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Preface“Mozambican men and women: We are dying!” It was withthese direct and clear words that, in his 2006 end of year message,the President of the Republic, Armando Emílio Guebuza,once again issued a warning to the nation, about the deadly HIVand AIDS pandemic, which now has reached the level of a truenational emergency.Despite the reinvigorated efforts by the government, civilsociety organisations, the private sector, and international partners,including the <strong>United</strong> Nations System, the number of peoplewho become infected every day remains extremely high – thereare an estimated 500 new adult HIV infections every 24 hours.The national HIV prevalence rate has risen from 13.3% in2002 to 16.3% in 2004 among those aged between 15 and 49years. This means that the pandemic is striking at the most economicallyactive age group of the population, with tragic economic,social and cultural consequences for the developmentand viability of Mozambique as a nation.While HIV prevalence rates are generally high in all threeregions (north, centre and south) of the country, it is the centralregion, covering the provinces of Sofala, Manica, Tete andZambézia, which is the most severely infected and affected, withan average rate of 20.4%, compared with 18.1% in the southernprovinces, and 9.3% on the north.It is under this scenario that the current report makes an indepthanalysis of the HIV and AIDS phenomenon inMozambique and its effects on the various dimensions of humandevelopment, including the capacity of people to lead long andhealthy lives, to enjoy access to knowledge, and to maintain adecent living standard.The Millennium <strong>Development</strong> Goals (MDGs) deal withvital aspects of human development, advocating the eradicationof poverty and hunger; the achievement of universal primaryeducation; gender equity and the empowerment ofwomen; the reduction of child mortality; the improvement ofmaternal health; the response to HIV and AIDS, malaria andother diseases; and environmental sustainability, all by 2015,as well as a global partnership for development.The impact of HIV and AIDS is a serious threat to the MDGs.It is now affecting negatively the development of Mozambique,exacerbating problems of poverty, malnutrition, poor schoolattendance and results, and gender disparities. Indeed, the estimatesindicate that HIV and AIDS in Mozambique could reduceper capita economic growth by between 0.3 and 1.0% per year.As a result, the reduction in poverty rates will be slower becauseof weaker economic growth.HIV and AIDS is a worldwide phenomenon; but sub-SaharanAfrica, with only 10% of the world’s population, has over twothirdsof the people living with HIV (25 million people). Almost2.8 million people became infected in 2006, and 70% of the twomillion deaths due to AIDS in the world have occurred in Africa.Southern Africa, where Mozambique is located, is the epicentreof the pandemic, with a third of the total number of HIVpositivepeople, and a third of all AIDS deaths.According to the UNAIDS annual report 2006, the countries ofthis region have the highest rates of HIV prevalence in the world.In Zimbabwe, about 20% of the population is infected, accordingto the World Health Organisation, and the numbers are over 20%in Botswana, Lesotho and Namibia. In South Africa some 5.5 millionpeople (UNAIDS 2006) including 240,000 children youngerthan 15 years were living with HIV in 2005. In Zambia a slightdecline in HIV infection levels – from 28% in 1994 to 25% in 2004– has been observed, especially in urban areas among pregnantwomen aged 15-39 years (Ministry of Health Zambia, 2005). TheKingdom of Swaziland, which also borders on Mozambique, hasthe highest rate in the world with a level of adult infection thatreaches more than one-third of the population.This scenario of a regional disaster impacts directly uponthe rate of spread of the epidemic in Mozambique, a countrythat is also marked by serious internal weaknesses and vulnerabilities,including infrastructural ones, and complex socio-culturalcontexts. Here the health network covers only about 50%of the population.Based on the literature available about the epidemic inMozambique, this report brings an independent intellectual discussionabout the disease in the country, as a phenomenonspreading in a generalised way among the various segments ofthe population.The report notes that, while the primary effects of the diseaseare devastating, at the individual, family, community and nationallevels, its secondary effects are equally serious, including the needto guarantee the survival and education of orphaned and vulnerablechildren, a reality that is a heavy burden for the present andfuture of Mozambique. The most recent studies show that 800,000people may die from the disease between 2004 and 2010, with asignificant increase in the number of orphans.The stigma associated with people living with, or affected byHIV and AIDS has led to still greater isolation and human suffering.The losses in productivity caused by deaths and prolongedperiods of illness associated with the virus that provokes AIDSconstitute a real threat to development and to governance, sinceiii


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007the indices of HIV prevalence in the public sector, including inthe health and education services, in agriculture and in thepolice, reach 17% of the qualified technical staff.Mozambique is a signatory to the Declaration of theMillennium <strong>Development</strong> Goals as well as other internationalpledges, including the undertaking adopted by the SpecialSession of the <strong>United</strong> Nations General Assembly on HIV andAIDS (UNGASS) and the Abuja Declaration, both of 2001, whichlay down measurable targets and objectives to reverse thespread of the pandemic, and call for the allocation of morerobust resources in response to the disease.These objectives have been fully appropriated nationally, inthe government’s Five Year Programme, made operational byPARPA II (2006-2009).The present report examines both the positive resultsachieved so far, and the prevailing constraints, in the context ofthe overall national response to HIV and AIDS. It presents seriousrecommendations, based on profound analyses of all theinformation available. Among the recommendations presented,the following stand out:• Continued reinforcement of the government’s strongpolitical commitment at the highest level, and of an efficientand systematic leadership, seeking to ensure the integrationof HIV and AIDS into the strategic plans of all sectors,including the private sector and civil society organisations,in a multi-sector perspective, coordinated by the NationalAIDS Council (CNCS);• Continued promotion of voluntary testing and counsellingas the way to ensure the provision of care and support, andthe reduction in stigma and discrimination;• Continued expansion of access to anti-retroviral treatment,under conditions of adequate technical and medical safety,and with the minimum nutritional levels required ofpatients;Prepared by ISRI, INE and SARDC for UNDPExecutive EditorTomás Vieira MárioThematic CoordinatorsDiogo Milagre and Rosa Marlene ManjateAuthors/ContributorsDiogo Milagre, Rosa Marlene Manjate, Felisbela Gaspar,Cristiano Matsinhe, Francisco Saúte, Mac-Arthur Jr., FranciscoSongane, Gertrudes Machatine, Manuel Gaspar, Sandra Manuel,Pedro Duce, Saide Dade, Elisa Mónica and Zuraida Khan.• Implementation of an effective, knowledge-based communicationsstrategy, which is integrated into the socioculturaldiversity of Mozambican communities;• Mitigation of the impact of the epidemic, by ensuringprogrammes to protect and support orphans and otherchildren who are vulnerable, due to the diseases associatedwith AIDS, and expanding the possibilities of preventingparental transmission of HIV;• Promotion of home and community-based care, and ofsocial support systems.To implement these recommendations, it is essential to followstrictly the objectives laid down by PARPA and the MDGs,including strengthening the budgetary provision. In order forthe National AIDS Council to perform to the full its tasks as thebody coordinating the multi-sector strategy for responses, itsauthorities, powers and resources must also be strengthened.Like the previous National <strong>Human</strong> <strong>Development</strong> <strong>Reports</strong>produced in Mozambique since 1998, the present documentwas written by a team of eminent consultants and advisors,under a dynamic partnership between the Higher Institute ofInternational Relations (ISRI) and the Southern AfricanResearch and Documentation Centre (SARDC) in Maputo, inclose collaboration with the National Statistics Institute (INE),the body responsible for the country’s official statistics.The institutions involved in preparing this report recognizethe important collaboration and support of the <strong>United</strong> Nations<strong>Development</strong> Programme (UNDP) at all levels, in particular theimportant contribution and support of the UNDP ResidentRepresentative in Mozambique, Mr Ndolamb Ngokwey.Comments and suggestions received from other UN agencies,including from outside Mozambique, have also contributed toenriching the final document.Dr. Joao Dias Loureiro, President of the INEDr Patrício José, Reitor do ISRIDr. Arlindo Lopes, Vice Chairperson of SARDC BoardWorking groupTomás Vieira Mário, Bayano Valy, Ricardo Mtumbuida, SaideDade, Ngila Mwase, Domingos Mazivila.Consultative groupJoão Loureiro, ChairpersonAnna Soumaré Coulibaly, Arlindo Lopes, Avertino Barreto,Carlos Machili, Diogo Milagre, Domingos Mazivila, ElsBergmans, Jamisse Taimo, Joana Mangueira, Maria AngelicaSalomão, Ngila Mwase, Pamela Mhlanga, Paulo Cuinica,Phyllis Johnson, Ricardo Mtumbuida, Rosa Marlene Manjate,Stella Pinto, Tomás Vieira Mário, Bayano Valy.iv


Forewordby the UN Resident CoordinatorKeeping open the window of hopeNational <strong>Human</strong> <strong>Development</strong> <strong>Reports</strong> are a majorpillar of UNDP’s analytical and policy work. The principalobjective is to raise public awareness and triggeraction on critical human development concerns.The NHDRs also contribute significantly to strengtheningnational statistical and analytical capacity.This is the sixth NHDR produced since 1998. Thetheme of the 2007 edition is the HIV and AIDS pandemic.The report looks carefully at the general statusof HIV and AIDS in Mozambique, its differentfacets and causes, its historical evolution, how it isregarded by society and its potential impact on thepublic and private sectors.The underlying argument is that efforts to acceleratedevelopment in Mozambique, to achieve localdevelopment aspirations as reflected in nationaldevelopment frameworks including the PARPA andAgenda 2025 as well as the MDGs would be underminedunless the state and society at large furtherexpand and strengthen the national, coordinatedresponse to curb the devastating spread of the disease.The report finds that HIV and AIDS are exacerbatingthe problems of poverty, malnutrition, loweducational levels and gender disparities, thusthreatening the attainment of the MDGs as well asslowing growth and development.Through various indices the report assesses thenation’s level of human development, an attempt tomeasure the standard of living and well-being of itspeople – effectively their ability to lead lives that areeconomically productive and personally fulfilling, andthat benefit the community and the nation as a whole.The Government of Mozambique has given priorityto HIV and AIDS in its national agenda, with extensiveevidence of political commitment. HIV and AIDShas also been mainstreamed into the national developmentframework and programmes. The PARPA(the country´s PRSP) identifies the response to theHIV and AIDS pandemic as one of the key areas forreducing poverty.UNDP and other UN agencies, especially UNICEFand UNAIDS, and the UN Theme Group on HIV andAIDS have provided technical assistance to the independentteam of national consultants who drafted thepresent report, under a process lead by a dynamicpartnership of the Higher Institute of InternationalRelations (ISRI), the National Institute of Statistics,and the Southern African Research andDocumentation Centre (SARDC) in Mozambique.UNDP is pleased to have provided its technicalassistance for the implementation of the reportingprocess, and expresses the hope that the report willhelp to further raise public awareness and foster thenational coordinated response to the pandemic, thuskeeping the country’s window of hope open for itspresent and future generations.Ndolamb NgokweyUN Resident CoordinatorUNDP Resident RepresentativeMaputo, September 2007v


viMozambique National <strong>Human</strong> <strong>Development</strong> Report 2007


ContentsPrefaceForewordContentsList of TablesList of GraphsList of BoxesList of MapsAcronymsiiivviixxxixixiiChapter 1 1<strong>Human</strong> <strong>Development</strong>, HIV and AIDS in Mozambique 1The concept of <strong>Human</strong> <strong>Development</strong> 1Evolution and measurement of <strong>Human</strong> <strong>Development</strong> 2The expansion of choice 3<strong>Human</strong> <strong>Development</strong>, HIV and AIDS, malaria and tuberculosis 3Chapter 2 7Updating <strong>Human</strong> <strong>Development</strong> in Mozambique 7Introduction 7<strong>Human</strong> <strong>Development</strong> in Mozambique 2001-2006 7The GDI of Mozambique 9<strong>Human</strong> <strong>Development</strong> in the regions of Mozambique 11Evolution of the HDI and the GDI 13Chapter 3 15Roots of the Pandemic and its DeterminingFactors in Mozambique 15Brief historical summary 15Accessibility of health services and the weight of traditional medicine 15Conformism and loss of confidence 16For a stronger civic movement 16Biological determinants of the pandemic 18Sexually transmitted infections, stigma and gender inequality 18Migration, urbanisation, commercial sex, and the prison population 19Vulnerability and vulnerable groups to the pandemic 19vii


ContentsChapter 8 57Planning for the Future: The Window of Hope 57The strategic approach in response to AIDS from 2005 to the present 57Sex and sexuality 57Window of Hope 58Sex education in childhood 59Strengthen ART through prioritising prevention 60Critical analysis of the national response 60Conclusions and recommendations 64Technical Notes 67Technical Note I 67Calculating the <strong>Human</strong> <strong>Development</strong> Index disaggregatedby Provinces and Regions 67Principles and Methods of Regionalisation 67Methods of Regionalisation 67Sources of Data 68Disaggregation/ Regionalisation of Operations 69Adjustment of the Provincial Values 69Quality and Precision of the Estimates 69Conclusions 69Technical Note II 70Calculating the <strong>Human</strong> <strong>Development</strong> Index (HDI) 70Technical Note III 70Calculating the Gender-related <strong>Development</strong> Index (GDI) 70Income Calculation 71References and Bibliography 73Statistical Annex 75ix


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007List of TablesTable 2.1 The <strong>Human</strong> <strong>Development</strong> Index of Mozambique, 2001-2006 7Table 2.2 Gender-adjusted <strong>Development</strong> Index for Mozambique, 2001-2006 10Table 2.3 Evolution of the GDP by provinces, regions and the country, 2001-2006 11Table 2.4 Contribution of industries within the sectors in 2006 13Table 2.5 HDI and GDI growth rates, 2001-2006 14Table 4.1Comparison of provincial, regional and national weighted HIVprevalence rates, 2001-2004 (%) 21Table 7.1 Projections of patients undergoing ART, 2004-2008 53Table 7.2 Distribution of PLWA on ART by sex/age/province/district,to November 2006 54Table 8.1 Financing of the health sector as %of public expenditure, 2000-2004 62List of GraphsGraph 1.1 HIV prevalence rates (%) in 2004 4Graph 1.2 Projection of HIV prevalence rates (%) 4Graph 2.1 Evolution of the HDI in Mozambique, 2001-2006 8Graph 2.2 Evolution of the components of the HDI in Mozambique, 2001-2006 8Graph 2.3 Evolution of net EP1 and EP2 enrolment rate by sex 8Graph 2.4 Comparative evolution of the literacy rate, 1997-2006 9Graph 2.5 Evolution of the GDI, 2001-2006 10Graph 2.6 Comparative evolution of the HDI and GDI, 2001-2006 10Graph 2.7 Gap between HDI and GDI, 2001-2006 11Graph 2.8 Average contribution to GDP by regions at constant prices, 2001-2006 12Graph 2.9 Average contribution to GDP by provinces, 2001-2006 12Graph 2.10 Contribution of the sectors to GDP, 2006 12Graph 2.11 Average real per capita GDP by provinces and the country, 2001-2006 13Graph 2.12 Accumulated variation of the HDI and GDI, 2001-2006 13Graph 3.1 Illiteracy Rate 16Graph 4.1 Projection of HIV prevalence in adults, 15-49 years, by regions 22Graph 4.2 HIV prevalence by age groups and sex, 2004 23Graph 4.3 HIV incidence in adults of 15-49 years, by sex,in each 100,000 inhabitants 23Graph 7.1 Evolution of ART in Mozambique, 2004-2005 53Graph 7.2 National distribution of PLWA on ART by province, July 2005 54x


ContentsList of BoxesBox 1.1 HIV and Tuberculosis: Double epidemic 5Box 3.1 Confidentiality and AIDS: An open debate 17Box 4.1Estimates of HIV and AIDS prevalence:Epidemiological Surveillance versus Sero-prevalence Survey 24Box 5.1 Condom use among secondary school students in Maputo 33Box 6.1 What communication strategies in a context of cultural diversity? 39Box 7.1 Let’s speak openly in our families:President Armando Emílio Guebuza 44Box 7.2 HIV and AIDS in PARPA II 46Box 7.3 The use of cotrimoxazole to prevent HIV-related infections in Africa 54Box 8.1 Stephen Lewis: “Time to Deliver” 65List of MapsMap 4.1 HIV prevalence rate 2004, 15-49 years 21xi


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007AcronymsAIDSAMETRAMOAMODEFAARVARTCNCSDNSDOTFDCGATVGDIGDPHAIHDDHDIHIVILOINEINJADISRIKAPMADERMISAUMMASAcquired Immune DeficiencySyndromeAssociation of MozambicanTraditional HealersMozambican Association for theDefence of the FamilyAnti-RetroviralAnti-Retroviral TreatmentNational AIDS CouncilNational Health DirectorateDirectly Observed TreatmentCommunity <strong>Development</strong> FoundationCounselling and VoluntaryTesting OfficeGender-adjusted <strong>Development</strong> IndexGross Domestic ProductHealth Alliance InternationalDay Hospital<strong>Human</strong> <strong>Development</strong> Index<strong>Human</strong> Immunodeficiency VirusInternational Labour OrganizationNational Statistics InstituteNational Survey of Young Peopleand AdolescentsHigher Institute of InternationalRelationsKnowledge, Attitudes and PracticesMinistry of Agriculture and Rural<strong>Development</strong>Ministry of HealthMinistry of Women’s Affairs andSocial ActionMPFMSFNGOOEOVCPARPAPENPESPLWAPMTPNSPNCTLPQGPVTSARDCSETSANSNSSTITBUEMUNAIDSUNDPUNICEFUSWHOMinistry of Planning and FinanceMedicins Sans FrontiersNon Governmental OrganisationState BudgetOrphaned and Vulnerable ChildrenAction Plan for the Reductionof Absolute PovertyNational Strategic PlanEconomic and Social PlanPeople Living with HIV and AIDSPractitioners of Traditional MedicineNational AIDS PlanNational Programme for the Controlof TuberculosisGovernment Five-Year PlanPrevention of Vertical TransmissionSouthern African Research andDocumentation CentreTechnical Secretariat for Food andNutritional SecurityNational Health ServiceSexually Transmitted InfectionsTuberculosisEduardo Mondlane UniversityJoint <strong>United</strong> Nations Programmeon HIV/AIDS<strong>United</strong> Nations <strong>Development</strong> Program<strong>United</strong> Nations Children’s FundHealth UnitWorld Health Organisationxii


Chapter 1<strong>Human</strong> <strong>Development</strong>, HIV and AIDS in MozambiqueThe concept of <strong>Human</strong> <strong>Development</strong><strong>Human</strong> development has to do, first and foremost,with the possibility of people living the kind of lifethat they choose – and with the provision of instrumentsand opportunities so that they can make theirchoices (UNDP, 2004). This statement expresses anew way of conceiving the scientific thought thatguides the problem of development today, centring iton human beings. It is the meeting place for the currentsof thought and theories which, in the last half ofthe 20th century, dominated economic thought andthe human sciences.Indeed, the theme of development has longattracted the attention of academics, politicians,activists, workers and members of civil society ingeneral. This attention has led to countless studiesand debates and even the establishment of institutionsspecialised in development studies andresearch.Arising out of the search for sustainable and adequatemeans for achieving development, thereappeared several currents and trends of thoughtaround the concept and how to approach the theme.The field of development economics, for example, asthat which has been most prominent in dealing withthe theme, has a history which, from the 1950s totoday, falls into three distinct periods:• the era of economic growth and modernisationof the 1950s and 60s, when development waslargely defined in terms of the average growth ofper capita income;• the period of growth with equity as from the1970s, when the concerns of many economistsabout development expanded, and came toinclude the distribution of income, employmentand nutrition; and,• the era of economic growth and policy reform ofthe 1980s (Staatz and Eicher, 1990).During these various phases in the evolution ofthe approach to development, critical voices wereraised and, by around the 1970s, there was universalrecognition that aggregate economic growth did notnecessarily lead to the elimination of poverty. Thisfinding led to the formulation of the basic needsapproach which was adopted by the InternationalLabour Organisation (ILO) in 1976. At that time theILO defined basic needs as adequate food, shelterand clothing, as well as some domestic requirements,including social services provided to individualsand communities, namely drinking water, sanitation,public transport, health and education.This approach began to orient the developmentproblematic towards meeting the needs of humanbeings. In this context, one should mention the meetingat Cocoyoc, Mexico in 1974, the declaration ofwhich strengthened the orientation towards meetingpeople’s needs, pointing out that growth that did notlead to the attainment of basic human needs was aparody of development. This declaration wentbeyond basic needs, and brought to the surface conceptsof freedom of expression and self-realisation atwork (Burkey, 1996).Today the concerns of development activists tosatisfy people’s needs has led and influenced theproblem of development towards the search forresponses to immediate and not-so-immediatehuman needs. <strong>Development</strong> is thus being understoodwithin a perspective which recognises that economicgrowth is a necessary condition, but also that itshould be based on equity and on the participation ofindividuals in designing, implementing ad evaluatingdevelopment programmes.Thus development now wears a human face,shifting from its statistical and numerical identity, andcoming to encourage the welfare of the individual,bringing together his or her material and immaterialneeds, namely access to clean drinking water, anadequate and balanced diet, physical and emotionalsecurity, physical, mental and spiritual peace, as wellas cohabiting in sustainable systems of sexual reproduction,systems of social education grounded oncultural preservation and continuity, and political1


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007systems with transparent leadership and decisionmaking processes, etc. (Burkey, 1996).This perspective, which began to achieve someexpression after the launch of the first human developmentreport by the <strong>United</strong> Nations <strong>Development</strong>Programme (UNDP) in 1990, introduced the newapproach to development at the human scale, whichis being used to measure the level of satisfaction ofhuman needs, in order to improve the lives of individualsand create freedoms that they may enjoy.Besides, in order to fulfil its human and humanistmission, development should provide opportunitiesthat allow people to lead long and healthy lives, to berecognised, to have access to the resources necessaryfor a decent standard of living, and to be capableof participating in the life of their communities(UNDP, 2001).This approach, although recognised and exercisedincreasingly in today’s world, faces a series ofadversities such as high indices of poverty, economicand social constraints, high maternal and child mortalityrates, and the probability of morbidity and mortality(the condition of being ill and the rate of deathsamong the population respectively) caused by HIVand AIDS and associated diseases, such as tuberculosisand malaria.Meanwhile, the recognition of a world evolutiondictated by globalisation and an accelerated erosion ofthe terms of trade for the countries of the periphery,dependent on exports of primary products, cannotpass unnoticed in the building of the material premisesfor human achievement. Furthermore, the challengesimposed by natural disasters and endemic diseases,imposing di<strong>version</strong> of resources that would otherwisebe invested in the promotion of developmentand social well-being, are issues that dominate theagenda in the development problematic.The combination of these issues demand a committedand sufficiently open universal mentality tofind solutions that seek not only to mitigate the effectsof adversities, but also promote a developmentmodel that confronts the challenges faced by themajority of people today.Evolution and measurementof human development<strong>Development</strong> is much more than the simple measurementof economic growth. Indeed, the indicatorson aggregate income of countries (GDP and percapita income), show that between the years 1960and 2000 the world recorded advances in the sphereof human development, which were expressed in therise in life expectancy in developing countries from46 to 63 years, and the reduction in infant mortalityrates by more than half. In that period there was alsoa qualitative and quantitative jump in school attendanceand particularly in adult literacy. In fact,between 1975 and 2000, the number of illiteratepeople fell by almost half (UNDP, 2004).This progress, however, is still faced with a seriesof human deprivations, including the chronic hungerfrom which many people still suffer throughout theworld, children of school age – particularly girls –who have not yet entered school, lack of access toclean drinking water or to basic sanitation, the violationof individual, political, democratic and civicfreedoms, among other constraints to real humandevelopment.Despite this, knowledge of the performance ofcountries in satisfying the material and spiritualneeds of their citizens and in promoting sustainablehuman development has been accepted as a requirementfor redirecting development strategies. Toobtain this knowledge, several human developmentmeasuring instruments have been used at particularstages of nations’ lives.For the same purposes, the UNDP has used the<strong>Human</strong> <strong>Development</strong> Index (HDI), which is basedon three indicators, namely:• longevity, measured by life expectancy at birth;• the level of knowledge acquired in the area ofeducation, measured through a combination ofadult literacy (with a weight of two-thirds), andthe combined school enrolment rate at primary,secondary and tertiary levels; and,• standard of living, measured by real per capitaGDP.The measurement of human development thustakes into account the three indicators describedabove. This fact, however, does not exhaust the importanceof other indicators in weighing the satisfaction ofdesires and needs that allow citizens to enjoy theirrights of citizenship. For example, in an era when freedomboth of expression and of participation are takenfor granted as gains and unequivocal forms of democracy,the measure of participation in the decisions anddestinies of a country, analysed by gender, is an importantdeterminant for assessing to what extent citizensof both sexes enjoy the same rights enshrined in theConstitutions of particular countries.2


<strong>Human</strong> <strong>Development</strong>, HIV and AIDS in MozambiqueHowever, the limitations that the <strong>Human</strong><strong>Development</strong> Index contains should be stressed.These can be mitigated by exploring other, to someextent alternative, indicators such as the <strong>Human</strong>Poverty Index, which expresses the proportion ofpeople living below the threshold in basic dimensionsof human development, as well as the Genderadjusted<strong>Development</strong> Index, which catches the differencesin achievement between men and women inthe same country, among others.The expansion of choice<strong>Human</strong> development thus assumes the creation of anenvironment in which people can develop their fullpotential, and lead productive and creative lives, inaccordance with their needs and interests. This factimplies the creation of favourable conditions in variousspheres of social and economic life so that peoplemay find opportunities for involvement and tocontribute with their knowledge and work, participatingin development and achieving their expectations.The creation of a favourable environment for theactive involvement of the individual in his or her owndevelopment process assumes expanding the choicespeople have to lead the lives that give them value(UNDP, 2001).The underlying assumption here for the understandingof choices includes a discussion that facestwo important data, namely:• the premise of willingness and need, and• the premise of supply and availability, or the dutyof provision.This leads us back to an old problem, that of thedefinition of the poverty (or wealth) of a country,which Nurks (1989) summarized in the followingterms: a country is poor because it is poor. To thisacceptance, there followed other propositions resultingfrom the experiences of decades of developmentstudies, which argued that the poverty of countrieswas much more than the express absence of naturalattributes or resources, and thus required anapproach that should look at the development policiesand options adopted, that is, poverty linked withpoor policies.That said, it might be concluded that choices, ina given society, are conditioned by the production ofgoods and services, and by the accessible and equitabledistribution of social wealth among the membersof that same society.Thus the expansion of choices assumes, amongother factors, promoting and sustaining continualeconomic development that can generate publicresources for education and health services, andraising the income of individuals such that they mayenjoy a decent standard of living, and improve variousaspects inherent to their daily lives.As a result, the human development perspective isintrinsically linked to economic growth, from which acontribution is expected that may pull people out ofthe conditions of deprivation in which they live.<strong>Human</strong> development, HIV and AIDS,malaria and tuberculosis<strong>Development</strong> has an influence on people’s ability toprotect themselves from infection with HIV, malariaand tuberculosis, and on the vulnerability of individualsand society to the consequences of these diseases.This is a basic assumption for understanding why theeffects of these endemic diseases in developed countriesare not on the same scale as that felt in developingcountries. In the latter, HIV and AIDS, malaria andtuberculosis will have adverse impacts on development,visibly reflected in key indicators such as lifeexpectancy at birth, and school attendance and literacyachievements, as well as on household incomes.This is why one of the Millennium <strong>Development</strong>Goals – Goal 6 – is “combat HIV and AIDS, malariaand other diseases”, with which tuberculosis is necessarilylinked. Thus, the continual increase in theimpact of these transmissible endemic diseases,linked to poverty, conditions the socio-economiclevel and health status of the public. The latest epidemiologicalsurveillance round showed that HIVprevalence has increased from 13.6% in 2002 to16.2% in 2004.This prevalence is not uniform and variesbetween 9.3%, 20.4% and 18.1% in the northern,central and southern regions respectively (MISAU,PNC STI/HIV-AIDS, 2005). This puts Mozambiqueamong the countries of the world and of the sub-Saharan region with the highest prevalence rates.The cumulative effects of the combination of thethree endemic diseases has adverse implications forthe population structure and for the age pyramids,revealing at once serious consequences for multiplevariables in society, from the economic sphere (productionand productivity) to the social arena (socialand cultural capital) and even those in the politicalsphere (governance capacity).3


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Graph 1.1 HIV prevalence rates (%) in 2004201510302520151050Graph 1.2 Projection of HIV prevalence rates (%)51998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010ProjectionAs with HIV and AIDS, Mozambique is among thecountries most affected by tuberculosis, following therevision of the estimated incidence of this disease in1999. Tuberculosis is the third largest cause of hospitalisation,after acute respiratory infections andmalaria. There are estimated to be around 21,000cases of tuberculosis in the country. (MISAU, PNCSTI/HIV/AIDS 2004-2008)In populations with an average HIV and AIDSprevalence of around 10%, it is estimated that about40% of tuberculosis cases can be attributed to HIVinfection. Likewise, it has been reported that in mostsub-Saharan African countries, 50% of HIV-positivepeople will develop tuberculosis in the course oftheir lives.In Mozambique, the average of HIV-positiveamong patients suffering from tuberculosis hasincreased from 32% in 2002 to 48% in 2004 (Box1.1). The figure varies between 2% and 53% in differentregions of the country.In many referral hospitals, where the HIV andAIDS test is administered on patients hospitalised sufferingfrom diseases related with internal medicine,40-50% of the tests show that the patient is HIV-positive.Furthermore, over 75% of the patients hospitalisedin referral hospitals suffering from tuberculosisare HIV-positive (MISAU, PNC, idem).The increase in AIDS cases is a dramatic humanitariansituation in terms of public and individualhealth within the National Health Service. In healthunits, such as, for example, the Maputo and Beiracentral hospitals, and the Tete and Manica provincialhospitals, in the medical wards, 60%-80% of thepatients have diseases related to AIDS.These figures show the already well-known andbaleful combination between HIV and AIDS andtuberculosis, as one of the main opportunist infections– but that which is largely curable, if strategicinterventions based on DOT (Directly ObservedTreatment), and guidelines for the patients toobserve strictly the drug regime, are properly supportedand adequately funded.Meanwhile, malaria, which has a high incidencein the country, is the main cause of hospitalisationand mortality. Children under five and pregnantwomen are among the groups most vulnerable to thisdisease. Malaria contributes to about 40% of all outpatientconsultations, and 60% of all paediatricadmissions in the rural and general hospitals. It isthe top cause of mortality among patients admittedand hospitalized in Mozambican paediatric wards.Malaria and the anaemia associated with it contributeto the high degree of maternal mortalityrecorded in the country (1,500 per 100,000 livebirths). Due to the anaemia, and the haemorrhagiccomplications associated with it, it becomes the foremostcause of the low weight at birth recordedamong new-born infants.According to the IDS (see Chapter 2) for 2004,the proportion of children under 15 in the populationis 44.5%, with a degree of dependence of about90%. Because HIV and AIDS mostly affects peoplewho are economically active, the degree of dependencewill be worsened by the collateral effects of theepidemic, such as an increase in the number oforphans, an increase in the number of householdsheaded by children, or by elderly people who arethemselves dependent. This list of effects of HIV andAIDS will directly affect the other parameters used incalculating the HDI, such as the level of school attendanceand the purchasing power of individuals andhouseholds.4


