Strengthening integrated primary health care in Sofala, Mozambique.

BACKGROUND: Large increases in health sector investment and policies favoring upgrading and expanding the public sector health network have prioritized maternal and child health in Mozambique and, over the past decade, Mozambique has achieved substantial improvements in maternal and child health indicators. Over this same period, the government of Mozambique has continued to decentralize the management of public sector resources to the district level, including in the health sector, with the aim of bringing decision-making and resources closer to service beneficiaries. Weak district level management capacity has hindered the decentralization process, and building this capacity is an important link to ensure that resources translate to improved service delivery and further improvements in population health. A consortium of the Ministry of Health, Health Alliance International, Eduardo Mondlane University, and the University of Washington are implementing a health systems strengthening model in Sofala Province, central Mozambique. DESCRIPTION OF IMPLEMENTATION: The Mozambique Population Health Implementation and Training (PHIT) Partnership focuses on improving the quality of routine data and its use through appropriate tools to facilitate decision making by health system managers; strengthening management and planning capacity and funding district health plans; and building capacity for operations research to guide system-strengthening efforts. This seven-year effort covers all 13 districts and 146 health facilities in Sofala Province. EVALUATION DESIGN: A quasi-experimental controlled time-series design will be used to assess the overall impact of the partnership strategy on under-5 mortality by examining changes in mortality pre- and post-implementation in Sofala Province compared with neighboring Manica Province. The evaluation will compare a broad range of input, process, output, and outcome variables to strengthen the plausibility that the partnership strategy led to health system improvements and subsequent population health impact. DISCUSSION: The Mozambique PHIT Partnership expects to provide evidence on the effect of efforts to improve data quality coupled with the introduction of tools, training, and supervision to improve evidence-based decision making. This contribution to the knowledge base on what works to enhance health systems is highly replicable for rapid scale-up to other provinces in Mozambique, as well as other sub-Saharan African countries with limited resources and a commitment to comprehensive primary health care.

Loss to follow-up of adults in public HIV care systems in central Mozambique: identifying obstacles to treatment.

INTRODUCTION: Access to antiretroviral treatment (ART) has expanded dramatically in resource-limited settings. Evaluating loss to follow-up from HIV testing through post-ART care can help identify obstacles to care. METHODS: Routine data were analyzed for adults receiving services in 2 public HIV care systems in central Mozambique. The proportion of people passing through the following steps was determined: (1) HIV testing, (2) enrollment at an ART clinic, (3) CD4 testing, (4) starting ART if eligible, and (5) adhering to ART. RESULTS: During the 12-month study period (2004-2005), an estimated 23,430 adults were tested for HIV and 7005 (29.9%) were HIV positive. Only 3956 (56.5%) of those HIV positive enrolled at an ART clinic < or =30 days after testing. CD4 testing was obtained in 77.1% < or =30 days of enrollment. Of 1506 eligible for ART, 471 (31.3%) started ART < or =90 days after CD4 testing. Of 382 with > or =180 days of potential follow-up time on ART, 317 (83.0%) had pharmacy-based adherence rates > or =90%. DISCUSSION: Substantial drop-offs were observed for each step between HIV testing and treatment but were highest for referral from HIV testing to treatment sites and for starting ART. Interventions are needed to improve follow-up and ensure that people benefit from available HIV services.

Commodity fetichismo, the Holy Spirit, and the turn to Pentecostal and African Independent Churches in Central Mozambique.

Pentecostal and African Independent Churches have rapidly spread throughout central Mozambique in the aftermath of war and in the midst of a recent structural adjustment program that has hastened commoditization of community life and intensified local inequalities. This extraordinary expansion signals a shift away from reliance on "traditional" healers to treat persistent afflictions believed to have spiritual causes. Survey data and illness narratives collected from recent church recruits and local residents during research in 2002 and 2003 in the city of Chimoio reveal that healers have increased fees and tailored treatments to clients searching for good fortune in ways that have alienated many other help seekers in this changing social environment. While traditional healing has been celebrated in the international health world, community attitudes are less generous; many healers are increasingly viewed with suspicion because of their engagement with malevolent occult forces to foment social conflict, competition, and confrontation for high fees. Church healing approaches offer free and less divisive spiritual protection reinforced by social support in a new collectivity. One vital source of church popularity derives from pastors' efforts to tap the already considerable community anxiety over rising healer fees and their socially divisive treatments in an insecure environment.

African independent churches in Mozambique: healing the afflictions of inequality.

The recent explosive proliferation of African Independent Churches (AICs) in central Mozambique coincided with rapid growth of economic disparity in the 1990s produced by privatization, cuts in government services, and arrival of foreign aid promoted by Mozambique's World Bank/International Monetary Fund Structural Adjustment Program. Drawing on ethnographic research in the city of Chimoio, this article argues that growing inequality has led to declining social cohesion, heightened individual competition, fear of interpersonal violence, and intensified conflict between spouses in poor families. This perilous social environment finds expression in heightened fears of witchcraft, sorcery, and avenging spirits, which are often blamed in Shona ideology for reproductive health problems. Many women with sick children or suffering from infertility turn to AICs for treatment because traditional healers are increasingly viewed as dangerous and too expensive. The AICs invoke the "Holy Spirit" to exercise malevolent agents and then provide a community of mutual aid and ongoing protection against spirit threats.