Reasons for implementation success despite health system constraints: qualitative insights on 'what worked' for cotrimoxazole preventive therapy.

BACKGROUND: Although Cotrimoxazole preventive therapy (CPT) has shown to be highly efficacious in reducing morbidity and mortality among people living with Human immunodeficiency virus (HIV) under 'ideal world' study conditions, operational challenges are limiting its effectiveness when implementing in countries most affected by the HIV epidemic. The fact that Mozambican authorities reported high coverage of CPT among patients with HIV, has led to this qualitative case study aimed at exploring possible factors responsible for the successful implementation of CPT in the Province of Maputo. METHODS: Between February and April 2019, we individually interviewed nine governmental stakeholders, including the person responsible for the HIV Program, the person responsible for the TB Program and the person responsible for Pharmaceutical management at three administrative levels (central, provincial and district level). Interviews were recorded, transcribed, and analysed thematically using MAXQDA Analytics Pro. Findings were translated from Portuguese into English. RESULTS: Five themes iteratively emerged: (a) Role of governance & leadership, (b) Pharmaceutical strategies, (c) Service delivery modifications, (d) Health care provider factors, and (e) Patients' perspectives. Interviews revealed that continuous supply of cotrimoxazole (CTZ) had been facilitated through multiple-source procurement and a push-pull strategy. One part of CTZ arrived in kits that were imported from overseas and distributed to public health facilities based on their number of outpatient consultations (push strategy). Another part of CTZ was locally produced and distributed as per health facility demand (pull strategy). Strong district level accountability also contributed to the public availability of CTZ. Interviewees praised models of differentiated care, the integrated HIV service delivery and drug delivery strategies for reducing long queues at the health facility, better accommodating patients' needs and reducing their financial and organisational burden. CONCLUSIONS: This study presents aspects that governmental experts believed to be key for the implementation of CPT in the Province of Maputo, Mozambique. Enhancing the implementation outcomes - drug availability and feasibility of the health facility-based service delivery - seemed crucial for the implementation progress. Reasons for the remarkable patient acceptability of CPT in our study setting should be further investigated.

Is workplace violence against health care workers in Mozambique gender related?

This report revisits data used to describe the typology and the perceived impact of violence against health care workers (VHCW) at the health services of the City of Lichinga in Mozambique, based on an observational, descriptive, cross-sectional study, carried out from March to May 2019. In this report we attempt to understand if our reanalysis of VHCW in Niassa can explain it as an example of gender-based violence. Our findings-particularly that women more than men reported not knowing if the health services had any policies or procedures to deal with VHCW, felt that they were not encouraged to report acts of VHCW and were more frequently threatened/violented by different sex aggressors-although not conclusive, support the need to consider gender as a dimension when conducting research on VHCW. If we do not do so, gender will continue to be an invisible and ignored dimension of intervention strategies to prevent and address VHCW.

Perceptions of Community Health Workers (CHW) on barriers and enablers to care for people with psychosis in rural Mozambique: findings of a focus group discussion study using the Capability, Opportunity, Motivation and Behaviour framework (COM-B framework).

BACKGROUND: Psychotic disorders contribute significantly to the global disease burden by causing disability, impaired quality of life, and higher mortality in affected people compared with the general population. In rural settings, where there is limited or no access to healthcare, individuals living with psychotic disorders often seek support from Community Health Workers (CHWs). However, little is known about what CHWs know about psychosis and how they manage such cases. This study aimed to explore the CHWs perception of psychosis and their experiences and beliefs about the factors that might enable or hinder care-taking for patients with psychosis in rural settings in Mozambique. METHODS: A qualitative study was conducted in rural districts of Maputo Province, a southern region of Mozambique, using six focus group discussions with participation of 79 CHWs. Thematic analysis was used informed by the Capabilities, Opportunities, Motivation and Behaviour framework (COM-B). RESULTS: Nine primary themes were identified. Overall, CHWs perceived psychosis as treatable medical conditions and held a positive attitude about being part of the care-taking process of patients with psychosis in rural settings. Partnerships with key-stakeholders such as traditional healers, health care workers, and families, were perceived by CHWs as enablers to improve access to care in rural areas. However, stigma, myths, and lack of competencies to treat people with psychosis were perceived by CHWs as barriers for appropriate care. CONCLUSION: CHWs, with adequate support, could play an important role in the care of patients with psychosis in rural settings, including identifying patients requiring care and referring them to appropriate healthcare professionals, and following up medicated patients with psychosis. Training of CHWs should consider inclusion of basic mental health care competencies.

