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Ministério da Saúde
República de Moçambique────
Achieving Effective Implementation of New Roles in Primary Care: Country experience –Mozambique
Fourth Global Forum on Human Resources for Health
15 November 2017Dublin, Ireland
Martinho Dgedge, MD; Msc; PhDGeneral Inspector of Health – Ministry of Health- Mozambiquemartinho.dgedge@gmail.com; mdgedge@misau.gov.mz
MISAU: O nosso maior valor é a vida
MISAU
Outline of the Presentation
1. Introduction
2. Mozambique general information
3. Primary Health Care Package and respective competencies
4. Primary Health Care Workforce
5. Key examples of increased health services coverage
6. Final considerations
212/7/2017
MISAU: O nosso maior valor é a vida
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Introduction
• The National Health Service operates mostly with mid-level cadre since the
independence in 1975.
• Therefore, for us, those new roles are not really new.
• What is new are the new tasks that these cadres perform
�Task shifting for HIV and AIDS Care and treatment from doctors to mid-
level clinicians, nurses and midwives
� Tuberculosis treatment by mid-level nurses
�Basic treatment and preventive interventions by Community Health
Workers
312/7/2017
MISAU: O nosso maior valor é a vida
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Mozambique General Information (1)
Socio-Demographic information
Population Close to 27 millions
Maternal Mortality Rate 408/100,000 live
births
Infant Mortality Rate 93/1,000 live births
GDP/Capita Close to 900 USD
MISAU: O nosso maior valor é a vida
MISAU
07/12/2017
5
Malaria Prevalence HIV Prevalence
Mozambique General Information (2)
MISAU: O nosso maior valor é a vida
MISAU Quaternary
Level
4 Central Hospitals
2 Specialized Hospitals
Quaternary
Level
4 Central Hospitals
2 Specialized Hospitals
Terciary Level: 8 (0.5%) 8 Provincial Hospitals
Total of HRH: 4,689 (12%)
Health Workers: 2,422 (11%)
Terciary Level: 8 (0.5%) 8 Provincial Hospitals
Total of HRH: 4,689 (12%)
Health Workers: 2,422 (11%)
Secundary Level: 50 (3%)
21 Rural Hospitals, 23 Distrital Hospitals, 6 General
Hospitals
Total of HRH: 7,828 (20%)
Health Workers: 4,565 (21%)
Secundary Level: 50 (3%)
21 Rural Hospitals, 23 Distrital Hospitals, 6 General
Hospitals
Total of HRH: 7,828 (20%)
Health Workers: 4,565 (21%)
Primary Level: 1,530 (96%)162 Urban Health Centres,
1,238 Rural Health Centres and 130 Health Posts
Total of HRH: 19,350 (50%)
Health Workers: 11,884 (54%)
Primary Level: 1,530 (96%)162 Urban Health Centres,
1,238 Rural Health Centres and 130 Health Posts
Total of HRH: 19,350 (50%)
Health Workers: 11,884 (54%)
Health Workforce and Health Facility Distribuition per level of care, National
Health Service, Mozambique, 2016
PH
C
Total of Health Facilities: 1,595
Health Workforce Stock in Health FacilitiesTotal HRH: 39,055Health Workers: 21,908
Source: MoH/HRD/HRIS (eSIP-Saúde)
Quaternary levelTotal of HF: 6 (0.4%)Total of HRH: 7,188 (18%)Health Workers: 3,077 (14%)
6
MISAU: O nosso maior valor é a vida
MISAU
7
Health Workforce by Occupational Categories, NHS, 2016
Source: MOH/HRD/HRIS (eSIP-Saúde)
[VALUE] (0,1%)
[VALUE] (0,1%)
[VALUE] (0,2%)
[VALUE] (0,2%)
[VALUE] (0,3%)
[VALUE] (0,5%)
188 (0,7%)
257 (0,9%)
287 (1,0%)
387 (1,4%)
483 (1,7%)
[VALUE] (1,7%)
493 (1,7%)
512 (1,8%)
1.845 (6,5%)
2.087 (7,4%)
2.149 (7,6%)
5.485 (19,4%)
5.517 (19,5%)
7.660 (27,1%)
0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000
Otolaryngology
Orthroprotesia
Surgery
Health Statistics
Others Professionals
Ophthalmology
Anesthesiology
Radiology
Instrumentation
Physical Medicine and Rehabilitation
Hospital administration
Nutrition
Psychiatry and Mental Health
Dental care
Laboratory
Pharmacy