<strong>Human</strong> <strong>Development</strong>, HIV and AIDS in MozambiqueBox 1.1Tuberculosis (TB) remains one of the most seriousglobal threats to public health. In March 2006Tuberculosis was declared a national emergency inMozambique. Mozambique is among the 22 countriesin the world most affected by TB (the HBC), withan estimated 91,000 cases in 2006 and an incidenceof 460 per 100,000 inhabitants in 2004.The incidence of TB has been growing rapidly inthe last 10 years, due, above all, to its association withHIV. In 1998, HIV prevalence among adult tuberculosispatients (aged 15-49) was 32% (that is, one out ofevery three tuberculosis patients was HIV-positive).In 2004, the HIV prevalence among adult tuberculosispatients was 48% (that is, one out of everytwo tuberculosis patients). Due to this association,and because tuberculosis is the opportunist diseasemost associated with AIDS, mortality among tuberculosispatients has been increasing. The most dramaticsituations are in Manica, Sofala and Gaza.Tuberculosis is not distributed equally across thecountry. The association of tuberculosis with HIV isvery serious in the central provinces, particularly inManica and Sofala, followed by Gaza, MaputoProvince and Maputo City.For example, data from studies held in the centralcity of Beira in 2003 and 2004 show that almost3,200 new cases of TB were recorded per year, whichis an incidence of 566 per 100,000 people.The patho-physiological link between TB andHIV is extremely deadly, since co-infection with HIVsignificantly increases the possibility of activatinglatent TB or a greater risk of re-infection, due to thelow immunity. Furthermore, the immunological stimuluscaused by TB can also increase the HIV viral load,the rate of progression of HIV and lead to higher mortality.It is this link between HIV and TB which has led tothe appearance of the terms “co-epidemic” or “doubleepidemic” to describe the lethal marriagebetween the two illnesses in the same patient.Due to the great number of patients living withTB and HIV, the World Health Organisation (WHO)has, since 2000, recommended and encouraged thestrengthening of an integrated approach betweenthe programmes controlling the two epidemics insub-Saharan Africa.HIV and Tuberculosis: Double epidemicThis integrated approach could facilitate, to agreat extent, the rapid and efficient diagnosis of dualHIV-TB infection, and provide beneficial interventionssuch as chemoprophylaxis with cotrimoxazol,reducing mortality among patients with dual HIV-TBinfection, and leading to a effective coordination oftuberculosis treatment and the concomitant administrationof anti-retrovirals.The National Tuberculosis Control Programme, setup in 1977, has used supervised treatment since 1984.Later, when WHO re-established the GlobalTuberculosis Programme in 1991, Mozambique contributedwith its experience to the world launch of thestrategy of the Directly Observed Treatment ShortCourse (DOTS). Under the current conditions of coverageby the national health network, the number ofcases detected is still well below the recommendedlevel. DOTS now covers about 40% of the population.The targets set by the WHO’s Global TuberculosisProgramme stipulate detection of 70% of the infectiouscases (that is, the pulmonary ones, since it is thesethat spread the disease) and the cure of 85% of them.The data presented by the National TuberculosisControl Programme (PNCTL) for 2005, indicate a detectionrate of 48% and a cure rate of 80%.The coordinated efforts of the sector, includingwith foreign partners, seeks to extend the coverageof the TB Programme to identifying 70% of cases,with a success rate of at least 85%, by 2010.The treatment of tuberculosis is the only way ofreducing the sources of infection in a community.Thus detecting and treating these cases is the priorityfor any tuberculosis programme in the world. Onecase of infectious (pulmonary) tuberculosis can infect10 to 20 people per year.Tuberculosis is curable and in Mozambique itstreatment is free of charge, as is Cotrimoxazol forchemoprophylaxy for tuberculosis patients withAIDS.Between 1995 and 2004, about 22 millionpatients were treated by the DOTS strategy acrossthe world. Internationally, 183 (of 192) countrieswere implementing the DOTS strategy in late 2004.The Millennium <strong>Development</strong> Goals include targetsfor containing the prevalence of and deathsfrom TB by 2015.5


6Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007


Chapter 2Updating <strong>Human</strong> <strong>Development</strong> in MozambiqueIntroductionThe chapter analyses the human developmentdimension together with human developmentindicators, which provides an assessment ofthe achievements of Mozambique in generaland of the country’s administrative regions inparticular, in the various areas of humanendeavour, in the period 2001 to 2006.The chapter is divided into two mainparts. The first summarises the evolution ofhuman development in Mozambique coveringthe 2001-2006 period, based on the behaviourof the main indicators for measuring theconcept, and resorting to official statistics andmethodologies that make it possible to compareMozambique’s level of human developmentto that of other countries.The second part of the chapter analyses theevolution of human development and its componentsin the regions of Mozambique. The differencebetween this and the previous sectionlies in the fact that the first adopts scrupulouslythe methodology of the Global <strong>Human</strong> <strong>Development</strong><strong>Reports</strong> (GHDR), which allows the resulting indicatorsto be comparable with those of other countries and thefigures published in the GHDR.The second section resorts to an adaptation andadjustment of the methodology to allow comparisonbetween the various administrative regions withinMozambique.It is important always to bear in mind the differencebetween the two methodologies used in calculatingthe indicators, since this implies that, in practicalterms, the final figures for the <strong>Human</strong><strong>Development</strong> Index (HDI) calculated in the two sectionsare not comparable.The main difference in methodology lies in theuse, in the first case, of real per capita GrossDomestic Product (GDP) converted into dollars PPP,Table 2.1which makes it possible to compare the level ofhuman development in Mozambique with that ofother countries. The HDI for the interior ofMozambique uses real per capita GDP in nominalmeticais, applying a deflator which allows comparisonbetween years along the series under analysis. 1<strong>Human</strong> <strong>Development</strong> in Mozambique2001-2006The HDI is a composite measure which analyses theaverage achievement of a country in three basic areasof human development:• A long and healthy life, as measured by lifeexpectancy at birth;• Knowledge, measured by the adult literacy rate(with a weighting of two-thirds), and by the<strong>Human</strong> <strong>Development</strong> Indexfor Mozambique, 2001-2006Basic Data a 2001 2002 2003 2004 2005 2006*Life expectancy at birth 45.0 45.6 46.3 46.7 47.1 47.4Adult literacy rate (%) 44.4 46.4 46.4 47.2 47.2 48.0Combined grossenrolment rate (%) 34.5 40.6 42.8 47.1 50.3 52.5Real GDP per capita (PPP dollars) b 1471.8 1537.8 1607.7 1749.8 1839.5 2088.9Calculation of the HDILife expectancy at birth index 0.333 0.343 0.355 0.362 0.368 0.373Educational index 0.411 0.445 0.452 0.472 0.482 0.485Adult literacy index 0.444 0.464 0.464 0.472 0.472 0.480Combined primary, secondaryand higher educationenrolment index 0.345 0.408 0.428 0.471 0.503 0.525Real per capita GDP index ($PPP) 0.449 0.456 0.464 0.478 0.485 0.507<strong>Human</strong> <strong>Development</strong> Index 0.398 0.415 0.424 0.437 0.448 0.458a) Maximum and minimum values: see Technical Note IIb) Estimates based on the PPP con<strong>version</strong> rate of the World Bank, World <strong>Development</strong> Report* Estimates of the GDP and of the literacy rate subject to change in later editions1 We draw the reader’s attention in particular to the importance of this key aspect to avoid the habitual misunderstanding of, on the one hand, comparingthe two figures obtained with the two methodologies and, on the other, of comparing the figures for the regions with those for other countries.7


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Graph 2.10.50.40.32001 2002HDIGraph 2.20.50.40.30.20.10.02001LEIEvolution of the HDIin Mozambique, 2001-2006200220032003EI20042004LEI = Life Expectancy IndexEI = Educational IndexGDPI = Real GDP per capita IndexGraph 2.31008060402002002EP1WEP2W200320052005GDPI2006Evolution of thecomponents of the HDI,2001-2006200420052006Evolution of net EP1 andEP2 enrolment rate by sexEP1MEP2M2006M = MenW = Womencombined primary, secondary and highereducation enrolment rate (with a weighting ofone-third);• A decent living standard, measured by GDP percapita (in US$ PPP).The performance of the HDI is expressed as afigure between 0 and 1. A figure for the HDI near to1 shows a better level of attaining human developmentthan an HDI near to 0. The methodology forcalculating the HDI is shown in Technical Note IIappended to this report.Graph 2.1 illustrates the trend for increase in theHDI and its main indicators, while showing thatMozambique still has a long path ahead to realize thecapacities of its citizens.In Table 2.1 it is estimated that the HDI hasevolved from 0.398 in 2001 to 0.458 in 2006, equivalentto an annual average growth of about 3%,which expresses a positive evolution, during the periodunder analysis, of one or all components of theHDI. Indeed, during this period:• The GDP grew on average by 8.7% a year, whichexpresses substantial economic gains for adecent standard of living.• The adult literacy rate advanced from 43.3% in2000 to 46.4% in 2003, according to theNational Institute of Statistics (INE), and it isbelieved that this rate will continue to grow, dueto an increase in those attending literacy classesacross the country of about 55.7%, whencompared with 2005, is envisaged (PES, 2006).• The gross combined primary, secondary andtertiary school attendance rate also had anaverage annual growth of about 8.9% between2001 and 2006, which expresses a greatercapacity to absorb pupils through the expansionof both the public and the private school network.• There is also a modest average gain of 1.02% inlongevity, measured by life expectancy at birth,due fundamentally to interventions in the healthsector and improved nutritional status, despitethe pressures imposed by the HIV and AIDSepidemic.Graph 2.2 strengthens the previous analysisand shows clearly that all components of the HDI,during the period under analysis, had a positiveevolution, even though the variables that form theindicators used in the index are, by their verynature, not subject to substantial variations in ashort period of time.8


Updating <strong>Human</strong> <strong>Development</strong> in MozambiqueIn disaggregated terms, the most dynamic indicatorshave normally been the GDP index, whichreflects recent economic gains; and the joint schoolattendance rate, which expresses the gradual, butsubstantial, increase in the number of places in thecountry’s educational network, particularly as from1995 (NHDR, 2001).It is estimated that about 3.8 million pupilsattended EP1 in 2006, which is an increase of about6.0% when compared with 2005. In the same period,the number of EP2 pupils grew by 9.5% comparedwith 2005 (PES, 2006). Thus the trend towardsstrong growth in this level of education, noted sincethe 1995 school year, and particularly as from 2000,is being maintained.Obviously all this represents a trend induced bythe increased supply in the education system. Toillustrate this perception, it is enough to note, by wayof example, the school coverage forecasts, namelythat the net EP1 attendance rate rose from 83.4% in2005 to 88.3% in 2006, and that the gross admissionrate increased by 1.2%, rising from 160.6% in 2005to 162.5% in 2006 (PES 2006).These results revive the hope that, although thereis still a long way to go, Mozambique is, in relativeterms, taking an important step in reducing the deprivationsof its population (UNDP, 2001).Graph 2.4 illustrates the growth in the literacyrate among adult women, compared with men, overthe period 1997 to 2006.Graph 2.4807060504030201001997WomenComparative evolutionof the literacy rate,1997-200620002003Men2006The GDI of MozambiqueThe Gender-adjusted <strong>Development</strong> Index (GDI) is acomposite index that measures average attainment inthe three basic dimensions captured in the HDI – along and healthy life, knowledge, and a decent standardof living – adjusted to reflect the inequalitiesbetween men and women. That is, the GDI adjustsaverage attainment to reflect inequalities betweenmen and women in the three dimensions of humandevelopment.Like the HDI, the GDI is expressed as a figurebetween 0 and 1. When the GDI is equal to 1, itreflects maximum attainment in the basic capacitieswith perfect equality between men and women(though no country has ever achieved this figure).On the other hand, a GDI approaching zero reflects alarger gulf between the development attainments ofwomen and of men. The methodology used in calculatingthe GDI is shown in Technical Note III appendedto this report.The first finding on analysing the data in Table2.2 and Graph 2.5 is the existence of disparities inattainment between women and men, as the historicfigures for the GDI over the 2001-2006 period show.The figure for the GDI in 2006, still well below 0.5,shows the long journey that must be travelledtowards reducing the disparities in attainmentbetween the two sexes.Graph 2.6, in showing the comparative evolutionbetween the HDI and the GDI between 2001and 2006, confirms the trend to parallel evolutionbetween the two indicators of human development,which does at least suggest that the gap inthe levels of attainment between men and womenhas not widened (NHDR, 2001). Indeed, while theHDI recorded an average annual growth of 3.2%between 2001 and 2006, for the same period,there was an average annual growth of 3.5% in theGDI.The conclusion that may be drawn from thisresult is that, since the disparities between men andwomen are not increasing, the policies intended topromote the advancement of women, particularly asregards access to education, health and other socialservices, are making steps towards reducing the gapbetween the development attainments of the twosexes. Graph 2.7 shows the evolution of the gapbetween the human development attainments of menand women.9


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Table 2.2Gender-adjusted <strong>Development</strong> Indexfor Mozambique, 2001-2006Basic Data a 2001 2002 2003 2004 2005 2006*Life expectancy at birth 45.0 45.6 46.3 46.7 47.1 47.4Women 46.8 47.5 48.2 48.6 49.0 49.3Men 43.2 43.8 44.4 44.8 45.2 45.5Adult literacy rate (%) 44.4 46.4 46.4 47.2 47.2 48.0Women 30.1 32.0 32.0 33.8 33.8 35.5Men 59.8 63.3 63.3 65.6 65.6 67.9Combined Gross Enrolment Rate (%) 34.5 40.6 42.8 47.1 50.3 52.5Women 33.0 35.4 37.9 42.3 45.5 48.1Men 44.0 45.9 47.8 52.4 55.0 57.0Real GDP per capita (PPP dollars) b 1471.8 1537.8 1607.7 1749.8 1939.5 2088.9Women 1301.9 1361.3 1424.4 1551.5 1721.1 1855.3Men 1655.3 1728.0 1805.1 1962.8 2173.7 2339.2Calculation of GDILife expectancy at birth 0.333 0.343 0.355 0.362 0.368 0.373Women 0.322 0.333 0.345 0.352 0.359 0.364Men 0.345 0.355 0.365 0.372 0.378 0.383Equally distributed life expectancy index 0.332 0.343 0.354 0.361 0.368 0.372Educational index 0.411 0.445 0.432 0.472 0.482 0.495Women 0.311 0.331 0.340 0.366 0.377 0.397Men 0.545 0.575 0.581 0.612 0.620 0.642Equally distributed educational index 0.388 0.412 0.421 0.450 0.461 0.483Real adjusted per capita GDP index ($PPP) 0.449 0.456 0.454 0.478 0.495 0.507Women 0.428 0.436 0.443 0.458 0.475 0.487Men 0.468 0.476 0.483 0.497 0.514 0.526Equally distributed real per capita GDP index 0.446 0.453 0.461 0.475 0.492 0.505Gender-adjusted <strong>Development</strong> Index 0.389 0.403 0.412 0.429 0.440 0.453a) Maximum and Minimum Values: see technical noteb) Estimates based on the PPP con<strong>version</strong> rate of the World Bank: World <strong>Development</strong> Report 2000/2001* Estimates of the GDP and of the literacy rate subject to alteration in later editionsGraph 2.5 Evolution of the GDI, 2001-2006 Graph 2.6 Comparative evolution of theHDI and GDI, 2001-20060.50.50.40.40.32001200220032004200520060.3200120022003200420052006GDIHDIGDI10


Updating <strong>Human</strong> <strong>Development</strong> in MozambiqueGraph 2.7Gap between the HDIand GDI, 2001-2006<strong>Human</strong> development in theregions of MozambiqueEstimated GDP disaggregated by provinceOne of the innovations of the Mozambique NHDRs isthe possibility of showing the HDI broken down byprovinces and by regions, which allows us to evaluatethe performance of the economic and social indicatorsin the various administrative regions of thecountry, using the instruments that measure humandevelopment. A fundamental step in reachingthis goal is the disaggregation of the GDP byprovinces and regions. This section analyses theeconomic indicators within Mozambique, morespecifically the GDP by provinces and regions.The assessment of human development inthe provinces took as its starting point themethodology adopted in the previous National<strong>Human</strong> <strong>Development</strong> <strong>Reports</strong> to estimate thecontribution made by each of the 11 administrativeregions to the economy. 2 The methodologyused which made it possible to break down theGDP for 2001-2006 by provinces is shown inTechnical Note I, appended to this report.In general, the estimates of economic activityshow that the performance of the provinces hasnot evolved in a uniform fashion. The results inTable 2.3 show that the average annual rate of realgrowth of the GDP in the 2001-2006 period variesTable 2.3between 5.4% (Gaza province) and 12.0% (Maputoprovince). However, although all provinces show noteworthyreal growth, only five of them (Niassa, CaboDelgado, Tete, Inhambane and Maputo province) areabove the national average of about 8.7%.The strong average growth of the economy inMaputo and Inhambane provinces in the periodunder analysis can be attributed to the constructionsector, because of the expansion of the aluminiumsmelter (Mozal II), and the building of the pipelinethat links Inhambane province to South Africa, andlater to the manufacturing industry sector, because ofthe increase in Mozal’s productive capacity resultingfrom the take-off of the second phase of aluminiumproduction, and the start of the exploitation of gas atTemane in the first quarter of 2004.In regional terms, the results of the economicperformance over the period under analysis continueto show heavy economic concentration in thesouthern region of the country, with an average ofabout 44% of real production. The central zone follows,with a contribution of 34%, and finally, thenorthern zone with 22% of national production. Thecontribution by region is summarized in Graph 2.8.Sofala and Zambezia provinces in the centre, andNampula in the north lead in their respective zones,with average contributions of 11.5%, 11.7% and13.7% respectively. Maputo City and MaputoEvolution of the GDP by provinces,regions and the country, 2001-2006Regions/Provinces Growth rate (%)2001 2002 2003 2004 2005 2006* AverageNorth 8.7 10.1 9.0 7.0 8.6 8.9 8.7Niassa 11.2 11.7 7.9 16.7 10.0 9.7 11.2Cabo Delgado 10.3 10.4 9.7 7.1 7.8 10.9 9.4Nampula 7.6 9.7 9.0 4.9 8.5 8.0 8.0Centre 10.7 9.2 6.9 5.4 8.6 7.0 8.0Zambézia 10.4 9.9 6.0 1.9 9.6 6.1 7.3Tete 10.1 11.0 8.6 11.3 11.5 9.0 10.2Manica 11.5 9.1 7.4 4.3 6.1 7.2 7.6Sofala 11.0 7.7 6.5 6.6 7.0 6.8 7.6South 15.3 8.8 5.0 10.2 8.2 8.2 9.3Inhambane 6.0 12.1 5.9 16.5 13.0 12.4 11.0Gaza 7.8 6.9 6.7 5.6 5.1 7.0 6.5Maputo Prov 30.2 12.3 4.6 13.5 3.3 7.9 12.0Maputo City 10.3 5.9 4.6 7.0 11.4 7.5 7.8Mozambique 12.3 9.2 6.5 7.9 8.4 8.0 8.7* Preliminary estimates2 Note that the base year of the estimates presented in this report has changed from 1996 to 2003. As a result, the estimates will differ from those ofprevious NHDR and they are not, therefore, directly comparable. The estimates for 2006 are preliminaries and therefore subject to revision in the nextpublications.11


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Graph 2.8Graph 2.93.14.913.711.7NiassaCabo DelgadoNampulaZambéziaGraph 2.10Average contributionto GDP by regions atconstant prices, 2001-20066.04.7TeteManica11.5 Sofala5.5Inhambane443422SouthCentreNorthAverage contributionto GDP by provinces,2001-20064.714.719.5GazaMaputo provinceMaputo cityContribution of thesectors to GDP, 2006Province lead the south region with an average contributionin the total GDP of 19.4% and 14.7%respectively. The remaining provinces contributebetween 3.1% (Niassa) and 6.0% (Tete). The contributionof each province is shown in Graph 2.9.Aside from the information depicted in Graph2.9, the contribution of each region and province tothe country’s economy is influenced by the respectivereal growth rates.The southern region shows the highest averagegrowth rate of the three regions of Mozambique, with9.3%, which is 0.6% above the national average. Theprovinces of Inhambane and Maputo contributedwith rates of average annual growth of 11.0% and12.0% respectively. The northern and central zonesalso had noteworthy growth rates, of 8.7% and 8.0%respectively, even though the latter was below thenational average.Among the sectors which contributed most to thereal average growth rate of 9.3% in the southernzone in the period under analysis, the constructionand manufacturing industries stand out, thanks to thecontribution of the Pande/Temane natural gas andMozal II aluminium smelter mega-projects.From the perspective of showing the degree ofspecialization, estimates allow us to note that agricultureremains the activity with the greatest weight inthe economy, both at national and provincial levels.But its share is declining, in favour of other sectors,mainly manufacturing industry and trade, thanks tothe contribution of the mega-projects, which alreadyhave a visible impact on the manufacturing industryand, as from 2004, on the extractive industry.At regional level, Graph 2.10 shows the dominanceof the primary sector in the northern regionwith a contribution of about 39.0%, slightly higherthan in the central region (35.0%), but three timeshigher than the contribution of this sector to the GDPof the southern zone (13.8%). The south is mostlydominated by the tertiary sector with a contributionthat is 10.9% higher than the national average, andalmost 2 times the contribution of this sector in thecentral region.GDP per capita by provinceIn terms of real GDP per capita, Maputo City showsaverage figures that are three times higher than thenational average, and four times higher than the GDPper capita of Niassa, Cabo Delgado, Nampula,Zambezia, Manica and Gaza. As Graph 2.11 shows,12


Updating <strong>Human</strong> <strong>Development</strong> in MozambiqueTable 2.4Contribution of industrieswithin the sectors in 2006Sectors North Centre South CountryPrimary 35.5 27.0 13.8 26.6Agriculture 35.1 24.6 11.7 23.8Fishing 3.1 1.6 0.9 1.8Secondary 13.8 17.2 27.0 22.5Industry 8.0 7.8 20.2 14.0Electricity 3.9 8.6 1.6 5.3Tertiary 35.0 25.7 49.3 38.4Trade 9.7 6.8 13.2 10.9Transport andCommunications 7.2 6.3 10.3 9.3Graph 2.11Average real percapita GDP by provincesand the country, 2001–20062000015000100002006, only two of them (CaboDelgado and Zambezia) hadgrowth rates higher than thenational average, with Zambeziashowing the greatest rates ofgrowth for both HDI and GDI(34% and 34.5% respectively).Graph 2.12 shows the evolutionof the cumulative growth rates ofthe HDI and the GDI of the 11administrative regions in theperiod 2001-2006.A further note worth stressing is the fact that thetwo provinces whose rates of growth, both of the HDIand of the GDI, are above the national average, arelocated in the central and northern zones. Particularnote should be taken of Zambezia in the centre, withgrowth rates of 34% and 34.5% respectively, and ofCabo Delgado in the north with 27.5% and 29.2%.This growth is attributed to efforts made in education(both public and private), in the expansion of accessto education and improved quality of schooling.50000Maputo province and Sofala province also show realper capita GDP that is higher than the national average– but Maputo Province has a per capita GDP thatis twice as high as that of Sofala.Evolution of the HDIand the GDIThe data from the period under analysis allow us tonote that the level of human development, both nationaland in the administrative regions, is continuing torise gradually, as a result of economic and social performance,which has been expressed in the positiveevolution of both the HDI and the GDI (Table 2.5).In fact, the national HDI grew by about 17.3%between 2001 and 2006. Over the same period, theGDI experienced parallel behaviour, with growth ofabout 22.5%. Though all provinces underwent noteworthygrowth rates in their GDIs between 2001 andGraph 2.1235302520151050HDIAccumulated variation of theHDI and GDI, 2001–2006GDI13


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2006Table 2.5 HDI and GDI growth rates, 2001-2006Region/ProvinceGrowth Rate (%) HDIGrowth Rate (%) GDI2001 2002 2003 2004 2005 2006 Cumulative 2001 2002 2003 2004 2005 2006 CumulativeNorth 4.1 3.9 2.4 2.8 4.0 2.1 20.9 3.7 5.5 2.5 3.4 3.0 2.6 22.7Niassa 4.4 2.6 1.3 4.1 2.5 2.0 18.0 3.6 3.8 2.5 4.7 2.6 2.5 21.3Cabo Delgado 4.6 5.7 4.5 2.9 5.0 2.2 27.5 4.5 9.3 3.4 3.5 2.9 2.7 29.2Nampula 4.1 3.9 2.1 2.6 4.2 2.3 20.8 3.9 4.3 2.3 3.3 3.5 2.7 21.8Centre 4.2 4.0 2.5 2.5 2.7 2.0 19.3 1.7 4.0 3.4 3.2 2.1 2.6 18.4Zambézia 6.7 9.2 6.8 2.2 3.1 2.2 34.0 6.6 11.7 4.5 2.7 2.6 2.6 34.5Tete 3.3 2.4 1.5 3.5 2.2 2.4 16.3 0.2 1.8 2.3 4.2 2.6 2.9 14.8Manica 3.9 3.3 1.9 2.5 2.2 2.1 17.0 3.3 4.3 2.0 3.1 1.7 2.8 18.5Sofala -2.9 2.4 0.6 2.5 3.1 1.6 7.3 2.8 3.5 1.9 3.2 1.8 2.1 16.2South 3.2 1.7 0.4 2.1 3.1 1.5 12.8 5.4 2.5 0.9 2.3 1.3 0.9 13.8Inhambane 2.8 1.9 0.2 3.3 4.0 1.9 15.1 1.1 4.0 1.3 3.5 2.2 1.7 14.6Gaza 3.7 1.9 1.0 2.0 2.8 1.7 13.7 1.9 0.9 1.4 2.2 1.4 1.2 9.3Maputo Prov. 4.4 1.3 1.8 1.9 3.0 1.9 15.2 3.7 3.8 0.9 2.6 0.6 0.8 13.0Maputo City 1.8 1.2 0.3 1.6 3.2 1.0 9.4 0.1 1.8 0.5 1.5 1.2 0.3 5.5Mozambique 4.4 3.9 1.6 2.7 2.0 1.8 17.3 5.1 3.7 2.2 4.0 2.7 2.9 22.514


Chapter 3Roots of the Pandemic and itsDetermining Factors in MozambiqueBrief historical summaryThe first diagnosed case of HIV and AIDS inMozambique occurred in 1986, and the person inquestion was a foreign citizen resident in the country.During 1987 the first five clinical cases inMozambican citizens were notified. In the followingperiod, up to 1989, the number of cases doubledevery year, and in July 1989 reached the total of 41.The age group worst hit was from 20 to 29 years old,as happens in other parts of the world. Children alsofeatured significantly, with 5 cases in this total. At thistime, it was known that these figures were far fromexpressing the real situation in the country.To the north and west, Mozambique borders onsix countries, including some of those most affectedby the pandemic, with current HIV prevalence ratesequal to or higher than the Mozambican nationalaverage, which, as mentioned earlier, was around16.3% in 2004. In the 1990s, when the epidemic wasin its incipient phase in Mozambique, these countrieshad the highest prevalence rates in the region.Almost immediately after independence in 1975until 1992, Mozambique lived through a war thatcaused mass displacement of entire populations insearch of refuge and safety, both in other parts of thecountry, and in neighbouring countries. These populationdisplacements ensured that the disease spreadvery rapidly, particularly in central Mozambique.Resulting from the General Peace Agreement, newpopulation movements took place, this time of peoplereturning to the country and their zones of origin. Thefirst consequence of this was to make even more visiblethe image of generalized absolute poverty. In thisperiod, the priority to guarantee the success of peacewas given to population resettlement, to demining theterritory, and to providing food and basic health carefor millions of people who had formerly been internallydisplaced persons and refugees. Meanwhile, theindices of the spread of HIV and AIDS were growingvery rapidly, but as yet without surveillance systems andappropriate and directed prevention campaigns.Along the national frontiers there is also intensivelocal and cross-border trade. Along the tradingcorridors that connect the countries of the hinterlandto the Mozambican ports of Beira, Nacala andMaputo, on the Indian Ocean, there are major movementsof people and of trade. This movement is supportedby rail and road networks that bear the mostintensive traffic in the country. In some places, suchas the area connecting Tete and Manica provinces, atthe times of peak activity there can be 1,000 trucksand cars a day.While recognising their weight in the initialphase of the epidemic in Mozambique, the factorsportrayed above are not sufficient in themselves toexplain the rapidity with which the HIV and AIDS epidemichas grown, and has reached the currentprevalence and spread, with a trend to worsen. Otherfactors that favour the rapid expansion of the epidemicshould be studied in order to identify the mosteffective ways of containing and controlling the disease.The country’s low health coverage should beput in a central position; according to informationfrom the Ministry of Health, the National HealthService offers care to between 40-50% of the population.Which means that the other 50%, evenwhen they are able to identify a health problem,cannot go to any health unit, because one does notexist near them.Accessibility of health services andthe weight of traditional medicineAccessibility to health services includes aspects of thestructure of health services or health facilities thatenhance the ability of people to reach a health carepractitioner, in terms of location, time, cost and easeof approach (WHO).Accessibility cannot therefore be seen solely inphysical terms, but also in terms of the existence ofqualified staff capable of making diagnoses and givingthe correct treatment, and of identifying and15


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007referring clinically complex cases to a nearby healthunit that has better human, technical and treatmentresources.This transfer is only possible when there arematerial resources, transport and roads, which arestill scarce, and are in a generally precarious conditionthroughout the country.Strong and diversified beliefs and habits amongthe rural communities have also contributed tohealth units not being the first, let alone the only,option to deal with illness. In fact, the majority ofMozambicans first seek out the traditional medicinesystem. This system shares common explanatorymodels for the health/sickness dualism, which oftendo not fall within the scientific/biological modelsexpressed in terms such as Virus, ImmuneDeficiency, Syndrome, Infection, HIV and AIDS.A further relevant factor in this analysis is thehigh degree of illiteracy. Indeed, illiteracy greatlyreduces the possibility of the public taking advantageof educational and information opportunities inorder to use health services better. Despite an 11%reduction in a three-year period (1999-2003), theilliteracy rate remains slightly above 50%, withgreater incidence among women.Furthermore, in a country characterised bybroad linguistic diversity, the lack of mastery ofPortuguese as the official <strong>language</strong> among potentialusers of the health facility and the lack of health staffwho speak local <strong>language</strong>s limits open and effectivecommunication between health workers and thecommunity they serve, and this is a huge constraint.Graph 3.1Percentage80706050199720002003Illiteracy rate2005Source General Population and Housing Census (INE, Census 97) 1997Questionnaire of Basic Indicators of Well-Being (QUIBB), 2000-2001Household Survey on the Family Budget (IAF) 2002-2003Conformism and loss of confidenceConformism, loss of confidence, hope and selfesteem,and the habit of living with fatalities, are attitudesthat have very serious consequences in people’slives. Fatalism leads many people to neglectadopting systematic and effective measures of prevention,in a long-term perspective for their lives,against the pressure of urgent and serious problemsto be solved at once. This is the context in which weshould look at commercial sex, seen as a means ofsurvival. The need for immediate subsistence (moneyto buy food) is prioritised above the danger of deathfrom AIDS in the long term.At the same time, frequent illnesses and deaths inthe communities also ensure that people begin tolook at deaths from avoidable diseases as a matter offate. Attending one funeral after another of peoplethey know also ends up diminishing the strong emotionalcharge that should result from such events.This behaviour has two explanations. One is thereflex of a defence mechanism in which, unconsciously,people protect themselves from suffering. Afurther explanation lies in an undesirable state ofspirit, in which death appears as a banal phenomenon,a matter of fate, with which one can live fromday to day without provoking serious concern. Theattempts, very common in communities, to try toconnect death to supernatural forces also ends upweakening the struggle against HIV and AIDS, particularlyin the countryside.For a stronger civic movementIn many countries affected by AIDS, there have beenvery strong movements of solidarity among peopleliving with HIV and AIDS, regardless of the socialstrata, race, religious creed, and sexual or politicalorientation of the persons in question. The entireworld is currently benefiting from the work of thesepeople living with HIV and AIDS, and who alwaysdemanded that societies and governments shouldprovide them with better opportunities of access tomeans of prevention and treatment. This struggle inpart galvanised access to the medicines and otherrights which are now recognised and granted.In the Mozambican experience, just a very fewpeople have had the courage to appear in public anddeclare that they are HIV-positive, bearing witness tohow they have been living positively with HIV andAIDS. Even so, they are generally unknown people,or people who are not necessarily models for most of16


