Llop-Gironés et al. Globalization and Health (2019) 15:67 https://doi.org/10.1186/s12992-019-0508-4 RESEARCH Open Access Health equity monitoring is essential in public health: lessons from Mozambique Alba Llop-Gironés1,2,3* , Lucinda Cash-Gibson1,2,3, Sergio Chicumbe4,5, Francesc Alvarez6, Ivan Zahinos6, Elisio Mazive7,8 and Joan Benach1,2,3,9 Abstract Background: Countries must be able to describe and monitor their populations health and well-being needs in an attempt to understand and address them. The Sustainable Development Goals (SDGs) have re-emphasized the need to invest in comprehensive health information systems to monitor progress towards health equity; however, knowledge on the capacity of health information systems to be able do this, particularly in low-income countries, remains very limited. As a case study, we aimed to evaluate the current capacity of the national health information systems in Mozambique, and the available indicators to monitor health inequalities, in line with SDG 3 (Good Health and Well Being for All at All Ages). Methods: A data source mapping of the health information system in Mozambique was conducted. We followed the World Health Organization’s methodology of assessing data sources to evaluate the information available for every equity stratifier using a three-point scale: 1 - information is available, 2 - need for more information, and 3 - an information gap. Also, for each indicator we estimated the national average inequality score. Results: Eight data sources contain health information to measure and monitor progress towards health equity in line with the 27 SDG3 indicators. Seven indicators bear information with nationally funded data sources, ten with data sources externally funded, and ten indicators either lack information or it does not applicable for the matter of the study. None of the 27 indicators associated with SDG3 can be fully disaggregated by equity stratifiers; they either lack some information (15 indicators) or do not have information at all (nine indicators). The indicators that contain more information are related to maternal and child health. Conclusions: There are important information gaps in Mozambique’s current national health information system which prevents it from being able to comprehensively measure and monitor health equity. Comprehensive national health information systems are an essential public health need. Significant policy and political challenges must also be addressed to ensure effective interventions and action towards health equity in the country. Keywords: Health information systems, Health equity, Public health, Social determinants of health, Sustainable development goals Background and take action on health inequalities, so as to ‘Leave No On-going debates about health equity in the context of One Behind’ [1]. United Nations (UN)‘s Sustainable Development Goals The minimum requirements for a comprehensive HIS (SDGs) have re-emphasized the need to invest in compre- that can report on the SDH and health equity have hensive health information systems (HIS) to enable coun- already been identified, as well as a list of essential tries to study the Social Determinants of Health (SDH) sources of health-related information; these include so- cial stratifiers such as gender, social class, race, ethnicity * Correspondence: alballopgirones@gmail.com and place of residence, as well as a diversity of mortality, 1 Health Inequalities Research Group-Employment Conditions Network morbidity and disability outcomes, which include self- (GREDS-EMCONET), Universitat Pompeu Fabra, Barcelona, Spain 2 Johns Hopkins University University Pompeu Fabra Public Policy Center, assessed physical and mental health [2, 3]. Yet in high- Barcelona, Spain and middle-income countries the best available HIS is Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Llop-Gironés et al. Globalization and Health (2019) 15:67 Page 2 of 7 limited. In low-income countries (LICs), which face it contains population surveys, such as DHS among some of the most severe health problems, the picture is others. much worse, and it is often not clear what kind of health In the MoH, a Planning and Cooperation Directorate and socio-demographic information is available, or (DPC) is responsible for long-term planning, statistical whether the information available can be used to effect- collection, and the analysis of health data. The Health ively analyse the SDH and monitor health equity [4]. Information Department, another directorate, is in Also, the feasibility of obtaining disaggregated data in charge of the management of the HIS and guaranteeing, LICs to support action at national and local level