Mozambique health system reconstruction supports the team’s conclusion that the reconstruction of health systems is mainly “gender blind”. Policy-makers in Mozambique have not adequately considered the role of gender in contributing to health or addressed women’s and men’s different health needs. Despite government commitment to gender mainstreaming, the health system is far from gender equitable. Donors have shied away from tackling the thorny issue of the social and cultural norms, including gender, which drive ill health. As such, an opportunity has been missed not only to promote gender equity in the health system but also gender equality in society.
CONTEXT AND CONFLICT
Gender equality: The brutal civil war in Mozambique (1977-1992) left one million people dead. Although the economy is one of the fastest growing in Africa, the country is characterised by high levels of inequality. Despite strong female participation in politics (almost 40% of MPs are women) and government’s rhetorical commitment to gender equality, women and girls suffer daily and pervasive discrimination. They have fewer opportunities to access education, health, income and employment than men and boys. Some progress has been made in closing the gender gap in school enrolment, however, girls remain less likely to finish primary school than boys, and the quality is poor. The country also has one of the world’s highest rates of child marriage.
Health equity: Health indicators testify to discrimination against women and girls: the maternal mortality ratio is one of the highest in the world. The total fertility rate has risen since 2003: the sexual and reproductive rights of women are not respected, as 56% of unmarried and sexually active adolescent girls are unable to access contraception. More women than men are HIV positive – the HIV rate is almost three times higher among young women than young men. Male risk-taking is the leading cause of male mortality with high rates of death through road accidents, occupational hazards, and violence.
Impact of conflict on gender roles: Women as well as men fought in the war, creating opportunities for them to participate in decision-making. The breakdown of traditional family units also increased women’s and young people’s independence. Nevertheless, sexual violence was reportedly rife during the war. After the war, patriarchal systems returned and traditional authorities won back influence in land allocation, undermining women’s access to and use of land.
INTERNATIONAL HEALTH ENGAGEMENT AND GENDER
Humanitarian: Despite widespread sexual violence during the war, humanitarian programmes did not specifically address the issue, making it difficult to raise awareness of gender-based violence. The focus of humanitarian aid was rebuilding infrastructure.
Health system: Unusually, Mozambique did not reform its health system after civil war had ended, keeping the pre-war system intact and focusing on reconstruction. Health policies since then have attempted to promote gender equity and equitable access to health care, particularly for women and children. In 1995, to facilitate gender mainstreaming, the Ministry of Health appointed a “Gender Focal Point”.
General gender programming: In the aftermath of war, Mozambique adopted the Beijing Platform for Action and a plan to integrate gender in government policies and programmes. Some progress has been made recently in collecting and analysing data broken down by sex. While laudable, these efforts have had little impact on the health indicators for women and girls.
IS THE HEALTH SYSTEM IN MOZAMBIQUE GENDER EQUITABLE?
In order to review whether the health system is gender equitable, the team assessed the country’s progress against the framework of WHO’s six aspirational building blocks of the health system:
- In health service delivery, women are disproportionately affected by challenges in accessing health care services, given their reproductive and care-giving roles. In 2011, just 54% of live births were attended by skilled health workers. A study in Maputo province to assess “near misses” in pregnant women and adolescent girls found that most were unable to make the decision by themselves to seek care, and had to rely on their husband or family.
- The health workforce is at crisis point, with one of the lowest health worker/population ratios in the world, hitting women who use health services more than men. More midwives are urgently needed to cut maternal deaths. The Ministry of Health has failed to prioritise gender equity in its human resource strategy, not encouraging the recruitment of female community health workers as part of its strategy to expand the community health worker programme.
- Health information systems are not fully developed and in many rural areas remain in paper form. Relevant health information that is broken down by sex is not routinely available. Data collection systems are very weak at the district level and centrally the Ministry of Health lacks the capacity to analyse data. This means that some diseases may be under-reported.
- Health system financing should be clear and fair in order to ensure gender equity, however, women face significant financial barriers in accessing care. Budgeting which is sensitive to gender concerns is limited to just three areas. Pregnant women, mothers and the poor are meant to be exempt from user fees, however, these exemptions are not always enforced.
- Access to and use of medical products and technologies is shaped by gender norms. In Mozambique, the pharmaceutical sector is ineffective and not adequately overseen by government. The supply of drugs is unreliable, affecting treatment of HIV/AIDS and TB, as is the supply of contraception.
- Rebuilding the health system after conflict presents an opportunity to foster gender equity in leadership and governance, however, this has not generally been the case in Mozambique. The Ministry has struggled to oversee donor funds and the decentralisation process. In practice, the Gender Focal Points lack resources and the authority to integrate gender into the health system.
Percival V, Richards E, Maclean T, Theobald S. Health systems and gender in post-conflict contexts: building back better? Conflict and Health. 2014;8(19):14 pps.
Baden S. Post-conflict Mozambique: Women’s special situation, Population Issues and Gender Perspectives: to be integrated into skills training and employment promotion. Brighton: Insitute of Development Studies, University of Sussex, 1997.
Tvedten I. Background Paper. Mozambique Country Case Study: Gender Equality and Development. Washington: World Bank; 2011.
UNFPA. Marrying Too Young: End Child Marriage. New York: UNFPA, 2012.
WHO. Mozambique: health profile. Geneva: World Health Organization, 2012.
Population Reference Bureau. Fecundidade e Planeamento Familiar no Inquérito Demográfico e de Saúde de Moçambique 2011 (IDS). In: Estatistica INd, editor. Maputo: Insituto Nacional de Estatistica; 2013.
CNCS. Global AIDS Response Progress Report. Maputo: Conselho Nacional de Combate ao HIV e SIDA 2014.
Sherr K, Cuembelo F, Michel C, Gimbel S, Micek M, Karianganis M, et al. Strengthening integrated primary health care in Sofala, Mozambique. BMC Health Services Research. 2013;13 (Supl 2:S4):12 pps.
David E, Machungo F, Zanconato G, Cavaliere E, Fiosse S, Sululu C, et al. Maternal mean miss and maternal deaths in Mozambique: a cross-section, region-wide study of 635 consecutive cases assisted in health facilities of Maputo Province. BMC Pregnancy & Childbirth. 2014;14(401):8 pps.
Geelhoed D, Lafort Y, Chissale E, Candrinho B, Degomme O. Integrated maternal and child health services in Mozambique: structural health system limitations overshadow its effect on follow-up of HIV-exposed infants. . BMC Health Services Research. 2013;13(207):8 pps.
Ministry of Health M. National Plan for Health Human Resource Development Maputo: Ministry of Health: National Directorate of Human Resources; 2008.