Roots of the Pandemic and its Determining Factors in MozambiqueBox 3.1Confidentiality around HIV and AIDS has become a theme forsharp debates that divide opinions. From the start, confidentialityis among the series of norms proper to the medical ethicsfollowed by health-care professionals.Faced with a specific situation of positive diagnosis of HIVin an individual in the socio-economic, political and culturalconditions that currently characterise Mozambique, is it legitimateto think about authorising that knowledge of this fact beplaced in the public domain, or should secrecy be pre-eminent?At present, in the context of health care for people who testpositive for HIV, not a few voices defend lifting the confidentialityand secrecy that surround AIDS. The reason for this positionis that if the result is communicated publicly, then society isprotected, particularly the partners with whom the individual inquestion is intimate. It is also added that such a measure wouldgradually eliminate stigma and discrimination, dissipating thefear of breaking the silence and demystifying the disease.This is indeed a matter that involves several complex considerations.These cross various areas, from that of humanrights, to ethical and moral questions, and to some extent flowsinto juridico-legal questions, not forgetting the essence ofmedical ethics, which from the start advises medical secrecy asan extremely important right of patients and an ethical obligationon the doctor (Rueff, 2004).But why should this question be a burning issue in thesphere of AIDS? It is because this is a disease, which, in the caseof Mozambique, is mostly spread through unprotected sexualrelations between individuals at least one of whom is HIV-positive.HIV-positive status among adults has generalised negativeconnotations. The social interpretation is that this status resultsfrom misconduct, promiscuity, etc.Since sexuality is a social construct still surrounded bytaboos, it is to be expected that HIV-positive status will belinked to stigma and discrimination, two evils that are anassault on the preservation of the life of someone who alreadyhas to resist the virus inside his or her body. Such people arethrust towards “a social death that precedes physical death”(Sontag, 1998).The right to life is primary, and under these circumstancesit precedes all other rights that an individual may possess. Thisbeing the case, when circumstances lead to the hypothesis ofcontaminating third parties, thus endangering their health,then protecting them from this danger becomes an imperativeand moral duty of those who know the truth.But since there is no consensus on the matter, it is importantto look into the other aspects of this question.Voluntary disclosureIt is important to mention that to a large extent what contributesto the secrecy surrounding HIV and AIDS infection isthe generalized ostracism that the individual in question mayeventually suffer. Discrimination because of disease is not anew phenomenon and is not limited to HIV and AIDS. Indeed, inthe history of the diseases that have most marked humanity,there are records of discriminatory behaviour that accompaniedtheir evolution and the way in which patients were viewedand treated. Leprosy and tuberculosis are two of the clearestand closest cases; at times, the impact they caused reached thescale of generalized alarm, because of ignorance about how toConfidentiality and AIDS: An open debateface the disease and prevent its spread. This knowledge camelater.As for HIV and AIDS, since it was diagnosed and typified in1981, the imperative of not unleashing generalised alarm, thatmight lead to panic and social instability, has accompanied thepositions not only of scientists, but also of politicians anddefenders of human rights. It is important to mention that thisis a pandemic with special characteristics and still without acure.Thus in the early years following the scientific diagnosis andtypification of AIDS, there was lobbying to ensure respect for certainprinciples that would, on the one hand, contribute to reducingthe possible panic that might be generated within the communityin general, and, on the other, to encourage individuals totake the test of their own free will, and to make the much-mentionedbreak in the silence.It is worth adding that the fact that the first HIV tests tookplace in individuals belonging to marginalised groups may, tosome extent, have contributed to strengthening the secrecywhich since then has characterised the treatment of this publichealth problem (Glum, 2002). Indeed, the first expressions ofwhat would come to be known as Acquired Immune DeficiencySyndrome (AIDS) were found among groups of homosexualsand drug users who injected. They already suffered stigmatisationand discrimination because of their social and, particularly,sexual behaviour, regarded as a per<strong>version</strong>.Thus the principles that shaped the lobbying agenda forobserving the rights of the individual in the HIV and AIDS contextwere summarised into what are today the main humanrights reference points, particularly for people living with AIDS,namely:• Anonymous and confidential testing;• Voluntary testing, preceded by counselling;• Special rights at the workplaces;• Banning of compulsory tests; and• Condemnation of all forms of discrimination and stigmacaused by HIV and AIDS.The social expectations of these principles was that implementingthem might really lead to generalised awareness,through prevention and counselling, and consequently to takingthe voluntary test, and particularly to publicly breaking thesilence in order to repress the taboos that surround the infection,and the stigma that accompanies it. This expectation,although it is beginning to gain ground, has yet to be fullyrealised.Contrary to this expectation, citizens’ voices are beginning tobe heard, publicly questioning the confidentiality surroundingHIV and AIDS, and asking why the results of the individuals whotest positively under medical examination are not publiclyannounced. It is wondered: is not this procedure one which, farfrom controlling the virus and the disease, helps to spreadthem?Meanwhile, there are not a few cases of couples where oneof the partners, although knowing that he or she is HIV-positive,keeps this secret and continues to have unprotected sexualrelations with his/her partner.Thus, the question of HIV and AIDS confidentiality, apart fromdealing with matters of a juridical and legal nature, is above allan ethical and moral issue. It seems to us that, in the case men-17


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Box 3.1 continuedtioned above, where silence about a situation which endangersthe life of somebody else and which, in the event of pregnancy,may also endanger the health of the unborn child, the questioncannot be limited to the patient-doctor relation, or to the rigidcontext of confidentiality. To us it seems a matter that meritswider treatment, at least at the level of the family, and of the circlesthat have emotional and amorous relations with the personconcerned.The HIV and AIDS situation is generalised in Africa, where themain route of transmission is unprotected sexual relations inwhich one partner is HIV-positive and the other is not. Its prevalenceis spread across all age groups, but particularly amongthose aged 15 to 49, regarded as the group of sexually activepeople.On the other hand, as mentioned in some studies from otherparts of the world, the violation of secrecy runs the risk of discrimination,and may lead to abandoning the health system –because it is not respecting the principle of confidence andsecrecy (Rueff, 2004). It is general knowledge in the literature onsexual and reproductive health that marginalized and ostracizedgroups of citizens rarely seek health services or medicaladvice (<strong>United</strong> Nations, 2005).those who know them. This fact has reduced theimpact of their testimony.Fear of stigma and discrimination are otherimportant factors that have a negative influence onMozambican attitudes, preventing them from seeingHIV and AIDS as a disease, like many other chronicdiseases, and which should be treated as such. Theseattitudes show a lack of preparation in society toaccept that HIV and AIDS are a national problem thataffects everybody.Biological determinants of the pandemicThe biological determinants or factors that influencethe transmission of HIV in Mozambique are partlysimilar to those already identified in other countries.On this theme there exists internally a large and variedamount of documentation, amongst which wemay mention the First HIV and AIDS Strategic Plan for2000-2002, and the Second HIV and AIDS StrategicPlan 2005-2009, drawn up by the National AIDSCouncil (CNCS).This work describes, with recognised scientificrigour, sex between different generations, casualunprotected sexual activity, multiple sexual partners orfrequent change of sexual partners, sexually transmittedinfections, the start of sexual activity at an earlyage, particularly for girls, as some of the factorsinvolved. However, there are other factors not frequentlydiscussed and relate to certain practices whichcause lesions on the skin of the genitals. The use ofplants and various other substances to contract thevagina during sex, or the rituals to “purify” widows followingthe death of their husbands are some of the factorsidentified that facilitate HIV transmission.Heterosexual relations remain the most commonform of transmitting HIV in the country. More than90% of HIV infections occur through sexual relationsbetween an infected individual and one who is notinfected. It does not necessarily have to be sexualactivity with many partners. However, having severalconcurrent sexual partners increases the likelihoodof infection and re-infection by HIV and other sexuallytransmitted diseases. This pattern is most commonamong sex workers who have a very high rate ofchanging partners.Sexually transmitted infections,stigma and gender inequalitySeveral studies have shown that Sexually TransmittedInfections (STI) are an important factor in HIV transmission.The STIs inflame the genitals, which facilitateHIV infection, particularly among women. Theanatomical configuration of the female genitalia providesan extensive surface for contact with infectiousagents, which makes women more vulnerable to STIsand to the risk of HIV infection. The complexity oftheir anatomical structure means that many sexuallytransmitted infections are not visible, and occur withoutsymptoms, which makes it difficult to diagnosethem.The early start to sexual activity facilitates thesexual transmission of HIV, particularly amongyounger women. The fact that their genital organs arestill developing makes them more vulnerable to thetransmission of disease.A further factor to bear in mind is that the surrounding,social, economic and political environment,in which people interact, also has a determinantrole in the pace of spread of the infection.Involved in this are factors such as poverty, discrimination,oppression, illiteracy, mobility or migrationof people, the status of women, levels of urbanisation,levels of violence, access to health care, and thedistribution of wealth, among others.Among the factors mentioned above, poverty,with an index in Mozambique of around 54% (INE,18


Roots of the Pandemic and its Determining Factors in Mozambique2004), deserves special mention since it contributesto vulnerability among individuals, households andcommunities, and it heavily influences the spread ofHIV. In turn, the impacts of the epidemic severelyaffect the environments less endowed with economicand social resources, worsening poverty, weakeningthe economic and food security systems and increasingthe number of poor people at risk of contractingthe infection.Indeed, the determinant variables of poverty,such as acute hunger, malnutrition, low level ofschooling, poor access to information, and particularlyto health services, among others, are associatedwith the conditions that increase social vulnerabilityto the epidemic.Women, particularly in the countryside, are still ata strong disadvantage in the economic, legal, culturaland social spheres, which increases their vulnerabilityto HIV infection, and to the epidemic’s impact. Thereare still a large number of girls of school age withoutaccess to education and women have few, if any, propertyrights or security of land tenure, or even inheritancerights, given the rule of the patriarchal structurethat influences customary law, used in many communitiesto settle disputes locally.Meanwhile, many of these women have beenexposed to the risk of sexual assault or rape or otherforms of violence. Coercive sex, for instance,expressed through non-consensual sexual activity,has been mentioned as a common practice restingon unequal power relations between men andwomen. This is an act that happens both domesticallyand outside the home, and the victims are children,youths and adult women. All forms of coercivesex can significantly increase the likelihood of HIVtransmission.The groups at high risk of HIV infection are generallythose who suffer from stigma and discrimination.Stigma increases vulnerability in several ways.Afraid of being discriminated against, individuals athigh risk of contracting the infection decline to seekinformation concerned with their sexual and reproductivehealth or other forms of disease prevention.Migration, urbanisation, commercial sex,and the prison populationA further factor contributing to the rapid spread ofHIV in Mozambique is the high level of mobility. Thecontinual degradation of living conditions in thecountryside, where young people and adults alikehave no work, and the decline in agricultural yields(due to constant climatic changes) have been factorsencouraging migration from the countryside to thecities, particularly after the end of the war in 1992.Concentrated in disorganised urban areas,where the traditional degraded neighbourhoods arespreading, these migrants increase, and rapidly, therisks of spread of the HIV virus, Generally, peopleemigrate from a rural area of low HIV prevalence tourban centres, where the prevalence rates are highand risky behaviour more frequent.Furthermore, urbanisation can favour inter-personalcontacts and encourage the search for unconventionalalternatives for survival. The option of manywomen for commercial sex has been common in theurban fabric. The fact that right from the start thesexual transaction occurs in a negotiating frameworkthat favours the man means that it is he who determinesthe nature and the conditions under which theact should occur. The women are potentially morevulnerable to infection.Additionally, the rate of change of partners, thecompeting partners, the sexual practices, and the useor not of condoms during the sex act are factors totake into account in determining the levels of vulnerabilityor exposure to infection under these conditions.As for the prisons, they are generally placeswhere infectious diseases such as HIV and AIDS,tuberculosis and hepatitis are spread. In general, theprison population comes from the poorest populationsegments of society, who are at a high risk of HIVinfection. The rates of infection among the prisonpopulation are generally higher than among the populationat large.Vulnerability and vulnerablegroups to the pandemicIn dealing with the content of this part, two conceptsdeserve attention, namely that of susceptibility and thatof vulnerability. Susceptibility to the pandemic is characterisedby a series of factors that determines the rateat which the disease spreads. It is thus easy to explainin the Mozambican case the reasons why areas contiguousto the great transit systems – the developmentcorridors – have relatively high prevalence rates. Theyare in fact converted into “inter-cultural” poles wherepeople from various parts of the country and fromneighbouring states cross paths. Commercial sex iscommon in these social interactions.19


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007It’s worthwhile to note, however, that this concepttends to gain a new dimension every time thereis a generalised epidemic (average sero-prevalenceabove 5%). A most common form with which the epidemicpropagates itself is the establishment of relationswith multiple and competing partners. Thismeans that certain people simultaneously keep goinga web of generally permanent sexual partners apartfrom the official partner through wedding ties.At a time when multiple sexual partners driven bya tenacious search for survival groups together differentsocial strata, brings together sexually differentages and throws social mores and indecent exposureto the dustbin it is natural that susceptibility to infectionhas gained new forms, with hardly any differencein indicating between corridor areas, hinterland andurban areas, where the practice abounds.On the other hand, vulnerability describes certaincharacteristics of society, and of social and economicinstitutions or processes, which make it probablethat the morbidity and mortality associated withthe pandemic will have negative impacts.Vulnerability increases in social strata severelyaffected by poverty, by natural disasters, or inversely,when factors that drive and stimulate the nationaleconomy take place in areas of extreme poverty, andwhere commercial sex is common, as is sex betweenpeople of different ages, generally older men withgirls in the flower of their adolescence or youth.These two concepts explain to us why not all themembers of a community will be affected by the epidemicin the same way. The effects will have differentialrepercussions according to the levels of povertyand wealth among households, social cohesion, thelevel of development of social capital, and alsoaccording to the availability of health information,and a series of services providing care, both of publicorigin and from civil society.In the period following the discovery of the disease,the perception of vulnerabilities and susceptibilitieswas aimed at specific risk groups. This maybe explained by the fact that HIV-positive diagnoseshad been common among homosexual men andpeople who had received blood transfusions.Currently, the epidemic has taken on wider dimensions,and is effectively generalized among almost allthe age pyramids. This generalization shows that thedisease is among us, and requires cross-cuttinginterventions in all population segments.Despite this fact, the concept of vulnerable groupswhich is being applied to the Mozambican case,according to the situation analysis preceding the formulationof the National Strategy for the Struggleagainst HIV and AIDS, is expressed in groups of individualswho, by their characteristics, show a potentialto contract, transmit, or suffer directly or indirectly theconsequences of HIV and AIDS.This concept aggregates sex workers, long distancetruck drivers, miners and migrant workers ingeneral, workers in brigades away from home, soldiersin barracks or military units, commercial travellers,certain professional categories connected tothe entertainment and tourism industries, the prisonpopulation, informal vendors and workers on theirstalls, women in polygamous families, wives of minersand truck drivers, widows and women in generalin the framework of traditional society, PLWHA,OVCs, and street children (PEN 2005-09).20


Chapter 4The Demographic Impact of HIV and AIDSin MozambiqueEpidemiological surveillanceIn Mozambique, there are two forms of notificationof Sexually Transmitted Infections (STI) andAcquired Immune Deficiency Syndrome (AIDS),namely: passive (in health units), and active(Sentinel Surveillance of HIV in Pregnant Women)(MISAU-PNC STD/AIDS, 2001).In the passive form, all health units should notify,every month, cases of STI/AIDS to district level.The district notifies to the provincial level, whichfinally reports to the PNC-STD/AIDS in Maputo.(Barreto et al, 2002). However, comparing the totalnumber of AIDS cases notified this way, with the totalexpected, according to estimates obtained throughthe active form, one notes that the system of passivenotification catches less than 20% of the real numberof AIDS cases.For this reason, for programmatic purposes, theprevalence estimates obtained through the activemeans are used. This data is gathered from pregnantwomen who present themselves consecutively fortheir first ante-natal consultation. These rates areconsidered as representative of the adult populationaged 15-49, and are thus used as a basis to estimatethe provincial and national HIV prevalence rates, andthe demographic impact of HIV and AIDS on thecountry.In the 2001, 2002 and 2004 rounds, theEpidemiological Surveillance (EV) systemoperated with 36 sentinel sites. Table 4.1and Map 4.1 show the evolution of theprovincial, regional and national weightedHIV prevalence rates over the period 2001-2004. As can be observed, in general thesouthern and northern regions show a risingtrend of the epidemic, although differencesmay be noted in the pace of growth betweenthe various provinces. In the south thesharpest growth was observed in Maputo cityand province; the weighted rate inInhambane also grew, due to the increaseTable 4.1Map 4.1Maputo20.7%Tete16.6%Manica19.7%Gaza19.9%Sofala26.5%Inhambane11.7%Maputo city20.7%HIV prevalence rate2004, 15-49 yearsNiassa11.1%Zambézia18.4%Cabo Delgado8.6%Nampula9.2%Below 10%Between 10% & 20%Above 20%Source: Report on revision of the HIV epidemiological surveillance dataround,2004 (INE/MISAU)Comparison of provincial, regional and nationalweighted HIV prevalence rates, 2001-2004 (%)Province 2001 2002 2004 Region 2001 2002 2004Maputo city 15.5 17.3 20.7 South 14.4 14.8 18.1Maputo province 14.9 17.4 20.7Gaza 19.4 16.4 19.9Inhambane 7.9 8.6 11.7Zambézia 15.4 12.5 18.4 Centre 16.8 16.7 20.4Sofala 18.7 26.5 26.5Manica 18.8 19.0 19.7Tete 16.7 14.2 16.6Niassa 5.9 11.1 11.1 North 6.8 8.4 9.3Nampula 7.9 8.1 9.2Cabo Delgado 5.0 7.5 8.6National 13.0 13.6 16.221


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Graph 4.1Population affected %2015105019882000observed in Maxixe. In the northern region, theprovinces with the sharpest growth were Nampulaand Cabo Delgado.Sofala province has the highest percentage ofHIV infections. In this province, HIV infects one infour people aged between 14 and 49. In Inhambane,Cabo Delgado and Nampula the situation is at its leastserious. In these provinces the virus that causes AIDSinfects less than one person in ten.HIV prevalence rate amongthe adult population (15- 49 years)It is estimated that in 2004 there were about 1.5 millionpeople living with HIV and AIDS in Mozambique,60% of them women, and the remaining 40%, men.Projections of the evolution of the HIV and AIDSepidemic in Mozambique indicate that, if the historicpattern of evolution is maintained, without immediateand effective intervention, then the epidemic willcontinue to grow until 2009, when it will be stabilizedat around 17%, as a result of reaching a balancebetween HIV infections and mortality fromAIDS; that is, when the number of deaths per day isequal to the number of new daily infections.At regional level, 1 the projections show differentpatterns of growth, as illustrated in Graph 4.1As shown in Graph 4.1, the central region as awhole has been experiencing a rapid growth in theepidemic, and it is forecast that as from 2005 or 2006it will reach the phase of maturity or stability at around17 or 18%, particularly in Tete province, if effectivemeasures to prevent the transmission of HIV in thisregion are not implemented and/or strengthened.2002Projection of HIV prevalencein adults, 15-49 yrs, by regions20042006North Centre South20082010A more detailed analysis of the evolution ofprevalence at the Sentinel Sites of this region suggestsa mosaic of trends in the pandemic, with someprovinces showing a pattern compatible with themature phase of the epidemic, some requiring moretime for observation, and finally one, Zambezia,where the disease still seems to be growing sharply.Finally, the northern region, with little historicalinformation prior to the year 2000, shows the lowestlevel of prevalence in the country. But likewise,unless effective preventive measures are implemented,it is forecast that the epidemic in this region willcontinue to grow rapidly, until around 2009-2010,when it will tend to reach its mature phase at about15%. It should be noted that the projections forprevalence in this region could undergo variationsin the future as more information becomes available,though it is expected that in the coming yearsthey will remain lower than those for the south andcentre.In conclusion, the projections presented hereare only valid in the current context.As more data are collected over the years, andshould the preventive and therapeutic (ARV) measuresbe effectively implemented, the projections forthe pandemic’s evolution could undergo significantchange in the coming years. For example, in someprovinces, particularly in the north and inInhambane, the opportunity is still there to preventthe spread of the epidemic from reaching the samespeed as observed in most of the provinces south ofthe Zambezi River.It is also possible to “anticipate” the maturephases of some provincial micro-epidemics, so thatthey may be reached at levels lower than those forecastfor most of the provinces south of the Zambezi.Estimate of HIV prevalence by sex and ageAs may be seen from Graph 4.2, most children whobecome infected in the peri-natal period die beforethey are 5 years old, and few survive to their 10thbirthday. More than half of the children living withHIV and AIDS in Mozambique are estimated to diebefore their second birthday. After this age, thereopens the so-called “window of hope”, in which childrenare seen to be virtually free of infection until theage of 14.1 Because of scarcity of data on the epidemic’s historical evolution, and because it has not yet reached its mature phase in most of the country’s provinces,provincial projections would produce results that are not very reliable. For this reason, the projections are made by region, namely the South (Maputo Provinceand City, Gaza and Inhambane), the Centre (Sofala, Manica, Tete and Zambézia) and finally the North (Nampula, Cabo Delgado and Niassa).22


The Demographic Impact of HIV and AIDS in MozambiqueGraph 4.22520151050HIV prevalence byage groups and sex, 2004WomenMe nAs from the 15-19 year age group, the time whenpeople begin sexual activity, (Wanderer & Radel,1986) HIV prevalence begins to rise rapidly in bothsexes, particularly among women (Graph 4.2).Indeed, as from this phase, the differences in HIVprevalence rates between the two sexes are somarked, that the rate among girls reaches aboutthree times that among boys of the same age. Thistrend to higher prevalence rates among women laststo the age of 30, when it is reversed (as a result of thehigher mortality from AIDS among the female population,and possibly an increase in sexual activityamong men of this age). From then on, the higherprevalence rates are among men.There may be several explanations for this patternof acquiring the infection, including:• the high speed at which sperm is injected intothe uterus (45 kms an hour, through the externalorifice of the neck of the uterus);• the mucous membrane of which is less resistantto infection than that of the vagina;• the woman’s greater length of time in contactwith the sexual fluids of her partner, (semendeposited in the vagina);• the difficulty of diagnosing and treating someSTIs in women; as well as,• the rather earlier onset of sexual activity amonggirls, particularly in the Mozambican countryside,worsened by the fact that their partners areusually several years older (as shall be seenbelow) with levels of HIV infection that arealready high.It should be mentioned that this pattern of thedistribution of HIV and AIDS prevalence by sex andage is in perfect accordance with the pattern of dis-tribution of confirmed cases of AIDS, by sex and age,generated by the AIDS notification system in thecountry’s health units (HIV/AIDS Multi SectorTechnical Unit, 2002).The absence of AIDS cases in the 10-14 year agegroup, shown in this graph, is explained by the simplefact that the adolescents who contract the infection inthis age group take time to become AIDS cases.This gender and age pattern in acquiring HIVinfection, which seems decisive for the distribution ofHIV and AIDS and its consequences at later ages, suggeststhat strategies to control the endemic should notneglect the age and sex factor, and should includeconcrete recommendations tending to encourage theadoption of safe sexual practices in the first sexualrelationship and the subsequent period.Incidence of HIV infection in MozambiqueGiven the difficulty of measuring the HIV incidence inthe population directly and easily, this measure hasbeen estimated indirectly through the prevalence data.The estimates of HIV incidence among adults showthat this has remained stable at high levels, of about500 new infections a day, since 2000 (MISAU-PEN ofSTI/AIDS 2004-2008). However, the evolution of incidencevaries by province and region, age and sex.Vertical transmission of HIV has been responsiblefor about 18% of these new daily infections.Again, the central provinces contribute more frequentlyto this form of transmission, with 60%, whilethe north and the south share the remaining 40%equally. Graph 4.3 shows that women have been consistentlyshowing a higher incidence than men.Graph 4.3New infections per hundred thousand300025002000150019982000Men and WomenHIV incidence in adults of 15-49 years,by sex, in each 100,000 inhabitants200220042006Women20082010Men23


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Box 4.1It has been 25 years since the HIV virus was reported as thecause of the AIDS disease.Several countries affected by the AIDS pandemic haveundertaken praiseworthy efforts to establish methods ofgathering statistical information for the purposes mentionedabove. As from the 1980s, many countries introduced epidemiologicalsurveillance systems to gather HIV data amongpregnant women. This method is based on the assumptionthat pregnant women are a sexually active, easily identified,accessible and stable population group. Thus HIV prevalencein the total population has been estimated based on datafrom this group.Very recently, in order to complement the informationobtained by the method mentioned above, population surveys(men, women and children) have also been used to estimatethe level of HIV prevalence, through blood and/or saliva samples.Among the African countries that have already carried outthis kind of survey are South Africa, Burkina Faso, Cameroon,Ghana, Kenya, Mali, Rwanda, Senegal, Tanzania, Uganda andZambia.Methodology currently used in MozambiqueThe Ministry of Health has set up an HIV EpidemiologicalSurveillance system, through Sentinel Sites located in selectedhealth units throughout the country. The system began in 1988with just 4 sentinel sites located in urban areas. This numberwas gradually increased to include rural areas and strengthenthe urban ones, so as to obtain increasingly representativeprevalence rates. As from 2001, the gathering of data has beenundertaken in 36 sentinel sites. The technical staff linked to thematter has recommended not expanding the number in future.The data are gathered in a maximum period of 3 months.At each site 300 pregnant women aged between 15 and 49who present themselves consecutively for their first ante-natalconsultation are selected. As is practice in other countries, thisinformation serves as the basis to estimate the HIV prevalenceand the demographic impact of HIV and AIDS for the total population.Calculating the provincial prevalence rates is undertakenby weighting the prevalence rate observed by the adult population(15-49 years) of the district, the regional rates by weightingthe provincial rates by the adult population of the province;and the national rate by weighting the regional rates by therespective adult population of the region.Estimates of HIV and AIDS prevalence:Epidemiological Surveillance versus Sero-prevalence SurveyOnly a quarter of the 144 districts in Mozambique possessSentinel Sites. To obtain prevalence rates for all districts, someassumptions have been made:• It is assumed that in the districts with Sentinel Sites, theprevalencerate observed is representative of the entire district;• To each district without a Sentinel site is attributed, as areference, the prevalence rate from another with a Sentinelsite, in accordance with established criteria of similarity.Added value of the new methodologyAlthough the results of HIV prevalence obtained via samples ofpregnant women are broadly acceptable, there remain someuncertainties and scepticism. The first concerns the representativenature of the samples used, as pregnant women with ahigh level of education are generally under-represented.Furthermore the high rate of pregnancy and births among HIVnegativewomen, compared with HIV-positive ones, is anotherfactor which generates some polemic.The second, which flows from the first, concerns the criteriaused to extrapolate from the HIV prevalence of the pregnantwomen to the total population and different geographicallevels. It is thought that that the combination of these two limitationsmay introduce distortions into the estimates of thedynamic of the HIV epidemic among the population.The introduction of the new methodology should not beseen as replacing the previous one, but as complementing it. Theliterature on the subject indicates that there is no single methodthat forecasts better estimates of HIV prevalence. The two methodsunder analysis are mutually complementary, since epidemiologicalsurveillance seeks to estimate the trend, while populationsurveys contribute to improving the calculation of the levels ofthe epidemic. Thus, the results of the surveys are used to calibrate(adjust) those obtained from epidemiological surveillance.To corroborate the above, recent studies show that HIVestimates based on results from the two methods in generalshow no significant differences.Finally, the survey may also contribute to examining thedeterminants of regional differences in relating information onthe sexual behaviour of the interviewees with HIV prevalence.For the survey to be relevant, in the current debate, its samplemust be representative not only at national, but also at provinciallevel. Otherwise a rare opportunity to consolidate estimateson the prevalence of the epidemic will be wasted.Impact of HIV and AIDS onindividuals and familiesUnderstanding the impact of the HIV and AIDS pandemicpresupposes understanding the transformations inthe socio-cultural and economic environment that itcreates with its immediate effect in terms of human morbidityand mortality. Without the HIV and AIDS pandemicany country in southern Africa would currently displaya different population structure and composition.In Mozambique, the impact of the disease onindividuals, families and communities has not beenwell studied. References to work oriented towardsbetter understanding this dynamic and directing thedevelopment of sectors in the light of the scenariosthat the epidemic presents are limited to a few isolatedcases of sector analyses of limited coverage. Thusgeneralizing from them is not recommended. What iscertain, however, is that as the epidemic spreads longitudinally,it becomes difficult to predict, qualify orquantify what its impact might be.Meanwhile, in low income countries, wherepoverty is the common denominator, studies have24


