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Dispatch No. 297 | 7 May 2019 Cyclones add to Mozambique’s public health challenges Afrobarometer Dispatch No. 297 | Thomas Isbell and Sadhiska Bhoojedhur Summary After two cyclones leaving death and devastation in their wake (eNCA, 2019a; 2019b), Mozambique faces a post-disaster danger – cholera. While endemic to Mozambique, cholera infections skyrocketed after the recent storms, leading the Ministry of Health and international partners to launch massive vaccination campaigns (World Health Organization, 2019a; Mbah, 2019). The outbreak shines a spotlight on Mozambique’s health-care and infrastructure sectors as rapid treatment and access to safe water and sanitation are vital to stopping the spread of cholera – but difficult to provide to hundreds of thousands of citizens in hard-hit areas. Even before the cyclones, Mozambique struggled to ensure adequate health care and infrastructure amid challenges such as high levels of poverty and food insecurity (Allianz Care, 2019; Ministry of Health, 2014). While health-care access, financing, infrastructure, and staffing have improved since the end of the civil war in 1992 (Allianz Care, 2019; World Health Organization, 2019b; Pose, Engel, Poncin, & Manuel, 2014), the country’s health sector continues to rely on external financial support – and will likely need more in the wake of Idai and Kenneth. In a national Afrobarometer survey in mid-2018, a majority of Mozambicans expressed satisfaction with the government’s progress in improving basic health services, as well as with their own experiences at public health facilities. But almost two-thirds of citizens – and almost all of the poorest citizens – reported going without needed care during the previous year. Afrobarometer survey Afrobarometer is a pan-African, non-partisan research network that conducts public attitude surveys on democracy, governance, economic conditions, and related issues in African countries. Six rounds of surveys were conducted in up to 37 countries between 1999 and 2015, and findings of Round 7 surveys (2016/2018) are currently being disseminated. Afrobarometer conducts face-to-face interviews in the language of the respondent’s choice with nationally representative samples. The Afrobarometer team in Mozambique, led by Ipsos Mozambique, interviewed a nationally representative, random, stratified probability sample of 2,400 adult Mozambicans between 13 June and 26 August 2018. A sample of this size yields country-level results with a margin of error of +/-2 percentage points at a 95% confidence level. Previous surveys have been conducted in Mozambique in 2002, 2005, 2008, 2012, and 2015. Copyright ©Afrobarometer 2019 1
Key findings
▪ As of mid-2018, more than six in 10 Mozambicans (63%) said they went without
needed health-care services during the previous year, including 41% who said this
happened “several times,” “many times,” or “always.” Among the poorest
respondents, almost all (98%) said they went without medical care at least once.
▪ About four in 10 Mozambicans (37%) said their ability to get medical care has
improved in recent years, while about half as many (21%) said it has worsened.
▪ Among respondents who sought services at a public clinic or hospital during the
previous year, two-thirds (65%) said it was “easy” or “very easy” to get the care they
needed, a substantial improvement from previous survey rounds. Poor and less-
educated citizens were less likely to find it easy to obtain care.
▪ Two-thirds of Mozambicans who sought medical care said they received services
either “right away” (20%) or “after a short time” (46%). But almost one in five (17%)
said they had to pay a bribe to get care.
▪ Health ranks sixth among the most important problems that Mozambicans want the
government to address, down from the top spot in 2015.
▪ A majority (56%) of Mozambicans said the government was performing “fairly well” or
“very well” on improving basic health services, but this reflects a 20-percentage-point
decline since 2008. Only 44% said the government was doing a good job of providing
water and sanitation services.
Access to medical care
In mid-2018, more than six in 10 Mozambicans (63%) said they went without needed medical
care at least once during the previous year, including 26% who said this happened “several
times” and 15% who said they lacked care “many times” or “always” (Figure 1).
Figure 1: Went without medical care | Mozambique | 2018
100%
80%
60%
40% 37%
26%
21%
20% 15%
0%
Never Just once or twice Several times Many times/Always
Respondents were asked: Over the past year, how often, if ever, have you or anyone in your family
gone without medicines or medical treatment?