Violence against health care workers in the workplace in Mozambique - An unrecognised managerial priority.

INTRODUCTION: Recognition of the relevance of violence against health workers in their work place has been growing around the world. In Mozambique, workplace violence in the health sector needs better documentation. Therefore, this article is part of a study that describes the typology and the perceived impact of violence against health care workers in their workplace at the Lichinga Provincial Hospital and at the Health Centre of the City of Lichinga in 2019. METHOD: This was an observational, descriptive, cross-sectional study. The study was carried out in a simple random sample of health workers victims of violence at the Provincial Hospital and the Health Centre of the City of Lichinga, in the Province of Niassa in northern Mozambique. The questionnaire applied was adapted from the original developed by the International Labour Organization, the International Council of Nurse, the World Health Organization and Public Services International and applied in Maputo, Mozambique during 2002. Statistical analysis was carried out with Statistical Package for the Social Sciences 20.0 and WinPepi 11.65. RESULTS: Two hundred and 60 healthcare workers (HCW) were selected to participate, 180 agreed, 145 had inclusion criteria and five gave up participating in the study during the consent procedure. Thus, a total of 140 HCW answered the questionnaire. Predominant types of violence were: verbal threat/aggression 34% (n = 62/180); moral pressure/bullying/mobbing 30% (n = 54/180); ethnic discrimination 9% (n = 16/180); against personal property 6% (n = 10/180); physical 4% (n = 8/180); sexual harassment 4% (n = 8/180). One hundred and 37 victims reported 154 episodes of violence, where 7% (n = 13/180) reported more than one type of violence. Most victims reported no reaction (55%, n = 76/137) and few said that they confronted the offender (16%, n = 22/137, particularly victims of sexual harassment, 38%, n = 3/8). Most HCW reported non-existence (39%, n = 54/137) or unawareness (32%, n = 44/137) of procedures to report violence within the Institution. Most (80%, n = 33/41) of those knowing about the procedures, knew how to use them. More than half (55%; n = 76/137) of HCW said that they were discouraged to report acts of violence. CONCLUSIONS: Like for previous studies in Mozambique and elsewhere in Africa, the study confirms: a relatively high prevalence, a reluctance to talk about the issue and unawareness about procedures on how to report incidents. The findings reconfirm the necessity for the development and implementation of procedures to address violence incidents towards HCW, to develop support services for victims of health workplace violence. Like elsewhere in Africa, successive health workforce plans in Mozambique have failed to address this issue.

From Easing Lockdowns to Scaling Up Community-based Coronavirus Disease 2019 Screening, Testing, and Contact Tracing in Africa-Shared Approaches, Innovations, and Challenges to Minimize Morbidity and Mortality.

The arrival of coronavirus disease 2019 (COVID-19) on the African continent resulted in a range of lockdown measures that curtailed the spread of the infection but caused economic hardship. African countries now face difficult choices regarding easing of lockdowns and sustaining effective public health control measures and surveillance. Pandemic control will require efficient community screening, testing, and contact tracing; behavioral change interventions; adequate resources; and well-supported, community-based teams of trained, protected personnel. We discuss COVID-19 control approaches in selected African countries and the need for shared, affordable, innovative methods to overcome challenges and minimize mortality. This crisis presents a unique opportunity to align COVID-19 services with those already in place for human immunodeficiency virus, tuberculosis, malaria, and non communicable diseases through mobilization of Africa's interprofessional healthcare workforce. By addressing the challenges, the detrimental effect of the COVID-19 pandemic on African citizens can be minimized.

Domestic violence in Mozambique: from policy to practice.

