James Pfeiffer

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.

Strengthening integrated primary health care in Sofala, Mozambique

BackgroundLarge 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 implementationThe 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 designA 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.DiscussionThe 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.

An assessment of routine primary care health information system data quality in Sofala Province, Mozambique

BackgroundPrimary health care is recognized as a main driver of equitable health service delivery. For it to function optimally, routine health information systems (HIS) are necessary to ensure adequate provision of health care and the development of appropriate health policies. Concerns about the quality of routine administrative data have undermined their use in resource-limited settings. This evaluation was designed to describe the availability, reliability, and validity of a sample of primary health care HIS data from nine health facilities across three districts in Sofala Province, Mozambique. HIS data were also compared with results from large community-based surveys.MethodologyWe used a methodology similar to the Global Fund to Fight AIDS, Tuberculosis and Malaria data verification bottom-up audit to assess primary health care HIS data availability and reliability. The quality of HIS data was validated by comparing three key indicators (antenatal care, institutional birth, and third diptheria, pertussis, and tetanus [DPT] immunization) with population-level surveys over time.Results and discussionThe data concordance from facility clinical registries to monthly facility reports on five key indicators--the number of first antenatal care visits, institutional births, third DPT immunization, HIV testing, and outpatient consults--was good (80%). When two sites were excluded from the analysis, the concordance was markedly better (92%). Of monthly facility reports for immunization and maternity services, 98% were available in paper form at district health departments and 98% of immunization and maternity services monthly facility reports matched the Ministry of Health electronic database. Population-level health survey and HIS data were strongly correlated (R = 0.73), for institutional birth, first antenatal care visit, and third DPT immunization.ConclusionsOur results suggest that in this setting, HIS data are both reliable and consistent, supporting their use in primary health care program monitoring and evaluation. Simple, rapid tools can be used to evaluate routine data and facilitate the rapid identification of problem areas.

Developing competencies for a graduate school curriculum in international health.

which does not have a school of public health (SPH) The University of Washington School of Public Health (UW SPH) in Seattle, Washington, has met this chal-lenge by expanding and reorganizing its international public health teaching. We have established competen -cies for our global health MPH scholars, with a focus on addressing large public health problems with a social justice perspective.The emergence of the global health concept over the last decade reflects heightened awareness of accelerating globalization processes that challenge the traditionally drawn boundaries between the interna-tional and domestic health professional worlds. While the precise definition of global health continues to be contested, it is widely agreed that increased global flows of resources, information, people, and infectious diseases, together with growing global inequality, have created new public health problems that require fresh and innovative approaches. With this recognition has come a spate of new global health centers, departments, institutes, and programs in American and European universities that seek to redefine approaches to public health and recalibrate training to new global health realities for the next generation of health researchers and practitioners. While the urgency for such redefined training is apparent, there is little in the current public health literature that attempts to identify just what this training should include. In spite of new global health program proliferation, core professional global health competencies have yet to be defined, and no consensus for development of appropriate curricula has emerged in the public health field. The recent creation of a new Department of Global Health (DGH) at UW has presented cur-riculum planners, charged with developing new MPH, doctor of philosophy (PhD), and doctor of medicine programs, with these immediate challenges. This article describes the consensus-building process conducted by the DGH curriculum committee over a one-year period in which global health competencies were identified and curriculum needs redefined. While debates about the meaning and scope of global health will continue, basic guidelines for new kinds of training are urgently needed to prepare health workers for the rapidly chang-ing environment they will soon confront.Through this recently established DGH (which has received much of its new funding through an endowed grant from the Bill and Melinda Gates Foundation), UW is poised to rapidly expand its international health student enrollment, course offerings, and degree programs. Other prominent universities have launched similar efforts in just the last two years. In 2006, Duke University in Durham, North Carolina, to date, launched a new Global Health Institute, which started its education program with an undergraduate certificate. The Johns Hopkins University in Baltimore, Maryland, launched a Center for Global Health, bringing together its SPHs, medicine, and nursing schools in a collaborative effort. In addition, other schools such as The George Washington University in Washington, DC, have recently started offering MPH degrees in global health.As UW prepared to launch its DGH—a collaboration between the SPH and the school of medicine—the curriculum committee of the existing international health program embarked on a complete review of UW’s current course offerings in anticipation of growth and expansion. We found very little guidance for this effort in the public health literature. Patrick reported major gaps in public health training, along with the implication of inadequate coursework in SPHs and in medical schools.

The role of nonphysician clinicians in the rapid expansion of HIV care in Mozambique.

