ATTACHMENT 3 - Moz MCH, and Nutrition Gender Assessment.pdf

Mozambique Maternal/Child Health and Nutrition Gender Assessment

BACKGROUND

In Mozambique, gender-related barriers contribute to leading causes of maternal morbidity and mortality, under-five mortality, poor nutrition, and other public health crises. These problems represent a critical burden for individuals, families, communities, the health system, and the growth and prosperity of the country.

Mozambique remains one of the MCHN office’s top 25 priority countries of concern, based on the magnitude and severity of maternal and child deaths and potential opportunity to integrate programs and leverage investments. The maternal mortality ratio in Mozambique is 289 deaths per 100,000 live births, compared to 534 for sub-Saharan Africa, on average.1 The child mortality rate is 74 deaths among children under 5 per 1,000 live births, roughly equal to 76 for the sub-Saharan region.2 Both of these figures have decreased significantly in the past two decades.3 Other key health indicators also show signs of improvement, e.g. in the institutional delivery rate, the cesarean delivery rate, institutional stillbirth and early neonatal death rates, cause-specific case fatality rates (CFRs), and met need for emergency obstetric care (EmOC). CFRs for most major obstetric complications declined between 17% and 69% in the period 2007 and 2012.4 However, Mozambique still has high rates of maternal mortality which are exacerbated by very high rates of child marriage and teen pregnancy. Child marriage often leads to teen pregnancy, but pregnancy also occurs outside marriage.5

Mozambique has one of the highest rates of child marriage in the world. Nearly half of all girls (48%) of women in Mozambique aged 20–24 were first married or in a union before the age of 18, while 14% were married before the age of 15.6 Early marriage and child marriages are particularly common in the center and north of the country, while the proportion of under-18 births (20-24 year-old women

1 World Bank. Maternal Mortality Ratio. https://data.worldbank.org/indicator/SH.STA.MMRT?locations=MZ 2 UN Inter-agency Group for Child Mortality Estimation https://childmortality.org/data/Mozambique 3 MMR was 798 per 100,000 live births in 2000. World Bank. Maternal Mortality Ratio.

https://data.worldbank.org/indicator/SH.STA.MMRT?locations=MZ; Child Mortality was 170 in 2000, UN Inter-agency Group for Child Mortality Estimation https://childmortality.org/data/Mozambique 4 Augusto O, Keyes EE, Madede T, et al. Progress in Mozambique: Changes in the availability, use, and quality of emergency obstetric and newborn care between 2007 and 2012. PLoS One. 2018;13(7):e0199883. Published 2018 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051588/ 5 Maternal and Child Survival Program - Mozambique (MCSP-Mozambique), https://www.globalwaters.org/HowWeWork/Activities/maternal-and-child-survival-program-mozambique#:~:text=Maternal%20and%20Child%20Survival%20Program%20%2D%20Mozambique%20(MCSP %2DMozambique),preventing%20child%20and%20maternal%20deaths.

6 UNICEF | Child Marriage in Mozambique: https://www.unicef.org/mozambique/en/child-marriage-mozambique#:~:text=English- ,Mozambique%20has%20one%20of%20the%20highest%20rates%20of%20child%20marriage,and%20southern%2 0African%20sub%2Dregion.

Mozambique: DHS, 2011 - Final Report (Portuguese), 2011. https://dhsprogram.com/publications/publication-fr266-dhs-final-reports.cfm

APS 72065623APS00001 ATTACHMENT 3 - Gender Analysis MCH+Nut+RI);

https://data.worldbank.org/indicator/SH.STA.MMRT?locations=MZ https://childmortality.org/data/Mozambique https://data.worldbank.org/indicator/SH.STA.MMRT?locations=MZ https://childmortality.org/data/Mozambique https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051588/ https://www.globalwaters.org/HowWeWork/Activities/maternal-and-child-survival-program-mozambique#:%7E:text=Maternal%20and%20Child%20Survival%20Program%20%2D%20Mozambique%20(MCSP%2DMozambique),preventing%20child%20and%20maternal%20deaths https://www.globalwaters.org/HowWeWork/Activities/maternal-and-child-survival-program-mozambique#:%7E:text=Maternal%20and%20Child%20Survival%20Program%20%2D%20Mozambique%20(MCSP%2DMozambique),preventing%20child%20and%20maternal%20deaths https://www.globalwaters.org/HowWeWork/Activities/maternal-and-child-survival-program-mozambique#:%7E:text=Maternal%20and%20Child%20Survival%20Program%20%2D%20Mozambique%20(MCSP%2DMozambique),preventing%20child%20and%20maternal%20deaths https://www.unicef.org/mozambique/en/child-marriage-mozambique#:%7E:text=English-,Mozambique%20has%20one%20of%20the%20highest%20rates%20of%20child%20marriage,and%20southern%20African%20sub%2Dregion https://www.unicef.org/mozambique/en/child-marriage-mozambique#:%7E:text=English-,Mozambique%20has%20one%20of%20the%20highest%20rates%20of%20child%20marriage,and%20southern%20African%20sub%2Dregion https://www.unicef.org/mozambique/en/child-marriage-mozambique#:%7E:text=English-,Mozambique%20has%20one%20of%20the%20highest%20rates%20of%20child%20marriage,and%20southern%20African%20sub%2Dregion https://www.unicef.org/mozambique/en/child-marriage-mozambique#:%7E:text=English-,Mozambique%20has%20one%20of%20the%20highest%20rates%20of%20child%20marriage,and%20southern%20African%20sub%2Dregion https://dhsprogram.com/publications/publication-fr266-dhs-final-reports.cfm https://dhsprogram.com/publications/publication-fr266-dhs-final-reports.cfm surveyed who gave birth before age 18) remains over 40% according to the latest figures.7 Early/child marriage is linked directly to MMR as girls between the ages of 15 and 19 are twice as likely to die in pregnancy and childbirth compared to women ages 20 to 24.8 United Nations International Children’s Emergency Fund’s (UNICEF) data shows that in Niassa, nearly a quarter of girls were married before the age of fifteen.9 The UNFPA-UNICEF Global Programme to End Child Marriage charactarizes child marriage as both a symptom and a result of deep-seated gender inequalities, restrictive gender norms and power dynamics.10 A previous USAID Gender Assessment noted the provinces of Zambézia, Nampula, Niassa, Cabo Delgado, and Manica have a high prevalence of child marriages.11 A UNICEF and UNFPA Report noted that Mozambique’s high vulnerability to frequent disasters pushes families to resort to negative coping strategies such as entering female children into early marriages.12 Persistent droughts have also forced women to spend in excess of six hours searching for and transporting water, increasing the likelihood that girls will need to drop out of school and have fewer options other than early/child marriage.13