BACKGROUND: To reduce the impact of domestic violence (DV), Mozambican governmental and non-governmental entities are making efforts to strengthen the legislative framework and to improve the accessibility of care services for survivors of violence. Despite this remarkable commitment, the translation of policies and legislation into actions remains a considerable challenge. Therefore, this paper aims to identify gaps in the implementation of existing national policies and laws for DV in the services providing care for survivors of DV. METHODS: This qualitative study comprised of two approaches. The first consisted of content analysis of guidelines and protocols for DV care provision. The second consisted of in-depth interviews with institutional gender focal points (Professionals with experience in dealing with aspects related to DV). The analysis of the document content was based on a framework developed according to key elements recommended by international agencies (PAHO and UN) for design of DV policies and strategies. Data from the in-depth interviews, where analysed in accordance with the study objectives. RESULTS: Eleven (11) guidelines/protocols of care provision and innumerable brochures and pamphlets were identified and analysed. There is a standardised form which contains fields for police and the health sector staff to complete, but not for Civil Society Organisations. However, there is no specific national DV database. Although the seventeen (17) focal points interviewed recognised the relevance of the reviewed documents, many identified gaps in their implementation. This was related to the weaknesses of the offender's penalisation and to the scarcity of care providers who often lack appropriate training. The focal points also recognised their performance is negatively influenced by socio-cultural factors. CONCLUSION: Within services providing care to survivors of DV, a scarcity of guidelines and protocols exist, compromising the quality and standardisation of care. The existence of guidelines and protocols was regarded as a strength, however its implementation is still problematic. There was also recognition for the need to strengthening by governmental and non-governmental entities the defined policies and strategies for DV prevention and control into practice.

A critical cartography of domestic violence policies in Mozambique.

BACKGROUND: Domestic violence (DV) affects millions of people worldwide, especially women impacting their health status and livelihoods. To prevent DV and to improve the quality of victims' lives, Mozambican governmental and non-governmental entities are making efforts to develop adequate policies and legislation and to improve the accessibility of services for victims of DV. However, a critical review of whether or not current policies and legislation concerning DV in Mozambique are in agreement with international guidelines has yet to be examined. Therefore, this paper aims to map the Mozambican legislative and policy responses to DV. It also strives to analyse their alignment with international treaties and conventions and with each other. METHODS: Through a critical cartography, documents were selected and their content analysed. Some of these documents were not available online, printed versions were not available on the field and some were not up to date. Therefore, we had to search for them via physical office visits at governmental institutions with a responsibility to deal with DV aspects. These documents were listed and analysed for key content applying a framework inquiring on recommendations of international agencies such as World Health Organization. Subsequently, we compared these policies with international conventions and treaties of which Mozambique is signatory and with each other to identify discrepancies. RESULTS: Overall, six institutions were visited assuring identification of all available information and policy documents on DV. We identified a total of fifteen national DV documents of which five were on laws, one on policy and nine institutional strategic/action plans. Most of the national DV documents focused on strategies for assistance/care of victims and prevention of DV. Little focus was found on advocacy, monitoring and evaluation. CONCLUSIONS: Mozambique has demonstrated its commitment by signing several international and regional treaties and conventions on DV. Despite this, the lack of consistency in the alignment of international treaties and conventions with national policies and laws is remarkable. However, a gap in the reliable translation of national policies and laws into strategic plans is to be found particularly in relation to naming type, beneficiaries, main strategies and multi-sectorial approach.

Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique.

BACKGROUND: Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals. METHOD: The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals. RESULTS: Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility. CONCLUSIONS: This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level.

Maternal mortality is an important public health problem in Mozambique. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. We conducted a study to describe the feasibility of task-sharing the screening and initiation of management for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and to document healthcare facility preparedness to respond to referrals. The study was done to inform a future intervention trial known as the Community-Level Interventions for Pre-eclampsia (CLIP) study. We interviewed community health workers, women, various community groups, health care providers, and policymakers and assessed health facilities in Maputo and Gaza provinces, Mozambique. Our results showed that community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they were not trained or equipped to provide obstetric emergencies care prior to referral. Nurses at primary health facilities were supportive of task-sharing with community health workers; however, some barriers mentioned include a lack of equipment, shortage of supervisors, and irregular drug availability. Local stakeholders emphasized the need for comprehensive training and supervision of community health workers to take on new tasks. Task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia was deemed feasible at the community level in southern Mozambique, but still, to be addressed some health system level barriers to the management of pregnancies complications.

