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Improving Health Systems Delivery in Mozambique – the role and opportunities for strengthening health systems March 01, 2011. Kenneth Sherr, PhD, MPH Assistant Professor Department of Global Health ksherr@uw.edu. Mark Micek, MD, MPH Clinical Assistant Professor Department of Global Health - PowerPoint PPT Presentation
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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
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)
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