A Introduction

Mozambique is a country with a surface area of around 800,000 km², located in Southeast Africa. It became independent in 1975 after around five centuries of Portuguese colonisation. At the time of independence, Mozambique was one of the poorest countries in the world. Between 1976 (less than a year after the proclamation of independence) and 1992, the country was ravaged by a war that caused large-scale destruction of its economic and social infrastructure and affected over 5 million Mozambicans, of whom around 1 million lost their lives and 4 million were forcibly displaced from their homes (Pim and Kristensen Reference Pim, Kristensen, Page and Pim2007).

Thus, in 1992, when the war ended, Mozambique was the poorest country in the world, with a per capita GDP of only US$354 (2011 PPP) (Gradín and Tarp Reference Gradín and Tarp2019). The economic growth seen in Mozambique from 1995 onwards led to a reduction in poverty levels, with the per capita GDP trebling in only twenty-five years (Gradín and Tarp Reference Gradín and Tarp2019). Despite this economic growth, Mozambique remains one of the poorest and least developed countries in the world.

In Mozambique today, over half the population (estimated at around 29,000,000, 66 per cent of whom live in rural areas) lives below the poverty line (less than US$2 per person per day) (Gradín and Tarp Reference Gradín and Tarp2019). According to data from 2017, Mozambique has a per capita GDP of US$1,136 and a Human Development Index of 0.442, putting it in 180th place out of 189 countries (UNDP n.d.). According to data from 2019, Mozambique has a Sustainable Development index of 53 points out of 100, putting it in 136th place out of 162 countries (Sachs et al. Reference Sachs, Schmidt-Traub, Kroll, Lafortune and Fuller2019: 21).

The process of economic growth that is leading to a reduction in poverty has occurred and occurs at the same time as an increase in economic and social inequalities. These take place in a country with previous inequalities between urban and rural areas and between regions (North, Centre, and South).

B Concept of Health and Social Determinants of Health

To study the topic of health in Mozambique, it is first necessary to understand the concepts of health and social determinants of health. According to the World Health Organization (WHO), ‘Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (WHO 2006). This means that a person might not be sick in the normal opinion of people (i.e. not suffering from fever, diarrhoea, cough, or headaches and going to work every day) and even so not enjoy good health.

There is a consensus that the living and working conditions of individuals and groups in the population influence their health situation. In other words, most illnesses and health inequalities – which exist in every country – are derived from the conditions under which people are born, live, work, and grow old. This is where the concept of social determinants of health comes from. For the WHO, social determinants of health are the social conditions under which people live and work (WHO n.d.).

Some examples of social determinants of health are – apart from the quality and accessibility to healthcare and services – the quantity and quality of food a person ingests regularly and the quality of the water and sanitation to which they have access. The same goes for housing and transport conditions, the education level, the working environment, the consumption or not of tobacco, alcohol and other drugs, and the state of mental health of individuals and community.Footnote ¹

One of the most important social determinants of health are the institutions in a country or a community. Institutions are the rules of the game (formal or informal) that the political, economic, and social players in the country or community are expected to follow. Each society operates with a set of political, economic, and social rules created by the state and the citizens together. In this chapter, we focus on the role institutions have in the state of health of Mozambicans.

C A Brief History of the Health Services in Mozambique before and after 1975

The history of the health services in Mozambique encompasses four different periods:

1. a) the period prior to the independence of Mozambique (1975);

2. b) the period immediately after independence (1975–80);

3. c) the period from 1980 to 1993;

4. d) the period from 1993 to the present day.

D Description of the Health Sector

In Mozambique, the health sector is called the National Health System and is structured in the following subsystems:

1. 1. a public subsystem run by the state and called the National Health Service;

2. 2. a private subsystem;

3. 3. a military and paramilitary health subsystem;

4. 4. socio-professional organisations such as the Medical Council, the Nursing Council, and the Medical Association of Mozambique, considered part of the National Health System.

