Mozambique

The Health Systems Strengthening Cluster includes:

• Human workforce
• Health information systems
• Medical products, vaccines, and technology
• Health financing
• Service delivery
• Governance of health
• Knowledge management and sharing

Support is provided for the strengthening of the Ministry of Health capacities to optimize development and utilization of its human resources for health.

WHO/Mozambique has also the responsibility to collaborate with the Ministry of Health in the generation and use of appropriate health information to support decision making, health care delivery and management of health services, at all levels.

Increasing access to essential drugs, monitoring the emergence of anti-infective drug resistance, and creating a safer environment for drug prescription, distribution, and consumption as well as the development of national drug policies within the framework of national health policies, constitute the main aims of the support provided by WHO/Mozambique within the area of essential drugs.

Within the concept that health is the driver of poverty reduction, investing in health is central to the achievement of the Millennium Development Goals (MDGs). To help the country to achieve the MDGs, this program encourages and helps the preparation of long term multi-sectoral investment plans, securing financing for its implementation, and the coordination of health interventions' scaling up, on the basis of health priorities, within a sound macroeconomics framework.

Sector policies and strategies

One of WHO’s core functions is to oversee and guide policies in the health sector. This involves interaction with the entire health system to protect public interest. It requires political involvement such as advocating for the most favorable allocation of limited resource and technical expertise for the development of comprehensive strategic plans to guide the health sector.

Mozambique is completing its National Health Sector Strategy (Plano Estratégico do Sector Saúde -PESS II  2007-2012), which has been extended to December 2013 to allow for the finalization of the next strategic plan. The new Plan, PESS III, will start in 2014, covering a 6 year period up to 2019.  The PESS III was informed by an extensive health sector reviewof the past 10 years. Prior to its completion, the Plan underwent an independent, external review, the Joint Assessment of National Strategies (JANS) and the recommendations were incorporated ensuring international quality alignment.  The JANS is a mechanism to improve the quality of the PESS III.

The PESS III aims at providing strategic guidance on the coordination of policies and programmes in the health sector. Furthermore, it includes a conceptual framework preparing the health sector to reform and decentralize over the next six years.

In addition to the PESS, Mozambique also has several disease specific & health programme and systems related strategic plans such as the Integrated MDG 4 & 5 plan, Strategic Plan for Malaria 2012-2016, and Human Resources Development Plan 2008-2015.

The health sector policies and strategies are guided by an overarching policy framework that includes the  Government Five-Year Development Plans (Programa Quinquenal do Governo - PQG), currently approved for 2010-2015 and the Action Plan for Reduction of Poverty (Plano de Acção para Redução da Pobreza - PARP 2011-2014 - PARP II ). 

The National Health Sector Strategic Plan serves as a framework for multi-annual operational plans named Economic and Social Plan (Plano Economico e Social – PES). These annual plans are informed by the Medium Term Expenditure Framework.

Key Resources

• Ministry of Health
• Government of Mozambique
• Health sector review 2012
• JANS
• PARP
• PESS 2007-2012

Situational analysis

Health information is the continuous collection and analysis of health data coming from different sources. Mozambique’s health information systems include a variety of population-based and health facility-based data sources. The main population-based sources of health information are census, household surveys and registration systems. The main health facility-related data sources are public health surveillance, health services data and health system monitoring data including human resources, health infrastructure, and financing.

Health information is vital for public health decision making, health sector reviews, planning and resource allocation, and programme monitoring and evaluation .

The WHO Health Information programme supports production, analysis, dissemination, and use of reliable and timely health information including health determinants , epidemiological data and health systems performance.

The Health Information System in Mozambique was created in 1976. In 1979, the Ministry of Health established a mechanism of data collection at every health facility of the national health system. In 1985, a notification system for communicable diseases through sentinel sites was introduced. In 1997, obligatory notification was introduced for a number of communicable diseases on a weekly basis for every health facility. Furthermore, the Ministry of Health is issuing regular bulletins on measles, neonatal tetanus, cholera, malaria, diarrhoea, acute flaccid paralysis , meningitis , rabies, plague, and dysentery . In 2003, the Health Information System Development Programme was approved, which was then translated into the Plano Estratégico do Sistema Informática da Saúde (PESIS) 2009-2014.

Data is disseminated through ministerial periodic reports and through the African Health Observatory (AHO) , which is an open and collaborative regional platform, serving as a gateway to WHO  data and statistics.

Three population censuses have been completed in Mozambique in the years 1980, 1997 and 2007. Socio-demographic data are routinely collected and accessible through the Social, Demographic and Economic Statistics of Mozambique (ESDEM) . The ESDEM functions as the main monitoring tool for the country development plans including the Poverty Reduction Strategy (PARPA) and the Millennium Development Goals (MDG) .

Regularly conducted surveys include:

• Demographic Health Survey 1997, 2003 and 2011
• Multiple Indicator Cluster Survey (MICS) 2008
• INSIDA 2009 (Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique). Next survey is scheduled for 2014.
• Questionnaire of Welfare Basic Indicators (QUIBB)

Despite the various data collection efforts, limited human resources for health and weak informatics infrastructure impair the systematic and timely collection of health information. This is mainly due to limited capacity at health facility level leading to poor quality of data. Furthermore, Mozambique faces challenges in transforming the collected data into clear policies, objectives and strategies corresponding to country needs.

Achievements

• On-going development of the new health information system, SISMA, which will replace the Modulo Basico. This will improve the quality of data and help targeting interventions.
• In 2012, the Sistemas de Informação de Registo de Óbitos Intra-hospitalares (SIS-ROH) was developed and implemented in the Regional and Provincial hospitals. This means that hospitals now are collecting comparative data nationwide.
• Implementation of annual data quality assessments as a key component of the Avaliaçao Conjunta Annual.

Key resources:

• Ministry of Health
• Mozambique National Institute for Statistics
• WHO Global Health Observatory
• World Bank

Situational analysis

Knowledge Management and Sharing (KMS) is the use of technologies and tools to enable people to create, capture, store, retrieve, use and share knowledge. In Mozambique, the KMS programme supports improved access to and use of health information and research.

Though access to online information is increasing, only 1% of Mozambicans have access to online resources. The remaining 99% rely on traditional forms of access, namely libraries, which are generally only available in the main cities. Furthermore, scientific contents are often out-dated. The situation is most discouraging in the districts where health professionals are working with old information, if any at all.

In collaboration with the National Health Institute in the Ministry of Health, the WHO KMS programme supports the implementation of a number of initiatives promoting access to health information for health professionals and the public. These include:

• African Health Observatory (AOH)
  
  For international comparison of health data, Mozambique reports epidemiological data to the Global Health Observatory and the African Health Observatory , which are the common gateways to WHO data and statistics, analysis and reports on key health themes.
  
  The AHO is supporting the MoH in developing a National Health Observatory. This new Observatory will serve as multi-stakeholder and collaborative platform. It will support and facilitate capturing, production, sharing, translation and application of information, evidence and knowledge. 
   
• ePORTUGUÊSe and Virtual Health Library (VHL)
  
  Mozambique is part of the ePORTUGUÊSe platform, which was created to support the development of human resources for health in Portuguese-speaking countries. ePORTUGUÊSe is an international network facilitating collaboration between institutions, disseminating health information, and promoting capacity building. One of the main objectives is to improve access to health-related information in Portuguese through the Virtual Health Library model. The VHL is a collection of all lectures produced in Mozambique and about Mozambique. It has a database with more than 3000 documents including published sources of information, governmental reports and grey literature aiming at providing access to updated health information in Mozambique.
   
• Blue Trunk Library (BTL)
  
  To support access to updated clinical guidelines and practical manuals, WHO developed the Blue Trunk Library (BTL). The BTL is a physical collection of country-specific, up-to-date clinical guidelines and medical manuals. The BTL is organized according to major health subjects and contains more than one hundred books on medicine and public health. Since 2006, WHO Mozambique and health partners have distributed 153 BTLs, to various district health facilities in all provinces of the country, and trained over 180 managers and 900 other health professionals in the use of BTLs.
   