Addressing conflicts of interest of ethical reviewers of health planning, management, policy and systems research proposals.

Steering health systems towards universal health coverage requires research on themes that are of particular interest to health planning, management, policy and systems researchers. Some issues, such as strikes regarded as illegal and health sector corruption, because of their social and political sensitivity have, for too long, remained outside adequate research inquiry. Their emergence in the research agenda raises some challenges for Human Research Ethics Committees, particularly related to their conflicts of interests as reviewers, that need clarification.

A survey of RNA viruses in mosquitoes from Mozambique reveals novel genetic lineages of flaviviruses and phenuiviruses, as well as frequent flavivirus-like viral DNA forms in Mansonia.

BACKGROUND: Mosquito-borne diseases involving arboviruses represent expanding threats to sub-Saharan Africa imposing as considerable burden to human and veterinary public health. In Mozambique over one hundred species of potential arbovirus mosquito vectors have been identified, although their precise role in maintaining such viruses in circulation in the country remains to be elucidated. The aim of this study was to screen for the presence of flaviviruses, alphaviruses and bunyaviruses in mosquitoes from different regions of Mozambique. RESULTS: Our survey analyzed 14,519 mosquitoes, and the results obtained revealed genetically distinct insect-specific flaviviruses, detected in multiple species of mosquitoes from different genera. In addition, smaller flavivirus-like NS5 sequences, frequently detected in Mansonia seemed to correspond to defective viral sequences, present as viral DNA forms. Furthermore, three lineages of putative members of the Phenuiviridae family were also detected, two of which apparently corresponding to novel viral genetic lineages. CONCLUSION: This study reports for the first-time novel insect-specific flaviviruses and novel phenuiviruses, as well as frequent flavivirus-like viral DNA forms in several widely known vector species. This unique work represents recent investigation of virus screening conducted in mosquitoes from Mozambique and an important contribution to inform the establishment of a vector control program for arbovirus in the country and in the region.

The politics and practice of initiating a public health postgraduate programme in three universities in sub-Saharan Africa: the challenges of alignment and coherence.

BACKGROUND: In-country postgraduate training programme in low and middle income countries are widely considered to strengthen institutional and national capacity. There exists dearth of research about how new training initiatives in public health training institutions come about. This paper examines a south-south collaborative initiative wherein three universities based in Ethiopia, Rwanda and Mozambique set out to develop a local based postgraduate programme on health workforce development/management through partnership with a university in South Africa. METHODS: We used a qualitative case study design. We conducted semi-structured interviews with 36 key informants, who were purposively recruited based on their association or proximity to the programme, and their involvement in the development, review, approval and implementation of the programme. We gathered supplementary data through document reviews and observation. Thematic analysis was used and themes were generated inductively from the data and deductively from literature on capacity development. RESULTS: University A successfully initiated a postgraduate training programme in health workforce development/management. University B and C faced multiple challenges to embed the programme. It was evident that multiple actors underpin programme introduction across institutions, characterized by contestations over issues of programme feasibility, relevance, or need. A daunting challenge in this regard is establishing coherence between health ministries' expectation to roll out training programmes that meet national health priorities and ensure sustainability, and universities and academics' expectations for investment or financial incentive. Programme champions, located in the universities, can be key actors in building such coherence, if they are committed and received sustained support. The south-south initiative also suffers from lack of long term and adequate support. CONCLUSIONS: Against the background of very limited human capacity and competition for this capacity, initiating the postgraduate programme on health workforce development/management proved to be a political as much as a technical undertaking influenced by multiple actors vying for recognition or benefits, and influence over issues of programme feasibility, relevance or need. Critical in the success of the initiative was alignment and coherence among actors, health ministries and universities in particular, and how well programme champions are able to garner support for and ownership of programme locally. The paper argues that coherence and alignment are crucial to embed programmes, yet hard to achieve when capacity and resources are limited and contested.

