When Rebels Become Governments: One Post-Conflict Health Example

In June 1975, after a military coup in Lisbon, Mozambique achieved independence and FRELIMO took control of the government. The health care system FRELIMO inherited was small and dysfunctional. During the colonial period most health workers were Portuguese settlers and these Europeans started leaving en mass at independence. Within a month, 85 percent of Mozambique’s doctors had left the country. Despite FRELIMO’s attempts to stem the flight of European health workers with offers of Mozambican citizenship, the fledgling state was left with only 30 doctors in the entire country. This exodus left many hospitals and other health facilities abandoned or crippled by understaffing. The problem was particularly damaging in rural areas that were often isolated during the chaotic first few months of independence. Health care in these areas was often provided by untrained orderlies and by the remnants of FRELIMO’s liberation zone health care network.

The new Mozambican government also lacked a pool of skilled and semi-skilled workers they could draw upon to manage the health care system. There were six economists, two agronomists, and fewer than 1000 African high school graduates in the country. The lack of capable senior and middle level technocrats made it difficult for the government to manage the disorganized health system it took over at independence. Decision-making was often deferred to a small cadre of administrators with little room for outside opinion or flexibility.

Despite these difficulties, in July 1975 Mozambique nationalized health care and launched a major effort to transform the disparate collection of private, public, military, and missionary health facilities into a single effective health system. The new health system was to be guided by the Marxist principles of FRELIMO and the health policies started before independence. Health reforms focused on expanding health care to rural regions of the country where a majority of the population lived through primary and preventative health care programs). FRELIMO political leaders believed that the country’s political and economic future lay in improving the country’s largest industry: agriculture. More specifically, FRELIMO hoped a rapid expansion of Mozambique’s health system would improve the productivity of rural agricultural workers and thus the entire economy.

FRELIMO’s post-independence health reforms were based around the concept of primary health care, a doctrine giving priority to the provision of basic health services and preventative care over specialized and curative care. Primary health care was seen by FRELIMO as the only way the government could improve the health of the vast majority of the population that had previously been without any health care access. To accomplish this, FRELIMO radically increased health care spending: from 4.6 percent of the government’s budget to 9.7 percent only a year later. By 1981, government health spending would reach 11.9 percent.

FRELIMO’s focus on expanding health care was rooted in both political strategy and ideology. Even before independence FRELIMO enjoyed widespread support amongst the population. This support was a valuable resource during the guerilla war against the colonial Portuguese Army who “faced fighting in a hostile country against a people overwhelmingly antagonistic to them” (Walt and Cliff 1986, 149). Furthermore, during the war while FRELIMO did receive some support from abroad, it relied heavily on the population for information and supplies. The close connection between FRELIMO and the population during the war had a profound impact on the development of national health policy after independence. Furthermore, FRELIMO’s Marxist roots played a role in the high priority given to health. FRELIMO believed western capitalism and colonialism were the enemies of the Mozambican people, and that improvements in the new state’s health and education systems were the key to escaping that poverty (Robinson 2006).

The FRELIMO government’s focus on the well being of the population was responsible for a rapid expansion of the health system in the years before and at the start of the country’s civil war. Between 1975 and 1982, over 2000 nurses, 110 x-ray technicians, 290 pharmacists, 272 midwives, and 1011 village health workers were trained. Similar improvements were seen in health facilities. In roughly that same period, the government built 593 health posts, 161 health centers, 130 laboratories, and 80 stomatology departments. The government also instituted a national drug formulary to reduce the amount the government and patients spent on pharmaceutical products. Mozambique’s drug formulary was considered to be one of the country’s most important reforms and was credited for keeping pharmaceutical spending significantly lower than other developing states. The effect on the health of Mozambican citizens was significant. By 1980, 30 percent of the population had access to health care facilities, up from 7 percent in 1974. Furthermore, by the early 1980s Mozambique had the highest vaccination rates for children under the age of five years old in any African country.

Christopher R. Albon is a political science Ph.D. specializing in armed conflict, public health, human security, and health diplomacy.

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Tagged as: FRELIMO, Mozambique