Contraceptive use is an important determinant of women having the de facto control of their reproductive lives and ability to determine the number, spacing, and timing of births.14 Contraceptive use among married women varies considerably by region, with Maputo Province (4.4%), Sofala (14%), Manica and Zambezia (18%) ranking lowest and Maputo Cidade (47%), Gaza (42%) and Inhambane (34%) ranking highest.15 The lack of access to services along with cultural practices and social norms, reflected in unmet need for family planning, are still major barriers to women’s control of their reproductive lives. In Maputo Province, 45% of married women have unmet needs. In Zambezia, 30%, in Niassa, 29%, the city of Maputo, 17%, Nampula, 19%, and in Sofala, 20% have unmet FP needs.16 The

7 Indicator: Early childbearing - percentage of women (aged 20-24 years) who gave birth before age 18, UNICEF, 2011.

https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq= MOZ.MNCH_BIRTH18.&startPeriod=1970&endPeriod=2022 8 Too Young to Wed: Education & Action Toward Ending Child Marriage. Washington, D.C.: International Center for Research on Women; 2005. https://www.icrw.org/wp-content/uploads/2016/10/Too-Young-to-Wed-Education-and-Action-Toward-Ending-Child-Marriage.pdf 9 UNICEF. Casamento Prematuro e Gravidez na Adolescência em Moçambique: Resumos de Análises. Maputo;

2015. https://www.unicef.org/mozambique/sites/unicef.org.mozambique/files/2019-02/Casamento-Prematuro- Gravidez-Adolescencia-Mocambique-Causas-Impacto.pdf 10 UNICEF-UNFPA Global Program to End Child Marriage, Mozambique Country Report, 2021.

https://www.unicef.org/media/113201/file/GTA-Mozambique-2021.pdf 11 USAID. 2019. Gender Assessment for USAID/Mozambique Country Development Cooperation Strategy Final Report. https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf 12 Mozambique Country Report, UNICEF/UNFPA Global Program to End Child Marriage, 2021.

https://www.unicef.org/media/113201/file/GTA-Mozambique-2021.pdf 13 CARE. Hope dries up? Women and Girls coping with Drought and Climate Change in Mozambique. CARE International; 2016.

https://careclimatechange.org/wp-content/uploads/2016/11/El_Nino_Mozambique_Report_final.pdf 14 USAID. 2019. Gender Assessment for USAID/Mozambique Country Development Cooperation Strategy Final Report. https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf 15 Arnaldo C, Cau B. Dinâmicas da População e Saúde em Moçambique. Maputo: CEPSA; 2013.

https://www.researchgate.net/profile/Carlos- Arnaldo/publication/318702836_Dinamicas_da_Populacao_e_Saude_em_Mocambique/links/597899d7aca27203ecc 4442b/Dinamicas-da-Populacao-e-Saude-em-Mocambique.pdf 16 Ministério da Saúde (MISAU), Instituto Nacional de Estatística (INE), ICF. Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique 2015. https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq=MOZ.MNCH_BIRTH18.&startPeriod=1970&endPeriod=2022 https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq=MOZ.MNCH_BIRTH18.&startPeriod=1970&endPeriod=2022 https://www.icrw.org/wp-content/uploads/2016/10/Too-Young-to-Wed-Education-and-Action-Toward-Ending-Child-Marriage.pdf https://www.icrw.org/wp-content/uploads/2016/10/Too-Young-to-Wed-Education-and-Action-Toward-Ending-Child-Marriage.pdf https://www.unicef.org/mozambique/sites/unicef.org.mozambique/files/2019-02/Casamento-Prematuro-Gravidez-Adolescencia-Mocambique-Causas-Impacto.pdf https://www.unicef.org/mozambique/sites/unicef.org.mozambique/files/2019-02/Casamento-Prematuro-Gravidez-Adolescencia-Mocambique-Causas-Impacto.pdf https://www.unicef.org/media/113201/file/GTA-Mozambique-2021.pdf https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf https://www.unicef.org/media/113201/file/GTA-Mozambique-2021.pdf https://careclimatechange.org/wp-content/uploads/2016/11/El_Nino_Mozambique_Report_final.pdf https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf https://www.researchgate.net/profile/Carlos-Arnaldo/publication/318702836_Dinamicas_da_Populacao_e_Saude_em_Mocambique/links/597899d7aca27203ecc4442b/Dinamicas-da-Populacao-e-Saude-em-Mocambique.pdf https://www.researchgate.net/profile/Carlos-Arnaldo/publication/318702836_Dinamicas_da_Populacao_e_Saude_em_Mocambique/links/597899d7aca27203ecc4442b/Dinamicas-da-Populacao-e-Saude-em-Mocambique.pdf https://www.researchgate.net/profile/Carlos-Arnaldo/publication/318702836_Dinamicas_da_Populacao_e_Saude_em_Mocambique/links/597899d7aca27203ecc4442b/Dinamicas-da-Populacao-e-Saude-em-Mocambique.pdf https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm

Government of Mozambique is currently partnering with USAID and others with a plan to increase investment in FP/RH to reach a projected modern contraceptive prevalence rate of 37.2 percent among all women aged 15 to 49, regardless of marital status, by 2020.17

