Actor power refers not only to the leadership of individuals involved in policy making or related processes, but also how cohesive the policy community is with the backing of guiding institutions or networks [15]. Under actor power, the mobilization of civil society in order to advocate at all key levels of influence is crucial.
The policy community could be seen as cohesive in that a few leading experts in Mozambique agreed on both the challenges of NCDs in Mozambique and the possible response. That said two challenges existed with regards to the policy community. Firstly, this was a limited set of individuals who despite their standing were unable to expand the cohesion beyond themselves to higher echelons in the MoH, other governmental institutions or donors.
The little that was done at that time was because of [the NCD head of department]’s noise. So you must have fibre to continue fighting. This was her fight - KI-1
The lack of leadership was clearly illustrated by one respondent, who compared Mozambique to Tanzania, an equally low-resourced country but seemingly more responsive to NCDs.
You know, Tanzania had only 2 or 3 champions there... They made a lot of work with a lot of impact. They do everything. They do research. They do policy influence. They do everything in Tanzania. You go there, they did not have money. They have the exact same situation as we have. Now, in Tanzania, you go to a health facility ...they do glucose to everyone... What did they do differently? It's because they had champions and drivers, no more than that - KI-2
The other issue was the possible focus of this group on clinical aspects, as many of them were clinicians, versus more public health interventions. In addition, although the NCD Strategy developed in 2007 [16] was integrated in its cross-cutting approaches to addressing different NCDs external support and funding was mainly focused on CVD and diabetes.
Interviewees clearly distinguished two periods in terms of leadership on the NCD agenda with the “early” years having strong technical leadership within the Ministry of Health supported by external expertise both from Mozambique and abroad. However, they stated that currently there was a lack of leadership. Some factors leading to the currently limited number of NCD champions in the country were described by the interviewees. First, there is the perception that the eminent, highly experienced NCD professionals previously playing an active role on the agenda had switched their focus to their own agendas mostly in the field of research, academia and health care provision. Second, the drivers for the creation and maintenance of new champions had shifted, meaning that what motivated professionals of older generations no longer motivated current ones.
Some of these champions are already getting retired, one of them….that one is still going on to play different rounds at the same time, so I don't see him as a champion in noncommunicable diseases… To find them today it's very difficult…– KI-5
Financial constraints were also highlighted as a reason for a lack of leadership. Due to the state’s lack of capacity to provide adequate salaries to its staff, retention is difficult. One respondent depicted this current situation by comparing it with the past, when professionals were motivated by the cause, not the money.
When you have money, you have champions. Money has decided everything. No more champions if you don't pay them. - KI-2
The MoH was seen as the main guiding institution by all KIs. On one hand, it was viewed as the entity that missed several opportunities to champion the needed drive to push NCDs into the national agenda, and on the other hand it was also seen as the central actor who could generate such a drive.
Interviewer: What opportunities do you see in the future for the improvement of… [NCD prioritization]?
Interviewee: What do I see? Health champions within the Ministry of Health. Health champions everywhere. – KI-3
It all boils down to political will…you may lack everything, including funding, but if there is no political will then you will not even get the funding you need. – KI-1
Within the MoH the NCD Department created in 2002, was responsible for the development and implementation of the NCD strategy [16]. However, this Division was not seen as powerful enough. The actions of this Division were limited and somewhat “underground”, as they were constantly feeling the lack of backing from higher level actors on the Government side, often with opposing ideas with regards to whether and how to prioritize NCDs among the numerous challenges faced by the health system.
We couldn´t do much more because we had no support, the department had only two persons, but we had no space to make structural decisions. If it [the department] was a national directorate perhaps we would have been able to do much more – KI-4
The absence of the much needed patronage of MoH as an institution was revealed through respondents’ recollections on missed opportunities to use their potential power to advocate for the prioritization of NCDs:
Imagine you are at a Coordination Board meeting [top-level planning annual meeting meetings chaired by the minister], and you have managed to include your hypertension topic in the agenda. Suddenly, they decide to cut the topics because time is running and different sectors still haven’t talked…the first topic that they cut is your [hypertension] topic! And then you think that you have to fight harder, alone – KI-1
In addition as highlighted by one of the respondents policy makers lack commitment to prioritise NCDs due to their perception that the typical time period of strategic documents did not allow to set and fulfil NCD targets.