• HINARI programme.
  
  In 2002, the Ministry of Health enrolled in the HINARI programme, which is an agreement between major publishers and the WHO to enable  developing countries to access one of the world’s largest collections of biomedical and health research for a symbolic price. The HINARI database contains around 11,400 journals in 30 different languages and 18,500 e-books benefitting health workers and researchers.
  
  Since the enrolment, 73 Mozambican institutions have registered to HINARI. WHO Mozambique in collaboration with the National Health Library have run more than 12 workshops on access, use and management of electronic health resources through HINARI for more than 500 participants from health training and research institutions, and health professionals from the National Health System. The table shows the number of users from 2007-2012.
   

Finally, WHO Mozambique has a Documentation Centre with a collection of WHO publications and other health materials including periodicals and CD-ROMs. The Documentation Centre provides library and information services in paper and electronic format including guidance on how to use the Library and its information resources. Internet is available for visitors.

The Library is open from Monday to Thursday from 8:00 AM to 4:30 PM and on Friday, from 8:00 AM to 1:30 PM.
 

Contacts

WHO Country Office in Mozambique
Documentation Centre
280 Rua Pereira Marinho
P.O. Box 377
Maputo, Mozambique

Tel: +(258) 21 49 27 32/49 19 91/49 21 65
Fax: +(258) 21 49 89 98/49 19 90

Flatiel Vilanculos
afwcomzdoc@who.int or vilanculosf@who.int

Key Resources

• WHO Library Databases:
  • WHO guidelines
  • WHO/HQ Library Database
  • WHO/AFRO Library Database
• The WHO Information Product catalogues provides information on WHO publications produced since 1948
• Basic Documents of the World Health Organization, Executive Board, and World Health Assembly.
• Health topics: This page links to WHO programmes, information products and contacts, organized by health and development topics. Look for the «Resources » or the « Publication » link.
• African Index Medicus (AIM) is an international index to African health literature and information sources published or related to Africa.
• AFRICAN JOURNALS ONLINE is the world's largest and pre-eminent collection of peer-reviewed, African-published scholarly journals. 
• National Virtual Health Library for Mozambique
• African Health Observatory
• Global Health Observatory
• Africa Health Workforce Observatory
• Ministry of Health
• National Health Institute
• University of Eduardo Mondlane

Situational analysis

Mozambique is experiencing steady progress towards strengthening the pharmaceutical sector, but faces challenges in logistics, rational use of medicines, and the use of traditional medicine.

In 2010, Mozambique had 5.6 pharmaceutical professionals per 100,000 persons. Shortages in human resources for health affect the rational use of medicines due to limited capacity in prescribing medicine at clinical level and in distributing it at pharmaceutical level. Compliance with medical guidelines is important for positive treatment outcomes and limiting drug resistance.

Logistical challenges exist in procurement, distribution, and storage of medicines and medical products. Poor infrastructure can cause delays and harm the quality of the drugs mainly because of exposure to heat. Access to electricity at the pharmacies affects the capacity for storing drugs at the right temperature ensuring quality of the drugs.

In 2009, the Ministry of Health estimated that 3 in 4 Mozambicans seek traditional medicine before seeking institutionalised health care. Thus, the Ministry established an Institute for Traditional Medicine in 2009 to exploit the knowledge and experience of traditional medical practitioners. One initiative is training traditional practitioners in recognising symptoms of major public health diseases and referring patients to institutionalised health care.  

The procurement system has improved with the adoption of a pre-qualified list of suppliers of medicines and medical products for the national health system. WHO pre-qualification aims to ensure that diagnostics, medicines, vaccines and immunization-related equipment for high burden diseases meet global standards of quality, safety and efficacy. This contributes to optimized use of health resources and improved health outcomes. Though counterfeit products still circulate in Mozambique, pre-qualification of suppliers in the public sector provides a level of international quality-assurance.

The Mozambican pharmaceutical law was published in 1998 and the latest revision of the national list of essential medicines was in 2010. The current National Formulary (FNM) was approved in 2007 and contains 1489 items, of which 338 are considered as essential meaning that they should always be available at all times.

Both the lists are currently under revision. Compliance with the list of essential medicines and the FNM is crucial for ensuring rational use of medicine.
 

Achievements

• Mozambique signed up to the EU/ACP/WHO renewed partnership for strengthening pharmaceutical systems and improving access. The WHO Country Office in collaboration with the Ministry of Health will thus implement activities to strengthen pharmacovigilance and essential medicines.
• Implementation of mandatory pre-qualification of suppliers of medicines and medical products to the public health sector. This ensures a level of international quality-assurance;
• The list of essential medicines and the National Formulary are currently being updated;
• During the African Traditional Medicines Day in August 2013, awareness was raised about the importance of increased research on traditional medicine;
• Trainings on rational use of medicines for health professionals including pharmaceutical staff at all levels and on logistics supply management are under development;
• External evaluation of the pharmaceutical sector was completed in 2007.
   

 Key resources

• Ministry of Health
• External Evaluation of the Pharmaceutical Sector in Mozambique 2007
• GAVI
• MDG 8 Gap Task Force Report 2012
• WHO Regional Office for Africa: Programme on Essential Medicines and Health Technologies
• Diploma ministerial
• Human Development Report 2013

Situational analysis

The Mozambican National Health System is financed through two main sources:

• Domestic funds from the state budget
• External funds received from different mechanisms including budget support, the Common Fund, which is a basket fund where partners pool their resources, and various bilateral project support initiatives.

Over recent years, there has been a steady increase in funding including the variety of funding mechanisms for health financing in Mozambique.  The difference between the two funding sources is almost constant with the exception of 2004, when the sector attracted significantly more external funds than in the previous years. 

The mechanisms for budgeting and allocation follow the main policy documents, namely, the Poverty Reduction Action Plan (PARP), the Health Sector Strategic Plan, and the Medium Term Expenditure Framework. As the Health Sector Strategic Plan was covering the period 2005-12, a new Plan is in its final phases of development. These strategic documents all follow the same overall objective of increasing accessibility to health care services while improving quality of care particularly in the area of primary health care.

According to the WHO Global Health Expenditure database, public expenditure on health as a proportion of the total health expenditure has been showing a decreasing trend since 2005.  After reaching about 14% of government expenditure in 2004, allocations to health have been affected by a substantial increase in external funds particularly for HIV/AIDS under the President's Emergency Plan for AIDS Relief (PEPFAR).

Total health expenditure per capita increased from US$ 4.6 in 1997 to US$ 21 in 2010. The share of external resources as a proportion of total health expenditure surpasses 60% in 2008-2009.  The Government of Mozambique is the main financial agent managing around 72% of the resources to purchase health care. Other agents purchasing health care include households (around 14%) and employers. While cost recovery accounts for about 1% of the health budget, out of pocket expenditure remains less that 30% of the total health expenditure in 2010. The table below illustrates trends in health expenditure from 2002-2010.

 Source: WHO Global Health Expenditure database

User fees for primary education were abolished in 2005 and a study was conducted to evaluate the impact of abolishing user fees for primary health care following the recommendations of the UN Report of the Special Rapporteur on the Right to Health, which called for a "need to clarify the role of user fees in the Mozambican health sector from the point of view of impeding access to the poor."

The health sector faces a challenge of sustaining increased allocations from the state budget while keeping external funding additional to governmental investments and not replacing it. At the same time, the health sector could further explore other financing mechanisms such as prepayment schemes and social health insurance. Performance Based Financing and Results Based Financing schemes are being piloted in 3 out of 11 provinces.

 
Achievements

• The second National Health Accounts exercise was launched in April 2013. These studies will provide detailed information on health expenditures in Mozambique.
• In 2012, a task force was established consisting of WHO, UNICEF, World Bank, UK Department for International Development, Swiss Agency for Development and Cooperation, and USAID to discuss contributions for a comprehensive health financing policy and strategy aiming at contributing to the next Health Sector Strategic Plan, a process to be completed in August 2013;
• Following a capacity building training for focal points in the Ministry of Health in July 2011, resource tracking for Mother and Child Health has been planned  as a country activity under the Commission of Information and  Accountability for Mother and Child Health;
• Training for the Ministry of Health on One Health and National Health Accounts methodologies;
• The Health Financing Review was completed as part of the Health Sector Review process in 2012.
   

