Mozambique: staying alive/IPS MS Solidarity 2000-News/

The High Cost of Staying Alive

By Antonio Gumede

MAPUTO June 2000 (IPS) - Whoever coined the phrase "life begins at 40" did not certainly have Mozambique in mind. With a life expectancy at birth of 42.3 years in 1997, the equivalent adage for Mozambique could be phrased as "life ends at 40".

In theory Mozambique allocates a substantial proportion of state expenditure to public health services - 13 per cent. However, given the fact that total annual state expenditure does not exceed US$ 500 million the actual amount allocated to health care is not enough to meet the health services needs of the country's 17 million inhabitants.

The fragility of the health delivery system is reflected in its vital indicators. Mozambique's infant mortality rate of 145.7 per 1,000 thousand live births and maternal mortality of 1,067 for every 100,000 births are amongst the highest in the world, and reflect the level of poverty which affects 69 per cent of the population.This means that 12 million Mozambicans survive on less than US$ 1 per day.

Although it has improved significantly after the country's independence in 1975, Mozambique has never been famous for having a sound health delivery system. The civil war that broke-out in 1976 and ended with in 1992 the signing of the peace agreement between the government and the Renamo rebel movement in Rome, Italy, left an already fragile health system in tatters.

Thousands of health units were destroyed and are now being rebuilt, but the country is yet to bring its health system network to pre-war level. The reconstruction effort has improved the access to health services but it is still far from satisfying the needs of the population.

In 1999 total health units numbered 1,155 of which 66 per cent were primary health units, 30 per cent secondary centres and 3.8 per cent hospitals. The whole country had just 519 ambulances and only 912 refrigerators to conserve important medicines such as vaccines and blood for transfusion in 1998.

There were 8.6 hospital beds per 10,000 inhabitants, and 5.9 health technicians for every 10,000 people. Only 35 per cent of the estimated 761,248 births in 1998 took place in health institutions with qualified personnel.

A substantial portion of the country's needs in drugs, estimated at more than US$ 50 million per annum, is acquired with foreign aid. The lack of financial and human resources have had a negative impact on the quality of the services, where these are available.

Medical doctors and nurses are generally overworked and underpaid: a medical doctor in public hospitals earns the equivalent of US$ 250 per month forcing most to seek alternative employment in the private clinics that have mushroomed since the liberalisation of the provision of medical services in the early 1990s.

The salary in private clinics ranges from US$ 500 to $700 per month. Private clinics provide a personalised services at a cost: a consultation at private clinic may vary from US$ 25 and US$ 40, in a country where the minimum wage is around US$ 28 per month.

Some clinics offer medical aid scheme at costs varying from US$ 20 and $60 per month per household covering medical consultation but excluding the cost of medication. However, for the upper classes, private health is care inside the country represents a significant improvement when compared to the days when patients had to be flown to neighbouring South Africa, Swaziland and Zimbabwe.

The government's five year plan running from 2000-2004 has taken the improvement of health service as one of the main priorities. The plan envisages the maternal death rate dropping to 100 per 100,000, reduction in the under-five mortality rate from 246 per 1,000 to 170 per 1,000 and to increase the coverage rate of institutional births to 50 per cent.The plan also aims at continuing to the expansion of the health network.

According to the plan 81 new health units will be built during the period while efforts will be made to increase the number of qualified health professionals. Around 4,000 new health technicians will be trained during the period while 72 medical specialists will be trained in the areas of gynaecology, surgery and anaesthetics.

However, these efforts may not be realised because of the AIDS pandemic. The Ministry of Health estimates that 14.5 per cent of the adult population is infected with the HIV virus that causes AIDS and the rate of infection is likely to increase reaching 20 per cent of the adult population in 10 to 15 years.

The government estimates that by 2010 the new number of cases will have risen to around 200,000 and life expectancy, which is already considerably, may fall to 35.4 years. The impact of the disease on an already fragile and over-stretched health delivery system will place additional constraints to the access to health care, particularly for the most vulnerable groups.