Health systems flattening – the failed promises of decentralisation in Mozambique

ABSTRACT

Over the past decade, health systems strengthening (HSS) has become a global health imperative. As an answer to the influence of large-scale initiatives and NGOs, HSS represents a backlash against disease-specific projects and funding. Depicted as a positive evolution, HSS advertises local autonomy, and a turn away from donor-driven agendas. Central to this shift was the hope that ‘vertical’ funding, especially for HIV/AIDS, could be better used to build up the ‘crumbling core’ of health infrastructure in sub-Saharan Africa. As part of the change in Mozambique, HIV specialty clinics known as ‘day hospitals’ were decentralised (closed down) nationwide. Done in the name of efficiency and increased treatment coverage, the full impacts of this remain uncharted. In this article, I critique the ethical adequacy of HSS as a reorganising principle, pointing out the pursuit not of robust health systems, but of easily monitored ones instead. Occurring alongside performance-based financing, HSS invites the removal of specialty services, exposing health systems to additional shaping by outside forces. Based on ethnography with HIV support groups, I suggest HSS was an inevitable policy choice, but partially coercive. Such changes are neither counter-hegemonic nor capable of ameliorating foreign distortions in the developing world.

KEYWORDS:

• Health systems strengthening
• Mozambique
• HIV/AIDS
• decentralisation
• performance-based financing

Acknowledgments

Earlier versions of this manuscript benefitted from comments by two anonymous reviewers. The author gratefully credits them both with substantial assistance to the final draft.

Disclosure statement

No potential conflict of interest was reported by the author.

ORCID

Joel Christian Reed http://orcid.org/0000-0002-2204-3154

Notes

1 WHO guidelines around eligibility criteria began to change in Mozambique in 2009, the same year of the HDD closures. Changes were implemented to raise the CD4 count from ≤200 cells/mm to 350, expanding the eligible population, and making coverage appear lower (worse). Estimates in Spectrum, the software used to model ART coverage data, were formerly presented in Mozambique’s annual reports in two ways. The first way, which is now phased out, used ‘patients eligible for ART’ as the denominator. An example is graphic 3 of MISAU (2015b). These data show declining coverage from 2008-2012. However, it is not possible to attribute this either to HDD closures or changes in eligibility criteria based on the available information; even total conformity to the CD4 count thresholds from one clinic site to another is subject to debate. The second way to model these data uses ‘HIV positive persons’ as the denominator. This method, while decidedly more precise, likewise prohibits distinguishing the impact of the HDD closures on ART coverage during the time period in question.

2 While the global financial crisis of 2008-2009 clearly fostered budget deficits throughout sub-Saharan Africa (Mpabanga, 2017), whether it ushered in healthcare decentralisation is an altogether different question. Here, I recount the conversation between MONASO’s director and civil society actors not to imply cause and effect, but to highlight the uneven way decentralisation (and by extension, HSS) was presented in popular discourse. Framed, however, by other successful achievements in health financing and the expansion of primary services over that same time—including reductions in infant and maternal mortality, and narrowing gaps in the rural/urban divide (Pose, Engel, Poncin, & Manuel, 2014)—cutting down on the number of community activists and the roles their organisations played suggests that certain selections were made on a centralised level leaving civil society out of the process, and indeed, discontent.

3 Statistics in figures and tables are taken from population-based surveys in Mozambique (INS, 2010; MISAU, 2015a) which included home HIV testing and confirmatory lab tests. For data from the 2003 and 2011 surveys, numbers are taken from statcompiler.com.

4 See the website for ThinkWell Global, http://thinkwell.global/projects/performance-based-financing-for-mozambique/.

5 Affiliated with USAID through the private sector contractor John Snow, Inc.

6 Problematising the African state apparatus as entwined with a subterranean array of clientelistic social networks, Juan Obarrio (2014) notes that executive and legislative power in Mozambique is coopted—proposed, funded and drafted—by foreign donors and consultants.

Additional information

Funding

This work was supported by Fulbright Association [grant number P022A080033].