c)
Without
52.6
7.3
2.0<a>
8.1<a)
Social security
fund
co
Ul
Notes. (a) See Tables 33A and 33B.
(b) Estimates based on annual growth of GDP and total government recurrent
expenditure from 1991 of 4 per cent.
(c) Percentages similar to those in 1991 (see Table 4).
(d) Percentages about midway between those of 1981 and 1991 (see Table 4).
Therefore, while the financing scenario with a social
security health fund is advantageous, the scenario
without a fund is also feasible.
Composition of International Aid
The change in the balance of external assistance for
investment and recurrent costs implied by this financing
strategy is illustrated in Table 35, which shows the
estimated contribution of aid to the public health sector
Total health aid is expected to rise
in the year 2000.
from $47.3 million in 1991 to $67.8 million (in 1991
prices) in the year 2000.
The proportion of the
assistance devoted to investment is projected to increase
from 30 per cent of the total in 1991 to 41 per cent in
2000, while that to recurrent costs would decrease from
70 per cent in 1991 to 59 per cent in 2000.
Changes are also foreseen in the composition of the
support for recurrent costs.
The target for the import
of drugs was shown in Table 32 and in this financing
strategy it is assumed that international aid will fund
90 per cent of the projected drug costs of the public
health service.
On this basis. Table 36 shows that the
proportion of total recurrent cost support devoted to
drug imports would increase from 49 per cent in 1991 to
57 per cent in 2000.
It is also assumed that the
proportion of recurrent health aid devoted to ’other
consumable items' would remain at 10 per cent of the
total (see Table 10).
In this case, the proportion of
recurrent cost aid allocated to technical assistance
would decrease from 41 per cent of the total in 1991 to
3 3 per cent in 2000.
It should be noted, however, that
in
absolute
terms
real
expenditure
on
technical
assistance is projected to stay more or less constant; if
the procedures for the recruitment of expatriate health
workers are improved as discussed earlier, these funds
should be sufficient for the health service to obtain
enough well qualified personnel to respond to its
immediate needs.
In this way, using the various internal sources of
finance and international aid, it is possible to fund the
strategy for the rehabilitation of the public health
sector of Mozambique in the medium term, with respect to
both investment and recurrent costs.
86
Table 35
<
Estimate of contribution of international aid to the public
health sector in the year 2000
(1991 prices: $ million)
Recurrent costs
Costs
% total
Total
costs
Year
Investment costs
Costs
% total
1991
14.4
30
32.9
70
47.3
2000
27.9<a>
41
39.9
59
67.8
(a) Estimate calculated as 90 per cent of projected average
annual investment costs.
Sources: Tables 10, 16, 30 and 33.
Note:
87
Table 36
Projected changes in composition of international aid
in support of public recurrent health expenditure
to the year 2000
v
(1991 prices: $ million)
Other consumable items
Costs
%total
Technical assistance
Costs
%total
Total
costs
Year
____ Drugs
Costs %total
1991
16.1
49
3.3
10
13.5
41
32.9
2000
22.9<a>
57
3.9
10
13.1
33
39.9
(a) Estimate calculated as 90 per cent of projected annual drug
costs of the rehabilitated public health service network
(derived from Table 32).
Sources: Tables 10, 32 and 35.
Note:
w
88
THE NEXT STEPS
4
This last section lists some steps which should be taken
to carry the rehabilitation process forward.
The steps
are mainly to obtain official government approval for the
policies and strategy outlined in this work and to
establish or strengthen mechanisms of implementation.
1.
The present document and the other outputs of PRANHP
should be debated within the Ministry of Health and
with other relevant ministries, in particular the
Ministries of Finance, Cooperation, and Commerce, and
the National Planning Commission. Official decisions
should be made about the proposed policies for the
health
sector
and
the
strategy
for
its
rehabilitation.
An official document incorporating
material from all the outputs of PRANHP and other
published,
relevant documents
should be published.
The
rehabilitation policies and strategy should be
discussed with the donor community.*
2.
A large part of the strategy presented in this work
depends on the capacity of the Ministry of Health to
control the allocation of resources according to the
defined priorities,
above all the division of
resources by level of health care and geographical
area.
A study should be made of how to strengthen
the mechanisms of planning, management and control of
resource allocation in the health sector.
3.
The
strategy establishes broad lines
for the
rehabilitation of the rural health service network.
It should now be filled out with detailed development
plans at the provincial and district levels.
4.
The urban health services, and above all the large
city hospitals, have not yet been investigated in the
same way as the rural health network.
A study of
these services should be performed as a step towards
the production of a development plan for urban health
care,
including
the
establishment
of
hospital
staffing patterns and norms for the consumption of
drugs and other operating items, and thereby norms
for overall recurrent costs.
The development plan
for urban health services should be made within the
economic framework established in this document.
5.
The National Directorate of Planning and Cooperation
of the Ministry of Health should coordinate the work
outlined in points 3. and 4. above and synthesise the
products
into
a
National
Development
Plan
for
the
Public Health Sector.
Editorial note: The present document was discussed and approved by
national and provincial health officials in a meeting held in the
Ministry of Health in March 1993 under the chairmanship of the
Minister.
The document has been circulated widely in the donor
community.
89
6.
The ability to improve and expand the health services
in the rural areas depends on the making of
efficiency savings in the urban health services,
which are relatively well developed and costly,
Studies should be made of hospital management and
efficiency in the wider context of the urban health
services, including the efficient use of health
centres and their links with the hospitals.
The
implementation of management and efficiency measures
should be monitored with performance indicators.
7.
The improvement in rural health services depends on
strengthening
the
system
of
district
health
management.
The instruments of a health management
system (referred to earlier in this document) should
be developed and personnel responsible for district
management and supervision should be trained in their
use.