Environ, and public health professionals
Healing Medicine
Midwifery
Nursing
MISAU: O nosso maior valor é a vida
MISAU
Accessibility: Ratios of Inhabitants per Primary Health Care Facility and per Primary Health Care Workers, NHS, 2014
8
MISAU: O nosso maior valor é a vida
MISAU
Primary Health Care Workforce (regulated by –Ministerial Decree127/2002)
• Generalist Doctors
• Basic/Mid level Paramedical Practioners
• Basic/Mid level nurses
• Basic/Mid level Midwifery Professionals
• Basic/Mid level Dental assistants
• Basic/Mid level Laboratory Practioners
• Basic/Mid level Pharmaceutical Practioners
• Basic/Mid level Nutricionist practioners
912/7/2017
MISAU: O nosso maior valor é a vida
MISAU
10
Staffing Norms by Health Facility Type, Ministerial Decree 127/2002 (1)
Health Facility Type Category DM 127/2002Staffing
Norms
Rural Health Center Type II 4
Mid-level Paramedical practitioners or Mid-level Nursing
professionals or Nursing associate professionals1
Mid-level Midwifery professionals or Midwifery associate
professionals1
Mid-level Nutrition professionals 1
Health support staff 1
Rural Health Center Type I 14
Mid-level Paramedical practitioners 1
Mid-level Environ, and public health professionals 1
Mid-level Dental assistants and therapists 1
Mid-level Nursing professionals or Nursing associate
professionals2
Mid-level Midwifery professionals or Midwifery associate
professionals2
Mid level Medical and pathology laboratory technicians 1
Mid-level Medical imaging and therapeutic equipment
operators1
Mid-level Pharmaceutical technicians and assistants 1
Health management workers/Skilled administrative staff
(Hospital Administration Agent)1
Health support staff 3
Source: MOH/HRD/HRIS (eSIP-Saúde)
MISAU: O nosso maior valor é a vida
MISAU
11
Health Facility Type Category DM 127/2002
Staffing
Norms
(without
maternity)
Staffing
Norms
(with
maternity)
Urban Health Center 25 31
Physicians and Mid-level Paramedical practitioners 3 3
Mid-level Environ, and public health professionals 1 1
Mid-level Dental assistants and therapists 1 1
Mid-level Nursing professionals 4 4
Mid-level Midwifery professionals or Midwifery
associate professionals5 5
Mid level Medical and pathology laboratory
technicians1 1
Mid-level Medical imaging and therapeutic
equipment operators1 1
Mid-level Pharmaceutical technicians and assistants 1 1
Health management workers/Skilled administrative
staff (Hospital Administration Assistant)1 1
Health management workers/Skilled administrative
staff (Clerk - Typist)2 2
Other health support staff 5 11
Source: MOH/HRD/HRIS (eSIP-Saúde)
Staffing Norms by Health Facility Type, Ministerial Decree 127/2002 (2)
MISAU: O nosso maior valor é a vida
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12
Primary Health Care Workforce Distribution by Health Centre Type, National
Health Service, Mozambique, 2016 (1)
Source: MOH/HRD/HRIS (eSIP-Saúde)
N %
Generalist medical practitioners 44 136 87 2 269 1,5%
High level Paramedical practitioners 0 5 3 0 8 0,0%
Mid-level Paramedical practitioners 1.352 1.044 736 213 3.345 18,5%
High level Nursing professionals 15 43 29 2 89 0,5%
Mid-level Nursing professionals 635 1.139 451 134 2.359 13,0%
Nursing associate professionals 93 111 86 36 326 1,8%
High level Midwifery professionals 4 9 5 0 18 0,1%
Mid-level Midwifery professionals 1.046 779 680 174 2.679 14,8%
Midwifery associate professionals 99 93 86 22 300 1,7%
Pharmacists 1 12 7 1 21 0,1%
Mid-level Pharmaceutical technicians 231 346 263 23 863 4,8%
Pharmaceutical assistants 10 18 21 4 53 0,3%
High level Medical and pathology laboratory technicians 0 9 6 0 15 0,1%
Mid-level Medical and pathology laboratory technicians 138 341 174 6 659 3,6%
Medical and pathology laboratory associate professionals 8 15 13 0 36 0,2%