The National Health Service is directly dependent on the Ministry of Health and is by far the largest provider of healthcare to the around 29 million Mozambicans. It includes four central hospitals (each one with over 600 beds), seven provincial hospitals (between 250 and 350 beds), two psychiatric hospitals, a little less than fifty district hospitals, and 1,585 health centres and facilities spread throughout the districts and communities in the country. It employs over 90 per cent of health workers in Mozambique.

The private subsystem is divided into (a) private for-profit; and (b) private not-for-profit medicine. The private for-profit sector is concentrated in the cities (mainly in the capital, Maputo) and includes two hospitals (both in Maputo City), a few dozen clinics, medical practices, pharmacies, laboratories, and imaging services. The for-profit private sector is devoted almost exclusively to curative activities.

The private not-for-profit subsystem includes religious organisations and non-governmental organisations (NGOs), mostly foreign and directly funded by the so-called cooperation partners (donors). It also includes health facilities in some large public and private companies and in educational establishments, such as the Eduardo Mondlane University.

The military and paramilitary health subsystem is in an early stage. Mozambique has no hospital to care specifically for paramilitary forces.

The National Health Institute (aimed at research) and the Traditional Medicine Institute are under the auspices of the Ministry of Health.

E Traditional Medicine

Traditional medicine exists alongside the National Health System. According to the WHO, ‘traditional medicine is the sum total of knowledge, skills and practices, used in the diagnosis, prevention or elimination of physical, mental and social illnesses, based exclusively on past experiences and observations handed down from generation to generation, orally or in writing’ (Ministry of Health 2015).

According to the Ministry of Health, around 70 per cent of the people in Mozambique use traditional medicine to treat physical, as well as mental and social, illnesses. The activity engaged in by traditional medicine practitioners, estimated at a ratio of 1 practitioner per 200 inhabitants, has more coverage of primary health services than the National Health Service.Footnote ⁵ This explains why there are still people in Mozambique who are born, grow up, and die using only traditional medicine for their healthcare. This fact is due, on the one hand, to the still poor geographic coverage of the National Health Service and, on the other hand, the intrinsic connection existing between traditional medicine and the defining traits of its users.

During colonial times, traditional medicine was perceived as associated with a lack of knowledge or superficial knowledge, superstitious, and based on folklore. Immediately after the proclamation of independence, the government of Mozambique recognised the importance of traditional medicine. In fact, Article 38(7) of the first decree-law of the government (Decree-Law No. 1/75, of 29 July), states: ‘Boost medical and pharmacological research and, particularly, studies on traditional medicine’. Since then, traditional medicine has been gaining ground and consideration in government policies. In 1977, the Office of Traditional Medicine Studies was set up under the Ministry of Health. In 2010, the Office of Traditional Medicine Studies was closed and gave way to the Traditional Medicine Institute, also set up under the Ministry of Health.Footnote ⁶

Despite these advances, the reality is that little is yet known about Mozambican traditional medicine (Tables 6.1 and 6.2).

F The State of Health of Mozambican People

The state of health of the majority of Mozambicans is precarious. The burden of disease is high. Endemic infectious diseases predominate, such as malaria, tuberculosis, AIDS, respiratory infections, diarrhoeal diseases (including cholera), and intestinal and bladder parasitosis, with the last three being very closely linked to access to drinking water and environmental sanitation.

Mozambique is one of the five countries in the world with the highest prevalence of tuberculosis (551 cases/100,000 inhabitants, compared to a world average of 140 cases/100,000 inhabitants) and among the 10 countries in the world with the highest prevalence of AIDS. Data for 2015 indicate that the overall prevalence of AIDS in people aged 15 to 49 was 13.2 per cent. Among women, it was 15.4 per cent versus 10.1 per cent for men, and AIDS is more prevalent in urban areas (16.8 per cent) than in rural areas (11.0 per cent) (Ministry of Health et al. 2013; Ministry of Health et al. 2018). Cholera is endemic, with outbreaks practically every year, varying only in the part of the country it appears. A study carried out between 2005 and 2007 and encompassing over 80,000 school-age children revealed a generalised occurrence of bladder infection caused by Schistosoma haematobium (national prevalence of 47 per cent) and intestinal helminths (national prevalence of 53.5 per cent) (Augusto et al. Reference Augusto, Nalá, Casmo, Sabonete, Mapaco and Monteiro2009). These diseases, related to lack of access to drinking water and basic environmental sanitation, are responsible for a higher number of deaths than malaria and AIDS combined. Mozambique is one of the few countries in the world where leprosy still exists.

