JOBS OUTCOMES STORY WORKING TOWARD BETTER HEALTH Expanding Community Health Services in Mozambique AT A GLANCE REGION/COUNTRY Africa Western and Central | Mozambique PROGRAM/PROJECT Mozambique Primary Health Care Strengthening Program FUNDING $80 million IDA, $25 million Global Financing Facility, $82.5 million MDTF (Canada, Netherlands),$7.0 million USAID TF, $8.7 million UK TF RESULTS THE CHALLENGE Mozambique more than doubled its In low-income countries, formal health systems workforce of trained and active com- are stretched thin, and rural and underserved munity health workers – from 3,380 areas often lack adequate primary healthcare in 2018 to 8,300 in 2022. coverage, delaying essential interventions and leaving populations vulnerable to preventable The number of technical health staff diseases. Mozambique was no exception. The assigned to primary care services country had particularly poor health outcomes went up by one-third, reaching among its peers, with high rates of stunting (40%) 22,086 in 2022. and malnutrition, as well as one of the highest The project expanded community rates of child marriage and adolescent fertility in access to health services from 1.7 the world. Its share of deaths from communicable million households to 3.6 million, diseases and maternal, perinatal, and nutritional leading to more home visits and conditions was 62% – three times the global aver- community gatherings on critical age. Only half of births were attended by a skilled health topics, and improving health professional, and the neonatal mortality rate was outcomes. 27.9 per 1,000 live births. But the problem went beyond reach and access: providers had weak Almost 6 million skilled deliveries at competencies, clinical guidelines were often not birth were facilitated between 2017 adhered to, and there were high levels of dropout and 2022 by enhancing healthcare for child immunization. To improve health out- access and quality of primary care comes, Mozambique would have to increase both services. coverage and quality of service. WBG APPROACH For twenty years, the World Bank has supported Mozambique’s efforts to improve its healthcare system. From 2018–2023, interventions through the Mozambique Primary Health Care Strengthening Program improved the coverage and quality of primary health care services, as well as the financial sustainability and stewardship of the health system. The effort targeted outcomes, using a Program for Results model: A disbursement-linked indicator incentivized the delivery of sexual reproductive health information and services in secondary and tech- nical schools, and the project facilitated the introduction of performance scorecards in district hospitals, which received additional funds based on agreed results. A key component was training and deploying community health workers (CHW), especially in rural and under- served areas. These workers bridge the gap between communities and formal health facilities, providing basic care, health education, and timely referrals. One of the sector’s challenges had been low worker motivation, accountability, and knowledge. Under the project, CHWs were trained on basic clinical skills, health promotion, and digital data collection, and their roles were formalized (with salaries and career pathways) to boost retention and professional growth. LESSONS LEARNED A key lesson was the importance of being proactive in the face of challenges. The program underwent multiple restructurings to adapt to the COVID-19 pandemic, two cyclones in 2019, escalating conflict in the North, and fluctuations in the co-financing resource envelope from health partners. Additionally, getting funds to the lowest administrative level enabled the decentralization of functions like budget execution and re-programming. A new- ly launched program, which began in March 2024, is incorporating this lesson into its approach by focusing on the district levels. NEXT STEPS The World Bank will be building on the project’s success by supporting reforms through more sustainable and cost-effective systems – for example, strengthening the supply chain using digital innovation for track-and- trace, and encouraging the government to adopt a fixed price list for imports of essential commodities. More broadly, the CHW network model could be adopted in other country contexts; it is particularly effective in low-income and fragile settings, where the health workforce is limited, and could help reduce the global shortage of 18 million health care workers that must be reached by 2030. I used to walk for about two hours to reach the nearest healthcare unit or spend a sub- stantial amount of money on transport every time a family member needed assistance. Now, unless it is a severe condition, the com- munity health worker comes to our house and provides the care we need. — Matola Mourana, 38, resident of Moamba District, Maputo Province, Mozambique