HIV infection remains a major public health problem, disproportionately affecting women with pronounced variation at the provincial level. HIV prevalence for women in Mozambique is 13.1% compared to 9.2% for men.18

HIV infection continues to be a major public health concern in Mozambique, and one that disproportionately affects women. Women in Mozambique made up nearly 60% of individuals living with HIV in 2015.19 Prevalence in women has remained steady at 14.4% compared to men at 8.6% in 2020,20 and even more prevalent among young women (6.2% compared to 2.4% of young men).21 However, some of these differences may be explained by reporting bias, as 52% of women are aware of their HIV status compared to 35% of men.22 Meanwhile, 86% of women testing positive are on ARVs compared to 82% of men.23 Women aged 15 to 49 have some knowledge regarding HIV/AIDS, but general knowledge is particularly lacking in some regions: Maputo Province (50%), Tete (47%), Cabo Delgado (17%), Nampula (18%) and Zambezia (20%).24 Transactional sex, low condom use, and multiple concurrent partnerships (CP) continue to place both women and men at greater risk.25 Meanwhile, barriers to HIV treatment include distance to clinics where medication can be obtained, irregular use due to sharing medication among families, a preference for traditional medicine, and the belief that medicine is no longer necessary because the patient does not have any negative symptoms.26

17 Impact Brief: Mozambique, Saving Lives and Improving Health Outcomes in Mozambique through Increased Access to Contraceptives, USAID, 2021. https://www.usaid.gov/global-health/health-areas/family-planning/resources/impact-brief-mozambique#:~:text=The%20maternal%20mortality%20ratio%20in,%2DSaharan%20Africa%2C%20on%20averag e.

18 WHO . HIV/AIDS. WHO Country Office - Mozambique. http://www.afro.who.int/en/mozambique/country-programmes/disease-prevention-and-control/hivaids.html 19 Mozambique | UNAIDS https://www.unaids.org/en/regionscountries/countries/mozambique 20 WHO . HIV/AIDS. WHO Country Office - Mozambique. http://www.afro.who.int/en/mozambique/country-programmes/disease-prevention-and-control/hivaids.html 21 WHO . HIV/AIDS. WHO Country Office - Mozambique. http://www.afro.who.int/en/mozambique/country-programmes/disease-prevention-and-control/hivaids.html 22 USAID. 2019. Gender Assessment for USAID/Mozambique Country Development Cooperation Strategy Final Report. https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf 23 National Strategic Plan for HIV Response - PEN (2015-2019) (Plano Estratégico Nacional de Resposta ao HIV e SIDA 2015–2019. Maputo: República de Moçambique; 2015 p. 64. https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_172584.pdf 24 Ministério da Saúde (MISAU), Instituto Nacional de Estatística (INE), ICF. Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique 2015. Maputo, Moçambique.

https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm 25 Bandali S. Exchange of sex for resources: HIV risk and gender norms in Cabo Delgado, Mozambique. Cult Health Sex. 2011. https://pubmed.ncbi.nlm.nih.gov/21452092/ 26 Audet CM, Chire YM, Vaz LM, Bechtel R, Carlson-Bremer D, Wester CW, Amico KR, Gonzaléz-Calvo L.

Barriers to Male Involvement in Antenatal Care in Rural Mozambique. Qual Health Res. 2016.

https://pubmed.ncbi.nlm.nih.gov/25854615/; Schwitters A, Lederer P, Zilversmit L, Gudo PS, Ramiro I, Cumba L, Mahagaja E, Jobarteh K. Barriers to health care in rural Mozambique: a rapid ethnographic assessment of planned mobile health clinics for ART. Glob Health Sci Pract. 2015. https://pubmed.ncbi.nlm.nih.gov/25745124/ https://www.usaid.gov/global-health/health-areas/family-planning/resources/impact-brief-mozambique#:%7E:text=The%20maternal%20mortality%20ratio%20in,%2DSaharan%20Africa%2C%20on%20average https://www.usaid.gov/global-health/health-areas/family-planning/resources/impact-brief-mozambique#:%7E:text=The%20maternal%20mortality%20ratio%20in,%2DSaharan%20Africa%2C%20on%20average https://www.usaid.gov/global-health/health-areas/family-planning/resources/impact-brief-mozambique#:%7E:text=The%20maternal%20mortality%20ratio%20in,%2DSaharan%20Africa%2C%20on%20average https://www.usaid.gov/global-health/health-areas/family-planning/resources/impact-brief-mozambique#:%7E:text=The%20maternal%20mortality%20ratio%20in,%2DSaharan%20Africa%2C%20on%20average http://www.afro.who.int/en/mozambique/country-programmes/disease-prevention-and-control/hivaids.html http://www.afro.who.int/en/mozambique/country-programmes/disease-prevention-and-control/hivaids.html https://www.unaids.org/en/regionscountries/countries/mozambique http://www.afro.who.int/en/mozambique/country-programmes/disease-prevention-and-control/hivaids.html http://www.afro.who.int/en/mozambique/country-programmes/disease-prevention-and-control/hivaids.html http://www.afro.who.int/en/mozambique/country-programmes/disease-prevention-and-control/hivaids.html http://www.afro.who.int/en/mozambique/country-programmes/disease-prevention-and-control/hivaids.html https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_172584.pdf https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_172584.pdf https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm https://pubmed.ncbi.nlm.nih.gov/21452092/ https://pubmed.ncbi.nlm.nih.gov/25854615/ https://pubmed.ncbi.nlm.nih.gov/25745124/

Nutrition: Stunting prevalence among children under 5 years of age, measured as the percentage of children with height-for-age less than two standard deviations from the mean, was 37.8 in 2020, down from 50.5 in 2000.27 Stunting and severe malnutrition are somewhat more prevalent among male children than female children. For example, 45% of male children under 5 are affected by stunting, measured as height for age, compared to 37% for females.28 Wasting is roughly equal between boys (4.1%) and girls (4.6%) under 5.29

