Mozambique’s political history has been shaped by its geography. Stretched from north to south along more than 1,500 miles of coastline, the territory was first colonized by the Portuguese, who established a series of trading ports. Through these ports the colonists extracted the agricultural and commercial wealth of the territory. Under Portuguese rule, the health system in Mozambique centered on the needs of the European settler community and their economic interests. The colony maintained a series of health facilities for settlers and a “cordon sanitarie” around the urban areas where many Europeans lived (Cabral and Noormahomed 1990, 175). Health care access for indigenous Mozambicans was limited. Colonists conducted public health campaigns to reduce endemic diseases such as malaria in areas with economic potential so as to make them more accessible for development. Settlers also often provided rudimentary health services to local forced laborers to protect against tuberculosis and other infectious diseases that, if unchecked, would reduce the size of the colonist’s workforce (Cabral and Noormahomed 1990, 175).
Mozambique’s health care system has its roots in the country’s war for independence. The Liberation Front Of Mozambique (FRELIMO), the main opposition group against the Portuguese colonists, was founded in Dar es Salaam in 1962 and launched its first military operation two years later. By the late 1960s, FRELIMO had successfully established a number of “liberated zones” around Mozambique. It was in these areas that the genesis of Mozambique’s health care system was formed. Realizing that many of the health problems of their civilian supporters in the liberated zones came from preventable diseases, FRELIMO started providing basic health care to citizens and soldiers alike. FRELIMO focused on providing simple health services and health education with widespread involvement by the local community. This model focused on preventing rather than curing diseases (Walt and Cliff 1986). Two important health policy doctrines emerged from FRELIMO’s health care provision during the war for independence: 1) health care is a universal right and 2) health care is essential for the economic development of Mozambique. Both would become central policies in Mozambique’s health care system after independence.
In June 1975, after a military coup in Lisbon, Mozambique achieved independence and FRELIMO took control of the government. The health care system FRELIMO inherited was small and dysfunctional. During the colonial period most health workers were Portuguese settlers and these Europeans started leaving en mass at independence. Within a month, 85 percent of Mozambique’s doctors had left the country (Walt and Cliff 1986). Despite FRELIMO’s attempts to stem the flight of European health workers with offers of Mozambican citizenship, the fledgling state was left with only 30 doctors in the entire country (Barker 1983). This exodus left many hospitals and other health facilities abandoned or crippled by understaffing. The problem was particularly damaging in rural areas that were often isolated during the chaotic first few months of independence. Health care in these areas was often provided by untrained orderlies and by the remnants of FRELIMO’s liberation zone health care network (Walt and Cliff 1986).
The new Mozambican government also lacked a pool of skilled and semi-skilled workers they could draw upon to manage the health care system. There were six economists, two agronomists, and fewer than 1000 African high school graduates in the country (Finnegan 1993). The lack of capable senior and middle level technocrats made it difficult for the government to manage the disorganized health system it took over at independence. Decision-making was often deferred to a small cadre of administrators with little room for outside opinion or flexibility (Walt and Cliff 1986).
Despite these difficulties, in July 1975 Mozambique nationalized health care and launched a major effort to transform the disparate collection of private, public, military, and missionary health facilities into a single effective health system. The new health system was to be guided by the Marxist principles of FRELIMO and the health policies started before independence. Health reforms focused on expanding health care to rural regions of the country where a majority of the population lived through primary and preventative health care programs (Pavignani and Durão 1997). FRELIMO political leaders believed that the country’s political and economic future lay in improving the country’s largest industry: agriculture (Walt and Cliff 1986). More specifically, FRELIMO hoped a rapid expansion of Mozambique’s health system would improve the productivity of rural agricultural workers and thus the entire economy.
FRELIMO’s post-independence health reforms were based around the concept of primary health care, a doctrine giving priority to the provision of basic health services and preventative care over specialized and curative care. Primary health care was seen by FRELIMO as the only way the government could improve the health of the vast majority of the population that had previously been without any health care access. To accomplish this, FRELIMO radically increased health care spending: from 4.6 percent of the government’s budget to 9.7 percent only a year later (Cabral and Noormahomed 1990). By 1981, government health spending would reach 11.9 percent (Walt and Cliff 1986).
FRELIMO’s focus on expanding health care was rooted in both political strategy and ideology. Even before independence FRELIMO enjoyed widespread support amongst the population. This support was a valuable resource during the guerilla war against the colonial Portuguese Army who “faced fighting in a hostile country against a people overwhelmingly antagonistic to them” (Walt and Cliff 1986, 149). Furthermore, during the war while FRELIMO did receive some support from abroad, it relied heavily on the population for information and supplies (Mondlane 1969). The close connection between FRELIMO and the population during the war had a profound impact on the development of national health policy after independence. Furthermore, FRELIMO’s Marxist roots played a role in the high priority given to health. FRELIMO believed western capitalism and colonialism were the enemies of the Mozambican people, and that improvements in the new state’s health and education systems were the key to escaping that poverty (Robinson 2006).