The Demographic Impact of HIV and AIDS in Mozambiqueshown a chain of impacts. According to these studies,the curve of infection is followed by the curve of sicknessand death, which in turn determine the thirdcurve – that of the impact (Benett and Whiteside,2002). Individuals, by families and by communities,will feel the impact in different ways.Regardless of the social responsibility of the individual,whether within the household or in otherareas of civic life, the consequences of HIV infectionwill be immediate and severe, varying, however, inaccordance with age and sex. The impact on the individualbegins with his/her awareness of his/her HIVpositivestatus. However, if the individual obtains indue time appropriate counselling on how to organisehis/her life as from that moment, the magnitude ofthe impact may be lessened.In the absence of treatment, the infected individualmay experience periods of illness, which is likelyto reduce productivity and income, and to increaseexpenditures for travel costs, laboratory tests andmedicines. Some individuals may, depending on theirlife style combined with good nutrition and other factors,hold back the disease and may even never experienceit. However, anybody in this state will be facedwith his/her health status and also, very frequently,with the resources he/she possesses.Where there are support systems, or free medicalcare, it is expected that the individual impactsbecome less serious.Access to free antiretroviral treatment, as is currentlybeing called up in Mozambique, impacts onHIV infected individuals in two ways: it improvestheir life expectancy and quality of life; and at thesame time it creates a lifelong dependence on antiretroviralmedicines and the interventions related toit (regular medical check ups, for example).The level of social cohesion, solidarity and experiencesof the past with regard to epidemics or similarscenarios also influence the impacts on the individual.Where the level of tolerance and the balance ofsocial togetherness are high, and also where acceptanceof the disease and community mobilisation aresufficiently strong to provide support to those who aresuffering, then levels of stigma and discrimination willtend to be low, thus minimizing the psychologicalpressure on the individual. The reverse will form thepremise for worsening the consequences on the individual,and it is expected that the effect of these willsurpass the individual dimension, and hit the family ofwhich the individual is a member.The impact of HIV and AIDS on the familyhousehold will be conditioned by a series of factorswhich determine the place of the infected individualwithin the household. If the epidemic mainly affectsproductive adults with a determinant influence inthe household’s economic and social affairs, withsickness or death, the consequences will becomeevident. These impacts will be expressed in thehousehold’s increased poverty, through the loss ofincome and consequent reduction in standards ofnutrition, and evidently by children becomingorphans.When children lose their parents and guardiansat a tender age, this has consequences in severalspheres of their lives. In the economic field, theseconsequences may be reflected in the loss of incometo sustain the household, guaranteeing food, schoolattendance for the children, clothing and housing,among others. In the legal field, the consequenceswill be expressed in the context of inheritance basedon customary systems.These consequences may also be visible asregards the social construction of personality, ininculcating values and norms of civic life, assimilatingwhich depends on individual reference pointsduring childhood. HIV and AIDS also increases longterm insecurity, arising from emotional suffering,deprivation and mourning.Since in most families, the task of caring for sickfamily members is a woman’s task, it is women inparticular who bear the burden of caring for peoplewith HIV or AIDS. When family members receive ART,the task shifts from taking care of a sick person tomaking sure that the children or male family memberstake their medication in the prescribed way andadhere to their treatment.While with illness the household’s economicreserves are called upon to pay for hospital care,with death these reserves are used for the funeral,which in the final analysis reduces the household’sincome. To mitigate the erosion of the householdeconomy arising from the effects of HIV and AIDS,women and children will be called upon to redoubletheir efforts in domestic work. Often this compromisesthe future of the children, particularly the girls,since in the first instance they are called on to interrupttheir schooling.The risks of stigma, isolation and rejection arealways present, depending however on the level ofcohesion and solidarity within the community. The25


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007immediate consequences of HIV and AIDS are thosethat speed up family instability arising from mutualaccusations about the genesis of the infection withinthe household. It may to some extent undermine trustbetween family members and evolve to situations thatrun out of control, often leading to separations andwith this to a greater vulnerability of the dependents.The impact on key socialand economic sectorsHIV and AIDS has unpredictable implications for economicand social sectors. Indeed, this epidemic ismainly concentrated on the active population, from 15to 49 years of age. It thus has a disproportionateweight on the age groups that play a key role in thedevelopment of the economy and of the country’ssocial sectors. AIDS does not only cause sickness,incapacity or death of workers, and severe emotionaland economic upheavals for families – it also increasesthe cost of doing business (UNAIDS, 1998).Analyses of the sector impact of HIV and AIDShave advanced predictions of economic catastrophe.These predictions have produced some light for amore objective and thorough interpretation of theprobable impacts of the pandemic on the economy,as they have also assisted in designing policies andstrategies in order to confront this scenario.Analyses of the behaviour of HIV and AIDS in thesectors also explain the size and scale of the impact,as well as the differential vulnerability in accordancewith the nature of the sector. The impacts haveproved that economic and social development incountries with high rates of HIV and AIDS prevalencewill be adversely affected, given that both the illnessand the deaths that eventually occur will cause enormouslosses among the work force (ILO, 2002).In Mozambique, the impact studies carried outin some sectors of the state have corroborated theprojections made and, to some extent, have soundedthe alert for what might become a generalized institutionalcrisis, if the combined efforts to halt thespread of the infection among the work force, or tomitigate its adverse impact, prove ineffective.Macro-economic impactIn May 2002, the sole macro-economic study on theimpact of HIV and AIDS in Mozambique (Channing,2002) was already confirming in its projections whathad been indicated as probable trends in the evolutionof the epidemic in the sectors, namely a negativeassociation between HIV prevalence in adults and thegrowth of per capita GDP.The explanation for this lies in the fact that withHIV and AIDS, the growth in productivity will bereduced, for the following reasons:• A sharp decline in (or interruption of) productiveactivities, due to the morbidity related withAIDS and deaths at all levels of the work force;• Break or reduction in the efficiency in theprovision of key government services;• A younger and inexperienced work force, withsignificantly limited capacities that must beadvised/trained on the job;• A generalised decline in the health status of thepopulation, even for those not carrying the virus,in that the care associated with AIDS overburdensthe resources of the health care system;• Reduced incentives for investment in trainingdue to people’s shortened life expectancy;• Great uncertainty associated with the establishmentof long-term contractual arrangements;and• The need to deal with the ramifications of thepandemic outside of the work place, such asattending funerals and seeking more appropriatemechanisms for the care to be given to orphansand to people suffering from AIDS, which willinevitably dilapidate capacities that would otherwisebe invested in improving productivity atwork.The study that was based on a simulation of twoscenarios (one with HIV and AIDS, and one without),projecting the implications to 2010, concluded thatHIV and AIDS could have a wide-ranging economicimpact, with a visible reduction in the growth of percapita GDP. Factors contributing to this include:reduction in the growth of productivity, the reductionin population growth and the accumulation of humancapital, and reduced accumulation of physical capital.Of these three significant factors, the most importwould be the effect on productivity.Impact on the education sectorThe impact on education also points to critical scenarios,particularly considering the evidence in some ofthe literature for a strong positive association betweenlevels of education and the growth of productivity.The association between education and agriculturalproductivity has already been demonstrated incountries such as Ethiopia, Kenya and Tanzania, just26


The Demographic Impact of HIV and AIDS in Mozambiqueto mention a few, where positive returns were documentedin this context, including the effect of educational“externalities”, which proved that illiterateneighbours of more educated producers who tendedincreasingly to innovate, obtained benefits simplyby observing and imitating what the others weredoing.In the provision of educational services, up to2010, the projection points to a loss of about 17% ofthe key staff. In terms of deaths at all levels, the forecastis that 9,200 teachers, and about 123 seniormanagers, planners and administrative staff will die(Verde Azul Consultant, 2000). Cumulatively, about18 months of productive work are estimated as thetime lost before these deaths occur.The area of the supply of education servicesshows the most severe impacts, which may also bereflected adversely on other sectors, considering theoverall needs to replace and renew skilled labour. Tomitigate this weight, the study projects that theteacher training centres (IMAPs, etc.), for example,will have to expand the number of trainees for thesystem because of AIDS. To replace teachers withuniversity degrees who die because of AIDS, theexpansion of training should be for an additional28%, compared to the scenario without AIDS.HIV and AIDS will thus lead to increaseddemand on the teacher training institutions.However, meeting this demand will face seriousproblems of quality, bearing in mind that trainedand experienced teachers who die will often bereplaced by recruiting individuals for these positionswithout the due training and educationalexperience.As for the costs that HIV and AIDS will imply forthe sector, taking into account the costs of sick peopleand other benefits, the expansion of teachertraining, the costs associated with system inefficiency,such as increased numbers of pupils dropping out orrepeating years, the development of preventive andmitigation activities in the sector, among other significantevents, an increase of about 6.9% is estimated.This percentage corresponds to estimated losses tothe system due to the impact of HIV and AIDS ofabout US$110 million during the period in question(2000-2010).Impact on the health sectorHealth workers are, like many other Mozambicans,exposed on the one hand to infection sexually. But onthe other hand, in a situation that is very specific tothis sector, they are exposed to risks of other formsof contracting HIV, such as contact with blood andother body fluids of infected patients.The impact of AIDS on the health sector stillrequires deeper analysis and treatment, so as toensure a more careful reading of the situation. Thepreliminary assessment of the impact undertaken in2002, although recognising that it brought to the surfaceweak or incipient evidence of the impact of AIDSon workers in the national health system, is a validstarting point for estimating and pondering whatcould become a situation difficult to control.In fact, estimates of prevalence undertaken inthis sector in 2002, pointed to an HIV and AIDSprevalence of 17% out of 15,101 workers registered,59% of them men and 41% women (Francisco, A etal, 2004). The age group most affected is those agedbetween 35 and 39, since that is the one containingmost workers. There were 172 recorded cases ofAIDS in the national health system, 103 men and 69women.An attentive reading of the results of this sectorimpact study clearly shows the difficulties that thesector will face in responding to the growing demandfor its services by the public throughout the country.In fact, for several years the entry into the system ofhigher level health professionals has declined. Byway of reference, it is worth noting that the proportionof doctors, and higher and mid-level health technicalstaff, has fallen from 69% in 1994, to 39% in2002. Meanwhile, the proportion of losses throughillness in 2002, for the staff of services not directlyrelated to health was 54%, against 32% for higherand mid-level technical staff, and 15% for health auxiliaries(Francisco, A et al, 2004).The impact of HIV and AIDS on the health sectorwill influence its level of response to the publicdemand for health services in general and particularlyto the care and treatment for HIV and AIDS andassociated infection. For 2004 the national statisticspointed to an average HIV prevalence of 16.2%among the public at large, with a cumulative figure of1.5 million HIV-positive people, 110,000 of whomdeveloped AIDS during the year, and 218,000 ofwhom required treatment with ARVs (PENSTI/HIV/AIDS 2004-2008). These figures mean additionalcosts for the health service in a country inwhich only half of the population has access to it.In Mozambique the ratio of health workers to27


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007population is 1/4000, which is one of the lowestinternationally and in the region. Even more abysmalis the ratio of doctors to the public: there is just onedoctor per 30,000 inhabitants. The figure reachesone doctor to more than 100,000 inhabitants in thepoorest areas in the interior of the country.In recent years, these indicators were undergoingrapid development, but now they are beginning tocome under threat due to the advance of the disease.HIV and AIDS is also killing nurses, doctors, laboratorystaff, pharmacists, dentists. In some health units,there are sectors which sometimes stop functioningbecause the sole technician died of AIDS. This situationis much worse under Mozambican conditions,where a very considerable number of the peripheralhealth units function with a single health technician.This situation will require redoubled efforts to stepup the training of doctors, nurses and other healthtechnicians to deal better with this problematic of AIDS,in terms of the provision of care, treatment of opportunistinfections, antiretroviral treatment and otheractivities concerning the normal operation of the sectorsuch as tuberculosis, malaria and other diseases.The increase in AIDS cases is a dramatic humanitariansituation in terms of public and individualhealth within the National Health Service. In healthunits, such as, for example, the Maputo and BeiraCentral hospitals, and the Tete and Manica provincialhospitals, in the medical wards, 60%-80% of thepatients have diseases related to AIDS.In this phase, without adequate drugs, increasinglylengthy absences from work begin, as do successiveand also increasingly lengthy periods in hospital.From the hospital’s point of view there is agrowing overload of work, due to the increase in thenumber of people seeking health care. This fact inturn means increased expenditure due to the longand repeated treatments that these patients need, onthe one hand, and to the increased consumption ofmore expensive drugs on the other, because thesepatients need special drugs to fight off infections.These situations are experienced today in most of thecountry’s health units.It is estimated that the general cost of caring foran AIDS patient is about US$30 (thirty dollars) ayear, without including treatment with anti-retroviral.The per capita budget for health in 2004 was US$12.If we take into account that the cost of treatment withantiretroviral varies from around US$200 toUSD$3,000 US$ per person per year, it can be clearlyunderstood that AIDS, given the costs it represents,could monopolise all extra funding in health.Since the budget is limited, other activities with aless visible but equally strong impact on publichealth in general, such as vaccinations, control ofmalaria and of other chronic and childhood diseases,may be compromised.With the increase of availability of antiretroviraltreatment and ARV prophylaxis for prevention ofmother-to-child transmission, the impact of the epidemicon the health sector is shifting from an acuteillness to a chronic disease. At present, the country isfacing these two situations simultaneously. The availabilityof antiretroviral has increased the need fortraining and refresher training of large numbers ofstaff and has created the need for the rehabilitationof health services to be able to ensure confidentialityand quality treatment for the eligible patients.Until a few years ago, the typical epidemiologicalpicture of Mozambique was characterised by a predominanceof acute infectious and contagious diseasessuch as malaria, diarrhoeal diseases and othersthat could be resolved immediately. The advent ofHIV and AIDS and the increase in tuberculosis andother chronic diseases bring other needs to the systemin structural and organizational terms, and interms of adequate resources that can allow appropriateand sustained response to the new demands.Impact on agricultureLike the other sectors documented above, the agriculturalsector is showing some instability in itshuman resources deriving from the impact that HIVand AIDS is beginning to cause. However, preliminaryconclusions, although they suggest that the additionalcosts due to HIV and AIDS might be significant,do not forecast a catastrophic decline in services,because there is a response capacity on the part ofthe institutions concerned – the study infers(MADER/Verde Azul Consult Lda, 2005).This scenario, however, has to be seen andanalysed in the context of the human resource managementof an institution that facilitates the developmentof services among the producers. It is thus notindicative of the context and environment that HIVand AIDS engenders among producers of the family,semi-commercial or industrial sectors.In a projection from 2004 to 2010, theAgriculture Sector (the Agriculture Ministry and itsProvincial and District Directorates) may lose28


The Demographic Impact of HIV and AIDS in Mozambiquethrough death around 1,700 staff at various levels.AIDS will account for about 84% of these deaths.Thus, in a time span of seven years, the sector maylose 25% of its total work force. Of the 1,700 it isestimated that about 881 deaths may occur amongbasic, mid-level and high technical staff. Of these,between 175 and 184 may be from the agriculturalextension area (MADER, Verde Azul Consultant,2005).ConclusionFrom the data presented, it is clear that all sectorsshow that they will, over time, suffer serous reductionsin their labour force, including skilled andexperienced technical staff of various levels and specialisations,which will have various implications forproduction and productivity. The conclusions thatcan be drawn are the following:• Without strong and sustained HIV and AIDSprevention programmes at the workplace,labour costs may increase significantly;• A significant part of the revenue or income fromundertakings may be used to pay for theexpenses arising from the above scenario, whichmay be expressed in reduced productivity orchanges in policies on social benefits and staffmanagement;• Many of these costs will be associated with healthcare, absenteeism and training;• The sectors that make intensive use of highlyskilled labour tend to be strongly affected, whilethose that make intensive use of unskilled labourtend to have less severe impacts;• The sectors that provide capital goods, such asconstruction and manufacturing are those thatwill suffer most from the effects of the epidemic;• To mitigate these impacts and sustain theeconomy as a whole, strong policies and strategiesin the areas of prevention, care and treatment,as well as at the level of impact mitigation,will have to be considered.29


30Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007


Chapter 5HIV, AIDS and GenderThe Social Construction of SexualityHIV and AIDS, apart from a medical and epidemiologicalquestion, are also a phenomenon with asocio-cultural dimension, and a development question.They therefore require an approach and understandingthat should include their social and culturaldimension, the institutionalised patterns of behaviour,the symbolic systems, the structures of productionand distribution of goods and services, and therelations of power.The progression of the epidemic is deeplyconnected to the sexuality of individuals, as well as tothe sexual behaviour they adopt. Indeed, the way inwhich individuals construct and express theirsexuality is influenced, not only by processes of anindividual nature, but also ones that are social,cultural, psychological, economic and political.Phenomena such as initiation rites, polygamous andtraditional marriages, rites of passage, taboos,traditional medicine, among others, are stronglythreaded by components of sexuality (PEN II 2005-2009).The concept of sexualityThe treatment of matters dealing with sex and sexualitycannot be dissociated from the body and fromindividual instincts and emotions. These elementsoften belong to the <strong>language</strong> of intimacy and/or ofsymbolism constructed in the mind, but it is veryembarrassing for many people to talk about it.For many Mozambican social strata, sex and sexualitylie in the realm of taboo, and thus are remittedto an area of shame and of the forbidden. Since sexualityis one of the pillars of traditional family moralities,mastery of its <strong>language</strong> is still an enormouschallenge, because it is different from day-to-day <strong>language</strong>s,and imposes a psychological order beyondthe contexts in which our socialisation evolves.In a multicultural and multilingual mosaic suchas Mozambique, sexuality and its expressions occurwithin the pattern of values that guide the way inwhich each community unit is structured anddefined.The structure of social organisation and the symbolicconventions that determine cultural order andidentity conceive of the man as the one who takes thesexual initiative. It is he who has the right to pleasure,while the woman has the duty to bear childrenand to satisfy the male biological instinct. This behaviouralorder, which is learnt at various moments ofsocialisation, whether through initiation rites, orthrough <strong>language</strong>s and rituals that are ever present inthe family and community, determines the socialexpectations of both men and women in the sphereof sexuality.Thus, in strongly patriarchal societies, socialisationbrings the <strong>language</strong> that instigates and encouragesmen to be “macho”, with their minds turnedtowards risk and to the use of social and sexualpower. It is common that they express their masculinitythrough scattered relations with multiple sexualpartners. Meanwhile, the same patterns of sexualsocialisation tend to inhibit women from taking careof their sexual health, particularly in contexts wheretheir economic power and psychological influence isreduced or nil. Thus sexuality is a resource of powerand of force.The symbolism that clothes the social constructionof sexuality is the result of knowledge of traditionalroutine, which goes beyond considerationsabout sex, and brings to the surface ideas and interpretationsabout diseases that are conventionallyassociated with sexuality.It is thus interesting to note, for example, thattuberculosis is often interpreted as resulting from theviolation of certain norms, including failure to “purify”the widow whose husband has just died.Furthermore, and particularly in the sphere ofpainful practices, the same interpretation of sexualityhas been used as a factor to cure particular diseasesor in the pursuit of easy enrichment. Thus insome societies children or virgins are still physically31


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007attacked or raped, in the belief that this will lead tothe cure of sexually transmitted infection, or to successin business, or to greater productivity from theman’s fields.This social construction is strongly rooted invariables that determine the male and female being.Their representation, and how they are learnt, reston values designed to provide norms for social andsexual relations. These values are transmissiblethrough a knowledge where the school is fundamentallythat of popular belief, and invested in individualsendowed with particular qualities and mastery,which allows them to impose behaviour on others,and particularly on the younger generation.This organisation imposes rules to be followed ingeneral by members of the social or communitygroup, and responsibilities in accordance with agestructure at the various phases of the individual’sdevelopment. Thus in the sphere of sexuality, theserules find an expression in the initiation rites towhich young people are submitted as soon as theyshow the first signs of puberty.With appropriate and varied messages in linewith their sexual determinant, these rituals convergeon the fact that, as a rule, they must take place beforemarriage. Indeed these are the conditions underwhich young men are trained to handle with virilitytheir future sexual life – the expression and exerciseof dominance and power, which flourish in the contextof socialisation. That is, if we are talking aboutmen: for in the case of women, the purpose of thesocialisation is that they should respond docilely andpassively, and objectively with the purpose of pleasingtheir partner.Gender inequalities and their relationshipwith the spread of the epidemicThe gender dimension with regard to HIV and AIDSis increasingly evident. Indeed, the evidence showsthat women are biologically more vulnerable thanmen to HIV and AIDS, since they have a larger surfacearea of mucous membranes exposed to the virusduring sexual relations.Girls are more vulnerable since their membranesare not yet fully developed, and are easilypenetrated. Linked to this is the evidence that girlstend to begin regular sexual relations earlier thanboys, increasing the risk of transmission.These differences are sharpened by genderinequalities and social norms deeply rooted in theroutine of the past, which demand that women, andparticularly girls, be passive and ignorant with regardto sex, and submit to men’s desire in decisions abouttheir sexual lives.Coerced or forced sex and sexual violence exacerbatewomen’s biological and social vulnerabilitiesto infection, and multiply their propensity to contractthe virus in situations beyond their control.Thus women account for more than half of theadults living with HIV and AIDS, In Mozambique,about 57% of those infected are women (INE/MISA,2005). This disproportion is very sharp in the 15-to-24 year age groups, where twice as many women asmen are HIV-positive. Increasingly high infectionrates among women and adolescents express theirgreater vulnerability, due to both biological andsocial factors.Inequalities based on sex and the dominanceexercised by men in sexual relations may increasethe risk of infection among women and limit theircapacity to negotiate the use of condoms.Linked with this, the lowly socio-economic statusof women, poverty, the levels of schooling whichremain low among women and are worse in ruralareas, subordination, particularly in decisions on sexand sexuality, as well as their traditional roles in thefamily and community, all expose the female sex togreater risk of infection.This exposure or propensity to risk of infectionis worsened by traditional practices such as the“inheritance” of one man’s wife by another man (inthe case of widows) and particularly within the samefamily, as well as the “purification” of the woman followingthe death of her husband.The denial of women’s basic rights, as well as thelow level of opportunities with regard to means ofsubsistence, of access to legal protection, of accessto information on health care, and to opportunitiesand meaning of treatment, denial of the right toinherit property in the customary system, and indeedfrequent cases in which women are stripped of property,as well as the stigma attached to widows in thecountryside, all significantly add to women’s poverty.HIV and AIDS and theirdual burden on womenThe feminisation of the epidemic is also worseningwomen’s traditional roles as managers of the household,and as those mainly responsible for caring forhousehold members infected by the disease.32


HIV, AIDS and GenderBox 5.1Condom use among secondary school students in MaputoHIV and AIDS is currently a pertinent health and social problemin Mozambican society. Most of the people infected arebetween 15 and 49 years old, but the peak of infection occursamong individuals who are under 20 years old (INE 2000). Thefact that young people aged between 15 and 20 belong to thegroup where there is the highest number of HIV and AIDS infectionsensured that this study would look at the responses to theepidemic from secondary school students.There are signs that among Mozambicans in general condomsare not widely used. Maputo, the Mozambican capital, isno exception.Demographic research (INE 1998) suggests that there aresome 509,364 sexually active individuals in Maputo – that is,individuals aged 15 or above, since the average age for the startof sexual activity in Mozambique is 15.7 years (INE 2001).A recent study on the distribution of condoms shows thatMaputo has 862 outlets (including pharmacies, shops, bars andothers) that sell condoms. Each of them sells an average of 50condoms a week (PSI 2000). Based on this data, we can concludethat about 43,000 condoms are sold per week, which suggestsa substantial deficit between the demand for and use ofone of the main means of preventing HIV and AIDS.In this context, the objective of the present study was toidentify obstacles to the use of condoms among young peoplein Maputo. It was of particular interest to find out how urbanyouth understand and handle their sexual behaviour. The studyalso tried to identify social and cultural values that contradictthe dynamic of “safe sex”, and particularly condom use.One of the fundamental aspects of the research was theprevailing belief among young people in Maputo that there isno need to use condoms in intimate relations based on loveand trust. Such ideas have been strengthened by the stereotypicalimages of high-risk groups (e.g., sex workers, gay men, peoplewho inject drugs) presented in the media, and with whomfew youths identify. These factors, associated with what may bedescribed as the “attitude of blaming the others” (Joffe 1999),ensures that many young people do not use condoms. Theirposition drew strength from the governmental discourse in theanti-HIV and AIDS campaigning of the late 1980s and the 1990s,which advocated the use of condoms with “casual sexual partners”,but not with regular partners.Data was gathered in 2002 using a combination of fourdifferent methods: questionnaires, discussions in focalgroups, semi-structured individual interviews, and informalconversations. Each of these methods was used for specificpurposes. The methods were designed so as to complementeach other.As a result of the study it was possible to identify six mainthemes that form the major obstacles that students face inusing condoms in their sexual liaisons. The themes are interconnected,and they mutually strengthen each other.Young love and trustIn general, the respondents felt that they did not need to usecondoms in stable and solid relationships normally associatedwith love, such as relations with a steady girl/boyfriend – forthey were in love, and partners in these relationships trustedeach others and were not sexually involved with other youngpeople.Relations of courtship and trust were seen as very important.[A] boyfriend is someone who is with you for a time.Sometimes he doesn’t stay for a long time, but you treat him withconsideration and respect. It varies...for example you can havebeen with him for just 3 months, but if you’ve been in his housemany times, or if you’ve had a very intensive relationship ... [thesituation] has all the responsibilities of courtship (Paula, 18).My girlfriend goes out with me, she comes to my house, myparents know her. I don’t like my friends talking to her in inappropriateways. What happens between us stays between us.We have a more mature relationship (Orlando, 17).Precisely because of the powerful ideal of faithfulness inrelations of courtship, many youths felt no need to use condomsbecause they trusted their partner. For the youths in thisstudy, trust means believing in one’s partner, and feeling safeand comfortable. Paradoxically, trust becomes an obstacle tothe use of condoms, since the young people concernedbelieved that their partner would never infect them, becausehe/she would not cheat on them. But these same youthsreported that they often changed partners, and with each newpartner established a relation of courtship in which they did notuse condoms.The power of trust and natural sexA partner with whom there is no promise of fidelity, who is nota regular companion, and where there is no public recognitionof the relationship is called a pito or pita. In sexual relations witha pito/a, condoms are more likely to be used, because the partnersfeel they have no guarantees about each other’s sexualpast. The rules that guide relations with a pito/a, are substantiallydifferent from those that operate in relations of courtship,where trust is the rule. As 17-year-old Júlio explained:“...With a pita things are different. With her it’s like this...Iwas with her today, I manage to achieve a sexual fantasy, I didsomething different, and later I told my friends, and we alltalked about it. I think this is bad, but it’s what happens... wedon’t walk hand in hand, we don’t take her home...ok, maybewhen nobody else is at home.”But on the other hand, in relations of courtship, there is areluctance to use condoms, because they imply accusations ofinfidelity and lack of trust. Requests to use condoms may resultin suspicion and arguments between partners, as 18-year-oldPaula explained:“...My boyfriend says he doesn’t want to use condoms withme because he trusts me, and he has never cheated on me.Every time I suggest that we use a condom, he gets veryannoyed with me. He starts asking me what I’ve done, or if I suspecthim. Now I’d rather not suggest condoms, because otherwisehe’ll stop talking to me. The question of condoms onlyspoils our day.”Explanations for the difficulties young people have in usingcondoms in relations of courtship are based both on the socialconstruction of love and on the way condoms have been promotedin campaigns to prevent HIV and AIDS. Love is constructedso as to stress intimacy, fidelity, trust and tenderness. Thus inloving relations, trust and fidelity offer protection. The existingsocio-sexual constructions simply do not associate the use ofcondoms with love.33


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Box 5.1 continuedOfficial speeches and casual sexThe initial campaigns against HIV and AIDS in Mozambique arelargely responsible for promoting such misunderstandings. Atthe start of the epidemic, a moralising narrative, which impliedthat young people should simply not be sexually active, guidedmany of the national campaigns coordinated by the Ministry ofHealth. The main target group for these HIV and AIDS preventioncampaigns was married couples, or couples living as manand wife. Slogans such as the following were used:Be faithful to your partner.... use condoms in all casual sexualrelations (author’s emphasis).In retrospect, this campaign had worrying consequences,because fidelity is not something that people practice all thetime, and when people have casual sexual liaisons, they do notalways use condoms. A further problem of the campaignderives from its primary focus on married couples, and similarunions. As a result, young people who frequently change theirpartners are forced to work with models designed for marriedcouples, a type of relation completely different from the relationsin which these youths are involved.Decent women and male regardA further contributory factor to students not using condomswas gender inequality linked to the common social acceptancethat men have more power in sexual negotiation. From girls, itis normally expected that they should be obedient, behavedecently, and have the lowest number of partners possible inorder to become good wives and mothers. On the other hands,boys are socialized to be adventurous, to be men of success, toenjoy themselves, and to be sexually free (Osório 1998).Because of this double standard of socialisation, womenfind it difficult to negotiate the use of condoms with their partners.When a girl suggests using a condom, this denotes thatshe is not a decent woman, not only because she is not obedient,but also because she suggested the use of something thatonly women with multiple partners use.The dominant sexual standard adopted by the womenwas also influenced by male expectations and by what may bedescribed as male regard. For example, the idea that men areunable to control their sexual urges is rooted among womento such an extent that they forgive their partners when theycheat on them, because such behaviour “is normal for men”(Paula, 18).Another factor with a negative impact on condom use concernssexual pleasure. Boys often used the argument that theyfelt less pleasure when they used condoms and thus did not likeusing them. In a significant way, friends encouraged andrespected those who showed off their masculinity by not usingcondoms and letting their semen penetrate and moisten thewoman.There is a further contradiction here. The boys said theyfeel less pleasure when they use condoms, but they also arguethat they would always use a condom if they had sex with aprostitute. So it seems that condoms only dampen pleasure inintimate and loving relationships, and not with people regardedas more likely to be infected with HIV. This contradictionbrings to the surface something of the complexity of the socialconstruction of pleasure, at least in this context.Local ideas and beliefsFinally, the young people interviewed lack adequate factualinformation on sexual matters. The students said they hadreceived little information on sex and sexuality either at schoolor at home. They stated that during the school year theyreceived occasional visits by governmental and non-governmentalorganisations, which included lectures on HIV and AIDSprevention and the promotion of condoms. Even so, they feltthey needed much more information.Many of these youngsters complained of a distance athome between themselves and their parents. This distance didnot allow them to talk with their parents about questions concerningrelationships and sexuality. Many preferred not to talkabout these matters with their parents because they would bemisunderstood or ignored. Thus friends become the greatestsource of information, and in turn these play an important rolein students taking sexual decisions.In the traditional concept of the household, adominant role is reserved for the man. The womanhas a passive role, particularly when it comes to takingdecisions on various matters of family and conjugallife. This disproportionate position bears with itthe idea or expectation that the man knows more andis better prepared to lead or determine the fate ofboth of them. However, the traditional role of women– expressed in their maternal and reproductiveresponsibilities – conditions the weight of theirresponsibility as regards providing care and domestichelp to those household members who are physicallyweak.It is curious to note, however, that, despite thisresponsibility, when the health of a household memberdeteriorates, it is the man, or someone who canstand in for him in these conditions, who takes thedecision as to whether and when to resort to a hospitalconsultation or to a traditional healer.Furthermore the seriousness of the illness andthe amount of attention needed in caring for thepatient lead to decisions that not only weigh upon thefemale sphere, but also impact negatively onwomen’s development and social progress, particularlyin those situations where cuts in social expenditurelead to increased pressure on women and girlsto play the role of caring for the sick people in thehousehold, while at the same time ensuring the continuityof other household reproductive and domesticmanagement activities.34


