Implementation outcomes of the integrated district evidence to action (IDEAs) program to reduce neonatal mortality in central Mozambique: an application of the RE-AIM evaluation framework.

BACKGROUND: Scarce evidence exists on audit and feedback implementation processes in low-resource health systems. The Integrated District Evidence to Action (IDEAs) is a multi-component audit and feedback strategy designed to improve the implementation of maternal and child guidelines in Mozambique. We report IDEAs implementation outcomes. METHODS: IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces between 2016 and 2020 and evaluated using a quasi-experimental design guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Reach is the proportion of pregnant women attending IDEAs facilities. Adoption is the proportion of facilities initiating audit and feedback meetings. Implementation is the fidelity to the strategy components, including readiness assessments, meetings (frequency, participation, action plan development), and targeted financial support and supervision. Maintenance is the sustainment at 12, 24, and 54 months. RESULTS: Across both provinces, 56% of facilities were exposed to IDEAs (target 57%). Sixty-nine and 73% of pregnant women attended those facilities' first and fourth antenatal consultations (target 70%). All facilities adopted the intervention. 99% of the expected meetings occurred with an average interval of 5.9 out of 6 months. Participation of maternal and child managers was high, with 3076 attending meetings, of which 64% were from the facility, 29% from the district, and 7% from the province level. 97% of expected action plans were created, and 41 specific problems were identified. "Weak diagnosis or management of obstetric complications" was identified as the main problem, and "actions to reinforce norms and protocols" was the dominant subcategory of micro-interventions selected. Fidelity to semiannual readiness assessments was low (52% of expected facilities), and in completing micro-interventions (17% were completed). Ninety-six and 95% of facilities sustained the intervention at 12 and 24 months, respectively, and 71% had completed nine cycles at 54 months. CONCLUSION: Maternal and child managers can lead audit and feedback processes in primary health care in Mozambique with high reach, adoption, and maintenance. The IDEAs strategy should be adapted to promote higher fidelity around implementing action plans and conducting readiness assessments. Adding effectiveness to these findings will help to inform strategy scale-up.

Cost-Effectiveness and Budget Impact Analysis of the Implementation of Differentiated Service Delivery Models for HIV Treatment in Mozambique: a Modelling Study.

INTRODUCTION: In 2018, the Mozambique Ministry of Health launched guidelines for implementing differentiated service delivery models (DSDMs) to optimize HIV service delivery, improve retention in care, and ultimately reduce HIV-associated mortality. The models were fast-track, 3-month antiretrovirals dispensing, community antiretroviral therapy groups, adherence clubs, family approach and three one-stop shop models: adolescent-friendly health services, maternal and child health, and tuberculosis. We conducted a cost-effectiveness analysis and budget impact analysis to compare these models to conventional services. METHODS: We constructed a decision tree model based on the percentage of enrolment in each model and the probability of the outcome (12-month retention in treatment) for each year of the study period-three for the cost-effectiveness analysis (2019-2021) and three for the budget impact analysis (2022-2024). Costs for these analyses were primarily estimated per client-year from the health system perspective. A secondary cost-effectiveness analysis was conducted from the societal perspective. Budget impact analysis costs included antiretrovirals, laboratory tests and service provision interactions. Cost-effectiveness analysis additionally included start-up, training and clients' opportunity costs. Effectiveness was estimated using an uncontrolled interrupted time series analysis comparing the outcome before and after the implementation of the differentiated models. A one-way sensitivity analysis was conducted to identify drivers of uncertainty. RESULTS: After implementation of the DSDMs, there was a mean increase of 14.9 percentage points (95% CI: 12.2, 17.8) in 12-month retention, from 47.6% (95% CI, 44.9-50.2) to 62.5% (95% CI, 60.9-64.1). The mean cost difference comparing DSDMs and conventional care was US$ -6 million (173,391,277 vs. 179,461,668) and -32.5 million (394,705,618 vs. 433,232,289) from the health system and the societal perspective, respectively. Therefore, DSDMs dominated conventional care. Results were most sensitive to conventional care interaction costs in the one-way sensitivity analysis. For a population of 1.5 million, the base-case 3-year financial costs associated with the DSDMs was US$550 million, compared with US$564 million for conventional care. CONCLUSIONS: DSDMs were less expensive and more effective in retaining clients 12 months after antiretroviral therapy initiation and were estimated to save approximately US$14 million for the health system from 2022 to 2024.

