Comparing COVID-19 physical distancing policies: results from a physical distancing intensity coding framework for Botswana, India, Jamaica, Mozambique, Namibia, Ukraine, and the United States.

BACKGROUND: Understanding the differences in timing and composition of physical distancing policies is important to evaluate the early global response to COVID-19. A physical distancing intensity monitoring framework comprising 16 domains was recently published to compare physical distancing approaches across 12 U.S. States. We applied this framework to a diverse set of low and middle-income countries (LMICs) (Botswana, India, Jamaica, Mozambique, Namibia, and Ukraine) to test the appropriateness of this framework in the global context and to compare the policy responses in these LMICs with a sample of U.S. States during the first 100-days of the pandemic. RESULTS: The LMICs in our sample adopted wide ranging physical distancing policies. The highest peak daily physical distancing intensity during this period was: Botswana (4.60); India (4.40); Ukraine (4.40); Namibia (4.20); Mozambique (3.87), and Jamaica (3.80). The number of days each country stayed at peak policy intensity ranged from 12-days (Jamaica) to more than 67-days (Mozambique). We found some key similarities and differences, including substantial differences in whether and how countries expressly required certain groups to stay at home. Despite the much higher number of cases in the US, the physical distancing responses in our LMIC sample were generally more intense than in the U.S. States, but results vary depending on the U.S. State. The peak policy intensity for the U.S. 12-state average was 3.84, which would place it lower than every LMIC in this sample except Jamaica. The LMIC sample countries also reached peak physical distancing intensity earlier in outbreak progression compared to the U.S. states sample. The easing of physical distancing policies in the LMIC sample did not discernably correlate with change in COVID-19 incidence. CONCLUSIONS: This physical distancing intensity framework was appropriate for the LMIC context with only minor adaptations. This framework may be useful for ongoing monitoring of physical distancing policy approaches and for use in effectiveness analyses. This analysis helps to highlight the differing paths taken by the countries in this sample and may provide lessons to other countries regarding options for structuring physical distancing policies in response to COVID-19 and future outbreaks.

Incentives for non-physician health professionals to work in the rural and remote areas of Mozambique--a discrete choice experiment for eliciting job preferences.

BACKGROUND: Successfully motivating and retaining health workers is critical for the effective performance of health systems. In Mozambique, a shortage of health care professionals and low levels of staff motivation in rural and remote areas pose challenges to the provision of equitable health care delivery. This study provides quantitative information on the job preferences of non-physician health professionals in Mozambique, examining how different aspects of jobs are valued and how health professionals might respond to policy options that would post them to district hospitals in rural areas. METHODS: The study used a discrete choice experiment (DCE) to elicit the job preferences of non-physician health professionals. Data collection took place in four Mozambique provinces: Maputo City, Maputo Province, Sofala and Nampula. DCE questionnaires were administered to 334 non-physician health professionals with specialized or university training ('mid-level specialists' and N1 and N2 categories). In addition, questionnaires were administered to 123 N1 and N2 students to enable comparison of the results for those with work experience with those without and determine how new N1 and N2 graduates can be attracted to rural posts. RESULTS: The results indicate that the provision of basic government housing has the greatest impact on the probability of choosing a job at a public health facility, followed by the provision of formal education opportunities and the availability of equipment and medicine at a health facility. The sub-group analysis suggests that job preferences vary according to stage of life and that incentive packages should vary accordingly. Recruitment strategies to encourage non-clinical professionals to work in rural/remote areas should also consider birthplace, as those born in rural/remote areas are more willing to work remotely. CONCLUSION: The study was undertaken within an overarching project that aimed to develop incentive packages for non-physician health professionals assigned to work in remote/rural areas. Based on the DCE results, the project team, together with the Mozambique Ministry of Health, has developed a range of health workforce retention strategies focusing on the provision of housing benefits and professional development opportunities to be utilized when assigning non-physician health professionals to rural/remote areas.

Assisted Partner Notification Services Are Safe and Effective as They Are Brought to Scale in Mozambique.