Copyright ©Afrobarometer 2019 2Poor Mozambicans were especially likely to go without needed health care. Among
respondents who experienced high lived poverty,1 only one in 50 (2%) said they “never” went
without care, compared to 16%, 53%, and 100% of those with moderate, low, or no lived
poverty (Figure 2). Similarly, Mozambicans with more education were less likely to be
deprived of medical care. But even among those with post-secondary education, more than
half (55%) said they lacked care at least once.
Figure 2: Went without medical care | by socio demographic group | Mozambique
| 2018
Rural 31% 51% 17%
Urban 46% 42% 11%
56+ years old 44% 41% 15%
36-55 years old 34% 50% 15%
18-35 years old 37% 47% 15%
Post-secondary 45% 43% 12%
Secondary 41% 46% 11%
Primary 34% 50% 15%
No formal education 27% 48% 22%
High lived poverty 2% 36% 63%
Moderate lived poverty 16% 74% 11%
Low lived poverty 53% 46% 1%
No lived poverty 100% 0%
Inhambane 71% 25% 4%
Cidade de Maputo 68% 27% 4%
Niassa 64% 23% 13%
Maputo Provincia 62% 36% 2%
Gaza 53% 46% 1%
Manica 47% 32% 21%
Sofala 43% 48% 9%
Cabo Delgado 36% 43% 18%
Nampula 18% 69% 11%
Tete 18% 54% 28%
Zambezia 14% 54% 29%
0% 20% 40% 60% 80% 100%
Never Just once or twice/Several times Many times/Always
Respondents were asked: Over the past year, how often, if ever, have you or anyone in your family
gone without medicines or medical treatment?
1
Afrobarometer assesses lived poverty based on responses to the following questions: “Over the past year,
how often, if ever, have you or anyone in your family gone without: Enough food to eat? Enough clean water
for home use? Medicines or medical treatment? Enough fuel to cook your food? A cash income?”
Copyright ©Afrobarometer 2019 3Rural residents were more likely than urbanites to go without care (68% vs. 53%). Regional
differences were also remarkable: While most respondents in Inhambane (71%) and Cicade
de Maputo (68%) said they “never” experienced going without medical care, fewer than
one in five in the northern, less developed regions of Nampula (18%), Tete (18%), and
Zambezia (14%) could say the same. Almost three in 10 residents of Zambezia (29%) and Tete
(28%) said they went without medical care “many times” or “always.”
The share of Mozambicans who went without needed medical care increased by 20
percentage points over the past decade, climbing back to about the same level as in 2002
and 2005 (Figure 3). Only in the most recent survey round did deprivation drop again, by just
4 points, including a 10-point drop (from 25% to 15%) in the proportion who went without care
“many times” or “always.”
Figure 3: Trend in going without medical care | Mozambique | 2002-2018
100%
80%
66% 67%
63% 63%
60% 56%
52%
40% 47%
43%
36% 37%
34%
31%
20%
0%
2002 2005 2008 2012 2016 2018
Never Just once or twice/Several times/Many times/Always
Respondents were asked: Over the past year, how often, if ever, have you or anyone in your family
gone without medicines or medical treatment?
Overall, about four in 10 Mozambicans (37%) said their ability to get medical care when they
need it has improved in the past few years, while about half as many (21%) said it has gotten
worse and 37% saw no change (Figure 4).
Older Mozambicans (40% of those over 55 years of age), as well as those with at least a
secondary education (42%), were more likely to report improvements in access to medical
care. But respondents with high levels of lived poverty were more likely to report worsening
accessibility of medical care (26%), as were residents of Manica (38%), Nampula (23%), and
Cabo Delgado (23%) regions.