Noncommunicable diseases are difficult to control. The time horizon of the five-year plans is short. It is not right for the Ministry to say that it did not meet the NCD targets because there are no immediate results for NCDs. Politicians change every 5 years, some stay but the momentum is lost – KI-5
Despite the very small number of actors within the MoH, and their low sense of self-efficacy, they had strong links with actors outside the MoH, both nationally and internationally. This included for example the WHO, World Diabetes Foundation (WDF), International Insulin Foundation (IIF) or Diabetes UK [17–19]. Such international links were also present for CVD and to a certain extent for cervical cancer through work with the US Centres for Disease Control. This was especially true during the initial phase of the NCD policy context in Mozambique.
WHO also played an important role throughout the NCD process in Mozambique, with beyond the technical support some fortuitous elements that enabled Mozambique to move forward with the NCD agenda. As stated in the quote below, the absence of a language barrier, which is usually a factor that hinders the international networking potential of Mozambican leaders, had an important role to play.
We had a lot of support from the regional representative of NCDs [at WHO] in Africa, since he was Angolan and we [Mozambique] were the only African Lusophone country represented. - KI-4
Civil society mobilisation around the overall issues of NCDs in Mozambique can be seen as lacking. That said non-governmental organizations especially in the area of CVD and diabetes were present in the overall environment. For CVD much of this was led by the professional association. Regarding the role of this association there was a certain disconnect and lack of inclusiveness by the MoH, but also members of this association themselves did not necessarily expecting to be involved in policy-making.
What we do, [is that] we're not much involved in policy – KI-6
For diabetes the National Association for Diabetes (AMODIA) had been active in the area of diabetes and provision of care. Through AMODIA external links had been established through their involvement in carrying out the Rapid Assessment Protocol for Insulin Access (RAPIA) with international partners, the IIF and financial support from the WDF [18, 20]. This work resulted in additional funding and a Twinning project [19] which further supported the development of the National NCD Action Plan and also resulted in the second RAPIA as a joint effort between the MoH, AMODIA and IIF [17, 21].
Ideas
Ideas in Shiffman and Smith [15] framework refer to how the heath problem attracts attention through the way it is described, which in turn depends on how easy it is to convey the problem and solutions. In Mozambique three disconnects can be seen with regards to the ideas component. Firstly, the overarching language used in certain key government documents starting with the Constitution and the Social Protection Law, which consistently highlight, among several fundamental principles, universality, equality and inclusiveness. Statements such as "...all citizens shall have the right to medical and health care, in accordance with the law, as well as the duty to promote and defend public health...", suggest that the State views health care delivery as a basic right and their duty from the outset. However, in practice this is not the case due to donor priorities, a weak health system reliant on external support as well as the verticalization of responses. Examining the contents of government strategic documents (Table 1) which have as their role to operationalise the overall vision of the government, it is clear that there is still dominance of CDs, such as, malaria, TB, HIV/AIDS, leprosy, and cholera, with little or no mention of NCDs. This is evident, for example, in the 2025 Government Agenda (launched in 2003), which is highly influential in the definition of policies, programs, and even funding priorities, but does not include NCDs.
The next disconnect is within the sphere of policy makers, public health and healthcare providers and their views on the issue of NCDs in Mozambique and the required response. For policy makers, especially those outside of the MoH, the challenge of NCDs is a lack of true understanding of the issue, as highlighted by one KI.
The problem is still in Africa. It's still here. Politicians, government officials, they don't really understand what does it [NCDs] mean. Although, the majority of them they have diabetes and high blood pressure, but they are not treated, most of them, here. They will go and be treated in the UK, whatever, Denmark, Sweden. They go there and they have very good medicine, so they are not worried. They think they are the only ones that have it. – KI-2
Included in the National Strategic Plan for Prevention and Control of NCDs (2008–2014) [16], is a focus on the common risk factors for NCDs and the need for awareness raising as a driving force to convey the health problem to the public’s attention. The strategies proposed take a public health approach to NCDs, with a focus in the Strategy on using IEC strategies to raise awareness and change community behaviours related to the risk factors, as well as health professionals’ attitudes and practices. However, practitioners tend to focus on diagnosis, appropriate management, and complications and mortality prevention, which they verbalise as being highly problematic at all levels of care. Linked to this misalignment regarding perceived solutions to NCDs, some respondents felt that there is a lack of communication between the NCD department and the National Directorate of Medical Assistance and its respective programs and departments.
Myself, as an NCD [person] I work mostly with the Nutrition [department] and Sports Medicine. Why do I have a relationship [with them]? Because when we talk about noncommunicable [diseases] we talk about diet, lifestyles, physical activity, so it is more related to…for example if I talk about hypertension, I talk about salt consumption, therefore I have to enter into nutrition…find out if they are doing something that requires population education so that they decrease salt consumption. – KI-7
Despite this mismatch of ideas between the different actors, a common view is shared among them which is that, there, is a poor translation and demonstration that NCDs are threatening the health and well-being of the Mozambican population, therefore the gap between CD and NCD priorities is unacceptably high.
