Kenneth Sherr, PhD, MPH Assistant Professor Department of Global Health ksherr@uw

1. Improving Health Systems Delivery in Mozambique – the role and opportunities for strengthening health systemsMarch 01, 2011 Kenneth Sherr, PhD, MPH Assistant Professor Department of Global Health ksherr@uw.edu Mark Micek, MD, MPH Clinical Assistant Professor Department of Global Health mmicek@uw.edu

2. Presentation Overview • Background on the know-do gap • What are health systems and their role for improving health • Example of one approach to strengthening health systems from Mozambique

3. ‘Know-do’ gap • Advancements in medical science have outpaced their application • >10 million annual deaths from diseases with proven, low cost prevention or treatment strategies • 1 million malaria deaths • 6 million preventable child deaths • ½ million maternal deaths • 3 million HIV-related deaths

4. Best Buys in Global Health Disease Control Priorities Project www.dcp2.org

5. Mozambique experience (ART) Survey of 32 facilities with comprehensive HIV care 5,642 patients enrolled (2,696 on ART, 2,946 pre-ART) Misau, 2008

6. Mozambique experience (ART)

7. US experience (Medicare) Jencks, et al, JAMA 2003; 289(3):305-12.

8. Role of Delivery Systems in closing know-do gap

9. The implementation bottleneck Vaccines Primary Health Care MCH Care Drug therapies Basic surgery

10. Trends in Official Development Assistance for Health, 1990-2007 Ravishankar N, et al, Lancet 2009;373:2113-24

11. What is a health system?

12. Satisfaction - Mozambique Source: IAF, 2002/3

13. Workforce in selected countries

14. DDCF’s African Health Initiative • Initiated in 2007 to catalyze shift away from vertical programs in favor of Primary Health Care • Aims to: • Achieve measureable, significant health improvements • Strengthen health systems • Increase the knowledge for evidence-based health delivery and health systems planning through implementation research (develop and test models)

15. DDCF’s funded projects • Population Health Implementation & Training (PHIT) Partnerships began August, 2009 • Rwanda: CHWs, HIS improvements, management training • Zambia: Clinical mentoring, EMR, CHWs • Tanzania: Community-based IMCI • Ghana: district resource allocation • Mozambique

16. Examples of OR/QI activities in Mozambique Mark Micek, MD, MPH

17. Mozambique PHIT Strengthening Integrated Primary Health Care in Sofala, Mozambique • Partners include: • Provincial Health Directorate • UW DGH/Health Alliance International • UW Department of Industrial Engineering • Eduardo Mondlane University

18. Background: Sofala Province Population 1.7 M, 13 districts 60% along “Beira corridor” 7% piped water, 6% electricity Year-round malaria transmission HIV: 15.5% (270,000) HIV+ (INSIDA, 2009) 70,000 ART eligible (26%) 25,000 on ART (36% of eligible) % <5 malnourished (MICS, 2008) Stunting: 41% Wasting: 16%

19. Background: National Health Service NHS primary provider of formal health services Introduction of PHC in 1977 Per capita health expenditure <$40 per year Sofala province: <3,000 health workers (2008) 40 physicians (2.4/100,000) 552 superior & mid-level providers (32.5/100,000) 1,044 basic/elementary level providers (61.4/100,000) 45% support staff

20. Importance of Primary Care Central Hospital Quarternary (1-<1%) • 93% ANC • 65% institutional births • 81% coverage DPT3 • (MICS, 2008) Specialized inpatient services & consults Inpatient, outpatient, basic surgical capacity ANC/FP, EPI, maternity, outpatient care High coverage of basic services in Sofala Secondary (4- 3%) Rural Hospitals Primary (137- 97%) Urban Health Centers (12 ) Rural Health Centers I (10 ) Rural Health Centers II (89) Health Posts (26)

21. Project Need Despite high coverage of primary care, many interventions not done Lack of management/supervision, drugs/reagents Money diverted to high-profile vertical programs Weak district management impedes decentralization Lack of staff, management capacity Weak data systems and use to inform decisions As a result: Weak program assessment & problem solving, poorly allocated resources, stock-outs Weak systems integration within & between facilities, and across vertical programs; fragmentation of care

22. Project Aim & Objectives Aim: Improve health outcomes in all 13 districts in Sofala province by strengthening health systems and improving delivery of integrated primary health care Objectives: Strengthen integrated health systems management in Sofala at district and provincial levels Improve quality of routine data and develop appropriate tools to facilitate decision-making for provincial and district managers (i.e. data feedback “dashboard”) Build capacity for and conduct innovative operations research and quality improvementactivities, to guide integration and system strengthening efforts

23. Conceptual Framework • Forms the basis for the design and measurement of the intervention • What processes are important within health systems? • What interventions can improve these processes? • How can we measure if the improvement improved health?

24. Obj 1: Strengthen health systems management in Sofala Training on leadership & management for health system managers Develop series of 1-2 day training modules on: Strategic planning and target setting Problem identification and solving (data driven decision making) Roles/responsibilities/team building/leadership Effective communication Resource management/budgeting Train health managers using modules District Management Team training (on site) Training of MDs pre-deployment (annually) Incorporation into pre-service curricula Sector-specific trainings (ie: MCH) on data systems and their use

25. Obj 2: Improve routine data systems & develop tools to facilitate decision-making • Training of staff on basics of M&E systems • Ongoing assessments of data consistency and validity, with feedback on HIS • Observation of consults  Registry book  Paper report  electronic database • Development of data feedback form (Dashboard) • Development of simulation/ optimization models for HR allocation, supply chain management

26. Obj 3: Carry out OR and QI projects, to improve health system functioning Act Plan Study Do

27. Opportunities & challenges in doing OR/QI • Opportunities: • Processes in resource-poor settings often complex • Little attention paid to efficiency, process mapping, redesign • Much data available to guide decisions • Challenges: • Often routine data is too poor to use • Easy to get too complex, too esoteric, too lengthy • End product may not apply to real world  no one uses it • Getting buy-in at all levels before starting

28. Example of OR: Low number of patients who starting ART

29. Steps to identify and treat people with HIV: The HIV treatment cascade

30. Results: Overall HIV treatment cascade Step 2: Drop-off 44% 3,049 lost Step 4: Drop-off 69% 1,035 lost

31. Results: Major bottlenecks • Number of additional people completing all 5 steps if drop-offs individually improved

32. Value Stream Mapping of pMTCT Services

33. Value Stream Mapping of pMTCT Services

35. Evaluation of change in workday No statistically significant increase in number or trend of visits after intervention (compared with before)

36. Measuring impact of PHIT

37. Measuring impact of PHIT • Comparison between intervention and control province • Responsiveness: separate studies • Impact: DHS

38. Health system responsiveness: Time and motion study • Waiting times, turn-aways are a measure of health system responsiveness and quality of care (like patient satisfaction) • Measured at years 0/1 (baseline), 4, 7 • 12 health facilities from 12 districts (6 intervention province, 6 control province) • Non-randomly chosen to include spectrum of facility types (large tertiary hospitals to small rural health posts) • 2 services chosen per facility (i.e. outpatient, prenatal care, well child care) + lab & pharmacy • Observers recorded arrival times, wait times, and turn-aways for consecutive patients (goal n=180 per service)