Mitigating Mozambique's Humanitarian Nightmare

By Jon Hyman and Shannon Kellman

Jon Hyman is Advocacy Manager at Friends of the Global Fight Against AIDS, Tuberculosis and Malaria. Shannon Kellman is Senior Policy Director at Friends of the Global Fight Against AIDS, Tuberculosis and Malaria.

WASHINGTON, DC – Since 2017, Islamic State-affiliated insurgents have wreaked havoc on Mozambique. Terrorizing the northern province of Cabo Delgado, the militants have killed more than 6,500 people, ravaged infrastructure, recruited child soldiers, and committed sexual and gender-based violence. All told, the conflict has displaced nearly one million people.

The World Food Program Representative and Country Director for Mozambique has called the resulting humanitarian crisis a “catastrophe beyond epic proportions.” Chief among the challenges facing the population is reduced access to health care. The insurgency has forced the closure of nearly half of Cabo Delgado’s health centers. As thousands of Mozambicans move south to escape the violence, their basic health-care needs are straining the infrastructure in other provinces, thereby weakening the country’s overall health security.

The international response has been substantial: the United Nations has appealed for $437 million in humanitarian aid to address the massive internal displacement in northern Mozambique, and the United States, in particular, is funneling considerable resources into the country. In addition to the sizeable US development assistance allocated to Mozambique each year, USAID announced a plan last July to provide $116 million in supplemental aid – mostly for food and nutrition purposes, though some funds are intended to meet health-care needs.

But President Joe Biden’s administration would be wise to make health security and infrastructure a central focus of its Mozambique strategy, using the new direction and flexibility offered by recent legislation. Guided by lessons from the wars in Iraq and Afghanistan, Congress passed the Global Fragility Act (GFA) in 2019 to prevent violent conflict and promote stability around the world. Enacted with broad bipartisan support, the law mandates officials to rethink US foreign policy in conflict-prone areas and to deepen engagement with civil society and local partners.

In April 2022, the Biden administration designated Mozambique a priority country under the GFA. Over the next ten years, the administration plans to transform US government agencies and pursue partnerships at all levels as a means to tackle instability and prevent future outbreaks of violence in Mozambique and other target areas.

But crafting an effective response to displacement is difficult, and many efforts to reach Mozambique’s most vulnerable have been hindered by logistical challenges like flooding from cyclones and widespread destruction of infrastructure. Poor health systems, in particular, are a roadblock to recovery and development, and the State Department’s 2020 strategy for implementing the GFA makes clear that health – alongside education, food security, and other factors – is a critical and necessary component of a stable country. On this front, Mozambique falls short.

Mozambique faces the current crisis from an already precarious position in terms of public health. It has an alarmingly high infectious-disease burden: HIV affects 13% of the adult population, and the country has Africa’s second-largest HIV+ population. Moreover, annual tuberculosis (TB) cases increased by 35% between 2011 and 2021, and around one-third of the population contracted malaria in 2020. Since both HIV and TB require continuous and often supervised medical treatment, hospital and clinic closures and forced displacement make it even more difficult for patients to access the necessary care. The combination of existing health challenges and the ongoing insurgency has only intensified the country’s fragility.

To be sure, Mozambique has made great strides in addressing its many public-health concerns, which could provide a helpful model for interventions under the GFA. The Global Fund to Fight AIDS, Tuberculosis and Malaria estimates that, through grants totaling more than $2.2 billion to fund infectious-disease programs and efforts to strengthen Mozambique’s health system, nearly three million new HIV infections and 220,000 TB deaths were averted between the Global Fund’s founding in 2002 and 2021.

Such successes illustrate for US policymakers the importance of civil-society engagement in a long-term strategy. Together with the Mozambican Ministry of Health, three organizations – Fundação para o Desenvolvimento da Comunidade, Centro de Colaboração em Saúde (CCS), and World Vision International – implement the Global Fund grants in Mozambique. These organizations perform essential functions, like providing medicine, educating community groups on prevention techniques, and funding community health workers.

Building ties with local partners isn’t a foreign approach for the US, making the Biden administration’s strategy to address the causes of fragility that much more attainable. In fact, under the President’s Emergency Plan for AIDS Relief, the US partnered with CCS in 2010 to begin the transition to a country-led HIV- and TB-response model. Since then, CCS has expanded its clinical work from Maputo, the capital, to eight other provinces, including Cabo Delgado.

USAID also works with civil-society groups like PIRCOM, an inter-religious organization that mobilizes leaders from several faiths to improve communication about pressing public-health challenges. Through local-level and individual engagement, programs like PIRCOM can help mitigate widespread distrust of health workers and medical professionals – a significant barrier to health-care delivery. By broadening this engagement with actors on the ground as part of a comprehensive strategy toward fragile states, the Biden administration can emphasize local ownership.

Mozambique’s record of successfully integrating civil society into its health system shows that targeting this area can save lives while improving the country’s economic-development prospects. The Biden administration should focus on health aid to capitalize on this record, and the GFA is a valuable tool for doing so. Although fighting in Cabo Delgado has subsided, the urgency to act has not. The US must make its move in Mozambique. The right approach there will save lives and could serve as an important example for mitigating future crises elsewhere.