Finally, the last disconnect is with the overall perceptions of NCDs in a context like Mozambique, where due to the chronic nature of most NCDs these are not perceived to be threatening compared to other diseases leading to more visible morbidity and mortality.
Hypertension doesn't kill us immediately. Malaria will kill…five days and you are dead. Hypertension will kill afterward, the patient suddenly dies or the patient suddenly has a stroke. There's no knowledge between a stroke [linking hypertension and stroke] ... for the general population, stroke is for disabled people related to the act of a very strong traditional doctor. I talk to someone, I don't like you and I want to give you some force and it immobilizes you. It's not because of any disease… - KI-6
The above quote further reveals that the ideas about NCDs were not disseminated with enough strength and consistency, as compared for example to information about malaria, which is a disease about which people, including the general public, have no doubt in regard to its potential fatality.
The lack of knowledge on NCDs among different segments of society, including policy makers, comes from the history of weak existing evidence on the magnitude and impact of NCDs in Mozambique, which in the view of some respondents is obfuscated by the overly disseminated information about CDs, and in the view of others is due to the national health system´s inability to generate reliable routine data on NCDs.
So far, diabetes is still a name which is different from HIV, from malaria, from accidents. People, they understand what this is, they have lived with it. Diabetes... although the numbers show that it is the biggest catastrophe that we might have in the world ... our politicians, some of them professional that are there dealing with patients, they don't understand the state at which diabetes is now, and start [being] active when it is too late. No one understands… It's complications and impact in the future. I don't blame them. Everyday they're talking about seven million cases of malaria, and they think, yeah, seven million ... and malaria kills immediately, and all those things. For them, some of these infectious diseases are still in their mind as their major priority. – KI-2
Political contexts
Context comprises the environment where the actors navigate but also their awareness of the features and changes in such environment and abilities to detect cues to action based on opportunities from which to take advantage of to influence other key actors [15].
There is no doubt that Mozambique had many “policy windows”, be it from the global, regional or national perspective. From a historical perspective the first policy window was a shift in the political environment at regional level in 2002, which drove subsequent inclusion of NCDs in national action plans in the African Region. Policy windows also existed through the implementation of different studies. For example the implementation of the STEPwise Approach to Chronic Disease Risk Factor Surveillance) studies were key contextual driver [12].
In 2002 or 2003…it was the first time that, me and another doctor ... We were invited to go to Cape Town, and we were trained for STEPS-1... It was supposed to start with an evaluation of non-communicable disease risk factors. We did a pilot just to see what would be our capacity to do this all over the country. When the summary results came out, we said "Look, we can do this, you know?". – KI-4
The results from the Mozambique study were some of the most comprehensive in the WHO African Region [22–28] and provided much needed data on the challenge of NCDs in Mozambique. The RAPIA in 2003 added to the overall knowledge of barriers to diabetes care and offered a policy window to highlight the challenges of diabetes management in Mozambique [18].
Of course the United Nations High-Level meeting in 2011 was also a policy window for Mozambique. However, not much was seen as a result of this meeting, as by 2011 the national action plan on NCDs had already been adopted, the NCD department had already been functioning for 8 years, and it was mostly a matter of implementing what was foreseen in the plan which was highly dependent on the national environment and funding.
The creation of the NCD Department within the MoH in 2003 was tangible evidence of the government´s commitment to this group of diseases and created the infrastructure for Mozambique to develop its NCD response. Some argued that this was mostly due to external pressure to have something visibly done about NCDs at national level. Therefore, despite this apparent commitment to NCDs, some respondents consider that the State’s response was and still is weak. Although the orientation to create the department was top-down, the department’s founding members seized this opportunity to establish a structure and what kept the department going was their capacity to take advantage of their outreach to the external context. In particular, the networks established with external collaborators.