Redressing the gender imbalance: a qualitative analysis of recruitment and retention in Mozambique's community health workforce.

BACKGROUND: Mozambique's community health programme has a disproportionate number of male community health workers (known as Agentes Polivalentes Elementares (APEs)). The Government of Mozambique is aiming to increase the proportion of females to constitute 60% to improve maternal and child health outcomes. To understand the imbalance, this study explored the current recruitment processes for APEs and how these are shaped by gender norms, roles and relations, as well as how they influence the experience and retention of APEs in Maputo Province, Mozambique. METHODS: We employed qualitative methods with APEs, APE supervisors, community leaders and a government official in two districts within Maputo Province. Interviews were recorded, transcribed and translated. A coding framework was developed in accordance with thematic analysis to synthesise the findings. FINDINGS: In-depth interviews (n = 30), key informant interviews (n = 1) and focus group discussions (n = 3) captured experiences and perceptions of employment processes. Intra-household decision-making structures mean women may experience additional barriers to join the APE programme, often requiring their husband's consent. Training programmes outside of the community were viewed positively as an opportunity to build a cohort. However, women reported difficulty leaving family responsibilities behind, and men reported challenges in providing for their families during training as other income-generating opportunities were not available to them. These dynamics were particularly acute in the case of single mothers, serving both a provider and primary carer role. Differences in attrition by gender were reported: women are likely to leave the programme when they marry, whereas men tend to leave when offered another job with a higher salary. Age and geographic location were also important intersecting factors: younger male and female APEs seek employment opportunities in neighbouring South Africa, whereas older APEs are more content to remain. CONCLUSION: Gender norms, roles and power dynamics intersect with other axes of inequity such as marital status, age and geographic location to impact recruitment and retention of APEs in Maputo Province, Mozambique. Responsive policies to support gender equity within APE recruitment processes are required to support and retain a gender-equitable APE cadre.

The COVID-19 pandemic presents an opportunity to develop more sustainable health workforces.

This commentary addresses the critically important role of health workers in their countries' more immediate responses to COVID-19 outbreaks and provides policy recommendations for more sustainable health workforces. Paradoxically, pandemic response plans in country after country, often fail to explicitly address health workforce requirements and considerations. We recommend that policy and decision-makers at the facility, regional and country-levels need to: integrate explicit health workforce requirements in pandemic response plans, appropriate to its differentiated levels of care, for the short, medium and longer term; ensure safe working conditions with personal protective equipment (PPE) for all deployed health workers including sufficient training to ensure high hygienic and safety standards; recognise the importance of protecting and promoting the psychological health and safety of all health professionals, with a special focus on workers at the point of care; take an explicit gender and social equity lens, when addressing physical and psychological health and safety, recognising that the health workforce is largely made up of women, and that limited resources lead to priority setting and unequitable access to protection; take a whole of the health workforce approach-using the full skill sets of all health workers-across public health and clinical care roles-including those along the training and retirement pipeline-and ensure adequate supervisory structures and operating procedures are in place to ensure inclusive care of high quality; react with solidarity to support regions and countries requiring more surge capacity, especially those with weak health systems and more severe HRH shortages; and acknowledge the need for transparent, flexible and situational leadership styles building on a different set of management skills.

Measuring motivation among close-to-community health workers: developing the CTC Provider Motivational Indicator Scale across six countries.