Managers' and providers' perspectives on barriers and facilitators for the implementation of differentiated service delivery models for HIV treatment in Mozambique: a qualitative study.

INTRODUCTION: In 2018, Mozambique's Ministry of Health launched a guideline for a nationwide implementation of eight differentiated service delivery models to optimize HIV service delivery and achieve universal coverage of HIV care and treatment. The models were (1) Fast-track, (2) Three-month Antiretrovirals Dispensing, (3) Community Antiretroviral Therapy Groups, (4) Adherence Clubs, (5) Family-approach, and three one-stop shop models for (6) Tuberculosis, (7) Maternal and Child Health, and (8) Adolescent-friendly Health Services. This study identified drivers of implementation success and failure across these differentiated service delivery models. METHODS: Twenty in-depth individual interviews were conducted with managers and providers from the Ministry of Health and implementing partners from all levels of the health system between July and September 2021. National-level participants were based in the capital city of Maputo, and participants at provincial, district and health facility levels were from Sofala province, a purposively selected setting. The Consolidated Framework for Implementation Research (CFIR) guided data collection and thematic analysis. Deductively selected constructs were assessed while allowing for additional themes to emerge inductively. RESULTS: The CFIR constructs of Relative Advantage, Complexity, Patient Needs and Resources, and Reflecting and Evaluating were identified as drivers of implementation, whereas Available Resources and Access to Knowledge and Information were identified as barriers. Fast-track and Three-month Antiretrovirals Dispensing models were deemed easier to implement and more effective in reducing workload. Adherence Clubs and Community Antiretroviral Therapy Groups were believed to be less preferred by clients in urban settings. COVID-19 (an inductive theme) improved acceptance and uptake of individual differentiated service delivery models that reduced client visits, but it temporarily interrupted the implementation of group models. CONCLUSIONS: This study described important determinants to be addressed or leveraged for the successful implementation of differentiated service delivery models in Mozambique. The models were considered advantageous overall for the health system and clients when compared with the standard of care. However, successful implementation requires resources and ongoing training for frontline providers. COVID-19 expedited individual models by loosening the inclusion criteria; this experience can be leveraged to optimize the design and implementation of differentiated service delivery models in Mozambique and other countries.

Impact of differentiated service delivery models on 12-month retention in HIV treatment in Mozambique: an interrupted time-series analysis.

BACKGROUND: HIV treatment has been available in Mozambique since 2004, but coverage of, and retention in, antiretroviral therapy (ART) remain suboptimal. Therefore, to increase health system efficiency and reduce HIV-associated mortality, in November, 2018, the Ministry of Health launched national guidelines on implementing eight differentiated service delivery models (DSDMs) for HIV treatment. We assessed the effect of this implementation on retention in ART 12 months after initiation, and explored the associated effects of COVID-19. METHODS: In this uncontrolled interrupted time-series analysis, data were extracted from the Mozambique ART database, which contains data on individuals in ART care from 1455 health facilities providing ART in Mozambique. We included individual-level data from facilities that were providing ART at the beginning of the study period (Jan 1, 2016) and at the start of DSDM implementation (Dec 1, 2018). We compared the proportion of individuals retained in ART 12 months after initiation between the periods before (Jan 1, 2017, to Nov 30, 2018) and after (Dec 1, 2019, to June 30, 2021) implementation of the DSDMs, overall and stratified by sex and age. We applied a generalised estimating equation model with a working independence correlation and cluster-robust standard errors to account for clustering at the facility level. In a secondary analysis, we assessed the effect of COVID-19 response measures during the post-intervention period on ART retention. FINDINGS: The study included 613 facilities and 1 131 118 individuals who started ART during the inclusion period up to June 30, 2020, of whom 79 178 (7·0%) were children (age ≤14 years), 226 224 (20·0%) were adolescents and young adults (age 15-24 years), and 825 716 (73·0%) were adults (age ≥25 years). 731 623 (64·7%) were female and 399 495 (35·3%) were male. Introduction of the DSDMs was associated with an estimated increase of 24·5 percentage points (95% CI 21·1 to 28·0) in 12-month ART retention by the end of the study period, compared with the counterfactual scenario without DSDM implementation. By age, the smallest effect was estimated in children (6·1 percentage points, 1·3 to 10·9) and the largest effect in adolescents and young adults (28·8 percentage points, 24·2 to 33·4); by sex, a larger effect was estimated in males (29·7 percentage points, 25·6 to 33·7). Our analysis showed that COVID-19 had an overall negative effect on 12-month retention in ART compared with a counterfactual scenario based on the post-intervention period without COVID-19 (-10·0 percentage points, -18·2 to -1·8). INTERPRETATION: The implementation of eight DSDMs for HIV treatment had a positive impact on 12-month retention in ART. COVID-19 negatively influenced this outcome. FUNDING: None. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.