The FRELIMO government’s focus on the well being of the population was responsible for a rapid expansion of the health system in the years before and at the start of the country’s civil war. Between 1975 and 1982, over 2000 nurses, 110 x-ray technicians, 290 pharmacists, 272 midwives, and 1011 village health workers were trained (Walt and Cliff 1986). Similar improvements were seen in health facilities. In roughly that same period, the government built 593 health posts, 161 health centers, 130 laboratories, and 80 stomatology departments (Cabral and Noormahomed 1990). The government also instituted a national drug formulary to reduce the amount the government and patients spent on pharmaceutical products. Mozambique’s drug formulary was considered to be one of the country’s most important reforms and was credited for keeping pharmaceutical spending significantly lower than other developing states (Cliff et al. 1986; Barker 1983). The effect on the health of Mozambican citizens was significant. By 1980, 30 percent of the population had access to health care facilities, up from 7 percent in 1974 (Barker 1983). Furthermore, by the early 1980s Mozambique had the highest vaccination rates for children under the age of five years old in any African country (Williams 1992).
After Mozambican independence, the neighboring state of Rhodesia worried that rebel groups — notably the Zimbabwe African People’s Union (ZAPU) and the Zimbabwe African National Union (ZANU) — attempting to overthrow the country’s white-run government would use FRELIMO-controlled Mozambique as a safe haven from which to train and launch attacks. In response, in 1976 the Central Intelligence Organization of Rhodesia covertly funded the creation of a rebel group to disrupt the Mozambican government and rebel groups operating in the Rhodesia-Mozambique border region. The group, called the Mozambican National Resistance (RENAMO), would eventually become one of the most active rebel groups in Africa.
Between 1976 and 1980, RENAMO was largely an indigenous fifth column controlled by the Rhodesian intelligence service (Vines 1991). Their primary role was providing reconnaissance for Rhodesian Special Forces during raids on ZAPU and ZANU bases in Mozambique. While after 1977 RENAMO conducted some attacks of its own on Mozambique’s infrastructure and rural villages, these were for the most part small operations (Vines 1991; Robinson 2006). It was only around 1981-1982, two years after black nationalists led by Robert Mugabe ousted the government of Rhodesia in general elections (soon renamed Zimbabwe), that RENAMO’s attacks began to significantly disrupt Mozambique’s health system. After Zimbabwean independence, RENAMO ceased to receive support from Rhodesian intelligence coffers. The rebels found a new patron in South Africa’s apartheid government (Young 1990). Rather than employing RENAMO fighters in support of its military operations, South Africa turned the group into a resistance movement in its own right. With more independence and funding, RENAMO attacks expanded rapidly and by 1982 8,000-10,000 RENAMO fighters were operating in nine out of ten of Mozambique’s provinces (Hall 1990; Vines 1991).
While RENAMO lacked a genuine political ideology, it’s attacks were part of a strategy to undermine the FRELIMO government through disrupting the operations of the state (Vines 1991; Nilsson 1993). RENAMO largely operated out of rural areas and while it had a traditional military organization on paper, at the tactical level operated as bands of irregulars (Robinson 2006). The majority of RENAMO military operations were not motivated by the desire to take and hold ground but instead were opportunistic raids and ambushes on villages, roads, bridges, oil pipelines, schools, and the health system.