is often where possible, the interoperability of the different discussed in the scientific literature [5] and international databases. forums, such as the UN Statistical Commission on SDG Users of the HIS include a number of non-governmental indicators. However, despite large data limitations, there organizations supporting vertical programs, the World are examples of data that allow differentiation by social Health Organization (WHO) and other UN organizations, group and geographical area, like that of reproductive, the Health Directorates of the MoH such as Public Health, maternal, newborn and child health included in the Medical Care, and Planning and Cooperation, the National Demographic and Health Survey (DHS). Health Instituto (INS), and the few national research Mozambique serves as a useful LIC case study, as it ranks centers, academic institutions and individual researchers. 181st out of 188 countries in the Human Development The country’s research practices are similar to other Index 2016 and is a major recipient of health aid [6] that post-colonial and resource-dependent countries in Sub- has large within-country health inequalities evaluated using Saharan Africa [8], with strong dependencies on top- household budget survey data [7]. The Constitution endows down policies, limited governmental support, and with all citizens with the right to health (art. 89), yet the focus of research funding almost exclusively provided by foreign national health policies is mainly on the provision of donors and international agencies. medical care. In most LICs, two main types of HIS data sources are The HIS in Mozambique dates back to 1976, when a found [9]: institution-based data, which contain infor- system for the registration of preventive, promotional mation on people who have interacted with a given insti- and curative activities was formally established. In the tution and population-based data, such as household early 1980s, the Ministry of Health (MoH) established a surveys that have information on a representative sample data collection mechanism for all public health facilities of the population, including census and vital registration based on an annual survey-type form that included some that have information on every individual. These two epidemiological indicators. In the 1990s, the HIS was main sources of health and well-being information, while introduced nationwide in the form that is still main- providing useful data, lack up-to-date key population in- tained as the base of the health statistical information dicators for comprehensive equity-oriented decision- today. In 2016, the MoH introduced an Information making. For example, poor vital registration systems System for Monitoring and Evaluation (SIS-MA), essen- mean that a large proportion of people are born and die tially the electronic equivalent of all paper-based data uncounted for, and the reasons for their deaths are summaries previously implemented in the HIS. SIS-MA largely unknown [10]. Additionally, indicator discrepan- aggregates and reports routine information at the health cies often arise, due to different data collection methods facility level. The information flux is transferred monthly [3], and data quality [11]. from the health facilities to the District Services of Health, Household surveys, such as the DHS, usually have Women and Social Work (SDSMAS in Portuguese), and some of the required information to be able to monitor towards the Provincial Health Directorate (DPS in the SDH and the progress towards achieving health Portuguese) and the MoH. equity (e.g. they collect data on health status, demo- The current HIS is composed of various database sys- graphics and living conditions), yet they are intermittent tems from different MoH departments, for example, and limited in power for district-level estimates [5]. routine information reporting (formerly known as “basic Household surveys are typically used by governments in module” and currently SIS-MA), aggregated hospital ser- LICs to monitor population health needs, however, as vice delivery data (SIS-H), and the registration of vital research funding in many LIC is predominantly provided events from hospital-based births and deaths (SIS-ROH). by foreign donors and international agencies, household Besides this, there are parallel database systems managed surveys are also used by donors to tie this information by vertical health programs such as Electronic Patient to reporting requirements and programme-specific mon- Tracking System (EPTS), a longitudinal information sys- itoring, such as maternal and child health or populations tem for HIV patients, the medicines and medical com- at