The shortage of health workers impedes universal coverage of quality HIV services, especially in those countries hardest hit by the epidemic. The dramatic increase in international aid to scale-up HIV services, including antiretroviral therapy (ART), has highlighted workforce deficiencies and provided an opportunity to strengthen health systems capacity. In Mozambique, a country with a high HIV burden and a staggering workforce deficit, the Ministry of Health looked to past experience in workforce expansion to rapidly build ART delivery capacity, including reliance on existing nonphysician clinicians (NPC) to prescribe ART and dramatically increasing the output of NPC training. As a result of responsible task shifting, the number of facilities providing ART tripled during a 6-month period, and patients from disadvantaged areas have access to quality ART services. Because the NPC-driven ART approach is integrated into primary health care, the addition of new clinical staff also promises to improve general health services.

Patient Volume, Human Resource Levels and Attrition from HIV Treatment Programs in Central Mozambique

Introduction:Human resource shortages are viewed as one of the primary obstacles to provide effective services to growing patient populations receiving antiretroviral therapy (ART) and to expand ART access further. We examined the relationship of patient volume, human resource levels, and patient characteristics with attrition from HIV treatment programs in central Mozambique. Methods:We conducted a retrospective cohort study of adult, ART-naive, nonpregnant patients who initiated ART between January 2006 and June 2008 in the national HIV care program. Cox proportional hazards models were used to assess the association of patient volume, clinical staff burden, and pharmacy staff burden with attrition, adjusting for patient characteristics. Results:A total of 11,793 patients from 18 clinics were studied. After adjusting for patient characteristics, patients attending clinics with medium pharmacy staff burden [hazard ratio (HR) = 1.39 (95% CI: 1.07 to 1.80)] and high pharmacy staff burden [HR = 2.09 (95% CI: 1.50 to 2.91)] tended to have a higher risk of attrition (P value for trend: <0.001). Patients attending clinics with higher clinical staff burden did not have a statistically higher risk of attrition. Patients attending clinics with medium patient volume levels [HR = 1.45 (95% CI: 1.04 to 2.04)] and high patient volume levels [HR = 1.41 (95% CI: 1.04 to 1.92)] had a higher risk of attrition, but the trend test was not significant (P = 0.198). Discussion:Patients attending clinics with higher pharmacy staff burden had a higher risk of attrition. These results highlight a potential area within the health system where interventions could be applied to improve the retention of these patient populations.

Using nurses to identify HAART eligible patients in the Republic of Mozambique: results of a time series analysis

BackgroundThe most pressing challenge to achieving universal access to highly active anti-retroviral therapy (HAART) in sub-Saharan Africa is the shortage of trained personnel to handle the increased service requirements of rapid roll-out. Overcoming the human resource challenge requires developing innovative models of care provision that improve efficiency of service delivery and rationalize use of limited resources.MethodsWe conducted a time-series intervention trial in two HIV clinics in central Mozambique to discern whether expanding the role of basic-level nurses to stage HIV-positive patients using CD4 counts and WHO-defined criteria would lead to more rapid information on patient status (including identification of HAART eligible patients), increased efficiency in the use of higher-level clinical staff, and increased capacity to start HAART-eligible patients on treatment.ResultsOverall, 1,880 of the HAART-eligible patients were considered in the study of whom 48.5% started HAART, with a median time of 71 days from their initial blood draw. After adjusting for time, expanding the role of nurses to stage patients was associated with more rational use of higher-level clinical staff at one site (Beira OR 1.9, 95% CI 1.1–3.3; Chimoio OR 0.2, 95% CI 0.1–0.5). In multivariate analyses, the rate of starting HAART in patients with CD4 counts of less than 200/mm3 increased over time (HR = 1.07, 95% CI 1.02–1.13), as did the total number of new patients initiating HAART (β = 7.3, 95% CI 1.3–13.3). However, the intervention was not independently associated with either of these outcomes in multivariate analyses (HR = 0.9, 95% CI 0.7–1.2) for starting HAART in patients with CD4 counts of less than 200/mm3; (β = -5.2, p = 0.75) for the total number of new patients initiating HAART per month. No effect of the intervention was found in these outcomes when stratifying by site.ConclusionThe CD4 nurse intervention, when implemented correctly, was associated with a more rational use of higher-level clinical providers, which may improve overall clinic flow and efficient use of the limited supply of human resources. However, this intervention did not lead to an increase in the number of patients starting HAART or a reduction in the time to HAART initiation. Study month appears to play an important role in all outcomes, suggesting that general improvements in clinic efficiency may have overshadowed the effect of the intervention. The lack of observed effect in these outcomes may be due to additional health systems bottlenecks that delay the initiation of treatment in HAART-eligible patients.

