Challenges and facilitators to evidence-based decision-making for maternal and child health in Mozambique: district, municipal and national case studies.

BACKGROUND: The need for evidence-based decision-making in the health sector is well understood in the global health community. Yet, gaps persist between the availability of evidence and the use of that evidence. Most research on evidence-based decision-making has been carried out in higher-income countries, and most studies look at policy-making rather than decision-making more broadly. We conducted this study to address these gaps and to identify challenges and facilitators to evidence-based decision-making in Maternal, Newborn and Child Health and Nutrition (MNCH&N) at the municipality, district, and national levels in Mozambique. METHODS: We used a case study design to capture the experiences of decision-makers and analysts (n = 24) who participated in evidence-based decision-making processes related to health policies and interventions to improve MNCH&N in diverse decision-making contexts (district, municipality, and national levels) in 2014-2017, in Mozambique. We examined six case studies, at the national level, in Maputo City and in two districts of Sofala Province and two of Zambézia Province, using individual in-depth interviews with key informants and a document review, for three weeks, in July 2018. RESULTS: Our analysis highlighted various challenges for evidence-based decision-making for MNCH&N, at national, district, and municipality levels in Mozambique, including limited demand for evidence, limited capacity to use evidence, and lack of trust in the available evidence. By contrast, access to evidence, and availability of evidence were viewed positively and seen as potential facilitators. Organizational capacity for the demand and use of evidence appears to be the greatest challenge; while individual capacity is also a barrier. CONCLUSION: Evidence-based decision-making requires that actors have access to evidence and are empowered to act on that evidence. This, in turn, requires alignment between those who collect data, those who analyze and interpret data, and those who make and implement decisions. Investments in individual, organizational, and systems capacity to use evidence are needed to foster practices of evidence-based decision-making for improved maternal and child health in Mozambique.

Access to and use of health and social services among people who inject drugs in two urban areas of Mozambique, 2014: qualitative results from a formative assessment.

BACKGROUND: Prior to 2014, data about health seeking behaviors or service uptake for People who inject drugs (PWID) in Mozambique did not exist. We present the results from the formative assessment component of the Biological and Behavioral Survey (BBS). METHODS: Standardized interview guides were used during key informant interviews (KII) and focus group discussions (FGD) in Maputo and Nampula/Nacala to discuss issues related to risk behaviors and access to and utilization of health and social services by PWID. The target sample size was not defined a priori, but instead KII and FGD were conducted until responses reached saturation. Data analysis was based on the principles of grounded theory related to qualitative research. RESULTS: Eighty-eight respondents, ages 15 to 60, participated in KIIs and FGDs. Participants were majority male from diverse income and education levels and included current and former PWID, non-injection drug users, health and social service providers, peer educators, and community health workers. Respondents reported that PWID engage in high-risk behaviors such as needle and syringe sharing, exchange of sex for drugs or money, and low condom use. According to participants, PWID would rather rent, share or borrow injection equipment at shooting galleries than purchase them due to stigma, fear of criminalization, transportation and purchase costs, restricted pharmacy hours, personal preference for needle sharing, and immediacy of drug need. Barriers to access and utilization of health and social services include distance, the limited availability of programs for PWID, lack of knowledge of the few programs that exist, concerns about the quality of care provided by health providers, lack of readiness as a result of addiction and perceived stigma related to the use of mental health services offering treatment to PWID. CONCLUSIONS: Mozambique urgently needs to establish specialized harm reduction programs for PWID and improve awareness of available resources. Services should be located in hot spot areas to address issues related to distance, transportation and the planning required for safe injection. Specific attention should go to the creation of PWID-focused health and social services outside of state-sponsored psychiatric treatment centers.

Assessment of linkages from HIV testing to enrolment and retention in HIV care in Central Mozambique.

INTRODUCTION: Effectiveness of the rapid expansion of antiretroviral therapy (ART) throughout sub-Saharan Africa is highly dependent on adequate enrolment and retention in HIV care. However, the measurement of both has been challenging in these settings. This study aimed to assess enrolment and retention in HIV care (pre-ART and ART) among HIV-positive adults in Central Mozambique, including identification of barriers and facilitators. METHODS: We assessed linkages to and retention in HIV care using a mixed quantitative and qualitative approach in six districts of Manica and Sofala provinces. We analyzed routine district and health facility monthly reports and HIV care registries from April 2012 to March 2013 and used single imputation and trimmed means to adjust for missing values. In eight health facilities in the same districts and period, we assessed retention in HIV care among 795 randomly selected adult patient charts (15 years and older). We also conducted 25 focus group discussions and 53 in-depth interviews with HIV-positive adults, healthcare providers and community members to identify facilitators and barriers to enrolment and retention in HIV care. RESULTS: Overall, 46% of the monthly HIV testing reports expected at the district level were missing, compared to 6.4% of the pre-ART registry reports. After adjustment for missing values, we estimated that the aggregate numbers of adults registered in pre-ART was 75% of the number of persons tested HIV-positive in the six districts. In the eight health facilities, 40% of the patient charts for adults enrolled in pre-ART and 44% in ART were missing. Of those on ART for whom charts were found, retention in treatment within 90 and 60 days prior to the study team visit was 34 and 25%, respectively. Combining these multiple data sources, the overall estimated retention was 18% in our sample. Individual-level factors were perceived to be key influences to enrolment in HIV care, while health facility and structural-level factors were perceived to be key influences of retention. CONCLUSIONS: Efforts to increase linkages to and retention in HIV care should address individual, health facility, and structural-level factors in Central Mozambique. However, their outcomes cannot be reliably assessed without improving the quality of routine health information systems.