Demand-side financing in the form of baby packages in Northern Mozambique: Results from an observational study.

BACKGROUND: The Maternal Mortality Ratio in Mozambique has stagnated at 405 deaths per 100,000 live births with virtually no progress over the last 15 years. Low Institutional Birth Rates (IBRs) levelling around 50% in many rural areas constitute one of the contributing reasons. Demand-side financing has successfully increased usage of maternal health services in other countries, but little information exists on in-kind incentives in rural Africa. The objective was to test the impact on Institutional Birth Rates of giving a USD 5.50 baby package incentive to every woman who came to give birth in a health centre in a rural, poor district of Cabo Delgado, Mozambique. METHODS AND FINDINGS: The intervention was implemented in one district in 2010 with the remaining 15 districts serving as controls. The total population in the 16 districts in 2006 was just under 1.5 million people. IBRs were observed from 2006 to 2013 (53 months before and 55 months after the intervention began). The non-intervention districts showed a slight increase, from a mean IBR of 0.39 (SD = 0.10) in 2006 to 0.67 (SD = 0.13) in 2014. The intervention district had a dramatic increase in IBRs within six months of the start of the intervention in 2010, which was sustained until the end of the study. Adjusting for the background increase and for confounders, including health facilities and health personnel per district, and taking clustering in districts into account, the estimated rate ratio of institutional births in the intervention district was 1.80 (95% CI 1.72, 1.89 p<0.001). CONCLUSION: Women were almost twice as likely to have an institutional birth following the introduction of the baby package.

Triage conducted by lay-staff and emergency training reduces paediatric mortality in the emergency department of a rural hospital in Northern Mozambique.

INTRODUCTION: The majority of emergency paediatric death in African countries occur within the first 24 h of admission. A coloured triage system is widely implemented in high-income countries and the emergency triage and assessment treatment (ETAT) is recommended by the World Health Organization, but not put into practice in Mozambique. We implemented a three-colour triage system in a rural district hospital with lay-staff workers conducting the first triage. METHODS: A retrospective, before and after, mortality analysis was performed using routine patient files from the district hospital between 2014 and 2017. The triage system was implemented in August 2016. Inclusion criteria were children under 15 years of age that entered the emergency centre. Primary outcome was child mortality rate. Secondary outcomes included the percentage agreement between the clinical and non-clinical staff and the duration from triage to first treatment. We used a negative binomial model in STATA 15 to compare mortality rates, and Kappa statistics to estimate the agreement between clinical and non-clinical staff. RESULTS: 4176 admissions were included. The mortality rate ratio (MMR) was 45% lower after the start of the intervention (2016; MRR = 0.55; 0.38, 0.81; p = 0.002), compared to before. To estimate the agreement between non-clinical and clinical staff, 548 (of the 671) patient files were included. The agreement was estimated at 88.7% (Kappa = 0.644; p < 0.001). The median waiting time decreased with urgency of the triage: 2 h33 for 'green'/least serious (IQR 1 h58-3 h30), 21 min for yellow/serious (IQR 0 h10-0 h58) and nine minutes for 'red'/urgent (IQR 2-40 min). CONCLUSION: In a rural setting with nurse-led clinical care and non-clinician staff working at the triage reception, implementation of a three-coloured triage system was feasible. Triage and ETAT training was associated with a decrease of 45% of paediatric deaths. The impact on mortality, low cost, and ease of the implementation supports scaling this intervention in similar settings.

Acceptability and performance of a directly assisted oral HIV self-testing intervention in adolescents in rural Mozambique.

INTRODUCTION: Whereas progress in HIV testing and treatment has been made globally, the UNAIDS goal of "90 90 90" is still out of sight in rural northern Mozambique. New strategies that promote testing in hard to reach groups will aid Mozambique's response to the HIV epidemic. HIV self-testing (HIVST) is recommended by the WHO as an additional approach to augment the HIV testing services available to adolescents. This study evaluates acceptability and performance of a directly assisted oral HIVST intervention for adolescents in rural Mozambique. METHODS: Adolescents aged 16-20 years were included at schools and invited to attend the local hospital's youth friendly service for directly assisted oral HIVST. Baseline and post-test questionnaires were obtained. OraQuick Rapid HIV-1/2 Anti body test® was used. Results were read by the participant and by a nurse. Results were confirmed by finger prick HIV test (Determine® HIV 1/2 Alere and Unigold™ HIV Trinity Biotech) according to the Mozambican national standard. RESULTS: Between September and November 2016, 496 adolescents were included, of which 299 performed an oral HIV self-test. 70% were first time testers. The positivity rate was 1.7%. The inter-rater agreement between adolescent and nurse was 99.6% (kappa 0.93); there were no false negative or false positive results of the oral HIV self-test. Five tests were invalid. 7.1% found the test difficult to use. Over 80% preferred directly assisted HIVST compared to the standard finger prick testing. While 20% thought it would be good to do HIVST at home, 76% preferred to do HIVST at the health centre, for reasons including increased security, privacy, and the presence of a counsellor. CONCLUSIONS: Directly assisted oral HIVST is a feasible intervention for adolescents in rural Mozambique and showed encouraging results for first time HIV testers.