Key Resources

• Ministry of Health
• Mozambique National Health Account
• World Bank Mozambique

Situational Analysis

Service delivery refers to prevention, treatment or rehabilitation provided in the home, community, workplace, or health facility.

Patient safety and improved quality of care are key aspects of service delivery. 

The main provider of health care services throughout Mozambique is the public National Health Service The private sector is formed by two components:

• Private-not-for-profit health care providers, which are mainly international and national NGOs.
• Private-for-profit providers. These are almost exclusive to main cities and constitute a rapidly growing sector, which competes with the public sector for the limited human resources for health.

In 2011, there were 1392 health units[1] organized into four structural levels providing three intensities of health care in Mozambique. The primary level includes urban and rural health centres providing essential curative services including vaccination and prevention of local endemic diseases. It constitutes the entry point and the first contact between the users and the health system. The secondary level includes rural and general district hospitals conducting routine surgical interventions with larger diagnostic capacity such as X-ray facilities. Provincial, central and specialized hospitals constitute the tertiary and quaternary level. These provide a broader range of specialized, curative, surgical and rehabilitative services. 

In some rural areas with low population density and limited access to institutionalized care, outreach activities and Community Health Workers (APE - Agente Polivalente Elementar) are providing community-based care.

Most Mozambicans’ first encounter with some kind of health care is through a network of traditional medical practitioners. They attend to health care needs within a strong cultural and spiritual context. Traditional practitioners do not form part of the National Health Service, which means that their practices are not regulated. The Institute of Traditional Medicine of the MoH is working towards stronger collaboration with traditional practitioners. Efforts are being made to document and exchange knowledge particularly on the medicinal characteristics of plants.

One of the challenges for the health service infrastructure is responding to the rapidly changing socio-economic environment at local level even in remote areas. The growing extractive industries in Mozambique have an impact on health because of increased in-migration due to income opportunities and potential environmental hazards. It is important to identify the effects on health to avoid negative health risks and enhance positive health benefits. Health Impact Assessment is a valuable tool to detect the changes and implement required measures.

Achievements

• In the new Health Sector Strategic Plan (PESS 2014-2019), more attention is given to reform processes of decentralization to district health care services.
• To increase basic health services at community level, the MoH and health partners are training more Community Health Workers (APE - Agentes Polivalentes Elementares). The APE programme was officially launched in August 2013.
• Establishment of the Institute for Traditional Medicine in the MoH and development of policy guidelines for regulation of traditional medical practitioners in the national health system.
• Awareness raising of the importance of traditional medicine at the African Traditional Medicine Day in Lichinga, Niassa in August 2013.

Key Resources

• Ministry of Health
• Health Sector Review 2012
• Inventory Report
• National Plan for Human Resources for Health Development 2008-2015

The Disease Prevention and Control Cluster (DPC) includes:

• Emergencies
• Communicable diseases
• Noncommunicable diseases, injuries and mental health
• HIV/AIDS
• Tuberculosis
• Malaria
• Neglected tropical diseases

Support is provided to the national authorities when dealing with natural disasters (floods, cyclones, droughts), especially concerning health issues such as the emergence of epidemic-prone diseases, malnutrition as a result of food insecurity, and increase of communicable diseases such as malaria, diarrhoea, etc.

Communicable diseases still represent the major public health problem. For this, WHO in Mozambique is providing support to the Ministry of Health concerning preparedness, surveillance and response in relation to these diseases. This includes support for organisation and coordination, for training of health staff and respective ancillary materials, etc.

This cluster offers technical support to the government for the definition of policies related to non-communicable diseases such as diabetes, high blood pressure, asthma, cancer, injuries and violence, etc., as well new strategies for mental health.

Situational analysis

Mozambique is prone to emergencies resulting from natural disasters particularly floods, droughts and cyclones. Fragile health infrastructure and scarce human resources for health make the public health consequences of emergencies even greater.

The primary objective in an emergency, whether natural or man-made, is to reduce avoidable loss of life and the burden of disease and disability.

During emergencies, poor sanitary conditions and limited of access to basic commodities often lead to outbreaks of communicable diseases. These typically include malaria, diarrhoea, cholera, and dysentery. Malnutrition as a result of food insecurity is also common.

Population displacement and camp settings lead to higher contact ratio among people, which facilitates transmission of infectious diseases particularly measles, tuberculosis and other respiratory tract infections.

Long-lasting droughts in the southern and central regions of Mozambique are relatively common. These have an impact on food security and livelihoods. Localized flooding is common in Mozambique during the southern African region’s rainy season from around October to March.

Most recently, between 23 January and 12 March 2013, the Government of Mozambique declared an “institutional Red Alert” due to flooding along the Zambezi and Limpopo river basin caused by heavy rains in the region. Eight districts in Gaza province were flooded and about 150,000 people were displaced into 23 registered accommodation centres. Over 50 people were reported dead. Infrastructures including roads, houses, electricity and water supply were destroyed and crops were damaged.

When an emergency is declared, the Ministry of Health and health partners start operating under the Humanitarian Country Team, which is a cluster coordination system facilitating communication and ensuring rapid response.

A major challenge is that populations affected by recurrent emergencies do not have sufficient time to recover from the economic and social impacts provoked by emergencies between one cycle and the next. While the situation has improved in recent years due to increased agricultural production and food security, communities are still suffering from the effects of the last drought. Many households, already vulnerable to other socio-economic factors including the impact of HIV, are often too weak to cope with the cumulative shocks caused by different types of emergencies.

Achievements

• Emergency Contingency Plan 2012-2013 including all key stakeholders intervening in humanitarian crisis. This plan serves to ensure rapid and coordinated response to reduce the impact of an emergency on people in Mozambique.
• Trainings on disease prevention and control during emergencies have been conducted for health staff in Gaza and Zambezia to in a better position to respond to potential future emergencies.
• The Emergency Cluster coordination meetings at central level ensure close coordination, proper communication flow and rapid response among health partners.
• Report on lessons learnt based on the experiences of the flooding in January 2013 is under development to improve future responses.

Key Resources

• Ministry of Health
• WHO African Region Disaster Preparedness and Response
• Inter-agency Standing Committee
• IASC Guidelines on Mental Health and Psychosocial support in emergencies
• WHO Emergency Response Framework (ERF)
• WHO Humanitarian Health Action

Situation analysis

Communicable diseases still represent the major public health problems leading to high morbidity and mortality rates among the population, particularly among children under 5 years old. Natural disasters often faced by the country turn the population vulnerable to water borne and drought related disease outbreaks such as cholera, dysentery, and meningococcal meningitis. Sporadic outbreaks of plague have occurred in the country.

The major causes of morbidity and mortality are AIDS, malaria, tuberculosis, respiratory infections, diarrhoea, and meningitis.

Challenges & achievements

Challenges

• Weak epidemiological surveillance system lacking infrastructure and appropriate intra and inter-sectoral coordination;
• Poor health care services, the impact of HIV, and economic migration weakening the health systems;
• Shortage of human resources to implement activities at all levels;
• Lack of radio-communication to liaise remote districts.

Achievements

• Establishment of an epidemiological surveillance system with a list of diseases to be reported by all health facilities;
• Revision of the system with the establishment of two sub-systems known as Weekly Epidemiologic Bulletin (BES) and Monthly Epidemiologic Bulletin-Sentinel Post (BEM-PS).
• Finalization of the national technical guidelines on epidemiological surveillance adapted to the national context.

Next steps

• Revitalization/establishment of the epidemic management committees at central, provincial and district levels;
• Establishment and training of Rapid Response Teams on preparedness and response at all levels;
• Adaptation and introduction of the case based and monthly reporting forms in the country health surveillance system;
• Revision and update the technical guidelines and the training manuals for district health workers;
• Training for health personnel on disease surveillance, reporting, data management, preparedness and response;
• Sensitization of clinicians at hospitals on disease surveillance with emphasis on cases detection and reporting on priority diseases;
• Development of a comprehensive national laboratory policy;
• Training at provincial labs in meningitis surveillance and provide adequate supplies.

