Improving Health Systems Delivery in Mozambique – the

role and opportunities for strengthening health systems

March 01, 2011

Kenneth Sherr, PhD, MPHAssistant ProfessorDepartment of Global Healthksherr@uw.edu

Mark Micek, MD, MPHClinical Assistant ProfessorDepartment of Global Healthmmicek@uw.edu

Presentation Overview

Background on the know-do gap What are health systems and their role for

improving health Example of one approach to strengthening

health systems from Mozambique

‘Know-do’ gap

Advancements in medical science have outpaced their application

>10 million annual deaths from diseases with proven, low cost prevention or treatment strategies 1 million malaria deaths 6 million preventable child

deaths ½ million maternal deaths 3 million HIV-related deaths

Best Buys in Global Health

Disease Control Priorities Project www.dcp2.org

Mozambique experience (ART) Survey of 32 facilities with comprehensive HIV

care 5,642 patients enrolled (2,696 on ART, 2,946

pre-ART)Aspiratio

nAction

CD4 test in the last 6 months

100% 66%

Eligible patients receiving ART

100% 79%

Adherence assessed in last 6 months for patients on ART

100% 68%

Cotrimoxazole prophylaxis

100% 31%

TB screening 100% 18%Misau, 2008

Mozambique experience (ART)

US experience (Medicare)

Aspiration

Action

Beta blockers within 24 hours of admission with chest pain

100% 69%

Antibiotic administered within 8 hours of admission with pneumonia

100% 87%

Mammography at least every 2 years

100% 60%

Fundoscopic examination for diabetic retinopathy

100% 70%

Jencks, et al, JAMA 2003; 289(3):305-12.

Role of Delivery Systems in closing know-do gap

Discovery Development

Health System

Improved Health

Outcomes

The implementation bottleneck

Vaccines Primary

Health Care MCH Care Drug

therapies Basic surgery

Trends in Official Development Assistance for Health, 1990-2007

Ravishankar N, et al, Lancet 2009;373:2113-24

What is a health system?

0%

10%

20%

30%

40%

50%

60%

70%

80%

NotSatisfied

Long Wait Lack ofMedicines

ProblemContinued

Lack ofPersonnel

Expensive Hygiene Corruption

OverallSofala

Satisfaction - Mozambique

Source: IAF, 2002/3

Workforce in selected countries

Country Doctors (per 100,000)

Nurses (per 100,000)

Malawi 2 59 Mozambique 3 21 Uganda 8 61 Kenya 14 114 WHO Standard 20 100 South Africa 77 408 Brazil 115 384 USA 256 937 Cuba 591 744 Source: World Health Report, 2006

DDCF’s African Health Initiative Initiated in 2007 to catalyze shift away from

vertical programs in favor of Primary Health Care Aims to:

Achieve measureable, significant health improvements Strengthen health systems Increase the knowledge for evidence-based health

delivery and health systems planning through implementation research (develop and test models)

DDCF’s funded projects

Population Health Implementation & Training (PHIT) Partnerships began August, 2009 Rwanda: CHWs, HIS improvements, management

training Zambia: Clinical mentoring, EMR, CHWs Tanzania: Community-based IMCI Ghana: district resource allocation Mozambique

Examples of OR/QI activities in Mozambique

Mark Micek, MD, MPH

Mozambique PHITStrengthening Integrated Primary Health Care in

Sofala, Mozambique

Partners include: Provincial Health Directorate UW DGH/Health Alliance International UW Department of Industrial Engineering Eduardo Mondlane University

Background: Sofala Province Population 1.7 M, 13 districts

60% along “Beira corridor” 7% piped water, 6% electricity Year-round malaria transmission

HIV: 15.5% (270,000) HIV+ (INSIDA, 2009) 70,000 ART eligible (26%) 25,000 on ART (36% of eligible)

% <5 malnourished (MICS, 2008) Stunting: 41% Wasting: 16%

Background: National Health Service

NHS primary provider of formal health services Introduction of PHC in 1977 Per capita health expenditure <$40 per year Sofala province: <3,000 health workers (2008)

40 physicians (2.4/100,000) 552 superior & mid-level providers (32.5/100,000) 1,044 basic/elementary level providers (61.4/100,000) 45% support staff

Central Hospital

Quarternary (1-<1%)

Secondary (4- 3%)Rural Hospitals

Primary (137- 97%)Urban Health Centers (12 )Rural Health Centers I (10 )Rural Health Centers II (89)

Health Posts (26)

