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Situational Analysis on Health Equity and Social Determinants of Health, Tete Province, Mozambique

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Situational Analysis on Health Equity and Social Determinants of Health, Tete Province, Mozambique República de Moçambique Governo Provincial de Tete Direção Provincial de Saúde Situational analysis on health equity and social determinants of health, Tete Province, Mozambique Tete, February 2015 Situational analysis on health equity and social determinants of health, Tete Province, Mozambique Rene Loewenson and Sarah Simpson Training and Research Support Centre In co-operation with DPS Tete and Embassy of Denmark Mozambique, February 2015 Table of Contents Executive Summary ...................................................................................................................... 2 1. Introduction ........................................................................................................................... 4 2. Methods ................................................................................................................................ 4 3. Contexts for and trends in social determinants of health equity ............................................ 5 3.1 Tete province and its population ............................................................................................ 5 3.2 Health status distribution and trends ..................................................................................... 7 3.3 Environmental assets and challenges for health ................................................................... 9 3.4 The economic context: high growth, high poverty, high inequality ...................................... 11 3.5 Expanding transport, energy, communications infrastructure ............................................. 15 3.6 Determinants of food security and chronic undernutrition ................................................... 17 3.7 Social development, education and social protection ......................................................... 19 3.8 Health service resources, coverage and distribution ........................................................... 21 3.9 Projections for key determinants ......................................................................................... 2 7 4. Areas of focus on SDH and health equity for the strategic plan .......................................... 30 4.1 Selecting areas of focus on SDH and health equity ............................................................ 30 4.2 Healthy living, working and community environments ......................................................... 31 4.3 Widening nutrition and health gains from agriculture and food markets ............................. 37 4.4 Enhancing equity in availability and access to priority health services ............................... 39 4.5 Strengthening corporate and community involvement and roles in health .......................... 42 5. Capacities, resources and co-ordination to deliver strategies ............................................. 45 5.1 Capacities to implement strategies on SDH and health equity ........................................... 46 5.2 Resourcing strategic interventions on social determinants ................................................. 48 5.3 Planning and co-ordinating social determinants and health equity ..................................... 50 6. References .......................................................................................................................... 51 7. Acronyms ............................................................................................................................ 57 8. Appendices ......................................................................................................................... 58 Appendix 8.1: Framework for analysis of SDH and health equity............................................................ 58 Appendix 8.2: Key informant interview list ............................................................................................... 59 Appendix 8.3: Economic developments in Tete Province, post 2005 ...................................................... 60 Appendix 8.4: Environmental laws and plans .......................................................................................... 62 Appendix 8.5: Tete Provincial government plan 2009 to 2014 ................................................................ 63 Appendix 8.6: Strategies in the Tete PESS undated ............................................................................... 64 Appendix 8.7 Overview of public social protection programmes ............................................................ 65 Appendix 8.8 Resources for EIA/ESIA/health impact assessment ......................................................... 66 Appendix 8.9: Statistical appendix: national and district data .................................................................. 67 Cite as: Loewenson R, Simpson S (2015) Situational analysis on health equity and social determinants of health, Tete Province, Mozambique. In co-operation with DPS Tete and Embassy of Denmark, Mozambique Training and Research Support Centre Acknowledgement and thanks to those who gave direction, review, inputs to the work including: From Tete DPS: chefias of the DPS Tete Carla das Dores T.P. Mosse Lazaro, Mulassua José Simango, Jorge Mário Real, Chief of Planning and Cooperation Department, Diederike Geelhoed, Technical Advisor SRHR at Tete Provincial Health Directorate for Ministry of Foreign Affairs of Denmark; João Manuel Cananda, José Manuel Meque, Calisto Leonardo Duzenta and DPS Tete colleagues, including those who participated in the consultative workshop. Key informants from other sectors in Tete province. From MISAU Mozambique: Dr Francisco Mbofana and Dr João Carlos de Timóteo Mavimbe Embassy of Denmark Mozambique: Kirsten Havermann, Mbate Pedro Matandalasse; Sanne Møller Jensen; Paulino D’Uamba, Mozambique. TARSC team/ support and further data: Marie Masotya, Laura Anselmi Photo credits: Cover Cattle trek home along a dry riverbed in Pacassa Village, Tete Province, Mozambique #1 photo credit: ILRI/Mann 2008 used under creative commons 1 Executive Summary In 2014 the Provincial Health Directorate (Direcção Provinciais de Saúde (DPS)) in Tete Province commissioned an assessment of evidence on social determinants of health (SDH) and health equity as input to its strategic five-year plan. The work was implemented between April 2014 and February 2015 through Training and Research Support Centre (TARSC), working in co-operation with DPS Tete and the Danish Embassy in Mozambique. This report presents the situational assessment on the current SDH and health inequities in Tete province. It outlines the current policies, institutions and services for addressing SDH and proposes options for strengthening responses to SDH and improving health equity in the province, within the three major goals of the PESS 2014-19. The assessment is based on published reports, government strategies and statistical evidence, key informant interviews and evidence from ad hoc surveys. The province has a health profile of: • Slow improvements in child survival and perinatal mortality and high maternal mortality; • High and early fertility, a mature and declining HIV epidemic, prevalent communicable disease (malaria, TB, diarrhoea, respiratory conditions) and reproductive health burdens; • Chronic undernutrition in children, adolescent females and lactating women and in poorest, food insecure households; and • Rising levels of non communicable disease (NCD), including transport accidents, circulatory problems, cancers, harmful alcohol use and occupational disease and injury. The 2014-2019 PESS priorities to reduce maternal, neonatal and under-5-year mortality, fertility, chronic malnutrition, endemic and NCDs are thus very relevant for Tete. However the province also needs to address a high population influx, improve birth registration, more rapidly accelerate reductions in IMR and U5MR; improve early screening and uptake of maternal health services, promote SRH in adolescents; sustain prevention interventions and promote improved water, sanitation, household energy and child nutrition. A double burden of communicable and NCDs in the next five years calls for a provincial survey of the distribution and determinants of NCDs to plan responses, and measures are proposed to raise population and health worker awareness on NCDs and for their prevention and early detection. Persistent chronic undernutrition in Tete arises from inadequate nutrient intake, prevalent infections and early pregnancy; poor access to or intake of nutritious food; deficits in health care, water and sanitation, poor food storage and processing; land pressures and a loss of biodiversity affecting food variety. Underlying this are low adult literacy, high poverty and gender inequalities. The distribution of undernutrition in districts would need to be surveyed to inform DPS work and contribution to intersectoral actions in the province. Education is a key SDH. Adult literacy in Tete is lower than national averages, as is enrolment, attendance in and completion of primary school, especially for girls. This undermines health and limits the coverage of health literacy and school health interventions. The rapidly growing economy in Tete from energy, mining and agriculture, investments in power, transport and communications infrastructure, population perception of an improved economic situation and fall in poverty are potentially positive features for health. However, this economic growth is dependent on capital intensive extractive activities, with low fiscal contributions and weak
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