BACKGROUND: Close-to-community (CTC) health service providers are a cost-effective and important resource in the promotion of and increasing access to health services. However, many CTC provider programmes suffer from high rates of de-motivation and attrition due to inadequate support systems. Recent literature has identified the lack of rigorous approaches towards measuring and monitoring motivation among CTC providers as an important gap. Building on scales used in previous studies, we set out to develop a short, simple-to-administer scale to monitor and measure indicators of CTC provider motivation across CTC programmes implemented in six countries: Ethiopia, Kenya, Malawi, Mozambique, Indonesia, and Bangladesh. METHODS: We used focus group discussions (n = 18) and interviews (n = 106) conducted with CTC providers across all six countries, applying thematic analysis techniques to identify key determinants of motivation across these contexts. These themes were then used to carry out a systematic search of the literature, to identify existing scales or questionnaires developed for the measurement of these themes. A composite 24-item scale was then administered to CTC providers (n = 695) across the six countries. Survey responses were subsequently randomly assigned to one of two datasets: the first for scale refinement, using exploratory techniques, and the second for factorial validation. Confirmatory factor analysis was applied to both datasets. RESULTS: Results suggest a 12-item, four-factor structure, measuring community commitment, organisational commitment, job satisfaction, and work conscientiousness as common indicators of motivation among CTC providers across the six countries. CONCLUSIONS: Consistent with previous studies, findings support the inclusion of job satisfaction, organisational commitment, and work conscientiousness within the CTC Provider Motivation Indicator Scale. In addition, findings further supported the addition of a fourth, community commitment, sub-scale. Practical applications of the revised scale, including how it can be applied to monitor motivation levels within CTC provider programming, are discussed.

Principalism in public health decision making in the context of the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic lead scientists and governmental authorities to issue clinical and public health recommendations based on progressively emerging evidence and expert opinions and many of these fast-tracked to peer-reviewed publications. Concerns were raised on scientific quality and generalizability of this emerging evidence. MAIN ARGUMENT: However, this way acting is not entirely new and often public health decisions are based on flawed and ambiguous evidence. Thus, to better guide decisions in these circumstances, in this article we argue that there is a need to follow fundamental principles in order to guide best public health practices. We purpose the usefulness of the framework of principalism in public which has been proved useful in real life conditions as a guide in the absence of reliable evidence. CONCLUSIONS: It is recommended the implementation of these principles in an integrated manner adopting an holistic system approach to health policies adapted to specificities of local contexts.

Policy review on the management of pre-eclampsia and eclampsia by community health workers in Mozambique.

BACKGROUND: Pre-eclampsia is one of the leading causes of maternal death in Mozambique. Limited access to health care facilities and a lack of skilled health professionals contribute to the high maternal morbidity and mortality rates in Mozambique and indicate a need for community-level interventions. The aim of this review was to identify and characterise health policies related to the role of CHWs in the management of pre-eclampsia and eclampsia in Mozambique. METHODS: The policy review was based on three methods: a desk review of relevant documents from the Mozambique Ministry of Health (n = 7), contact with 28 key informants in the field of health policy in Mozambique (n = 5) and literature review (n = 699). Policy documents obtained included peer-reviewed articles, government and institutional policies, reports and action plans. Seven hundred and eleven full-text documents were assessed for eligibility and included based on pre-defined criteria. Qualitative analysis was done to identify main themes using content analysis. RESULTS: A total of 56 papers informed the timeline of key events. Three main themes were identified from the qualitative review: establishment of the community health worker programme and early challenges, revitalization of the CHW programme and the integration of maternal health in the community health tasks. In 1978, following the Alma Alta Declaration, the Mozambique government brought in legislation establishing primary health care and the CHW programme. Between the late 1980s and early 1990s, this programme was scaled down due to several factors including a prolonged civil war; however, the decision to revitalise the programme was made in 1995. In 2010, a revitalised programme was re-launched and expanded to include the management of common childhood illnesses, detection of warning signs of pregnancy complications, referrals for maternal health and basic health promotion. To date, their role has not included management of emergency conditions of pregnancy including pre-eclampsia and eclampsia. CONCLUSION: The role of CHWs has evolved over the last 40 years to include care of childhood diseases and basic maternal health counselling. Studies to assess the impact of CHWs in providing services to reduce maternal morbidity and mortality are recommended.

Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation.

BACKGROUND: The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation. METHODS: We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members. RESULTS: We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related "expectation gaps", including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector. CONCLUSIONS: Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or "broken promises", which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.

