Health system structure

 The Ministry of Health (MISAU) is responsible for health policy and prioritisation. It develops national health guidance and policies and is responsible for their implementation and for monitoring their progress. It is also responsible for providing the necessary materials, equipment and training for health staff to fulfil their responsibilities.

In Mozambique the public health sector is a six-tiered pyramid system: Hôpital Central, Hôpital Provincial, Hôpital Général, Hôpital Rural, Centro de Saude, Posto de Saúde. Health service provision is by health district and can be divided into four key groups: 1) The public sector, grouped under the National Health Service (Serviço Nacional de Saúde -SNS) is the most accessible, geographically.

 The SNS is organised into four levels of service provision. Level I is the most peripheral and includes both rural and urban health centres and health posts. These health facilities provide a package of primary health care services, have very limited laboratory capacity, and usually have a maternity ward but do not provide other inpatient services. According to a 2004 World Bank Report, Level I facilities represent at least 40% (MISAU, 2013) of all health services and are typically the first point of contact with the health system for a large portion of the population, with the exception of areas that are serviced by community health workers.

 Level II is composed of the district, general, and rural hospitals, which may serve more than one district, and represent the primary referral level. Levels I and II are devoted to providing primary health care. Level III consists of provincial hospitals, which in addition to offering curative and diagnostic services also act as training centres for MoH staff. Finally, Level IV is made of the country’s three referral hospitals in Maputo, Beira and Nampula, serving the southern, central and northern regions respectively. Access to the SNS network is limited and it is estimated that only 60% (ibid) of the population had access to health services in 2010. 

Excluding the urban zone of Maputo, the reference population for each primary care health unit (unidade sanitária – US) exceeds 17,000 persons. 2) The growing private sector is limited to major cities and formed of two groups: for-profit – found almost exclusively in urban areas, such as Maputo, Beira and Nampula – and not-forprofit, the latter group having strong ties to the public sector and largely run by faith-based organisations. Public access to retail outlets and pharmacies for malaria treatment is largely dependent on easy physical access to community health workers or US (NMCP, 2015). 3) Community Health Workers (agentes polivalentes elementares – APEs) provide basic services in areas where access to the SNS infrastructure is limited, and are paid a basic stipend by MISAU.

 The APEs provide preventive and basic curative services, including malaria diagnosis (using rapid diagnostic tests, or RDTs) and treatment (with artemisininbased combination therapy, or ACT). As such, it is an important component of Mozambique’s malaria case management plan. Agentes polivalentes elementares serve as the first line of defence against malaria for people living in rural Mozambique, and for many people are the only opportunity to receive proper diagnosis and treatment for malaria. 

The President’s Malaria Initiative’s (PMI) support for the APE programme has focused on the provision of RDTs and ACTs for the kits used by APEs for community case management, and limited central support to continue the expansion and training of APEs throughout the country. The GFATM also contributes support for these activities. Up until November 2015, 2,300 of the total targeted 3,600 had been trained. They are currently reporting through a parallel system to the HMIS but will be absorbed in to the new DHIS2 system. 4) Lastly, practitioners of traditional medicine (PMT), widely accepted by the communities, offer non-allopathic medicine (MISAU, 2013).

Malaria control in the public health system is implemented at three administrative levels: central, provincial and district. The NMCP is the central level, but challenged by understaffing with many of the existing staff being over-stretched as a result. Each province has a provincial malaria focal point, who is responsible for coordinating the implementation of malaria control activities at that level. In 2013, district malaria focal points were created and are responsible for all malaria control activities at district level and improving data management and reporting for malaria at district level (PMI-MOP, 2015; RBM, 2013).

 Mozambique has had one of the highest rates of under-5 mortality in the world (79/1000) (World Bank-IDA, 2016), but has made substantial progress towards achieving MDG 4 (to reduce the U5MR rate by two-thirds between 1990 and 2015) since 2000; nationally, the rate fell from 226 per 1000 livebirths in 1990 to 97 per 1000 livebirths reported in the 2011 Demographic and Health Survey (DHS) (Fernandes et al., 2014; MISAU, 2011).

 More than 75% of deaths in children under five years of age in Mozambique are caused by infectious diseases, with more than 60% attributable to malaria (42.3%), HIV (13.4%), and pneumonia (6.4%) (Mazive et al., 2009). The health policy framework for Mozambique is articulated through the government’s five-year plan (Plano Quinquenal – 2010-2014), the Action Plan for the Reduction of Poverty (Plano de Acção para Redução da Pobreza – PARP 2011-2014) and the annual National Economic and Social Plans.

The Sector Strategic Plan comprises seven objectives and is based on principles of primary health care, equity and better quality of services:

 • Increase access and utilisation of health services 

• Improve quality of service provision 

• Reduce geographic inequities and between different population groups in accessing and utilising health services 

• Improve efficiency on service provision and resource utilization; 

• Strengthening partnerships for health 

• Increase transparency and accountability on management of public goods; • Strengthen the health system.