Situational analysis

The burden of non-communicable diseases (NCD) is on the rise in Mozambique as a sign of an ongoing epidemiological transition. This means that the burden of disease is increasingly linked to behavioral lifestyle factors such as physical activity, diet, alcohol - and tobacco consumption. Particularly prevalent diseases include cardiovascular diseases, diabetes, chronic obstructive pulmonary disease and different types of cancer[1]. However, also injuries, violence, and mental health contribute to morbidity and mortality in Mozambique.[2]

Cardiovascular diseases are the 4^th cause of death in Mozambique[3]. One in every three Mozambican has hypertension – a major risk factor for stroke. In Maputo City alone, 2-3 strokes occur every day with a lethality rate of 40%.

Cervical cancer is the most common cancer in women. It has a high lethality, as six out of every ten diagnosed women die from the disease. This is followed by breast cancer where half of all diagnosed women die.[4]  For men, prostate cancer is one of the most prevalent types of cancer. Eight out of every ten diagnosed men die from prostate cancer in Mozambique.

Injuries are the third cause of mortality among people over five years, with road traffic injuries and violence as the main causes of injury-related deaths. Annually, almost 1700 people die on the Mozambican roads due to road traffic injuries. Furthermore, one third (33.4%) of women and one fourth (24.8%) of men between 15-49 years reported to have been victims of physical violence during the past 12 months[5].

Mental health disorders and psychosis are affecting respectively 5% of the rural and 2% of urban population.

Reverting the growing burden of NCDs requires a multi-sectorial approach with coordinated efforts among key line ministries including Ministry of Health , Ministry of Women and Social Action , Ministry of Transport and Ministry of Interior plus the private sector, community involvement and other health partners and civil society organizations.

Furthermore, there is a need to strengthen surveillance for non-communicable diseases. Updated quality data is important to target interventions.  Raised awareness about prevention of all types of NCDs and injuries is also a priority. Health promotion and community empowerment are crucial tools for creating healthier lifestyles and environments.

Achievements

• Raising awareness about risk factors for high blood pressure during World Health Day 2013.
• Ministry of Health is planning to introduce the human papilloma virus (HPV) vaccine for cervical cancer in the coming years. This vaccine will protect young women from developing cervical cancer.
• Development and approval of the National Strategic Plan for Prevention and Control of Non-communicable Diseases 2008-2014 , which aims at creating a healthier living environment for Mozambicans, reducing exposure to risk factors for non-communicable diseases and improving access to treatment.
• Development and approval of the National Strategy for the Prevention and Control of Injury and Violence (2011-2015 ), which focuses on reducing the many road traffic accidents in Mozambique and thereby also the number of people dying.
• Development of the Norms for Management of Cervical and Breast Cancer in health facilities and creation of the National Program for Cervical and Breast Cancer Control, to improve diagnosis and treatment of these diseases.
• Creation of mechanisms for integrated care services and follow-up for victims of violence (including health care, legal advice, and police and social protection). These efforts aim at supporting victims of violence and to prevent re-victimization.
• To strengthen surveillance and quality of data, “injury and violence” are now integrated into the Integrated Disease Surveillance and Response using the International Classification of Diseases-10 coding tools.

Key Resources

• Ministry of Health
• WHO STEP Survey 2005 fact sheet
• New Road Traffic Regulation 2011. 
• National Multi-sectorial Road Safety Strategy (2011-2016 ) 

HIV/AIDS is a major public health concern in Mozambique. With a prevalence of 11.5% among adults between 15-49 years, Mozambique is facing a generalised epidemic. This means that the virus is spread among the general population and is not exclusive to specific risk groups.

In the national survey, INSIDA 2009 , the Ministry of Health estimates that 1.6 million Mozambicans are currently living with the virus. The study describes a feminisation of the epidemic with an overall prevalence of 13.1% among women compared to 9.2% among men. Urban areas (15.9%) are generally more affected than rural areas (9.2%). HIV is more prevalent in the southern region than in the northern region, see table below.

In Mozambique, the primary route of HIV transmission is heterosexual contact, which accounts for around 9 out of 10 infections. The remaining occurs through mother to child transmission (MTCT) (5%) and through injectable drug use , men who have sex with men and the use of diverse unsterilized instruments.

In National Strategic Plan for HIV/AIDS (PEN III 2010-2014), male circumcision forms part of the prevention plan. In 2009, around of half (51.7%) of all Mozambican men from 15-64 years were circumcised . The prevalence of circumcision is higher in the North of the country and in Inhambane, where the prevalence of HIV is also lower.

Access to anti-retroviral treatment (ART) has increased significantly during the past five years throughout the entire country. From 2008 to 2012, the number of people on ART almost tripled (308,578 in 2012 compared to 118,937 in 2008).  In the same period, the number of public health facilities providing ART has also increased. In December 2012, more than 316 public health facilities were providing ART.

Despite the remarkable progress in scaling up access to ART, some challenges remain to be tackled including weak coverage of MTCT prevention services and ART coverage for children. Other challenges include the limited human resources for health , a need for more holistic programmes integrating tuberculosis and nutrition components in existing HIV programmes, and improved coordination of the numerous development partners and civil society involved in the fight against HIV.

Achievements

• In April 2013, Mozambique hosted the 18^thglobal HIV/TB taskforce meeting to promote the integration of holistic approaches to tackle both diseases.
• Signing of the Code of Conduct for HIV/AIDS Partners’ Forum between the Government of Mozambique and partners working on HIV/AIDS. This document aims at strengthening coordination and aligning priorities.
• In 2000, the Government approved the National Strategic Plan (PEN I) and established the National Council to Combat AIDS (CNCS) . This provides a long-term strategic approach to tackle HIV/AIDS in Mozambique

Key Resources

• Ministry of Health
• Inquérito Nacional de Prevalência, Riscos, Comportamentais e informação sobre o HIV e SIDA em Moçambique (INSIDA) 2009
• UNAIDS Mozambique
• UNAIDS Global Progress Report 2012, Mozambique
• The Global Fund to Fight AIDS, Tuberculosis and Malaria

Situational analysis

Tuberculosis (TB) pose a public health challenge for Mozambique. With an estimated incidence rate of 548 per 100.000 population and a prevalence of 490 per 100.000 (both figures incl. HIV/TB co-infections) in 2011, Mozambique is one of the 22 High Burden Countries in the world.  

Tuberculosis is a priority area for the Ministry of Health . In March 2006, TB was declared a national emergency and in 2008, a National TB Strategy 2008-2012 was adopted by the Government . The Plan focuses on the recommendations from the Global TB Initiative and aims at reducing the burden of TB in line with the Millennium Development Goals and the Global TB partnership targets.

Despite the commitments from the Ministry of Health, Mozambique still faces challenges in tackling TB. According to the Global Tuberculosis Report 2011 , the case detection rate in Mozambique is around one third (34%) for all forms of TB cases. This is below the global TB outcome target of 84%.

Another challenge is reducing the level of TB-HIV co-infections. In 2011, 88% of all TB cases knew their HIV status, of which 63% were positive for HIV. Of cases with detected co-infection, 91% were receiving co-trimoxazole prophylactic therapy (CPT) and 29% antiretroviral therapy (ART) .

To increase access to treatment, the Ministry of Health updated the eligibility criteria for initiating antiretroviral therapy (ART) in January 2012 in line with the WHO recommendations . This means that any co-infected is patient is eligible for ART regardless of their CD4 count, which is the usual indicator for initiating ART. Furthermore, efforts are currently underway to establish a “One Stop Model” to foster full integration of management of the two diseases, including better conditions to prevent TB transmission in health care facilities.

Detailed surveillance data on TB in Mozambique will soon be available; the National TB Program intends to conduct a nation-wide population based TB prevalence survey in 2014. Other analytical efforts to target TB control programmes include a Knowledge Attitudes and Practices (KAP) survey currently being coordinated by Family Health International.