Strengthening referral systems in community health programs: a qualitative study in two rural districts of Maputo Province, Mozambique.

BACKGROUND: Effective referral systems from the community to the health care facility are essential to save lives and ensure quality and a continuum of care. The effectiveness of referral systems in Mozambique depends on multiple factors that involve three main stakeholders: clients/community members; community health workers (CHWs); and facility-based health care workers. Each stakeholder is dependent on the other and could form either a barrier or a facilitator of referral within the complex health system of Mozambique. METHODS: This qualitative study, aiming to explore barriers and enablers of referral within the lens of complex adaptive health systems, employed 22 in-depth interviews with CHWs, their supervisors and community leaders and 8 focus group discussion with 63 community members. Interviews were recorded, transcribed and read for identification of themes and sub-themes related to barriers and enablers of client referrals. Data analysis was supported by the use of NVivo (v10). Results were summarized in narratives, reviewed, discussed and adjusted. RESULTS: All stakeholders acknowledged the centrality of the referral system in a continuum of quality care. CHWs and community members identified similar enablers and barriers to uptake of referral. A major common facilitator was the existence of referral slips to expedite treatment upon reaching the health facility. A common barrier was the failure for referred clients to receive preferential treatment at the facility, despite the presence of a referral slip. Long distances and opportunity and transport costs were presented as barriers to accessibility and affordability of referral services at the health facility level. Supervisors identified barriers related to use of referral data, rather than uptake of referral. Supervisors and CHWs perceived the lack of feedback as a barrier to a functional referral system. CONCLUSIONS: The barriers and enablers of referral systems shape both healthcare system functionality and community perceptions of care. Addressing common barriers to and strengthening the efficiency of referral systems have the potential to improve health at community level. Improved communication and feedback between involved stakeholders - especially strengthening the intermediate role of CHWs - and active community engagement will be key to stimulate better use of referral services and healthcare facilities.

Measuring Health Literacy Among Adults with HIV Infection in Mozambique: Development and Validation of the HIV Literacy Test.

The role of health literacy on HIV outcomes has not been evaluated widely in Africa, in part because few appropriate literacy measures exist. We developed a 16-item scale, the HIV Literacy Test (HIV-LT) to assess literacy-related tasks needed to participate in HIV care. Items were scored as correct or incorrect; higher scores indicated higher literacy skill (range 0-100 %). We tested internal reliability (Kuder-Richardson coefficient) of the HIV-LT in a convenience sample of 319 Portuguese-speaking, HIV infected adults on antiretroviral treatment in Maputo, Mozambique. Construct validity was assessed by a hypothetical model developed a priori. The HIV-LT was reliable and valid to measure participants' literacy skills. The mean HIV-LT score was 42 %; literacy skills applicable to HIV care were challenging for many participants. The HIV-LT could be used to assess the relationship of literacy and HIV-related outcomes in diverse settings, and evaluate interventions to improve health communication for those in HIV care.

The impact of a supportive supervision intervention on health workers in Niassa, Mozambique: a cluster-controlled trial.

BACKGROUND: Regular supportive supervision is critical to retaining and motivating staff in resource-constrained settings. Previous studies have shown the particular contribution that supportive supervision can make to improving job satisfaction amongst over-stretched health workers in such settings. METHODS: The Support, Train and Empower Managers (STEM) study designed and implemented a supportive supervision intervention and measured its' impact on health workers using a controlled trial design with a three-arm pre- and post-study in Niassa Province in Mozambique. Post-intervention interviews with a small sample of health workers were also conducted. RESULTS: The quantitative measurements of job satisfaction, emotional exhaustion and work engagement showed no statistically significant differences between end-line and baseline. The qualitative data collected from health workers post the intervention showed many positive impacts on health workers not captured by this quantitative survey. CONCLUSIONS: Health workers perceived an improvement in their performance and attributed this to the supportive supervision they had received from their supervisors following the intervention. Reports of increased motivation were also common. An unexpected, yet important consequence of the intervention, which participants directly attributed to the supervision intervention, was the increase in participation and voice amongst health workers in intervention facilities.