Management of expatriate medical assistance in Mozambique

Shortly after independence (1975), the mass repatriation of the Portuguese cadres working in the Health System left the MOH with the urgent need of finding specialized medical doctors (MD) for its referral hospitals. In 1972 there were 289 MDs in the country [1]. In 1976, only about 60 MDs had remained [2]. The solution was found thanks to the assistance of the socialist countries, which promptly provided a contingent of mainly Russian and Cuban doctors. The political and economic collapse of the socialist block after 1990 caused a new crisis, threatening to leave hospitals without specialized MDs. After a rather chaotic period, the situation improved in 1996, through the activation of a pool funded by Switzerland, the Netherlands and Norway, which granted salaries for senior specialists, mainly from the former USSR republics, and kept the best of them in place. Under what was called the "pooling agreement", the MOH identified the need for personnel and took care of selection, supervision and assessment, while UNDP administered the contracting and payment of salaries. Meanwhile, national specialists were slowly increasing in number, but they continued to be insufficient to satisfy the public system needs. Moreover, virtually all of them were working in Maputo. As a way to encourage the few national medical specialists to work outside the capital, the MOH and Switzerland agreed a salary scheme (known as 'topping up'), which filled the gap between the public sector and expatriate salary scales working out of Maputo. In the meantime, bilateral cooperation still held a key role; in 1999, of a total of 406 MDs holding clinical posts, there were 204 foreigners abiding by different kinds of contract [3], most of them through inter-governmental agreements with Cuba and, to a lesser extent, China and Nigeria. This state of affairs remained almost unchanged until 2004.The health sector in Mozambique is heavily dependent on external financial support (about 60% of the budget i