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Decentralization of Health Services in Mozambique: A Look at the

Process of Transferring Health Services to Authorities in the

Context of Decentralization of Care to the State Representation

Councils and Provincial Executive Councils

Criscêncio Luís Sande Botão, Emília José Alberto Manuel, Nélia Lobo Jaime

methodology was used through the technique of bibliographical review of books, articles, dissertations, which allowed to

highlight the need to transfer or create the financial, human and material resources necessary to guarantee the viability of the

services, once assumed by the municipalities. Likewise, it justifies the need for the Central Government to stop prioritizing its

coordination through the OLE (provincial and district governments) only through this route, privileging the municipalities.

Finally, it emphasizes the need to sign more memoranda of a binding nature so that the process of transferring health services can

take place.

Keywords: Decentralization of Health Services, Municipalities, State Representation Council, Provincial Executive Council

I. Introduction

For a decentralization process to be successful, it must be based on an equal process of deconcentration. According to Taveira

(2011), the State can either carry out the administrative activities constitutionally entrusted to it itself or perform them through

materializing.

The methodology used is qualitative, using a bibliographic review of books, articles, dissertations, and legislation on the

centralization and decentralization process

Based on Law No. 02/97 of May 28, the legal framework for the implementation of local authorities was created, under Article

135.1 of the Constitution of the Republic of Mozambique (CRM).

Consequently, Decree No. 33/2006 of August 30 established the framework for the transfer of functions and powers to local

authorities, including health, as stated in Article 12 of the aforementioned decree.

However, its implementation began in 1998. However, approximately 16 years later, only one (Maputo City Council) of the 53

municipalities has assumed some of the powers granted by the aforementioned Decree.

Meanwhile, through Decree No. 63/2020, which regulates Law No. 7/2019, of May 31, which establishes the legal framework for

Authorities (SPS). Now, given the facts, the question that arises is, what barriers contribute to the process of transferring

competencies in the health area not having its normal follow-up, aiming to cover all municipalities in Mozambique?

II. Review Of Literaturereview Of Literature

Municipalities and their creation

The first socialist-oriented government, established in 1975 with the proclamation of national independence from Portuguese

colonization, adopted a popular democracy political regime, in accordance with Articles 1 and 4, § 5 of the Constitution of the

People's Republic of Mozambique (CRPM, 1975) (Simione et al., 2018. P: 529).

Consequently, in the administrative sphere, the approval of Decree No. 1/75 of July 27, which established the organization of

public administration for the central apparatus, and Laws No. 5/78; 6/78; and 7/78, both of April 22, which established,

respectively, the regulation of the functions of provincial governments; the abolition of all colonial administrative bodies and the

approved provisions in Mozambique necessarily involve knowledge of some aspects related to decentralization, which embody

the knowledge of municipalization, whose legal aspects were described in the "Municipal Legislation Package enacted in 1997

and reformulated in 2007 and 2008" (Ezekwesili et al. 2009, p. 15).

Municipalities were established by law in Mozambique in 1997, and local elections were held for the first time in 1998

(Ezekwesili et al. 2009).

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As such, decentralization in Mozambique emerged in a context of transition from a socialist regime to multiparty democracy. It

was linked to the strengthening of democracy and the greater involvement of new actors, such as civil society, in participatory

governance practices, removing the dominance of the public sphere by the centralized state in the provision of public services

(Ombe and Catique, 2017).

However, Law 2/97 established the legal framework for the creation of the first 33 local authorities and the holding of the first

Once the legal framework for transferring health services to municipalities has been created, knowledge of the legal reasons for

this constitutes gray literature, and other reasons should be listed, as emphasized by Forquilha et al. (2018), citing Notícias, 2015.

In this regard, the central government's discourse attributes the slowness in transferring functions and powers to local authorities

to the lack of technical, material, and financial resources and capacity on the part of the municipalities requesting the transfer of

these services. For municipalities, particularly those under the management of the Democratic Movement of Mozambique

(MDM) (especially the municipality of Beira), the slowness and/or "hesitation" in transferring functions and powers is explained

by a mere "political maneuver" on the part of the central government, aimed at hindering the work of municipalities.

In any case, the aforementioned argument that municipalities lack technical, material, and financial resources and capabilities as

the reason for the slow transfer process is contradictory, since decentralization implies that the central government not only

transfers functions and powers, but also resources (human, material, financial, etc.). In the health sector, for example, transferring

To this end, Matsinhe & Namburete (2019) note that in the 1990s, Mozambique underwent significant political transformations,

with the democratic transition and the adoption of a new Constitution, which paved the way for the creation of the National

Health System (SNS) […] reestablishing the conditions for the provision of health services within a more complex framework,

which includes the decentralization process linked to territorial reorganization and the introduction of Municipal Authorities.