At the same time – and as is the case in other African countries – an epidemiological transition is underway. Thus, the incidence and prevalence of non-communicable diseases, particularly high blood pressure and other cardiovascular diseases, diabetes, chronic respiratory diseases, cancer, and trauma (especially road traffic accidents) is increasing inexorably. A study on cardiovascular risk factors carried out in 2005 shows a high prevalence of high blood pressure (34.9 per cent).

Data from the UNICEF Annual Report 2019 entitled The State of the World’s Children 2019: Children, food and nutrition (UNICEF 2019) indicate that Mozambique has one of the highest rates of child malnutrition in the world (43 per cent of children under five suffer from chronic malnutrition and 8 per cent from acute malnutrition). Chronic malnutrition increases the morbidity and mortality rate in children aged under five and reduces their cognitive abilities. The same report reveals that, for the first time in many years, Mozambique reported cases of pellagra, a disease linked to niacin (vitamin B3) deficiency.

Other indicators reflecting the deficient nutritional situation of Mozambicans are the following (Ministry of Health et al. 2013; Ministry of Health et al. 2018):

• Fourteen per cent of newborns (whose birth weight was registered) weighed less than 2.5 kg at birth (underweight);

• Sixty-four per cent of children under five, and 54 per cent of pregnant women, were suffering from anaemia;

• in 2011, only 45 per cent of the families questioned used iodised salt;

• in 2015, the exclusive breastfeeding rate was only 55 per cent.

Mozambique is among the countries in the world with the highest birth rates (five children per woman) and gross mortality (11.8/1000 inhabitants) and a low life expectancy (53.7 years). Maternal mortality (452/100,000 live births) and infant mortality (68/1,000 live births) are also very high (INE 2019).

A Rule of Law and Judicial Independence

Despite it being enshrined in the constitution, Mozambique is still far from being a state under the rule of law.

With regard to the health sector, there are several factors – mainly related to non-compliance with the laws in force – which contribute to this:

• The process of contracting companies to carry out public works (such as building health centres, hospitals, human resource training centres and institutes, warehouses, housing for healthcare staff, etc.), as well as the acquisition of medicine, medical supplies, hospital equipment, and the like (such as ambulances), is very often done on the fringes of the law. There is frequent, abusive, and illegal recourse to what is called private treaties to the detriment of public tenders. This all leads to the construction of poor-quality buildings, the acquisition of medical supplies and equipment of inferior quality, and the unlawful siphoning of money to dishonest business people.

• In clear breach of the law, the processes of selecting people for jobs are frequently carried out without being offered for public tender. This gives rise to this selection being based on party political affiliation, nepotism, friendships, ethnic identity, and even the provision of sexual favours.

• With regard to promotions and career progression, it is common for the time periods provided for by law not to be complied with, allegedly due to budgetary restrictions.

• These practices are also contributed to by the fact that both trade union organisations (such as the Medical Association of Mozambique) and socio-professional organisations (such as the Medical Council and the Nursing Council) are weak and not very proactive.

The fact that these irregular situations persist – despite being frequently reported in the media and the repeated criticism in the annual report from the Administrative Court (Court of Auditors) to the National Assembly – gives citizens the feeling that the culprits can get away with anything because of the state’s lack of political will, calling the legitimacy of that very state into question in the eyes of its citizens.