Dentists 9 30 25 0 64 0,4%
Mid-level Dental assistants 27 109 49 0 185 1,0%
Mid-level Medical and dental prosthetic technicians 0 3 0 0 3 0,0%
Grand TotalUrban
Health
Centre
Rural
Health
Centre
Type I
Rural
Health
Centre
Type II
Professional CategoriesHealth
Post
MISAU: O nosso maior valor é a vida
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13
Source: MOH/HRD/HRIS (eSIP-Saúde)
N %
Physiotherapists 0 2 0 0 2 0,0%
Mid-level physiotherapy assistants 4 39 7 0 50 0,3%
Physiotherapy associate professionals 1 0 0 0 1 0,0%
Mid-level Opticians 7 30 15 0 52 0,3%
Mid-level Medical imaging and therapeutic equipment
operators8 25 3 0 36 0,2%
Subtotal Mid-level Health Professionals 3.448 3.855 2.378 550 10.231 89,5%*
Subtotal Health Professionals 3.732 4.338 2.746 617 11.433 63,2%
High level Health management workers/Skilled
administrative staff.9 37 63 3 112 0,6%
Mid-level Health management workers/Skilled
administrative staff.239 464 415 24 1.142 6,3%
Health management workers/Administrative Assistant staff. 23 64 35 22 144 0,8%
Other health support staff 1.862 2.676 1.623 358 6.519 36,0%
Grand Total 5.617 7.078 4.404 997 18.096 100,0%
* 89.5% of the health professionals were mid-level health professionals at the primary health care level
Grand TotalUrban
Health
Centre
Rural
Health
Centre
Type I
Rural
Health
Centre
Type II
Professional CategoriesHealth
Post
Primary Health Care Workforce Distribution by Health Centre Type, National
Health Service, Mozambique, 2016 (2)
MISAU: O nosso maior valor é a vida
MISAU
Primary Health Care Workforce Ratio, National Health Service, Mozambique, 2016
Total Ratio Per Primary Health
Facility
Ratio Per doctor
Ratio per Non Phycisian clinicians
Primary Health Facility
1530
Doctor 269 0,2
Non Physician clinicians
3345 2,2 12,4
Midwifery 2979 1,9 11,1 0,9
Nurses 2685 1,8 10 0,8
1412/7/2017
MISAU: O nosso maior valor é a vida
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• Antenatal and post natal consultations (incluing ART/B+,
Intermittent Preventive treatment of Malaria).• Prescription and apply non-definitive Family Planning Methods
(oral and injection contraceptives...).• Delivery of pregnant women and care to new borns.
Competencies Cadre
• Mid-level Midwife
• Mid-level Environmentand Public Health
Technician
• Mid-level Midwife
• Mid-level Nutritiontechnician
• Mid-level Midwife
• Planning and implementation of educational programes in the
community for health promotion and dissemination of preventativemeasures of HIV-SIDA and other endemic diseases.
• Implementation of the national programme on immunization• Promotion of environment health interventions.
• Nutritional promotion for healthy child development: exclusive
breast feeding and supplementary feeding.• Promotion of local food production and consumption of required
food according to endemic disease (TB and AIDS).15
Skill mix for the Implementation of Primary Health Care Package-Preventive Interventions
MISAU: O nosso maior valor é a vida
MISAU
• Delivery of obstetric care.
• Diagnostic and treatment of hypovolemic shock before transfert of patient.
Competencies Cadre
• Mid-level Midwife
• Mid-level paramedicalpracticioners
• Mid-level Midwife
• Evaluation, classification and treatment of most frequent child
diseases according to IMCI protocols and transfert whennecessary.
• Diagnostic and treatment of pediatric HIV.
16
Skill mix for the Implementation of Primary Health CarePackage- Curative Interventions
• Diagnostic and treatment of more commun diseases:
pneumonia, diarrheia, acute malnutrition aguda, Malaria, TB,HIV.
• Little surgery (treatment and/or stitches of superficial wounds,abcess drainage, stitches removal, extraction of foreign bodies,
etc.).