RENAMO frequently targeted rural health posts, clinics, and hospitals. The extent of attacks on health facilities between in 1982 and 1990 is significant. Refugees fleeing into South Africa described health clinics as regular targets for RENAMO forces (Gersony 1988). By the end of 1988, RENAMO operations had destroyed 291 rural health posts and health centers, with many more looted. One account of a RENAMO attack on the small town near Inhambane in 1987 exemplifies the unabashed violence utilized by the rebel group:
Some went from house to house, shooting and stabbing people as they hid in the shadows. Others headed toward the police station and from there to the hospital, where they broke into cabinets, stealing supplies and medicines, and kidnapped a nurse. They then turned their weapons on the patients, shooting them as they lay in their beds. ‘They killed pregnant women with bayonets’, eyewitnesses reported. Nor were newborn babies or young children spared. By the end of the day, 388 people were dead and many others wounded. (Cammack 1987, 65)
The civil war also disrupted health facilities indirectly, between 1986 and 1988 183 rural health units were non-functional due to violence and seven rural hospitals were looted and forced to shut down (Chelala 1991). The end result of both collateral damage and RENAMO attacks on health facilities was a partial or total loss of twenty-five percent of the primary health care network by the end of the war (Cabral and Noormahomed 1990). By another account a total of around 900 primary health care units were destroyed or looted. The destruction left just one working health facility per 12,300 Mozambicans (de Luz Vaz and Bergström 1992). Some health posts resorted to shutting down in the afternoon to allow staff and patients time to hide in the bush before nightfall (Summerfield 1988). The disruption of the health care system from collateral damage and attacks changed when and where patients sought treatment. There are reported instances of RENAMO fighters entering rural villages at night and threatening to kill residents who used government health posts (Cammack 1987). One account by a Canadian working as a district medical officer in Nampula describes the extent of fear around areas where health facilities were located:
I visit three health centers in the district surrounding Nampula each week. I drive a half-ton Toyota pick-up truck sometimes filled to the brim with sacks of grain or pulse, distributed through CARE, to feed hospital patients and refugees from the war. The truck is usually filled with nurses and even patients, who live in the city and travel out each day to these health centers because it is considered too risky to live close by. (Williams 1992, 1131)
The prevalence of RENAMO activity in rural areas “amputated the health network of most of its rural component” and strengthened the natural bias of health systems towards urban areas where doctors and government leaders often lived (Noormahomed and Cliff 1988).
The destruction of Mozambique’s health system was not limited to its facilities; the civil war also drained the country of skilled health workers. RENAMO units actively targeted health workers who, as agents of the FRELIMO government, were subjected to brutal treatment if captured, including mutilation and execution (Hanlon 1991). In 1985 alone RENAMO murdered 21 health workers and forced a further 250 to flee. By 1983, Mozambique’s health system had only five working ambulances, the rest were broken, stolen, or destroyed in RENAMO ambushes (Summerfield 1988). The war was particularly dangerous for Agentes Polivalentes Elementares (APEs), a new type of health worker created in the pre-war years by FRELIMO to extend health care to rural regions. Instead of being paid by the government, APEs were supported by the rural villages where they were assigned. However, these villages were frequently outside the security umbrella of government soldiers. APEs’ rural assignments made them extremely vulnerable to RENAMO attacks, both against them directly or against the villages that supported them. Threats of RENAMO violence forced many of the APEs trained by FRELIMO to flee their assigned villages and find work providing health care to farms, plantations, and private businesses (Cliff et al. 1986). As a result of insecurity in rural areas of Mozambique, the number of health workers in these regions decreased rapidly over the course of the war. By 1992, the number of health workers per population in rural areas fell to one nurse per 21,000 and one doctor per 814,000 respectively (de Luz Vaz and Bergström 1992). The destruction of Mozambique’s health system also affected government immunization campaigns. The threat from RENAMO attacks prevented vaccination teams from operating in many rural areas (Hanlon 1992). The inability of vaccination teams to work had significant negative effects on the immunization coverage of rural regions, which dropped from almost 45 percent to 30-35 percent in 1986 alone (Cabral and Noormahomed 1990). Infectious diseases in the countryside had direct effects on health in even urban areas. After RENAMO units attacked rural areas near Maputo, civilians fleeing to the safety of the city triggered a scabies epidemic and over 500 children were treated in Maputo Central Hospital (Cliff and Noormahomed 1993). Patients were also not spared RENAMO’s violence. RENAMO often slaughtered patients alongside health workers when rebel fighters overran health posts, clinics, centers, and even one hospital (Finnegan 1993). RENAMO forces even went so far as to attack hostels adjacent to maternity units used by expectant women (Hanlon 1992; Cliff and Noormahomed 1993).
Prior to the civil war, the Mozambican government invested significant resources in the country’s health system. At its peak in 1977, the Ministry Of Health’s operating budget constituted 12.8 percent of total state expenditures (Cabral and Noormahomed 1990). However, after RENAMO activity increased in 1982, the amount of funding available to support the health system decreased. Specifically, the civil war reduced economic resources available to the Mozambican government by causing the looting, damage or destruction of much of the country’s economic capital, by reducing taxpayer base of the state, increasing the financial demands of the military, and by creating uncertainty around the country’s political and financial future (Brück 1997). With less economic resources at their disposal, government spending on health suffered. By 1986, the Ministry Of Health’s share of total state expenditures had dropped by almost half to 7.8 percent (Cabral and Noormahomed 1990). Furthermore, the nominal budget allotment often differed from the amount of funds made available to the Ministry Of Health. At the end of 1985, only five percent of the state budget for drug supplies had been made available (Cliff et al. 1986).