Wasting persists at alarming rates and trends in numbers of overweight will need to be reversed to reach 2030 targets.30 Chronic malnutrition in Mozambique has remained relatively steady for 15 years, while extremely chronic malnutrition in children under the age of 5 remains very high at 43%.31 Chronic malnutrition is particularly pronounced amongst children living in the northern provinces of Nampula, Cabo Delgado, Niassa and Zambézia, where the prevalence is double that of the southern province of Maputo. Chronic malnutrition is twice as common among poor families compared to the wealthiest families.32

While the reasons for chronic malnutrition are many and complex, a major factor is that 81% of the population relies on agriculture for livelihood and over 95% of food crops are produced under rain-fed conditions in a country that suffers frequent drought and floods. 70% of displaced men and women report their migration is due to lack of food, drought conditions, or lack of water.33 Along with infant deaths and poor child health, chronic malnutrition has a severe impact on school performance, household income, and intergenerational cycles of deprivation.34

GBV: In 2007, the Committee on the Elimination of Discrimination against Women (CEDAW) expressed concern about the “high prevalence of domestic violence and sexual violence against women, which appear to be socially legitimized and accompanied by a culture of silence and impunity.”35 The

27 UNICEF, Cross-sector indicators, Mozambique, Indicator: Height-for-age <-2 SD (stunting), Modeled Estimates, 2020.

https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq= MOZ.NT_ANT_HAZ_NE2_MOD.&startPeriod=1970&endPeriod=2022 28 Prevalence of Stunting, Weight for Height (% of children under 5), Mozambique, 2015:

https://data.worldbank.org/indicator/SH.STA.STNT.MA.ZS?end=2015&locations=MZ&start=2015&view=bar 29 Prevalence of Wasting, Weight for Height (% of children under 5), Mozambique, 2015:

https://data.worldbank.org/indicator/SH.STA.WAST.MA.ZS?end=2015&locations=MZ&start=2015&view=bar 30 UNICEF, Cross-sector indicators, Mozambique, Indicator: Height-for-age <-2 SD (stunting), Modeled Estimates, 2020.

https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq= MOZ.NT_ANT_HAZ_NE2_MOD.&startPeriod=1970&endPeriod=2022 31 UNICEF | Nutrition, https://www.unicef.org/mozambique/en/nutrition 32 UNICEF | Nutrition, https://www.unicef.org/mozambique/en/nutrition 33 CARE. Hope dries up? Women and Girls coping with Drought and Climate Change in Mozambique. CARE International; 2016.

https://careclimatechange.org/wp-content/uploads/2016/11/El_Nino_Mozambique_Report_final.pdf 34 UNICEF | Nutrition, https://www.unicef.org/mozambique/en/nutrition 35 Concluding observations of the Committee on the Elimination of Discrimination against Women (CEDAW), 2007. https://evaw-global-database.unwomen.org/- /media/files/un%20women/vaw/country%20report/africa/mozambique/mozambique%20cedaw%20co.pdf?vs=1429 https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq=MOZ.NT_ANT_HAZ_NE2_MOD.&startPeriod=1970&endPeriod=2022 https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq=MOZ.NT_ANT_HAZ_NE2_MOD.&startPeriod=1970&endPeriod=2022 https://data.worldbank.org/indicator/SH.STA.STNT.MA.ZS?end=2015&locations=MZ&start=2015&view=bar https://data.worldbank.org/indicator/SH.STA.WAST.MA.ZS?end=2015&locations=MZ&start=2015&view=bar https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq=MOZ.NT_ANT_HAZ_NE2_MOD.&startPeriod=1970&endPeriod=2022 https://data.unicef.org/resources/data_explorer/unicef_f/?ag=UNICEF&df=GLOBAL_DATAFLOW&ver=1.0&dq=MOZ.NT_ANT_HAZ_NE2_MOD.&startPeriod=1970&endPeriod=2022 https://www.unicef.org/mozambique/en/nutrition https://www.unicef.org/mozambique/en/nutrition https://careclimatechange.org/wp-content/uploads/2016/11/El_Nino_Mozambique_Report_final.pdf https://www.unicef.org/mozambique/en/nutrition https://evaw-global-database.unwomen.org/-/media/files/un%20women/vaw/country%20report/africa/mozambique/mozambique%20cedaw%20co.pdf?vs=1429 https://evaw-global-database.unwomen.org/-/media/files/un%20women/vaw/country%20report/africa/mozambique/mozambique%20cedaw%20co.pdf?vs=1429

Committee added that the responses of social services and systems of justice were still inadequate to meet this challenge.36

A 2012 cross-sectional study of 1500 women in Maputo found that 70.2% had experienced intimate partner violence.37 The same study found higher levels of education were positively associated with violence,38 but this could be due to an association between education and reporting bias, with women in high education levels being more likely to contact resources and report violence. A study in 2015 found that over half (54%) of women who had experienced physical or sexual violence did not seek help.39 A recent rapid assessment carried out in Cabo Delgado revealed that girls in IDP camps as young as 13 years-old were either pregnant, had a child or were already in a marital union. Also, women and girls with and without disabilities were forced “to exchange sexual favors as a survival strategy, for example, to secure their names on beneficiary lists. Community leaders in the resettlement centers were allegedly accused of perpetuating this practice.”40 Women and girls with disabilities also face limitations in accessing support and response to GBV and studies highlight that this group is up to 10 times more likely to experience GBV than non-disabled women and girls.41

Due to societal discrimination and lack of economic opportunities, members of the LGBTQI community may be highly vulnerable to GBV. Many existing GBV shelters do not include the LGBTQI community and staff are not prepared to receive and care for the specific needs of this group. As a result, LGBTQI victims/survivors of violence do not have a place of refuge and have less access to health and psychosocial response services.42

Education: UNICEF, UNESCO, and other organizations have noted that girls frequently have fewer years available to complete their schooling because their average marriage age is lower than that of boys.