B Voice, Participation, and Accountability

• Although it is provided for and heralded in the Constitution of the RepublicFootnote ⁷ (Articles 89 and 116) and in the Charter of Patient Rights and Responsibilities,Footnote ⁸ the right of citizens to healthcare is not clarified or sufficiently protected.

• In the National Health Service – and in clear breach of Article 116(4) of the Constitution – citizens are discriminated against by the state on a socio-economic basis. All but one of the central and provincial hospitals have special clinics, special consultations, and private rooms that are off limits to anybody who cannot pay the prices stipulated. It should be noted that there is no legal basis for the existence and operation of these special clinics, special consultations, and private rooms. All attempts made to close these special clinics, special consultations, and other special services have been thwarted due to resistance linked to the combined interests of the doctors, on the one hand, and the political and economic elite on the other.

• Even in the services considered to be free by law, citizens are frequently subject to unlawful charges.

• The involvement of citizens and communities in the management and monitoring of health sector activities is very poor. Despite there being regulatory documents on the connection between the health sector and the communities, it is the norm for there to be no accountability to citizens regarding health activities. The citizens know little or nothing about the annual budget for the health sector, from its preparation to resource allocation priorities and how these resources are spent. This is one of the reasons explaining why the Ministry of Health budget favours allocations to:

  1. a) central and provincial bodies to the detriment of district bodies, where primary healthcare takes place;

  2. b) spending mainly on curative actions to the detriment of health promotion and disease prevention actions; and

  3. c) money spent on needless bureaucracy (travelling abroad with the corresponding travelling expenses, expensive meetings at hotels and tourist resorts, acquisition of cars for leaders) to the detriment of the acquisition of medicine and medical supplies and equipment and ambulances that would improve the quality of healthcare.

• Particularly in rural areas – and because of fear of reprisal – citizens are afraid to report any abuses by health workers, such as absenteeism, non-compliance with schedules, ill-treatment, and unlawful charges.

C Political Instability, Violence, and the Legitimacy of the State

Over forty years after the proclamation of independence, the National Health Service still does not cover the entire country or respond to the basic needs of all citizens, both in cities and towns and in rural areas. As previously mentioned, there are three causes:

1. a) the colonial legacy;

2. b) the destruction of hundreds of health units during the war that ravaged the country between 1976 and 1992; and

3. c) the difficulty in moving forward more quickly, both in the replacement of the infrastructures destroyed and in the building of new infrastructures, due to the lack of human resources and financial constraints.

After a twenty-year period of calm, political and military instability re-emerged in the centre of the country in 2013. To further aggravate the situation, in October 2017, a military conflict broke out in Cabo Delgado Province, the cause of which is still not clear, and which is tending to spread.

The political and military instability:

• has negative repercussions on the lives of the people in towns and rural areas (where physical safety has been threatened and economic activities paralysed);

• negatively affects activities in the health sector and leads to stagnation or to setbacks in many health indicators. Two concrete examples of this negative impact are the temporary cessation of health promotion and disease prevention activities;

• ultimately calls the legitimacy of the state into question, either because the state cannot protect its citizens or because it does not assure the provision of basic health services, drinking water, basic sanitation, education, etc. in adequate quantity and quality.

D State Capacity and Independence from Private Interests

Since 1975, the government of Mozambique has generally outlined appropriate policies for the health sector. The main problem lies in the weak capacity of the state to assure the implementation of these policies. There are many examples of this deficient implementation and the following are of particular importance:

E Sovereignty and Independence

Now more than ever, it is clear that Mozambique needs help from the international community to improve the provision of quality healthcare to its citizens, especially the poorer ones. However, it is equally clear that this help must be given correctly to ensure that it does not have the opposite effect to what is intended.

Unfortunately, facts show that in the last thirty years, the government of Mozambique has not defined the public health policy independently. This applies both to the definition of priorities and particularly to the preparation of the budget for the health sector. The health policy is defined more by the international community (the cooperation partners or donors) than by the government of Mozambique.

