Sofala Province, located in central Mozambique, has a relatively high-population density and an estimated population of more than 1.8 million, 37% of which is urban [1
]. Nearly 62% of the population is concentrated along the major shipping and transport route connecting the sea port of Beira to Zimbabwe. Of the 11 provinces in Mozambique, Sofala ranks among the poorest, though key health indicators are above the country average and have improved at a more accelerated pace than other provinces. Latest estimates show that the infant mortality rate is 81 per 1,000 live births, and the under-5 mortality rate is 134 per 1,000 live births, compared with 107 per 1,000 live births and 157 per 1,000 live births nationally [2
]. Despite substantial reductions in mortality indices over the past decade, the four principal causes of under-5 mortality in Sofala remain diseases with available low-cost and effective prevention or treatment strategies, including malaria (32.9%), acute respiratory infections (10.9%), HIV (9.9%), and diarrheal diseases (8.9%) [3
]. High levels of chronic (35.7%) and acute (7.4%) malnutrition result from persistent food insecurity [4
]. Nationally, the maternal mortality ratio, which has seen a 50% reduction in the last decade, is still high at an estimated 490 per 100,000 live births [5
Approximately 15.5% (over 185,000) adults aged 15-49 in Sofala Province are HIV-infected, with 60,000 estimated to be eligible for antiretroviral therapy (ART) [6
]. Pediatric HIV infection is high, with an estimated 23,800 HIV-infected children in 2007 [7
]. Tuberculosis (TB) incidence is estimated at more than 400 per 100,000 people, and HIV co-infection is common, with more than 60% of TB patients in Sofala also testing positive for HIV [8
Health systems coverage
Despite the high burden of disease, the use of formal health services provided through the National Health Service (NHS) remains high, particularly for basic preventive and curative maternal, newborn, and child health services.
Coverage of antenatal care services (at least one visit) is high in Sofala and has increased from 82% to 95% in the past decade. In the same time period, the institutional birth rate increased from 51% to 71%. Both measures are higher than the national average [4
]. Of those receiving routine antenatal care services, more than 90% received syphilis testing and treatment, 46% received at least one dose of intermittent preventive treatment for malaria [10
], and 74% received testing for HIV, reflecting variations in the delivery of effective interventions through the antenatal care platform [2
]. Five hospitals in the province are equipped to perform cesarean births, and they perform these at a low rate of 2% of estimated births. Modern contraceptive use is low in Sofala among women of reproductive age (8%) and lower than the national average (12%).
Immunization coverage in Sofala Province is high, with 85% of children 12-23 months having received diphtheria-tetanus-pertussis (DTP3) vaccine, 87% measles vaccine, and 78% receiving all required vaccinations. An estimated 25% of children under 5 sleep under insecticide treated bednets [10
]. Utilization of formal health services among symptomatic children under-5 is also high and above the national average, including among those with diarrheal symptoms (71.2% in Sofala compared with 58.5% nationally) and fever (75.4% compared to 58.8% nationally) [4
]. Basic ambulatory care services are broadly available throughout the province and nearly 3 million people are reached annually through outpatient visits [11
]. Integration of HIV care into outpatient services at smaller health centers has improved adult and pediatric access to HIV care, and in 2012 more than 27,300 people (nearly 50% of ART eligible patients) are on ART, including more than 2,800 children under 15 [12
]. Case detection of new sputum smear positive pulmonary TB cases is estimated at 88.3%, and 83% of those initiating TB treatment are treated to completion [13
The Mozambique National Health Service
Since its inception in 1975 following national independence, the Mozambique National Health Service (NHS) has rapidly expanded primary health care (PHC) services through a widespread network of health facilities. As a result of this expansion, the NHS is the major provider of formal health care services in Mozambique, providing 98% of outpatient services in Sofala Province.