Data on multi-drug resistant TB is limited. In 2011, only 1% of new TB cases and 10% of retreatment cases were tested for multi-drug resistance. Drug resistance arises due to inconsistent treatment. Inconsistency can be a result of various factors such as poor health infrastructure affecting access to treatment, misconceptions about the treatment, and limited capacity at the health facilities.
 

Achievements

• Almost nine out of ten (88%) of TB patients know their HIV status. Furthermore, nine out of ten (91%) known co-infected HIV/TB patients are receiving co-trimoxazole preventive therapy, which is a low-cost therapy preventing secondary bacterial and parasitic infections.
• Mozambique now has three laboratories performing drug susceptibility testing (DST) on first line anti-TB drugs. These laboratories contribute to faster and more accurate diagnostics and are located in Maputo, Beira and Nampula serving the Southern, Central and Northern provinces of the country.
• A TB working group with specific agenda and concrete deliverables has been established to strengthen coordination and intensify control efforts.
• In April 2013, Mozambique hosted the core group meeting of the Global TB/HIV Working Group . This annual meeting aims at promoting a more coherent response to the two diseases.
   

Key Resources

• Global Tuberculosis Report 2012
• Ministry of Health
• The Global Fund to Fight AIDS, Tuberculosis and Malaria
• Global TB Strategy
• Antiretroviral treatment as prevention (TASP) of TB and HIV
• Report of an external mid-term review of the National Tuberculosis Control Programme Strategic Plan 2008-2012
• News on the expansion of diagnostic tools in Mozambique

Situational analysis

In Mozambique, malaria is a major cause of morbidity and mortality especially among children. The disease represents around 45% of all cases in outpatient visits, approximately 56% of inpatient at paediatric clinics and around 26% of all hospital deaths. ^.According to the Demographic Health Survey 2011, the prevalence of malaria among children under five years is 46.3% in rural areas compared to 16.8% in urban areas. The relatively high prevalence in many parts of the country puts the entire population at risk and poses a challenge for malaria elimination efforts nationally and in neighboring countries.      

Malaria is endemic throughout Mozambique with seasonal peaks during and after the rainy season, which is between November and December. The seasonal intensity of transmission varies depending on the amount of rain and air temperature. The tropical climate combined with the presence of some of the most efficient vectors for malaria transmission (namely Anopheles gambiae s.s., An. Arabiensis from the Gambiae complex and An. Funestus) facilitate malaria transmission throughout the entire calendar year.

Plasmodium falciparum is the most common parasite, responsible for more than 9 out of 10 of all infections. Plasmodium malariae accounts for approximately 6% of infections, with the rest being mixed infections from these two species. Infections caused by plasmodium ovale are relatively rare.

Main prevention methods include long-lasting insecticidal nets (LLIN), indoor residual spraying and intermittent preventive treatment for pregnant women (IPTp).

Mozambique faces a number of specific challenges in combatting malaria:

·         The Health Information System (HIS) does not collect data on most malaria indicators;

·         Limited available data from laboratories on rapid diagnostic tests and microscopy;

·         Inadequate health infrastructure affecting the distribution and availability of treatment (artemisinin-combination therapies – ACT);

·         Scarce human resources for health impairing the quality of care provided at health facilities;

·         Limited use and logistical capacity in the distribution of long-lasting insecticidal nets;

·         Limited funds for campaigns for indoor residual spraying, and

·         Finalization of the Integrated Vector Management (IVM) Guidelines

In October 2010, the Ministry of Health decided to undertake an in-depth review of the National Malaria Control Program (NMCP). In response to the recommendations of the Malaria Program Review 2010, the NMCP developed and finalized the Malaria Policy and Strategic Plan (MSP) 2012-2016. In line with the Global Malaria Program, the MSP includes a monitoring and evaluation plan to measure to aim of scaling up malaria control interventions to achieve universal health coverage by 2015 according to the Millennium Development Goals.

The overall objective of the MSP 2012-2016 is to halve malaria morbidity and mortality rates relative to the rates observed in 2009.

Specific Objectives of the MSP 2012-2016 include:

1. By 2014, all districts should have the capacity to manage malaria control activities.
2. By 2014, the entire population should have access to at least one malaria prevention method.
3. By 2014, all suspected malaria cases presenting to health and community health workers (CHWs) should receive a malaria diagnostic test and receive treatment according to the national guidelines.
4. By 2014, surveillance, monitoring, and evaluation systems should be strengthened so that districts are able to report routinely on key malaria indicators.
5. By 2016, all of the population should have received information on malaria prevention and treatment.

Achievements

Some of the main achievements include the development of a number of technical guidelines on how to reduce morbidity and mortality caused by malaria in Mozambique:

• Malaria Treatment Guidelines updated
• National supervision guidelines developed  in 2011
• Laboratory guidelines developed  in 2011
• Integrated Vector Management Guidelines under development
• Annual distribution of LLIN to reach universal access:
  • 2010: 1.525.979
  • 2011: 3.311.246
  • 2012: 2.601.953
  • According to the plan of the MoH, 6,229,492 LLIN are expected to be distributed in 2013.
• Raising awareness of malaria on World Malaria Day 2013 during an event in Ndlavela .

Key Resources

• Ministry of Health
• WHO global update and treatment guidelines
• WHO Policy Recommendation: Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP)
• Malaria Consortium Mozambique
• The Global Fund to Fight AIDS, Tuberculosis and Malaria
• WHO travel recommendations for Malaria and Yellow Fever

Situational analysis

Neglected tropical diseases (NTD) refer to 17 infectious diseases particularly prevalent in the tropics. The African Region bears about half of the global burden of NTDs. In addition, NTDs such as Guinea-worm disease, Buruli ulcer and Human African Trypanosomiasis affect only or mainly the African continent. All the 47 countries of the African Region are endemic to at least one NTD.

Neglected diseases tend to lose priority because they often do not kill. However, lack of action leads to serious developmental and economic consequences because of diminished school performance, retarded growth, absenteeism from school and work, as well as a loss of productivity.

Neglected tropical diseases typically affect children, peasants and the poor causing varying degrees of disability and perpetuating the cycle of poverty. In Mozambique, the most prevalence NTDs include schistosomiasis, trachoma, intestinal parasites, lymphatic filariasis, and onchocerciasis. The map illustrates the worldwide distribution of schistosomiasis in 2011.

Cheap and effective tools are available to control most neglected tropical diseases. Access to clean drinking water is one of the main methods of prevention.

In recent years, there has been a global focus on combating three major global killers; HIV/AIDS, tuberculosis and malaria. However, fighting these is not mutually exclusive with controlling neglected diseases. Synergies with particularly HIV/AIDS initiatives need to be exploited to ensure better use of available health infrastructure and equipment.

In Mozambique, improved epidemiological surveillance to would help to better understand extend, scope and cost of neglected tropical diseases. Surveillance data are also needed to inform policy decisions as well as raising awareness among primary health care workers about tropical diseases. Clinical protocols need to be revisited and simple algorithms need to be designed for primary health care staff to improve diagnosis and treatment. It is important that neglected diseases are managed by the public health workers rather than specialized staff because of limited human resources for health. Training and retraining of health care providers is therefore important.

Achievements

• In August 2013, a medicine (diethylcarbamazine - DEC) to treat the neglected tropical disease, lymphatic filariasis (also known as elephantiasis) was pre-qualified. The prequalification means that the medicine can be used in large-scale treatment campaigns aiming at eliminating lymphatic filariasis. This is the first pre-qualification of a drug treating a neglected tropical disease. 
• Development of the National Integrated Plans for Control of Neglected Diseases 2012-2016. The Plan aims at reducing the burden of neglected tropical diseases by focusing on prevention.
• In May 2013, the World Health Assembly adopted a resolution on all 17 neglected tropical diseases. This meant that ministers of health in Member States in the African Region committed to scaling up proven and effective interventions against the NTDs.
• In Mozambique, mass drug administration is conducted every year in affected provinces and districts. This initiative reaches more than 500,000 people with medication every year;
• More than 50% of health staff in affected provinces has been trained in neglected tropical disease case management. This means that they are in a better position to diagnose and treat patients presenting with neglected tropical diseases;
• Leprosy is under control in Mozambique with an incidence of less than one case per 10,000 inhabitants.

