Eff ects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in Mozambique

Background Knowledge of the relation between health-system factors and child mortality could help to inform health policy in low-income and middle-income countries. We aimed to quantify modifi able health-system factors and their relation with provincial-level heterogeneity in under-5, infant, and neonatal mortality over time in Mozambique. Methods Using Demographic and Health Survey (2003 and 2011) and Multiple Indicator Cluster Survey (2008) data, we generated provincial-level time-series of child mortality in under-5 (ages 0–4 years), infant (younger than 1 year), and neonatal (younger than 1 month) age groups for 2000–10. We built negative binomial mixed models to examine health-system factors associated with changes in child mortality. Findings Under-5 mortality rate was heterogeneous across provinces, with yearly decreases ranging from 11·1% (Nampula) to 1·9% (Maputo Province). Heterogeneity was greater for neonatal mortality rate, with only seven of 11 provinces showing signifi cant yearly decreases, ranging from 13·6% (Nampula) to 4·2% (Zambezia). Health workforce density (adjusted rate ratio 0·94, 95% CI 0∙90–0∙98) and maternal and child health nurse density (0∙96, 0∙92–0∙99) were both associated with reduced under-5 mortality rate, as were institutional birth coverage (0∙94, 0∙90–0∙98) and government fi nancing per head (0∙80, 0∙65–0∙98). Higher population per health facility was associated with increased under-5 mortality rate (1∙14, 1∙02–1∙28). Neonatal mortality rate was most strongly associated with institutional birth attendance, maternal and child nurse density, and overall health workforce density. Infant mortality rate was most strongly associated with institutional birth attendance and population per health facility. Interpretation The large decreases in child mortality seen in Mozambique between 2000 and 2010 could have been partly caused by improvements in the public-sector health workforce, institutional birth coverage, and government health fi nancing. Increased attention should be paid to service availability, because population per health facility is increasing across Mozambique and is associated with increased under-5 mortality. Investments in health information systems and new methods to track potentially increasing subnational health disparities are urgently needed

Measuring health systems strength and its impact: experiences from the African Health Initiative.

BACKGROUND: Health systems are essential platforms for accessible, quality health services, and population health improvements. Global health initiatives have dramatically increased health resources; however, funding to strengthen health systems has not increased commensurately, partially due to concerns about health system complexity and evidence gaps demonstrating health outcome improvements. In 2009, the African Health Initiative of the Doris Duke Charitable Foundation began supporting Population Health Implementation and Training Partnership projects in five sub-Saharan African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) to catalyze significant advances in strengthening health systems. This manuscript reflects on the experience of establishing an evaluation framework to measure health systems strength, and associate measures with health outcomes, as part of this Initiative. METHODS: Using the World Health Organization's health systems building block framework, the Partnerships present novel approaches to measure health systems building blocks and summarize data across and within building blocks to facilitate analytic procedures. Three Partnerships developed summary measures spanning the building blocks using principal component analysis (Ghana and Tanzania) or the balanced scorecard (Zambia). Other Partnerships developed summary measures to simplify multiple indicators within individual building blocks, including health information systems (Mozambique), and service delivery (Rwanda). At the end of the project intervention period, one to two key informants from each Partnership's leadership team were asked to list - in rank order - the importance of the six building blocks in relation to their intervention. RESULTS: Though there were differences across Partnerships, service delivery and information systems were reported to be the most common focus of interventions, followed by health workforce and leadership and governance. Medical products, vaccines and technologies, and health financing, were the building blocks reported to be of lower focus. CONCLUSION: The African Health Initiative experience furthers the science of evaluation for health systems strengthening, highlighting areas for further methodological development - including the development of valid, feasible measures sensitive to interventions in multiple contexts (particularly in leadership and governance) and describing interactions across building blocks; in developing summary statistics to facilitate testing intervention effects on health systems and associations with health status; and designing appropriate analytic models for complex, multi-level open health systems

Effects of appointment scheduling on waiting time and utilisation of antenatal care in Mozambique

Background Poor patient experience, including long waiting time, is a potential reason for low healthcare utilisation. In this study, we evaluate the impact of appointment scheduling on waiting time and utilisation of antenatal care. Methods We implemented a pilot study in Mozambique introducing appointment scheduling to three maternity clinics, with a fourth facility used as a comparison. The intervention provided women with a return date and time for their next antenatal care visit. Waiting times and antenatal care utilisation data were collected in all study facilities. We assessed the effect of changing from first come, first served to scheduled antenatal care visits on waiting time and complete antenatal care (≥4 visits during pregnancy). Our primary analysis compared treatment facilities over time; in addition, we compared the treatment and comparison facilities using difference in differences. Results We collected waiting time data for antenatal care from 6918 women, and antenatal care attendance over the course of pregnancy from 8385 women. Scheduling appointments reduced waiting time for antenatal care in treatment facilities by 100 min (95% CI -107.2 to -92.9) compared with baseline. Using administrative records, we found that exposure to the scheduling intervention during pregnancy was associated with an approximately 16 percentage point increase in receipt of four or more antenatal care visits during pregnancy. Conclusions Relatively simple improvements in the organisation of care that reduce waiting time may increase utilisation of healthcare during pregnancy. A larger scale study is needed to provide information about whether appointment scheduling can be sustained over time. Trial registration number NCT02938936