risk of HIV [9]. modities warehouse information system, and the human Over the last two decades, and particularly in line resources health information system (eSIP). Additionally, recommendations of the final report of the WHO’s Llop-Gironés et al. Globalization and Health (2019) 15:67 Page 3 of 7 Commission on SDH in 2008, additional efforts have from the MoH of Mozambique and the National Insti- been made to support the mapping of national HIS cap- tute of Statistics of Mozambique to reach consensus on acities, the integration of a health equity lens into HIS scoring the indicators. The final document was agreed [12], and the creation of observatories to measure on by the research team. health inequalities in low and middle income countries [13]. Yet a great number of challenges still exist glo- Results bally, in terms of developing valid and complete sources Table 1 provides an overview of the data sources, of information, integrating sectors, linking health data- periodicity and funding of the available information to bases, embedding infrastructure at the institutional report on each of the 27 SDG3 indicators in level, as well as gathering, analysing and interpreting Mozambique. There are eight identified data sources: 1) data in the local context, and disseminating results to a four institution-based sources consisting of SIS-MA, the diverse audience [13, 14]. electronic Personnel Information System for health Knowledge on the progress of national HIS to measure (eSIP), Hospital Module and, Spectrum; and, 2) four and monitor health equity in LIC, in particular, remains population-based sources: DHS; Household Budget very limited. In response to this knowledge gap, we Survey; Vaccination, Malaria and AIDS Indicator Survey evaluate the national indicators available in Mozambique (IMASIDA in Portuguese); and, Survey of chronic dis- to monitor progress towards health equity in line with ease risk factors (STEPS in Portuguese). The time period SDG3 on health and well-being. of the available information in most of the indicators (i.e. nine indicators) is 5 years, with seven of the indica- Methods tors providing information every year, and one indicator We mapped the capacity of the HIS of Mozambique to that updates information on a weekly basis. As part of measure progress towards health equity, in line with the data source mapping process, a mix of national and SDG3. Data source mapping involves cataloguing and external-funded data sources were identified, specifically, describing all available institution- and population-based seven indicators bear information with nationally funded data sources for a given country to determine which data sources, ten with data sources externally funded, sources can be used for health inequality monitoring [9]. and ten indicators either lack information or it does not The mapping consisted of four steps [15]: (1) the se- applicable for the matter of the study. lection of the indicators to measure health inequalities - Results from the data source mapping also show that in this case we selected the 27 SDG3 indicators; (2) the none of the 27 SDG3 indicators to measure progress on identification and selection of relevant data sources health equity in Mozambique, can be fully disaggregated available from the HIS, which included national-level by an equity stratifier. Currently, the indicators either data from institution-based and population-based data lack some information (i.e. 15 indicators) or do not have sources. Furthermore, to establish an overview of the any information at all (i.e. nine indicators). The national capacity and trends in the investment in data in average inequality score indicates that those indicators Mozambique, for each relevant data source identified we that have more information, are the ones related to ma- also noted its funding source (i.e. national or external), ternal and child health (Table 2). and the time period of new available information; (3) an Of the total 27 SDG3 indicators, the majority can be assessment of each data source to evaluate whether, and disaggregated by sex and age, 15 cannot be stratified by what type, of information was available for the main socio-economic position or education, only nine indica- equity stratifier (i.e. socio-economic position, education, tors have complete information of the geographical area, sex, age, place of residence and race/ethnic group), using and five indicators have gaps in the geographical infor- a three-point scale [9]; One point was given when the in- mation. Finally, none of the indicators can be disaggre- formation was available, two points if there was a need gated by race or ethnicity (Table 2). for more