This is the case because the international community (a) makes the largest financial contribution to the health budget and (b) orders and funds the ‘consultations’ where the diagnosis of the health sector is made and where health policy proposals are presented. It is based on these ‘consultations’ ordered and paid for by the international community that the government of Mozambique is pressured into prioritising selected strategies, programmes, and activities ‘proposed’ by the donors, not always coinciding with the strategies, programmes, and activities that are really a priority for improving the state of health of Mozambicans. We will cite examples of the negative role the cooperation partners play in the health sector in Mozambique.

First, human resources. Sufficient well-trained human resources are of vital importance for the correct operation of any health system. The shortage of human resources undermines the capacity of the health system to meet the health needs of the population. In Mozambique, the shortage of human resources is the biggest weakness of the National Health Service. Unfortunately, this shortage is aggravated by health workers (especially those more qualified and/or more experienced) leaving the National Health Service for work at embassies, NGOs, cooperation partner agents based in Maputo, and the private for-profit sector.

The main reason for this, but not the only one, is that these organisations pay higher salaries than the government. This is an internal brain drain, as opposed to the brain drain out of Mozambique. In Mozambique, the internal brain drain is at least three times higher than the brain drain out of the country. In other words, recruitment practices by the donor community in Mozambique undermine and weaken the National Health Service that this community claims it wants to strengthen.

At the same time, the macroeconomic policies imposed on Mozambique by the World Bank and by the International Monetary Fund mean there are tight limits to the contracting of human resources for the health and education sectors by the government. This is why, over the last fifteen years, the government has been unable even to hire and employ all of the doctors, nurses, and other health workers trained in Mozambique.

Secondly, almost all of the cooperation partners decided to channel the largest slice of their financial resources not into the National Health Service (which provides healthcare to over 90 per cent of the population), but rather to NGOs and other partners dedicated to the so-called vertical programmes for fighting diseases. While this is motivated in part by corruption, already discussed above, it leads to overlapping competencies adding another source of inefficiency.

These vertical programmes, dedicated at the most to three diseases or a specific segment of the population (such as mother and child health), and with bottom-up dynamics, contribute to the weakening of the public health sector due to the duplication of efforts, the distortion of national health plans, the ‘thefť of scarce human resources, and the chronic underfinancing of the National Health Service.

In addition to the above – and because the ultimate causes of diseases are not properly taken into account – these vertical programmes for combating diseases have a limited impact on improving the health conditions of poorer citizens and communities, despite the hundreds of millions of US dollars invested each year by the international community in health in Mozambique.

Thirdly, it is important to mention another nefarious aspect of the World Bank’s policy. From the 1980s, the World Bank began demanding that all developing countries should introduce user fees as an option for funding health services. It is now agreed that user fees punish the poor and constitute an obstacle to access to healthcare by citizens. According to the WHO, user fees are ‘the most unequal way of funding health services’ (OXFAM 2013: 11). Worldwide, around 150 million people incur financial catastrophe due to direct payments for healthcare, while 100 million are being pushed into poverty, the equivalent of 3 people per second (OXFAM 2013). Although the WHO has already taken a clear stance against user fees and the World Bank has issued a mea culpa (see the speech of the then president of the World Bank, Jim Yong Kim, at the World Health Assembly in 2013), the reality is that user fees persist in Mozambique.

Finally, it should be pointed out that the majority of the reforms and strategies proposed for the health sector by the so-called cooperation partners are unrealistic given the poor economic capacity of the country and because the cooperation partners are not willing to provide the necessary funds for the policies they themselves advocate as the most correct for Mozambique. There are many examples, the most important of which is the much-acclaimed universal health coverage, which is a constant in speeches by the World Bank, the WHO, UNICEF, and others in the United Nations and in other international forums. This is how a situation is created where a poor country like Mozambique is eternally ‘plagued’ by serious problems in terms of the credibility of the health sector arising from the poor quality of the healthcare provided.

The question that naturally arises is: what causes this state of affairs?

