Baltazar Chilundo

Brain drain and health workforce distortions in Mozambique.

Introduction Trained human resources are fundamental for well-functioning health systems, and the lack of health workers undermines public sector capacity to meet population health needs. While external brain drain from low and middle-income countries is well described, there is little understanding of the degree of internal brain drain, and how increases in health sector funding through global health initiatives may contribute to the outflow of health workers from the public sector to donor agencies, non-governmental organisations (NGOs), and the private sector. Methods An observational study was conducted to estimate the degree of internal and external brain drain among Mozambican nationals qualifying from domestic and foreign medical schools between 1980–2006. Data were collected 26-months apart in 2008 and 2010, and included current employment status, employer, geographic location of employment, and main work duties. Results Of 723 qualifying physicians between 1980–2006, 95.9% (693) were working full-time, including 71.1% (493) as clinicians, 20.5% (142) as health system managers, and 6.9% (48) as researchers/professors. 25.5% (181) of the sample had left the public sector, of which 62.4% (113) continued working in-country and 37.6% (68) emigrated from Mozambique. Of those cases of internal migration, 66.4% (75) worked for NGOs, 21.2% (24) for donor agencies, and 12.4% (14) in the private sector. Annual incidence of physician migration was estimated to be 3.7%, predominately to work in the growing NGO sector. An estimated 36.3% (41/113) of internal migration cases had previously held senior-level management positions in the public sector. Discussion Internal migration is an important contributor to capital flight from the public sector, accounting for more cases of physician loss than external migration in Mozambique. Given the urgent need to strengthen public sector health systems, frank reflection by donors and NGOs is needed to assess how hiring practices may undermine the very systems they seek to strengthen.

Policy challenges facing integrated community case management in Sub‐Saharan Africa

To report an in‐depth analysis of policy change for integrated community case management of childhood illness (iCCM) in six sub‐Saharan African countries. We analysed how iCCM policies developed and the barriers and facilitators to policy change.

An Institutional Perspective on Health Sector Reforms and the Process of Reframing Health Information Systems Case Study From Mozambique

Health sector reform, including structural and process changes such as the incorporation of feasible information and communication technologies, is a priority in many least developed countries. However, such changes have not been particularly effective, the reasons for which will be explored in this article. Particular attention will be paid to attempts to integrate information systems in HIV/AIDS program in Mozambique. The article draws on new institutional theory to argue that the focus of this program on formal rules (i.e., Sector Wide Approach policy and national plans), which deemphasize the informal constraints at the point of service delivery (i.e., priority given to health care over reporting), has resulted in limited change. Furthermore, the limited overlap between the formal and informal domains raises the need for enhancing incentives and enforcement as key mechanisms through which more effective change can be enabled in the future.

Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM AND Pepfar-funded HIV-activities

BackgroundGlobal Health Initiatives (GHIs), aiming at reducing the impact of specific diseases such as Human Immunodeficiency Virus (HIV), have flourished since 2000. Amongst these, PEPFAR and GFATM have provided a substantial amount of funding to countries affected by HIV, predominantly for delivery of antiretroviral therapy (ARV) and prevention strategies. Since the need for additional human resources for health (HRH) was not initially considered by GHIs, countries, to allow ARV scale-up, implemented short-term HRH strategies, adapted to GHI-funding conditionality. Such strategies differed from one country to another and slowly evolved to long-term HRH policies. The processes and content of HRH policy shifts in 5 countries in Sub-Saharan Africa were examined.MethodsA multi-country study was conducted from 2007 to 2011 in 5 countries (Angola, Burundi, Lesotho, Mozambique and South Africa), to assess the impact of GHIs on the health system, using a mixed methods design. This paper focuses on the impact of GFATM and PEPFAR on HRH policies. Qualitative data consisted of semi-structured interviews undertaken at national and sub-national levels and analysis of secondary data from national reports. Data were analysed in order to extract countries’ responses to HRH challenges posed by implementation of HIV-related activities. Common themes across the 5 countries were selected and compared in light of each country context.ResultsIn all countries successful ARV roll-out was observed, despite HRH shortages. This was a result of mostly short-term emergency response by GHI-funded Non-Governmental Organizations (NGOs) and to a lesser extent by governments, consisting of using and increasing available HRH for HIV tasks. As challenges and limits of short-term HRH strategies were revealed and HIV became a chronic disease, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives, increase in HRH production and mitigation of internal migration of HRH, sometimes in collaboration with GHIs.ConclusionSustainable HRH strengthening is a complex process, depending mostly on HRH production and retention factors, these factors being country-specific. GHIs could assist in these strategies, provided that they are flexible enough to incorporate country-specific needs in terms of funding, that they coordinate at global-level and minimise conditionality for countries.