information, and three points in the case of an information gap. Also, for each indicator, we calculated Discussion the national average inequality score using the results of The development of a sustainable and effective national the three-point scale for each equity stratifier; (4) the de- HIS that is capable of analysing the SDH and health in- velopment of a final list compiling all the information equalities, as well as assessing and monitoring action to- obtained. wards health equity, is an essential public health need in To ensure quality control of the study, the selection of every country. Such systems need to be strengthened databases followed a rigorous screening process, which across all country income groups, particularly in LICs. involved a number of authors. The first author was re- This study aimed to evaluate the current capacity of the sponsible for screening and charting the main available national HIS in Mozambique to monitor health inequal- information, and this was distributed among the authors ities in line with the 27 indicators of the SDG3 on health Llop-Gironés et al. Globalization and Health (2019) 15:67 Page 4 of 7 Table 1 Data sources, periodicity and funding of the information to report on the indicators to measure SDG3 in Mozambique Indicators of the SDG 3: Ensure healthy lives and promote wellbeing for all at all ages Data sources Time period Funding 3.1.1 Maternal mortality ratio DHS Five-year External 3.1.2 Proportion of births attended by skilled health personnel IMASIDA Five-year External 3.2.1 Under-five mortality rate DHS Five-year External 3.2.2 Neonatal mortality rate DHS Five-year External 3.3.1 Number of new HIV infections per 1000 uninfected population, SPECTRUM Yearly External by sex, age and key populations 3.3.2 Tuberculosis incidence per 100,000 population SIS-MA Yearly National 3.3.3 Malaria incidence per 1000 population SIS-MA Weekly National 3.3.4 Hepatitis B incidence per 100,000 population SIS-MA Yearly National 3.3.5 Number of people requiring interventions against neglected Not available – – tropical diseases 3.4.1 Mortality rate attributed to cardiovascular disease, cancer, diabetes Hospital Module Yearly National or chronic respiratory disease 3.4.2 Suicide mortality rate Not available – – 3.5.1 Coverage of treatment interventions (pharmacological, psychosocial Not available – – and rehabilitation and aftercare services) for substance use disorders 3.5.2 Harmful use of alcohol, defined according to the national context STEPS Five-year External as alcohol per capita consumption (aged 15 years and older) within a calendar year in litres of pure alcohol 3.6.1 Death rate due to road traffic injuries Not available – – 3.7.1 Proportion of women of reproductive age (aged 15–49 years) who SIS-MA Yearly National have their need for family planning satisfied with modern methods 3.7.2 Adolescent birth rate (aged 10–14 years; aged 15–19 years) per 1000 DHS Five-year External women in that age group 3.8.1 Coverage of essential health services Not available – – 3.8.2 Proportion of population with large household expenditures on HBS Five-year External health as a share of total household expenditure or income 3.9.1 Mortality rate attributed to household and ambient air pollution Not available – – 3.9.2 Mortality rate attributed to unsafe water, unsafe sanitation and lack HBS Five-year External of hygiene (exposure to unsafe Water, Sanitation and Hygiene for All (WASH) services) 3.9.3 Mortality rate attributed to unintentional poisoning Not available – – 3.a.1 Age-standardized prevalence of current tobacco use among persons DHS Five-year External aged 15 years and older 3.b.1 Proportion of the target population covered by all vaccines included SIS-MA Yearly National in their national programme 3.b.2 Total net official development assistance to medical research and Not applicable – – basic health sectors 3.b.3 Proportion of health facilities that have a core set of relevant Not applicable – – essential medicines available and affordable on a sustainable basis 3.c.1 Health worker density and distribution eSIP Yearly National 3.d.1 International Health Regulations (IHR) capacity and health Not applicable – – emergency preparedness Note: Information System for Monitoring and Evaluation (SIS-MA in Portuguese); electronic Personnel Information System for health (eSIP in Portuguese); Demographic and Health Survey (DHS); Household Budget Survey (HBS); Vaccination, Malaria and AIDS Indicator Survey (IMASIDA in Portuguese); Survey of chronic disease risk factors (STEPS in Portuguese) and well-being, and potentially provide some insight into of its importance to measure progress towards health the