Copyright ©Afrobarometer 2019 4Figure 4: Better or worse: Ability to get medical care | by socio-demographic group
| Mozambique | 2018
Average 37% 37% 21%
Rural 36% 38% 20%
Urban 39% 36% 21%
56+ years old 40% 27% 23%
36-55 years old 36% 39% 21%
18-35 years old 37% 38% 20%
Post-secondary 42% 40% 18%
Secondary 42% 37% 20%
Primary 35% 38% 23%
No formal education 31% 34% 21%
High lived poverty 29% 38% 26%
Moderate lived poverty 37% 36% 22%
Low lived poverty 41% 36% 19%
No lived poverty 37% 46% 15%
Niassa 56% 26% 18%
Cidade de Maputo 49% 34% 16%
Maputo Provincia 46% 31% 22%
Tete 46% 26% 11%
Sofala 44% 31% 21%
Gaza 33% 51% 15%
Inhambane 32% 49% 19%
Manica 32% 26% 38%
Cabo Delgado 31% 41% 23%
Zambezia 31% 48% 19%
Nampula 30% 38% 23%
0% 20% 40% 60% 80% 100%
Better/Much better Same Worse/Much worse
Respondents were asked: Please tell me if the following things are worse or better now than they were
a few years ago, or are they about the same: Your ability to get medical care when you need it?
Experiences with medical care
Among the 75% of Mozambicans who said they had contact with a public clinic or hospital
during the 12 months preceding the survey, two-thirds (65%) said it was “easy” or “very easy”
to get the care they needed. The proportion of respondents who report difficulty in obtaining
care declined substantially between 2012 (53%) and 2018 (35%) (Figure 5).
Respondents with moderate (39%) or high lived poverty (33%) were most likely to say they
found it difficult to obtain required medical treatment (Figure 6). Again, regional differences
were large: While more than eight in 10 residents of Inhambane (87%) and Tete (83%) said it
was easy to get care, only half said so in Maputo Provincia (52%) and Zambezia (51%).
Copyright ©Afrobarometer 2019 5Figure 5: Difficulty obtaining medical care | Mozambique | 2005-2018
100%
80%
53% 55%
60%
52% 65%
40% 47%
45% 44%
35%
20%
0%
2005 2012 2016 2018
Easy/Very easy Difficult/Very difficult
Respondents who had contact with a public clinic or hospital were asked: How easy or difficult was it to
obtain the medical care you needed? (Respondents who had no contact with a public clinic or
hospital are excluded.)
Figure 6: Difficulty obtaining medical care | by socio-demographic group
| Mozambique | 2018
Post-secondary 65% 34%
Secondary 65% 34%
Primary 64% 33%
No formal education 53% 34%
High lived poverty 55% 33%
Moderate lived poverty 57% 39%
Low lived poverty 69% 31%
No lived poverty 76% 24%
Inhambane 87% 13%
Tete 83% 17%
Sofala 74% 26%
Cidade de Maputo 67% 33%
Gaza 66% 34%
Manica 65% 35%
Niassa 65% 35%
Nampula 59% 38%
Cabo Delgado 58% 40%
Maputo Provincia 52% 48%
Zambezia 51% 33%
0% 20% 40% 60% 80% 100%
Easy/Very easy Difficult/Very difficult
Respondents who had contact with a public clinic or hospital were asked: How easy or difficult was it to
obtain the medical care you needed? (Respondents who had no contact with a public clinic or
hospital are excluded.)
Copyright ©Afrobarometer 2019 6Among respondents who sought care at a public clinic or hospital during the previous year,
almost two out of three said they received care “right away” (19%) or “after a short time”
(44%), while one in three reported having to wait “a long time” (33%) or never receiving
services (1%) (Figure 7).
Figure 7: Time taken to receive medical care | Mozambique | 2018
100%
80%
60%
46%
40% 33%
20%
20%
1%
0%
Right away After a short time After a long time Never
Respondents who had contact with a public clinic or hospital were asked: How long did it take you to
receive the medical care that you needed? (Respondents who had no contact with a public clinic or
hospital are excluded.)
