Author: Ilaria Catalano (Junior Researcher Mondo Internazionale GEO - Economia)
Introduction
Over the past two decades, Mozambique has made great progress in improving population health. Life expectancy has increased, child mortality has declined, and large-scale interventions have significantly expanded access to treatment and prevention programmes for HIV/AIDS, malaria and tuberculosis. These achievements have been made possible through the combined efforts of the Mozambican government and a vast network of international partners. Yet, beneath these successes, lies a fundamental paradox. The country's health system continues to suffer from severe shortages of qualified personnel, persistent territorial inequalities and chronic underfinancing. Above all, many of these improvements remain heavily dependent on external assistance.
This paradox reflects a broader debate within development studies. Dependency theorists have long argued that excessive reliance on external actors can reproduce asymmetric relationships and limit the development of domestic capacities. By contrast, state-building approaches emphasize that sustainable development depends not simply on financial resources but on institutions capable of mobilizing domestic revenues, coordinating actors and providing public goods effectively. Mozambique's health sector offers a particularly interesting case through which to explore this tension. Moreover, Italy's renewed engagement with Africa through the Mattei Plan raises an important question: can international cooperation strengthen state capacity and foster sustainable development, or does it risk reproducing existing forms of dependency?
A picture of Mozambique's Health Sector
Mozambique’s health data has improved significantly over the last twenty years. Life expectancy has risen to approximately 60 years, reflecting important reductions in mortality from communicable diseases and improvements in access to healthcare services. Child mortality has also declined considerably, with the under-five mortality rate falling from 97 deaths per 1,000 live births in 2011 to around 60 in 2022. However, despite these achievements, communicable diseases continue to dominate the country's disease burden.
HIV/AIDS is one of Mozambique's most pressing public health challenges. Specifically, HIV prevalence among adults aged 15 to 49 stood at approximately 11.5 per cent in 2024, and women account for most of adults living with HIV. For context, the same indicator of HIV prevalence for the whole of the European Union has averaged between 0.2-0.3 per cent for decades. To face these challenges, the country has made progress in treatment coverage and reached the peak of 2.1 million individuals receiving antiretroviral therapy in 2023. While this expansion contributed to a substantial reduction in AIDS-related mortality, the country also has to deal with the high mortality caused by tuberculosis and malaria, which are particularly widespread among children and rural populations. In this regard, large-scale donor-supported programmes have expanded screening and treatment coverage for both diseases, with almost 110,000 people receiving treatment in 2022. At the same time, Mozambique is beginning to experience an epidemiological transition. While communicable diseases remain the dominant concern, Ministry of Health officials have increasingly been paying attention to the growing importance of non-communicable diseases such as cardiovascular diseases, diabetes, cancer and chronic respiratory illnesses, which risk placing additional pressure on an already constrained health system.
Having painted a picture of the country’s health statistics, it can be recognized that the structure of Mozambique's National Health System is characterized by both achievements and persistent weaknesses. While the public system is the largest provider of healthcare services and employs more than 90 per cent of health workers, its ability to deliver health services is still undermined by personnel shortages. To better grasp this, in 2019, Mozambique had approximately one physician for every 15,000 inhabitants and one nurse for every 2,000 inhabitants, with healthcare workers heavily concentrated in urban areas and persistent shortages affecting rural and northern provinces. In addition, infrastructure deficiencies make inequalities in access to care even more pronounced: many districts lack basic hospital facilities, while millions of people continue to live far from the nearest health center.
Figure 1: Distribution of Health Facilities by Ownership and Level in Mozambique as of 2019
Source: USAID, Overview of private actors in the Mozambican health system and rapid assessment of the supply chain.
Against this backdrop, the sustainability of Mozambique's health system has long been constrained by chronic domestic underinvestment. Public expenditure on health averages only around 2.25 per cent of GDP, well below WHO recommendations indicating that the share of GDP devoted to healthcare should average around 5-6 per cent. As a result, the expansion of healthcare services has relied heavily on external financing, making international partners central to the functioning of the sector. This raises a broader question that extends beyond health outcomes alone: can a health system whose achievements depend so heavily on external support generate the institutional foundations necessary for long-term, self-sustaining development?
The Risks of Aid Dependency
Mozambique's health sector is therefore a clear example of the opportunities and contradictions associated with contemporary development assistance. International aid has played a key role in expanding access to healthcare, financing large-scale programmes against communicable diseases and improving health indicators over the past two decades. At the same time, the sector remains one of the most aid-dependent in Sub-Saharan Africa: whether such dependence represents a necessary stage of development or a constraint on long-term state capacity has become a central question in the development literature.