The health network in Sofala Province includes 146 health facilities within its 13 districts, translating to a health facility to population ratio of 1/12,000 [14
]. This network is organized into four basic levels of care, including 1) one quaternary-level hospital in Beira; 2) four secondary-level rural hospitals; 3) 114 urban and rural health centers; and 4) 27 health posts [11
]. Over the past decade, the Mozambique Ministry of Health has prioritized expanding the overall number of facilities and enhancing facility capacity by transforming lower level health posts into health centers and increasing rural and district hospitals. Over the last decade, economic growth and increased development assistance has led to dramatic health sector spending increases, growing from less than USD$10 per capita in 2001 to approximately US$26 per capita in 2008, of which more than 70% is financed by external aid [15
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 ). Each of Mozambique’s 11 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.
Simplified functional representations of PHC and support systems.
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.
Despite Mozambique’s successes in improving the health care infrastructure and the high utilization of primary health care services, chronic resource shortages, vertical funding, and management challenges limit service coverage and quality. Mozambique ranks among the highest human resource-constrained countries in the world, with 2.4 doctors and 21 nurses/100,000 people; in Sofala, a population of 1.8 million, there are just 2,400 technical health workers and 2,400 support staff [17
]. District health directorates also remain underfunded with limited technical, managerial, and workforce capacity to assume newly devolved responsibilities. District management is further hampered by a combination of weak data collection systems and limited capacity to analyze data for district level decision making and planning.
District management and health systems strengthening
Government decentralization has become a cornerstone of public sector reform in Mozambique and in other low- and middle-income countries (LMICs), including in the health sector. The decentralization agenda has been promoted by multi and bilateral donors as a strategy to bring decision making closer to the people,[18
] and has been sequentially implemented over the past decade [22
]. District directorates are the health system unit that will determine the success of health sector decentralization. As described above, challenges remain in Mozambique to sufficiently support and build district management capacity for leadership, planning, resource allocation, and financial management. This district level capacity is essential for improving service delivery and quality at the facility level, and, ultimately, population health.
There is little evidence, however, on effective approaches to strengthening district-level management capacity. Fundamental to achieving this goal is the establishment of robust health information systems (HIS) and the capacity to use routine data for decision making. Approaches to improving HIS quality and consistency have been developed and are being implemented in LMICs, including in Mozambique [24
]. Efforts have also been made to link HIS with improved service delivery, primarily focused on disease-specific services within limited geographic areas [29
]. However, there is little evidence on successful efforts to improve data utilization among district managers and broadly across large health systems. This lack of acting on data is a critical gap in achieving better health outcomes. Research is needed on what works to increase the use of evidence for decision making and the rational use of scarce resources.
Mozambique Population Health Implementation & Training (PHIT) Partnership
The PHIT Partnership aims to improve health system capacity and the functioning of the primary health care system – including more effective resource allocation, better integration of services, and high coverage of quality services – across the provincial, district, and facility levels in Sofala Province by focusing on strengthening data systems, management, and bottleneck resolution (Figure ). Considering Sofala’s expansive primary health care network and high service utilization, it is envisioned that these improvements in health system performance will result in better health outcomes, including reduced child mortality.
District management teams are an essential link to achieving improvements in health systems performance and population health. With better training and new tools, managers can approach their operations as interconnected systems, focusing on facility-level and service-sector indicators, rather than isolated indicators of disease-based vertical programs. By considering the inputs and outputs of the entire health care system, this management approach facilitates the expansion of integrated PHC at the facility level and reduces service delivery gaps that occur if services are organized on disease-based classifications. Strengthening district level management capacity across Sofala’s 13 districts is a fundamental strategy to achieving the aim of the PHIT Partnership in Mozambique.
The partnership objectives are synergistic and include:
1. Improve the quality of routine data and develop appropriate tools to facilitate decision-making for provincial and district managers;
2. Strengthen integrated health systems management and planning in Sofala at district and provincial levels;
3. Build capacity and carry out innovative operations research (OR) to guide integration and system strengthening efforts.