While most patients reported getting care easily and without long delays, almost one-fifth
(17%) said they had to pay a bribe to obtain the services they needed (Figure 8).
Figure 8: Paid bribe to obtain medical care | Mozambique | 2018
100%
78%
80%
60%
40%
17%
20%
4%
0%
Never Once or twice/A few Refused/Don't know
times/Often
Respondents who had contact with a public clinic or hospital were asked: How often, if ever, did you
have to pay a bribe, give a gift, or do a favour for a health worker or clinic or hospital staff in order to
get the medical care you needed? (Respondents who had no contact with a public clinic or hospital
are excluded.)
Copyright ©Afrobarometer 2019 7Government performance
Health ranked sixth among the most important problems that Mozambicans wanted their
government to address, cited by 21% of respondents as one of up to three priorities. While still
seen as an important issue, health dropped from the No. 1 ranking in 2015, when almost
twice as many respondents (38%) cited it as a top priority (Figure 9).
Figure 9: Most important problems | Mozambique | 2015-2018
Unemployment 36%
49%
Water supply 25%
29%
Electricity 19%
26%
Poverty/Destitution 12%
25%
Infrastructure/Roads 13%
24%
Health 38%
21%
Transportation 12%
15%
Management of the economy 4%
14%
Education 34%
11%
Corruption 5%
11%
0% 20% 40% 60%
2015 2018
Respondents were asked: In your opinion, what are the most important problems facing this country
that government should address? (Up to three responses per respondent were recorded.)
A majority (56%) of Mozambicans said the government was performing “fairly well” or “very
well” in improving basic health services. While this was a slight improvement from 2015 (52%),
it was a far less positive assessment than citizens offered a decade earlier (76% approval in
2008) (Figure 10).
Approval of the government’s performance on health care increased with respondents’
level of education and economic status, suggesting that citizens who are less well-off and
less educated are benefiting less from improvements in health care. Only about half of
respondents with no formal education (52%) and with high lived poverty (49%) praised the
government’s performance, compared to more than two-thirds of those with post-secondary
education (70%) and with no lived poverty (67%) (Figure 11).
Regional differences were again pronounced, ranging from 42% in Gaza to 79% approval in
Inhambane (79%) and Sofala (79%) Partisan differences2 were also reflected in appraisals of
the government’s performance on health care: While six of 10 supporters of the ruling Frelimo
party (61%) approved of the government’s performance, a majority (55%) of Renamo
supporters disapproved.
2
Afrobarometer assesses political-party affiliation based on responses to the questions “Do you feel close to
any particular political party?” and, if yes, “Which party is that?”
Copyright ©Afrobarometer 2019 8Figure 10: Government performance in improving basic health services
| Mozambique | 2002-2018
100%
76%
80% 70%
59% 62%
52% 56%
60%
40%
34% 38% 37%
20% 33%
25%
18%
0%
2002 2005 2008 2012 2016 2018
Fairly badly/Very badly Fairly well/Very well
Respondents were asked: How well or badly would you say the current government is handling the
following matters, or haven’t you heard enough to say: Improving basic health services?
Figure 11: Government performance in improving basic health services
| by socio-demographic group | Mozambique | 2018
56+ years old 64% 36%
36-55 years old 60% 40%
18-35 years old 59% 41%
Post-secondary 70% 30%
Secondary 63% 37%
Primary 57% 43%
No formal education 52% 48%
High lived poverty 49% 51%
Moderate lived poverty 58% 42%
Low lived poverty 64% 36%
No lived poverty 67% 33%
Inhambane 79% 21%
Sofala 79% 21%
Tete 71% 29%
Cidade de Maputo 68% 32%
Maputo Provincia 63% 37%
Manica 57% 43%
Nampula 57% 43%
Zambezia 57% 43%
Cabo Delgado 48% 52%
Niassa 45% 55%
Gaza 42% 58%
Renamo supporters 45% 55%
Frelimo supporters 61% 39%
0% 20% 40% 60% 80% 100%
Fairly well/Very well Fairly badly/Very badly
Respondents were asked: How well or badly would you say the current government is handling the
following matters, or haven’t you heard enough to say: Improving basic health services?