HIV, AIDS and GenderHIV and AIDS thus sharpens gender inequalitiesand challenges the whole concept of approachinggender based on equality of rights between men andwomen.Among the themes that shape the gender equalityagenda, there stands out the urgency of dealingwith the conjunctural and structural questions thatmake women vulnerable to HIV and AIDS. Policiesand programmes to reduce women’s vulnerabilitymust deal forcibly with the socio-cultural and economicfactors facing women’s empowerment, suchas the sexual behaviour of men, power relationsbetween women and men, poverty, structuraladjustment programmes and oppressive culturalpractices.Paradigmatic changes are still necessary, startingfrom the assumptions that have made the approachof women in development a visible theme in modernthought. In the past the interpretation of the genderperspective was that of feminisation, in which womenwere the first and only focus. Thus women were giveninformation and services, including access to microcredit,to return it in many cases to the same unjustand discriminatory structures that generated theirsubordination.The urgency and emergency of the response toHIV and AIDS, particularly bearing in mind that genderinequalities are behind the levels of contaminationnoted, impel us to deal proactively with the causesor roots of the problem.Bearing in mind the influence and power thatmen exert over women in relations between the twogenders, and because men’s sexual behaviour has adirect impact on the exposure of women to the riskof infection, it is evident that men must be at the centreof inventions against HIV and AIDS from a genderperspective.The suave approach of treating matters concerningwomen’s sexual and reproductive health, whichpromotes men’s participation and their responsibilityin family planning, should, in light of the battleagainst HIV and AIDS, open paths towards more daringinitiatives that deal with sexual and reproductivehealth, as well as the sexual rights of men, in a moreholistic and wide-ranging fashion.The current approach of getting men to use condoms,while maintaining the status quo, in terms ofthe dynamics of the sexual relations with women,contributes to treating symptoms and not causes. Itwould be treating the obvious.It is necessary to understand clearly the factorsthat lead men to embark upon unhealthy sexualbehaviour – multiple partners, infidelity, sexualabuse of women and girls etc. – and to take decisionsto attack those factors. “Empowering” men toadopt healthy sexual behaviour (not just the use ofcondoms) will help attenuate the vulnerability ofwomen to HIV and AIDS and to other sexually transmittedinfections.Preventing parental transmission of HIVThe parental transmission of HIV means passing onthe HIV infection from a pregnant HIV-positivewoman to her baby. One of the most dramaticimpacts of the growth of HIV and AIDS amongadults is the increase in cases of infection amongchildren. The literature describes that, in theabsence of any intervention to reduce the risk oftransmitting the HIV virus from mother to child,about 15-30% of children born to HIV-positivemothers can be infected during pregnancy andbirth, and 10-20% from being fed on breast milkduring a two year period.Based on the national projections for theincrease of infection among adults, the number ofHIV infections in children under five years old hasbeen rising in recent years. In 2006 it was estimatedthat about 99,000 children aged 0-14 were infected(Impacto Demográfico do HIV e SIDA). Amongthese, the vast majority (78,658) are estimated to beless than 5 years old and the second largest groupare the 5-9 year olds (19,639).The numbers among those aged between 10 and14 are very low (372). This leads to considering thisgroup of children, the only one currently free of HIVand AIDS, as the “window of hope” for controllingHIV and AIDS in Mozambique (Impacto Demográficodo HIV e SIDA, INE/MISAU 2002).In 2006, throughout the country, the numbersrose to an estimated average of 100 HIV infections aday through vertical transmission.With the aim of reducing the impact of HIV andAIDS on women and children, the Mozambican government,through the Health Ministry’s NationalProgramme against HIV and AIDS, set up theProgramme to Prevent Vertical Transmission (PTV)in 2002.The general goal of the PTV is to reduce thetransmission of HIV from mother to child, providingfollow-up and prophylactic treatment to the mothers35


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007during the whole period of pregnancy and birth, aswell as to the children until they are 18 months old.This programme has as its specific objectives:• To disseminate information on mother-to-childvertical transmission, promoting people to jointhe PTV programme in the communities, and toundertake advocacy inside and outside thehealth institutions;• To improve the quality of care in the mother-andchildhealth services so that they can integratethe PTV;• To ensure the integration of PTV into the otherHIV and AIDS services so as to guarantee thatpregnant women and their partners receivecounselling, treatment and follow-up on STI/HIV/AIDS;• To ensure liaison between the health units andthe community HIV and AIDS programmes.State of programme implementationThe strategies for implementing this programmeare very wide-ranging, bearing in mind that informationabout vertical transmission must be disseminatedso as to prevent, on the one hand, people ofreproductive age from becoming infected and, onthe other, to allow access to the information and tothe programme by those who know that they areHIV-positive. Effective implementation of this programmedemands improving the knowledge ofhealth workers, the quality of services provided,and total integration of these services into the overallpackage of care for pregnant women at birth andafter birth.Since it began in 2002 up to December 2006, theprogramme to prevent parental transmission wasimplemented in 222 health units across the country.During this period, 371,717 women were counseledand tested, 24,152 received ART prophylaxis. Of thistotal, 12,510 were tested in 2006, against theMinistry of Health’s target of 16,000. With a total of146,245 pregnant women estimated to be HIV positivein 2006, the percentage of those who receivedART prophylaxis represents only 8.3% of total.As for the children, by mid 2006, 16,092 childrenin this group received nevirapine and 1,321 HIVexposed children were tested at the age of 18 monthsand 141 (10.7%) of them tested positive. Despitevarious difficulties on the ground, the programmehas improved considerably. In 2002, the programmetargeted 5,685 pregnant women in their first antenatalcontrol, in only three provincial capitals. But byend 2005, there was a qualitative advance and thisnumber was increased to 158,273 women throughoutthe country, of whom 102,116 received counsellingand testing (National Programme againstSTI/HIV/AIDS, MISAU, 2006).All the components of the National Programmeagainst HIV and AIDS are undertaken in partnershipsestablished between the Ministry of Healthand other institutions, such as national and internationalNGOs, UN agencies and bilateral cooperationagencies.These activities show the concern of all the actorsto reduce HIV infections and their impact. These effortsare far from covering all those in need. According tothe projections, in 2005 there were 140,072 HIV-positivepregnant women. But during that year only 7,690pregnant women received ARV prophylaxis to preventmother-to-child transmission, which is 5.5%.Despite the efforts undertaken, many children arestill born HIV-positive. Of those born HIV-negative,some become HIV-positive through drinking theirmothers’ milk. This is a real dilemma for people livingin poverty. It is not sufficient to make drugs available toprevent infection, because there are other problemsthat should be looked at in a more over-arching fashion,such as health service coverage, health workers,and the existence of support services. The presence ofthese conditions will determine whether the state of thechildren’s health improves.The probability of a child born with HIV inMozambique surviving does not depend solely onthe biological conditions of the parents, but alsoon whether he was born near or far from a healthunit, as well as the socio-economic conditions ofthe parents.36


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007investment that, under normal circumstances,parental socialisation provides, such as education,care and love.The HDD 2003 showed a negative impact oforphanhood on school attendance: the ratio of theproportion of double orphans ages 10-14 attendingschool to the proportion of non-orphans (childrenliving with at lest one parent) of the same age groupattending school was 0.8 in 2003. The situation ofmaternal orphans is particularly worrying: this wasthe group with the lowest percentage (62%) schoolattendance. In general, the school attendance oforphans is improving: the school attendance rationwas 0.47 in 1997.Strengthening of communitylevel support systemsThe growing numbers of orphaned and vulnerablechildren, within a weakened economy, will continueto be faced with the fragility of community-level systemsof social cohesion and solidarity, which willincrease social marginalisation, or discrimination,and the unbridled struggle for economic survival. Tochange this scenario, there is every need to invest indefending the rights of these children and in the needfor a positive reaction from the community in orderto make viable a balanced growth and promotion oftheir welfare.However, so that this advocacy may becomesomething concrete, a clear vision and strategy onthe sharing of responsibilities, or on coordinatinginterventions between the state and civil society, isproving determinant.As regards the social responsibility fororphans, social expectations are divided. In oneperspective, the responsibility of the state is arguedas an imperative to minimise the risks these childrenrun of becoming street kids. This position isintimately linked to the promotion of communitycentres that shelter orphans, under the directadministration of the state (AIDS Analysis AfricaVol 6 no 1, 1996).The responsibility of the state is also seen as criticalsince it can help to avoid the trend towardsabuse of minors, or their exploitation as child labour,which is not uncommon in some social circles, makingpreferential victims of children in the direct careof foster families.Another perspective sees the need for actionsarising at the level of the extended family and of thecommunity, but coordinated with interventions andsupport that should come from the relevant stateinstitutions. The need to find ways to educate thesechildren inside the community is based on theadvantages this provides for their healthy growthwithin the standard of values applicable to otherchildren.This perspective rests on the assumption that thesocial insertion of orphaned and vulnerable childrenis above all one of the most efficient and effectiveways of avoiding the stigma that orphanages or sheltersmay create, regardless of the conditions theymay provide for these children.As one may understand, the discussion on thismatter attracts various opinions and they are notalways consensual. In any case, there exists a generalunderstanding of the importance of effective coordinationto ensure that orphaned and vulnerablechildren are not seen as “parasites” and undesirablesin the community.When the government emerges as the main actorand provider of social welfare for orphaned and vulnerablechildren, community tolerance for themproves difficult. Indeed, intervention undertakenthrough orphanages – with their countless financialdifficulties, which can lead to malnutrition and tolack of adequate socialization (and often to access toeducation) – have so far had limited success in theMozambican context.Hence sheltering orphaned and vulnerable childrenin the family and/or community context, in theabsence of systems with some tradition in this kind ofsocial service, remains the way to ensure balancedinsertion, as long as it is properly accompanied bythe supervisory bodies, and given material support.And where this shelter does not exist, there willalways be the risk of increasing the number of streetchildren, child prostitution, drug consumption andother kinds of child and juvenile delinquency, includingrobbery and violence.To avoid these predictable consequences andguarantee a balanced growth of the OVCs, it is necessaryto strengthen the coordination betweenstate institutions and community authorities, NGOsand community organizations in order to undertakea survey of these children, and provide documentationand basic care that can help them realizetheir citizenship rights, and ensure ever smallerchances of exposure and vulnerability to contractingHIV.38


The General Threat posed by HIV and AIDS to the Country’s FutureBox 6.1What communication strategies in a context of cultural diversity?During the initial years of the post-independence period, undera socialist approach to the promotion of development andnational welfare, the country invested in attempts to suppresssocio-cultural values, expressed under reductionist headingsand labelled as “archaic”, “obscurantist” and “traditionalist”,which, in the dominant perspectives of the time, clashed withthe modernizing values of so-called “scientific” socialism.Despite this, efforts at reconciliation with these cosmologieswere among the first steps taken in the process of opennessand democratising the country, which characterizes the presentconjuncture.During the political opening of Mozambique, begun in themid-1980s, AIDS appeared, and with it, the country embarkedon the invention of the modus operandi of neo-liberal societies,establishing and adopting policies in response to AIDS, underlyingwhich are the <strong>language</strong> and terminologies of practicesand forms of social structuring that are currently hegemonic inwestern culture, such as “democracy” which must doubtlessalways be accompanied by a strong “civil society” and by consultationand involvement of various social strata.When the AIDS crisis set in, at a moment of change in thepolitical and ideological conjuncture, a space was opened forthe start of a process of looking at aspects that, under thesocialist regime, were regarded as hidden and unworthy of consideration,such as the diversity of socio-cultural practices,which were pigeonholed into the universe of “obscurantism”and of supposedly “archaic” values which ought to be suppressed.From the ostracisms and denial which the country tried toestablish with its cultures (at least formally since, in practice,various subterfuges were used by communities to continuallymanipulate cultural values and references) the country movedon, with the advent of AIDS, to encourage a questioning stance,and even a re-invention of bits and pieces of aspects held asculturally characteristic to compose a framework for understandingthe phenomenon of AIDS. Thus, also as a function ofHIV, the cosmologies and social and cultural values ofMozambicans were declared as important in order to producean “informed basis” on which the national response to HIV andAIDS could rest.Studies and research into the behaviour, attitudes andpractices of Mozambicans were promoted. An ethnographiclook into various population groups, particularly as regards sexuality,is being encouraged. The results of these studies andreflections, most of which are of a quantitative nature, are contributingto nourish the repository of representations that characterizeMozambican society.Even so, the policies, strategies, and above all the messages,reflect more the emphases that are circulating globallyabout the forms and methods of combating HIV and AIDS, andless the forms of dialogue with the multiple stereotypes andrepresentations that circulate about HIV and AIDS among thevarious population groups and categories in Mozambique.However, the impact of the data concerning knowledgeabout attitudes and practices is, in itself, relatively limited forstimulating the change of behaviour desired by the programmescombating AIDS. In general, the actions undertakenassume the theory of rational choice, based on which it isbelieved that the availability of adequate information about therisk of HIV infection, transmitted through argued persuasion,would be sufficient in itself to encourage rational decision making,which would end up leading to a change of behaviour, andthus to a significant decline in the risk of infection.But what the numbers don’t say is that alongside the representationsof HIV and AIDS regarded as correct, there isanother repository of values and meanings which are beingbuilt and rebuilt as the national response against AIDSadvances, and which do not necessarily meet the expectationsor teachings of those who promote and implement thatnational response.These cognitive mismatches should not be seen as deviationsfrom the standards it is intended to promote, as somehave argued when they interpret the competing perceptions ofpeople on what was taught about condoms, for example, as“ignorance”, despite the “clear messages” that were “widely disseminated”.If, on the one hand, we assume that the numbers and datatransmitted have their methodological rationale and validity asreference models of social thought and behaviour, on the otherhand, the contradictions, that which the numbers do not catch,the so-called preconceptions and stereotypes, are also ways oftranslating the complexity of meanings and values that glidethrough the socially imagined world, and that should be takeninto consideration when weighing up the advances and setbacksin the national response against HIV and AIDS.However this may be, it cannot be forgotten that theinvestment made in making the socio-cultural dimension standout, as an important factor for understanding the phenomenonof AIDS is significant, and made it possible, in a singular way, toexpress verbally some questions associated with notions ofhealth, disease and sexuality.With this investment, aspects concerning the rites of“purification” (such as pitakufa), the behaviour of witchdoctors,characteristics of polygamy in the south and north of the country,notions of sexual guidebooks, meanings and motivationsfor sex between people of different generations, systems andnetworks of inter-family solidarity, and many other aspects thatcrisscross the territory of culture, sexuality, morals and ethics,have been scrutinized.But recognizing the existence of elements that characterisethe socio-cultural universe, and even cognitive and cosmologicalsystems that coexist, and forms of their production andreproduction, as the national response against AIDS has doneso far, is still not the same as holding a dialogue with them inpolitical and pragmatic terms.Assuming that in society we are not faced with a blankslate, on which we can write and prescribe codes and values,and expect these codes to be assimilated in an intact fashion,then perhaps we should pay more attention to cognitive andinterpretative nuances, to what appears to be a simple contaminationof the social, and also bring these factors and their basesas a constituent part of the dialogue of values and meaningsthat it is intended to advance, in the context of an epidemicthat still shows no sign of slackening.This should not be taken as an effort to essentialise or crystalliseculture, but on the contrary, an investment in order toelevate the capacity or change and for the cohabitation of valueswithin people in society.39


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007The non-quantifiable impact –the case of social capitalIn dealing with the impact (generally not fully quantifiable)that HIV and AIDS exert upon the community,the systems of organising community life shoulddeserve attention and analysis, including those thatgenerate, transfer and sustain knowledge.For the case of Mozambique, this attentionbecomes all the more justified, since it is known thatmore than two-thirds of its population lives in thecountryside and manages their life based on systemsand patterns of behaviour and communication rootedin custom. Custom is, in a manner of speaking,the reservoir and at the same time the most subtleexpression of knowledge, values and convictions,expressed in culture that governs the modes of materialand spiritual production.For some time, academics have been mentioningthe possibility that HIV and AIDS may contribute to thedisappearance of traditional social structures at household,village or regional level, which have a critical rolein the welfare and management of family or socialresources (Norse, 1991). These structures are definedwithin a broader framework known as social capital.Here, social capital refers to a series of “characteristicsof social organisation such as trust, normsand work networks which can improve the efficiencyof society by facilitating coordinated actions”(Whiteside & Sunter, 2000). It is, indeed, a series ofspecific processes that evolve between persons andorganisations, working in a collaborative manner inan atmosphere of trust, with the purpose of achievinggoals that bring mutual or collective social benefits.Social capital has a significant role in reproducingor transforming social inequities. It stimulates the participationof people in working networks that, apartfrom producing community benefits, consolidate levelsof trust based on identification with the objective ofcollective action. Likewise it increases practices of solidarityand mutual aid, as well as positive local identity.Its action is part of social awareness, and is thus notquantifiable through direct methods.Examples are togetherness based on churches,campaigns of mutual support among peasants inpreparing fields and in harvests, popular associationsaround informal savings schemes, etc.Communities characterised by high levels ofsocial capital provide better conditions for a healthylife. Linked to this fact, it has been argued that communitycapacity to mobilise or create social capital isan important determinant for the success of participatoryinterventions in promoting community health(Campbell, 2003).The organisation and functioning of communitiesbring together decisive elements for the successof interventions that catalyse social capital.Furthermore, people living in communities with highlevels of social capital will very probably display highstandards of control over their daily lives.The fact that the morbidity and mortality causedby AIDS falls upon individuals whose contribution tothe maintenance or transfer of social capital is determinant(36-49 years are the age groups most affectedamong men) will create social erosion with strongnegative impacts on community development. Theseimpacts will be reflected in the traditional systems ofsolidarity and social cohesion, as well as in the transmissionof values through the pure socialization andinteraction between generations of different ages.The most representative expression of this chainof impacts is shown through the break in the naturalsequence of the passage of “social testimony” (traditionsand habits of life) through the daily routine andthe community life between parents, children, grandparentsand grandchildren and a gradual loss of collectivesocial memory.A study undertaken in Chókwè, in Gaza province,on “The Impact of HIV and AIDS on the knowledge offarmers concerning seeds” (Links, 2005), showedthat HIV and AIDS is one of the many factors that mayresult in the loss of traditional crops and varietiesand erode knowledge about seeds. The study alsoindicates that the loss of active and adult farmers,and the increase in the number of orphans, willdeprive the children of the opportunities of learningfrom other members of the household.Yet more critical is the forecast of this impact onother rural systems where the management of communalproperty is important. Indeed, on the assumptionthat learning through daily socialisation takesplace informally, both the mortality and the morbiditycaused by AIDS will result in the loss of valuespeculiar to individuals but generally invested for thecommon good, particularly the skills of improvisingand responding promptly to specific events, basedon the combination of common sense and the exerciseof influence resulting from peculiar and nontransmissiblequalities.The loss of these characteristic and essentialtraits of a social system with solid social capital will40


The General Threat posed by HIV and AIDS to the Country’s Futureconstitute a major setback for rural households andcommunities, and may impose a new form of organisationand structuring of communal life. These arethe scenarios that are beginning to characterise communitieswhere there are an ever growing number ofhouseholds headed by children (who have lost theirfather) and where the mortality caused by AIDS hasled to declines in material and spiritual productionand productivity in general.The impact of HIV and AIDS on social capital isstill a subject that deserves deeper analysis in thegeneral framework of studies that the area is beginningto mobilise. As already reported, these impactsare proving severe and adverse for many ruralMozambican communities. Analysis in other countrieswhere the epidemic matured earlier posestrongly the possibility that the weight of the epidemicon social capital may lead to a trend towards thedestructuring or even the disappearance of traditionalsocial systems at community level (Norse, 1991).Food security, HIV and AIDS and nutritionFood security presupposes access by everybody andat all times to sufficient food for an active and healthylife. It is thus a basic condition for the human organismto create conditions to defend itself from possibleinfirmities. The lack of resources to produce oracquire food leads to food insecurity.While all those infected by HIV need specialattention in food and nutritional terms, pregnantwomen who are infected need to ensure an optimalnutritional status in order to reduce the likelihood oftransmitting the virus to their babies, and so that theycan have a safer birth. HIV-positive children havesocial nutritional needs so as to avoid retarding theirnormal development and help them survive.HIV and AIDS increase vulnerability to food insecurity.In turn, food insecurity contributes to susceptibilityto HIV infection and its progression to AIDS.Food security is part of a concentric chain of theprovision of interlinked services, which includes theproduction, availability and access to food, as well asstandards of food consumption. That is why, for amore thorough analysis of the influence that foodinsecurity exerts over susceptibility to HIV and AIDS,an integrated examination of the agro-ecological,housing and socio-economic characteristics of eachregion becomes important (SETSAN, 2004).In Mozambique, food security is influenced byseveral risk factors that condition how prone individ-uals are to food insecurity. These risks are structuredinto:• Production risks associated with drought, floods,pests or animal diseases;• Risks linked to difficulties in access to food, dueto poverty, unemployment, instability, or theimperfect functioning of the market;• Risks associated with endemic diseases, particularlymalaria, tuberculosis, cholera and HIV andAIDS; and• Risks associated with social instability amonghouseholds, which may lead to violence and/orto divorce.National statistics show that almost 80% of thecountry’s population live in the countryside, and thatabout 95% of the national labour force is absorbedby the agricultural sector, which is the base that sustainsproduction and thus food security (SETSAN,2004). This fact, when confronted with the progressionof the epidemic, and particularly with the factthat the groups most affected are those of active age,leads to the conjecture that HIV and AIDS will have asignificant impact on the agrarian sector and henceupon food security.However, this impact will depend on the structureof the agricultural sector, particularly of the family sectorand on the production techniques of systems usedin agricultural activity. In fact, the Mozambican familyagricultural sector is not only prone to constraintssuch as natural disasters (drought, floods and pests),but also faces production limitations, such as access tocredit or to pesticides.Bearing in mind that AIDS affects, to a largeextent, those of productive age, the death of a householdmember weakens that household’s productivecapacity, by reducing the work force needed to cultivatethe fields. The subsequent reduction in the areaunder cultivation will in practice be expressed in adecline in income.With the sickness or death of the main householdproviders of resources, a chain of complicationsarises in managing the life of the surviving members,namely the crisis in family agricultural work, managementskills, changes in cultivation systems, anincrease in the number of orphans, medical costs,di<strong>version</strong> of labour in order to look after the sick,loss of production income, and reduced ability tobuy agricultural inputs (seeds, fertilizer, etc.). Theseaggregate factors often end up generating situationsof chronic food insecurity.41


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007The nutrition factorIn the relationship between HIV and AIDS and foodsecurity, nutrition plays a significant role. Indeed, therole that good nutrition performs in the health andfunctioning of the human immunological system haslong been recognised. Good nutrition is thus a necessarycondition for any individual who is HIV positive,and to some extent, many people in this situationmight even need more focused assistance.People infected by HIV face enormous challengesas they struggle to keep up their nutritionalhealth. Inadequate diet increases people’s vulnerabilityto disease, and since the virus weakens thebody’s immune defences, opportunist infections tendto occur very frequently. Good nutrition helps toreduce this risk significantly.While all those infected by HIV need specialattention in food and nutritional terms, pregnantwomen who are infected need better nutrition inorder to reduce the likelihood of transmitting thevirus to their babies, and so that they can have a saferbirth. HIV-positive children have social nutritionalneeds so as to avoid retarding their normal developmentand help them survive.However, it is important to note that nutritionalneeds change over the course of infection and developmentof the disease. This change is influenced bythe nutritional state of the individual under normalconditions. The organism of individuals who weremalnourished before they contracted the virus will,now that they are HIV positive, require an increase inthe body’s energy intake, to confront the pressurethat the virus will impose on the immune system.HIV and AIDS, governanceand national securityThe effects of HIV and AIDS are gradually hamperingthe capacity and the administrative and organizationalpower of the state, globally. This has implicationsfor government effectiveness, particularly regardingthe provision of goods and services. The picturebecomes all the more worrying when it is knownthat, in Mozambique, the state remains the majorproducer, employer and provider of social and welfareservices, just as happens in most poor countries(Barnett & Whiteside, 2002).The sector impacts dealt with in the previouspages show that the threat posed by HIV and AIDS isnot limited only to the most vulnerable strata of thepopulation. In a situation of generalized epidemic, andfed by processes that accommodate the constructionof individual and social identity, the threat from HIVand AIDS is felt everywhere. There are signs that seniorstate and government cadres in various sectors ofactivity have died from the disease, although greatsecrecy still prevails over these deaths.Compliance with state duties through the provisionof public services is an imperative of governance.Pursuing this fully requires not only money,but above all, capable and motivated staff to complywith duties inherent to the public administration.Since a large part of the professional groups orspecialised areas in the state machinery – such as militaryand para-military personnel, the police forces orjudicial staff – are among the sectors with the highestrates of HIV prevalence, and with high mortality rates,carrying out the state’s mission, particularly as regardsbasic public security is not only threatened, but is alsoconfronted with new challenges.These challenges include, among others, theneed to define and implement preventive and correctivestrategies. This involves diverting budgetaryfunds, and continually realigning objectives, in order,for example, to recruit and train new technical staff.HIV and AIDS is a development question andshould be viewed as such. But at the same time it isa national emergency, and measures should be takento stabilize government action. Seen from this perspective,it is prudent to note that, in order to minimisethe adverse impacts the pandemic will imposeon state revenue and expenditure, political optionsthat combine prevention, treatment, and impact mitigationin a balanced manner should continue to bestrengthened and made more efficient.Because governance has the duty, among others,of establishing an environment of safety and stabilityfor its citizens, the threat posed by HIV and AIDSrequires that it be confronted with the example of adetermined and committed leadership. For peopletend to pay greater attention to, and value more highly,initiatives from their leaders when they go publicand break the taboos surrounding the pandemicwhich have to some extent contributed to discriminationand stigmatization in the community.As a national priority, the context in which thestruggle against HIV and AIDS should occur must beassumed straightaway as an act of governance, and itis in public fora where the government leadershipshould confront the factors that may help or hinderthe adoption of new behaviour.42


Chapter 7National Strategies against the Spreadand Impact of HIV and AIDSPolitical commitmentIn many of the countries affected by AIDS, the governmentsare in a dilemma. AIDS is a serious developmentproblem, but it is also a problem that cannotbe tackled with the ordinary instruments, methodsand approaches of policy planning.The ability and skill of governments to react tothe pandemic with more creative interventions, continuallyadapted to a constantly changing reality, hasbecome an imperative. It is from this that to someextent the level of political commitment that statesconfer on the problem has been assessed.Political commitment is a determinant factor inthe concrete expression of the response to HIV andAIDS. It shows the level of priority the government,and in the final analysis the state, attributes to thematter on the national agenda, bearing in mind thecontinually rising levels of infection and its impact onthe lives of individuals, households, and communities,and finally on the human development of thecountry.In Mozambique, the first sign of political commitmentdates from two decades ago when, for thefirst time, a concerted response against the diseasewas established, in compliance with the recommendationsof WHO, that emerged from a meeting of specialistsheld in Bangui in 1985. This meeting urgedmember countries to set up national committees inresponse to AIDS.In August 1986, the first body in response toAIDS in Mozambique was set up. Named theNational AIDS Commission, it was based inside theNational Health Institute (INS). In 1988, a NationalProgramme for the Prevention and Control of AIDS(PNPCS) was set up in the National HealthDirectorate. The activities carried out under thisprogramme made a significant contribution toawareness and to expanding knowledge about theepidemic, with particular stress on the ways thevirus could be contracted, as well as preventivemeasures in general.As a result of increasing awareness of thesocio-economic, cultural, demographic, epidemiologicaland governance impacts provoked by HIVand AIDS, a national strategy for fighting the epidemicwas developed, involving various populationstrata from district to central level. At the culminationof this review and discussion with all sectors ofsociety, the first National Strategy in response toHIV and AIDS was born, approved by the governmentin 1999.The following year, in 2000, the Council ofMinisters set up the National AIDS Council (CNCS), acoordinating body at the highest level for the nationalresponse against the pandemic, chaired by thePrime Minister, and including representatives of thegovernment, of civil society and prominent individuals.This step marked the recognition that the scale ofthe epidemic went beyond the health context, andrequired multi-sector treatment, that could deal withthe socio-cultural, economic, political and healthdimensions in their broader context.On 1 December 2005, on the occasion of WorldAIDS Day, the Head of State, Armando EmilioGuebuza, launched the “Presidential Initiative toCombat HIV and AIDS”, a specific programme ofadvocacy activities focused on open, public debateson the causes and consequences of the pandemicfrom households to organized social groups andrural communities. Under this initiative, thePresident of the Republic has held open discussionmeetings with various sectors of society, duringwhich he made the appeal to “Mozambicanise” messagesagainst HIV and AIDS. The “PresidentialInitiative” has been replicated in the provinces, alsowith activities to mobilise community and religiousleaders, agents of the informal economic sector, andinfluential professional groups, such as teachers andhealth workers (Box 7.1).While political commitment can also be recognisedin the shape of the budgetary allocation to theanti-AIDS programme overall, there are still difficul-43


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Box 7.1 Let’s speak openly in our families: President Armando Emílio Guebuza 1I want to talk with you, but particularly I would like to learn fromyou. I don’t bring clear ideas, but I am bringing clear concerns.How do we deal with this problem? I too don’t know!For we’ve been waging campaigns for years against HIVand AIDS on television, on radio, in the papers, at meetings,through song, through theatre and other forms of communication.Everywhere we say: let’s be careful, let’s reduce our numberof partners, let’s have more responsible behaviour, but thenumber of people infected with HIV and AIDS is increasing, it’sgradually increasing... And that’s why I say I don’t understand! Idon’t understand! I’m here so that, together with the leadingfigures who are with me, we can try to understand.What can we do? I believe none of us here knows everything,but I believe that if each of us were to say what he or shethinks about this, it’s going to help solve the problem. In thiscontext, I’m making an appeal to the secretaries, to the traditionalchiefs, to the teachers, to the doctors, to the businesspeople. I’m making an appeal: Bring your concerns for debate.Let’s talk openly to solve this problem!Ten years ago, when HIV and AIDS were talked about,nobody believed it. They didn’t believe in the existence of HIVand AIDS. Today, 10 years later, we now see many people sickwith AIDS. I’m not talking about those people we see and don’trealise they’re infected with HIV, but we’ve already seen manyAIDS patients, many people have died of AIDS, and in this countryof ours we have zones, regions, settlements where there areno youths. We only find children and old people. There’snobody in between. It’s the grandparents who look after thechildren.So I ask: will the message we transmit reach the peoplehere in the countryside properly? Do parents speak easilywith their children about this problem? Do young people, ourchildren, ask us without fear about what they can do andwhat they shouldn’t do? In our homes, do the cultural valueswe bear within us allow us to pass on information on sexualityand behaviour, which is what is missing? Why does thishappen? Why does the number of cases of the disease go onrising?Why is this the case now, when it’s not like it was someyears ago, when we heard that somebody died of AIDS, but wedidn’t know where this person came from? We didn’t knowwhat village this person lived in. But today all families havesomeone who died of AIDS or have someone sick with AIDS,What is preventing us from communicating properly with eachother?We have to halt this pandemic. The solution is in our hands,in our will. Let’s speak openly to solve this problem.There are no “orphans” in our traditionChildren in our communities have no lack of fathers or mothers.Those who are regarded as “uncles” or “aunts” in the nuclearfamily are considered, in our tradition, as father and mother.Children become orphans. They lose their parents. But inour tradition, and I speak from my own experience of where Igrew up, the concept of orphan does not exist. And I think thatthis part of our tradition should be recovered, valued and practised.When I was a child, I and the children of my uncles regardedourselves as brothers and not cousins. We treated everybodyas father and mother. That’s why it was sometimes saidthat x and y are brothers from the same womb. Wasn’t it likethat ?!I’ll tell you a personal story. My father scarcely knew hisown parents. I didn’t know my grandparents, and my fathergrew up in his uncle’s house. He was treated as a son.Coincidentally my mother had the same experience. I didn’tknow my mother’s mother. Or her father. She also grew up in anuncle’s house, and was never discriminated against. Whenevershe meets her cousins, she is regarded as a sister and not as acousin. She grew up in this environment, which is a good partof our tradition.There are no orphans! If the parents die, somebody elselooks after them as though they were their own children!No to discrimination and to stigmaIn Mozambique there are now many orphanages. It’s even saidthat these are orphanages whose parents have died of AIDS.Today, why are we talking about orphans whose parentshave died because of AIDS? Generally we say that this child’sfather died of AIDS. And we’re marking the child. He or she is adifferent child. And even in orphanages, we have orphanagesfor children who are orphans because their parents died ofAIDS. But there are other children who don’t have parents,whose parents have died, and they’re suffering too. They aren’tsupported, or they grow up differently. And again I ask: What iswrong in our society? Why aren’t we managing to halt AIDS?This is the question! My brothers: Let’s open up our hearts andspeak openly.We came here without answers, but above all we want yourcontributions. Your contributions can help us define policiesthat can lower, reduce the level of infections. We want communitiesto be able to find, at the most varied levels, answers tothis question, and that the responsibility for fighting AIDSshould not be attributed exclusively to the government. I thinkthat all of us, from the individual to the family, to the neighbourhood,to the locality, to the school, we all have an answerto give to this pandemic that is threatening our future.HIV and AIDS can be fought against. The current AIDS situationcan change, it can be beaten. Yes, it has no cure, but muchmore can be done, so that it doesn’t make people suffer somuch. For this, it is enough to be determined, for us to believethat we can make a difference, by each of us changing our attitudes,being frank with ourselves, all of us working on this linein the same direction.1 Extracts from the dialogue held by the President of the Republic, Armando Emílio Guebuza, with community leaders in the “3rd February” village, in Manhiça district, Maputo province,on 1 December 2005, the International Day for the fight against HIV and AIDS. This meeting opened a series of activities, headed personally by the Head of State, throughout 2006, knownas the “Presidential Initiative in the Fight against HIV and AIDS”.44