Key Resources

• Ministry of Health
• WHO Programme on Neglected Tropical Diseases
• WHO Report: Sustaining the Drive to Overcome the Global Impact of Neglected Tropical Diseases
• Social determinants of health
• Yellow fever and malaria traveller recommendations
• Traveller vaccinations
• Vaccine-preventable diseases

The Mother and Child Health Cluster (MCH) includes:

• Making pregnancy safer
• Child and adolescent health/nutrition
• Expanded program of immunization
• Prevention of mother-to-child transmission

The MCH Cluster's work aims at supporting the country to reduce the maternal, neonatal and under-five mortality and morbidity, so as to enhance the quality of life, by promoting the reproductive health of families and individual women, men, adolescents and children as well as by improving access to skills development, knowledge and information and services.

The Enlarged Program of Immunizations (EPI) Cluster works with the MCH and Disease Prevention and Control Clusters. It provides support to Mozambique for the improvement of the health of children through the eradication of polio and the control of other vaccine preventable diseases in the context of health system strengthening. Immunization strengthening support, including epidemiological surveillance, accelerating disease control, and introducing new vaccines and relevant technologies and tools are the current main areas of work within this Cluster.

Contact the Mother and Child Health Cluster

Situation analysis

WHO/Olivier Asselin

Mozambique made considerable progress in terms of reducing the child mortality rate: the Demographic and Health Surveys of 1997 and 2003 show that the neo-natal mortality rate decreased from 59/1000 live births to 48/1000 live births while the infant and under five mortality rates decreased respectively, from 147 to 124 and from 219 to 178 per 1,000 live births.

Nevertheless, these mortality rates still remain high and, in spite of this significant progress, it is important to highlight that these gains have not been identical across the country. Disparities of the mortality rate and of the health outcomes are found among provinces, with the Northern provinces presenting the highest child mortality rates. Significant variations between urban and rural areas are also found.

Newborns die mainly due to premature birth, low birth weight, sepsis and neonatal asphyxia. Neonatal tetanus is still a concern in the country. That is understandable because, although 84.2% of pregnant women attend at least one antenatal care session, only 48% of the deliveries are institutional while the remaining occurs at home.

In 2006, data from the paediatrics wards of every hospital show that among the under-five years old, malaria remains the main killer (36.7%). This is followed by malnutrition (13.8%), HIV (12.4%), pneumonia (8.2%) and diarrhoea (3.1%).

The proportion of one year old children fully immunized against the six main preventable diseases (tuberculosis, polio, diphtheria, pertussis, tetanus, and measles) has increased from 47% in 1997 to 63% in 2003.

According to the WHO international classifications, stunting prevalence and underweight prevalence among children under five are very high (respectively 41 % and 24 %).

The main micronutrient deficiencies are: vitamin A deficiency (68.8%), iron deficiency anaemia (74.7%) and iodine deficiency (42% of children aged 6-12 years moderately iodine deficient). The overall prevalence of goitre in the country was estimated at 15%.

The main reasons explaining malnutrition are inadequate and/or insufficient dietary intake, multiple and repetitive infectious diseases, poor feeding practices (exclusive breastfeeding rate the 1st 6 months of life: 30% and nearly one quarter (22%) of children less than six months of age receiving other foods, in addition to breast milk).

Poor access to safe water and sanitation, and the low level of education of the mothers also contribute to the poor child health care and nutrition.

Maternal malnutrition in Mozambique is of particular concern considering the effect this has on foetal and infant growth as well as other birth outcomes. 8.5% of mothers of children under five years old have a body mass index or Body Mass Index less than 18.52 showing chronic energy deficiency.

Vulnerability to malnutrition is now also exacerbated by HIV which is becoming a major cause of under five years old mortality. The number of new HIV infections among children has continuously increased from an estimated 23.400 in 2000 to 37.300 in 2006, which represents about 102 new infections every day . By September 2007, there were 211 sites providing ARV, and 86000 ART beneficiaries, of whom 6320 children under the age of 15.

In 1998, the Ministry of Health adopted the Integrated Management of Childhood Illnesses (IMCI) as a main strategy to reduce child mortality.

Key partners are WHO, UNICEF, and USAID through its NGOs.

Achievements

• Integrated Management of Childhood Illnesses (IMCI) is now implemented nationwide and 70% of health facilities at national level have at least one health worker trained on IMCI caring for sick children. The health facility survey carried out in 2005 with support from WHO and other partners showed a net improvement of the health workers skills on case management of the sick children.
• Multiple actions have taken place within the IMCI strategy in order to strengthen the system, such as:
  • the incorporation of IMCI drugs into the essential drugs kits;
  • the supply of drugs for injection needed for pre-referral treatment of seriously ill children;
  • the establishment of Oral Re-hydration Therapy (ORT) corners;
  • and the provision of bicycle ambulances to communities for emergency transport.
• In 2003, IMCI pre-service training was introduced in the curricula of health sciences training institutions and later at the medical school as a means of supporting the sustainability of the strategy.
• Since 2004, Mother and Child health nurses are trained on both Emergency Obstetric and Newborn Care.
• IMCI training material was updated in 2006, to address the 1st week of newborn life, and to include the HIV component as well as the new WHO recommendations related to breastfeeding, diarrhoea (the new ORS & zinc) and malaria treatment.
• Mozambique adopted in 2005 the Code of Marketing of breastmilk substitutes and drafted the infant feeding policy which addresses HIV issues.
• Along 2006 and 2007, Mozambique developed the newborn and child health policy and the newborn and child health strategic plan;
• The child health card was updated in 2007 to the new WHO child growth standards and also to include PMTCT;
• Establishment of a technical working group for maternal, newborn and child health within the Health SWAp under the leadership of the Ministry of Health.

Next steps

• To achieve the Millennium Development Goal Number 4, meaning a reduction from 246 deaths per 1,000 live births in 1997, down to 82 in 2015;
• Strengthen national capacity including the provincial and district team in planning and implementing priority child health interventions taking advantage of the Reach Every District (RED) approach for scaling up towards universal access and coverage;
• Strengthen national capacity for effective monitoring and evaluation of child survival and use of the findings to improve the child health program implementation;
• WHO will continue to support the Ministry of Health to improve and strengthen collaboration and coordination mechanisms among child health related programs and among partners aimed at better delivery of integrated interventions through MNCH services;
• WHO will continue to advocate among partners towards a common agenda ensuring the continuum of care throughout the life course at all levels including the promotion of community based interventions and contributing to strengthening the health system.
• Renewed interest in strengthening community involvement and community based services.

The Enabling Environment Cluster includes:

• Human rights
• Community involvement
• Health promotion

The WHO office in Mozambique is actively strengthening its role in providing technical support , in the field of Health and Human Rights, Documentation, Health Promotion Dissemination of Information and advocacy for people with disabilities. On the other hand, WHO in Mozambique supports the Ministry of Health in strengthening of community involvement and community based in the national plan and priorities for health. In order to improve quality, coverage and coordination of health interventions at community level.

The Health Promotion Unit helps to increase the capacity of the country to use health promotion strategies to address the broad determinants of health and assist communities gain control over, and improve their health through integrated action.

Overview

Human rights are an internationally agreed upon set of principles and norms adopted at international and regional levels. Many international instruments refer to the right to health or health-related rights.

Promoting and protecting health and respecting, protecting and fulfilling human rights are inextricably linked:

Violations or lack of attention to human rights (e.g. harmful traditional practices, slavery, inhuman and degrading treatment, and violence against women) can have serious health consequences;

Health policies and programs can promote or violate human rights in their design or implementation (e.g. freedom from discrimination, rights to participation, privacy and information);

Vulnerability to ill health can be reduced by taking steps to respect, protect and fulfil human rights (e.g. freedom from discrimination on account of ethnicity, sex and social status and the rights to food and nutrition, water, education and adequate housing).