Concerns about the long-term sustainability of externally financed development lie at the heart of dependency theory. Classical dependency theory argues that sustained reliance on external resources reproduces asymmetric economic and political relationships that constrain the emergence of autonomous development. While originally formulated to explain structural inequalities between the Global North and South, scholars have recently adapted these concerns to the field of international aid. Moss, Pettersson and van de Walle argue that foreign assistance may generate an "aid-institutions paradox": although aid can significantly improve development outcomes, prolonged dependence on external financing may simultaneously weaken the very institutions required to sustain those outcomes. Their argument introduces a new perspective to international aid: rather than looking at aid volumes alone, its institutional consequences should be considered, suggesting that large and persistent aid inflows may reduce incentives for domestic revenue mobilization, fragment public administration through parallel donor structures, distort bureaucratic incentives and weaken the accountability of governments towards their own citizens. The critical question is not just whether aid works, but whether it strengthens or substitutes domestic state capacity.
Mozambique provides a relevant case for assessing these dynamics. The country has consistently failed to meet the Abuja Declaration (1) target of allocating 15 per cent of government expenditure to health, with public spending averaging only 11.8 per cent in recent years. As a result, approximately 58 per cent of total health expenditure originated from external sources in 2021, making Mozambique one of the most aid-dependent health systems in Africa. International organizations, bilateral donors, multilateral development banks and international and local NGOs have therefore become central actors not only in financing healthcare but also in shaping policy priorities, programme implementation and service delivery. For instance, the Global Fund alone has invested more than US$3 billion in Mozambique since 2003, which makes the country one of its largest portfolios. Alongside it, bilateral initiatives such as PEPFAR have become indispensable for HIV prevention and treatment, while Gavi has substantially expanded immunisation coverage. Multilateral institutions, including the World Bank and the Global Financing Facility (GFF), have increasingly supported primary healthcare, maternal and child health and broader health system reforms. Without these actors, many of the gains achieved in communicable diseases and child and maternal mortality would almost certainly not have occurred.
Nevertheless, the aid-institutions paradox suggests that the effectiveness of aid cannot be assessed solely through improvements in health indicators. Equally important is whether aid contributes to building domestic institutions or instead bypasses them. In Mozambique, international assistance has traditionally been organized through vertical programmes targeting specific diseases, frequently operating alongside rather than through the National Health Service. Although these programmes have delivered important health gains, they have also produced fragmented governance structures that complicate coordination across the sector, as explained by former Mozambican Health Minister Garrido. Coordination among international organizations, bilateral agencies and NGOs is indeed a long-standing challenge due to weak communication and limited interoperability between information systems. Even the Global Fund's system of principal recipients and sub-recipients, designed to improve accountability and reduce duplication, has introduced additional layers of administrative complexity that often complicate national planning and coordination. Ultimately, as Moss et al. also argue, project proliferation and parallel implementation mechanisms may unintentionally weaken governments' ability to coordinate policy, even when individual programmes are highly effective.
These dynamics extend beyond institutional coordination to the functioning of the health workforce itself. Mozambique already suffers from severe shortages of qualified healthcare personnel, yet donor-funded programmes frequently find themselves competing with the public sector for the same limited pool of professionals. International organizations are generally able to offer higher salaries and more attractive working conditions, encouraging skilled workers to leave government institutions. While this undoubtedly strengthens the implementation capacity of donor-funded programmes, it may simultaneously weaken the long-term capacity of the National Health Service itself. Rather than expanding domestic bureaucratic capacity, externally financed interventions may unintentionally relocate it, reinforcing dependence on donor-funded organizations. This reflects another mechanism identified by Moss et al., whereby aid improves service delivery in the short term while creating institutional incentives that complicate the development of a professional and autonomous public administration in the long-run.
Finally, recent developments in the global aid architecture emphasize more vulnerabilities associated with prolonged external dependence. With approximately 95 per cent of Mozambique's HIV financing originating from international donors, healthcare delivery can become subordinate to sudden shifts in the priorities of donor countries, with immediate repercussions for millions of beneficiaries. The recent restructuring of United States development assistance under the "America First Global Health Strategy" is a clear example of this phenomenon, which is becoming more frequent in an increasingly polarized global landscape. The dismantling of USAID, previously one of the country's principal health donors, was followed by the introduction of new aid arrangements and conditions governing international health cooperation. These developments have even attracted criticism from organizations such as Human Rights Watch, particularly regarding concerns over privacy, data governance and national sovereignty. More broadly, they illustrate how international health cooperation is being shaped by geopolitical considerations rather than exclusively by development objectives and reinforce one of the central insights of the aid-institutions literature: dependence on external financing inevitably exposes recipient countries to policy decisions taken beyond their own political control.