Specialized inpatient services & consults

Inpatient, outpatient, basic surgical capacity

ANC/FP, EPI, maternity, outpatient care

93% ANC65% institutional births

81% coverage DPT3(MICS, 2008)

High coverage of basic services in

Sofala

Importance of Primary Care

Project Need Despite high coverage of primary care, many interventions not

done Lack of management/supervision, drugs/reagents Money diverted to high-profile vertical programs

Weak district management impedes decentralization Lack of staff, management capacity Weak data systems and use to inform decisions

As a result: Weak program assessment & problem solving, poorly allocated

resources, stock-outs Weak systems integration within & between facilities, and across vertical

programs; fragmentation of care

Project Aim & Objectives

Aim: Improve health outcomes in all 13 districts in Sofala province by strengthening health systems and improving delivery of integrated primary health care

Objectives:1. Strengthen integrated health systems management in

Sofala at district and provincial levels

2. Improve quality of routine data and develop appropriate tools to facilitate decision-making for provincial and district managers (i.e. data feedback “dashboard”)

3. Build capacity for and conduct innovative operations research and quality improvement activities, to guide integration and system strengthening efforts

Conceptual Framework Forms the basis for the design and measurement of the

intervention What processes are important within health systems? What interventions can improve these processes? How can we measure if the improvement improved health?

Obj 1: Strengthen health systems management in Sofala

Training on leadership & management for health system managers Develop series of 1-2 day training modules on:

Strategic planning and target setting Problem identification and solving (data driven decision making) Roles/responsibilities/team building/leadership Effective communication Resource management/budgeting

Train health managers using modules District Management Team training (on site) Training of MDs pre-deployment (annually) Incorporation into pre-service curricula

Sector-specific trainings (ie: MCH) on data systems and their use

Obj 2: Improve routine data systems & develop tools to facilitate decision-making

Training of staff on basics of M&E systems Ongoing assessments of data consistency and

validity, with feedback on HIS Observation of consults Registry book Paper report

electronic database Development of data

feedback form (Dashboard) Development of simulation/

optimization models for HR allocation, supply chainmanagement

Obj 3: Carry out OR and QI projects, to improve health system functioning

Population Council IHI Collaborative

Linear Cyclical

1. Identify program problem 1. Plan

2. Generate program solution 2. Do

3. Test program solution 3. Study

4. Use/disseminate results 4. Act

Act Plan

DoStudy

Opportunities & challenges in doing OR/QI

Opportunities: Processes in resource-poor settings often complex Little attention paid to efficiency, process mapping,

redesign Much data available to guide decisions

Challenges: Often routine data is too poor to use Easy to get too complex, too esoteric, too lengthy End product may not apply to real world no one uses it Getting buy-in at all levels before starting

Example of OR: Low number of patients who starting ART

0

20

40

60

80

100

120

Q1 2004 Q2 2004 Q3 2004 Q4 2004 Q1 2005 Q2 2005 Q3 2005

Beira

Chimoio

National ARV Program

Steps to identify and treat people with HIV: The HIV treatment cascade

HIV testing centers VCT

Home-based Care

Pregnant

Youth

Community

TB patients

Ill/Hospitalized Hospital

Youth VCT

pMTCT

STEP 1 HIV Testing

STEP 2 Arrival to ART clinic

STEP 3 CD4 Testing

STEP 4 Start ART (if eligible)

STEP 5 Adhere to

ART

ART clinics ART clinic Clinical

evaluation (including CD4)

Adherence to ART

Start ART in eligible patients

Results: Overall HIV treatment cascade

Summary of flow in HIV Care system, Beira and Chimoio, July 2004 - June 2005

0

1000

2000

3000

4000

5000

6000

7000

8000

Step 2 Step 3 Step 4 Step 5

HIV+

Enroll ART clinic <30d(56%)

CD4 testing <30d(77%)

Eligible for ART(49%)

Started ART <90d(31%) On ART >180d

(81%)

Adherence >90% at 180d(83%)

Step 2:Drop-off 44%

3,049 lost

Step 4:Drop-off 69%

1,035 lost

Results: Major bottlenecks

Number of additional people completing all 5 steps if drop-offs individually improved

Step 1: Step 2: Step 3: Step 4: Step 5:HIV HIV Enroll at CD4 ART Start On ART Adhere

Total adult testing positive ART clinic testing eligible ART 180 days to ARTpopulation 23,430 7,005 3,956 3,046 1,506 471 382 317