According to Ezekwesili et al. (2009), a strategy with clear criteria and methodologies for transferring state functions to

municipalities has not yet been fully developed, including the transfer or creation of the financial, human, and material resources

necessary to ensure the viability of services once they are taken over by municipalities. This situation is further aggravated by

Mozambique's tendency toward a highly centralized political system and the lack of a vehicle for expressing the challenges facing

municipalities in a coordinated manner, as well as the limited role municipalities have to play in national debates on public sector

reform and poverty reduction, among other issues.

decentralization as an action to strengthen the health system in Mozambique by bringing services closer to the user and an

indispensable condition for improving the provision of quality services (MISAU, 2014, cited by Mbofana, 2018), on the other

Health has its own specificities due to the nature of its activity. It is in this sense that, according to Zoon et al. (2017), cited by

Mbofana (2018), they list four types of health service decentralization. It is important to observe the four types of health service

decentralization:

a) Decentralization when the authority shifts to provincial or district offices;

b) Devolution when the shift is to provincial or municipal governments;

c) Delegation when semi-autonomous agencies receive new powers; and

d) Privatization when ownership is granted to private entities.

Therefore, the devolution related to the shift to provincial or municipal governments still seems to be a pipe dream, measured by

the number of municipalities to which services have been transferred.

Since the early 2000s, municipalization has been characterized by the introduction of rules that have evolved in ways that are

The Central Government's Action in Decentralizing Health Services to Local Authorities

According to Simione et al. (2018), regarding public policies, the Central Government prioritizes coordination through the OLE

(provincial and district governments) and their agencies, rather than through municipalities. Since public policies in Mozambique

are mostly pre-established or adopted through programs developed nationwide by the central government and operationalized

through the OLE, the latter wield significant political influence, as they play an important role in ensuring compliance with

nationally established goals, which tends to reduce the autonomy of municipalities in managing national policies.

Clearly, the aforementioned approach can significantly reduce the willingness of municipalities to act accordingly so that services

can be effectively transferred, with all the attendant constraints, including the necessary financial, human, and material resources.

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What has been observed are attempts marked by political and administrative fears and boycotts, highlighting resistance from

higher authorities to the reforms intended with the implementation of this decree. After analyzing the feasibility of transferring

more responsibilities in the areas of primary healthcare, elementary education, and transportation, the Gaza Provincial

Government and the municipalities of Xai-Xai and Chibuto, through their leadership, signed two memorandums of understanding

that defined the transfer of services in these areas to these municipalities in 2013 (Ombe and Catique, 2017).

However, despite the interest and attention that should be paid to political settlement, almost 16 years later, the memorandum has

significant political and administrative influence over municipal structures. This distribution of power between governmental

spheres can also be seen in Law No. 6/2007, of February 9, which granted supervisory powers to the governor and the provincial

government's collective body, whose actions often tend to determine the municipalities' policy behavior. Ombe and Catique

(2017) further argue that, in the application of this law, it is clear that the compatibility of the principle of autonomy with that of

interdependence, resulting from the division of functions and powers between levels of government, has not worked effectively,

as significant interference tends to hinder innovation and the development of municipal actions. Regarding the sharing of

resources and municipal revenue, one of the main aspects relates to the inadequacy of the legal mechanisms that guide fiscal

decentralization to provide the financial resources required in the management of local public policies.

Although municipal governments' autonomy has developed fiscal practices never before seen in the national context, the central

government holds greater taxing powers and the capacity to finance public policies. Law No. 11/1997, of May 31, created a

regime for municipal finances and taxes that entailed new forms of coordination between the central, provincial, and municipal

The health sector in Mozambique, like other sectors, has been undergoing important reforms in recent years, particularly within

Consequently, health responses within the scope of decentralization and beyond have been observing the aspects of the 2014-

2019 Health Sector Strategic Plan, as one of the commitments, according to Mbofana (2018), citing MISAU (2014), stems from

the fact that MISAU has embraced effective decentralization as an action to strengthen the health system in Mozambique by

bringing services closer to users and as an essential condition for improving the provision of quality services.

particularly at the primary level (Forquilha et al., 2018).

improvement in the provision of health services, especially primary care. In reality, the context in which the reforms are

decentralization is an inherently highly political process, whose effects and outcomes are strongly influenced by contextual

involves political will.

However, despite the absence of a clear policy and strategy, Mozambique has opted for a decentralization model that combines

decentralized and deconcentrated institutions, but also, as a result, leads to conflict between districts and municipalities in

municipalized spaces (Forquilha et al., 2018).

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governments) and their agencies rather than through municipalities, this is substantiated by the fact that municipal governments

have no guarantees (despite legal provision) that the central and provincial governments will act if the transfer of further

responsibilities is implemented. There is an urgent need to, on the one hand, observe the specificities of the health sector, listing

the four types of decentralization of health services in a careful and technically operational manner, specifically with regard to

devolution when the transfer is to provincial or municipal governments, highlighted in identical memoranda. those signed in 2013