This organisational structure was complemented by the following policy documents: The National Strategic Plan for Prevention and Control of NCDs (2008–2014) [16], which prioritises asthma, diabetes, and CVDs (including hypertension), and supports an integrated response to NCDs through awareness raising of NCDs and risk factors, improved access to and quality of services, training actions, strengthened surveillance, research, monitoring and evaluation systems. Although currently out-dated, this is the first document presenting clear indicators, yearly targets and responsibilities in regard to each of the proposed actions. The second document is the tobacco consumption and marketing regulatory document (2007) [29], which refers to the common risk factors for NCDs, and specifies CVDs. The concrete actions oriented by this document are framed from the commercial, rather than the health perspective, focusing on supply reduction, taxation, fixing of high prices to the consumer, and the prohibition of advertisement and sales to minors, with some importance given to awareness raising, assuming that these measures contribute to the attainment of health objectives. The final document is the regulation on the control of the production, marketing and consumption of alcoholic beverages (2013) [28], which addresses the response to alcohol consumption related health risk factors along similar lines as the tobacco regulatory document. While the first document is specific for the Health Sector, the latter two imply the engagement of not only the Health but also of at least the Industry and Commerce sectors, offering some room for intersectoral action. Remarkably, despite dating back to as early as 2007 and 2008, meaning that their conceptualization took place even earlier, they already referred to common risk factors to NCDs, in alignment with the global policies in terms of language and priorities. This shows the early reflection of Mozambique’s formal recognition of NCDs as public health issues, before these were firmly on the global agenda.
Among the Government strategies, the National Development Strategy (2015–2035) recognizes the chronically ill as a group requiring special attention [30]. However when it comes to data to support this statement, it is heavily linked to HIV/AIDS, evidenced by the lack of indicators related to NCDs. The Government´s five-year Action Plan (2014–2019) was the first to notably include NCDs either from the perspective of the diseases of this category in general, or from the stand point of risk factors [31]. However, the indicators seem to have a sports and political undertone rather than focused on health or NCDs, as they relate to the number of medals won in international competitions and the number of young beneficiaries of youth initiatives, whereas indicators of lack of physical activity as risk factor are disregarded. Moreover, the sole focus on the youth contradicts the efforts for streamlining the issue of equality expressed in all higher level policy and strategic documents [32].
Regarding health sector documents, the Strategic Health Sector Plan (PES) alludes to NCDs, with a focus on reducing the currently progressive trend of NCDs [33]. Among other important health sector-level documents, the Essential Medicines List (2010) [34] had some reference to NCDs, and the Health Promotion strategy (2015–2019) [35] recognized that NCDs, in particular CVD, cancer, diabetes and COPD, share four risk factors: tobacco consumption, excessive alcohol consumption, poor eating habits and lack of physical activity. This seems to be the first policy document actively aiming to encourage healthy life styles and well-being, directly linking these to the control of NCDs. Previous NCD policy documents had mostly focused on diagnosis and treatment of NCDs rather than preventive measures at community level, even though the local literature does not touch upon the most cost effective ways to tackle NCDs in the Mozambique context. The scattered mention of selected NCDs in policy documents seems to have resulted from political level (top-down) pressure to comply with the ratification of the SADC Protocol on Health [14], rather than a sector level initiative to address those concrete health problems, as evidenced by the very little concrete action on the ground, as a result of weak coordinated disease control efforts, compared to other health problems such as communicable diseases and maternal health. This impacted the political context with opportunities to address the NCD challenge in Mozambique and develop the first national NCD strategy.
Despite the pressure to act upon NCDs at national level, the NCD department had to go through lengthy efforts to advocate for the inclusion of NCDs in the National Health Policy. Indeed this policy was revised in that direction but the specific changes related to NCDs were not approved. Besides attempts to influence the National Health Policy, the NCD department engaged in policy making pertaining specific issues. A specific case was that of the salt regulatory document, which was never approved.
We started working on the salt issue. It was the NCD and the Nutrition department. The document was drafted, it was to adjust the quantities of salt in the bread. The NCD department exposed [to me] the problem and the Nutrition Department had to establish norms for public consumption foods. We approved the norm, but it was never discussed in the parliament. More important things had to happen at the time, therefore they [legislators] may put these things behind. - KI-3
Issue characteristics
The characteristics of the issue being addressed include the extent to which there are credible indicators that can be used to assess severity and to monitor progress and the size of the burden, as well as an evidence base on cost-effective interventions that can be implemented at scale [15].
Soon after its inception, the NCD department was clear about the need for data as a tool to increase the visibility of NCDs, and was very pro-active not only in influencing the generation of such data at national level, but also on the participation in research activities to obtain such data.
In 2004, we fought with the National Institute of Statistics to include two modules in the Health and Demographic Surveys. WHO gave us money…and for the first time in Africa we had a database with population level information on trauma and risk factors for NCDs.- KI-4
In parallel in 2003 the RAPIA provided an overview of the barriers to care for diabetes and an in-depth health systems analysis. This in turn was complemented by two rounds of the WHO STEPS surveys, the first one in 2005 [11], providing a comprehensive understanding of the burden of NCDs and associated risk factors in Mozambique. Although these studies served as a basis for the initial NCD Strategic Plan, the current leadership from the MoH do not feel ownership, and seem to be quite distanced from the results and recommendations. This is in contrast to WHO where the global NCD agenda and the local availability of data helped in furthering the NCD response in Mozambique.
