Vertical funding, non-governmental organizations, and health system strengthening: perspectives of public sector health workers in Mozambique

Background: In the rapid scale-up of human immunodeficiency virus (HIV) care and acquired immunodeficiency syndrome (AIDS) treatment, many donors have chosen to channel their funds to non-governmental organizations and other private partners rather than public sector systems. This approach has reinforced a private sector, vertical approach to addressing the HIV epidemic. As progress on stemming the epidemic has stalled in some areas, there is a growing recognition that overall health system strengthening, including health workforce development, will be essential to meet AIDS treatment goals. Mozambique has experienced an especially dramatic increase in disease-specific support over the last eight years. We explored the perspectives and experiences of key Mozambican public sector health managers who coordinate, implement, and manage the myriad donor-driven projects and agencies. Methods: Over a four-month period, we conducted 41 individual qualitative interviews with key Ministry workers at three levels in the Mozambique national health system, using open-ended semi-structured interview guides. We also reviewed planning documents. Results: All respondents emphasized the value and importance of international aid and vertical funding to the health sector and each highlighted program successes that were made possible by recent increased aid flows. However, three serious concerns emerged: 1) difficulties coordinating external resources and challenges to local control over the use of resources channeled to international private organizations; 2) inequalities created within the health system produced by vertical funds channeled to specific services while other sectors remain under-resourced; and 3) the exodus of health workers from the public sector health system provoked by large disparities in salaries and work. Conclusions: The Ministry of Health attempted to coordinate aid by implementing a "sector-wide approach" to bring the partners together in setting priorities, harmonizing planning, and coordinating support. Only 14% of overall health sector funding was channeled through this coordinating process by 2008, however. The vertical approach starved the Ministry of support for its administrative functions. The exodus of health workers from the public sector to international and private organizations emerged as the issue of greatest concern to the managers and health workers interviewed. Few studies have addressed the growing phenomenon of "internal brain drain" in Africa which proved to be of greater concern to Mozambique's health managers.