information gaps that might exist in the national equity [16], our results show that in the case of HIS of other LIC. Mozambique, a large proportion of the SDG3 indicators re- Despite the increased interest and sophistication in moni- quire information that is only available from externally toring the SDH, as well as the growing acknowledgement funded data sources, and none of the indicators can be fully Llop-Gironés et al. Globalization and Health (2019) 15:67 Page 5 of 7 Table 2 Indicators to measure SDG3 in Mozambique, inequality by equity stratifier and national average inequality score Note: A value of 1 (green) indicates information available, 2 (yellow) a need for some information and 3 (red) indicates information gap. Grey boxes indicate “not applicable” disaggregated by the equity stratifiers due to the lack of in- maternal and child health programmes which are often formation on race and ethnicity, since the country does not external-donor-funded programmes. collect such information. The improvement of HIS is com- Studies assessing the national health research systems plicated, particularly in LIC setting where there are numer- in Guinea-Bissau, Gambia and Mali have shown that ous global health initiatives [17], and the limited public health research in Sub-Saharan Africa depends to a health information that is available in LIC, appears to be greater extent to external donor funding and top-down partly tied to those who demand certain types of data for policies rather than on domestic support [18–20]. All of specific funding or reporting purposes [3]. For example, this has likely influenced the evolution of national health our results show that the most complete information to research training and infrastructure, the nature of health monitor health equity in Mozambique is related to the (and health inequalities) research conducted, as well as Llop-Gironés et al. Globalization and Health (2019) 15:67 Page 6 of 7 the use of health (and health inequalities) research find- Data source mapping enables the critical review of ings; collectively, this might have hindered progress in a range of data sources and can embed an equity lens strengthening the capacities of national HIS to integrate in the appraising of HIS, not only at the national a health equity lens, within this context. This might also level, but at lower administrative levels if desired [9]. partly explain why Mozambique has only made a limited However, it should be noted that data source map- contribution to the global scientific production on health ping is limited in the appraisal of the quality of the inequalities [21]. data, and it lacks capacity to capture information The SDGs and their ‘Leaving No One Behind’ agenda, fluxes outside official data sources, such as verbal, ob- have brought a renewed momentum and commitment servational or written information that could occur at to strengthening national HIS with a focus on health health facility level. Nevertheless, our results identify equity; however, as Palmer et al. note, this promotion specific systems gaps that need to be addressed in should also emphasise the importance of health (and order to strengthen the measuring and monitoring of health inequalities) research being internally driven, health equity at country level, and to our knowledge, owned by the country, and in line with identifiable na- this is the first study that has assessed the capacity of tional health and well-being priorities, as well as to en- the national HIS to monitor progress towards health sure that this research feeds into local policy and equity, and SDG3. As such, these study findings could practice to improve population health and well-being, be used to directly inform and support the current and address the SDH inequalities, in the context of na- action that is underway in Mozambique to strengthen tional development [19]. the national HIS. The introduction of the SIS-MA in 2016 in Mozambique, was a step forward of the MoH towards producing comprehensive and up-to-date routine infor- Conclusion mation of good quality, however, the results of the study Information gaps in the current health information show a lack of routine health information able to cap- system in Mozambique prevent the country from ture health and mortality trends differentiating social being able to comprehensively measure and monitor groups and geographical area. These results suggest that health equity, so as to leave no one behind. A large there is a need to define a set of determinants and indi- proportion of the 27 indicators of SDG3, focused on cators that are issue-specific and match populations health and well-being, require information that