Client experiences with antenatal care waiting times in southern Mozambique

BACKGROUND: Antenatal care (ANC) provides a range of critical health services during pregnancy that can improve maternal and neonatal health outcomes. In Mozambique, only half of women receive four or more ANC visits, which are provided for free at public health centers by maternal and child health (MCH) nurses. Waiting time has been shown to contribute to negative client experiences, which may be a driver of low maternity care utilization. A recent pilot study of a program to schedule ANC visits demonstrated that scheduling care reduces waiting time and results in higher rates of complete ANC. This study aims to explore client experiences with waiting time for ANC in standard practice and care and after the introduction of appointment scheduling. METHODS: This study uses a series of qualitative interviews to unpack client experiences with ANC waiting time with and without scheduled care, in order to better understand the impact of waiting time on client experiences. Thirty-eight interviews were collected in May to June 2017 at three pilot study clinics in southern Mozambique, with a focus on two paired intervention and comparison facilities sharing similar facility characteristics. Data were analyzed using inductive thematic analysis methods using NVivo software. RESULTS: Clients described strong motivations to seek ANC, pointing to the need to address convenience of care, and highlighted direct and indirect costs of seeking care that were exacerbated by long waiting times. Direct costs include time and transport costs of going to the clinic, while indirect costs include being unable to fulfill household and work obligations. Other barriers to complete ANC utilization of four or more visits include transport costs, negative provider experiences, and delayed ANC initiation, which limit the potential number of clinic contacts. CONCLUSIONS: Findings demonstrate that the scheduling intervention improves the client experience of seeking care by allowing women to both seek ANC and fulfill other productive obligations. Innovation in healthcare delivery should consider adapting models that minimize waiting times

Early effects of COVID-19 on maternal and child health service disruption in Mozambique

This article is part of the Research Topic ‘Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'IntroductionAfter the World Health Organization declared COVID-19 a pandemic, more than 184 million cases and 4 million deaths had been recorded worldwide by July 2021. These are likely to be underestimates and do not distinguish between direct and indirect deaths resulting from disruptions in health care services. The purpose of our research was to assess the early impact of COVID-19 in 2020 and early 2021 on maternal and child healthcare service delivery at the district level in Mozambique using routine health information system data, and estimate associated excess maternal and child deaths.MethodsUsing data from Mozambique's routine health information system (SISMA, Sistema de Informação em Saúde para Monitoria e Avaliação), we conducted a time-series analysis to assess changes in nine selected indicators representing the continuum of maternal and child health care service provision in 159 districts in Mozambique. The dataset was extracted as counts of services provided from January 2017 to March 2021. Descriptive statistics were used for district comparisons, and district-specific time-series plots were produced. We used absolute differences or ratios for comparisons between observed data and modeled predictions as a measure of the magnitude of loss in service provision. Mortality estimates were performed using the Lives Saved Tool (LiST).ResultsAll maternal and child health care service indicators that we assessed demonstrated service delivery disruptions (below 10% of the expected counts), with the number of new users of family planing and malaria treatment with Coartem (number of children under five treated) experiencing the largest disruptions. Immediate losses were observed in April 2020 for all indicators, with the exception of treatment of malaria with Coartem. The number of excess deaths estimated in 2020 due to loss of health service delivery were 11,337 (12.8%) children under five, 5,705 (11.3%) neonates, and 387 (7.6%) mothers.ConclusionFindings from our study support existing research showing the negative impact of COVID-19 on maternal and child health services utilization in sub-Saharan Africa. This study offers subnational and granular estimates of service loss that can be useful for health system recovery planning. To our knowledge, it is the first study on the early impacts of COVID-19 on maternal and child health care service utilization conducted in an African Portuguese-speaking country

Waiting time, wasted time : a pilot study to investigate the effect of reduced waiting time on demand for antenatal care, South region Mozambique 2016

This one-page brief outlines a study aimed at reducing wait times for antenatal care. The intervention had significant impacts on workload management. The caseload was better distributed with health facilities less overwhelmed in the first hours of the day, thus allowing for nurses to better manage concurrent tasks. Of 1600 pregnant women surveyed, 99% were satisfied with the intervention. Workable appointment systems can be implemented in low-income countries, improving antenatal care

The role of health systems strengthening and HIV in under-five mortality trends: time series analyses from 2000 to 2010 in Mozambique

