Strengthening Mozambique’s District Health System to Improve Access and Quality of HIV Care and Treatment Services 21 July 2014

Main Challenges High HIV prevalence Low ART coverage Scarcity and misallocation of resources Low managerial capacity at district level 2 Mozambique Health Statistics at a Glance Population (2014)26 million HIV Prevalence11.5% PLHIV(2014)1.6 million Nº of HFs with ART644 of 1,445 (45%) PLHIV Eligible for ART865,877 Nº Active in ART 508,890 ART Coverage59% 12 month ART retention71% % Below Poverty Line55% Ratio of doctors to pop3/100,000 Access to healthcare56%

Can strengthening health systems improve access, quality and sustainability of HIV services? 3 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

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) 7

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

10 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 Service s 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 Improvement Standards

Baseline vs. Post-Baseline 12

Preliminary Findings 13 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 programs

Initial Lessons Learned 14 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

Can strengthening health systems improve access, quality and sustainability of HIV services? 15 Driving Question

Next Steps 16 Quasi-experimental design to test hypothesis Difference-in-difference approach Regression-discontinuity design Intervention Start Date Project End Date Clinical Outcome Indicators Experimental Group Experimental Group: High HSS 06/1612/1506/1512/1406/1412/ End of project Baseline, First measure Start of project, Pre-Baseline Second measure t1 t2t4t3t5t6t0 Comparison Group Experimental Group: Low HSS

Acknowledgements 17

18 OBRIGA DO Daniel D. Lee