Copyright ©Afrobarometer 2019 9Water and sanitation
Heavy storm damage to Mozambique’s infrastructure multiplies persistent challenges in
providing the population with clean water and sanitation and facilitates the spread of
cholera and other diseases (World Health Organization, 2019; Mari et al., 2012; Reliefweb,
2019).
As of mid-2018, two-thirds (65%) of Mozambicans said the source of their water for household
use lay outside their compound. Only about one in three said they had a water source within
the home (3%) or the compound (31%) (Figure 12). Rural residents were about twice as likely
as their urban counterparts to have to leave the compound to access water (80% vs. 42%).
Similarly, respondents with high or moderate lived poverty were more likely to have to go
outside their compound to get water (74%-80%, vs. 47%-57% of those with low or no lived
poverty).
Figure 12: Source of water for household use | by residence location and lived
poverty | Mozambique | 2018
Average 3% 31% 65%
Rural 1% 19% 80%
Urban 7% 51% 42%
High lived poverty 1% 19% 80%
Moderate lived poverty 1% 24% 74%
Low lived poverty 5% 39% 57%
No lived poverty 8% 46% 47%
0% 20% 40% 60% 80% 100%
Inside the house Inside the compound Outside the compound
Respondents were asked: Please tell me whether each of the following are available inside your house,
inside your compound, or outside your compound: Your main source of water for household use?
With regard to sanitation, more than two-thirds (68%) of Mozambicans said they had access
to a latrine or toilet within their compound, in addition to 6% who had these inside the home
(Figure 13). One in four respondents (24%) said the latrine they used was outside their
compound, while 1% said they had no access to a latrine. As might be expected, poor
respondents and rural residents were considerably more likely than their better-off and urban
counterparts to have no latrine inside the compound.
Copyright ©Afrobarometer 2019 10Figure 13: Access to toilet or latrine | by residence location and lived poverty
| Mozambique | 2018
Average 6% 67% 24% 1%
Rural 3% 64% 31% 2%
Urban 12% 75% 13% 1%
High lived poverty 3% 55% 40% 2%
Moderate lived poverty 4% 71% 24% 1%
Low lived poverty 8% 71% 19% 1%
No lived poverty 11% 70% 17% 2%
0% 20% 40% 60% 80% 100%
Inside the house Inside the compound
Outside the compound No latrine
Respondents were asked: Please tell me whether each of the following are available inside your house,
inside your compound, or outside your compound: A toilet or latrine?
Mozambicans were divided in their assessments of the government’s performance in
providing water and sanitation services. Half (50%) said the government was doing “fairly
well” or “very well,” while 44% said the opposite. Except for high points in 2005 (51%) and 2008
(55%), approval of the government’s performance in this sector has consistently been a
minority view (Figure 14).
Figure 14: Government performance in providing water and sanitation services
| Mozambique | 2002-2018
100%
80%
53% 55%
60% 51% 51% 50%
47%
40%
43% 44% 43% 44%
40% 37%
20%
0%
2002 2005 2008 2012 2016 2018
Fairly badly/Very badly Fairly well/Very well
Copyright ©Afrobarometer 2019 11Respondents were asked: How well or badly would you say the current government is handling the
following matters, or haven’t you heard enough to say: Providing water and sanitation services?
Conclusion
As of mid-2018, a majority of Mozambicans were satisfied with the government’s
performance in improving basic health care, but that majority was dwindling – by 20
percentage points over the past decade. Most had no complaints about difficulties or
delays in getting care, yet almost two-thirds – and even more poor, less-educated, and rural
Mozambicans – had gone without needed care during the previous year. Post-Idai and
Kenneth, the country’s health sector and water/sanitation infrastructure are certain to need
even greater attention to face down the threat of cholera, to get back to 2018 levels, and to
move forward.
