Critical perspectives on global health partnerships in Africa

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Negotiating social memory in postcolonial Mozambique: the case of heritage sites in Mandhlakazi District

Abstract This research deals with the construction, contestation and negotiation of social memory involving the postcolonial state of Mozambique, elites and subaltern social groups with a focus on heritage sites in Mandhalakazi District, Mozambique. Construction of social memory is current in Mozambique, mainly dominated by state attempts at reproducing national memory by establishing a national historical narrative, and in continuity with colonial practices. This is strategically used by Mozambican and South African elites, and contested by subaltern groups in Mandhalakazi. Subaltern contestations outline critiques of precolonial, colonial and postcolonial state power and mainstream historiography. Elites’ use suggests future contests relating to precolonial politics and future dynamics of national and transnational memory and potential heritage tourism involving South Africa and Mozambique. Research was conducted using multi-sited ethnography, participant and nonparticipant observation, semi-structured individual and group interviewing, and archival research in Maputo City, Mandhlakazi and Xai-Xai, for ten weeks, between June and September 2007

Donor data vacuuming

In this essay, we seek to understand how the stunning rise of data vacuuming, necessitated by the pretense of ‘partnership’ within global health, has fundamentally altered how routine health data in poor countries is collected, analyzed, prioritized, and used to inform management and policy. Writing as a team of authors with experiences on multiple sides of global health partnerships in the United States, Mozambique, Nepal, Lesotho, Kenya, and Cote d’Ivoire, we argue that solidarity-based partnership between donor and recipient countries is impossible when evidence production and management is effectively outsourced to external organizations to meet the criteria of donor partners. Specifically, to meet the 2030 Sustainable Development Goals, equity-oriented strategies are critically needed to create data collection, analysis, and use activities that are mutually beneficial and sustainable

Access to and use of health and social services among people who inject drugs in two urban areas of Mozambique, 2014 : qualitative results from a formative assessment

BackgroundPrior to 2014, data about health seeking behaviors or service uptake for People who inject drugs (PWID) in Mozambique did not exist. We present the results from the formative assessment component of the Biological and Behavioral Survey (BBS).MethodsStandardized interview guides were used during key informant interviews (KII) and focus group discussions (FGD) in Maputo and Nampula/Nacala to discuss issues related to risk behaviors and access to and utilization of health and social services by PWID. The target sample size was not defined a priori, but instead KII and FGD were conducted until responses reached saturation. Data analysis was based on the principles of grounded theory related to qualitative research.ResultsEighty-eight respondents, ages 15 to 60, participated in KIIs and FGDs. Participants were majority male from diverse income and education levels and included current and former PWID, non-injection drug users, health and social service providers, peer educators, and community health workers. Respondents reported that PWID engage in high-risk behaviors such as needle and syringe sharing, exchange of sex for drugs or money, and low condom use. According to participants, PWID would rather rent, share or borrow injection equipment at shooting galleries than purchase them due to stigma, fear of criminalization, transportation and purchase costs, restricted pharmacy hours, personal preference for needle sharing, and immediacy of drug need. Barriers to access and utilization of health and social services include distance, the limited availability of programs for PWID, lack of knowledge of the few programs that exist, concerns about the quality of care provided by health providers, lack of readiness as a result of addiction and perceived stigma related to the use of mental health services offering treatment to PWID.ConclusionsMozambique urgently needs to establish specialized harm reduction programs for PWID and improve awareness of available resources. Services should be located in hot spot areas to address issues related to distance, transportation and the planning required for safe injection. Specific attention should go to the creation of PWID-focused health and social services outside of state-sponsored psychiatric treatment centers

Lessons learned and study results from HIVCore, an HIV implementation science initiative

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138261/1/jia21261.pd

Community Health Workers: Lives, Labor, and Hopes for an AIDS-free generation in Maputo, Mozambique