Girls also start school later on average because of barriers related to distance, transportation, and safety.43 While high levels of dropout and poor educational attainment are a problem for all children, girls especially suffer from low retention. Even with enrolled students, about half (mostly girls) are absent every day.

36 Concluding observations of the Committee on the Elimination of Discrimination against Women (CEDAW), 2007. https://evaw-global-database.unwomen.org/- /media/files/un%20women/vaw/country%20report/africa/mozambique/mozambique%20cedaw%20co.pdf?vs=1429 37 Zacarias AE, Macassa G, Svanström L, Soares JJ, Antai D. Intimate partner violence against women in Maputo city, Mozambique. BMC International Health and Human Rights, 2012.

https://bmcinthealthhumrights.biomedcentral.com/articles/10.1186/1472-698X-12-35 38 Zacarias AE, Macassa G, Svanström L, Soares JJ, Antai D. Intimate partner violence against women in Maputo city, Mozambique. BMC International Health and Human Rights, 2012.

https://bmcinthealthhumrights.biomedcentral.com/articles/10.1186/1472-698X-12-35 39 Ministério da Saúde (MISAU), Instituto Nacional de Estatística (INE), ICF. Inquérito de Indicadores de Imunização, Malária e HIV/SIDA em Moçambique 2015. Maputo, Moçambique.

https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm 40 CARE. Conflict Sensitive Rapid Gender Analysis Cabo Delgado, Mozambique, 2022 41 Young Persons with Disabilities: Call for Equal Rights and a Life Free of Violence (3 December 2021) 42 Trust and Choice INCREASING ACCESS TO HIV SERVICES FOR LGBT PEOPLE IN MOZAMBIQUE & UGANDA by Frontline AIDS 2021 43 See, e.g. UNICEF | Casamento prematuro em Moçambique; Moçambique tem uma das taxas mais elevadas de casamento prematuro do mundo, https://www.unicef.org/mozambique/casamento-prematuro-em-mo%C3%A7ambique. See also Fox LM. Beating the Odds: Sustaining Inclusion in Mozambique’s Growing Economy, World Bank; 2008.: https://openknowledge.worldbank.org/handle/10986/7981 https://evaw-global-database.unwomen.org/-/media/files/un%20women/vaw/country%20report/africa/mozambique/mozambique%20cedaw%20co.pdf?vs=1429 https://evaw-global-database.unwomen.org/-/media/files/un%20women/vaw/country%20report/africa/mozambique/mozambique%20cedaw%20co.pdf?vs=1429 https://bmcinthealthhumrights.biomedcentral.com/articles/10.1186/1472-698X-12-35 https://bmcinthealthhumrights.biomedcentral.com/articles/10.1186/1472-698X-12-35 https://dhsprogram.com/publications/publication-ais12-ais-final-reports.cfm https://www.unicef.org/mozambique/casamento-prematuro-em-mo%C3%A7ambique https://www.unicef.org/mozambique/casamento-prematuro-em-mo%C3%A7ambique https://openknowledge.worldbank.org/handle/10986/7981

2019 UNESCO data show girls make up more than 70% of all out-of-school children. While most boys and girls are enrolled in primary school, the gross enrollment ratio at the secondary level is 33% for girls and 37% for boys.44 Adult literacy remains a challenge for many women, with 70% of women illiterate, compared to 40% of men.45

Progress has been made toward overall educational attendance and quality, including in gender parity in enrolled students. New initiatives include Mozambique’s financial investments in education, the provision of free primary schooling starting in 2003, provision of free textbooks for students, and the recent revocation of former laws requiring the segregation of pregnant girls.46 With these changes, primary school enrollment of girls in grades one through five has increased, especially among girls in the poorest quintile and rural areas.47

Labor/Access to Markets: The informal economy is large, with most Mozambicans, and especially women, self-employed or working in unpaid family jobs. Of Mozambique’s 11 million people, of whom 62.1% are self-employed, 24.6% work for other family members with no remuneration, and only 10.9% receive salaries. Of people who receive salaries, 4.1% work in the public sector and 6.9% work in the private sector.48 Wage jobs are scarce, even in urban areas. Meanwhile, many self-employed urban workers working long hours still struggle to obtain a sustainable livelihood.49

There is a dramatic gender gap between men and women in the formal labor force, with 82.3 % of men employed, compared to only 39.4% of women. Among women living in rural areas, 80% work in the agricultural sector compared to 56.1% of rural men.50 Apart from the agricultural sector, women are most active in the sales and services sectors.51

44 Education | Mozambique | U.S. Agency for International Development. Available from:

https://www.usaid.gov/mozambique/education 45 Women’s Literacy in Angola and Mozambique, Mozambique, published 18 November 2015.

https://uil.unesco.org/case-study/effective-practices-database-litbase-0/womens-literacy-angola-and-mozambique-mozambique 46 UNICEF. Education | UNICEF Mozambique: http://www.unicef.org.mz/en/our-work/what-we-do/education/. See also UNICEF Educação | Para cada criança, educação https://www.unicef.org/mozambique/educa%C3%A7%C3%A3o; See also Save the Children. MINEDH compromete-se a revogar o Despacho 39/2003. 2018. https://mozambique.savethechildren.net/news/minedh-compromete-se-revogar-o-despacho-392003 47 Fox LM. Beating the Odds: Sustaining Inclusion in Mozambique’s Growing Economy, World Bank, 2008.

https://openknowledge.worldbank.org/handle/10986/7981 48 World Bank | Jobs Diagnosis, Mozambique, 2018.