The starting point is that it is the political process, which determines the type of institutions existing, and that it is the institutions (mainly political), which influence how this process operates. It is the political institutions of a nation, which define the capacity of its citizens to control the politicians and influence their behaviour. In turn, this determines whether the politicians are representatives and defenders of the rights of the citizens who elected them or if they have the ability to abuse the power entrusted to them to achieve their own ends, even if this is to the detriment of the majority of the citizens.

Mozambican society is a profoundly unequal society, divided between a privileged minority that holds the reins of political and economic power and ‘the others’, that is a vast majority of poor, disadvantaged, and marginalised citizens, who have little capacity of controlling the actions of the political leaders and very little influence on the determination of the fate of the country.

The final cause explaining the weakness of the institutional factors with an impact on the health sector and, very particularly, on the poor capacity of the Mozambican state to prioritise the public health sector (which as we have seen is responsible for the healthcare provided to over 90 per cent of Mozambicans) lies in the lack of political will of the political leaders to put the satisfaction of healthcare needs in the poorer segments in first place. These leaders are part of, or have close connections with, the privileged minority groups in society, who relegated the public health sector to second place, largely because their own healthcare needs are met by going to organisations (such as hospitals, clinics, rehabilitation centres, etc.) abroad or, when this is not possible, the national private sector.

Another no less important aspect lies in the fact that in Mozambique there is limited and deficient understanding of the problems in the health sectors among political leaders, citizens, and the so-called civil society. There is confusion between the narrow concept of curative medicine and the broader concept of health and public health at all levels of Mozambican society. This results in the healthcare being predominantly curative and revolving around procedures in health centres and hospitals, with the consequent subordination of the promotion of health, the prevention of illness, community participation, and inter-sector cooperation. This is called medicalisation of healthcare. At meetings between the people and politicians, requests from the citizens revolve around the construction of more hospitals and maternity hospitals or at least requests for ambulances. This lack of knowledge results in there not being more interest or political merit in the promotion of public health on the part of political leaders.Footnote ¹¹

At the same time, both the opposition leaders and the majority of civil society organisations (including the media) do not give due priority to or show any ability to present concrete solutions for the most pressing health problems for the majority of Mozambicans.

To give an example, a Mozambican opposition force has never presented a duly prepared document on (i) the deficient implementation of the primary healthcare policy, (ii) the chronic underfinancing of the health sector, (iii) the inequities in health, (iv) the discrimination that poorer Mozambicans are subject to, even in the public health sector, the problem of leprosy (whose elimination in Mozambique was proven by the WHO in 2009, only to resurge due to the negligence of the government), or, (v) finally, on a coherent policy for the relationship of the government with the foreign donor community for the health sector.

The disputes and ‘contradictions’ between the party in power, on the one hand, and the opposition forces, on the other, revolve mainly around the sharing of resources by the different factions of the privileged elite.

It is interesting to note that these ‘contradictions’ always disappear when, for example, parliament is discussing increases in salaries and the allocation of more privileges to different party representatives. On these occasions, unanimity is the rule that has never been broken.

Finally, in Mozambique, the executive power controls and dominates both the legislative power and the judicial power. Under these conditions, there are no checks and balances, which would perhaps make the elite in power take interests other than their own into account.

These are the institutional factors that ultimately explain the poor performance of the health sector, particularly in the quality of the healthcare provided to the majority of poor, disadvantaged, and marginalised citizens.

A The Nosological Point of View

Over at least the next two decades, the burden of disease will continue to be very high in Mozambique. Although there is a trend towards a reduction in their incidence and prevalence, the infectious diseases referred to above (diarrhoeal diseases, respiratory illnesses, intestinal diarrhoeal diseases, schistosomiasis, tuberculosis, malaria, and HIV-AIDS) and child malnutrition will continue to predominate, all linked to the poverty that affects the majority of Mozambicans. At the same time, with the growth of the so-called middle class and the adoption of new and harmful lifestyles by an increasing number of Mozambicans (such as sedentarism, smoking, exaggerated and uncontrolled consumption of food high in fat, of alcohol, of soft drinks and sugary drinks, etc.) will continue to increase the incidence of non-communicable diseases.