Thesis (Ph.D.)--University of Washington, 2018In this dissertation, I describe how current efforts to meet the globally-defined ambitious HIV treatment goals to end AIDS by 2030 marginalize community health workers (activists and counselors) who have dedicated their lives, skills and experience to helping address HIV and AIDS. My focus fits within a broader research agenda that has been documenting the “social aspects of antiretroviral therapy scale-up” for the last decade and a half in the global south. It contributes to efforts to relativize the dominance of grand theory, and to value ordinary people’s empirical and analytical contributions to social theory that Foucault (2003) articulated as political historicism, which resonates with calls for ethnography as a fruitful avenue for theory grounded on fieldwork experience and data (Biehl 2013, Nader 2011). The dissertation is based on nearly 18 months of ethnographic research, between February 2016 and July 2017, mostly at a health facility in Maputo, Mozambique, using participant observation, ethnographic interviews and archival research. It was supplemented by nearly a month of exploratory research between August and September 2015, and a short weekly visit during dissertation writing in July 2018. For ethical reasons, I concealed the names of people who participated in the research and of the health facility and province where I conducted research. Community health workers have for several years contributed with labor, experience and dedication that build and maintain enduring social ties that help ensure compliance to antiretroviral therapy and reproduce sociality. They also help bridge the gaps between the public-driven and the international non-governmental organization- driven patient tracking systems. This contribution is being marginalized by current efforts to meet the ambitious HIV treatment goals, under which experienced community health workers are being demoted, moved to other roles, reduce work hours, and train new staff that replaces them from their previous positions. Experienced community health workers perceive these changes as instantiating their marginalization, economic exploitation and disposability, in ways that have precedents in the scale up of universal antiretroviral therapy, about a decade ago (documented in Mozambique and in sub-Saharan Africa). This marginalization reveals a neglect for knowledge and skills represented as hierarchically inferior within the health sector (epistemic violence) and signal a growing risk of global HIV interventions contributing to neoliberal politics of social abandonment that produce undervalued and disposable labor, while undermining the institutional arrangements that have historically enabled the implementation of equity-oriented strategies through public health systems (political expression of structural violence)

Ambitious HIV treatment goals, viral suppression, and laboratory readiness in Maputo, Mozambique

Thesis (Master's)--University of Washington, 2018Introduction: Following international recommendations and guidelines, in 2016, Mozambique started implementing the ‘test and treat’ approach to meet the ambitious HIV treatment targets by 2020, and ‘end AIDS’ by 2030. Mozambique took a staggered and conservative implementation approach that suggested local reservations about meeting the international targets and is consistent with the slow improvements in epidemiologic and data quality indicators, despite more than a decade of international investment in the response to HIV/AIDS. This thesis describes challenges to achieving the third HIV treatment target at a public health facility receiving technical and logistical assistance from an international nongovernmental organization (NGO) in Maputo, Mozambique. Methods: I reviewed medical data on all patients whose sample for viral load had been collected between September 1-November 30, 2016, conducted participant observation and ethnographic interviewing between September 2016-February 2017. I conducted thematic analysis using Atlas.ti, version 7.5 (Scientific Software Development GmbH), and descriptive and inferential analysis (reporting 95% confidence intervals where appropriate) using Stata 13 (StataCorp, 2013) and graphing in R3.5 (Core Team, 2018). The study was approved by the Ministry of Health and the National Bioethics Committee for Health (CNBS) of Mozambique and the University of Washington Institutional Review Board (IRB). Results and discussion: Between September-November 2016, 362 samples were sent for viral load testing at the reference laboratory. However, they had availability and data quality issues: 43.6% received results by February 2017, 16.9% were available in the NGO electronic-based patient tracking system (e-PTS); 2.8% and 2.2% had missing and duplicate patient ID’s, 2.2% had duplicate names, patient IDs (15.7%) and names (5.0%) in the public health system’s paper-based laboratory registry did not match with the e-PTS. These challenges occurred in a three-fold context that shaped facility unreadiness to manage viral load. Recoding protocols were implemented before receiving registries from the national level (structural), disconnections between paper-based and electronic registries remained at the facility (process), and new staff at the facility laboratory had not developed the capacity to manage viral load registry and communications (individual). These findings resonate with the low readiness for the ambitious treatment goals and chronic routine HIV data quality issues nationally. They help question the reasonableness of trying to meet internationally-defined targets, that has defined the ending AIDS agenda, without making appropriate investments in public health information system infrastructures that can provide information for timely clinical decision-making and monitoring of progress towards the very targets the international agenda defined

