Strengthening integrated primary health care in Sofala, Mozambique

BAMBANG HERMANTO

KMPK 2014

Large 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.

At the national level the Ministry of Health sets country health policy and manages both health programs and operational support services, including procurement and distribution of medicines and medical supplies to the provincial level (Figure 1).

Each of Mozambique's11 provinces has its own health directorate that also performs operational and programmatic management functions and represents a key organizational unit through which primary health care services are managed, coordinated, and brought to scale. Each district health directorate has a management team comprised of a district director, chief medical officer, pharmacist, statistician and administrator, which is responsible for providing support for, and managing, health facilities that, in turn, provide primary health care services.

The Mozambique health system's current decentralization process has moved important management and planning tasks from the provincial level to the district level. District management teams have become the vital link in the NHS to improve integrated care. Duties of these teams include planning, budgeting, human resources management, medical supply distribution, supervision, and data collection.

Given the integrated nature of the partnership approach, the project objectives are designed to lead to improvements across all six health system building blocks identified by WHO (Figure 2)

Experience to date designing and implementing the evaluation approach has highlighted a number of challenges and opportunities. The impact evaluation relies largely on data from community surveys financed and implemented for use outside the partnership. Because these surveys are powered to the partnership's geographic unit of focus – the provincial level – they are an effective, cost-saving evaluation approach that reserves partnership resources (financial, human, and logistical) for implementation and complimentary applied research efforts.

Furthermore, using standardized community surveys at the country level reinforces their utility for countryowned evaluation. However, the use of these community surveys results in a number of evaluation constraints. For example, there is little flexibility in adapting evaluation measures, defining the survey implementation timeframe, or increasing sample size to meet PHIT-specific evaluation needs given that the baseline household survey was carried out prior to initiation of Mozambique PHIT activities. In some cases, the sample size may be insufficient to detect changes in less frequent outcome measures important for assessing the effect of the partnership activities on strengthening the health system and improving health. Another notable challenge is the pre-existing temporal trends in coverage and impact measures in both the intervention and comparison provinces, and the potential for contamination associated with the passive adoption of successful elements of the intervention in the comparison province, which may complicate attempts to demonstrate improvements attributable to the PHIT Partnership.

Referensi

(Sherr et al., 2013)Sherr, K., Cuembelo, F., Michel, C., Gimbel, S., Micek, M., Kariaganis, M., … Gloyd, S. (2013). Strengthening integrated primary health care in Sofala, Mozambique. BMC Health Services Research, 13(Suppl 2), S4. doi:10.1186/1472-6963-13-S2-S4