457,106 5.1% 29.9% 56.5% 77.0% 49.4% 31.3% 81.1% 83.0%

Extra if Extra if Extra if Extra if Extra iftesting drop-off drop-off drop-off drop-off

doubled eliminated eliminated eliminated eliminated317 244 95 697 65

Value Stream Mapping of pMTCT Services

♀p arrives for 1st

pre-natal visit with ANC nurse

Day 1

HIVRapidTest

Reception activist opens a chart for ♀p+

Day 1ANC activist accompanies ♀p+ to reception

CD4 Nurse• Blood draw for CD4 count (if initial

visit is on Monday, Tuesday orWednesday)

• Evaluates treatment urgency• Determines WHO clinical stage

(I-IV)

Day1

CD4

♀p+

returns to nurse for

CD4 results

≥ Day 28

III-IV

♀p+ receives AZT & sdNVP> 250

+

CD4 nurse prescribes CTZ and biochemical blood tests

ART Committee (at Nhamatanda)

reviews case to determine

eligibility

ART ?

Evaluation with Medical Officer

(Tuesdays)

~1-4 weeks after diagnosisSocial worker gives ♀p+ the

ART prescription

~1-4 weeks after diagnosis

≤ 250

DOT for the first 14 days of treatment

PMTCT

no

yes

Health Center Tica ♀p+ PMTCT Flow

At 28 weeks

♀p+ takes duNVP

Contractions start

Labor Starts At Home

Duovir (AZT+3TC)

During labor

At Hospital Maternity

AZT

For one week postpartum

In The Home

Newborn gets: sdNVP & AZT

Postpartum

Picks up medicines at

pharmacy

StageI-II

CD4 blood draw (if

initial visit was

Thursday or Friday)

Next week

♀p+ starts 3 phases of ART adherence counseling with a

social worker (takes 1-3 weeks). CD4 blood draw (if initial visit was Thursday or

Friday)

Phase 3

Phase 2

Phase 1

Drops off ART card at pharmacy

2-3 days later

32

Value Stream Mapping of pMTCT Services

♀p arrives for 1st

pre-natal visit with MCH nurse

Day 1

HIVRapidTest

Reception activist opens a chart for ♀p+

Day 1MCH activist accompanies ♀p+ to reception

CD4 Nurse• Blood draw for CD4 count (if initial

visit is on Monday, Tuesday orWednesday)

• Evaluates treatment urgency• Determines WHO clinical stage

(I-IV)

Diay1

CD4

♀p+

returns to nurse for

CD4 results

≥ Day 28

III-IV

♀p+ receives AZT & sdNVP> 250

+

CD4 nurse prescribes CTZ and biochemical blood tests

ART Committee (at Nhamatanda) reviews case to determine

eligibility

ART ?

Evaluation with Medical Officer

(Tuesdays)

~1-4 weeks after diagnosisSocial worker gives ♀p+ the

ART prescription

~1-4 weeks after diagnosis

≤ 250

DOT for the first 14 days of treatment

PMTCT

no

yes

Health Center Tica ♀p+ PMTCT Flow

At 28 weeks

♀p+ takes duNVP

Contractions start

Labor Starts At Home

Duovir (AZT+3TC)

During labor

At Hospital Maternity

AZT

For one week postpartum

In The Home

Children receive: sdNVP

& AZT

Postpartum

Picks up medicines at

pharmacy

StageI-II

CD4 blood draw (if

initial visit was

Thursday or Friday)

Next week

♀p+ starts 3 phases of ART adherence counseling with a

social worker (takes 1-3 weeks). CD4 blood draw (if initial visit was Thursday or

Friday)

Phase 3

Phase 2

Phase 1

Drops off ART card at pharmacy

2-3 days later

33

Evaluation of change in workday

No statistically significant increase in number or trend of visits after intervention (compared with before)

5,000

10,000

15,000

20,000

25,000

Tota

l num

ber

of o

utpa

tien

t vi

sits

Number of outpatient visits in Munhava Health Center before/after lengthening of workday

Change in workday

(12/23/09)

Measuring impact of PHITINPUTS Provincial-level spending on health

DDCFGovernment

NGOPrivate

Out of pocket

PROCESSES Mgt/supervision HR Clinical care Pharmacy LaboratoryFunctioning District Management Team HR allocation between facilities Services delivered Stockouts of key medications Stockouts of key lab reagents

Calculated per workload performed and population covered

DPT3, 1st PNC, PNC syphilis tested/treated, IPT, bednet distribution, institutional births, HIV testing, IP tested HIV, TB testing HIV,

pMTCT tested HIV, ART, TB treatment outcomes

CTX, amoxicillin, anti-malarials, ART Hb, LFTs CD4, HIV; working infrastructure: heme, biochem, CD4,