Applying the Consolidated Framework for Implementation Research to Identify Implementation Determinants for the Integrated District Evidence-to-Action Program, Mozambique

Introduction: The Integrated District Evidence-to-Action program is an audit and feedback intervention introduced in 2017 in Manica and Sofala provinces, Mozambique, to reduce mortality in children younger than 5 years. We describe barriers and facilitators to early-stage effectiveness of that intervention.Method: We embedded the Consolidated Framework for Implementation Research (CFIR) into an extended case study design to inform sampling, data collection, analysis, and interpretation. We collected data in 4 districts in Manica and Sofala Provinces in November 2018. Data collection included document review, 22 in-depth individual interviews, and 2 focus group discussions (FGDs) with 19 provincial, district, and facility managers and nurses. Most participants (70.2%) were nurses and facility managers and the majority were women (87.8%). We audio-recorded all but 2 interviews and FGDs and conducted a consensus-based iterative analysis.Results: Facilitators of effective intervention implementation included: implementation of the core intervention components of audit and feedback meetings, supportive supervision and mentorship, and small grants as originally planned; positive pressure from district managers and study nurses on health facility staff to strive for excellence; and easy access to knowledge and information about the intervention. Implementation barriers were the intervention's lack of compatibility in not addressing the scarcity of human and financial resources and inadequate infrastructures for maternal and child health services at district and facility levels and; the intervention's lack of adaptability in having little flexibility in the design and decision making about the use of intervention funds and data collection tools.Discussion: Our comprehensive and systematic use of the CFIR within an extended case study design generated granular evidence on CFIR's contribution to implementation science efforts to describe determinants of early-stage intervention implementation. It also provided baseline findings to assess subsequent implementation phases, considering similarities and differences in barriers and facilitators across study districts and facilities. Sharing preliminary findings with stakeholders promoted timely decision making about intervention implementation

Managers’ and providers’ perspectives on barriers and facilitators for the implementation of differentiated service delivery models for HIV treatment in Mozambique: a qualitative study

Abstract Introduction In 2018, Mozambique's Ministry of Health launched a guideline for a nationwide implementation of eight differentiated service delivery models to optimize HIV service delivery and achieve universal coverage of HIV care and treatment. The models were (1) Fast‐track, (2) Three‐month Antiretrovirals Dispensing, (3) Community Antiretroviral Therapy Groups, (4) Adherence Clubs, (5) Family‐approach, and three one‐stop shop models for (6) Tuberculosis, (7) Maternal and Child Health, and (8) Adolescent‐friendly Health Services. This study identified drivers of implementation success and failure across these differentiated service delivery models. Methods Twenty in‐depth individual interviews were conducted with managers and providers from the Ministry of Health and implementing partners from all levels of the health system between July and September 2021. National‐level participants were based in the capital city of Maputo, and participants at provincial, district and health facility levels were from Sofala province, a purposively selected setting. The Consolidated Framework for Implementation Research (CFIR) guided data collection and thematic analysis. Deductively selected constructs were assessed while allowing for additional themes to emerge inductively. Results The CFIR constructs of Relative Advantage, Complexity, Patient Needs and Resources, and Reflecting and Evaluating were identified as drivers of implementation, whereas Available Resources and Access to Knowledge and Information were identified as barriers. Fast‐track and Three‐month Antiretrovirals Dispensing models were deemed easier to implement and more effective in reducing workload. Adherence Clubs and Community Antiretroviral Therapy Groups were believed to be less preferred by clients in urban settings. COVID‐19 (an inductive theme) improved acceptance and uptake of individual differentiated service delivery models that reduced client visits, but it temporarily interrupted the implementation of group models. Conclusions This study described important determinants to be addressed or leveraged for the successful implementation of differentiated service delivery models in Mozambique. The models were considered advantageous overall for the health system and clients when compared with the standard of care. However, successful implementation requires resources and ongoing training for frontline providers. COVID‐19 expedited individual models by loosening the inclusion criteria; this experience can be leveraged to optimize the design and implementation of differentiated service delivery models in Mozambique and other countries