is only health and well-being needs. For example, despite in available from externally funded data sources, and Sub-Saharan Africa only 24.2% of the population has ac- none of the indicators can be fully disaggregated by cess to safe water [22], the mortality rate attributed to the equity stratifiers. The main recommendations unsafe water is currently unavailable. Also, it will not be towards the development of a sustainable and effect- adequate to restrict the indicators whose Mozambique ive national health information system capable of ana- has more information (i.e. maternal and child health), lysing the social determinants of health will be to since it only concerns certain population groups, as define the set of determinants and indicators that are women of reproductive age and children. issue-specific and match populations health and well- Despite the limitations identified in the national HIS being needs of the country, as well as strengthen the capacity to monitor health equity, Mozambique has re- health sector and intersectoral data linkages. In cently made steps forward towards aiming to strengthen addition, adequate investment in technical and human the capacity of its national HIS to monitor population resource capacities to address health inequalities is health and strengthen the intersectoral data linkages. It needed, which is likely to be the case in similar is currently undergoing a process of strengthening the settings. To support this, a number of policy and civil registration and vital statistics (CRVS) – an urgent political challenges must also be addressed to support country need, as the registration rate of children under transparency in decision making process and account- five has been estimated to be less than 50% [23]. This ability for action. For example, the coexistence of progress involves different ministries and national insti- political leadership, together with effective communi- tutions such as Ministries of Justice, Constitutional and cation and collaboration between Ministries and the Religious Affairs, Ministry of Health, National Institute National Statistics Offices, and whole-of-government and of Statistics and Ministry of Interior; in addition to inter- whole-of society engagement is required. Comprehensive national partners (i.e. WHO and UNICEF) and donors national health information systems are essential public (i.e. the government of Canada). Currently, they are fo- health needs, as their absence not only hides the health cusing on the legislative and policy framework, the regis- equity gap within countries, but also limits national tration of all vital events, and the interoperability capacity to effectively inform local interventions and between data management systems. action towards achieving health equity. Llop-Gironés et al. Globalization and Health (2019) 15:67 Page 7 of 7 Acknowledgements 8. Mtenga S, Masanja IM, Mamdani M. Strengthening national capacities for JB gratefully acknowledges the financial support by ICREA under the ICREA researching on social determinants of health (SDH) towards informing and Academia Programme. addressing health inequities in Tanzania. Int J Equity Health. 2016. https:// doi.org/10.1186/s12939-016-0308x. Authors’ contributions 9. World Health Organization. Handbook on Health Inequality Monitoring with ALG and JB conceived the idea for the study and developed the design of a special focus on low- and middle-income countries. Geneva: World Health the study. ALG, SC, FA, IZ, EM participated in the mapping of the data. All Organization; 2013. authors made substantial contributions to the document. ALG and LCG 10. Setel PW, Macfarlane SB, Szreter S, Mikkelsen L, Jha P, Stout S, et al. A initially drafted the document, and SC, FA, IZ, EM and JB made substantial scandal of invisibility: making everyone count by counting everyone. Lancet. and critical revisions. All authors have given final approval of the version 2007;370(9598):1569–77. submitted for publication. 11. Lim SS, Stein DB, Charrow A, Murray CJ. Tracking progress towards universal childhood immunisation and the impact of global initiatives: a systematic Funding analysis of three-dose diphtheria, tetanus, and pertussis immunisation This study was supported by medicusmundi (AECID: 14-CO1–424) and Euro- coverage. Lancet. 2008;372(9655):2031–46. pean Commission: Nova Domus – Chemedpho project (545700-EM-1-2013-1- 12. Hosseinpoor AR, Bergen N, Schlotheuber A, Boerma T. National health ES-ERAMUNDUS-EMA22). inequality monitoring: current challenges and opportunities. Glob Health Action. 