The little boy born just before sunset was lucky.
He had stopped breathing just after his mother delivered him into a shawl as she lay in a cramped hospital ward here in this provincial town 100 miles north of the capital, Maputo. Fortunately, a group of nurses was a few beds away. After a frenzied, 15-minute scramble with a suction machine and ventilator bag, they resuscitated the baby.
Two hours later, there would have been no nurse. The ward is staffed only until 7 p.m. The boy probably would have died, joining tens of thousands of children who perish prematurely every year in this southern African nation.
On the other side of the continent, Ebola has focused attention on the inability of local health systems to contain a major disease outbreak. But even in African nations untouched by the epidemic, health systems are struggling with insufficient financing and poor organization. That is holding back progress against malaria, HIV/AIDS and basic health problems such as infant mortality.
Although children in Mozambique have substantially better odds of surviving than two decades ago, they are still 15 times more likely to die before turning 5 than an American child.
“It seems like healthcare is always at the end of the queue,” said Dr. Inacio Chichango Jr., the 31-year-old director of the Chokwe hospital.
Despite rapid economic growth, countries including Mozambique are spending on areas other than healthcare, leaving much of Africa with too few clinics, hospital beds, doctors and health workers and with inadequate systems for linking them together. At the Chokwe hospital, doctors have had to make do without an ultrasound machine since spring.
Over the last decade, more than half of sub-Saharan countries have either cut the share of government spending devoted to healthcare, or barely increased it, according to World Health Organization data. In Mozambique, healthcare dropped from 15% of the government budget in 2001 to 9% in 2012.
Although simply spending more isn’t sufficient, additional investment is frequently necessary, said former World Bank health director Julian Schweitzer, who now advises developing countries for Results for Development Institute, a Washington-based nonprofit.
“Countries that have been successful have built systems. They trained doctors and health workers, expanded insurance schemes, created financial incentives.... These countries learned you have to do all these things together.”
Ethiopia, still one of the world’s poorest countries, has deployed nearly 40,000 community heath workers in the last decade.
And after its 1994 genocide, Rwanda built a national health insurance system and began rewarding clinics that provide appropriate care, such as delivering babies in health facilities rather than at home.
The two countries are among just 10 worldwide on track to meet the United Nations’ 2015 targets for reducing child and maternal mortality.
The lagging investment in health elsewhere in Africa is even more worrisome at a time when many industrialized nations, including the United States, are under pressure to scale back foreign assistance amid their own economic struggles.
After nearly tripling between 2000 and 2010, global health aid has hit a plateau over the last four years, according to data compiled by the Institute for Health Metrics and Evaluation at the University of Washington.
“The need here is still huge,” warned Jean-Luc Anglade, chief of mission in Mozambique for Doctors Without Borders.
The aid group — which for months led the international response to Ebola — has developed new systems to distribute drugs to HIV/AIDS patients in Mozambique. The country has some of the highest infection rates in the world.
Rapid economic growth in Mozambique, where large coal and natural gas deposits have been discovered in recent years, had fueled hopes that the national government would assume responsibility for more of these health services.
As in many cities in Africa, the growth is transforming Maputo, a once-sleepy capital where luxury hotels and bank towers now rise over the pastel Art Deco buildings that Portuguese colonizers built in the last century.
The government in recent years has put up a new airport and sports stadium. Sprawling villas now line the Indian Ocean beachfront on the road north from town.
“We don’t have any politicians talking about health. There are no champions,” said Jorge Martin, an activist for CIP, a local advocacy group that has highlighted Mozambique’s under-investment in health as well as its reluctance to sufficiently tax foreign companies.
“Oil and gas are changing things,” he said. “But they are like a poisoned present that only looks beautiful.”
Dr. Francisco Mbofana, Mozambique’s public health director, insisted that the country’s leaders are committed to greater investment.
“Healthcare is a priority of the government,” he said, noting plans to deploy thousands of community health workers in coming years. “We are expecting more progress.”
Not far from Chokwe, there are some signs of change in Zucula, a village of straw huts in the shade of banana plants and cashew nut trees.
Crisaldo Julio Mawelele, a young community health worker who dreams of becoming a doctor, makes regular stops here, working with villagers on hygiene and nutrition and on treating basic illnesses.
On one visit, she tended to a listless toddler whose grandmother carried him on her back to a clearing at the center of the village. The little boy, who had recently been treated for malaria and anemia, now had severe diarrhea.
After examining him carefully as he sat in his grandmother’s lap, Mawelele gave the grandmother a packet of electrolytes and ground up a zinc tablet for him.
Mawelele is one of about 3,000 such health workers in the country, part of the system being developed jointly by the Health Ministry and the United Nations Children’s Fund, or UNICEF. The government aims to eventually expand the force to 12,000.
In a country where one doctor can have responsibility for tens of thousands of patients, the health workers are a first line of defense against malaria, pneumonia and diarrhea, three of the deadliest threats to young children. Many global health experts believe such programs can make a huge difference if implemented correctly.
Each worker is given basic medical training and outfitted with a green bag with basic diagnostic kits, antibiotics and other drugs to treat the three illnesses.
Mawelele, who grew up in this village, said she enjoys the work. She wanted to do something to help her community.
But the challenge remains enormous. UNICEF delayed a planned transfer of the health worker program to the Health Ministry amid concerns the program wasn’t ready to operate on its own.
For her part, Mawelele faces her own obstacles. She was without malaria kits for much of this year and had to wait more than six months for a paycheck from last year.
Reporting for this story was partially supported by a fellowship from the International Center for Journalists and the United Nations Foundation.