Redefining Rural Healthcare: Mozambique’s Scalable Model for Global Health Gaps

Mozambique, once emblematic of fragile healthcare systems in sub-Saharan Africa, has achieved a remarkable transformation in primary healthcare delivery, thanks to a strategic and well-financed reform initiative. Supported by the World Bank, Canada, the Netherlands, USAID, and the UK, with crucial technical guidance from the Ministry of Health and Mozambique’s National Institute of Health, the Mozambique Primary Health Care Strengthening Program was launched in 2018. Over $200 million in funding fueled this effort, designed to fix a system plagued by poor outcomes, limited access, and workforce shortages. Central to the intervention was the scaling up of community health workers (CHWs), who form the crucial first line of care in underserved areas. The number of CHWs more than doubled, from 3,380 in 2018 to 8,300 in 2022. These workers expanded healthcare access to 3.6 million households, up from just 1.7 million, and played a critical role in ensuring nearly 6 million skilled deliveries at birth between 2017 and 2022. Their work catalyzed broader community health improvements, including increased reproductive health awareness and disease prevention.

A Crisis-Ridden Health Landscape

Before these interventions, Mozambique’s healthcare system faced dire challenges. Health outcomes were among the worst in the region, with 40 percent of children stunted and high levels of chronic malnutrition. The country had one of the world’s highest rates of child marriage and adolescent pregnancy, along with a neonatal mortality rate of 27.9 per 1,000 live births. Only half of births were attended by skilled professionals, and the overall disease burden was dominated by communicable and nutritional disorders, which accounted for 62 percent of all deaths, three times the global average. The crisis extended beyond infrastructure and reach. Clinical competence was low, adherence to treatment guidelines was weak, and essential services such as child immunization had disturbingly high dropout rates. The need for sweeping, system-level reform was unmistakable.

Performance-Based Financing Drives Results

To address these challenges, the World Bank introduced its innovative Program for Results financing model. This approach linked funding to measurable outcomes, thereby incentivizing efficient, targeted delivery of services. A prime example was the expansion of sexual and reproductive health services to secondary and technical schools. Performance scorecards were introduced in district hospitals, which earned additional resources upon meeting agreed-upon indicators. These accountability mechanisms increased transparency, drove institutional improvements, and aligned local and national goals toward measurable health impact. Crucially, the program didn't just focus on top-down targets. It prioritized people, the workers at the frontline, by boosting their capabilities and improving the conditions in which they operated.

Empowering Community Health Workers

The linchpin of this reform was the empowerment and professionalization of community health workers. Previously overlooked and poorly supported, CHWs became central agents of change under the new program. They were trained in basic clinical care, health promotion, and digital data reporting. Their roles were formalized with salaries and career progression frameworks, helping to address chronic issues of worker attrition and low motivation. This shift was particularly impactful in rural districts, where access to formal health facilities was either cost-prohibitive or logistically impossible. Residents who once walked hours for medical attention or paid heavily for transport could now rely on a local health worker to visit their home and provide basic services, referrals, or critical information on maternal and child care.

Adapting in the Face of Adversity

The reform program’s resilience was tested by a series of national and global shocks. In 2019, Mozambique was struck by two devastating cyclones. Soon after came the COVID-19 pandemic, and simultaneously, conflict escalated in the country’s northern provinces. Each crisis demanded adaptive responses. The program was restructured multiple times, proving agile in reorienting funds and operations. A key takeaway was the importance of decentralization. By directing funding to the lowest administrative levels, the government enabled district-level authorities to manage budgets, reallocate resources, and respond to on-the-ground realities more effectively. This approach is now foundational to a follow-up program launched in March 2024, which strengthens district-level governance and prioritizes community-based care.

A Scalable Model for Global Health

Looking forward, Mozambique's reforms are being used as a springboard for deeper systemic changes. These include modernizing the health supply chain through digital track-and-trace systems and establishing fixed import pricing for essential medical commodities. But perhaps most significantly, Mozambique has created a replicable model for other low-income and fragile countries. With a projected global shortfall of 18 million healthcare workers by 2030, Mozambique’s CHW-driven approach could be vital in closing this gap. Its success shows that even in resource-constrained settings, well-structured programs with community-centered strategies and accountability mechanisms can deliver transformative results. Mozambique's journey stands as a testament to what can be achieved when political will, international cooperation, and grassroots empowerment converge to improve public health.