8.
The health services in the rural areas cannot be
improved without the deployment of more health
personnel there.
A system of incentives for rural
service (including
(including staff housing, allowances, and
priority in post-basic training) should be developed
and implemented as soon as possible.
9.
The health service cannot afford to waste investments
made
in
buildings,
equipment
and
vehicles.
Appropriate
systems
of
maintenance
should
be
instituted at all levels of the service.
10. The considerable potential of employment-related
insurance for generating revenue for the health
service was shown in this work,
The feasibility of
introducing a social security health fund in the
economic and social conditions of Mozambique should
be studied.
11. The
last.
last,
but
not
least,
step
relates
to
international aid, which will be a critical factor in
the success of the rehabilitation strategy.
The
Ministry of Health should strengthen its capacity to
negotiate proactively and creatively with the donor
community.
The National Development Plan for the
Public Health Sector will facilitate this process,
since the Ministry will be able to present well
defined plans to donors. The The Ministry should
establish or strengthen mechanisms whereby it can
discuss fundamental questions of cooperation policy
with donors, with a view to increasing the ’value for
money’ of aid.
Among the questions to be discussed
are: the need to improve the system of recruitment
of technical assistance personnel in order to obtain
appropriate health workers at reasonable cost; and
the need to increase the proportion of international
aid in the form of untied budget support, which will
improve the cost-effectiveness of the assistance and
reduce the number of separate projects that the
Ministry of Health must manage.
90
>
V
LIST OF TABLES
Page
3
Table 1
Evolution of gross domestic product and population
2
Table 2
Evolution of health service network at the primary
level
4
Table 3
Evolution of some categories of health personnel
5
Table 4
Evolution of expenditure from government recurrent
budget: total and health
15
Evolution of expenditure from government recurrent
health budget by main categories of use
17
Evolution of total recurrent health expenditure of
internal origin
18
Table 7
Indices of exchange rate and deflators
20
Table 8
Evolution of recurrent health expenditure
of internal origin in constant prices
21
Evolution of ’real’ health resources
financed by government recurrent budget
A. Health personnel
23
Evolution of ’real’ health resources
financed by government recurrent budget
B. Drugs and other operating items
24
Evolution of recurrent health expenditure
financed by international aid:
imported products and technical assistance
26
Evolution of numbers of expatriate health
personnel employed through technical assistance
27
. Table 12
Evolution of total recurrent health expenditure
28
Table 13
Evolution of total recurrent health expenditure
in constant prices
30
Table 14
Evolution of availability of drugs
32
Table 15
Evolution of expenditure from government
investment budget: total and health
35
Table 16
Evolution of total investment health expenditure
36
Table 17
Three Year Public Investment Plan for Health
Sector 1991-93
38
Evolution of total health expenditure
of internal origin
39
Table 5
Table 6
Table 9A
Table 9B
Table 10
Table 11
Table 18
91
Page
Table 19
Table 20
Evolution of total health expenditure of internal
origin and from international aid
40
Percentage distribution of health expenditure
by level of care 1991
43
-j
Table 21
Table 22
Table 23
Table 24
Table 25
Table 26
Table 27
Table 28
Table 29
Table 30
Table 31A
Table 3IB
Table 32
Table 33A
Trends in percentage distribution of some
categories of health personnel by level of care
44
Trends in population to health worker ratios for
some categories of personnel by urban/rural areas
46
Trends in population to health worker ratios for
some categories of personnel by province
48
Trend in distribution of drug expenditure
per person by province
50
Average staffing patterns of rehabilitated
health facilities at the primary and secondary levels
61
Rural and general hospitals for rehabilitation
or construction in the medium term
63
Projection of rural population to rural hospital
ratios by province resulting from the
rehabilitation strategy
64
Rehabilitation of the health service network
at the primary level in the medium term
66
Estimates of investment and recurrent costs for the
rehabilitation of the health service network at the
primary and secondary levels in the medium term
71
Estimates of investment costs for the
rehabilitation of the health service network and
training institutions in the medium term
72
A scenario for the evolution of public recurrent
health expenditure to the year 2000
A. Expenditure projections
74
A scenario for the evolution of public recurrent
health expenditure to the year 2000
B. Division of growth in expenditure
77
Estimates of annual drug costs of the
rehabilitated health service network and retail
pharmacy outlets in the medium term
78
Financing the growth of public recurrent health
expenditure to the year 2000
A. A scenario including a social security health fund
82
92
B
Page
4
Table 33B
Table 34
Table 35
Table 36
Financing the growth of public recurrent health
expenditure to the year 2000
B. A scenario without a social security health fund
84
Comparison of government contribution to public
recurrent health expenditure in the year 2000
according to the scenarios with and without a
social security health fund
85
Estimate of contribution of international aid
to the public health sector in the year 2000
87
Projected changes in composition of international
aid in support of public recurrent health
expenditure to the year 2000
88
3
93
ACRONYMS
CHM
DAF
DPh
DRH
DS
ERP
FRELIMO
GDP
GH
IMF
MCH
MoF
MoH
Mt
NA
NDPC
NPC
PRANHP
RH
US
Central Hospital of Maputo
Directorate of Administration and Finance
Department of Pharmaceuticals
Directorate of Human Resources
Directorate of Supplies
Economic Recovery Programme
Front for the Liberation of Mozambique
Gross domestic product
General hospital
International Monetary Fund
Mother and child health
Ministry of Finance
Ministry of Health
Metical
Not available
National Directorate of Planning and Cooperation
National Planning Commission
Project for the Revision of some Aspects
of National Health Policy
Rural hospital
United States of America
<
I
I
i
I
94
Position: 1768 (3 views)