If there is political will and better organisation, it will be possible to eliminate and then eradicate leprosy ad then substantially reduce the prevalence of other diseases that are now neglected, such as trachoma, lymphatic filariasis, scabies, and rabies.

B The Institutional Point of View

As previously mentioned, the Mozambican state is characterised by the weakness of its institutions, particularly political ones, which:

• on the one hand, make them vulnerable to the private interests of the privileged minority and the pressure from foreign organisations, whether international (the World Bank, the International Monetary Fund, etc.) or governmental, which, as we have seen, are commonly called cooperation partners; and

• on the other hand, they limit their capacity to respond adequately to the material and spiritual needs and desires of the majority of Mozambicans.

Ultimately, the aim is for there to be strong institutions in Mozambique, capable of outlining a health policy that puts the needs of the majority of its citizens in first place, provided with effective regulatory capacity, capacity to suppress all forms of crime, capacity to negotiate with the cooperation partners and make the interests of Mozambicans prevail, and that contribute towards balanced political, economic, and social development in the country.

With regard to the health sector, the ultimate aim is the provision of quality, free healthcare to all Mozambicans, without any economic, social, racial, ethnic, sexual, religious, or geographic discrimination.

Even in a country as poor as Mozambique, it is possible to advance progressively towards quality, free healthcare at all levels, and not just basic healthcare. Obviously, this is a long-term process, but it all depends on political will, a clear definition of what the priorities are and what can be achieved in health sector at each stage and the sustained implementation of an economic and social policy that will reduce poverty levels, as well as economic and social inequalities.

The crucial question is: how can this goal, which is as noble as it is ambitious, be achieved?

Our proposal focuses on six priorities:Footnote ¹²

1. 1 – Enshrining clearly in the constitution that: a) all Mozambicans have the right to quality, free public healthcare at all levels of care, without any economic, social, racial, sexual, religious, or geographic discrimination; and b) it is the responsibility of the government to progressively assure universal health coverage in Mozambique.

2. 2 – Based on the experience of other countries that made advances in political and administrative decentralisation, introducing changes to the structure and operation of the public health sector. One example that is a good source of inspiration is the Unified Health System (SUS) in Brazil, a country with social and anthropological characteristics similar to Mozambique.

Here, it is important at least to:

• Legislate the separation between the Ministry of Health (regulatory body) and the National Health Service (implementing body) with different budgets.

• Legislate the links between the National Health Service and the health services in municipalities and other local authorities.

All the aspects mentioned above should be contained in a law that defines a National Health Policy suitable for the next five decades, to be approved by the National Assembly (Parliament).

1. 3 – Clearly defining how to progressively increase funding for the public health sector so that – as recommended by the WHO – the goal of at least US$60 per inhabitant per year for health sector expenses is achieved by 2050. To do this, the government must:

   • Implement the Abuja Commitment (Nigeria) of allocating 15 per cent of the state budget to health instead of the present 8 per cent.

   • Institute a specific health tax (for example, through an increase in current taxes on tobacco, alcoholic drinks, soft drinks, luxury products like jewellery, cosmetic, perfume and cars, and charge a percentage fee on each airline ticket sold in the country).

   • Change the priorities in the health budget so that at least 50 per cent of the governmenťs health expenditure is allocated to districts and 25 per cent to primary healthcare.

   • Eliminate user fees and other forms of direct payment for the healthcare provided by the public sector.

   • Harmonise the different mechanisms for funding health under a universal coverage framework.

   • Be guided by austerity and strenuously fight against needless expenditure.

   • Significantly improve budget management at all levels.

It is important to clarify here that a national health insurance system set up and run either by the state or by private entities is not presently a viable option for Mozambique. And the reason is simple: Mozambique is one of the poorest countries in the world and with over half the population living on less than US$2 per person per day, who would pay that insurance?Footnote ¹³

On the other hand, we see no reason why private health insurance should not exist for the citizens who wish to have their healthcare provided by private health organisations.