In light of the linkages between health and human rights, it is more and more important to increase awareness and to have an added systematic application of human rights to a range of public health challenges. In this context, the right to health is an important tool that can be used to tackle health inequalities.

Situation analysis

Mozambique has ratified several major international and regional human rights treaties that address the right to health and a number of rights related to conditions necessary for health. However, Mozambique is not yet party to the International Covenant on Economic Social and Cultural Rights.

At national level, the Mozambican constitution (2004) refers to the protection and promotion of human rights, including the right to health. The rights-based approach is also reflected in other important strategic documents such as the Poverty Reduction Strategic Paper (PARPA II) and the National Declaration of Health Policy (Declaração Nacional de Política da Saúde).

Challenges

• Lack of adequate human rights network to develop specific projects (including weakness of civil society);
• Limited strategic position in some priority health programs such as tuberculosis, malaria, etc.
• Key documents not available in Portuguese.

Achievements

The WHO office in Mozambique is actively strengthening its role in providing technical, intellectual and political leadership in the field of health and human rights. Indeed, it has established strong links with partners at Ministry level, but also with the civil society to introduce the human rights based approach to health. At international level, WHO is also actively collaborating with the UN Special Rapporteur on the Right to Health, and his team.

WHO office in Mozambique is working towards the dissemination of information on health and human rights as well as important related subjects, such as the effects of discrimination on the response to HIV, or the rights of people with disabilities.

Next steps

• Introduction of the notion of the right to health in the Health Sector Strategic Plan (PESS).
• Implementation of the recommendations made by the Special Rapporteur on the Rights to Health, who visited Mozambique in 2003.
• Collaboration with the Ministry of Justice for setting up the National Human Rights Commission and to tackle the issue of rights of HIV positive inmates.

Situation analysis

In Mozambique, there is a renewed interest in strengthening community involvement and community based services. The Ministry of Health (MoH) considers that community involvement must be strengthened as an explicit and priority objective of the national plan for health in order to:

• Strengthen health interventions at community level;
• Achieve the Millennium Development Goals (MDGs);
• Face the human resource crisis;
• Improve quality, coverage and coordination of health interventions at community level.

Challenges

• Limited number of people familiar with the community based approach for health at all levels;
• Need for the development of a programmatic approach to community interventions so that the community's role in the formal health system is identified and supported and that elements of their roles are captured in the health management information systems;
• The development of standards and training material for community-based prevention, treatment, care and support;
• The promotion of community based initiatives;
• Revitalization of a community health workers program as an intermediate solution to bring health care to remote areas;
• Sustainability of community health workers: issues of remuneration remain unsolved in Mozambique, development of better supervision mechanisms;
• Revision of the manuals for community health workers;
• Revision of the national strategy on community involvement;
• Development of tools for monitoring and evaluation.

Achievements & next steps

Achievements

• Draft of the Plan of action to promote community involvement for health;
• National meeting on community involvement for health.

Perspectives

• To build capacity of the MoH and their partners to support communities' participation;
• To face the priority challenges at community health level to accelerate, promote and coordinate community involvement strategy and activities.

Non-governmental organizations

Despite numerous NGOs interventions, Mozambique is still facing various critical problems in the health sector and is not getting the targets at community level.

The proliferation of NGOs and programs in Mozambique has, at times, occurred at the expense of accountability and quality programming, and has led to fragmentation of the NGO "voice." It is a fact that NGOs tend to compete amongst themselves rather than to work together. Since the MoH is still not completely prepared to orient and control most of NGOs activities, the principles of collaboration between the MoH and NGOs need to be strengthened.

As it was confirmed by the recent creation of the health partners group on NGOs in July 2007, the MoH and NGOs agree that their health services are complementary and absolutely in need of optimal coordination through strategic partnerships and policies.

There are key priority issues that need to be strengthened:

• To establish a common diagnosis of the situation;
• To develop a data base and mapping on NGOs information and activities;
• To share best practices of NGOs evidence-based interventions;
• To create complementarities and efficient interventions in line with the MoH strategic plan;
• The development of the NGO unit at the MoH;
• To improve coordination and partnership mechanisms between the MoH and NGOs through a better contractual approach and policies documents;

Situation analysis

Prof. Paulo Ivo Garrido H.E. the Ministry of Health mobilizing community during the celebration of Africa Malaria Day on 25 April 2007, in Zambezia

Health Promotion is the process of enabling people to increase, control and improve their health. Community involvement and participation are essential to sustain health promotion actions.

In 2001, The African Region endorsed the Health Promotion Strategy, whereby Member States are urged to develop national strategies incorporating policy frameworks and action plans to strengthen the institutional capacity for health promotion as well as provide support at various levels of the health system, as appropriate. The aim of the strategy is to foster actions that enhance the physical, social and emotional well-being of the people, and contribute to the prevention of leading causes of disease, disability and death.

Prof. Paulo Ivo Garrido H.E. the Ministry of Health mobilizing community during the celebration of Africa Malaria Day on 25 April 2007, in Zambezia.

Prof. Paulo Ivo Garrido H.E. the Ministry of Health mobilizing community during the celebration of Africa Malaria Day on 25 April 2007, in Zambezia.

The new structure of the MoH shows the high ranking given to Health Promotion by the Mozambican health authorities: there is a Health Promotion National Directorate with two Deputy National Directorates namely Health Protection, and Prevention and Disease Control.

A study conducted by the Ministry of Health (STEPS) has shown that non-communicable diseases (NCDs) are a matter of concern for health in Mozambique.

The country faces a lack of skilled professionals for Health Promotion, namely for strategic planning and monitoring and evaluation. Also, the unavailability of translated versions of WHO key documents in Portuguese contributes to keep a weak visibility of Health Promotion.

WHO and its partners are supporting a number of initiatives in the area of health promotion in Mozambique - Roll Back Malaria, Making Pregnancy Safer, Health Promoting School Initiatives, Road Safety - under the coordination of the Ministry of Health, jointly with other sectors of the government such as Education and Culture, Agriculture, Women and Welfare, Sports and Youth, Transport and Communications, and the Parliament. Many other actors are also part of these initiatives such as mass media (modern and traditional), civil society, national and international NGOs, religious groups, sports groups, traditional medicine practitioners, and other relevant stakeholders.

Challenges

• Diseases that can be prevented - malaria, tuberculosis, respiratory infections, diarrhoea, sexual transmitted diseases, HIV infection, non-communicable diseases - are increasing sharply;
• Young people are more and more exposed to trauma, alcohol, tobacco and substance abuse;
• Developing and implementing a National Health Promotion Strategy;
• Training of Health Promotion staff countrywide;
• Improvement of coordination among partners.

Achievements & next steps

Achievements

• Support provided to the Mozambique Association of Public Health (AMOSAPU) for the organization of two meetings for tobacco prevention and control for the Lusophone, Southern Africa and East Africa countries;
• Strengthened partnership with mass media;
• Support provided for the development of the health communication strategy of the National Program for Malaria Control (PNCM).

In the context of Roll Back Malaria (RBM) an Inter-Religious Campaign was established by 10 national faith leaders in Maputo, Mozambique. In 2006, these leaders requested the participation of the Washington National Cathedral and the Adventist and Development Relief Agency in moving forward with their dream of a Mozambique without Malaria.

National Campaign members include: the Roman Catholic Church, the Islamic Congress of Mozambique, the Islamic Council of Mozambique, the Anglican Church, the United Methodist Church, the Seventh-Day Adventist Church, the Hindu Community, Assemblies of God, the Christian Council of Mozambique, and the Baha'i Community. The Co Chairs of the IRCMM are Bishop Dinis Sengulane and Mr Hassan Makda.

This inter-faith group is implementing the first stage of its "Together Against Malaria" program in the province of Zambezia by providing health education, training, and community mobilization through trained faith leaders. Faith communities exist in every village in the country; therefore, faith leaders can reach their members and impact their attitudes and behavior related to malaria.