In sum, Mozambique illustrates both the strengths and the limitations of the aid-institutions paradox. The main challenge is not just whether aid should continue, but how international cooperation can be organized in ways that strengthen domestic state capacity rather than substituting for it. This perspective provides the basis for the alternative approach explored in the following section, which shifts attention from the risks of aid dependence to the role of health cooperation as a potential instrument of state-building.
Health Cooperation, State Capacity and the Mattei Plan
If aid dependency identifies the limitations of externally financed development, state-building offers an alternative framework through which international cooperation can be evaluated. Rather than asking whether aid increases the availability of financial resources or improves short-term development outcomes, the state capacity approach focuses on whether external assistance strengthens the institutions required for sustainable development. As Fukuyama argues, long-term development ultimately depends on the ability of states to provide public goods, mobilize domestic resources, implement policies effectively and maintain legitimacy among their citizens. From this perspective, the objective of international cooperation should not be to substitute for weak institutions but to strengthen them, enabling recipient countries to progressively reduce their reliance on external assistance.
Mozambique's health sector again illustrates the importance of this different approach. The challenges facing the country's health system go beyond shortages of medicines or the financing of disease-specific programmes. As discussed in the previous section, decades of donor assistance have deepened weaknesses in governance, fiscal sustainability and administrative capacity. Strengthening the health system therefore requires more than additional financial resources; it requires reinforcing the institutional foundations through which healthcare is planned, financed and delivered.
A first dimension of state capacity concerns the relationship between public service provision and domestic resource mobilization. One of the structural weaknesses of the Mozambican state remains its limited fiscal capacity, which has, until now, forced it to depend on foreign assistance. Yet recent evidence suggests that this relationship is not purely financial. A field experiment conducted in Quelimane by Sandholtz and Vicente found that citizens who were informed about improvements in local public services became significantly more willing to pay taxes and contribute to collective goods. Rather than viewing taxation solely as an economic obligation, citizens appeared more willing to contribute when they perceived the state as capable of delivering tangible benefits. These findings point to the existence of a fiscal social contract in which effective public services reinforce state legitimacy, while greater legitimacy strengthens domestic revenue mobilization. Healthcare should therefore be understood not only as a social sector but also as an investment in state capacity. By improving citizens' trust in public institutions, stronger health systems can indirectly contribute to expanding the domestic fiscal base necessary to sustain them.
Administrative capacity constitutes a second pillar of sustainable development. Effective healthcare systems do not depend on financial resources only, but also on institutions capable of coordinating policies, managing information and delivering services efficiently. In Mozambique, decentralization has long been presented as a central objective of health sector reform, but its implementation has stalled. Although responsibilities have increasingly been transferred to provincial and district authorities, financial resources and decision-making powers continue to be concentrated at the central level, limiting the capacity of local governments to respond to territorial needs. At the same time, investments in digital governance have begun to address some of these structural weaknesses. For instance, the World Bank's Mozambique Digital Governance and Economy Project seeks to strengthen public administration through interoperable registries, digital identification systems and improved administrative coordination. Reforms like these are crucial to strengthen local institutions and equip them with better capacities to support broader economic and social development, with benefits extending beyond the health sector alone.
Finally, state capacity also depends on the relationship between governments and citizens. Health systems function most effectively when public institutions enjoy social legitimacy and citizens trust both the services provided and the authorities responsible for delivering them. This dimension is particularly evident in Mozambique, where community health workers have become essential intermediaries between local communities and the formal health system. Beyond expanding access to healthcare, they facilitate referrals, promote treatment adherence and strengthen communication between citizens and public authorities. Similarly, research conducted during the COVID-19 pandemic demonstrated that vaccine acceptance increased when communication strategies appealed to previous experiences of successful vaccination programmes and addressed misinformation directly. These findings suggest that trust is not simply an outcome of effective institutions but also one of the conditions necessary for their success. Strengthening health systems thus requires investments not only in infrastructure and human resources but also in the social relationships that underpin institutional legitimacy.
Taken together, these examples suggest that international health cooperation should not be evaluated solely according to the volume of financial resources it provides or the number of beneficiaries it reaches. Rather, its success depends on whether it contributes to strengthening fiscal, administrative and institutional capacity. This perspective offers a useful framework for assessing the ambitions of Italy's Mattei Plan.