National Strategies against the Spread and Impact of HIV and AIDSties in reflecting in a sufficiently clear way that part ofthe state budget that is spent on the struggle againstAIDS. This can be attributed to the cross-cuttingnature of the subject, and the way the correspondingheadings are scattered through the sector budgets.Some legal and economicexpressions of commitmentExternally, Mozambique signed the Abuja Declarationof 2001. Through this declaration, the country notonly recognised the setback that HIV and AIDS wouldmean for the national economy, but also the need forenergetic commitment and sacrifice to attenuate theadverse effects of the deadly disease. The AbujaDeclaration set a figure of 15% of the total statebudget that should be allocated to health expenditurein general, and particularly to finance the nationalresponses to the pandemic.Mozambique also subscribed to the Declarationfrom the Special Session of the <strong>United</strong> NationsGeneral Assembly on the epidemic, known as theUNGASS Declaration. This declaration, which recognisedHIV and AIDS as a global crisis which demandsaction that is also global, recommends that strongleadership is essential for an effective response to thepandemic. It stresses that this leadership must beheaded by governments, and complemented by theactive and total participation of civil society, of thebusiness class and of the private sector. It especiallyrecommends that leaders should commit their personalundertaking and concrete actions at nationallevel.In the legal area, and in recognition of the needto protect the human rights of people living with HIVand AIDS, the Assembly of the Republic in 2002passed Law no. 5/2002, which established the legalregime that protects the labour and social rights ofHIV-positive people. It prohibits employers from submittingworkers or candidates for employment tocompulsory HIV tests, without their consent, and outlawssacking workers, or otherwise discriminatingagainst them in the workplace because they are HIVpositive.2In the 2005 Economic and Social Plan (PES2005), passed by the Assembly of the Republic, thepandemic is for the first time treated prominentlyamong the government activities to be undertaken forpoverty reduction, benefiting from a specific budget-ary line. The 2005 PES envisages continuity of actionsconcentrated on treating opportunist infection andcounselling on forms of prevention, including supplyinganti-retroviral treatment to 25,000 people, ofwhom about 15,000 are pregnant women, and providinghome care to AIDS patients. In 2006, thisapproach grew even more crystallized with progressiveindicators, be it regarding anti-retroviral treatmentfor the majority of the population by double theprevious year, or in terms of prevention of verticaltransmission.At the same time, a series of measures have beentaken in the strengthening of advocacy work by politicalleaderships among the population, with concretemeasures on holding provincial government bodiesresponsible for coordinating the response down tothe most remote areas.Resulting from these actions, the provincial governmentshave been given added responsibilities ofchairing the Provincial Social Harmonisation Forumsto prioritise actions and budgets at local level, inorder to speed up the joint efforts in prevention andin fighting the pandemic. In this context, the action ofleaderships at local level has contributed to raisingthe level of public awareness of the grave danger thatHIV and AIDS poses to the survival of the nationalcommunity, as well as to a more effective demystificationof the disease, eliminating the taboos surroundingit.On the other hand, this strategy has improved thebureaucratic processes of allocating the availablefinancial resources for strengthening local communityinitiatives in response to the pandemic. As aresult of this strategy, the CNCS programme inresponse to AIDS has since 2004 experienced anotable expansion translated into a range of evermore funding for subprojects, be it in the public orprivate sectors, and at the level of civil society, whichgreatly increased the number of beneficiaries, as wellas the diversity of activities undertaken, always withinthe context of the new National Strategic Plan (PENII) 2005-2009.Exercises in sectoral planning at various levelshave brought HIV and AIDS to the centre of debateand attention, particularly as a crosscutting issue inthe development problematic. Thus this material hasmerited treatment in the context of formulatingstrategies that should constitute the main pillars for2 The fact that this law only protects formal sector workers, and leaves out those working in the informal sector and ordinary citizens in general has raisedsuggestions that it should be revised in order to make it more inclusive.45


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Box 7.2approaching the country’s development over the nexttwo decades, which are contained in Agenda 2025.Likewise, PARPA II, approved by the Council ofMinisters on 2 May 2006, stresses the need forgreater strengthening and coordination of multi-sectoractivities in response to the deadly disease (Box7.2). The relationship between and relative weight ofprevention and treatment has been placed at the centreof the strategic lines of PARPA II in this specificfield.HIV and AIDS in PARPA IIThe central objective towards HIV and AIDS is to halt and begin to reversethe spread of the disease. Based on PEN II, 2005-2009, it is intended tofocus on some selected results in the following five areas: prevention,stigma and discrimination, treatment, impact mitigation, and coordinationof the national response.The PEN stakeholders are the Ministry of Health, the entire privatesector, and the NGOs that work for a reduction in the spread of the pandemic,and who work with the directly or indirectly affected population,under the coordination of the National AIDS Council.The fundamental goals in this area are:• reducing the number of new infections from the current level of 500per day, to less than 350 in five years, and less than 150 in 10 years;• transforming the response to HIV and AIDS into a nationalemergency;• reducing the stigma and discrimination linked to HIV and AIDS;• prolonging and improving the quality of life of people infected withHIV and of AIDS patients;• reducing the consequences of HIV and AIDS for individuals, families,communities, companies and also the overall impacts;• increasing the level of scientific knowledge about HIV and AIDS, theirconsequences and the best practices for fighting against them;• strengthening the planning, coordination and decentralisationcapacity of the decision taking and resource managementmechanisms;• promoting actions that reduce the weight of home care on women;and,• taking action to prevent the feminisation of the epidemic.An increase is envisaged in the proportion of the State Budget allocatedto specific areas of the HIV and AIDS programme that will implementactivities in the thematic areas mentioned above.In the final analysis, the degree of political commitmentwill be assessed in accordance with achievingthe Millennium <strong>Development</strong> Goals, particularlythe struggle against absolute poverty and hunger,success in which is strongly dependent on the level ofcontrol achieved against the spread of HIV and AIDSand the combined effects of other associated diseases,such as malaria and tuberculosis.Community leadership andtraditional normative systemsThe socio-economic and political transformationsthe country has been undergoing in recent years,with the civil war, and with the economic opening toa regional and world liberalization, have dictatednew ways of being which tend to generate a conflictof values between the old and the new.This new form is sharpened by the growing deteriorationin household living standards, which isexpressed in weakening the traditional normativeand organizational systems, and in the consequentweakening of their role in responding to the generalchallenges of survival, such as that which HIV andAIDS represents today.This is the social reality, which has been markingincreasingly visibly the distinction between the oldand new generations, as well as between the urbanand rural worlds.Gender relations, the traditional rights of menand of women, the norms about what can be spokenof and what is forbidden, questions of a religiousnature and other human sensitivities, can find treatmentat community level through a complex web cultural,social and political questions that influence thepandemic.The prestige, respect and obedience that generallysurround traditional leaders in their respectiveterritories of jurisdiction and influence, as depositoriesof the local historical consciousness and respectivesocio-cultural values, form a privileged space, aneffective starting point, for community actionsresponding to the challenges that HIV and AIDS representat local level.The relevance of such an approach lies in thefact that the responses communities find locally, veryoften headed by these traditional leaders, are basedon a solid knowledge of the local beliefs and practicesin response to serious crises, such as diseaseand death, over time.The coordinated nationalresponse against HIV and AIDSThe overall national response against this pandemic,in the multi-sector perspective, has been underimplementation since the approval of the firstNational Strategic Plan (PEN) 2000-2002. This documentwas written at a critical moment in the courseof the epidemic in the country and in the world,characterised by discussions, not only about strategicoptions (Prevention vs Treatment), but above allabout the evolution of the question of anti-retroviraldrugs, their manufacture and availability on the mar-46


National Strategies against the Spread and Impact of HIV and AIDSProvince by DANIDA, three years later (2004) whichcontinued to show relatively high levels of knowledgeabout HIV and AIDS — “the majority of the populationhave already heard of HIV and AIDS, and individuals,families and community groups are broadlyaware that AIDS is a lethal disease that has no cure.A large part of the population recognises that peoplewho look healthy may be infected. There is also abroad awareness that ‘the AIDS creature’ is in theblood and cannot be seen,” the final report mentions.However, as regards specific preventive attitudesand practices, the situation remains very worrying, asthe level of condom acceptance in Maputo Cityshows. (Box 5.1, Chapter 5)Various programmes were implementedthroughout the country, combining prevention, careand treatment and impact mitigation. Some deserveattention because they have become reference pointsfor good practices.In the southern zone, for example, among manyother interventions, the Kulhuvuka Project of theCommunity <strong>Development</strong> Foundation (FDC), was theone with the largest audience, through its social marketingstrategy, and through the involvement andempowerment of grassroots community organisations,among other national NGOs.As regards the treatment, the experiences of thepartnership between MISAU and the Sant’ EgidioCommunity (focusing on prevention of vertical transmissionof the HIV virus from parent to child), wellas between MISAU and Médicins Sans Frontiers, HAI,USAID, the Clinton Foundation, among others, areworth mentioning, and it was through these initiativesthat ART started becoming more encompassing andto cause some impact throughout the country.In the sphere of impact mitigation efforts, theexperience to note is the partnership that Kindlimuka– the first national NGO of people living with the HIVvirus (PLWA) and sympathisers – developed withTotal, an international fuel company. Through anaccord between the two, it was possible to set up aviable income-generating project run by PLWA, consistingof making and supplying uniforms for Totalworkers.In Manica province, an experience should berecorded in the area of home care and psychologicalsupport for AIDS patients and their relatives, undertakenby Kubatsirana, an organisation with a religiousbase, as well as community mobilisation activket,accessibility and conditions for their expandedadministration, and particularly their cost per yearper patient.In the framework of the strategic options definedby the PEN 2000-2002, primacy was given to preventinginfection, recommending the development ofexpanded awareness activities through means ofcommunication, information and education in general;peer education, theatre and dramatization,among others, at the same time as other, importantinterventions.These interventions included:• the care and treatment of sexually transmittedinfections;• the expansion of the Counselling and VoluntaryTesting Offices;• the observance of biosecurity;• actions to mitigate impact; and• the incorporation of material on sexual andreproductive health and HIV and AIDS into theschool curricula, providing it with contents thatexplore knowledge about the disease by teachersand students.During the implementation of the first NationalStrategic Plan 2000-2002, a notable dynamism waswitnessed on the part of the actors most directlyinvolved, whether within the government, or in theprivate sector and civil society organisations in general.However, notorious fragility in coordination andweaknesses noted in the prior assessment of theexpected impacts, as a result of the cost-effectivenessrelation, left the overall final results below the levelsgenerally hoped for.It should be stressed that the activities undertaken,albeit in an isolated, sporadic form, lacking coordinationon the ground, to some extent helped raisethe level of awareness and general knowledge aboutHIV and AIDS infection, although this awakening ofminds did not have objective reflections in changingbehaviour through suitable attitudes and practices.The National Survey of Youths and Adolescents(INJAD), undertaken by the INE in 2001, for example,showed above average levels of knowledge aboutHIV and AIDS in both urban and rural areas. Over70% of the adolescents and young people surveyedhad already heard of HIV and AIDS. But there wassubstantial variation between men and women intheir knowledge about this epidemic.This fact was confirmed by a study on Behaviour,Attitudes and Practices (BAP) carried out in Tete47


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007ities undertaken by Kubatana, an NGO of PLWA andsympathizers, spreading messages that not onlydemystify the interpretation of HIV and AIDS in thepoorest communities, but above all develop hopeand the value of life among PLWA.In Zambézia, a province with strong interventionby national and international NGOs in this struggle,mention should go, among others, to the experiencesof multifaceted interventions by organisations suchas the World Vision, Save the Children, and FNUAP,with the viability of a programme for adolescents andyouths – BIZ Generation, among others.Social marketing and publicising the struggleagainst HIV and AIDS (PSI; FDC; MISAU; CNCS), aswell as the movement to raise community awarenessthrough mobile cinema – partnerships betweennational bodies and the Italian and Japanese internationalcooperation agencies, notably in Sofalaprovince, as well as between UNICEF and GESOM(Manica Social Education Group), for informationand education activities along the Beira Corridor,with the use of mobile communications units, alsodeserve particular reference.In this list – merely of examples and by no meansexhaustive – one should also include the bicycleraces carried out by World Vision to raise awarenessand the telephone line “Aló Vida”, which has a freeservice of information, clearing up doubts and counselling,managed by the FDC.Initiatives aimed at making young peopleaware, and building up safer behaviour, expressedin introducing questions of sexual and reproductivehealth, including HIV and AIDS, into the school curricula,benefiting young people attending school;the programmes aimed at stimulating young peopleoutside of school, undertaken by the Ministry ofYouth and Sports and its partners in the <strong>United</strong>Nations system – UNICEF and UNFPA – as well as bynational NGOs such as the Mozambican Associationfor the Defence of the Family (AMODEFA), throughthe Generation BIZ programme, are also part of therange of initiatives and national efforts to confrontthe pandemic.The place of traditional medicinein national responses to HIV and AIDSAs in most African countries, a great majority of theMozambican population resorts in the first place totraditional medicine to treat bodily and spiritual diseases,before considering going to a hospital. This isalso encouraged by the fact that the national healthservice covers only 40% of the country’s populationand with a reduced average capacity.The WHO recognises that traditional medicineshould play a significant role in implementing thenational strategies for fighting diseases in each country,since it is part of the community and individualhealth practices of the population, and strongly relevantin the provision of community assistance asregards Primary Health Care (WHO TraditionalMedicine Strategy 2002-2005).The role of Traditional Medical Practitioners(PMT) as community leaders and providers ofhealth care is recognised and accepted by themajority of the population, since they form part ofthe decision-making systems in the community.Problems of a medico-biological nature, withsocial implications, are solved with the interventionof the PMTs, traditional midwives and othercommunity leaders, which strengthens the authorityof these groups and the trust that the communitydeposits in them.Their capacity for communication in the area ofhealth and social questions, made effective by theirdeep knowledge of the socio-cultural and even economiccontexts of the community, is a vital resourcethat should be used in a variety of crucial areas ofdisease prevention and control, such as HIV andAIDS, malaria, tuberculosis and others.Although it has pharmaceutical and therapeuticknowledge which, albeit empirical, science can test,the effectiveness of traditional medicine is based,above all, on the mastery by its practitioners of psychological,sociological and anthropological factorsassociated with disease, and important for curingthe patient. These factors tend to consider health asa complex including both physical and mental orsocial well-being, whose balance depends on thesocio-economic and cultural make-up of the individual.Thus the factor of cultural identity between thePMT and the community and the ease of access of thecommunity to him or her are conditions that offer apersonalized, culturally adequate means of attendance,in a holistic perspective.For these reasons, the practice of traditionalmedicine and the use of the medicines on which it isbased should be considered as allies of modern orconventional medicine, and not a threat to publichealth. The official bodies in the sector should thus48


National Strategies against the Spread and Impact of HIV and AIDScreatively seek out strategies of negotiating with andupgrading the PMT, particularly by freeing them ofconcepts and beliefs that may damage the health andharmony of community life.Indeed, it happens that, as a result of associatingmedico-biological problems with complex spiritualbeliefs and/or interpretations, the patient’s decisionto seek assistance in health units is taken very late,thus making the chances of cure more remote, andalso contributing to the spread of the disease, in thecase of infectious and contagious diseases, such asHIV and AIDS or tuberculosis.By way of example, we may note the case of TB,which in several parts of Mozambique is linked tobreaking social rules or taboos associated with deathor with sex, such as those according to which the diseaseresults from sexual relations with a woman whohas just aborted, or from failure to comply with ceremoniesto “purify” widows after the death of theirhusbands, etc.There are also cases in which the diagnosis andtreatment of a variety of diseases is undertaken in anempirical manner which relates the illness with, forexample, the environment, e.g. plants that arecoloured red would be used to deal with problems oflack of blood. Or when a patent, in a high fever, mentionssomebody’s name, that person is immediatelyaccused of causing the illness. These accusationsresult in disharmony in the community, and sometimesin serious human damage.Thus recognising, above all, the relevance of thepharmaceutical knowledge of traditional medicine,strengthened by the socio-cultural identity betweenthe practitioners and the community, an officialapproach, in the sense of greater involvement by thePMT to defend community health, and particularlyagainst HIV and AIDS, malaria and tuberculosis,should be developed and strengthened. The first stepin this direction should certainly be the establishmentof a climate of trust and collaboration betweenthe two medicines, thus facilitating the developmentof strategies and programmes for a multi-sectorapproximation, where the PMTs are regarded asimportant actors.According to the WHO (2000), the place androle of traditional medicine remains undefined andcontroversial in many African countries. The majorobstacles are the lack of adequate policies and legislation,the inadequate evidence of the safety andeffectiveness of traditional medicine, the lack ofknowledge of the attitudes, practices and behaviourof traditional medicine, the lack of coordinationbetween institutions, the scarcity of documentation,and the lack of protection for intellectual propertyrights and for species of medicinal plants at risk ofextinction.Thus WHO encourages overcoming these obstaclesthrough strengthening and developing this sector,seeking its integration into the health systems ofmember states.Mozambique already has an approved policy ontraditional medicine, and the government is draftinga bill that will define the legal regime for the practiceof traditional medicine, and facilitate the developmentof the sector, in a clear legal framework.At the same time, the Ministry of Health has beenimplementing a programme of working with thepractitioners of traditional medicine, specificallyaimed at strengthening strategies to prevent thespread of HIV and AIDS. The main objectives of theprogramme are as follows:• To assess the real potential and limitations of thePMT in preventing HIV transmission throughsystematic research;• To develop effective ways of establishingsynergies and collaboration between the capacitiesof the PMT and those of the formal healthsystem, particularly in the area of reducing riskypractices and distributing condoms;• To develop specific training material for the PMT;• Training the PMT for their integration into homecare teams, and their participation in information,education and communication activitiesabout the epidemic in general.• Training of PMT as facilitators of the provincialgroups coordinating activities against HIV andSIDA.As general objectives of the established trainingactivities, the following stand out:• To train the PMT in matters of preventing STI/HIV/AIDS, namely in the early detection ofopportunist infections caused by AIDS, and morefrequent diseases, giving them skills in elementaryquestions of biosecurity associated to thepractice of traditional medicine;• To discuss with them habits, taboos, initiationrites and traditions that risk spreading HIV in thecommunities and to negotiate with them ways ofmaintaining such rituals without the risk oftransmitting the AIDS virus;49


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007• To encourage the PMT so that the leadership roleentrusted to them by the communities may alsobe used to influence the public to accept safepractices of hygiene, nutrition and diseaseprevention.Information, education, communicationand counselling by PMTThe role of the PMT in activities concerned with diseaseprevention, by raising the awareness and knowledgeof the communities and of their clients in particular,about the most common routes of HIV infection,should be regarded as of the greatest relevancein the overall national strategies.To this end, it will be important for the associationsof PMT, notably the Association of TraditionalMedicine Practitioners of Mozambique (AME-TRAMO), to receive from the public health bodies,information and basic training about the main epidemics,particularly HIV and AIDS, concerning thecharacteristics and symptoms of the disease and thebasic care that an infected person should take rigorously,in order to avoid spreading the disease.Many PMT and traditional midwives have widerangingexperiences in matters of counselling couplesand solving family disputes. They also knowabout matters connected with the reproductivehealth and sexuality of special groups such as pregnantwomen and young people (through the initiationrites). They are thus in a privileged position totransmit, with potentially greater success, relevantinformation and advice to these target groups on sexuallytransmitted infections – which facilitate HIVinfection – and about AIDS itself.Thus, bearing in mind their privileged position toinduce the community to change customs and traditionsthat are high risk factors in spreading HIV, thePMT should be encouraged to express their perceptionabout diseases with high rates of morbidity andmortality, including their views on control and treatment.This should be achieved through their participationin focus group discussions and thematic seminars,so as to ensure that their knowledge and positiveexperiences may be taken into account andincluded in the national programmes to prevent andcontrol the epidemic.Focal points who will liaise between PMT andother health workers at various levels of the healthsystem should be identified. This liaison may bestrengthened and extended to coordinate andmobilise collaborative activities in the prevention andcontrol of other serious diseases, such as malaria,and tuberculosis, as well as in other Primary HealthCare activities, such as vaccinations, ante-natal consultations,etc.An effective and fruitful involvement of the PMTin these activities, implies that they be also involvedat all stages of the design, implementation and controlof HIV and AIDS activities, notably those based inthe community, through lectures, theatre groups andother effective forms of portraying the disease andwarning communities about it, as part of the educationfor health programme.A mutual referral system between the two systemsof medicine (modern and traditional) could beestablished. This system should be supported by aprogramme of continual education to equip the PMTwith the necessary information and skills for efficienthandling and care of patients in the community.Likewise of the greatest relevance is the involvementof PMT in joint studies with the practitioners offormal medicine to evaluate the safety and effectivenessof traditional remedies, especially the medicinalplants used to treat opportunist infections and AIDSsymptoms.One of the fronts of combat against the spread ofHIV concerns the vertical transmission of the virus,which causes the birth of HIV-positive children.Knowing that most Mozambican mothers, even if theyattend ante-natal hospital consultations, end up givingbirth at home, attended by traditional midwives,then adequate training of the latter by nurses in conventionalmedicine would offer them knowledge coveringaspects such as:• Refrain from practices that increase the risk ofHIV infection, such as the use of cuttinginstruments on more than one patient;• Encourage pregnant women and their partnersto use the health services to prevent verticaltransmission;• Perform births without risk of contaminationand with self-protection;• Sterilise the instruments used in attending births;• Encourage breast-feeding as a recommendationfor good nutrition, but exclusive bottle-feedingfor HIV-positive mothers.To implement these objectives, the provision ofbudgetary resources should be considered within theNational Programme to Combat AIDS, Tuberculosisand Malaria, focused on NGOs.50


National Strategies against the Spread and Impact of HIV and AIDSThe role of PMT in providing home careIn seeking to cure and improve their general state, alarge majority of AIDS patients resort to multipletreatment alternatives, including traditional medicine.The PMT, in regular contact with thesepatients, are in a privileged position to follow themin the treatment they take when medicated by thehealth units. The PMT always provide the patientswith a hope for life, and the patients, for their part,have great trust in the recommendations theyreceive from them.This important role played by the PMT couldbe still more significant if the group is officiallyinvolved in caring for patients at home, firstbecause they already know about the disease andare used to dealing with the patient, and secondbecause many questions concerning the patientand his family could have the support of thisgroup since, because of the nature of their work,they are already giving advice and form part of thegroup of leaders who solve family problems in thecommunities.Likewise, it is important to note that many traditionalcultural aspects that may be associatedwith the situation of the AIDS or tuberculosispatient and the stability of their family (ceremoniesto “purify” widows, managing the inheritance ofthose who have died, etc), may benefit from positivemanagement with the collaboration of the PMT,if these are trained to this end, since traditionalcommunities better accept recommendations tochange attitudes and behaviour when these comefrom someone who belongs to the same culturalenvironment.Thus, and to sum up, PMT support in homecarefor AIDS patients can cover the following areas:• Advise patients to stick to hospital treatment(ARVT) and to follow strictly the medicationinstructions;• Support and counsel the household in solvingproblems that may result from discriminationand stigmatisation in the community, and thatmay culminate in such acts as denying householdmembers access to community standpipes, orisolating children at school;• Channel to the relevant official bodies thematters that imply their intervention, such as thesupport of Social Welfare in basic foodstuffs, theintervention of community chiefs to ensure thatchildren stay at school, etc.Anti-retroviral treatment in MozambiqueIn 2001, in preparing the system for the new challengeof providing care and treatment for people livingwith HIV and AIDS, the Mozambican government,though the Ministry of Health, adopted MinisterialDiploma n° 183 of 18 December 2001, which introducedwithin the National Health Service the normsfor treating people living with HIV and AIDS, and theguiding principles for treating patients infected withHIV, through the policy of introducing anti-retroviralin the country and the respective technical guides.These guides, cover, among other specific areas, thefollowing general normative aspects.It was decided to reactivate some attendanceservices to create the Day Hospitals (HDD), whichshould complement other specific services supportingAIDS patients, such as counselling and voluntarytesting, me care, prevention of vertical transmission;sexual and reproductive health services for youngpeople and adolescents, with the greatest stress oneducation and communication for behaviouralchange.This strategy was the most adequate one for theinitial phase of introducing ARV, for the patients, forthe health workers, and for the system itself: it correspondedto a phase of familiarisation with theprocess, an exercise that would not be feasible if itwere intended to cover at once the entire nationalterritory.The following step was the total integration of thecare services for people living with HIV and AIDS,starting with counselling and voluntary testing, up tothe approach of counselling and health testing, in thecontext of turning this into a service covering anyuser of the health unit carrying any other particularlychronic diseases, such as diabetes, high bloodpressure, etc. In this stage of great expansion, thetraditional organisation of the health services facilitatedincreased coverage of people on ART, fromabout 20,000 patients in 2005 to 44,000 in 2006.The undertaking for 2007 is to manage to cover alldistrict capitals in the first six months, and to ensuretreatment for 96,000 patients by December 2007.Since AIDS is a chronic disease, this means thatthe total number of patients to be covered by the endof 2007 is the approximate sum of the 44,000 of2006 and the 52,000 to be reached in 2007.Obviously these numbers make the challenges posedto the health sector, in ensuring expansion and quality,more critical. In particular, they imply greater51


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007capacity in terms of properly trained humanresources, as well as in material and infrastructure.It is known, however, that the supply of ARV is guaranteed(MISAU 2007).With a population of around 20 million inhabitantsin 2007, Mozambique has a total of some24,000 health workers, of whom only about 600 aredoctors, and a third of these are expatriates. To minimisethis shortfall, and to provide at least a minimumresponse to the challenges posed by theincrease in epidemics such as HIV and AIDS, malariaand tuberculosis, diarrhoeal and chronic diseases,the Health Ministry has adopted a <strong>Human</strong> Resource<strong>Development</strong> Plan for 2006-2010, which takes intoaccount the epidemiological profile and the availabilityof funds. Thus the plan envisages the raining of2,800 mid-level staff, 2,400 basic level staff and 625specialised mid-level staff. This does not include estimatesfor training higher level staff, such as doctors,since their training depends on other institutions.Thus, the Health Ministry plans to train, by 2010,a total of 6,554 health staff, of whom 2,394 correspondto the Plan for the Accelerated Training ofHealth Staff from June 2006 to June 2009, in order tomeet the additional needs arising from the responseto the AIDS epidemic.The policy of ART and the target groupsThe policy of Anti-Retroviral Treatment (ART) wasestablished bearing in mind the financial and coverageconstraints of the country’s health units. UnderMozambican conditions, an inclusive and universalpolicy was not yet possible. Given the prevailing financialand structural limitations, under the policy treatment,in the initial <strong>version</strong> of the Ministerial Diploma,the state did not assume any cost in treatment withARVs, except improving the conditions for prophylaxisand treatment of opportunist infections. This wasone of the most wide-ranging interventions forimproving the quality of life of the majority of peoplein need, who could not afford the cost of ART.There were several phases of evolving criteriafor defining the target groups. In 2002 the first antiretroviralin the National Health Service were madeavailable experimentally through a foreign organisation– the Italian Sant’Egidio Community – inMatola and Beira cities, for a pilot project to preventtransmission of the infection from mother tochild. A very limited number of people wereinvolved. There was a great deal of questioning as towhy only a small number of women who met theselection criteria envisaged in the protocol, benefitedfrom the intervention?In the first year the number was very small, coveringonly about 500 women and their children. Dueto improved prices of ARV, pressure on the Ministry ofHealth began to increase, mainly through the organisationsof people living with HIV and AIDS. UnderMinisterial Diploma 21/96, which envisages medicalcare for civil servants and their direct relatives, it wasdecided to establish a partnership with Sant’Egidio, totreat 100 civil servants a year, since the Ministry hadno funds for a more inclusive intervention.During implementation many questions wereposed to the health ministry, first because few drugswere available and these did not cover the needs ofmost civil servants, much less the inclusion of theirfamilies. Those treated should be distributedthroughout the country. In some provincial capitalsthere were already complaints and lists of civil servantswaiting to start treatment.At the same time there was some concern abouthealth workers who, due to the nature of their work,are often exposed to risks of HIV infection. To safeguardtheir rights, under the same law, the use ofanti-retrovirals was introduced for HIV prophylaxisin the event of suspecting possible contaminationthrough contact with blood or other body fluids ofinfected patients. The problems raised by theseworkers were the same as those of the other civil servants.The anti-retroviral did not reach everywhere.Here the major problem was information and immediateavailability, since prophylaxis should be startedwithin 24 hours of the contact.Other target groups were people living with HIVand AIDS who met the biological criteria for inclusionrecommended by WHO and by UNAIDS. Sincethe state could not pay the expenses, a fundamentalcondition, a sine qua non for the start of treatmentwas the proven financial capacity of the patient topay for his or her treatment without interruption.People living with HIV and AIDS who had, with theirown resources, begun treatment abroad or in privateMozambican clinics, were another targetgroup.The selection of beneficiaries had a great deal todo with the quantity of drugs and financial capacity.This dilemma did not last long because a year laterthe process began of expanding anti-retroviral treatmentin Mozambique.52


