Forty years after Alma-Ata: primary health-care preparedness for chronic diseases in Mozambique, Nepal and Peru.

BACKGROUND: Four decades after the Alma-Ata Declaration, strengthening primary health care (PHC) remains a priority for health systems, especially in low- and middle-income countries (LMICs). Given the prominence of chronic diseases as a global health issue, PHC must include a wide range of components in order to provide adequate care. OBJECTIVE: To assess PHC preparedness to provide chronic care in Mozambique, Nepal and Peru, we used, as 'tracer conditions', diabetes, hypertension and a country-specific neglected tropical disease with chronic sequelae in each country. METHODS: By implementing a health system assessment, we collected quantitative and qualitative data from primary and secondary sources, including interviews of key informants at three health-system levels (macro, meso and micro). The World Health Organization's health-system building blocks provided the basis for content analysis. RESULTS: In total, we conducted 227 interviews. Our findings show that the ambitious policies targeting specific diseases lack the support of technical, administrative and financial resources. Data collection systems do not allow the monitoring of individual patients or provide the health system with the information it requires. Patients receive limited disease-specific information. Clinical guidelines and training are either non-existent or not adapted to local contexts. Availability of medicines and diagnostic tests at the PHC level is an issue. Although medicines available through the public health care system are affordable, some essential medicines suffer shortages or are not available to PHC providers. This need, along with a lack of clear referral procedures and available transportation, generates financial issues for individuals and affects access to health care. CONCLUSION: PHC in these LMICs is not well prepared to provide adequate care for chronic diseases. Improving PHC to attain universal health coverage requires strengthening the identified weaknesses across health-system building blocks.

Disruption, changes, and adaptation: Experiences with chronic conditions in Mozambique, Nepal and Peru.

Chronic conditions are an increasing problem in Low- and Middle-Income Countries (LMICs) yet, the challenges faced by low-income populations with these conditions in such countries are not well understood. Based on in-depth interviews with people affected by chronic conditions and their family members, this paper describes the experience of patients suffering from diabetes or hypertension in rural communities of Mozambique, Nepal, and Peru. We analysed our data using the concepts of disruption and adaptive strategies, finding that despite being very different countries, the implications in daily lives, interpersonal relationships, and family dynamics are similar, and that oftentimes such impact is defined along gender lines. We show that adjustments to living with a chronic disease are not always easy, particularly when they imply changes and reconfiguration of roles and responsibilities for which neither the individual nor their families are prepared. The study adds to the literature on the disruptive effects of chronic conditions and stresses the importance of contextualising disruptive experiences among disadvantaged populations within weak health systems. Our findings highlight the relevance of understanding the challenges of developing adaptive solutions to chronic care in resource-scarce contexts.

Moving from formative research to co-creation of interventions: insights from a community health system project in Mozambique, Nepal and Peru.

Different methodological approaches for implementation research in global health focusing on how interventions are developed, implemented and evaluated are needed. In this paper, we detail the approach developed and implemented in the COmmunity HEalth System InnovatiON (COHESION) Project, a global health project aimed at strengthening health systems in Mozambique, Nepal and Peru. This project developed innovative formative research at policy, health system and community levels to gain a comprehensive understanding of the barriers, enablers, needs and lessons for the management of chronic disease using non-communicable and neglected tropical diseases as tracer conditions. After formative research, COHESION adopted a co-creation approach in the planning of interventions. The approach included two interactions with each type of stakeholder at policy, health system and community level in each country which aimed to develop interventions to improve the delivery of care of the tracer conditions. Diverse tools and methods were used in order to prioritise interventions based on support, resources and impact. Additionally, a COHESION score that assessed feasibility, sustainability and scaling up was used to select three potential interventions. Next steps for the COHESION Project are to further detail and develop the interventions propositioned through this process. Besides providing some useful tools and methods, this work also highlights the challenges and lessons learned from such an approach.

Progress in Mozambique: Changes in the availability, use, and quality of emergency obstetric and newborn care between 2007 and 2012

Maternal mortality in Mozambique has not declined significantly in the last 10-15 years, plateauing around 480 maternal deaths per 100,000 live births. Good quality antenatal care and routine and emergency intrapartum care are critical to reducing preventable maternal and newborn deaths. Materials and methods: We compare the findings from two national cross-sectional facility-based assessments conducted in 2007 and 2012. Both were designed to measure the availability, use and quality of emergency obstetric and neonatal care. Indicators for monitoring emergency obstetric care were used as were descriptive statistics. Results: The availability of facilities providing the full range of obstetric life-saving procedures (signal functions) decreased. However, an expansion in the provision of individual signal functions was highly visible in health centers and health posts, but in hospitals, performance was less satisfactory, with proportionally fewer hospitals providing assisted vaginal delivery, obstetric surgery and blood transfusions. All other key indicators showed signs of improvements: the institutional delivery rate, the cesarean delivery rate, met need for emergency obstetric care (EmOC), institutional stillbirth and early neonatal death rates, and cause-specific case fatality rates (CFRs). CFRs for most major obstetric complications declined between 17% and 69%. The contribution of direct causes to maternal deaths decreased while the proportion of indirect causes doubled during the five-year interval. Conclusions: The indicator of EmOC service availability, often used for planning and developing EmONC networks, requires close examination. The standard definition can mask programmatic weaknesses and thus, fails to inform decision makers of what to target. In this case, the decline in the use of assisted vaginal delivery explained much of the difference in this indicator between the two surveys, as did faltering hospital performance. Despite this backsliding, many signs of improvement were also observed in this 5-year period, but indicator levels continue below recommended thresholds. The quality of intrapartum care and the adverse consequences from infectious diseases during pregnancy point to priority areas for programmatic improvement.