Health System Drivers of Universal Health Coverage in Mozambique: Scrutinization of Service Delivery and Human Resources for Health building blocks

Abstract

Achieving Universal Health Coverage (UHC) is the most sustainable way to establish social justice and contribute to the well-being of all. Strong and resilient health systems are the foundation for achieving and sustaining UHC. Six building blocks of the health systems have been identified by the World Health Organization (WHO. Understanding health system building blocks challenges remains an essential step for achieving UHC. This dissertation analysis two of the six building blocks, service delivery and human resources for health. The first study focuses on understanding the impact of an important weather event – the Idai cyclone – on measures of health service utilization. Mozambique is vulnerable to extreme weather events; therefore, describing the immediate impacts of such events, as well as post-event recovery patterns, can inform efforts to improve health system resilience. We used routine data capturing health service utilization, aggregated to the district level, from pre- and post-event periods to perform an uncontrolled interrupted time series analysis and describe changes in 10 maternal and child health indicators across 25 districts. Overall, we demonstrated a negative impact on several indicators immediately after Idai, including 23% (95% CI: 0.62, 0.96) and 25% (95% CI=0.64, 0.87) reductions in antenatal care and measles vaccination, respectively. However, promising signs of recovery were evident three months later. The second study focused on assessing the health workforce landscape in Mozambique. We used a longitudinal design to assess two measures of health workforce (density of personnel and the ratio of male to female health workers) in all districts between 2016 and 2020. In Mozambique, in January 2016, the average district-level workforce density was estimated at 75.8 per 100,000 population (95% CI: 65.9, 87.1) and was increasing at an annual rate of 8.0% (95% CI: 6.00, 9.00) through January 2018, declining to 3.0% (95% CI: 2.00, 4.00) after that point. Sex ratio imbalances were evident in this study, with northern provinces reporting twice the sex ratio relative to Maputo province. Guided by the Consolidated Framework for Implementation Research (CFIR), the third study deepens the analysis of human resources to describe the individual and institutional drivers of health worker satisfaction. We conducted 63 In-Depth Interviews (IDIs) and seven Focus Group Discussions (FGDs) with health workers in five districts of Manica province. The results of the study suggest that poor working conditions, lack of clear criteria to select health workers for trainings and workshops, and scarcity of housing are among the most relevant determinants of dissatisfaction. Overall, CFIR proved helpful in identifying and summarizing the determinants of job satisfaction. Together, the results presented in this dissertation describe important challenges that Mozambique's health system should address to accelerate progress toward UHC. The methods applied in this study are replicable and could inspire other countries to conduct similar analyses.