National Strategies against the Spread and Impact of HIV and AIDSProgramme of expanding ARTand the Health PEN 2004-2008In 2003, because of the increased threat of nationalcollapse due to HIV and AIDS, and greater internationalsensitivity, there were many improvements inthe approach to the disease which resulted in reducingthe prices of anti-retroviral at world level, makingthem more available to poor countries. This waslinked to various bilateral and multilateral financialinitiatives supporting the neediest countries, such as:the Global Fund against HIV and AIDS, Tuberculosisand Malaria; the initiative of US President George W.Bush, initiatives of the World Bank, the ClintonFoundation and others.Mozambique is one of the countries benefitingfrom these initiatives, which allowed the health ministryto revise PEN1, in order to include the treatmentcomponent. This revision culminated with the draftingof the PEN 2004-2008 of the health sector whichstressed the need to improve the quality of carethrough integrating all the components into a functionalunit that was named the Integrated Network forProviding Care to People Living with HIV and AIDS.With funding guaranteed for anti-retrovirals andother necessities needed for treatment and follow upwith AIDS patients, Ministerial Diploma n° 183 of 18December 2001, under which the state did not coverthe costs of anti-retroviral treatment, was partiallyrevoked. Currently in Mozambique, in the publicservice and in non-profit making health units, thewhole package of care for patients undergoing treatmentis free of charge.Counselling and voluntary testing, laboratoryexams, treatment with anti-retroviral and other drugsfor opportunist infection are fully subsidized by thestate. All drugs, reagents and tests are acquired andmade available through the Ministry of Health to allthe institutions and organisations operating in thecountry in the area of treatment to allow uniformityin treatment and follow-up of the patients.Under the PEN 2004-2008, as shown in Table7.1, it is envisaged that treatment will reach 132,000people by 2008. Bearing in mind the growth of theepidemic, these figures are below the needs. Thesecalculations were made based on the capacity of thesystem and the possibilities of funding. To improvethis estimate, there must be a major increase infinancial, human and material resources, and fundamentallyin infrastructures of the entire NationalHealth Service for a more wide-ranging response,Table 7.1which does not seem possible under the country’spresent conditions.Thus, since 2002, the health ministry and itspartners have been providing anti-retroviral treatmentin Mozambique. By late 2004, the ministry andits implementing partners provided treatment forslightly more than 6,000 Mozambicans, which isapproximately 4% of all Mozambicans who neededtreatment. As Table 7.1 indicates, the number of peoplebenefiting from treatment has been growing verysignificantly, and in September 2005 there were15,000 patients undergoing treatment. This figurecorresponds to about 6.8% of the total number ofpeople needing treatment.WHO recommends that at least 10% of the totalnumber of people undergoing treatment should bechildren under 15 years of age. In Mozambique, thenumber of children in treatment has been increasingevery year. In 2006, it was 3,416, and the projectionfor 2007 is a total of 7,200 children (Ministry ofHealth, 2006).In late 2005, there were 30 health units in thecountry providing anti-retroviral treatment. Graph7.1 shows the reflex of availability of services andresources in treatment coverage. Maputo City con-Projections of patientsundergoing ART 2004-2008Number of Beneficiaries 2004 2005 2006 2007 2008People HIV+ aged 15-49 1 262 000 1 355 000 1 435 000 1 509 000 1 575 000With criteria for ART (25%) 315 000 339 000 359 000 377 000 394 000Included in ART with GF 1 000 3 000 7 000 14 000 22 000Included in ART with GF 8 000 21 000 58 000 96 000 132 000and Clinton FoundationUnmet ARV needs 306 000 313 000 291 000 271 000 251 000People undergoing other carewith Clinton Foundation 4 000 29 000 56 000 123 000 163 000Graph 7.1 Evolution of ART in Mozambique, 2004-20052500020000150001000050000Real growthPEN forecast53


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Box 7.3The use of cotrimoxazole to preventHIV-related infections in AfricaUNAIDS and WHO recommend the use of cotrimoxazole in Africa for prophylaxisin adults and children living with HIV and AIDS, as part of a minimumpackage of treatment. Criteria for the use of the medication havealready been established, covering the selection of patients, the drug regimen,the duration of treatment, follow-up, the supply of the drug, educationand training, monitoring of drug resistance and adverse effects.Manuals for prophylaxis programmes have already been published.Cotrimoxazole costs between US$8 and US$17 per person per yearfor prophylaxis. It is widely available on the continent, and preliminaryanalyses have shown that the use of cotrimoxazole prophylaxis is a costefficientintervention in Africa, particularly when combined with growingaccess to voluntary counselling and testing for HIV infection.The generalised prophylactic or preventive use of cotrimoxazole inAfrica was postponed for a long time due to inconsistencies in the researchresults. Two studies held in Ivory Coast in 1999, one by French researchersand the other by American scientists, showed that the drug reduces the frequencyof opportunist diseases among HIV-positive people. One of thesestudies recorded a fall in the death rate from HIV-related diseases.Preliminary results from two studies sponsored by UNAIDS in SouthAfrica and Malawi confirmed that cotrimoxazole is safe in people withHIV, and the study in Malawi indicated significant beneficial impacts onmortality (WHO 2000).Common HIV-related infections in sub-Saharan Africa, which can beprevented by cotrimoxazole, include certain bacterial pneumonias anddiarrhoeal diseases. The fact that administering cotrimoxazole does notrequire medical staff with special training is an advantage, comparedwith ART.Graph 7.2National distribution of PLWHon ART by province, July 2005Niassa 2%C. Delgado 1%Nampula 2%Zambézia 4%Tete 8%Manica 5%Sofala 8%Inhambane 1%Gaza 4%Maputo P. 7%Maputo C. 58%Table 7.2Distribution of PLWA on ART bysex/age/province/district, to November 2006Province Number


National Strategies against the Spread and Impact of HIV and AIDSlogical criteria, the selected individuals shoulddemonstrate guarantees of compliance. They sign oragree verbally to an undertaking that they will complywith all the recommendations. To start the treatment,the protocol for including patients must bestrictly complied with, and the evaluation process atthe health units may last for approximately a month.This delays the onset of treatment, worsening stillfurther the state of the patient. (Survey on Adherenceto the ARS, MISAU/University of Columbia, 2004).There is a limit per health unit in the quotasattributed. The decision on who will benefit from thetreatment depends on the treatment managementcommittee operating in each health unit.But the greatest constraint is that most HIV-positivepeople do not know that they are HIV-positive.Those with access to the GATV mostly have initial difficultiesin accepting their condition, which compromisestimely guidance on the various possibilities ofpreventing the rapid evolution of the infection to thestate of illness.More than this, cultural factors, and particularlybelief in the possibility of cure through certain traditionalpractices impact negatively on the attitude andbehaviour of people towards the disease and its treatment.But above all, the lack of adequate informationis the main constraint in this sphere.Although there is little local factual informationabout the problems faced by the PLWA who arereceiving anti-retroviral treatment, a few studies, thatcannot be generalised, show that many peopleundergoing treatment keep it secret from their familyand even from their spouses (Survey on Adherenceto the ARS, ibid, 2004).Often this attitude makes it difficult to complycorrectly with the medication, namely taking thedrugs daily and at specific times, or abstaining fromalcohol. Those who work fear that their colleaguesmay find out that they are taking regular medication,and will discover that they are AIDS patients undergoingtreatment. This means that often they fail withthe medication. Stigma and discrimination are stillcommon in the workplace, and there are alsoreports of some patients being abandoned by theirfamilies.In the case of children, caregivers need to betrained to provide the drugs to them. Particularly theprovision of paediatric syrups to the youngest childrenrequires specific skills. Often, these caregiversare mothers or fathers who are infected with HIV andmight be weak or sick themselves, or elderly peoplewho might also be weak.A further important factor is diet. Taking thedrugs requires a regular and balanced diet. Most ofthe patients are very poor, with serious financialproblems, and often find themselves involuntarilycompelled to interrupt the treatment because ofhunger, since ingesting the drugs while fasting exacerbatesdiscomfort and weakness. There are someinitiatives to grant a basic basket of foodstuffs to peopleundergoing treatment, but these do not covereveryone.Undesirable side effects caused by the drugs areamong the factors that often influence temporaryinterruption of the medication, which is very serious,since it increases the risk of developing resistanceand of therapeutic failure.This expansion necessarily involves lifting thecommunity taboos about HIV infection and AIDS. Tocontrol AIDS, it must be accepted that it is a diseaselike many others, and that people living with HIV andAIDS are normal. Only by overcoming stigma, discriminationand fear can we improve the impact ofthe various interventions until we reach the lastwoman in the most remote parts of the country.Confidentiality, stigma and discriminationConfidentiality and the duty of maintaining patients’state of health private involve a compulsory internationalnorm of professional ethics. It is the duty of allhealth professionals to keep the diagnosis of thepatient secret, whatever it may be, while at the sametime it is the patient’s right to want, or not, his or herdirect relatives, or anybody else, to be informed ofhis or her state of health.Nowadays, because of AIDS, this concept isbecoming more complex. There is an urgent need todeal with human rights around the principles of confidentialityand privacy and the possible consequencesfor public health in responses against HIVand AIDS.Furthermore, for a campaign of HIV and AIDSprevention to be crowned with success, strategiesmust be defined to encourage people bearing the diseaseto break the silence. Up to now, a large proportionof the Mozambican population still sees AIDS,not as a problem for everybody, but only as somethingthat concerns other people, since many havenever seen an AIDS patient, although they exist nearthem and even in their own families.55


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Governments and world leaders have made varioushigh level and unprecedented undertakings tofight against HIV and AIDS. One of the undertakingsgiven by governments during the Special Session ofthe <strong>United</strong> Nations General Assembly on HIV andAIDS (UNGASS) in June 2001 was to promote thedrafting of policies, laws and regulations, as well asother norms to protect AIDS patients and HIV-positivepeople. Thus, in April 2001 in Abuja a declarationby all African leaders was issued, that says:“We commit ourselves to take all necessarymeasures to ensure that the needed resourcesare made available from all sources and that theyare efficiently and effectively utilized. In addition,WE PLEDGE to set a target of allocating at least15% of our annual budget to the improvement ofthe health sector. WE ALSO PLEDGE to makeavailable the necessary resources for theimprovement of the comprehensive multisectoralresponse, and that an appropriate andadequate portion of this amount is put at thedisposal of the National Commissions/Councilsto Combat HIV/AIDS, Tuberculosis and OtherRelated Infectious Diseases.”(Abuja Declaration, 27 April 2001).This pledge was taken and approved at UNGASSand the leaders of the developed countries alsopromised to assist African leaders in the efforts toreach the targets established in the Abuja declaration.In relation to confidentiality and privacy, theserights are enshrined in various international andnational legislation. At international level, we shouldstress the Universal Declaration of the Rights of Manof 1948, the African Charter of <strong>Human</strong> and People’sRights, the International Charter of Patients’ Rights,which fixes the right to privacy and confidentiality.To complement these initiatives, several analyseshave been made in terms of developing support policies,legislation and other norms that defend theright to confidentiality and privacy, faced with problemsof an ethical nature that arise on the variousfronts of fighting this epidemic (Hamblin 2003).In Mozambique the number of AIDS cases and ofdeaths from this epidemic have contributed to someextent to changes in public opinion about the strategiesfor fighting HIV and AIDS. In this context it isurgent to define or revise policies and legislation andother relevant norms, with the purpose of guaranteeingthe rights to confidentiality and privacy, as thesame times as establishing mechanisms to inform themost direct relatives, such as spouses, and all peopleliving with the patient, about his/her situation, andsetting forth the necessary rules of conduct.In fact, under the umbrella of the principle ofprivacy and confidentiality, many patients, whoseclinical situation is known to doctors, have continued,in a conscious and voluntary manner, to infectother people, mainly through sexual relations, andbrusquely refuse to authorise doctors and otherhealth professionals to reveal their HIV-positive statusto their closest relatives.Thus many women and men, married to HIVpositivespouses, end up contracting the diseasewithout knowing about it because, under cover of theright to privacy and confidentiality, the patient keepshis status secret from his relatives, and does notallow health professionals to reveal his real situation(Plano Estratégico de Combate as ITS/HIV/SIDA actualizado2004-2008).Furthermore, those who, for various reasons,agree to break the silence, still receive as theirreward attitudes of contempt, stigmatisation and discriminationwhere they live and at their workplaces.There are patients who are prevented from usingpublic and semi-collective transport because citizens,who think they are immune to the disease,refuse to share the same transport with them(Khindlimuka & Monaso 2002).There are citizens who, recognising that theyhave been infected by HIV, declare publicly that theyare “living positively” in civil society organisationssuch as, for example, Khindlimuka and Monaso.Thus, through the media, many of these citizens,whose physical appearance does not give rise to anysuspicion that they may be ill, as soon as their clinicalcondition is publicly known, suffer ill-treatment,harassment and all manner of gross and flagrant violationsof their rights by their fellow citizens whoimagine themselves HIV-negative, even if they havenever taken an HIV test (Khindlimuka & Monaso2002).In approaching this problem it is intended to layheavy stress on developing policies and laws that, onthe one hand, protect those infected with HIV againststigma and discrimination, safeguarding themagainst segregation, while at the same time ensuringthe preservation and defence of public health.56


Chapter 8Planning for the Future: The Window of HopeThe strategic approach in responseto AIDS from 2005 to the presentThe National Strategic Plan to Combat AIDS 2005-2009 (PEN II) is a consensual document coordinatedby the National AIDS Council (CNCS). PEN IIbrings together strategic approaches and guidelinesthat challenge the traditional form of viewingthe response to AIDS, and gives clear suggestionson how to guide interventions so as to encouragethe situational and contextual environments thataccommodate and facilitate infection with HIV, withthe view to reverse the prevailing trend.Efforts are becoming visible to bring to the surfacethe entire approach sustained in the socio-culturalcontext in which the personality of the individualis structured, and the entire learning of the elementsof life, including sexuality and morality, amongother reference points for guiding the behaviour ofhuman beings.The approaches contain clear support elements:• a communications strategy that seeks to reclaimthe socio-cultural values of Mozambican identityto confront the epidemic;• advocacy that begins at the highest level of governance,involving intervention by the Head ofState, for change in behaviour and understandingabout sexuality (Box 7.1, PresidentialInitiative to Combat HIV and AIDS);• The advocacy of the First Lady of the Republic,based on promoting the Global Campaign “Unitefor Children, Unite against AIDS”, convened byUNICEF and involving a broad range of sectors,and targeting:• Prevention of infection among young people,• Prevention of mother-to-child transmission,• Social protection of minors, orphans andvulnerable children in general, and• Paediatric treatment.• the strategy of mass treatment in the context ofuniversal access to prevention, care andtreatment.Complimentary to these actions there is the newvision of the health sector towards:• integrating and unifying the system;• eliminating the fragmentation of care services inresponse to the epidemic (GATV, Day Hospital,etc.); and,• generating an attitude of combating stigma anddiscrimination, from the ordering and structuringof the service to the forms of care.Despite this investment, the projections made inthe past as to the evolution of the epidemic point to arise of rates of HIV prevalence to around 18% nationallyin the coming years. This figure needs to bereconfirmed, starting with the next rounds of epidemiologicalsurveillance, which will update the evolutionof the epidemic.The question to be asked then is: Is an entirestrategy and its investments failing? Although it is noteasy to present a substantiated answer to this question,one fact is certain: Mozambique has not yetreached stable levels of infection rates and, judgingfrom the continued waves of new infections, it can besaid that the investment made is still not having thedesired effects.Sex and sexualityIf HIV is mostly transmitted through unprotected sexualrelations, then understanding the motivations, situationsand contexts that precede or condition thesexual involvement should not be underestimated.Sexuality is not an easy area to discuss, since it issurrounded with a wide variety of taboos and stereotypes.It is no accident that in traditional education,when young people enter into puberty, it is theresponsibility of adults often outside of the family toteach them matters linked to sexuality. But when sexuallytransmitted infections are contracted, there isalso resort to older people and to the traditionalhealers.This results from the fact that traditional mattersthat by their nature concern shame and modesty – as57


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007is the case of sexuality – meet with a carefully structuredtreatment, under particular criteria based onage, which symbolizes experience of life, and otherattributes that, in the individual charged with handlingthem, inspire confidence in others.Underlying this social experience is the conceptof sexuality and desire generally rooted in ideasabout the different roles of male and female identities,where the man is represented as strong andimpetuous, where the male drive and skill at dealingwith the world are synonyms with potency and virility,the opposite of women, transfigured into a suave,candid and fundamentally receptive femininity, underthe prism of sexual relations.Furthermore, in the social construction of sexuality,sexually transmitted diseases are traditionallyinterpreted as a transgression of sexual morality.These considerations, which are the basis forperceiving the motivations of sexual behaviour,escape the attention of the usual approaches of HIVand AIDS prevention efforts expressed in the nationalstrategies, which often err by basing themselves onstereotyped orientations of action (message) and ofreply (behavioural change), inspired in the biomedicaland behavioural understanding of sexuality andof reproductive health in general.The need for a deeper understanding of the determinantsof sex and sexuality is essential in order toseek out alternative and less conventional interventionsfor AIDS prevention. Indeed, it must be understood thatepidemics are, by definition, extraordinary events. Theyarise because the current understanding of health anddisease, and the prevailing health systems and institutions,are not able to cope with the particular form thatthey follow, and to staunch the particular mechanismsthrough which they are spread.Window of HopeAssuming that unprotected sex is the main route of HIVinfection in Mozambique, and considering that themedian age for first sexual relation is 16 years forwomen and 16.8 for men (IDS, 2003), the period thatprecedes these ages offers fertile ground for preventiveactions to curb the growing pace of HIV infection andreverse its pyramid among adolescents and youths.Even so, infection is possible, notably throughvertical transmission – that is the transmission of HIVfrom mother to child, among other abnormal events.Diagnosis and confirmation of HIV infection at anyage requires laboratory testing.Although there are other, more sophisticatedforms of laboratory diagnosis to detect HIV, viral particlesin body fluids, the diagnosis to confirm thepresence of the virus in the organism of a child bornto an HIV-positive mother, is undertaken as from the18th month, since that offers the best chance of interpretingwhether or not the virus is present in thechild (Patient and Orr, 2003).At birth, children possess maternal antibodiesfor various diseases, including HIV antibodies, butthis does not necessarily mean they are infected. Thematernal HIV antibodies decline gradually until theyare totally suppressed when the child is 18 monthsold. Definitive testing is advisable as from this age,since the antibodies detected then will indicate solelythe presence of HIV infection in the child (PTV,UNAIDS, 2003; Manual TTT. HIV Criança).Other signs and clinical symptoms of infection ofthe child by the HIV virus are used alternatively todetermine the situation and what should be done –for example, delayed growth and development,repeated opportunist infections, or persistent signsof malnutrition, among others.Following up the situation of child infections inthe first five years of life has shown that in manycountries, including Mozambique, children whocontract HIV through vertical transmission – duringpregnancy, birth or breast-feeding – have littlechance of surviving beyond their fifth or sixth birthday(PTV, UNAIDS, 2003; Manual TTT. HIVCriança).This fact, if it is not given due attention, may naturallycompromise the overall objectives of reducinginfant and maternal mortality rates, which have beenshowing signs of improvement (Government FiveYear Assessment 2000-2004). The reversal of theseindices of maternal and infant mortality associatedwith HIV and AIDS requires a more complete pictureof concrete activities to reduce HIV infection at allages, particularly after the first signs of the onset ofpuberty.In this context, the period from the 10th to the14th year of life is known as the Window of Hope.This is a period in which the HIV infection is certainlyabsent (apart from extraordinary or unusualsituations). The Window of Hope offers the bestprospects for educational and moral investment, formeasurable results in the future.The Window of Hope is so named because it isassumed that it offers an optimal entry point for pro-58


Planning for the Future: The Window of Hopemoting among adolescents the messages and educationimbued with sustained information on sexuality,the prevention of sexually transmitted diseases, valuesof collective life, and signs that can help to builda well-advised personality equipped to take correctdecisions, and make safe sexual choices in thefuture. The Window of Hope Campaign coordinatedby CNCS and implemented by the FDC and N´wetiorganizations is based on this strategy.In fighting HIV and AIDS, prevention remains theonly “cure” until medicines are developed that cantreat and eliminate HIV infection. In the context ofpreventive messages or those leading to safe decisionsto prevent infection, abstinence and fidelity arethe best options in that they rest on decisions andchoices that the individual formulates fully aware ofhis or her actions.Abstinence and fidelity, unlike condoms which,among other things, require knowledge and observanceof particular conditions – expiry date, storageand handling, knowledge of how to use them –depend less on factors external to the individual, andare thus those that offer decisions and options thatcan be controlled by the individual conscience.The individual conscience is shaped within asocialising context that begins in the family and isprolonged throughout the individual’s life untildeath. It is the product of constantly learning socialculture and of the constant confrontation and siftingof scattered data that characterise various facets oflife and of knowledge that may influence the socialbehaviour of the individual positively or negatively.This is why the moral component in the socialconstruction of the individual personality is determinantsince it offers the basic elements for distinguishingbetween good and evil, and to express behaviourin line with the shared culture and values of the individual’ssocial environment.As for the Window of Hope, it is crucial tomake use of this period to instil in children and adolescentsthe values and virtues that can help to formulatein the future correct and safe decisions ontheir sexuality. On this use rests judgment in thefuture on the real meaning of the expression.“Window” represents an entrance into a particularplace, which in this case is the preparation and educationof children for their future lives; and “Hope”is the expectation of a result that compensates for theeducational investment in children, and hence in thecountry’s future.Sex education in childhoodEducation in childhood about values and convictionsconcerning sexuality is complex and often collapsesinto irreconcilable polemics. The form and formulasof sex education and/or the approach to sexuality inchildhood require greater depth, both in school curriculaand in the whole cycle of socialisation andconstruction of the child’s personality.While in the broader context of the vastMozambican cultural mosaic, it seems an accomplishedfact that sex education is generally aresponsibility of elders – normally grandparentsand people recognised and legitimised by customamong the communities (educators/promoters ofinitiation rites) – modern educational psychologyhas defended the prime importance of parents inthe sex education of their children (Haffner,2000).The argument underlying this position is thatparents are responsible for giving children their firstteachings about gender roles, relationships and values,as well as their first sense of self-esteem andemotional care.Research in developmental psychology has longshown that parents educate their children about theirsexuality when they talk to them, dress them, soothethem and play with them, without neglecting the factthat older children continue to learn about sexualityas they develop relationships with their relatives andobserve the interactions around them (Clifford T.Morgan et al, 1986).Since the need for investment in prevention asfrom the Window of Hope generation is now recognisedin order to ensure that adolescents do not contractHIV, the challenge that arises is that of implementingthe specific actions so that hope producesthe desired effects, and this investment thus makes acontribution to halting the gradual spread of the HIVinfection.This challenge poses critical questions, namely:• the definition of the programmatic context of sexeducation, and the expansion of preventionbased on the framework for the children at thevarious stages of their development;• the role of parents and guardians, teachers andeducational monitors in the various spheres oflife, especially in adolescence; and,• the role of society in general, but particularly themain socialising environments – schools,churches, sports clubs and others.59


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007The concept of the Window of Hope, as seenabove, is strong and requires not only commitment, butabove all social responsibility, which should be borneand monitored by all sectors of society. Saving children,adolescents and youths from HIV infection is a key conditionfor the development of the country tomorrow.The prevention of infection, expressed in messages thatstrengthen abstinence at these ages, until the psychologicaland physical growth of the human organism isconsolidated, and young people, no longer children,feel they are able to formulate a correct decision ontheir sexuality, should be the banner of the campaign.Faithfulness should accompany the educationalmodels that seek to instil a moral approach to sexualityfrom a tender age. It will be difficult to controlHIV and AIDS with palliatives. Prevention mustalways be the battlefront. It should be consistent withthe values it is intended to instil in children from theearliest ages of their development.Putting these principles into practice will requirethe development of curricula on how to approachmatters connected with knowledge of healthy and balancedgrowth and respect for one’s body in anunashamed way in early childhood. Duly designed andstandardised programmes can be transmitted by radioor in simple brochures which give clear instructionson the role that parents and guardians or educationmonitors in infancy can play in this area. In line withthis, the Window of Hope Campaign coordinated bythe CNCS and implemented by two NGOs, the FDC andN´weti, are to be highlighted as relevant experiencesin the national response to HIV and AIDS inMozambique.Meanwhile, the pre-school curriculum and allsubsequent education should strengthen in stages thecontents on the sex education of children, dependingon their psychological and bodily development andthe association of these contents with other schoolmaterials, through placing them on the curriculum.In adolescence, specialised services should beset up with a strong impact on the personality,including personalised assistance to all adolescentsand young people who seek information about sexualand reproductive health.Strengthen ART throughprioritising preventionDespite the various questions that can be posed, andalthough the number of people undergoing treatmentis still insignificant, the growth in treatment means agreat qualitative and quantitative improvement incare for PLWA. In terms of individuals this means agreat advance for those benefiting from treatment,but in terms of public health the significance of thisintervention is minimal because it still excludes manypatients who require treatment.However great the commitment of the governmentfor all to gain access to treatment, the possibilitiesof success along this line will always be limited,if the costs implied are taken into account(Table 8.1).While it is the conviction of government and itsmain national and international partners that ARTshould be reinforced and made as widely accessibleas possible nationally, the truth is that treatment initself will never solve the problem.The success of HIV and AIDS control programmesin reducing the spread of the epidemic incountries such as Senegal, Uganda and Thailand wasnot achieved with treatment, but with prevention programmesthat deter the occurrence of new infections.Along these lines, the strategy implies certainundertakings. The state should make efforts to continueexpanding the opportunities for treatment toensure that every Mozambican has the same chancesof survival. For their part, the patients undergoingtreatment should comply strictly with the therapeuticrules and guarantee that they will infect nobody else.Critical analysis of the national responseThe prevention strategy:from the first PEN to 2005Using a similar approach to the one widely used bycountries that have experienced and are still experiencinga growing epidemic, Mozambique has, fromits First National Strategic Plan to the present, beenguided by interventions along the classic “ABC” line– that is, Abstinence, Be faithful and use Condoms.If the final goal to be achieved through thisthree-pronged approach is to reduce infection, themessages used to encourage behaviour aligned toeach of the targets of this approach have been frequentlyquestioned. The inadequate nature of themessages has been mentioned, in that they often donot respect certain principles of ethics and decency,and are thus referred to as competing in the promotionof promiscuity, particularly among the youth(Report of the National Debate on Prevention,CNCS, 2004).60


Planning for the Future: The Window of HopeBut it is not just the messages that have beenqueried. An entire communication strategy forchanging behaviour is considered as somehow aliento the way individuals navigate their social and sexuallives, and also to how they establish their identitieswithin communities.Instead of making a point of using a contextualisedapproach that exploits the socio-cultural variablesthat govern specific human relations fromplace to place, the interventions undertaken lapseinto information flows and audio-visual pieces in themedia that are saturated with contradictory and sensationalmessages on sex, love and relationships.It is a fact that in the traditional African, andspecifically the Mozambican, context, sexuality is asubject which, when approached within the community,is done so in a way where not only the sexes, butalso age groups are separated; and there are alsotimes that are considered appropriate for this. But theprevention programmes carried into the communityand domestic spheres for the purposes of consciousness-raisingintended to change sexual behaviourhave often not observed these criteria and requirements,bringing together, for the same purpose, oldpeople and children, parents and their sons ordaughters, without any age or sex discrimination.Messages drawn from the one-fits-all communicationapproaches, in disregard of the differentsocio-cultural contexts may slip into rejection by thetargeted groups (e.g. when young activists use awooden imitation penis to simulate how condomsare worn to elder people).This is also apparent in many of the interventionsexpressed through other conventional means of influencinga target group. (In fact, the leaflets and visualresources that seek to awaken awareness for a visiblechange in behaviour always reflect the stereotypicalvision and sentiment of what change means for theactivist communicator.) There is no fluid cognitivecommunication between them and the audience, sincethe <strong>language</strong>, the symbolism, the context and the idiosyncrasiescontain irreconcilable differences.That is why many studies on Knowledge, Attitudesand Practices (KAP) have shown that there has beenfor some time a considerable rise in the level ofknowledge about what HIV and AIDS is, how it istransmitted, and how it can be avoided, but withoutthis being reflected in visible changes of behaviour,since the same studies show that the attitudes andpractices remain at worrying levels.Rather than information, people need motivationand skills to begin a visible change in behaviour.They also need a welcoming environment that betterencourages the changes that it is urgent to make.This is what Catherine Campbell is referring to, in herwork on Why HIV/AIDS Intervention ProgrammesFail (2003), when she states that:“…giving people information about health risksis unlikely to change the behaviour of more than onein four people, and these are generally the moreaffluent and better-educated members of a socialgroup. This is because health-related behaviours(such as condom use) are determined not only byconscious rational choice by individuals, on the basisof good information, but also by the extent to whichbroader contextual factors support the performanceof such behaviours.”Indeed, when we compare the investment madeto date with the gains achieved in the prevention ofAIDS in Mozambique, we have good reason to saythat we are still rather a long way from finding theright approach for halting the damage that the pandemicimposes on us. In fact, in the absence of a sensitivityabout how to anchor these approaches withinthe context and social determinants that conditionthe acceptance and assimilation of outside contributions,intended to encourage behavioural changes,the investment in HIV and AIDS prevention, in theway that it has been taken to the communities, howeverwell-intentioned, brings marginal returns.It will be said that it is useful to bring in lessonsand good practices from other countries that havealready found instruments more or less able toreduce risk and provoke a relative change in behaviour.Such references should not be underestimated.However, it is useful to note that the few examples ofcountries which have experienced some success canoften be reduced to the specific context of the placeswhere they occur. It is difficult to recommend, in letterand spirit, their mechanical replication.Since HIV and AIDS is an epidemic that communitieswill live with for a long time, and since there isa need for care about its effects, it is useful to rethinkwhat looks like probable weaknesses in the currentstrategies.The allocation of financial resourcesThe growing level of HIV and AIDS infection, and thematuring of its evolution towards the state of illnessin the human organism, are beginning to bring to the61