Do your own analysis of Afrobarometer data – on any question,
for any country and survey round. It’s easy and free at
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Copyright ©Afrobarometer 2019 12References
Allianz Care. (2019). Healthcare in Mozambique. https://www.allianzworldwidecare.com/en/
support/health-and-wellness/national-healthcare-systems/healthcare-in-mozambique/.
eNCA. (2019a). Cyclone Idai's death toll nears 1,000 in Mozambique, Zimbabwe. 10 April.
https://www.enca.com/news/cyclone-idais-death-toll-nears-1000-mozambique-zimbabwe.
eNCA. (2019b). Rescuers struggle to reach Mozambique cyclone victims. 28 April.
https://www.enca.com/news/rescuers-struggle-reach-mozambique-cyclone-victims.
Mari, L., Bertuzzo, E., Righetto, L., Casagrandi, R., Gatto, M., Rodriguez-Iturbe, I., & Rinaldo, A.
(2011). Modelling cholera epidemics: The role of waterways, human mobility and sanitation.
Journal of the Royal Society Interface, 9(67), 376-388.
Mbah, F. (2019). Cyclone Idai: Number of cholera cases surges in Mozambique.
https://www.aljazeera.com/news/2019/04/cyclone-idai-number-cholera-cases-surges-
mozambique-190402162730499.html.
Ministry of Health. (2014). Health sector strategic plan 2014-2019.
http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/mozambiq
ue/mozambique_-_health_sector_strategic_plan_-_2014-2019.pdf.
Reliefweb. (2019). Cyclone Idai and Floods Cause Massive Destruction, Deaths in Mozambique,
Zimbabwe, and Malawi. 18 March 2019. https://reliefweb.int/report/mozambique/cyclone-idai-
and-floods-cause-massive-destruction-deaths-mozambique-zimbabwe-and.
Pose, R. R., Engel, J., Poncin, A., Manuel, S. (2014). Against the odds: Mozambique’s gains in primary
health care. Overseas Development Institute. https://www.odi.org/sites/odi.org.uk/files/odi-
assets/publications-opinion-files/8981.pdf.
World Health Organization. (2019a). Cholera vaccination campaign begins in Mozambique.
https://www.who.int/news-room/detail/03-04-2019-cholera-vaccination-campaign-begins-in-
mozambique.
World Health Organization. (2019b). Mozambique's health system.
https://www.who.int/countries/moz/areas/health_system/en/index1.html.
Copyright ©Afrobarometer 2019 13Thomas Isbell is a PhD student at the University of Cape Town in South Africa. Email:
tisbell@afrobarometer.org.
Sadhiska Bhoojedhur is a research analyst at StraConsult Ltd, the Afrobarometer national
partner in Mauritius. Email: sadhiska.bhoojedhur@gmail.com.
Afrobarometer is produced collaboratively by social scientists from more than 30 African
countries. Coordination is provided by the Center for Democratic Development (CDD) in
Ghana, the Institute for Justice and Reconciliation (IJR) in South Africa, the Institute for
Development Studies (IDS) at the University of Nairobi in Kenya, and the Institute for Empirical
Research in Political Economy (IREEP) in Benin. Michigan State University (MSU) and the
University of Cape Town (UCT) provide technical support to the network.
Financial support for Afrobarometer Round 7 has been provided by the Swedish International
Development Cooperation Agency (SIDA), the Mo Ibrahim Foundation, the Open Society
Foundations, the Bill & Melinda Gates Foundation, the William and Flora Hewlett Foundation,
the U.S. State Department, the U.S. Agency for International Development via the U.S.
Institute of Peace, the National Endowment for Democracy, and Transparency International.
Donations help the Afrobarometer Project give voice to African citizens. Please consider
making a contribution (at www.afrobarometer.org) or contact Felix Biga
(felixbiga@afrobarometer.org) to discuss institutional funding.
For more information, please visit www.afrobarometer.org.
/Afrobarometer @Afrobarometer
Afrobarometer Dispatch No. 297 | 7 May 2019
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