Mozambique has made important progress in improving utilization of health services for fever and by 2018 the NMCP target for care-seeking was nearly achieved with 69.1% of mothers reportedly seeking care for their febrile children. This 2018 MIS complements the analysis of the 2011 and 2015 national surveys conducted in Mozambique which found lower care-seeking [5]. While these results reflect important progress since 2015, it is important to note that nearly one in every four children under five years old with fever in Mozambique did not seek care. Malaria services are freely provided in public health facilities and by community health workers in Mozambique, but appropriate access clearly continues to be a challenge, particularly for specific populations. Failure to seek care can lead to malaria morbidity, mortality, and onward transmission, compromising Mozambique’s malaria control efforts. While care-seeking is largely from public health services, some care is still sought from traditional and private providers.
Different from earlier results in Mozambique [5], this analysis showed that care-seeking in 2018 was associated with having a younger child (< 6 months old, 6–11 months old and 11–23 months old), which might be associated with a mothers’ perception that younger children are more vulnerable and require appropriate care seeking, as shown in a study from Nigeria [13]. This higher care utilization for the youngest children is a positive finding given that younger children are more likely to have worse health outcomes associated to malaria.
Care-seeking in Mozambique was also associated with the family’s middle and richest wealth quintiles, despite the fact that most of the mothers sought care in the public sector (95.9%) [4] where malaria diagnosis and treatment are free. This is indicative that while there might not be costs for services, economic factors such as indirect costs like transportation can increase the economic burden to the household, potentially inhibiting care seeking, as shown in previous studies [14, 15]. A prior study in a high burden district of Mozambique found that the median household costs associated with care-seeking for uncomplicated malaria were US$ 3.46 (IQR US$ 0.07–22.41) and US$ 81.08 (IQR US$ 39.34–88.38) per severe case. This median cost of care-seeking for uncomplicated malaria was approximately 21% (US$ 3.46) of the monthly expenditure of a family in the study province [16], indicating that malaria care-seeking may still represent a catastrophic cost for many families in Mozambique. This economic burden was also described in Malawi, with high direct and indirect costs for malaria illness episode in a country where malaria treatment is free in the public sector [17]. Additionally, maternal education continues to influence care seeking.
The main reason reported by mothers for not seeking care was the long distance to the health facility. Previous studies have also found that distance to facilities was associated with delays in care-seeking and increased risk of severe malaria [18, 19]. This provides additional evidence that there remain broader socioeconomic barriers to care seeking, underscoring the need to address systemic barriers to care such as physical access to health facilities/community case management. For example, the most frequently cited reason for not seeking care was that the facility was too far. As such, there is a critical need to improve physical and economic access to health services to improve utilization. This is reinforced by the fact that more educated and wealthier mothers were more likely to report having sought care, as previously described [10].
This study found no association between key SBC intervention objectives such as maternal comprehensive malaria knowledge and care-seeking for fever. This finding is similar to some previous studies from Ethiopia [20] and Myanmar [9]. Additionally, there was no association between reported exposure to malaria messages and care seeking. Thus, in a context such as Mozambique where there is relatively high malaria knowledge, these behavioural interventions may not be as effective as structural interventions. In the current study, sex of the child, area of residence and province are no longer significantly associated with care-seeking which is different than 2015 findings [5].
The major limitation of this study is the sample size and the relatively low number of mothers that reported hearing or seeing malaria messages in the prior 6 months. The generalizability of the finding that there was no association in this setting between exposure to malaria messages and malaria knowledge and the target behaviour of care-seeking to settings with higher coverage of SBC interventions may be limited.