https://openknowledge.worldbank.org/bitstream/handle/10986/30200/129408.pdf?sequence=6 49 USAID. 2019. Gender Assessment for USAID/Mozambique Country Development Cooperation Strategy Final Report. https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf 50 USAID. 2019. Gender Assessment for USAID/Mozambique Country Development Cooperation Strategy Final Report. https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf 51 USAID. 2019. Gender Assessment for USAID/Mozambique Country Development Cooperation Strategy Final Report. https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf https://www.usaid.gov/mozambique/education https://uil.unesco.org/case-study/effective-practices-database-litbase-0/womens-literacy-angola-and-mozambique-mozambique https://uil.unesco.org/case-study/effective-practices-database-litbase-0/womens-literacy-angola-and-mozambique-mozambique http://www.unicef.org.mz/en/our-work/what-we-do/education/ https://www.unicef.org/mozambique/educa%C3%A7%C3%A3o https://mozambique.savethechildren.net/news/minedh-compromete-se-revogar-o-despacho-392003 https://mozambique.savethechildren.net/news/minedh-compromete-se-revogar-o-despacho-392003 https://openknowledge.worldbank.org/handle/10986/7981 https://openknowledge.worldbank.org/bitstream/handle/10986/30200/129408.pdf?sequence=6 https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf

It is estimated that about 300,000 young people enter the labor market each year, but there is an inadequate supply of jobs relative to the demand for work they represent.52 In rural areas, women cite domestic tasks as the main barrier to working full time in agriculture, cutting down on income for women. Lack of public services such as reliable water supplies, and low incomes, leading to more time cooking and doing household tasks, mean that rural women must spend much of their time on household chores, not earning from full-time agricultural work.53 Agricultural seasonality affects all agricultural workers, but the lack of assets and the burden of household chores are particular barriers for women’s full time agricultural work.54

Insecurity: IOM currently estimated there are over 784,000 internally displaced persons (IDPs) in northern Mozambique due to insecurity in the northern province of Cabo Delgado.55 Conflict-related displacement was exacerbated by natural disaster in March 2022 when cyclone Gombe made landfall, impacting the stability of around 700,000 affected people in Nampula Province.56 In 2021 (before cyclone Gombe) it was estimated around 750,000 people had been displaced by security incidents and violence in northern Mozambique.57 As with all conflict and natural disasters, young women are particularly vulnerable. The majority of IDPs in Nampula, Cabo Delgado, and Niassa are women and adolescent girls. In 2021, Save the Children marked an increase in unaccompanied and separated children in IDP camps. With swelling numbers and insufficient resources, GBV, sexual exploitation, and early marriage increased among displaced women and girls.58

FINDINGS BY DOMAIN

The gender inequalities and vulnerabilities facing women and girls include important structural, cultural and normative barriers to early and appropriate access and use of disease prevention, diagnosis, and treatment services. As defined in ADS 205 and the WEEE (Women's Entrepreneurship and Economic Empowerment) Act, the gender analysis findings are described following the key gender domains : 1) laws, policies, and institutional context; 2) cultural norms and beliefs; (3) roles, responsibilities, and time use; (4) access to and control of resources; and 5) patterns of power and decision-making.59

DOMAIN 1: LAWS, POLICIES, REGULATIONS, AND INSTITUTIONAL CONTEXT

52 Jones S, Tarp F. Jobs and Welfare in Mozambique: Country case study for the 2013 World Development Report United Nations University World Institute for Development Economics Research, 2012.

https://openknowledge.worldbank.org/handle/10986/12136 53 World Bank | Jobs Diagnosis, Mozambique, 2018.

https://openknowledge.worldbank.org/bitstream/handle/10986/30200/129408.pdf?sequence=6 54 USAID. 2019. Gender Assessment for USAID/Mozambique Country Development Cooperation Strategy Final Report. https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf 55 IOM: “Over 700,000 Affected by Cyclone Gombe in Mozambique Still in Need of Humanitarian Assistance as IOM Scales up Response” 2022, https://mozambique.iom.int/news/over-700000-affected-cyclone-gombe-mozambique-still-need-humanitarian-assistance-iom-scales-response 56 Ibid.

57 Protection Cluster Mozambique. (2021). Mozambique Protection Cluster National Strategy 2021.

https://reliefweb.int/sites/reliefweb.int/files/resources/20210827_moz_protection_cluster_strategy.pdf 58 USAID. 2019. Gender Assessment for USAID/Mozambique Country Development Cooperation Strategy Final Report. https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf 59 S.3247 - Women's Entrepreneurship and Economic Empowerment Act of 2018:

https://www.congress.gov/bill/115th-congress/senate-bill/3247/text https://openknowledge.worldbank.org/handle/10986/12136 https://openknowledge.worldbank.org/bitstream/handle/10986/30200/129408.pdf?sequence=6 https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf https://mozambique.iom.int/news/over-700000-affected-cyclone-gombe-mozambique-still-need-humanitarian-assistance-iom-scales-response https://mozambique.iom.int/news/over-700000-affected-cyclone-gombe-mozambique-still-need-humanitarian-assistance-iom-scales-response https://reliefweb.int/sites/reliefweb.int/files/resources/20210827_moz_protection_cluster_strategy.pdf https://www.congress.gov/bill/115th-congress/senate-bill/3247/text

Overall, Mozambican laws/policies and national and institutional plans proactively emphasize gender equality and encourage participation of women & girls in civil life. Equality before the law, however, underlines the de facto unequal experience of women and girls, who’s lived reality does not comply with policy. Child marriage, for example, is illegal, yet nearly 50% of all girls in Mozamobique are married before age 18, while 14% are married before the age of 15.60 Reasons for the disconnect between de jure and de facto life are attributed to deeply rooted cultural practices, a lack of will among government authorities and community leaders to enforce laws and policies and, to a lesser degree, a lack of institutional knowledge and resources to enforce policy.61 The National Directorate for Women (DNM) was established in 2000, housed in the The Ministry of Women and Social Action (MMAS), with the goal of defining and promoting programs that support women and gender equality in Mozambique. The Department of Women and Family, within DNM, coordinates strategies specifically related to vulnerable women, including on HIV/AIDS and gender-related barriers to health.62