Despite widespread insecurity, the FRELIMO government went to great lengths to maintain, protect, and rebuild the health system during the war years. This effort is particularly remarkable given that in Mozambique, as a new and poor state, skilled administrators needed to manage the work were particularly rare and valuable (Walt and Cliff 1986). In spite of the dangers posed by operating in rural regions and the natural tendency of health systems to contract to urban areas during conflict, Mozambique continued to make rural regions the focus of their health efforts. In 1986, near the height of RENAMO attacks on the country’s people and infrastructure, a remarkable 69 percent of medical assistants, 48 percent of nurses, and 60 percent of maternal and child health nurses and midwives were serving in rural regions — amounting to 41 percent of all of Mozambique’s health workers (Cabral and Noormahomed 1990).
Throughout the war, the Mozambican government continued to repair and build health facilities. During the first five years of major RENAMO activities (starting in 1982), 822 health units were destroyed by RENAMO while 567 were reconstructed by FRELIMO (Chelala 1991). FRELIMO was, in a very real sense, racing to build health facilities faster than they could be destroyed or forced to close. Before the start of major RENAMO operations in 1982, the rapid expansion of the health system that started in the pre-war era continued to increase the number of health facilities in the country. However, after 1982 the total number of each type of health facility stayed the same or decreased as RENAMO attacks and collateral damage took their toll on the health system.
Along with continuing to construct the health system, the government maintained a vigorous medical education program during the war. From 1976 to 1985, the Mozambican government trained thousands of health workers, including 569 medical aids, 818 midwives and maternal/child health nurses, 2181 nurses, 268 preventative medicine workers, 486 pharmaceutical personnel, 406 laboratory personnel, 76 health administrators, 384 specialized nurses, and 1,402 village health workers (Cabral and Noormahomed 1990). In addition, around the same time 6,242 paramedical workers were trained (Cliff et al. 1986). The training of these health workers represented a significant cost for the wartime government. The result of this training program during the first years of the war was that the number of health workers in semi-rural and rural areas increased from 8,163 to 10,593 between 1980 and 1984 (Cliff et al. 1986). While the number of health workers in these areas likely decreased as RENAMO stepped up its attacks after 1982, the numbers demonstrate the high priority the FRELIMO government gave the operations of the health system. In addition to training new health workers, the government invested in the improvement of its existing personnel. After the civil war made it impossible to train enough new health workers to provide child and maternal health, the Ministry Of Health started new education and training programs for the country’s existing health workers, including training medical technicians to conduct emergency obstetric surgeries and educating traditional birth attendants (de Luz Vaz and Bergström 1992).
The Mozambican government also tried new and innovative approaches to provide health services during the war. Immunization campaigns were a major priority for the Mozambican government and humanitarian groups. In 1985, the United Nations funded a vaccination campaign by the FRELIMO government in two regions of the country. Traditionally vaccination teams often announce the dates and locations of immunization teams in radio and newspaper advertisements weeks, even months, ahead of time to give people advance notice. However, during the civil war government health officials worried that broadcasting the time and location of a health team would invite a RENAMO attack (Finnegan 1993).
To overcome the problem of RENAMO attacks, the FRELIMO government designed an innovative approach: they organized the campaign in secret. First, small teams travelled to the targeted regions and educated citizens on the importance of vaccination campaigns. However, these teams would not provide information on when the campaign would take place. Then one day, long after the initial visit FRELIMO would spread the word through loyal party members in the area that the vaccination teams would arrive the next day. On the day of the vaccination campaign people would arrive, be receive the immunization and be disperse quickly before RENAMO could react (Cutts et al. 1988; Finnegan 1993). This innovative strategy allowed immunization campaigns to be conducted quickly during lulls in RENAMO operations. Through campaigns like this, the country’s immunization program and material-child health program did not collapse during the war. In fact, during one year of the war 82 percent of children zero to two years old in one region were fully immunization (Cabral and Noormahomed 1990).
The scale of the health system’s destruction was extensive. Between the start of major RENAMO operations in 1982 and the end of major fighting in 1990, 48 percent of Mozambique’s primary health care network was destroyed or forced to closed and near the end of the war the Ministry Of Health estimated over two million people had lost access to health care (Cliff and Noormahomed 1993). The disruption of the health system had major short and long-term consequences for health in Mozambique. Despite its ferocity, violence accounted for a relatively small number of deaths during the war. The largest source of deaths came from infectious diseases — grim testament to the disruption of the health system during the war (Garenne 1997). These indirect health consequences of the war had a disproportionate effect on children less than five years old (including still births), which represented fifty-eight percent of all deaths (Noden et al. 2011). Prior to the war, mortality was decreasing in Mozambique, likely due to the FRELIMO government substantial investment in the health infrastructure. However, by the end of the war, child mortality had increased 73 percent, “reversing 40 years of health improvements” (Garenne 1997, 322). The health impact of the conflict was not limited to the wartime period: Mozambican women who were young or born during the war continue to have weaker lifetime health on average (Domingues 2010).
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