1. 4 – Implementing the primary healthcare policy nationwide, comprehensively and at all levels of healthcare. To do this, the government must:

   • Progressively strengthen the National Health Service, which is the main subsystem of the National Health System.

   • Give due priority to health promotion and disease prevention activities, rehabilitation, and palliative care, as well as curative activities.

   • Implement effective coordination between the Ministry of Health and other sectors (Ministries, local authorities such as municipalities, NGOs, religious persuasions, unions, etc.) whose activities have an impact on the state of health of Mozambicans. As explained above, the health sector alone cannot assure an improvement in the state of health of Mozambicans. Many other sectors of governance and society play a crucial role in the improvement of living conditions – and, through this, the improvement of health conditions – of the people, through the provision of diversified food in quantity, drinking water, environmental sanitation, housing, transport, quality education, etc. The implementation of this inter-sector coordination should be inspired by the experiences in other countries.

   • For inter-sector coordination to be effective and efficient, it must be institutionalised. It is under this framework that an Inter-Sector Health Coordination Council (CCIS) should be set up, a body whose mission will be to ensure inter-sector coordination, with the aim of taking concerted action on the social determinants of health at the different levels. It is important to specify the mission, the tasks, and the composition of the CCIS.

   • Give priority to community participation. Community participation has two main aspects: (a) the right and duty of each citizen to participate individually and collectively in the planning and implementation of the healthcare aimed at them; and (b) the need for the entities responsible for the provision of healthcare to be accountable to the citizens (or their representatives) for their actions.

 In this framework – and based on the experience of other countries, such as Brazil (Cornwall and Shankland Reference Cornwall and Shankland2008) and Thailand (Rasanathan et al. Reference Rasanathan, Posayanonda, Birmingham and Tangcharoensathien2011) – community participation must be institutionalised through the set-up of bodies at all levels responsible for ensuring increasing involvement by the citizens and communities in health sector activities.

1. 5 – Boosting the activities of the Traditional Medicine Institute.

   Given the importance and the potential of traditional medicine in the provision of healthcare to Mozambicans, the government must further bolster the activities of the Traditional Medicine Institute, providing it with financial resources and qualified human resources at all levels. The Traditional Medicine Institute, working closely with the National Health Institute, must base itself on the experience of other African countries, as well as the experience in Asian countries (like China, Vietnam, North and South Korea, etc.) to define the best ways to stimulate research into traditional Mozambican medicine, seeking ultimately to make the most of its enormous potential.

2. 6 – Engaging the international community in the efforts with the aim of improving the quality of healthcare in Mozambique.

Such engagement implies, first, progressively reducing interference from cooperation partners in the formulation of health policies and the implementation of sovereign decisions made by Mozambicans.

On the other hand, if the international community does in fact want to help improve the quality of healthcare in Mozambique – so that the much-heralded universal health coverage that enshrines the values of universality, equity, and solidary can be achieved – it should undertake the following actions:

• Allocate a larger proportion of closely monitored aid in the form of direct support for the National Health Service budget. Government-to-government aid through direct support for the state budget or the Ministry of Health budget is the best way of helping the government of Mozambique to achieve the aim of universal health coverage.

• Cease the promotion of inappropriate approaches in the name of universal health coverage, especially vertical programmes.Footnote ¹⁴

• Help the government of Mozambique to make equity and universality explicit priorities from the outset. It is fundamental that poor people (i.e. the majority of Mozambicans) benefit at least in the same way as better-off citizens, at all stages.

• Help the government of Mozambique to measure and assess the progress and results of the actions aimed at universal health coverage, especially equity.Footnote ¹⁵

• Take steps to combat the tax evasion that prevents Mozambique from having access to the financial resources that are so necessary in order to ensure quality healthcare for all Mozambicans.

• Honour their commitment to allocate at least 0.7 per cent of their gross domestic product (GDP) to official aid for the development and improvement of the effectiveness of aid to the health sector.