Launched in 2024, the Mattei Plan presents itself as an alternative model of cooperation based on partnership, local ownership and capacity-building, rather than traditional donor-recipient relationships, operating in 18 African countries including Mozambique. In principle, this approach reflects many of the characteristics associated with the state-building perspective. Beyond financing individual projects, the Plan emphasizes training, technology transfer, institutional cooperation and investments intended to generate long-term economic development. If effectively implemented, such priorities could contribute to strengthening the institutional foundations upon which sustainable health systems ultimately depend. Health is formally identified as one of the Plan's six strategic pillars, alongside education, energy, agriculture, water, physical and digital infrastructure. However, the current distribution of projects suggests that healthcare has so far received comparatively limited attention. According to the official project portfolio, health accounts for the smallest number of initiatives among the six pillars, while in Mozambique only one active project can be directly associated with the health sector. Consequently, despite the prominence of health in the Plan's official discourse, it remains difficult at this stage to assess whether it will emerge as a genuine strategic priority in implementation or whether other sectors will continue to receive greater emphasis.
Mozambique occupies a key position within the Plan. Italy has maintained a long-standing presence in the country through institutions such as the Italian Agency for Development Cooperation (AICS), the Embassy in Maputo and non-governmental organizations including Medici con l’Africa CUAMM, whose activities have traditionally focused on strengthening primary healthcare and supporting local health institutions. Unlike many vertical disease-specific programmes, many of these initiatives operate through existing public structures rather than through parallel systems. Although their financial scale remains modest compared with actors such as the Global Fund, PEPFAR or the World Bank, their comparative advantage may lie exactly in their emphasis on institutional strengthening rather than service substitution.
Nevertheless, the extent to which the Mattei Plan can genuinely represent an alternative to traditional development assistance, specifically within the health sector, remains uncertain. Although the Plan emphasizes partnership and local ownership, its practical contribution to strengthening Mozambique's health system is still difficult to evaluate, given the limited number of health-related initiatives currently underway. Its rhetoric of equal partnership and mutual benefit does not automatically eliminate the structural asymmetries that characterize international cooperation. As critics have noted, geopolitical and economic interests continue to shape development partnerships, while the proliferation of new initiatives risks adding further complexity to an already fragmented aid landscape. To avoid reinforcing these dynamics, future health interventions under the Mattei Plan should prioritize integration within Mozambique's existing health system, support nationally identified priorities and complement, rather than duplicate, the work of established development partners. In a country that already struggles with coordination among donors, the effectiveness of the Mattei Plan will depend less on the resources it mobilizes than on its ability to align with and reinforce domestic institutions.
Ultimately, the debate surrounding the Mattei Plan reflects a broader question concerning the future of international development cooperation. The challenge is no longer simply to provide more aid, but to organize cooperation in ways that progressively reduce the need for aid itself. Mozambique demonstrates that improvements in health outcomes and the strengthening of state capacity are not necessarily incompatible objectives, but they require forms of cooperation that prioritize institutional development alongside service delivery. In practice, this means measuring the success of international cooperation not only by the services it delivers, but also by its contribution to stronger public institutions and greater domestic capacity. If the Mattei Plan succeeds in this regard, it may contribute to shifting development cooperation from a model of external substitution towards one of genuine state-building, becoming an example for other countries. If it fails to do so, it risks reproducing the same dynamics of dependency that have characterized Mozambique's health sector for decades.
Conclusion
The Mozambican case illustrates that health cooperation is ultimately about more than healthcare. It is also about how states build legitimacy, mobilize resources and develop the institutional capacity required to sustain development independently. As this analysis has argued, the paradox of international aid lies precisely in its dual nature: external assistance has been indispensable in improving health outcomes, yet, when delivered through fragmented and externally driven mechanisms, it may also reinforce the institutional weaknesses it seeks to address. For this reason, the debate should move beyond the traditional distinction between "more aid" and "less aid" towards a broader reflection on the quality and purpose of international cooperation.
Recent developments including the new “America First Global Health Strategy" and the Mattei Plan reflect an awareness that traditional aid models require rethinking. Their ability to facilitate sustainable development will increasingly depend on whether they can help strengthen the conditions that make external assistance progressively less necessary. While this shift has already happened in the rhetoric of international cooperation, whether it can be translated into practice remains an open question.
Source Classification
Information Content | ||
1 | Confirmed | Confirmed by other independent sources; logical in itself; coherent with other information on the topic |
2 | Presumably true | Not confirmed; logical in itself; coherent with other information on the topic |
3 | Maybe true | Not confirmed; reasonably logical in itself; coherent with some other information on the topic |
4 | Uncertain | Not confirmed; possible but not logical in itself; no other information on the topic |
5 | Improbable | Not confirmed; not logical in itself; contradicts with other information on the topic |
6 | Not able to be evaluated | No basis to evaluate the validity of the information |
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(1) The Abuja Declaration refers to the commitment adopted by African Union member states, including Mozambique, in 2001 to allocate a minimum of 15 per cent of annual public expenditure to health, with the objective of strengthening national health systems and improving access to healthcare across the continent.