Mrs. Laura Bush during the Seminar, on the President's Malaria Initiative (PMI), held in Maputo in June 2007, announced the first grant to the Inter-Religious Campaign against Malaria in Mozambique. Through the President's Malaria Initiative, with a three-year, nearly $2 million grant that is expected to benefit over a million and a half people. The Adventist Development and Relief Organization provides program implementation support to the faith leaders, and Washington National Cathedral's Center for Global Justice and Reconciliation also provides support and assists with procuring additional resources for the project.

Perspectives

• Formulation of the national Health Promotion strategy;
• Support to the national campaign for sanitation and hygiene.

The Immunization and Vaccines Development (IVD) Cluster includes three programmatic areas:

• Routine Vaccination and New Vaccines
• Surveillance
• Logistics

The IVD Cluster provides technical support to the Ministry of Health to reduce the level of morbidity, disability and mortality due to vaccine-preventable diseases. It aims at achieving and sustaining high immunization coverage; eradicating, eliminating and controlling diseases; and introducing new vaccines.

The Cluster provides technical assistance for monitoring the performance, quality and safety of the Mozambican vaccination system through identified indicators and compliance with the WHO list of pre-qualified vaccines.

To improve public health and lower the burden of infectious diseases, the Cluster assists the Ministry of Health in developing and implementing sustainable vaccination strategies promoting universal coverage. The impact of the strategies is assessed through on-going epidemiological surveillance and reliable laboratory confirmation.

Aiming at reaching regional and global targets, the Cluster supports the monitoring of the overall proportion of children and women who are vaccinated (immunization coverage), ensuring that all districts of Mozambique are well covered with vaccination services. 

Situational analysis

Vaccination is a key priority to reverse the high child mortality of 97/1000 live births in Mozambique . As part of the Expanded Program on Immunization, the Mozambican national routine vaccination programme includes:

• Polio; measles; tuberculosis (BCG); diphtheria, pertussis, and tetanus (DPT1/3); hepatitis B; Hib, and pneumococcal (PCV-10) for children under one year:
• Tetanus for pregnant women.

According to the Demographic Household Survey (DHS) 2011, almost 64% of children had completed the full vaccination programme before the age of one year, compared to 63% in 2003 and 47% in 1997. The vaccination coverage is thus far below the global immunization goal of at least 80% coverage in all districts, and 90% nationally. The coverage is also unevenly distributed within the country. The province of Zambézia continues to have to lowest coverage rate of 47.3% in 2011. Furthermore, coverage varies between urban and rural areas. In 2011, the DHS reported coverage to be 75% in urban and 60% in rural areas compared to 81% and 56% in 2003, respectively. 

Many districts have communities that are difficult to access with the existing health services infrastructure. Outreach programmes are therefore essential to improve coverage at district level. However, only 30% of fixed vaccination units are provided with transport needed to conduct outreach activities.

To increase coverage at district level, the Reaching Every District (RED) strategy was implemented in 131 districts out of 148 by 2012. However, the strategy faces irregularities and disruption in the implementation due to funding limitations. Furthermore, low population density in many districts makes the RED strategy costly though essential to increase the number of fully vaccinated children.

Another concern is the high level of dropout for DPT1/3 at district level. According to DHS 2011, the national DPT1/3 dropout rate was 17%. The most affected provinces with dropout rates above the national average were Cabo-Delgado (28%), Zambézia (27%), Nampula and Manica (both 19%).  

Another key challenge for strengthening the vaccination system and increase coverage is the shortage of trained health personnel leading to fragile programme management. Poor infrastructure also complicates logistical necessities including the cold chain system and transport for outreach activities. 

Achievements

• PCV-10 was successfully introduced into the national immunization programme in April 2013. 
• The Ministry of Health plans to introduce rotavirus into the childhood vaccination programme in 2014 and human papilloma virus (HPV) for women in 2016. An HPV demonstration project will be conducted in Manhiça district in 2014 and 2015, prior to the nationwide introduction of the vaccine.
• The African Vaccination Week (AVW) was introduced in 2008 as part of the National Health Weeks, taking place twice per year. Preparatory committees exit at national, provincial and district levels. These include Nutrition, EPI, social mobilization and health promotion units at each level. Results from African Vaccination Week 2013 include:

Key resources

• Ministry of Health
• GAVI Alliance
• Traveller Vaccinations
• UNICEF Mozambique
• Launch of the Pneumococcal Vaccine PCV10

Situational Analysis

Surveillance is the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice.

To monitor vaccination coverage and identify gaps, Mozambique introduced a weekly surveillance system in 1987. In1997 a case based surveillance system for polio was introduced, and further expanded for maternal and neonatal tetanus and measles in 2006.

Data collected through the surveillance system is reported to the global WHO Vaccine-preventable Diseases Monitoring System and summarised in the Mozambique Country Profile.

To monitor disease outbreaks, every health facility is obliged to notify the weekly caseload of a number of communicable diseases including measles, meningitis, and polio. In 2012, the most recent outbreak of measles was notified in Niassa province, Lago district.

Despite the surveillance systems in place, low capacity at facility level including shortage in human resources for health often causes delayed and fragmented data. Furthermore, many provinces are facing challenges in implementing vaccination programmes.

The fragile health infrastructure and limited human resources for health complicate disease control particularly for reaching international goals of polio eradication and measles elimination.

Achievements

• In 2012, all provinces achieved the Non-Acute Flaccid Paralysis (AFP) rate of at least 2/100,000 children under 15 years;
• Diagnostics have been improved by using case definition;
• Continuous training of health workers in surveillance at provincial level;
• Introduction of countrywide measles case-based surveillance integrated into the already existing AFP surveillance system.

Key Resources

• Ministry of Health
• World Bank
• Eradicating Polio in the African Region: 2011 Regional Update
• GAVI Alliance

Situational analysis

Logistical support is crucial for vaccination services. It aims at ensuring the availability of appropriate equipment and an adequate supply of high-quality vaccines and immunization-related materials to all levels of the vaccination programme. The main areas of logistical support include vaccine management and monitoring, cold chain management and immunization safety.

If the logistics programme is well-managed, it can help saving on programme costs by ensuring efficient programme implementation without sacrificing the quality of service delivery. On the contrary, poorly managed logistics systems can lead to high and unnecessary vaccine wastage, stock outs, or improper management of waste, resulting in increased operational programme costs, as well as negative effects on public health.

The planning of vaccination programmes is heavily reliable on accurate population data and precise information about inventory at health care facilities. Inaccurate data impairs the planning and management of vaccination services including the cold chain systems, which is the temperature-controlled series of storage and distribution ensuring quality and shelf life of the vaccines.  

Mozambique faces several logistical challenges in increasing vaccination coverage and in introducing new vaccines into the national vaccination programme. The country is divided into 148 districts throughout 11 different provinces. Vaccination services are offered in approximately 1,372 fixed entities representing 98% of all health units in the primary and secondary health care system. Low population density of around 26 inhabitants per square kilometre  on average complicates vaccination services and requires costly outreach vaccination programmes in most districts. Communication flow between district, provincial and central level is complicated by lack of access to communication tools including internet and limited human resources for health. This affects the ability to communicate needs and coordinate supply. 

To ensure immunization quality and safety, only WHO pre-qualified vaccines are purchased via UNICEF procurement channels. Each Expanded Program on Immunization (EPI) unit is in charge of ordering and allocating supplies to the different provinces based on the feedback received from the respective provinces. Some vaccines are financed solely by the Government of Mozambique (BCG, OPV, measles, tetanus) and others are co-financed by GAVI Alliance (Diphtheria-Pertussis-Tetanus, Hepatitis B, Hib, PCV-10). 

Achievements
 

• Introduction of the pneumococcal PCV-10 vaccine in April 2013
• Cold chain inventory assessments conducted of 98% of all health facilities in 2012.
• In 2000, the Monthly Health Days (MHD) outreach strategy was introduced. The outreach services depart from health units to visit the communities in most of Mozambique’s 148 districts.

Key Resources

• Ministry of Health
• UNICEF Mozambique
• GAVI Alliance
• Global Vaccine Action Plan 2011-2020
• Micro Planning for Vaccination Service Delivery using the Reaching Every District (RED) Strategy