Under USAID’s Health Policy Plus (HP+) project in Mozambique, ThinkWell collaborated with Mozambique’s MISAU (Ministry of Health) to design a sustainable financing mechanism for strengthened maternal, newborn, child, and adolescent health (RMNCAH) interventions and outcomes.


Access to quality RMNCAH services remains a challenge in Mozambique. As a result, the country experiences one of the highest maternal mortality rates in the world: 408 deaths per 100,000 live births. Additionally, infant mortality is 64 deaths per 1,000 live births and under-five mortality is at 97 deaths per 1,000 live births.

Those numbers are tied to the fact that only 55% of Mozambican women deliver at health facilities and facility-based deliveries vary widely between rural (44%) and urban (80%) areas and between those in the richest wealth quintile (89%) and poorest wealth quintile (31%).

Inequitable coverage of essential services and low quality of care have challenged progress towards improving RMNCAH outcomes. Furthermore, Mozambique’s health system is highly aid dependent and faces sustainable financing challenges; the health system isn’t fully responsive to clients’ needs; health sector resources are inefficiently targeted; evidence isn’t always available or best used to design interventions; and health workforce distribution and shortage issues weaken service delivery. All of this hinders efficient and equitable use of RMNCAH resources.


The government of Mozambique created an enabling environment to improve equitable, quality RMNCAH through increased, strengthened financing mechanisms. Specifically, the government prepared to transition into a Global Financing Facility (GFF) recipient. The GFF enables countries to get more results from their existing resources and to increase their total volume of financing.

To enable this transition, MISAU undertook a situation analysis of the country’s health financing system, developed ways to address financing gaps, and designed an operational plan for service delivery. MISAU also established a taskforce to drive the GFF process. At the same time, they leveraged an existing health sector coordinating platform to mobilize RMNCAH stakeholders, both domestic, international, and private sector.

Breaking New Ground

Building on Mozambique’s commitment to accelerate RMNCAH progress, ThinkWell developed a GFF investment case. The case focused on how prioritization of improved RMNCAH investments could increase service effectiveness, stimulate user demand, and enhance utilization and efficiency of referral services.

The investment case described evidence-based, high-impact interventions that equitably improve RMNCAH. The case also considered broader governance and development issues and investments that may have RMNCAH implications and how interventions can be responsive to those issues.

With the investment case as a building block, Mozambique moved towards receiving GFF funds in 2018. The case was used to inform the development of disbursement-linked indicators to facilitate the GFF’s provision of RMNCAH financing. As a next step, Mozambique integrated and operationalized the investment case’s recommendations into the national health system at the central, provincial, and district level. The investment case also informed Mozambique’s development of a national health financing strategy. This strategy aims to reduce the financing gap between planned activities and current levels of funding.