Primary Health Care Management Effectiveness as a Driver of Family Planning Service Readiness: A Cross-Sectional Analysis in Central Mozambique.

INTRODUCTION: The effectiveness of facility-level management is an important determinant of primary health care (PHC) reach and quality; however, the nature of the relationship between facility-level management and health system effectiveness lacks sufficient empirical grounding. We describe the association between management effectiveness and facility readiness to provide family planning services in central Mozambique. METHODS: We linked data from the Ministry of Health's 2018 Service Availability and Readiness Assessment and a second 2018 health facility survey that included the World Bank's Service Delivery Indicators management module. Our analysis focused on 68 public sector PHC facilities in Manica, Sofala, Tete, and Zambézia provinces in which the 2 surveys overlapped. We used logistic quantile regression to model associations between management strength and family planning service readiness. RESULTS: Of the 68 facility managers, 47 (69.1%) were first-time managers and (18) 26.5% had received formal management training. Managers indicated that 63.6% of their time was spent on management responsibilities, 63.2% of their employees had received a performance review in the year preceding the survey, and 12.5% of employee incentives were linked to performance evaluations. Adjusting for facility type and distance to the provincial capital, facility management effectiveness, and urban location were significantly associated with higher levels of readiness for family planning service delivery. CONCLUSIONS: We found that a higher degree of management effectiveness is independently associated with an increased likelihood of improved family planning service readiness. Furthermore, we describe barriers to effective PHC service management, including managers lacking formal training and spending a significant amount of time on nonmanagerial duties. Strengthening management capacity and reinforcing management practices at the PHC level are needed to improve health system readiness and outputs, which is essential for achieving global Sustainable Development Goals and universal health coverage targets.

Maternal and Child Health Care Service Disruptions and Recovery in Mozambique After Cyclone Idai: An Uncontrolled Interrupted Time Series Analysis.

INTRODUCTION: Climate change-related extreme weather events have increased in frequency and intensity, threatening people's health, particularly in places with weak health systems. In March 2019, Cyclone Idai devastated Mozambique's central region, causing infrastructure destruction, population displacement, and death. We assessed the impact of Idai on maternal and child health services and recovery in the Sofala and Manica provinces. METHODS: Using monthly district-level routine data from November 2016 to March 2020, we performed an uncontrolled interrupted time series analysis to assess changes in 10 maternal and child health indicators in all 25 districts before and after Idai. We applied a Bayesian hierarchical negative binomial model with district-level random intercepts and slopes to estimate Idai-related service disruptions and recovery. RESULTS: Of the 4.44 million people in Sofala and Manica, 1.83 (41.2%) million were affected. Buzi, Nhamatanda, and Dondo (all in Sofala province) had the highest proportion of people affected. After Idai, all 10 indicators showed an abrupt substantial decrease. First antenatal care visits per 100,000 women of reproductive age decreased by 23% (95% confidence interval [CI]=0.62, 0.96) in March and 11% (95% CI=0.75, 1.07) in April. BCG vaccinations per 1,000 children under age 5 years declined by 21% (95% CI=0.69, 0.90) and measles vaccinations decreased by 25% (95% CI=0.64, 0.87) in March and remained similar in April. Within 3 months post-cyclone, almost all districts recovered to pre-Idai levels, including Buzi, which showed a 22% and 13% relative increase in the number of first antenatal care visits and BCG, respectively. CONCLUSION: We found substantial health service disruptions immediately after Idai, with greater impact in the most affected districts. The findings suggest impressive recovery post-Idai, emphasizing the need to build resilient health systems to ensure quality health care during and after natural disasters.

Managers' and providers' perspectives on barriers and facilitators for the implementation of differentiated service delivery models for HIV treatment in Mozambique: a qualitative study

In 2018, Mozambique's Ministry of Health launched a guideline for a nationwide implementation of eight differentiated service delivery models to optimize HIV service delivery and achieve universal coverage of HIV care and treatment. The models were (1) Fast­track, (2) Three­month Antiretrovirals Dispensing, (3) Community Antiretroviral Therapy Groups, (4) Adherence Clubs, (5) Family­approach, and three one­stop shop models for (6) Tuberculosis, (7) Maternal and Child Health, and (8) Adolescent­friendly Health Services. This study identified drivers of implementation success and failure across these differentiated service delivery models.