It is because the scientific evidence, we work always on the bases of evidence, so when it became noticeable that NCDs were becoming a problem based on the evidence that WHO complied at the global level, and we had the mission to take this information to each member state – and this is what we did for Mozambique – KI-1
Despite this data on the specific NCD burden in a context like Mozambique all government documents and strategies as well as insight from the interviews show the predominance of the communicable disease agenda. Malaria, TB and HIV/AIDS are the leading causes of disease in the country, with around 9 million cases and over 10,000 deaths per year due to malaria [36], a TB incidence rate standing at 551 per 100 000 population [37], and an HIV prevalence among adults of 13% with 25% of deaths attributable to HIV/AIDS in 2017 [2, 38]. Yet, 32% of the total mortality is due to NCDs [1]. In contrasting the impact of this prioritisation one KI stated,
The HIV rooms in the health facilities had all the resources…the next door room had nothing… - KI-7
The core individuals involved in NCDs saw the problems clearly with one-third of the adult population being hypertensive, that diabetes prevalence was increasing, and that the double-burden of NCDs and communicable diseases is a reality, exacerbated by the increase in life expectancy.
The prevalence of hypertension and diabetes is increasing, therefore it is necessary for us to pay more attention also to these diseases though we know that we still have many cases of infectious diseases…at some point they will be at the same level!...and more…people are living longer [laughs] – KI-4
Many effective interventions exist for NCDs, including the WHO’s so called “Best Buys” [39] many of these included in the NCD National Strategic Plan. In the case of diabetes and hypertension, there are no disease-specific action plans or national strategies, as opposed to diseases such as cancer, HIV and malaria [40–42]. Instead there is dominance of norms, guidelines and training materials, the most prominent relating to case management: Standards for Diagnosis, Treatment and Control of Hypertension and Other Cardiovascular Risk Factors (2011), which targets specialists and PHC frontline health professionals [43] and the Diabetes Mellitus training module (2017), which seems to be a tool mainly used by Maputo Central Hospital’s health care providers [44]. No evidence was found on easy access to these materials by PHC providers although in both manuals the chronic diseases approach to primary health care is considered as a gold standard strategy. On the front of research and monitoring and evaluation there has been a significant number of initiatives focused on NCDs during the period under study, ranging from epidemiological research, risk factors assessments (diet, exercise, tobacco, alcohol), and health sector’s readiness studies [22–28, 45–47].
The main barrier to effective interventions being implemented are socio-economic factors which shape the governance structure in Mozambique where politicians constantly face the challenge to balance their decisions with the country’s financial constraints. The 2012 report on national expenditure on health revealed that the annual per capita expenditure on health was only about US$ 38, equivalent to 40% lower than the minimum standard recommended by WHO [48]. The budget for 2010 for the NCD Department at the Ministry of Health was US$ 97,000 [17]. In contrast in 2012, for example, HIV, tuberculosis, malaria and reproductive health represented, altogether, 40% of the current health expenditure [48] and there was still no specific budget to NCDs, being these diseases lumped together under “general MoH expenses”. From interviews with KIs resources to pursue initiatives regarding NCDs, lacked financial support.
Unfortunately, then it becomes difficult for us. We are thinking about the solution that everyone knows, but there is no money. I… seriously, since the beginning of the year I have not had a penny from the State Budget (…) - KI-7
(…) you have competing priorities, very scarce resources. […]What are the resources you have to deal with the disease pattern that is vast ... diverse? It's not a matter of political issue. You don't have enough resources to do it. It's not only financial resources. It's also qualified human resources ... enough numbers of human resources. - KI-2
Participants expressed that CD initiatives do not seem to be impacted by the financial difficulties faced by the entire health sector as well as not being open for collaboration.
Everything was HIV. So what we managed to implement that program was a cancer screening ... was cervical and breast cancer screening. Because in the documents, you wrote a lot of possibilities to work with HIV programs. – KI-7
Cancer has more funds because the majority of [HIV/AIDS] patients have pre-cancerous lesions. Us, the NCD people, exposed the case so that the HIV [program] would give more money for cervical cancer screening, and CDC eventually accepted. – KI-5
When I went to speak with the head of the HIV program, she said no, we have so many good works to do… Don't come around with high blood pressure…we have to go through a lot of things…It is a pity because...every month at least, these 700,000 people go through primary care to receive treatment, but they don't measure blood pressure there. – KI-6