Strengthening Primary Health Care with a Community Health Strategy in Mozambique

Mozambique has embarked on a journey to strengthen its primary health care (PHC) services and community health initiatives, through a decentralized governance model since 2019. With support from a collaborative effort between the Global Financing Facility (GFF), Global Fund to Fight AIDS, Tuberculosis and Malaria (GF), United Nations Children's Fund (UNICEF), United Nations Population Fund (UNFPA), World Health Organization (WHO) and World Bank (WB), Mozambique has made progress to meet many of its health goals. According to the Demographic and Health Survey of 2023, the under-five mortality rate improved to 60 per 1000 live births, down from 97 in 2011, and the neonatal mortality rate decreased from 30 to 24 per 1000 live births over this period (1).  Additionally, the maternal mortality ratio in Mozambique has improved from 532 deaths per 100 000 live births in 2000 to 127 in 2020, which is lower than the regional average (2).  Addressing maternal mortality stands as a top priority under the Community Health Strategy (CHS), which aims to diminish mortality rates by promptly identifying risks among pregnant women and ensuring early referrals from the community to health facilities with greater capacity.

Religious sermon on maternal, neonatal and child health at the Rasague Mustafa Mosque, Mozambique.
Credit: The Interfaith Communication Platform for Health.

From the National Health Policy to a Community Health Strategy (CHS)

UNICEF and WHO actively collaborated with the Ministry of Health (MoH) in 2021 to develop a comprehensive CHS and design its pilot implementation, which was subsequently approved by the MoH in 2022. WHO continues to provide technical support for the strategic process, piloting and development of legal documents, while UNICEF offers technical support for the information system, evidence generation, piloting and procurement of equipment for community health workers (CHWs). GFF and WB provide financial support for the implementation of the strategy in specific areas as part of the PHC strengthening program. GF offers financial support for comprehensive implementation of the strategy covering governance, CHW training and education, evidence generation, quality assurance, supervision systems and overall system functionality at both the national and provincial levels. UNFPA supports the training and supervision of CHWs on reproductive, maternal, newborn, child and adolescent (RMNCAH) health services.

This initiative puts a particular focus on the broader context of Universal Health Coverage (UHC), emphasizing the delivery of an essential package of integrated PHC services, community leadership and coordination, as well as the provision of higher quality care through well-trained, consistently remunerated and adequately supported CHWs. WHO is providing technical assistance to the MoH to develop a legal framework enabling the formal recognition of CHWs and providing them the opportunity to receive some form of remuneration. The CHS also complements the National Strategic Health Plan and the Provincial Strategic Health Plans of Tete and Niassa.

A visit by Director General, Dr. Tedros Adhanom Ghebreyesus, during community engagement in Boane District, Mozambique, July 2023.
Credit: Jaime Machel

Scaling up and maintaining community health services

One of the objectives of the pilot was to test the competency-based training curricula for the CHWs. Consequently, the government adjusted its training strategies. Furthermore, it actively solicits feedback from partners at the community level to enhance the performance of CHWs.

The MoH is guiding and scaling up the implementation of the CHS. GFF, GF, WB, UNICEF and WHO, play a pivotal role by financing the expansion plan and the implementation process that aims to gradually cover all 11 provinces.

Furthermore, collaboration with parliamentarians played a crucial role in advocating for increased resources for primary and community health services, encompassing investments in health determinants and advancing UHC. During CHS implementation, WHO delivered introductory training sessions to provincial parliamentarians in Niassa, Tete and Maputo on SDG targets, UHC, and enhanced their ability to analyze health budgets and expenditures. On average, these sessions were attended by 40 to 60 parliamentarians from two key commissions: the Commission for Health and Social Affairs and the Commission for Finance and Budget. The training significantly bolstered the parliamentarians' capacity to oversee and comprehend the challenges within the health sector at the subnational level. It also emphasized the importance of integrating health considerations into all policies at the provincial level.

Summary of contributions by specific SDG3 GAP partners to the Community Health Strategy in Mozambique

Moving forward

Various challenges persist in the implementation of the CHS, stemming from a range of factors, such as extreme weather events, including cyclones, floods and droughts, which lead to the internal displacement of people and the disruption of health services. The PHC network must be bolstered, by ensuring there are enough skilled staff, essential medicines and supplies available – especially for vulnerable groups like children, pregnant women, the elderly and adolescent persons. Strengthening this network would increase equitable coverage and access to essential health programs such as routine immunizations and maternal and childcare.

The Mozambique Government's responses to the Global Action Plan for Healthy Lives and Wellbeing for All (SDG3 GAP) monitoring survey highlighted a need for better coordination among development partners, in terms of aligning more closely with national priorities. The contributions by SDG3 GAP partners to the CHS in Mozambique is a clear demonstration of SDG3 GAP partners’ commitment to improved collaboration among themselves, behind national strategies and plans, for better health outcomes. The CHS has been a crucial document guiding partner support to the Government.

Partners’ collaborative efforts to mobilize specific funds for nationally led health interventions and joint actions are fundamental to sustaining progress and addressing emerging challenges in the health sector. For example, other joint initiatives to strengthen PHC include the development of a Country Acceleration Plan for Ending Preventable Maternal Mortality, which integrates the Every Newborn Action Plan, and incorporates the Emergency Obstetric Care Network prioritization. These initiatives are facing significant funding shortfalls, despite presenting a unique opportunity to enhance the PHC component of the health system, and thereby ensure it functions optimally and addresses the health needs at the community level.

The potential for CHS to drive reform in the health sector is an exciting prospect as it would improve access to health services for the most out-of-reach and facilitate Mozambique’s accelerated progress towards the health-related SDGs.

What is the SDG3 GAP?

The Global Action Plan for Healthy Lives and Wellbeing for All (SDG3 GAP) is a set of commitments by 13 agencies that play significant roles in health, development and humanitarian responses to help countries accelerate progress on the health-related SDG targets. The added value of the SDG3 GAP lies in strengthening collaboration across the agencies to take joint action and provide more coordinated support aligned to country owned and led national plans and strategies.

(1) Demographic and Health Survey of Mozambique, 2022-2023

(2) World Bank, Mozambique. World Bank Gender Data Portal.