2018;11(sup1):1392216. Availability of data and materials 13. Guerra G, Borde E, Salgado de Snyder VN. Measuring health inequities in The datasets analysed during the current study are available under request low and middle income countries for the development of observatories on to the Ministry of Health of Mozambique. inequities and social determinants of health. Int J Equity Health. 2016. https://doi.org/10.1186/s12939-016-02979. Ethics approval and consent to participate 14. Valentine NB, Koller TS, Hosseinpoor AR. Monitoring health determinants This work has the approval of the ethical committee of the Ministry of with an equity focus: a key role in addressing social determinants, universal Health of Mozambique “Comité Institucional de Bioética do Instituto health coverage, and advancing the 2030 sustainable development agenda. Nacional de Saúde (CIBS-INS)” reference 046/CIBS-INS/2015. The article Glob Health Action. 2016. https://doi.org/10.3402/gha.v9.34247. handled secondary and anonymized data; therefore, consent to participate 15. Hosseinpoor AR, Nambiar D, Suparmi, Kusumawardani N. Data source was not required/ not applicable. mapping: an essential step for health inequality monitoring. Glob Health Action. 2018;11:1456743. 16. Pedrana L, Pamponet M, Walker R, Costa F, Rasella D. Scoping review: national Consent for publication monitoring frameworks for social determinants of health and health equity. Not applicable. Glob Health Action. 2016. https://doi.org/10.3402/gha.v9.28831. 17. Nutley T, Reynolds HW. Improving the use of health data for health system Competing interests strengthening. Glob Health Action. 2013. https://doi.org/10.3402/gha.v6i0.20001. The authors declare that they have no competing interests. 18. Albert MA, Fretheim A, Maïga D. Factors influencing the utilization of research findings by health policy-makers in a developing country: the Author details 1 selection of Mali’s essential medicines. Health Res Policy Syst. 2007;5(1):2. Health Inequalities Research Group-Employment Conditions Network 19. Palmer A, Anya SE, Bloch P. The political undertones of building national (GREDS-EMCONET), Universitat Pompeu Fabra, Barcelona, Spain. 2Johns health research systems – reflections from the Gambia. Health Res Policy Hopkins University University Pompeu Fabra Public Policy Center, Barcelona, Syst. 2009;7:13. Spain. 3GREDS-EMCONET, Department of Political and Social Sciences, 20. Kok MO, Rodrigues A, Silva AP, de Haan S. The emergence and current Universitat Pompeu Fabra, Ramon Trias Fargas 25-27, 08003 Barcelona, Spain. 4 performance of a health research system: lessons from Guinea Bissau. National Institute of Health, Ministry of Health of Mozambique, Maputo, Health Res Policy Syst. 2012;10:5. Mozambique. 5Instituto Nacional de Saude, Eduardo Mondlane Ave, 1008 21. Cash-Gibson L, Rojas-Gualdrón DF, Pericàs JM, Benach J. Inequalities in Maputo, Mozambique. 6Medicus Mundi Mediterrània, Secretari Coloma st global health inequalities research: a 50-year bibliometric analysis 112, 08024 Barcelona, Spain. 7National Institute of Statistics of Mozambique, (1966-2015). PLoS One. 2018;13(1):e0191901. Maputo, Mozambique. 8Instituto Nacional de Estatística, 24 de Julho Ave, 22. The World Bank. World Development Indicators. 2019. http://datatopics. 1989 Maputo, Mozambique. 9Grupo de Investigación Transdisciplinar sobre worldbank.org/world-development-indicators. Accessed 4 Sept 2019. Transiciones Socioecológicas (GinTRANS2), Universidad Autónoma de Madrid, 23. Ministério da Saúde. Mozambique demographic and health survey. Madrid, Spain. Maputo: Ministério da Saúde; 2011. Received: 9 May 2019 Accepted: 11 October 2019 Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in References published maps and institutional affiliations. 1. United Nations. Transforming our world: the 2030 agenda for sustainable development. New York: United Nations; 2015. 2. CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: WHO; 2008. 3. AbouZahr C, Boerma T. Health information systems: the foundations of public health. Bull World Health Organ. 2005;83(8):578–83. 4. Marmot M, Bell R. The sustainable development goals and health equity. Epidemiology. 2018;29(1):5. 5. Wagenaar BH, Sherr K, Fernandes Q, Wagenaar AC. Using routine health information systems for well-designed health evaluations in low- and middle-income countries. Health Policy Plan. 2016;31(1):129–35. 6. IHME. Financing Global Health 2015: development assistance steady on the path to new global goals. Seattle: IHME; 2016. 7. Llop-Gironés A, Julià M, Chicumbe S, Dulá J, Odallah AAP, Alvarez F, et al. Inequalities in the access to and quality of healthcare in Mozambique: evidence from the household budget survey. Int J Qual Health Care. 2018. https://doi.org/10.1093/intqhc/mzy218.