HIV/AIDS reporting systems in Mozambique: the theoretical and empirical challenges of Representations

Acquired immunodeficiency syndrome is a disease with profound effects on the global society, as it affects individual lives, communities, societies, and even nations. As governments try to gear up on the war against this pandemic, an issue of importance pertains to the use of information systems. The systems are used to collect data on the prevalence of the disease, and analyze and transmit the data from the lower levels of the health administration where the testing is done to the higher levels of national policy making where different kinds of interventions are designed. In this article, we argue that the manner in which the representation of the disease is constructed is an important area of concern as it shapes the picture of the disease prevalence and influences how these statistics then get used for the planning of interventions such as supplying drugs and pro-health campaigns. Drawing from the domain of Science and Technology Studies (STS), with a focus on Bruno Latours (1999) ideas of “circulating reference” we first develop the theoretical notion of representation, and then apply it to an empirical analysis of the reporting systems, both paper- and computer-based, of HIV/AIDS in Mozambique. The successive movements of information about HIV/AIDS prevalence across the various administrative levels are seen as translations that are being constructed through the communication and work practices of the health care workers at different levels, and are shaped by the political interests of the different stakeholders involved, including international agencies and national health authorities. Latours notion of circulating reference is drawn upon to analyze the question of what is lost, what is gained, and what remains invariant through the successive stages of translation in the construction and use of the representation.

A pragmatic randomised controlled trial on routine iron prophylaxis during pregnancy in Maputo, Mozambique (PROFEG): rationale, design, and success

The effects of prophylactic iron during pregnancy on maternal and child health in developing settings with endemic malaria and high prevalence of HIV remain unclear. This paper describes the rationale, implementation and success of a pragmatic randomised controlled trial comparing routine iron supplementation vs. screening and treatment for anaemia during pregnancy. The setting was two health centres in Maputo, Mozambique. Pregnant women (≥ 12-week gestation; ≥ 18 years old; and not with a high-risk pregnancy, n=4326) were recruited. The main outcomes are preterm delivery and low birthweight. The women were randomly assigned to one of two iron administration policies: a routine iron group (n=2184) received 60 mg of ferrous sulphate plus 400 μg of folic acid daily while a selective iron group (n=2142) had screening and treatment for anaemia and a daily intake of 1 mg of folic acid. The recruitment, follow-up, and collection of follow-up data were successful; both groups were similar to each other in all the trial stages. Collection of delivery data was challenging and data on about 40% of births is missing. These are currently being traced through different hospitals and health centres. The compliance of the study personnel and the women with regard to regular measurement of haemoglobin and intake of the iron and folic acid tablets was high and similar in both trial arms. Taking into account the various constraints encountered, the stages of the present trial prior to delivery were carried out well.

Comparison of routine prenatal iron prophylaxis and screening and treatment for anaemia: pregnancy results and preliminary birth results from a pragmatic randomised controlled trial (PROFEG) in Maputo, Mozambique

Objective To present the pregnancy results and interim birth results of a pragmatic randomised controlled trial comparing routine iron prophylaxis with screening and treatment for anaemia during pregnancy in a setting of endemic malaria and HIV. Design A pragmatic randomised controlled trial. Setting Two health centres (1° de Maio and Machava) in Maputo, Mozambique, a setting of endemic malaria and high prevalence of HIV. Participants Pregnant women (≥18-year-olds; non-high-risk pregnancy, n=4326) attending prenatal care consultation at the two health centres were recruited to the trial. Interventions The women were randomly allocated to either Routine iron (n=2184; 60 mg ferrous sulfate plus 400 μg of folic acid daily throughout pregnancy) or Selective iron (n=2142; screening and treatment for anaemia and daily intake of 1 mg of folic acid). Outcome measures The primary outcomes were preterm delivery (delivery <37 weeks of gestation) and low birth weight (<2500 g). The secondary outcomes were symptoms suggestive of malaria and self-reported malaria during pregnancy; birth length; caesarean section; maternal and child health status after delivery. Results The number of follow-up visits was similar in the two groups. Between the first and fifth visits, the two groups were similar regarding the occurrence of fever, headache, cold/chills, nausea/vomiting and body aches. There was a suggestion of increased incidence of self-reported malaria during pregnancy (OR 1.37, 95% CI 0.98 to1.92) in the Routine iron group. Birth data were available for 1109 (51%) in the Routine iron group and for 1149 (54%) in the Selective iron group. The birth outcomes were relatively similar in the two groups. However, there was a suggestion (statistically non-significant) of poorer outcomes in the Routine iron group with regard to long hospital stay after birth (relative risk (RR) 1.43, 95% CI 0.97 to 1.26; risk difference (RD) 0.02, 95% CI −0.00 to 0.03) and unavailability of delivery data (RR 1.06, 95% CI 1.00 to 1.13; RD 0.03, 95% CI −0.01 to 0.07). Conclusions These interim results suggest that routine iron prophylaxis during pregnancy did not confer advantage over screening and treatment for anaemia regarding maternal and child health. Complete data on birth outcomes are being collected for firmer conclusions. Trial registration The trial is registered at ClinicalTrials.gov, number NCT00488579 (June 2007). The first women were randomised to the trial proper April 2007–March 2008. The pilot was November 2006–March 2008. The 3-month lag was due to technical difficulties in completing trial registration.