BACKGROUND: The World Health Organization recommends that persons diagnosed with HIV be offered assisted partner notification services (APS). There are limited data on the safety of APS as implemented in public health programs. SETTING: Three public health centers in Maputo, Mozambique, 2016-2019. METHODS: Counselors offered APS to persons with newly diagnosed HIV and, as part of a program evaluation, prospectively assessed the occurrence of adverse events (AEs), including (1) pushing, abandonment, or yelling; (2) being hit; and (3) loss of financial support or being expelled from the house. RESULTS: Eighteen thousand nine hundred sixty-five persons tested HIV-positive in the 3 clinics, 13,475 (71%) were evaluated for APS eligibility, 9314 were eligible and offered APS, and 9219 received APS. Index cases (ICs) named 8933 partners without a previous HIV diagnosis, of whom 6137 tested and 3367 (55%) were diagnosed with HIV (case-finding index = 0.36). APS counselors collected follow-up data from 6680 (95%) of 7034 index cases who had untested partners who were subsequently notified; 78 (1.2%) experienced an AE. Among 270 ICs who reported a fear of AEs at their initial APS interview, 211 (78%) notified ≥1 sex partner, of whom 5 (2.4%) experienced an AE. Experiencing an AE was associated with fear of loss of support (odds ratio [OR] 4.28; 95% confidence interval [CI]: 1.50 to 12.19) and having a partner who was notified, but not tested (OR 3.47; 95% CI: 1.93 to 6.26). CONCLUSION: Case-finding through APS in Mozambique is high and AEs after APS are uncommon. Most ICs with a fear of AEs still elect to notify partners with few experiencing AEs.

What if we decided to take care of everyone who needed treatment? Workforce planning in Mozambique using simulation of demand for HIV/AIDS care.

BACKGROUND: The growing AIDS epidemic in southern Africa is placing an increased strain on health systems, which are experiencing steadily rising patient loads. Health care systems are tackling the barriers to serving large populations in scaled-up operations. One of the most significant challenges in this effort is securing the health care workforce to deliver care in settings where the manpower is already in short supply. METHODS: We have produced a demand-driven staffing model using simple spreadsheet technology, based on treatment protocols for HIV-positive patients that adhere to Mozambican guidelines. The model can be adjusted for the volumes of patients at differing stages of their disease, varying provider productivity, proportion who are pregnant, attrition rates, and other variables. RESULTS: Our model projects the need for health workers using three different kinds of goals: 1) the number of patients to be placed on anti-retroviral therapy (ART), 2) the number of HIV-positive patients to be enrolled for treatment, and 3) the number of patients to be enrolled in a treatment facility per month. CONCLUSION: We propose three scenarios, depending on numbers of patients enrolled. In the first scenario, we start with 8000 patients on ART and increase that number to 58,000 at the end of three years (those were the goals for the country of Mozambique). This would require thirteen clinicians and just over ten nurses by the end of the first year, and 67 clinicians and 47 nurses at the end of the third year. In a second scenario, we start with 34,000 patients enrolled for care (not all of them on ART), and increase to 94,000 by the end of the third year, requiring a growth in clinician staff from 18 to 28. In a third scenario, we start a new clinic and enroll 200 new patients per month for three years, requiring 1.2 clinicians in year 1 and 2.2 by the end of year 3. Other clinician types in the model include nurses, social workers, pharmacists, phlebotomists, and peer counsellors. This planning tool could lead to more realistic and appropriate estimates of workforce levels required to provide high-quality HIV care in a low-resource settings.

Management of expatriate medical assistance in Mozambique.

This paper discusses how Mozambique coped with the health system needs in terms of specialized doctors since independence, in a troubled context of war, lack of financial resources and modifying settings of foreign aid. The Ministry of Health (MOH) managed to make up for its severe scarcity of specialist MDs especially through contracting expatriate technical assistance. Different scenarios, partnerships and contract schemes that have evolved since independence are briefly described, as well as self-reliance option possibility and implications. Lessons learned about donor initiatives aimed at contracting specialists from other developing countries are singled out. The issue of obtaining expertise and knowledge in the global market as cheap as possible is stressed, and realistic figures of cost planning are highlighted, as determined by the overall health system necessities and budget limitations.

The role of nonphysician clinicians in the rapid expansion of HIV care in Mozambique.

The shortage of health workers impedes universal coverage of quality HIV services, especially in those countries hardest hit by the epidemic. The dramatic increase in international aid to scale-up HIV services, including antiretroviral therapy (ART), has highlighted workforce deficiencies and provided an opportunity to strengthen health systems capacity. In Mozambique, a country with a high HIV burden and a staggering workforce deficit, the Ministry of Health looked to past experience in workforce expansion to rapidly build ART delivery capacity, including reliance on existing nonphysician clinicians (NPC) to prescribe ART and dramatically increasing the output of NPC training. As a result of responsible task shifting, the number of facilities providing ART tripled during a 6-month period, and patients from disadvantaged areas have access to quality ART services. Because the NPC-driven ART approach is integrated into primary health care, the addition of new clinical staff also promises to improve general health services.