Mozambique - Population, health and nutrition sector report

e S Report No. 7422-MOZ Mozambique Population, Health and Nutrition Sector Report January 9, 1990 Population and Human Resources Operations Division Southern Africa Department FOR OFFICIAL USE ONLY Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS Currency Unit Metical (plural Meticais) (Mt) Exchange Rates 1975 US$1 - Mt 25.55 1980 US$1 = Mt 32.40 1981 US$l = Mt 35.35 1982 US$1 = Mt 37.77 1983 US$1 = Mt 40.18 1984 US$1 = Mt 42.44 1985 US$1 = Mt 43.18 1986 US$1 = Mt 40.43 1987 (Feb) US$1 = Mt 202.00 1987 (July) US$l M St 404.00 1988 (Jan) US$1 = Mt 454.50 1988 (July) US$1 = Mt 585.80 1988 (Oct) US$1 = Mt 620.00 1989 (Jan) US$1 = Mt 651.00 1989 (Nov) US$1 = Mt 813.00 MEASURES 1 meter (m) = 3.28 feet 1 square meter (m sq.) = 10.76 square feet 1 gram (g) = 0.035 ounces 1 kilogram (kg) = 2.20 pounds Government Fiscal Year January 1 - December 31  - i - FOR OFFICIAL USE ONLY ABBREVIATIONS AND ACRONYMS APE : Agente Polivalente Elementar (Elementary Health Aide) CRDS : Centro Regional de Desenvolvimento Sanitario (Regional Center for Health D6velopment) CFA : Centro de Formacao Agraria (Agricultural Training Center) CENE t Comite Executivo Nacional para a Emergencia (National Executive Committee for the Emergency) CSD/UCI : Child Survival and Development/Universal Child Immunization Program CTTF : Comite Tecnico para Terapeuticos e Farmacia (Tecnical Committee for Therapeutics and Pharmacy) DPCCN : Departamento de Prevencao e Combate das Calamidades Naturais (Department for the Prevention and Control of Natural Calamities) EACB : Empresa de Abastecimento a Cidade de Beira (Supply Company for the Ci:y of Beira) EACM : Empresa de Abastecimento a Cidade de Maputo (Supply Company for the City of Maputo) E.E. FARMAC : State Pharmaceutical Corporation E.E. MEDIMOCt State Import/Export Agency for Medical Supplies EMOFAR : Parastatal ORT Factory EDP : Essential Drugs Program EPI : Expandeid Program of Immunization ERP : Economic Rehabilitation Program FAO : Food and Agriculture Organization FRELIMO : Frente de Libertacao de Mocambique (Mozambique Liberation Front) GDP : Gross Domestic Product GOAM : Gabinete de Organizacao do Abastecimentc a Cidade de Maputo (Organizational Secretariat for Supply in Maputo) HIS : Health Information System HIV : Human Immunodeficiency Virus IEC : Information, Education and Communication IPPF : International Planned Parenthood Federation IUD : Intra-uterine Device KAP : Knowledge, Attitude, Practice MCH : Maternal and Child Health MCH/FP s Maternal and Child Houlth/Family Planning MOC : Ministry of Commerce MOH : Ministry of Health NGO : Non-government Organization NSA : Novo Sistema de Abastecimento (New Supply System) OMM : Organizacao das Mulheres Mozambicanas (Mozambican Women's organization) ORS : Oral Rehydration Salts ORT : Oral Rehydration Therapy PHC : Primary Health Care RENAMO : Movimento Nacional da Resistencia (National Resistance Movement) This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  - ii - SCF : Save the Children Fund SNS : Servico Nacional de Saude (National Health Service) TFR : Total Fertility Rate UNDP s United Nations Development Program UNFPA : United Nations Fund for Population Activities UNHCR : United Nations High Commission for Refugees UNICEF : United Nations Children's Fund WHO : World Health Organization  ABSTRACT At Independence, Mozambique had some of the worst social indicators in the World - with infant mortality at 144 per thousand and life expectancy of only 43 years. The FRELIMO Government gave health a high priority in its development plans following Independence. Thus, the health system was ezpanded rapidly. Mortality and other health indicators started to improve by the late 19709. However, with the results of an intensified war, these early gains have been lost. Over one-third of the health system has been destroyed as a result of attacks by armed bandits. Throughout most rural areas, service delivery is severely hampered and frequently rendered impossible by the security