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Survey: Integrated Health Systems Strengthening and Child-Friendly Districts

Findings of a household survey conducted in nine districts of Mozambique

Mozambique, March 2009 – In 2008, UNICEF Mozambique contracted an independent consultant to conduct a household survey in nine districts of Mozambique. The survey aimed to collect information for use as baseline data for the Integrated Health System Strengthening (IHSS) initiative carried out by the Canadian International Development Agency and UNICEF, and UNICEF’s Child Friendly Districts (CFD) initiative. 

The survey reached a total of 3,209 households in nine districts of the country (Montepuez, Namuno, Nacala, Changara, Chimoio, Manica, Jangamo, Chibuto, Manjacaze). Six of the nine survey districts are reached by either both the IHSS and CFD interventions or by one of the two, while three ‘non-intervention’ districts were surveyed as comparison group. 


The districts were selected using a mix of random and purposive sampling methods, but within each selected district, a probability sample of 320 households was selected using a cluster design. The resulting sample consists of 3,240 households with at least one eligible woman (15 to 49 years or younger than 15 but married) or one eligible child (less than 5 years of age).

Summary of the findings

In the nine selected districts, approximately 40 per cent of children under 5 years of age had either diarrhoea, fever or the symptoms of acute respiratory infection (ARI) over a two-week reference period. 

Diarrhoea: Seventeen percent of children under 5 years had diarrhea in the two weeks preceding the survey. Almost two-thirds of those who had diarrhoea were taken to a health facility for treatment. Seventy-three percent of those who had diarrhea received oral rehydration treatment (ORT), and three-quarters received appropriate home treatment, this being defined as more fluids and continued feeding.

Fever, malaria and mosquito nets: Thirty per cent of children under 5 years of age had fever in the two weeks preceding the survey but there is considerable variation across the districts. Two-thirds of those who had fever were taken to a facility for treatment. Sixty percent of households own a net and two out of five under-5 children slept under a mosquito net the night before the survey.

ARI symptoms and treatment: Six percent of children under 5 years of age exhibited symptoms of acute respiratory infection (ARI), these being cough, fever, and problems in the chest. Two-thirds of those who had ARI symptoms received some treatment, but only 18 percent received antibiotics.

Immunisation: Immunisation coverage in the nine survey districts is nearly universal.  Ninety-five per cent of children 12 to 23 months of age have received all three doses of DPT immunization by their first birthday and 91 percent have received a measles shot.

Child feeding: In the nine survey districts breastfeeding is almost universal, and most children are put to the breast soon after birth. Almost three-quarters of all women put their newborn infant to the breast within an hour of birth. Another 20 percent put them to the breast within a day of birth, implying that 95 percent of newborn infants are put to the breast within a day of birth.

Vitamin A:  Most children (89 percent) 6 to 49 months old had a vitamin A capsule in the six months preceding the survey. While coverage is uniformly high in most districts, two districts – Nacala (64 percent) and Montepuez (72 percent) - stand out for significantly lower coverage.

Deworming:  Only a little over one-third (34 percent) of all children 12 to 59 months of age were dewormed in the six months preceding the survey.

Nutritional status:  Anthropometric data indicate that four percent of children 6 to 59 months of age are wasted, but 15 percent are underweight for their age, and 52 percent are stunted. Economic status is clearly correlated with nutritional status as the incidence of stunting and weight-for-age shortfall is consistently lower for children from better off households.

Tetanus toxoid:  Sixty-nine percent of women who have had a pregnancy in the past two years received two or more doses of tetanus toxoid injections during their most recent pregnancy. High coverage of pregnant women translates to high levels of protection of infants so that almost 69 percent of infants less than a year old had mothers who received two or more doses of tetanus toxoid injections in the past 2 years.

© UNICEF/MOZA0777/Giacomo Pirozzi
A nurse verifies blood pressure of a young pregnant woman.

Antenatal care:  Almost all (98 percent) pregnant women received some type of antenatal care during their last pregnancy in the past two years. Almost all of these (97 percent) were attended to by health professionals (defined as doctor, nurse or midwife, and auxiliary midwife). For all practical purposes, in these nine districts, this essentially translates to a nurse or midwife (93 percent).

Assistance with child delivery:  Seventy percent of women were assisted by a trained health professional (doctor, nurse/midwife, or auxiliary midwife) at their most recent delivery in the past two years. Most of this assistance is provided by nurses and midwives but traditional birth attendants and family and friends also play an important role, especially in some districts.

Water and sanitation: Forty per cent of the population has access to ‘improved’ water sources, these being defined as piped water, protected well or open sources like surface water and water from rainwater collection. Fifteen per cent of the population uses improved sanitation facilities, these being defined as toilets with or without a flush and improved latrines.

Orphanhood and vulnerability:  Data on the living arrangements of children under the age of 18 years show that 61.5 live with both (biological) parents, 25 percent with only one parent, and about 13.5 percent live with neither parent. Twelve 12 percent of children under the age of 18 years are orphaned (one or both parents dead), and there are large differences between districts.

Child Friendly District Survey

Questions on high risk sex, domestic violence, HIV/AIDS, birth registration and school attendance were asked only in Changara and Chibuto (two of the three CFD districts).

Birth registration: In the two intervention districts for which data were collected, only 12 percent of children under 5 years had their birth registered.  The proportion is substantially higher in Chibuto (16 percent) than Changara (9 percent), and birth registration is much more prevalent in urban areas (23 percent versus 10 percent in rural areas).

Domestic Violence: A significant proportion of women consider wife beating to be acceptable: 12 percent if the wife burns the food during cooking, 14 percent if she goes out without saying goodbye, 18 percent if she does not take good care of the children, 24 percent if she argues with him, and 30 percent if she refuses to have sex with him.

High-risk sex and condom use: In the two CFD districts – Changara and Chibuto - 30 percent of young women (15 to 24 years of age) reported having had sex with a non-cohabiting partner in the past 12 months. Forty-four percent of young women who had high-risk sex in the previous 12 months reported using a condom at last sexual intercourse.

Awareness and attitudes towards HIV/AIDS: Most women (94 percent) have heard of HIV/AIDS but there is a large difference between the two districts. With respect to mother-to-child transmission, 81 percent of women noted breastfeeding, 74 percent pregnancy, and 53 percent noted childbirth as relevant transmission mechanisms. In terms of prevention methods, 70 percent of women believe that the only way to protect is to have an uninfected partner or only one partner. Sixty-nine percent also believe that protection is possible if a condom is used correctly every time a couple has sex.

HIV testing: A little over one-half (56 percent) of the women who received ANC services in Changara and Chibuto in the past two years were tested for HIV.

School attendance: Seventy-eight percent of primary school age children (ages 6 to 12 years) attended EP1 (primary school) during the year preceding the survey and there is no difference between Changara and Chibuto. There is considerable dropout after primary schooling so that only 17 percent of secondary school age children (13 to 16 years) attended ESG1 in the year preceding the survey. There is gender parity at the primary school level but at the secondary level there is greater drop out among boys and so a larger percentage of school attendees are girls. The gender parity ratio – male-to-female attendance ratio - at the secondary level is only 0.85.

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Survey: Integrated Health Systems Strengthening and Child-Friendly Districts

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