Thesis (Master's)--University of Washington, 2013Globally, the number of deaths of children under 5 (U5) decreased substantially from 12 million in 1990 to about 6.9 million in 2011; during the same period under five mortality (U5M) decreased steadily in Mozambique as a result of the implementation of several interventions. This study aimed to determine the role of health systems strengthening and HIV in U5 mortality trends in Mozambique. We performed an exploratory analysis with U5M as the outcome variable. First, we conducted a univariate analyses by provinces over time periods, as well as Pearson correlations between each independent predictor and the outcome; second a bivariate analysis was performed to determine the association between each independent variable and the outcome variable followed by a multivariate analysis. Model selection was achieved by using backward selection where in each step were removed the variable with the highest p-value, The final significance level selected was 0.05. Overall the U5M in Mozambique dropped substantially during 2000 to 2010 and for each additional year we predicted a decrease of 7.4 per 1000 live births of the U5M on average across all provinces (95% CI: -9.4 , -5.3). After adjusting for time trend population per health facility with β= 2.7 (95% CI 0.19, 5.2), health work force density with β= -0.41 (95% CI: -0.81, -0.01) and institutional birth attendance β= -0.45 (95% CI:-0.77, -0.14) remained significantly associated to U5M. These results suggest that improvements on health human resources particularly with maternal and child nurses and interventions which resulted in improvements of institutional birth attendance were important in the reductions of the U5M rates in Mozambique during the period of the study. If these results are confirmed with other studies, investments on health should prioritize innovative interventions to accelerate human resources trainings, health infrastructure buildings and better access and quality of services for pregnant women

Health System Drivers of Universal Health Coverage in Mozambique: Scrutinization of Service Delivery and Human Resources for Health building blocks

Thesis (Ph.D.)--University of Washington, 2023Achieving Universal Health Coverage (UHC) is the most sustainable way to establish social justice and contribute to the well-being of all. Strong and resilient health systems are the foundation for achieving and sustaining UHC. Six building blocks of the health systems have been identified by the World Health Organization (WHO. Understanding health system building blocks challenges remains an essential step for achieving UHC. This dissertation analysis two of the six building blocks, service delivery and human resources for health. The first study focuses on understanding the impact of an important weather event – the Idai cyclone – on measures of health service utilization. Mozambique is vulnerable to extreme weather events; therefore, describing the immediate impacts of such events, as well as post-event recovery patterns, can inform efforts to improve health system resilience. We used routine data capturing health service utilization, aggregated to the district level, from pre- and post-event periods to perform an uncontrolled interrupted time series analysis and describe changes in 10 maternal and child health indicators across 25 districts. Overall, we demonstrated a negative impact on several indicators immediately after Idai, including 23% (95% CI: 0.62, 0.96) and 25% (95% CI=0.64, 0.87) reductions in antenatal care and measles vaccination, respectively. However, promising signs of recovery were evident three months later. The second study focused on assessing the health workforce landscape in Mozambique. We used a longitudinal design to assess two measures of health workforce (density of personnel and the ratio of male to female health workers) in all districts between 2016 and 2020. In Mozambique, in January 2016, the average district-level workforce density was estimated at 75.8 per 100,000 population (95% CI: 65.9, 87.1) and was increasing at an annual rate of 8.0% (95% CI: 6.00, 9.00) through January 2018, declining to 3.0% (95% CI: 2.00, 4.00) after that point. Sex ratio imbalances were evident in this study, with northern provinces reporting twice the sex ratio relative to Maputo province. Guided by the Consolidated Framework for Implementation Research (CFIR), the third study deepens the analysis of human resources to describe the individual and institutional drivers of health worker satisfaction. We conducted 63 In-Depth Interviews (IDIs) and seven Focus Group Discussions (FGDs) with health workers in five districts of Manica province. The results of the study suggest that poor working conditions, lack of clear criteria to select health workers for trainings and workshops, and scarcity of housing are among the most relevant determinants of dissatisfaction. Overall, CFIR proved helpful in identifying and summarizing the determinants of job satisfaction. Together, the results presented in this dissertation describe important challenges that Mozambique's health system should address to accelerate progress toward UHC. The methods applied in this study are replicable and could inspire other countries to conduct similar analyses

Drivers of success: improving implementation research tools for better health outcomes

Abstract A thorough examination of context, and how it influences implementation of evidence-based interventions, is a promising strategy for enhancing child survival initiatives. Spreading approaches that are identified as drivers of successful reduction in under-five mortality from ‘exemplar’ countries could be pivotal in leading to reductions in other settings facing stagnant mortality rates, in particular for low- and middle-income countries with high disease burden and insufficient programmatic capacity to effectively implement evidence-based interventions at scale. Yet there remains a lack of robust analytic methods to accurately assess mortality and describe the drivers of interventions’ implementation success at both national and subnational levels. The field of implementation science and its defining targets and tools is well positioned to address this knowledge gap by integrating qualitative and quantitative research methods into an adaptable evaluation framework that can be tailored to meet the specific needs across varying country contexts. These tools enhance the measurement of population health outcomes and provide crucial evidence on implementation barriers and facilitators that can inform policies that can be adjusted for diverse contexts. This commentary aims to emphasize the role of implementation research in understanding how exemplar countries achieved significant improvements in child survival and in identifying replicable lessons for other settings. Ultimately, all manuscripts underscore the relevance of implementation research in bolstering the reduction of under-five mortality