RPR

Data collection DMT composition HR assigned to each facility Workload Pharmacy reports Laboratory reportsFully staffed DMT- Monthly Complete and on-time reporting-

MonthlyComplete and on-time reporting- Monthly Complete and on-time reporting-

MonthlyComplete and on-time reporting-

MonthlyFully trained DMT staff- Monthly

Data feedback Activity of DMTs Analysis of HR allocation (HR/workload)

Number of DMT meetings- Monthly

Number of facilities with DMT supervision visits- Monthly

Data use Management decisions made to improve indicators

Improved HR allocation Clinical processes changed to improve service coverage/patient flow

Reduced stock-outs Reduced stock-outs

Introduction of job Aids, patient flow changes, staff clinical on-the-job training

HR allocation equity and optimization against standard- Quarterly

Number/type of processes changed- Quarterly Number of stock-outs/facility/month- Quarterly

Number of stock-outs/facilility/month- Quarterly

OUTPUTS & Quality of care / Responsiveness Service coverage / utilizationOUTCOMES Time per visit- before/after

Waiting times- before/afterTurned away from care- before/after

Patient satisfaction- before/after

IMPACT Improved healthInfant mortality (1q0)Child mortality (5q0)

Adult mortality (45q15)Child anthopometric indices

%DPT3, %1st PNC, %1st PNC syphilis tested/treated, %bednet distribution/use, %IPT, %institutional births, %HIV testing,

%IP tested HIV, %TB testing HIV, %pMTCT tested HIV, %ART, TB treatment ouctomes-

Yearly

Measuring impact of PHITINPUTS Provincial-level spending on health

DDCFGovernment

NGOPrivate

Out of pocket

PROCESSES Mgt/supervision HR Clinical care Pharmacy LaboratoryFunctioning District Management Team HR allocation between facilities Services delivered Stockouts of key medications Stockouts of key lab reagents

Calculated per workload performed and population covered

DPT3, 1st PNC, PNC syphilis tested/treated, IPT, bednet distribution, institutional births, HIV testing, IP tested HIV, TB testing HIV,

pMTCT tested HIV, ART, TB treatment outcomes

CTX, amoxicillin, anti-malarials, ART Hb, LFTs CD4, HIV; working infrastructure: heme, biochem, CD4,

RPR

Data collection DMT composition HR assigned to each facility Workload Pharmacy reports Laboratory reportsFully staffed DMT- Monthly Complete and on-time reporting-

MonthlyComplete and on-time reporting- Monthly Complete and on-time reporting-

MonthlyComplete and on-time reporting-

MonthlyFully trained DMT staff- Monthly

Data feedback Activity of DMTs Analysis of HR allocation (HR/workload)

Number of DMT meetings- Monthly

Number of facilities with DMT supervision visits- Monthly

Data use Management decisions made to improve indicators

Improved HR allocation Clinical processes changed to improve service coverage/patient flow

Reduced stock-outs Reduced stock-outs

Introduction of job Aids, patient flow changes, staff clinical on-the-job training

HR allocation equity and optimization against standard- Quarterly

Number/type of processes changed- Quarterly Number of stock-outs/facility/month- Quarterly

Number of stock-outs/facilility/month- Quarterly

OUTPUTS & Quality of care / Responsiveness Service coverage / utilizationOUTCOMES Time per visit- before/after

Waiting times- before/afterTurned away from care- before/after

Patient satisfaction- before/after

IMPACT Improved healthInfant mortality (1q0)Child mortality (5q0)

Adult mortality (45q15)Child anthopometric indices

%DPT3, %1st PNC, %1st PNC syphilis tested/treated, %bednet distribution/use, %IPT, %institutional births, %HIV testing,

%IP tested HIV, %TB testing HIV, %pMTCT tested HIV, %ART, TB treatment ouctomes-

YearlyComparison between intervention and control province•Responsiveness: separate studies•Impact: DHS

Health system responsiveness: Time and motion study

Waiting times, turn-aways are a measure of health system responsiveness and quality of care (like patient satisfaction)

Measured at years 0/1 (baseline), 4, 7 12 health facilities from 12 districts (6 intervention province, 6

control province) Non-randomly chosen to include spectrum of facility types

(large tertiary hospitals to small rural health posts) 2 services chosen per facility (i.e. outpatient, prenatal

care, well child care) + lab & pharmacy Observers recorded arrival times, wait times, and turn-aways

for consecutive patients (goal n=180 per service)