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007surface the need for a financial rescaling of healthexpenditure, in order to provide a response in termsof care services and treatment of infections.The health sector in Mozambique is one of themain contributors to improved welfare among thepopulation and thus to the <strong>Human</strong> <strong>Development</strong>Index (HDI).Agenda 2025 concluded that implementing itsvision in the health sector involves expanding theNational Health Service across the entire country,training staff for the health units, and providing medicines.According to the government’s Five YearProgramme (PQG) 2005-2009: “…government policytowards the health sector will be guided towardsimproving the availability of and access to qualityhealth care, based on criteria of efficiency and equityin the distribution of resources and in their use.”To improve attainment of the strategic vision presentedin Agenda 2025 and the PQG, one priority inthe sector, which has been considered in PARPA II,should be appropriate distribution of budgeted fundsand the modality of budget flows.As a whole, the PARPA priority sectors, and particularlyhealth and education with 32.4% of totalplanned expenditure, are approaching the targets setwith the donors in the Joint Review of April 2004(65% for all of the priority sectors and 32.5% forhealth and education, relative to total expenditure,excluding debt servicing). However, this overall sumtends to disguise a reduction in the allocation of thehealth sector.Indeed, with the volume of funds available, thehealth sector allocation in the country’s state budgetshows a worrying trend, falling from 14% in 2002 to13% in 2003 and 11% in 2004, according to estimatesfrom the planning and finance ministry.Budgetary execution for the same period wasabout 51%, 65% and 69% respectively, showing agrowth trend. However, it is difficult to establish theoverall levels of expenditure in the sector because ofthe large amount of “off-budget” funds, which arestill not included in the budget. There is little informationabout the level of execution in this particulararea.A recently concluded study of the health sectorshows that 29% of resources in the sector are notprogrammed in the State Budget, 60% are not executed,and 44% are not covered by the PublicAccounts within the State Budget system (Cabral et al,2005). This large amount of funds and financialflows outside the system makes planning and efficiencydifficult.Estimating the cost of interventions in reponse toHIV and AIDS is extremely difficult, starting with thefact that it is not possible to calculate the volume ofrelated activities undertaken by the health services.Furthermore, there are no specific cost estimates forthese activities with reference to Mozambique, andthose in international literature are not always comparable.The projections presented here representalmost exclusively the financial gap the country facesin fighting the disease.Several documents have been published inrecent years assessing the intervention in terms ofcost-effectiveness, thus introducing a rough calculationof the financial burden of implementingthese programmes. Most of the studies try to beuseful to the process of decision-making in thecontext of allocation of resources. More than simplyestablishing the costs of implementing a givenactivity (which should be planned and budgeted),what is done is to compare the difference in thecosts of avoiding an HIV infection with those ofgaining another year of healthy life (DALY or QALY)– between the various interventions, to decidewhich ought to be prioritised.Table 8.1 Financing of the health sector as % of public expenditure, 2000-2004STATE BUDGETProjections in millions of meticais2000 2001 2002 2003 2004Total public expenditure 15 966 200 14 482 454 28 666 306 27 891 091 29 810 733Public expenditure on health 1 437 415 1 973 849 3 905 377 3 630 848 3 275 233Public expenditure as % of GDP 27% 20% 35% 27% 24%Health sector as % of GDP 2% 3% 5% 4% 3%Health sector as % of budget 9% 14% 14% 13% 11%Source: MPF62


Planning for the Future: The Window of HopeThe cost estimates presented are not alwaysdirectly comparable. Some include all the costs, othersonly the cost of drugs, while staff and otherexpenses are included on the days of hospitalisationor outpatient consultation. For ART, there are still noreliable estimates of costs in a mass treatmentapproach. Furthermore, prices are falling dramatically,and estimates calculated a year ago are alreadycompletely out of date the following year.Resources allocated still belowthe Abuja undertakingsThe few studies of costs undertaken in Mozambiquecorrespond to different methodologies and periods,and propose much less expensive measures for hospitalisationand consultations. Thus, according to theunit studies obtained in several of the country’shealth units, US$5 per day of hospitalisation andUS$0.5 per consultation, would be the costs of thesetwo activities, although the methodology is difficult tocompare.To cover the estimated number of people sufferingfrom AIDS, the total cost would be US$12 millionfor hospitalisation and US$500,000 for consultations,covering the total number of patients in 2004.There are much lower estimates for treatingSexually Transmitted Infections (STI), generally lessthan US$4 per occurrence, but this includes onlydrugs and home-based care. For the latter componentthere are two estimates that situate the cost perpatient at US$45 and US$200 respectively, but withsignificant differences in the model of care offered(more or less medicalised) and in the area covered(rural/urban), so that US$100 has been used as theaverage. For opportunist infections, an average estimateis used of US$20 in antibiotics per patient peryear.A great limitation of the calculation methods presentedto date is the lack of consideration for the factthat interventions against AIDS do no happen in isolation,but as part of a system that has to provideother services. In Mozambique, as in other countries,the system as a whole must be improved, so thatother interventions may be integrated into it, specificallyfor HIV and AIDS. Thus, the expenditure neededto offer good quality care should be increased toinclude training and investments.A projection of costs, including this systemiccomponent, estimated the financial needs at aboutUS$500 million for five years, but with relativelymodest objectives for ART coverage (PENITS/HIV/SIDA 2004-2008).Important questions in this sector include:• how can we improve the quality of the data in theHealth Information System; and• how can we improve the levels of absorption ofhealth professionals trained inside and outsidethe health ministry’s training institutions, stressingtheir placement in the areas most lacking inprofessionals (especially because of the impactof HIV and AIDS).Due to the feeble funding allocated to the sectorin recent years, as well as the type of activities undertakenat each level of care, the funding channeled tothe primary level, recently increased, is still relativelylow, particularly for rural areas.In addition, great inequalities remain betweenthe provinces, suggesting that, in the coming years,through an allocation of adequate funding, morestress should be put on expanding the network to thepoorest parts of the country. Priority should be givento the more remote rural areas, and particularlyZambézia, Nampula, Niassa, Cabo Delgado andInhambane, which have been identified as the worstserved provinces.Over the next five years (2005-2010), it is essentialto ensure that 15% of the State Budget is directedto the health sector, in line with the promise givenby the government in the Abuja Declaration (2000).The sector should also establish mechanisms toimprove financial management and thus improveefficiency in the use of resources. Finally, it is importantto develop sustainable and community-basedfinancing mechanisms (including pre-paymentschemes for health care provided above the primarylevel), which can have a significant impact on thequality of services, and on the incentives to seekhealth services.Given the context of the significant shortage ofresources that the country faces, and consideringthe persistent inequalities, together with the difficultiesinherent to implementing poverty-sensitivestrategies, the main challenges for this sector arethe following:• to review the criteria for allocation of resources,in order to guarantee that adequate resourcesare directed to the poor;• to expand and improve the implementation ofpriority programmes, so as to reach the pooreststrata;63


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007• to develop community participation schemes;• to improve dialogue with other sectors;• to develop knowledge and increase its useassociated with the adoption of appropriatetechnologies;• to reduce the financial and non-financialbarriers to using the health services;• to promote and develop sustainable financingmechanisms, including pre-payment systems.Consideration should be given to the implicationsof an anti-AIDS programme with a strong ARVcomponent for the future funding needs of the sector.For the first time in Mozambique, the health sectormust face exponential costs with a health programme—the programme’s success in the number ofpatients on ART means an undertaking to keep up thetreatment for an indefinite period.The risk of committing an excessive portion ofthe system’s resources for an activity with no foreseeableend should be faced in two ways.On one hand, the allocation for preventive andcurative interventions should be properly balanced,so as to reduce the future load by reducing the numberof new patients.On the other hand, gains in efficiency should beobtained by integrating the responses to HIV andAIDS into the regular functioning of the system(which will certainly imply a change in the way ofproviding health services), and directing the funds toactivities that benefit the system.Conclusions and recommendationsHIV and AIDS are officially recognized as a majorproblems on a “devastating scale” (PARPA II). It ispredicted that 800,000 Mozambicans will die of AIDSbetween 2004 and 2010. The target is to get 165,000adults onto anti-retroviral treatment by 2009. Ofthose infected, 57% are women. PARPA II notes inparticular the problem of poor women “who runextra risks because they are involved in sexual activitiesfor subsistence.”This report puts a strong emphasis on the needfor the Ministry of Health to greatly improve itscapacity for delivery of services. The first priority ofthe health sector should be to spend the money ithas been given; in 2004 the health sector spent only62% of its budget. And, as stressed in the PARPA IIdocument, the health coverage remains limited,with just 36% of the population living within 30minutes of a health facility. A new priority is toestablish health facilities in poorly serviced areasand especially in the poorly served provinces, toraise access to 45% by 2009.The national response to HIV and AIDS pandemicwill depend, to a large extent, on the success ofthis strategy, in which prevention is maintained as apriority, in parallel with increased access to ART andstronger prevention of parental transmission of thevirus that causes AIDS.For this strategy to succeed the following recommendationsmust be considered:• Continued reinforcement of the government’sstrong political commitment at the highest level,and of an efficient and systematic leadership,seeking to ensure the integration of HIV andAIDS into the strategic plans of all sectors,including the private sector and civil societyorganisations, in a multi-sector perspective,coordinated by the National AIDS Council(CNCS);• Continued promotion of voluntary testing andcounselling as the way to ensure the provision ofcare and support, and the reduction in stigmaand discrimination;• Continued expansion of access to anti-retroviraltreatment, under conditions of adequate technicaland medical safety, and with the minimumnutritional levels required of patients;• Implementation of an effective, knowledge-basedcommunications strategy, which is integratedinto the socio-cultural diversity of Mozambicancommunities;• Mitigation of the impact of the epidemic, byensuring programmes to protect and supportorphans and other children who are vulnerable,due to the diseases associated with AIDS, andexpanding the possibilities of preventing parentaltransmission of HIV;• Promotion of home and community-based care,and of social support systems.For the implementation of these recommendations,it is essential to follow strictly the objectiveslaid down by PARPA II in this area, includingstrengthening of the budgetary provision. In orderfor the National AIDS Council to fully perform itstasks as the body coordinating the multi-sectoralresponse strategy, its authority, powers and resourcesmust also be strengthened.64


Planning for the Future: The Window of HopeBox 8.1This is the last speech I shall make at any of theseinternational conferences in my role as <strong>United</strong>Nations Special Envoy on AIDS.* I’m pleased that thishas been a good conference, covering an extraordinaryrange of ground, and I therefore feel confidentin asking you to join with me in giving force to theoft-repeated mantra: “Time to Deliver”.Of what would that meaning consist? Allow meto set out a number of items.Number 1: Abstinence. Only programmes don’twork. Ideological rigidity almost never works whenapplied to the human condition. Moreover, it’s anantiquated throwback to the conditionality of yesteryearto tell any government how to allocate itsmoney for prevention. That approach has a name: it’scalled neo-colonialism.Number 2: Circumcision, as a preventive intervention,should not be subject to bureaucratic contemplationforever. We have enough information now toknow that it is an intervention worth pursuing. Whatremains is a single-minded effort to get the word out,respect cultural sensitivities, and then for those whowant to proceed, make certain that we have welltrainedpersonnel to do the operating.Number 3: In the hierarchy of preventive measures,the Prevention of Mother To Child Transmission(PMTCT) is very near the top. It is a bitter indictmentthat so few HIV-positive pregnant women haveaccess to PMTCT. It is inexcusable that in Africa andother parts of the developing world we continue touse single-dose Nevirapine, rather than full tripletherapy during pregnancy, as we do in western countrieslike Canada. I ask: What kind of a world do welive in where the life of an African child or an Asianchild is worth so much less than the life of a Canadianchild?Number 4: It is now accepted as unassailable truththat people in treatment need nutritious food supplementsto maintain and tolerate their treatment.And yet, there is a growing clamour from PeopleLiving with AIDS that decent nutrition simply isn’tavailable, leaving them in a desperate predicament.The World Food Programme released a study at thisconference calculating the cost of food supplementationat 66 cents a day for an entire family; whatmadness is it that denies the World Food Programmethe necessary money?Stephen Lewis: “Time to Deliver”Number 5: One of the issues that received an insufficientairing at this conference is sexual violenceagainst women. Just a few months ago, I was visitingthe local hospital in Thika, Kenya, which housesthe one rape counselling centre in that part of thecountry. The rise in sexual violence has meant thatthere are over 30 reported cases every month, withmultiples of that number never of course reported.The phenomenon is by no means singularly African;we live in a world community where the depravityof sexual violence has run amok. And yet, we lackthe laws, the jurisprudence, and the enforcementthat would give to women even a modicum of protection.Number 6: There is an ongoing epidemic of childsexual abuse. The dynamic of abuse of children isoften different from that of the sexual abuse ofwomen; what is common to both is the terrifyingdanger of transmission. Children require differentinterventions. Alas, we are nowhere near the articulationof a response. In this instance, as in every suchinstance, children are relegated to the scrap heap ofsociety’s priorities, and have been so relegatedthroughout the 25 years of this pandemic.Number 7: It is impossible to talk about childrenwithout talking about orphans. And it is impossibleto understand how, in the year 2006, we still continueto fail to implement policies to address the torrent,the deluge of orphan children. Countries haveprogrammes of action; they languish unfunded. Oneof the most chilling pieces of statistical data is thefinding that only three to five per cent of orphansreceive any intervention of any form.Number 8: It is impossible to talk about orphanswithout talking about grandmothers. Who wouldever have imagined it would come to this? In Africa,the grandmothers are the unsung heroes of the continent:these extraordinary, resilient, courageouswomen, fighting through the inconsolable grief ofthe loss of their own adult children, becoming parentsagain in their fifties and sixties and seventiesand eighties. We need major social welfare programmesthat will recognize these essential caregivers’contributions to society as legitimate and difficultlabour, and offer the guarantee of sustainableincomes to the grandmothers of Africa; from food toschool fees to income generation, the answers mustbe found.65


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007Box 8.1 continuedNumber 9: In the midst of everything else, we mustcontinue to roll out treatment. I am worried by thenew figures. There were one million, three hundredthousand people in treatment at the end of 2005. Sixmonths later there are one million, six hundred andfifty thousand in treatment. Treatment is keepingpeople alive; treatment is bringing hope; treatment isstimulating prevention.Number 10: Unbeknownst to many, we are on thecusp of a huge financial crisis in response to the pandemic.I think we have been lulled into a damagingfalse security by the fact that we jumped from roughlyUS$300 million a year from all sources in the late1990s, to US$18 billion in 2007 and US$22 billion in2008. Projections indicate the need for US$30 billionin 2010, from the moment of universal access totreatment. The financial promises made at the G8Summit in Gleneagles in 2005 are already unraveling.We will never accumulate the extra US$25 billion forAfrica by 2010 as was committed.* These are selected extracts from remarks by the UN Special Envoy on AIDS, Stephen Lewis, at the closing ceremony of the 16thInternational AIDS Conference in Toronto, Canada, on 18 August 2006.66


Technical NotesTechnical Note 1Calculating the <strong>Human</strong> <strong>Development</strong> Indexdisaggregated by Provinces and RegionsOne of the innovations of Mozambique’s National <strong>Human</strong><strong>Development</strong> Report (NHDR) is the presentation of the <strong>Human</strong><strong>Development</strong> Index (HDI) disaggregated by provinces andregions. A fundamental step for this innovation is the disaggregationof the Gross Domestic Product (GDP) by provinces andregions at both current prices and constant prices.This technical note describes in terms of national accountsthe methodology used to break down the Gross Value Added(GVA) from 2000 to 2005 by provinces and regions and howthis indicator is adjusted to arrive at the concept of the GDP. Thematerial takes up and updates the methodologies for disaggregatingthe national GVA by provinces and regions described inthe previous NHDRs.Principles and Methods of RegionalisationThis section explores the general principles used in disaggregatingthe GDP produced by the INE’s Department of NationalAccounts by provinces and regions. Thus we start by definingthe concept of Regional Accounts and regional territory, andthen establish rules for the provincial/regional breakdown ofthe GDP.In an initial approach, the regional/provincial accountsconsist of the regionalised registration of operations concerningthe flow of goods and services between the residents of aregion/province, and make possible the construction of a seriesof macro-economic indicators that facilitate comparisons ofstructure and evolving analyses of different regions. Thus eachregion is treated as a specific economic entity. However, thisundertaking runs into some serious conceptual obstacles, particularlythe fact that the regional territory is not a “closed area”from the point of view of its economy; that is, the completedescription of the economy of each region/province cannot beobtained with the same depth or breadth as a national economy,given the multiplicity of statistical restrictions on deeper knowledgeof regional or provincial activities.Like the national accounts, the regional accounts are governedby the principle of residency, according to which eacheconomic or productive unit is allocated to a particular economicterritory in relation to which it has a centre of economicinterest. Thus the application of the principle of residency, as ageneral principle, in the regional/provincial accounts by area ofactivity means that the Gross Value Added should be allocatedwhere the production unit resides. In the case of households,since they are single-region institutional units, it is consideredthat their centre of economic interest is in the region where themajority of their activities take place, which corresponds to theregion where they live, but not necessarily the region where theywork.Delimiting the regional economy rests on the functionalperspective, that is, the technical economic unit of reference isthe establishment whose activity in the region where it is locatedit is intended to capture. Since the establishment is the unitwhich best represents regional activity, it is also here that onefinds the greatest constraints on constructing an accounting systemidentical to that used for the national accounts, since theestablishment, unlike the company, does not possess legal status,and has no autonomous accounting. This fact makes it difficultto individualise an important part of the flows supportingthe production of regional accounts (IGBE, 1999).Methods of RegionalisationThe regionalisation of operations varies since it is determinedby the type of data available, and on the organisation of theNational Statistical System itself. According to IBG (1999) andEurostat (1995), in general there are three methods of regionalisation:• The Ascending Method, which presupposes the collectionand treatment of the elementary statistical units, taking intoconsideration local level units of economic activity (establishments)and institutional units (households and publicadministrations) and gradually adding them together untilreaching the desired regional level. This method, although itensures the use of statistical data strictly linked to the variablesthat it is intended to measure at regional level, doesnot guarantee a priori consistency with national figures.• The Descending Method consists of disaggregation of thenational product on the basis of a regional indicator resultingin the use of apportioning units, i.e. it functions by ref-67


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007erence to a regional indicator that is as close as possible tothe variable to be estimated. The method is called descendingbecause the aggregate is allotted to a region and a yearon the basis of a local or regional unit of economic activity.However, the notion of unit of local economic activity, inmost cases, continues to require an accurate regional allocation.For example, the Gross Value Added of rail transportcan be allocated to regions according to the number of passengersand aggregate tonnage transported. This methodhas advantages over the previous one because of guaranteesthat the national figures and the regional figures are consistent,since the latter result from a division of the nationaltotal based on a distribution key – but it has disadvantagesin that the regional valuations do not always result from datadirectly linked to the variables to be measured and the basicunits in question. But this disadvantage can be less seriousif the distribution indicator is correlated with the operationin question.• The Mixed Method, which consists in using simultaneouslythe ascending and descending methods, since the ascendingmethod is rarely found in its pure form. There are alwaysgaps in the data which have to be filled by using thedescending approach. Similarly many descending methodsfrequently include data from exhaustive sources, as doascending estimates. Thus mixed methods are the norm,and their degree of reliability depends above all on the availablestatistical sources.In this work, priority has been given to the descendingmethod, where the main regional aggregate is a replica of thefollowing aggregates in the national accounts: Production,Gross Value Added and the Gross Domestic Product (GDP), inthe perspective that the resulting estimates reflect the NationalAccounts produced by the National Statistics Institute (INE).One advantage of this method is the numerical coherencebetween the national accounts and the regional ones, i.e. itguarantees that the national figures and the regional figures areconsistent, knowing that the latter result from a division of thenational total based on a distribution key. This method is cheaperto develop in that its uses existing data, and does not requirenew exhaustive records. It is the method most recommended insituations where there is no information from the units of localeconomic activity.Sources of DataTo regionalise most of the operations, priority was given to thesources and statistical indicators from the provinces/regions,while simultaneously verifying whether they admit the possibilityof certain operations being multi-regional. In cases where thequality of the data was mediocre or unsatisfactory, or because itsimply did not exist and hence for a particular operation it wasnot possible to use sources or indicators based on place of residence,the regional allocation of production was undertakenon the basis of estimates and approximations resting on empiricalknowledge of the reality of the provinces.Thus for the operations of allocating production and GrossAdded Value where adjustments were made to reach the conceptof regional/provincial GDP, the main statistical sourceswere the balance sheets for 143 products drawn up by the INE’sDepartment of National Accounts, the State Budget, theProvincial Statistical Yearbooks, the data from the Early WarningSystem, the data from surveys and censuses (IAF, QUIBB, CAP,TIA, IAF, RGPH, etc.), accompanied by estimates and approximationsresting on empirical knowledge of the reality of theprovinces.For agricultural products, the annual data from the EarlyWarning System was used, which provides estimates of productionand cultivated area by province for seven major crops(unhusked rice, maize, sorghum, beans, fresh cassava, groundnutsand millet). It is estimated that, taken together, these cropsaccount for about 75% of agricultural production (IAF96).Apart from the data from the Early Warning System, the provincialyearbooks have information on other crops. For theremaining agricultural produce, for which there is no detailedprovincial/regional information, the authors took the populationgrowth rate, on the assumption that, when the market issaturated and there is no possibility of exports, productionbecomes stabilised at the size of the market, and its growth, inthe case of perishable products, in the absence of other distortingfactors, approaches the population growth rate.For livestock produce, the data from the Agricultural andLivestock Census held by the INE in 1999- 2000 was used. Thisinformation is updated by using data on livestock inventories byprovince, and by category and species, providing data on cattle,goats, pigs and other species.For the fisheries, mining and commercial services sectors,the allocation of production to provinces was based on thenumber of people employed in the respective economic activity,in accordance with the results from IAF 2002/03 and the projectionsfrom the 1997 Population Census.For the industry and construction sectors, the allocationwas based not only on the number of people employed in therespective economic activity, but also on estimates and approximationsresting on empirical knowledge of the reality of theprovinces. For example, allocation of production in the constructionsector paid a great deal of attention to Maputo andInhambane provinces which in the last four years have benefitedfrom large investments in manufacturing industry and inmining respectively.For electricity, both the amount generated and the amountinvoiced by provinces, and included in the EDM annual reports,68


Technical NotesConclusionsIn this work, the Descending Method has been used to disaggregatethe 2000-2005 GDP by provinces and regions. For sourcesof data, the authors used the balance sheets, the ProvincialStatistical Yearbooks, data from the Early Warning System, aswell as the data from surveys and censuses (IAF, QUIBB, CAP,TIA, IAF, RGPH, etc.), accompanied by estimates and approximationsbased on empirical knowledge of the reality of theprovinces to disaggregate production and Gross Value Added byprovinces/region and produce estimates of the GDP from theperspective that the resulting estimates would mirror the nationalaccounts compiled and published by the INE.Based on these assumptions, first distribution keys wereconstructed based on the balance sheets of the nationalaccounts formed by a sample of 143 products. Based on the diswereused. The application of the principle of residence accordingto which production of Gross Value Added should be allocatedwhere the unit of production is resident allowed the productionof HCB to be entirely allocated to Tete province. Fromthe production point of view, for piped water services, the referencedata come from the water companies in each province.This information was complemented by the IAF data registeringexpenditure on water that is not piped. This value is updatedannually by the population growth rate, on the assumption thatthe service bears a direct relation to the number of people whoneed these services.For most activities in the tertiary sector (trade, banking andinsurance, and real estate services), although they have a hugeweight in the national economy, 1 they are the least known partof the regional estimates. In many countries, the methodologyused for estimating even the national Gross Value Added of thissector is not very good. In this work, recognizing the poor qualityof the data or this sector, the allocation of operations wasbased on the number of people employed in the service sector.For restaurants and hotels, production was allocatedaccording to the guest-nights in hotel establishments, as registeredin the provincial yearbooks. This criterion is more consistentwith that used by the INE’s Department of National Accountsin calculating quantitative indices for the sector.The distribution of production in the transport and communicationssector was based on an index combining statistics ofthe number of vehicles, cargo handled in the ports, passengerstransported, and telephone coverage.Finally, for the public administration and defence services,and for health and education services, the authors used theexpenditure in the State Budget, and number of health staff andschool attendance respectively.Disaggregation/Regionalisation of OperationsTo allocate production to provinces, the reference point takenwas the balance sheets for each year drawn up by the INE’sDepartment of National Accounts for each of the 143 products,on the assumption that the sum of the production of all of theprovinces should be approximately equal to the value of productionon the balance sheets.As the main rule, the regional data with provincial detail isused to estimate the relative participation of each region in thenational sum by areas by variables. This establishes a key of distributionby province. However, it is not possible for all areas toobtain regional information for all variables. Hence alternativemethods are used so as to obtain better estimates for the variablein question. This implies, in practice, that the same regionaldistribution can be applied both for production and for valuein the various fields of activity at the most detailed level. Thusthe technical coefficient of intermediate consumption isassumed, that is, the ratio between production and intermediateconsumption is the same in all regions. This hypothesis,although difficult to confirm, cannot be avoided as a result ofthe methodology used in this study.Adjustment of the Provincial ValuesFrom the conceptual point of view, it was not possible to establishan objective criterion for a provincial allocation of customsduties and services of indirectly measured financial intermediation(SIFIM). Arising from the difficulties in obtaining indicatorsto share out the customs duties and SIFIM by provinces, the distributionwas done proportionately to each province. Thisadjustment made it possible to reach the concept of the GDP.Quality and Precision of the EstimatesThe precision and quality of the estimates presented heredepend on the type of methodology applied, but above all on thequality of the data, a factor which is beyond our control, andnecessarily involves improving the provincial statistical information.In general, the regional/provincial data are less exact thanthe national data, because they are based on smaller samples,and on data bases of inferior quality.The national economy has a strong identity: the nationalfrontiers are fixed and cross-border flows (of people, goods,services and financial assets) are habitually measured, or areeven regulated. The regional economy is much more open: theregional/provincial boundaries vary from time to time, and theflows between regions/provinces are so common that they arerarely regulated or measured. Even so, based on the availabledata and the criteria we have defined, it has been possible topresent an estimate that we believe reflects what is really happeningin the Mozambican economy.1 As a whole, the tertiary sector accounted for 48% of the GDP in 200469


Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007tribution keys, proportional allocation of the national sums wasmade for each field of activity and by provinces/regions. Arisingfrom the difficulties of obtaining indicators for sharing out customsduties and SIFIM by provinces, the national values of theseoperations were allocated proportionately to the Gross ValueAdded of each province. This adjustment made it possible toreach the concept of the Gross Domestic Product of theprovince or region.The precision and quality of the estimates presented heredepend on the type of methodology applied, but above all on thequality of the data, a factor which is beyond our control, andnecessarily involves improving the provincial statistical information.Even so, based on the available data and the criteria wehave defined, it has been possible to present an estimate that webelieve reflects what is really happening in the Mozambicaneconomy.Technical Note IICalculating the <strong>Human</strong> <strong>Development</strong> Index (HDI)The HDI is based on three indicators: longevity, as measured bylife expectancy at birth; educational attainment, as measured bya combination of adult literacy (two-thirds weight) and thecombined gross primary, secondary, and tertiary enrolment rate(one third weight); and standard of living, as measured by realper capita GDP (in PPP $).To calculate the HDI, the parameters used are derivedstrictly from the methodology of the Global <strong>Human</strong><strong>Development</strong> <strong>Reports</strong>, which fix for each of the indicators of theHDI, the following minimum and maximum values:• Life expectancy at birth: 25 years and 85 years;• Adult literacy: 0% and 100%;• Combined gross enrolment rate: 0% and 100%;• Real per capita GDP (PPP $): $100 and $40,000.Thus, the results obtained are comparable with the indicatorsof other countries and to the figures published in theGHDRs, diverging only in the sources of the data used. However,since it makes no sense to use a per capita GDP in PPP dollarsto compare the level of human development between regionswithin Mozambique, the minimum and maximum values of theGHDRs were converted into Meticais based on the PPP dollarcon<strong>version</strong> rate, and then applying a deflator allowing comparisonsbetween years along a series under analysis.Based on these fixed minimum and maximum values, theindices for life expectancy and educational attainments werecalculated according to the following general formula:Index =Actual x i value – minimum x iMaximum x i value – minimum x ivaluevalueTaking as an example Mozambique’s life expectancy at birth(43.3 years), the adult literacy rate (43.3) and the combinedgross primary, secondary and tertiary enrolment rate (31.6), allfor the year 2000, then the life expectancy index (I LE ) and theeducational attainment index (I EA ) for this year would be:43.3 31.62* +44.3 – 25 100 100ILE = = 0.322 IEA = = 0.39485 – 25Constructing the income index (Iy) is a little more complex,and it is not the aim of this technical note to present the detailsof how it is built. But we can summarise the construction of theincome index by using the following formula:Log (y actual) – Log (y minimum)Iy =Log (y maximum) – Log (y minimum)Taking as an example the real per capita GDP in PPC dollarsof 2000 (996.3), we can calculate the corresponding index inthe following way:Log (996.3) – Log (100)Iy = = 0.384Log (40000) – Log (100)Once the indices for life expectancy, educational attainmentand income have been obtained, the HDI is calculated as a simpleaverage of the three indices.0.322 + 0.394 + 0.384HDI = = 0.3663Technical Note IIICalculating the Gender-adjusted<strong>Development</strong> Index (GDI)Calculating the GDI is based on the same variables as the HDI,with the difference that the GDI adjusts the average achievementin life expectancy, educational attainment and income in accordancewith the disparity in achievement between women andmen. In other words, the GDI is the HDI adjusted to takeaccount of sexual inequality.In this study the weighting formula was set at ?=2, takenfrom UNDP (2004) which expresses a moderate a<strong>version</strong> toinequality. 2 As in the HDI, in constructing the GDI the following70


Technical Notesmaximum and minimum values were established, taken from When data on the wage ratio are not available, as is the casethe GHDRs:in Mozambique, the same document suggests an estimate ofLife expectancy at birth: Maximum 82.5 e 87.5 years for 75%, the weighted average of the wage ratios for countries withmen and women respectively: Minimum 22.5 and 27.5 years for wage data out of the series of countries included in the study, ofmen and women respectively. The difference reflects the fact which Mozambique was part. This value means that, on average,that women tend to live longer than men, given the same care the wages of women are 25% lower than those of men.(medical care, nutrition etc.)The same maximum and minimum values as used in calculatingthe HDI were maintained for the Adult Literacy Rate, the try (Y) is divided between men and women in accordance withIt is then assumed that the total GDP (PPP US$) of a coun-Combined Gross Enrolment Rate, and real per capita GDP, as the female share of earned income. Formally,well as the formula for calculating the individual indices.However, to allow comparability of the administrative regions Total GDP (PPP US$) going to women = S f x (Total GDPwithin Mozambique, the minimum and maximum values were PPP$ of the country)converted into nominal meticais, based on the PPC con<strong>version</strong>rate, and then applying a deflator that allows comparability Total GDP (PPP US$) going to men = Total GDP PPP$ of thebetween years along a series under analysis.country x (1 – S f )The equally distributed life expectancy index is given The per capita GDP (in PPP US$) of (y f ) and of men (y m ) isby:obtained by division by the female and male population of thecountry.{Female population share x (Female life expectancy index) (1-?) +male population share x (Male life expectancy index) (1-?) } (1-?) The adjusted income both for women W (y f ) and for men W(y m ) is dealt with in the same way as in the construction of theLikewise, the equally distributed educational index is HDI:given by:Log (y f ) – Log (y minimum){Female population share x (educational attainment index) (1-?) + W(y f ) =male population share x (educational attainment index) (1-?) } (1-?)Log (y maximum ) – Log (y minimum)&Income CalculationLog (y m ) – Log (y minimum)Values of real per capita GDP (PPP US$) for women and for W(y m ) =men, in an ideal situation, are calculated, following UNDPLog (y maximum ) – Log (y minimum)(2004:264) recommendations, from the female share (S f ) andmale share of earned income, using the ration between female The equally distributed income index is given by:non-agricultural wages (W f) and male non-agricultural wages(w m ) and the percentage shares of women (ea f ) and men (ea m ) {Female population share x [W (y f )] (1-?) + Male populationin the economically active population. Formally:share x [W (y m) ] (1-_) } (1-_)(W f / W m )* ea fFemale share of the wage bill =(W f / W m )* ea f + ea mAssuming that the female share of earned income is exactlyequal to the female share of the wage bill:(W f / W m )* ea fS f =(W f / W m)* ea f + ea m2 Expresses a moderate degree of inequality a<strong>version</strong> and is calculated as a constant average of the male and female values.71


72Mozambique National <strong>Human</strong> <strong>Development</strong> Report 2007


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Statistical Annex75

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