Effects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in Mozambique

Summary Background Knowledge of the relation between health-system factors and child mortality could help to inform health policy in low-income and middle-income countries. We aimed to quantify modifiable health-system factors and their relation with provincial-level heterogeneity in under-5, infant, and neonatal mortality over time in Mozambique. Methods Using Demographic and Health Survey (2003 and 2011) and Multiple Indicator Cluster Survey (2008) data, we generated provincial-level time-series of child mortality in under-5 (ages 0–4 years), infant (younger than 1 year), and neonatal (younger than 1 month) age groups for 2000–10. We built negative binomial mixed models to examine health-system factors associated with changes in child mortality. Findings Under-5 mortality rate was heterogeneous across provinces, with yearly decreases ranging from 11·1% (Nampula) to 1·9% (Maputo Province). Heterogeneity was greater for neonatal mortality rate, with only seven of 11 provinces showing significant yearly decreases, ranging from 13·6% (Nampula) to 4·2% (Zambezia). Health workforce density (adjusted rate ratio 0·94, 95% CI 0·90–0·98) and maternal and child health nurse density (0·96, 0·92–0·99) were both associated with reduced under-5 mortality rate, as were institutional birth coverage (0·94, 0·90–0·98) and government financing per head (0·80, 0·65–0·98). Higher population per health facility was associated with increased under-5 mortality rate (1·14, 1·02–1·28). Neonatal mortality rate was most strongly associated with institutional birth attendance, maternal and child nurse density, and overall health workforce density. Infant mortality rate was most strongly associated with institutional birth attendance and population per health facility. Interpretation The large decreases in child mortality seen in Mozambique between 2000 and 2010 could have been partly caused by improvements in the public-sector health workforce, institutional birth coverage, and government health financing. Increased attention should be paid to service availability, because population per health facility is increasing across Mozambique and is associated with increased under-5 mortality. Investments in health information systems and new methods to track potentially increasing subnational health disparities are urgently needed. Funding Doris Duke Charitable Foundation and Mozambican National Institute of Health.

Competency-Based Curricula to Transform Global Health: Redesign With the End in Mind

Purpose To define the education and training priorities for a new 21st-century, competency-based, global health curriculum for the University of Washington’s Department of Global Health (DGH). Method In 2008 and 2009, the authors conducted 26 in-depth interviews with global health leaders. They asked interviewees to envision key roles and competencies for global health professionals at least 20 years from now. The authors also explored training approaches and recruitment priorities with the interviewees. The majority of interviews were conducted by telephone and audio-recorded. Transcriptions were analyzed and coded to identify themes. Results Interviewees viewed determinants of health and systems thinking as two essential areas of knowledge; they identified analytical, leadership and management, and policy-development skills as priority skill sets. Participants emphasized that training should focus on experiential learning, on interdisciplinary and interprofessional collaboration, and on information analysis and synthesis. Conclusions The University of Washington’s DGH is currently revising its curriculum across programs and mapping it to interrelated competencies: (1) knowledge of social, economic, and environmental determinants of health, (2) knowledge of the architecture and levers of health, health-relevant systems, and health service delivery, (3) skills in epidemiology and in monitoring and evaluation, (4) capacity to manage and lead, and (5) skills in policy analysis and development. The curriculum, which provides evidence-based education and training in these areas, is designed with the end—global health competency in the 21st century—in mind.

Treatment partners and adherence to HAART in Central Mozambique

Abstract Adherence to highly active antiretroviral treatment (HAART) has been associated with increased survival rates and decreased drug resistance in various settings. There is growing concern that loss to follow-up will increase and adherence rates will decrease as HAART programs are expanded in resource-limited settings. In Central Mozambique, an innovative program was implemented, using community-based (trained community activists) and self-selected (family members or friends) “treatment partners” to provide psycho-social support to patients on HAART. We calculated adherence rates based on pharmacy records for all patients who refilled their medication for at least six consecutive months between September 2004 and June 2006. Medical charts were reviewed for a subset of 375 patients having high (≥90%) adherence and 59 patients having low (<90%) adherence. Multivariate logistic regression analysis assessed the association between the type of treatment partner used and adherence to HAART. A total of 305 patients (70%) had self-selected treatment partners, 121 (28%) had community-based treatment partners, and 8 (2%) had no treatment partner. In adjusted analysis, patients who had no treatment partner were more likely to have low adherence (OR 9.47; 95% confidence interval 2.37–37.86 compared to self-selected treatment partner). Patients with community-based treatment partners did not have significantly lower adherence than patients with self-selected treatment partners. While it cannot be determined from these data which aspects or types of peer support are most effective in maintaining adherence, it appears that peer support was beneficial to this study population. While the study results are not directly applicable to other populations, other HAART programs should consider the potential benefit of providing treatment support to patients.