• Mid-level Nurse
• Mid-level paramedicalpracticioners
MISAU: O nosso maior valor é a vida
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Key examples of increased health services coverage (1)Outpatient and Institutional Deliveries Distribution per Health Facility type, National Health Service, 2014
1712/7/2017
14%
86%
0%
25%
50%
75%
100%
Hospitais Centros de Saúde
Outpatient
21%
[VALUE]
Hospitais Centros de Saúde
DELIVERIES
Hospitais
Centros de
Saúde
MISAU: O nosso maior valor é a vida
MISAU
Key examples of increased health services coverage (2)HIV Counceling and Testing per Activity Sector and Province, 1st
Semester 2017
MISAU: O nosso maior valor é a vida
MISAU
Key examples of increased health services coverage (3)Evolution of Number on Health Facilities providing ART, 2003 - 1st
semester 2017
MISAU: O nosso maior valor é a vida
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Key examples of increased health services coverage (4)Coverage and number of Patients on ART, 2003 -1º Sem 2017
MISAU: O nosso maior valor é a vida
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Key examples of increased health services coverage (4)Evolution of Pediatric TB cases notification,NHS, 2010-2016
34493214
36893890
5776
6726
9254
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
2010 2011 2012 2013 2014 2015 2016
Nú
mero
de c
aso
s n
oti
ficad
os
PEDIATRIC TB
MISAU: O nosso maior valor é a vida
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COMMUNITY HEALTH WORKERS
12/7/2017
22
MISAU: O nosso maior valor é a vida
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� Revitalization of community health workers programme in 2010
� To provide health care to communitinities of 500 to 2000 inhabitants in a distance of 8 to 25 Km of the health center;
�20% limited curative care and treatment;
�80% preventive and health promotion activities.
Community Health Worker Programme (1)
MISAU: O nosso maior valor é a vida
MISAU� Revision of CHW’s profile and introduction of new community –based
interventions in 2014
o Delivery of modern methods of family planning
o Prevention of of post-partum haemorragy
o Supplement of Vitamin A for children 6-59 months old
o Treatment adherence to HAART, PMTCT and TB
o Malaria Diagnosis and treatment
o 3.380 CHWs trained in 2015 and 2016
Community Health Worker Programme (2)
MISAU: O nosso maior valor é a vida
MISAU
Evolution of CHWs’ activities, 2015-2016 (1)
-
100,000
200,000
300,000
400,000
500,000
600,000
700,000
Maláriaconfirmada
Malária Clínica Diarreia Pneumonia MaláriaConfirmada
Malária Clínica Diarreia
Diagnóstico de casos (2meses -5anos) Diagnóstico de caso ( ≥ 5anos)
Diagnoses of Malaria, Diarrhoea, Respiratory Infections
2015
2016
MISAU: O nosso maior valor é a vida
MISAU
Evolution of CHWs’ activities, 2015-2016 (2)
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
RN (0-28dias)
Vacinaçãoincompleta
CPN CPP PF DAG, graveou mod
Sinal geralde perigo
Transfer to Health Facilities
2015
2016
MISAU: O nosso maior valor é a vida
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Redution of Health Unit pressure
Potential Complementarity of CHWs
651316
(22%)
2318628
(78%)
Malaria cases 0-4 anos
APE's US's
524606
(17%)
2649125
(83%)
Malaria cases >5 anos
APE's US's
MISAU: O nosso maior valor é a vida
MISAU
Family Planing
Potential Complementarity of CHWs
597363
(94%)
757145
(97%)
38429 (6%)
21475 (3%)
0
100000
200000
300000
400000
500000
600000
700000
800000
900000
Utentes que escolheram
Pílulas
Utentes que escolheram
Depo
US's APES
%
Contribuição dos APEs no PF
34
269
353
255
75 66 27 22 6 33
148
66
128
58
54 5692
38 6944
Maternal Deaths reported by The Health Information System
2016
MM reportadas APEs MM reportadas US's
MISAU: O nosso maior valor é a vida
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1. The ministerial decree describes the skill mix needed for the implementation of primaryhealth care services
• However, due to the limited number of mid-level medical practitioners, strategies toincrease health interventions coverage were:
� Task-shifting to mid-level nurses and mid-level midwives who are the second mostrepresented category in primary health care
� Increase of Mid-level midwives competencies scope, implementing a wide range ofinterventions from maternal and neonatal to adolescent care
� Increase of Community Health Workers competencies to widen the range of primaryhealth care services offered to the population
2. Training of more mid-level clinicians is necessary to reduce the workload of mid-levelmidwives 29
Final Considerations
MISAU: O nosso maior valor é a vida
MISAU
MUITO OBRIGADO
THANK YOU
GO RAIBH MAITH AGAIBH
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