Abstract
In many African countries, hundreds of health-related NGOs are fed by a chaotic tangle of donor funding streams. The case of Mozambique illustrates how this NGO model impedes Universal Health Coverage. In the 1990s, NGOs multiplied across post-war Mozambique: the country’s structural adjustment program constrained public and foreign aid expenditures on the public health system, while donors favored private contractors and NGOs. In the 2000s, funding for HIV/AIDS and other vertical aid from many donors increased dramatically. In 2004, the United States introduced PEPFAR in Mozambique at nearly 500 million USD per year, roughly equivalent to the entire budget of the Ministry of Health. To be sure, PEPFAR funding has helped thousands access antiretroviral treatment, but over 90% of resources flow “off-budget” to NGO “implementing partners,” with little left for the public health system. After a decade of this major donor funding to NGOs, public sector health system coverage had barely changed. In 2014, the workforce/ population ratio was still among the five worst in the world at 71/10000; the health facility/per capita ratio worsened since 2009 to only 1 per 16,795. Achieving UHC will require rejection of austerity constraints on public sector health systems, and rechanneling of aid to public systems building rather than to NGOs.
Highlights
Selective primary health care and austerity A troubling 2018 piece, commissioned by the Lancet for the WHO-sponsored Astana conference on primary health care to commemorate the 40th anniversary of the Alma Ata Declaration on Primary Health Care, emphasizes the key role of ministries of finance in supporting state health budgets [10]
In heavily indebted poor countries such as Mozambique, the challenges are bigger than those found in wealthier parts of the world, but the choices are simpler
At the beginning of the antiretroviral therapy (ART) scale-up in Mozambique, the Ministry of Health quickly realized that HIV treatment services needed to be integrated into the existing primary health care facilities in order to reach coverage targets, ensure equity, and link to other services that patients needed
Summary
Selective primary health care and austerity A troubling 2018 piece, commissioned by the Lancet for the WHO-sponsored Astana conference on primary health care to commemorate the 40th anniversary of the Alma Ata Declaration on Primary Health Care, emphasizes the key role of ministries of finance in supporting state health budgets [10]. Most HIV-positive patients receive their care through the National Health Service; PEPFAR partners generally do not set up separate clinics, instead grafting their activities onto existing facilities Their support normally includes health workforce training (usually brief two to three-day seminars), some HIV-specific materials, technical assistance, data collection, and support for HIV-specific community health workers, with subcontracting to local NGOs for social support and adherence. Internal NGO budgets are not public, nor are they shared with the Ministry of Health; rigorous costing analyses are rare or nonexistent Many of these partners are known for their high administrative costs, very high six-figure expatriate salaries with major benefits, comparatively lavish in-country offices, big fleets of new SUVs, and large staffs dedicated to managing subcontracts, collecting data, and managing operations—while the health systems they are ostensibly meant to support remain dilapidated and understaffed. Even with the massive infusion of new vertical funding, progress toward achieving Universal Health Coverage as these data show has been minimal, and on some measures Mozambique has lost ground
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