situation. Difficult access resulting from the war has pushed up the operating costs of the health system. The war has resulted in massive dislocation of the population, with two million people displaced, and a further 2.5 million seriously affected, out of a total population of about 15 million. Marketed domestic food production has declined to minimal . wels. The urban population is now almost entirely dependent upon food aid. There have been serious consequences for the nutritional status of the population. The report analyses current issues in the fields of population, health and nutrition against the backdrop of the war, and the possible return to peace. Given the war, the issue of rapid population growth is not uppermost on the Government agenda. Moreover, Mozambique is a resource- rich country, with a population carrying capacity substantially greater than the current population. Despite this, the report notes the large budgetary burdens of rapid population growth, in terms of the demand for social services, and social overhead capital and makes the case that the Government should place diminishing the rate of population growth higher on its list of priorities. In health, the report discusses the need to raise coverage of the population substantially - something which is only truly possible with a return to peace - and the budgetary implications of this. Existing cost- recovery mechanisms provide less than 10 percent of the health budget. The scope for real increase in these revenues is limited due to the pervasive poverty and low income of the Mozambican population. Even improved efficiency in resource use in the health sector, for which there is considerable scope, will still not bring resource demand and availability into equilibrium. On top of this, a major reconstruction and rehabilitation effort will be required, once peace returns. Substantial donor support for both capital and recurrent expenditures is thus essential. In nutrition, the report argues strongly for the continuation and even strengthening, of the food ration system in urban areas whilst food supplies are disrupted as a result of the war. As peace returns, the Government should focus on catalyzing and supporting community nutrition initiatives.  TABLE OF CONTENTS Page No. ABBREVIATIONS AND ACRONYHS ............................. . i I. MXECUTE SSUMMAARY AND INTRODUCTION ........................N 1 Overview .............................. ...... *; . ... 1 Background and Contextt... ........ . 4 Issues and Recommendations... 5 Slowing the Pace of Population Growth . ........ 5 Improving the Quality, Coverage, and Cost-Effectiveness of Health Services.... 7 Alleviating Nutritional Deficiencies and Improving Food Security.. . . . 12 _I. POPULATION . ...................... 15 A. Present Demographic Situation and Trend s...... 15 Sources of Demographic Data. . . ... 15 Population Size and Distribution ............... .... 15 Migratio-i. . .... 17 Age and Sex Structure of the Population 8...... 4ortality.. ........ 19 Fertility......... 20 Natural Increase in Population Growth ............. 21 B. Projected Future Population Growth . ... ...... 23 Projection Methodology . . .............. 23 Scenarios8cens........ 23 Results of Alternative Scenarios . ...... 24 C. Implications of Rapid Population Growtl o... .... 27 D. Policies, Programs and Institutions............... 31 Family Planning Activities. .. ..... 31 Demand for and Use of Family Planning . .... 33 III. HEALTH..... . .. 34 A. Present Situation and Trends . ................ 34 This report is the product of a mission composed of Messrs./Ms. Robert Castadot (mission leader), Althea Hill, E.J.R. Heyward (consultant), and Drs. Gerald Bloom and Maria Wawer (consultants), who visited Mozambique in June, 1987. The report was subsequently updated based upon missions in February and July 1988 led by Mr. John Innes. The report was prepared by Mss. Althea Hill and Kreszentia Duer.  Page No. B. Policies ............................................... 35 C. Facilit'Les and Programs .. 36 Structure o