Prevalência do Antígeno de Superfície do Vírus da Hepatite B em Mulheres em Idade Fértil na Cidade de Maputo / Prevalence of Hepatitis B Virus Surface Antigen in Women of Childbearing Age in Maputo City

O Vírus da Hepatite B (HBV) infecta 2 biliões de indivíduos no mundo, dos quais 400 milhões transformam-se em portadores crónicos e um milhão morre por ano. De acordo com a Organização Mundial de Saúde (OMS), a hepatite B é endémica em Moçambique, onde espera-se que a prevalência seja igual ou superior a 8% e a transmissão vertical seja a principal forma de perpetuação da infecção. É também um dos países com maior prevalência, a nível mundial, do carcinoma hepatocelular (CHC), que é a mais grave e fatal complicação da infecção pelo HBV. Adicionalmente, é um país de alta prevalência do Vírus de Imunodeficiência Humana (HIV) que, como se sabe, coinfecta indivíduos HBV positivos. Esta coinfecção influencia negativamente a evolução da infecção pelo HBV e exige uma intervenção médica mais cuidadosa e dispendiosa do que seria indicado em caso de monoinfecção. O presente estudo foi realizado em quatro unidades sanitárias da cidade de Maputo, onde 4.000 mulheres em idade fértil foram rastreadas para determinar a prevalência da infecção pelo HBV nesta população. A prevalência de hepatite B activa (HBsAg positivo) encontrada foi de 2,9% (95% IC 2,4 ­ 3,4) e a prevalência de HIV entre as mulheres HBsAg positivas foi de 28% (95% IC 20,2 ­ 36,6). Mais de um parceiro sexual; troca de sexo por dinheiro, bens ou serviços; relação sexual ocasional desprotegida; escarificação por médico tradicional; uso de drogas injectáveis; história de transfusão sanguínea e antecedente de infecção de transmissão sexual (ITS), nos últimos 6 meses, foram os factores de risco investigados nas mulheres HBsAg positivas. O factor de risco mais observado foi escarificação por médico tradicional. Com o presente estudo, demonstramos que a prevalência de hepatite B activa nas mulheres em idade fértil, na cidade de Maputo, é intermédia (entre 2-7%) e que a coinfecção HBV/HIV é importante. O rastreio de HBsAg às mulheres grávidas e indivíduos HIV positivos, a adopção do esquema de imunização recomendado pela OMS e a introdução do tratamento para hepatite B, em monoinfeção, no Sistema Nacional de Saúde (SNS), devem ser considerados para o controle da infecção pelo HBV em Moçambique.

Two billion people in the world are infected with Hepatitis B virus (HBV), of which one million die per year and 400 million will become chronic carries. According to the World Health Organization (WHO), Hepatitis B infection is endemic in Mozambique, where the prevalence is expected to be equal or superior to 8% and vertical transmission the main mechanism for perpetuating the infection. Mozambique is also among the countries with the highest prevalence of hepatocellular cancer (CHC) which is the most severe and fatal complication of HBV infection. Moreover, it is a country with a high prevalence of HIV, which is known to co-infect HBV positive individuals and to negatively influence the progression of HBV infection. HBV/HIV co-infection requires more careful and costly treatment when compared to HBV mono-infection. The present study was undertaken in four health facilities in Maputo City, where 4.000 women of child bearing age were screened to determine the prevalence of HBV infection in this population. The prevalence of active hepatitis B (HBsAg positive) was found to be 2,9% (95% CI 2,4 ­ 3,4). Among those positive to HBsAg, HIV was identified in 28% (95% CI 20,2 ­ 36,6). The HBsAg positive women were assessed for exposure to the following risk factors in the previous 6 months: more than one sex partner; exchange of sex for money, goods or services; occasional unsafe sex; use of injectable drugs; blood transfusion; Sexually Transmitted Infections (STI) and scarifications by traditional healers. The latter was the most observed risk factor. With the present study we demonstrated that the prevalence of active hepatitis B in women of child bearing age is intermediate (between 2 to 7%) and that HBV/HIV co-infection is substantial. The screening for HBsAg in pregnant women and HIV positive individuals, the adoption of the immunization Schedule recommended by the WHO and the introduction of the treatment for hepatitis B monoinfection should be considered for the control of HBV infection in Mozambique.

