Likened to the Tower of Babel legend, the Mozambican national health system speaks several languages and pursues a range of different interests, answering to a number of partners and other bilateral and multilateral actors who all have some kind of circumstantial and contextual interest. When the Paris Declaration on Aid Effectiveness was endorsed, Mozambique may have been the kind of case they had in mind. Various donors are clearly and tacitly incorporated into the country’s health system, which coexists with their conflicting interests and diverse views on how it should be structured and financed.
Thirty-years of external influence on the national health sector
For the last 30 years countries defining themselves as “friends of Mozambique” have imposed their specific priorities for the health sector. Employing the jargon of the development sector, in the name of ‘alignment’, ‘standardisation’, ‘efficiency and effectiveness’, ‘technical assistance’, ‘capacity-building’ or ‘coordination’, countries have come together and formed collective pressure groups to push forward their perspectives on how the national health system should be structured. These groups also propose what type of priorities should be taken forward in a ‘unified plan’ to be financed by ‘common mechanisms’, like a ‘common health fund’. There are often multiple versions of the plan, with the frequency with which they are updated (e.g. Health Common Fund I, II and III in the space of 12 years) demonstrating how easily the proposed models become irrelevant. This highlights a real lack of approaches that are both long-term and clearly grounded in the Mozambican health system.
Lack of an effective common fund approach
Disputes over accountability, delays and unpredictability in the transfer of funds, challenges with coordination and alignment, a high level of staff turnover (within both donor agencies and the Ministry of Health), the global financial crisis, Mozambique’s own financial crisis resulting from an illicit debt scandal; and changes in global health financing policies have all culminated in the hollowing-out of the common fund approach. At the same time, Mozambique has failed to construct a solid and sustainable foundation for the financing of the health sector that could underpin a holistic health system.
Meanwhile, in a truly neoliberal market where actors compete to sell their products, there are donors who use the inflexibility of domestic politics in their countries of origin to ‘protect’ their lines of funding. They keep their resources away from the ‘basket fund’, maintaining and preserving the existence of vertical (off budget) lines of health system financing. The volatility of health sector financing models in Mozambique is directly linked to institutional instability and structural inconsistencies.
Little commitment for a long-term and shared vision of the health agenda
The health agenda suffers from seasonal fluctuations in implementation, with little commitment to learning from past mistakes, and little shame about the continual reinvention of the wheel by each incoming administration. The most senior positions are unstable and highly politicised, influenced by political loyalties and even personal links with whoever is in power at any given moment, and there is a culture of subservience among those occupying key roles. All this, in addition to the pressure exerted on the scarcely qualified and precariously remunerated human resources, creates a system with a high turnover of staff. A further brain drain of public sector staff who leave for jobs in funding agencies and international NGOs, makes it hard to consolidate the system and means that institutional memory is lost.
Without this, it is easy to keep accepting the multitude of proposals that are repetitive and pushed forward by the same partners who come onto the scene under the guise of ‘health systems strengthening’. Over the last 20 years, there been more than a dozen programmes that aimed to strengthen the health system: initiatives to strengthen financial management systems; to strengthen information systems; to strengthen recruitment systems; to develop human resources; to improve lab logistics, and more – and that is not to mention the disease-specific programmes.
How can the Government step up and assume more responsibility?
The limited level of investment of the Mozambican government’s own resources in social sectors, such as health, is particularly glaring when compared to the funds that it allocates to the military, to the defence of national sovereignty and to strengthening the state’s apparatus of repression. The argument that the country doesn’t have resources to spare seems to be convenient and strategically framed to drum up ‘compassion and solidarity’ from the donors, who then take the lead in the health sector.
At the same time, the Mozambican government is relegated to a minimal regulatory role, reproducing the situation in which the country’s health planning and management system is effectively headless. As long as the Mozambican state doesn’t take responsibility for the effective leadership and regulation of the national health system, the country will continue to be a perfect and privileged playground for donors wishing to try out different models and approaches to health, subject to the whims of a multitude of self-interested donors who can freely carry out their investments and experiments in a country where a shared vision and structured framework for investment in health are non-existent.
In a context that is culturally defined by the coexistence of multiple pathways to health, such externally-driven programmes have limited potential to respond to supposedly overarching ‘multi-annual objectives and goals’, and guarantee slow progress in reducing inequalities of access to and use of health services, in improving quality and in ensuring universal coverage.