Gender equality has been integrated into Mozambique’s health laws and policies. In recent years, health policies and plans have included decriminalization of homosexuality, a loosening of laws restricting abortion and guidance for comprehensive male involvement. In 2015, civil society and government partners succeeded in removing homosexuality from the penal code, and ministries have since developed strategies addressing the health needs of LGBT communities.63 Despite this progress, organizations like LAMBDA who represent the LGBTQI community in Mozambique, have not yet been registered. They have been advocating this right to the Ministry of Justice for over a decade. In 2008, when LAMBDA had first requested registration, the motion was blocked due to a clause stating that organizations whose purpose is “contrary to the moral, social, and economic order of the country and offend the rights of others or the public good” could not be registered. In 2017, however, the country’s highest constitutional body “ruled that the clause contradicted Article 53 of the constitution.” The hope was that the organization would be registered by 2018, however, LAMBDA still has not been registered, without a valid reason from the relevant government bodies.64

In 2018, Mozambique’s Ministry of Health/ Ministério da Saúde (MISAU) created a Strategy for Gender Equality in the Health Sector.65 The Health Sector’s Strategy for Gender Inclusion aims to remove gender barriers to accessing health by also addressing the reality that health services are women-centered and acknowledges the need to increase men's access to health services not only for their own health but

60 UNICEF | Child Marriage in Mozambique: https://www.unicef.org/mozambique/en/child-marriage-mozambique#:~:text=English- ,Mozambique%20has%20one%20of%20the%20highest%20rates%20of%20child%20marriage,and%20southern%2 0African%20sub%2Dregion.

Mozambique: DHS, 2011 - Final Report (Portuguese), 2011. https://dhsprogram.com/publications/publication-fr266-dhs-final-reports.cfm 61 USAID. 2019. Gender Assessment for USAID/Mozambique Country Development Cooperation Strategy Final Report. https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf 62 African Development Fund (2005). Women’s Entrepreneurship and Skills Development for Food Security: Pilot Project Appraisal Report. https://www.afdb.org/fileadmin/uploads/afdb/Documents/Project-and- Operations/Mozambique_-_Women_s_Entrepreneurship_and_Skills_Development_for_Food_Security_- _Pilot_Project_-_Appraisal_Report.pdf 63 BBC, “Mozambique decriminalises gay and lesbian relationships,” 2015. https://www.bbc.com/news/world-africa-33342963 64 Mozambique's Recent Ruling Moves LGBTQ Organization Closer to Legal Recognition- HRC Staff (2017) 65 Strategy to provide gender sensitive health care, 2018. https://www.undp.org/mozambique/news/strategy-provide-gender-sensitive-health-care#:~:text=Mozambique%20Ministry%20of%20Health%20launched,human%20right%20of%20every%20citizen.

https://www.unicef.org/mozambique/en/child-marriage-mozambique#:%7E:text=English-,Mozambique%20has%20one%20of%20the%20highest%20rates%20of%20child%20marriage,and%20southern%20African%20sub%2Dregion https://www.unicef.org/mozambique/en/child-marriage-mozambique#:%7E:text=English-,Mozambique%20has%20one%20of%20the%20highest%20rates%20of%20child%20marriage,and%20southern%20African%20sub%2Dregion https://www.unicef.org/mozambique/en/child-marriage-mozambique#:%7E:text=English-,Mozambique%20has%20one%20of%20the%20highest%20rates%20of%20child%20marriage,and%20southern%20African%20sub%2Dregion https://www.unicef.org/mozambique/en/child-marriage-mozambique#:%7E:text=English-,Mozambique%20has%20one%20of%20the%20highest%20rates%20of%20child%20marriage,and%20southern%20African%20sub%2Dregion https://dhsprogram.com/publications/publication-fr266-dhs-final-reports.cfm https://dhsprogram.com/publications/publication-fr266-dhs-final-reports.cfm https://pdf.usaid.gov/pdf_docs/PA00WGW3.pdf https://www.afdb.org/fileadmin/uploads/afdb/Documents/Project-and-Operations/Mozambique_-_Women_s_Entrepreneurship_and_Skills_Development_for_Food_Security_-_Pilot_Project_-_Appraisal_Report.pdf https://www.afdb.org/fileadmin/uploads/afdb/Documents/Project-and-Operations/Mozambique_-_Women_s_Entrepreneurship_and_Skills_Development_for_Food_Security_-_Pilot_Project_-_Appraisal_Report.pdf https://www.afdb.org/fileadmin/uploads/afdb/Documents/Project-and-Operations/Mozambique_-_Women_s_Entrepreneurship_and_Skills_Development_for_Food_Security_-_Pilot_Project_-_Appraisal_Report.pdf https://www.bbc.com/news/world-africa-33342963 https://www.bbc.com/news/world-africa-33342963 https://www.undp.org/mozambique/news/strategy-provide-gender-sensitive-health-care#:%7E:text=Mozambique%20Ministry%20of%20Health%20launched,human%20right%20of%20every%20citizen https://www.undp.org/mozambique/news/strategy-provide-gender-sensitive-health-care#:%7E:text=Mozambique%20Ministry%20of%20Health%20launched,human%20right%20of%20every%20citizen https://www.undp.org/mozambique/news/strategy-provide-gender-sensitive-health-care#:%7E:text=Mozambique%20Ministry%20of%20Health%20launched,human%20right%20of%20every%20citizen also for the health of their families. Understanding that gender is a social construct, the strategy seeks to create links with the media (for gender sensitive messaging), ensure a link between the gender action plan and the district economic and social plan, promote coordination at multi-sectoral level with regards to GBV activities and always engage with community and religious leaders. The strategy’s action plan seeks to have adequate infrastructure from men, women and people with other sexual identities, however, it does not detail specific challenges and needs the LGTBQI community faces in accessing health services.

