Domestic and International Health Expenditure and Health and Healthcare Use: Evidence From Mozambique

Evidence on the relationship between public health expenditure and health is mixed and particularly scarce for low-income countries. Existing studies overlook the subnational distribution of expenditure and rarely distinguish between sources and governance over funding. We estimated the relationship between three types of health expenditure across 121 districts in Mozambique and multiple outcomes from 2008 to 2015. We generated a unique dataset covering individual outcomes from Demographic and Health Surveys and district-level domestic and international health expenditure, channelled to local institutions via provincial budget support or earmarked projects. We related lagged expenditure to outcomes using logit regressions, controlling for time-varying mother, household, and district characteristics, and district and year fixed effects. Domestic expenditure was positively associated with institutional delivery, infant and child survival, budget support with infant and child survival, lower child anaemia, and higher vaccination, and earmarked projects with recommended antenatal care. Associations with health outcomes were driven by wealthier households, with institutional delivery by households closer to facilities and with vaccinations and antenatal care by households with lower service access. Domestic expenditure is essential to improve child health and to support international expenditure, which is more effective when managed by local governments through sustained and predictable funding schemes.