The quality of HIV/AIDS case-detection and case-reporting systems in Mozambique

Despite the underlying importance of surveillance systems for the management of HIV/AIDS prevention and control programmes, there has been limited analysis of the quality of HIV/AIDS case-detection and case-reporting systems, beginning with peripheral facilities through to those at national levels. In Mozambique, HIV cases are generally correctly detected despite some unreliable use of test kits beyond their expiry date, uneven distribution of test kits among facilities, frequent disregard for bio-safety measures and irregular external quality assessment. Furthermore, HIV/AIDS case-reporting is compromised by poor data quality, including under-reporting and discrepancies across different reporting channels and organisational levels, as well as a lack of standardised data forms, data items collected and report formats. Our analysis of HIV/AIDS surveillance systems in Mozambique leads to the following key recommendations: (1) a strengthening and standardisation of both the case-detection and case-reporting systems at all levels; (2) the regular training of staff at peripheral facilities, to allow for better testing and improved local data analysis, validation and interpretation; (3) the redesign of reporting systems for blood banks, including integration of the AIDS case-reporting subsystems into one; and (4) the use of baseline data as a foundation for more comprehensive analysis across the country, in response to UNAIDS advice regarding second-generation HIV surveillance.

Characteristic of victims of family violence seeking care at health centers in Maputo, Mozambique.

Background: Family violence (FV) is a common, yet often invisible, cause of violence. To date, most literature on risk factors for family, interpersonal and sexual violence is from high-income countries and might not apply to Mozambique. Aims: To determine the individual risk factors for FV in a cohort of patients seeking care for injuries at three health centers in Maputo, Mozambique. Setting and Design: A prospective multi-center study of patients presenting to the emergency department for injuries from violence inflicted by a direct family member in Maputo, Mozambique, was carried out. Materials and Methods: Patients who agreed to participate and signed the informed consent were verbally administered a pilot-tested blank-item questionnaire to ascertain demographic information, perpetrator of the violence, historical information regarding prior abuse, and information on who accompanied the victim and where they received their initial evaluation. De-identified data were entered into SPSS 13.0 (SPSS, version 13.0) and analyzed for frequencies. Results: During the 8-week study period, 1206 assault victims presented for care, of whom 216 disclosed the relationship of the assailant, including 92 being victims of FV (42.6%). The majority of FV victims were women (63.0%) of age group 15-34 years (76.1%) and were less educated (84%) compared to national averages. Of the patients who reported assault on a single occasion, most were single (58.8%), while patients with multiple assaults were mostly married (63.2%). Most commonly, the spouse was the aggressor (50%) and a relative accompanied the victim seeking care (54.3%). Women most commonly sought police intervention prior to care (63.2%) in comparison to men (35.3%). Conclusion: In Mozambique, FV affects all ages, sexes and cultures, but victims seeking care for FV were more commonly women who were less educated and poorer.

Is selective prenatal iron prophylaxis better than routine prophylaxis: final results of a trial (PROFEG) in Maputo, Mozambique

Objective To compare routine versus selective (ie, screening and treatment for anaemia) prenatal iron prophylaxis in a malaria-endemic and HIV-prevalent setting, an extended analysis including previously missing data. Design A pragmatic randomised controlled clinical trial. Setting 2 health centres in Maputo, Mozambique. Participants Pregnant women (≥18 years old; non-high-risk pregnancy) were randomly allocated to routine iron (n=2184) and selective iron (n=2142) groups. Interventions In the routine group, women received 60 mg ferrous sulfate plus 400 μg folic acid daily. In the selective group, women received 1 mg of folic acid daily and haemoglobin (Hb) screening at each visit; with low Hb (cut-off 9 g/dL) treatment (120 mg+800 μg of folic acid daily) for a month. Outcome measures Primary outcomes: preterm birth, low birth weight; secondary outcomes: self-reported malaria, labour complications, caesarean section, perinatal death, womans death. Nurses collected pregnancy data. Birth data were abstracted from hospital records for 52% of women and traced using various methods and linked with probabilistic matching for 24%. Womens deaths were collected from death registers. Results Birth data were available for 3301 (76%) of the women. Outcomes were similar in the two groups: preterm births (27.1% in the selective vs 25.3% in the routine group), low birthweight infants (11.0% vs 11.7%), perinatal deaths (2.4% vs 2.4%) and caesarean sections (4.0% vs 4.5%). Womens deaths during pregnancy or <42 days postpartum were more common in the selective group (0.8% among the two best matched women) than in the routine group (0.4%). Extra deaths could not be explained by the cause of death, Hb level or HIV status at recruitment. Conclusions Birth outcomes were similar in the two iron groups. There might have been more womens deaths in the selective iron group, but it is unclear whether this was due to the intervention, other factors or chance finding. Trial registration number NCT00488579.