21 july 2014

Strengthening Mozambique’s District Health System to Improve Access and Quality of HIV Care and Treatment Services

21 July 2014

2

Main Challenges

• High HIV prevalence

• Low ART coverage

• Scarcity and misallocation

of resources

• Low managerial capacity

at district level

MozambiqueHealth Statistics at a Glance

Population (2014) 26 million

HIV Prevalence 11.5%

PLHIV(2014) 1.6 million

Nº of HFs with ART 644 of 1,445 (45%)

PLHIV Eligible for ART 865,877

Nº Active in ART 508,890

ART Coverage 59%

12 month ART retention 71%

% Below Poverty Line 55%

Ratio of doctors to pop 3/100,000

Access to healthcare 56%

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Can strengthening health systems improve

access, quality and sustainability of HIV

services?

Driving Question

4

Health Systems and Clinical Services

The plan…

5

Health Systems and Clinical Services

The reality…

The plan…

The reality…

The Reality

The Plan

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Intervention Response

Graduation Path Strategy• District focused• District assessment tool (DAT)• Integrated technical assistance (TA)

through Equipes Polivalentes• Support package (tutoring, subgrants,

equipment, minor renovations, and emergency funds)

2. Development of Standards and Sub-Criteria

6. Self-Assessment (Base Line)

1. Definition of Functions and Standards

5. Training of staff and external evaluators

7. Identification of Areas of Improvement

8. Action Plan

4. Development of an scoring system

9. Execution

10. Follow up Assessments(Self or External)

Design & Implementation Process

3. Development of assessment tool

District HSS Assessment Framework

Functions (8)

Standards (23)

Sub-Criteria (115)

Follow up & Progress Monitoring

Measurable Indicators Scoring System

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Functions

Health Systems

Management Capacity

1. Planning Systems and Capacities

2. Information Systems and Capacities

3. Financial Management Systems

4. Human Resources Systems

5. Pharmacy Supply and Logistic Systems

Health Services

Management Capacity

6. Health Programs Management

7. Key Laboratory and Support Services

8. Community Mobilization

District Health System Functions

“Continuous QI is achieved by iterating through the cycle and consolidating achieved progress through standardization” (Johannes Vietze, 2013)

Time

Continous Improvement

Standards Consolidation through

Standardization

Quality Im

provement

StandardsPlan

Do1

Do2Study

Act

Plan

Do1

Do2Study

Act

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Baseline vs. Post-Baseline1. Planning Systems

2. Information Systems

3. Financial Management

4. Human Resources

5. Supply and logistics

6. Health Programs

7. Laboratory & Support

8. Community Mobilized

58% 74%

54%

40%26%

20%29% 27%

88%

79%

49%

37%

61%68%

72%

38%

Basline 2nd Measure

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Preliminary Findings• Baseline:

– High variation across health system functions– Weaker areas: pharmacy supply & logistics, lab, health programs

mngmt– Stronger areas: HIS, Planning systems and capacities– Insufficient systems to track problems and implement solutions

• Post-Baseline– Highest improvement in weakest areas (pharmacy & health programs)– Strongest areas: HIS, planning, pharmacy & health programsBasline 2nd Measure Difference

1. Planning Systems 58% 88% 30%2. Information Systems 74% 79% 5%3. Financial Management 54% 49% -5%4. Human Resources 40% 37% -3%5. Supply and logistics 26% 61% 35%6. Health Programs 20% 68% 48%7. Laboratory & Support 29% 72% 43%8. Community Mobilized 27% 38% 11%TOTAL 36% 66% 30%

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Initial Lessons Learned

• District assessments increased MoH staff awareness of management standards

• Assessment-based action plans are effective tool for guiding quality improvement (PDSA cycle works!)

• Action plans owned by districts and used to guide activities

• Project staff support district health officers to implement action plans to improve results

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Can strengthening health systems improve

access, quality and sustainability of HIV

services?

Driving Question

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Next Steps

• Quasi-experimental design to test hypothesis• Difference-in-difference approach• Regression-discontinuity design

Intervention Start Date Project End Date

Clin

ical

Out

com

e In

dica

tors

Experimental Group Experimental Group: High HSS

06/1612/1506/1512/1406/1412/132011-2012End of project

Baseline,First

measure

Start of project, Pre-Baseline

Second measure

t1 t2 t4t3 t5 t6t0

Comparison Group Experimental Group: Low HSS

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Acknowledgements

18OBRIGADO

Daniel D. Lee dlee@chasssmt.com