There have also been improvements in access to safe abortion for women, with revisions to the penal code and removal of legal barriers to vital services for vulnerable and marginalized women.66 Finally, the National Plan and the Strategy for the Reduction of Maternal and Newborn Mortality of 2000 was designed to reduce maternal mortality by improving diagnosis and treatment of obstetric complications.67

Laws, Policies, Regulations, & Plans

Scope and Impact

Constitution of the Republic of Mozambique

Ensures equal rights and duties for all Mozambicans. Articles 35 and 36 establish that men and women are equal before the law in all aspects of political, economic and social life with the same rights and subject to the same duties, without discrimination. Article 122 promotes and supports women’s participation, role, and empowerment in all spheres of the country’s political, economic, social and cultural life.

Lei da Família: Lei nº 10/2004 (Family Code) (2004)68

On divorce and dissolution of marriage, Employment discrimination, Forced and early marriage, Gender discrimination, Property and inheritance rights:

● The law defines family relationships and establishes certain “rights of the family.”

● The law guarantees men and women equal rights to property ownership

● The law prohibits various forms of discrimination against women, including through polygamy, inheritance, age at marriage and choice of children.

● The law defines marriage as a “voluntary union between a man and a woman”, which requires mutual consent.

● The law makes marriage before age 16 illegal under any circumstance and requires parental consent for girls to marry under age 18.

● Coerced marriage is subject to annulment.

● The law provides that both husband and wife have the right to

“represent the family”, to administer the family finances, and to work.

● The law also outlines provisions for divorce. Husbands are required to pay child support in case of divorce, 66 Penal Code 2014: Lei nº 35/2014 (2014), https://www.law.cornell.edu/women-and-justice/location/mozambique 67 USAID. Opportunities for integrating gender transformative programming throughout MCHIP. Maputo: USAID;

2013. https://pdf.usaid.gov/pdf_docs/PA00KNSH.pdf 68 Lei da Família: Lei nº 10/2004 (Family Code), 2004. https://www.law.cornell.edu/women-and-justice/location/mozambique https://www.law.cornell.edu/women-and-justice/location/mozambique https://pdf.usaid.gov/pdf_docs/PA00KNSH.pdf https://www.law.cornell.edu/women-and-justice/location/mozambique

The Government's Five-Year Program (Plano Estratégico do Sector da Saúde) (2014-2019)

Establishes within the framework of its priorities, “Combat all manifestations of discrimination and exclusion based on differences in culture, ethnicity, origin, gender, race, religion, region of origin and political party affiliation.” Recognizes that differences in social relations are based on gender and culturally constructed, especially access to resources, power and decision-making and gender roles and responsibilities affect the health of women. Recognizes that gender has implications for the exposure to risk and vulnerability of women, access to services and quality of care and treatment. Defines principles of equity that must be taken into account in allocation, delivery and use of services to ensure that gender and other factors do not pose barriers.

Agenda 2025 (2003)

Defines the achievement of gender equity, through the strengthening of institutions that deal with women's issues; strengthening inter-institutional coordination mechanisms; and the change in mentality with a view to enhancing the role of women.

Gender Policy & Implementation Strategy (Politica de Género e Estratégia de Implementação) (2018).

Operationalizes the Government's intentions to address integrated guidelines for Gender equality and respect for human rights which focus on various critical areas. Those that are most related to maternal/child health and nutrition include the guidelines to: (I) Contribute to elimination of harmful practices against women, men, boys and girls rights; (II) Promote and develop actions to guarantee equal representation and participation of men and women in the decision making bodies at all levels; (III) Promote equality of rights and opportunities for girls and boys accessing education, quality training and other benefits; (IV) Promote rights and opportunities equality for women and men regarding possession and control over productive resources and income, as well as related to formal and informal employment and non-paid domestic work;

(VIII) Incentivize the social communication organs to contribute to the transformation of Mindset by promoting a balanced representation non-stereotyped of girls and women, and also broaden the access to information technologies and communication between girls and women.

The Strategy will contribute to the development and implementation of strategies to prevent, eliminate and transform social and cultural practices that legitimize and tolerate GBV, sexual harassment, rape, child marriage and adolescent pregnancy.

The strategy ensures the development of transformative strategies regarding gender that address the unequal status and vulnerabilities of women and girls, and harmful practices. Strengthen the participation of men and boys in SRHR programs, services and processes by transforming masculine social norms.

Strategy for Gender inclusion in the health sector (A Estratégia de Inclusão da Igualdade de Género no Sector da Saúde) (2018- 2023)69

Defines a vision, mission and priorities for the broader health sector. The vision is a national health service with equal opportunities for men and women in the management, provision and access to health. Related to this, the mission is to promote gender equity and equality among men and women, community and health providers in the planning, implementation, and health service provision to improve access and utilization of health services. In order to advance this vision and mission, the following priorities were developed: (i) Promote institutional capacity for the integration of gender, human rights and response to violence in the health sector; (ii) Develop training actions and health promotion for the inclusion of gender perspective, human rights and response to gender based violence; (iii) Provide sensitive health services to gender inclusion, human rights and response to gender based violence.

Aims to guarantee that programs and policies relevant to health, at all stages, integrate the concerns of women, men and other gender identities so that all may benefit in an equal manner. The involvement of men receives special attention, ensuring they receive services that respond to their specific needs and that promote their participation in family health.

National Strategic Plan for HIV Response - PEN (Plano Estratégico Nacional de Resposta ao HIV) (2015-2019)

Response centered in human rights and gender justice calls for inclusion of these questions in all strategic areas and responses to HIV/AIDS. Refers to necessity of reaching 10-14 year-olds with primary prevention, taking into account social norms and cultural practices; promotes interventions that contribute to social and community change; focuses on gender equality, prevention of GBV including in indices of early marriage and pregnancy; highlights need to empower influential local leaders in the area of sexuality (especially counselors, madrinhas of initiation rites, etc.) and HIV prevention.

Guideline for the Integration of HIV and AIDS Prevention, Care and Treatment Services for Key Populations

(MSM, MTS, PJD,

Prisoners) in the Health Sector (Directriz para

Identifies structural factors based on sociocultural, political and economic conditions that affect vulnerability to HIV infection.