Prevalencia do antigio de superficie do virus da hepatite B em mulheres em idade fertel na cidade de Maputo / Prevalence of hepatitis B virus surface antigen in women of fertile age in Maputo city

Vírus da Hepatite B (HBV) infecta 2 biliões de indivíduos no mundo, dos quais 400 milhões transformam-se em portadores crónicos e um milhão morre por ano. De acordo com a Organização Mundial de Saúde (OMS), a hepatite B é endémica em Moçambique, onde espera-se que a prevalência seja igual ou superior a 8% e a transmissão vertical seja a principal forma de perpetuação da infecção. É também um dos países com maior prevalência, a nível mundial, do carcinoma hepatocelular (CHC), que é a mais grave e fatal complicação da infecção pelo HBV. Adicionalmente, é um país de alta prevalência do Vírus de Imunodeficiência Humana (HIV) que, como se sabe, coinfecta indivíduos HBV positivos. Esta coinfecção influencia negativamente a evolução da infecção pelo HBV e exige uma intervenção médica mais cuidadosa e dispendiosa do que seria indicado em caso de monoinfecção. O presente estudo foi realizado em quatro unidades sanitárias da cidade de Maputo, onde 4.000 mulheres em idade fértil foram rastreadas para determinar a prevalência da infecção pelo HBV nesta população. A prevalência de hepatite B activa (HBsAg positivo) encontrada foi de 2,9% (95% IC 2,4 ­3,4) e a prevalência de HIV entre as mulheres HBsAg positivas foi de 28% (95% IC 20,2 ­36,6).Mais de um parceiro sexual; troca de sexo por dinheiro, bens ou serviços; relação sexual ocasional desprotegida; escarificação por médico tradicional; uso de drogas injectáveis; história de transfusão sanguínea e antecedente de infecção de transmissão sexual (ITS), nos últimos 6 meses, foram os factores de risco investigados nas mulheres HBsAg positivas. O factor de risco mais observado foi escarificação por médico tradicional.Com o presente estudo, demonstramos que a prevalência de hepatite B activa nas mulheres em idade fértil, na cidade de Maputo, é intermédia (entre 2-7%) e que a coinfecção HBV/HIV é importante. O rastreio de HBsAg às mulheres grávidas e indivíduos HIV positivos, a adopção do esquema de imunização recomendado pela OMS e a introdução do tratamento para hepatite B, em monoinfeção, no Sistema Nacional de Saúde (SNS), devem ser considerados para o controle da infecção pelo HBV em Moçambique.

Two billion people in the world are infected with Hepatitis B virus (HBV), of which one million die per year and 400 million will become chronic carries. According to the World Health Organization (WHO), Hepatitis B infection is endemic in Mozambique, where the prevalence is expected to be equal or superior to 8% and vertical transmission the main mechanism for perpetuating the infection. Mozambique is also among the countries with the highest prevalence of hepatocellular cancer (CHC) which is the most severe and fatal complication of HBV infection. Moreover, it is a country with a high prevalence of HIV, which is known to co-infect HBV positive individuals and to negatively influence the progression of HBV infection. HBV/HIV co-infection requires more careful and costly treatment when compared to HBV mono-infection. The present study was undertaken in four health facilities in Maputo City, where 4.000 women of child bearing age were screened to determine the prevalence of HBV infection in this population. The prevalence of active hepatitis B (HBsAg positive) was found to be 2,9% (95% CI 2,4 ­3,4). Among those positive to HBsAg, HIV was identified in 28% (95% CI 20,2 ­36,6). The HBsAg positive women were assessed for exposure to the following risk factors in the previous 6 months: more than one sex partner; exchange of sex for money, goods or services; occasional unsafe sex; use of injectable drugs; blood transfusion; Sexually Transmitted Infections (STI) and scarifications by traditional healers. The latter was the most observed risk factor. With the present study we demonstrated that the prevalence of active hepatitis Bin women of child bearing ageis intermediate (between 2 to 7%) and that HBV/HIV co-infection issubstantial. The screening for HBsAg in pregnant women and HIV positive individuals, the adoption of the immunization Schedule recommended by the WHO and the introduction of the treatment for hepatitis B monoinfection should be considered for the control of HBV infection in Mozambique.