Abstract
BackgroundLarge 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. A consortium of the Ministry of Health, Health Alliance International, Eduardo Mondlane University, and the University of Washington are implementing a health systems strengthening model in Sofala Province, central Mozambique.Description of implementationThe Mozambique Population Health Implementation and Training (PHIT) Partnership focuses on improving the quality of routine data and its use through appropriate tools to facilitate decision making by health system managers; strengthening management and planning capacity and funding district health plans; and building capacity for operations research to guide system-strengthening efforts. This seven-year effort covers all 13 districts and 146 health facilities in Sofala Province.Evaluation designA quasi-experimental controlled time-series design will be used to assess the overall impact of the partnership strategy on under-5 mortality by examining changes in mortality pre- and post-implementation in Sofala Province compared with neighboring Manica Province. The evaluation will compare a broad range of input, process, output, and outcome variables to strengthen the plausibility that the partnership strategy led to health system improvements and subsequent population health impact.DiscussionThe Mozambique PHIT Partnership expects to provide evidence on the effect of efforts to improve data quality coupled with the introduction of tools, training, and supervision to improve evidence-based decision making. This contribution to the knowledge base on what works to enhance health systems is highly replicable for rapid scale-up to other provinces in Mozambique, as well as other sub-Saharan African countries with limited resources and a commitment to comprehensive primary health care.
Highlights
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
Evaluation design: A quasi-experimental controlled time-series design will be used to assess the overall impact of the partnership strategy on under-5 mortality by examining changes in mortality pre- and post-implementation in Sofala Province compared with neighboring Manica Province
This contribution to the knowledge base on what works to enhance health systems is highly replicable for rapid scale-up to other provinces in Mozambique, as well as other sub-Saharan African countries with limited resources and a commitment to comprehensive primary health care
Summary
A number of lessons have been learned about building health system capacity from the early years of implementing PHIT Partnership activities in Mozambique. (See Table 2 for a description of the key success, challenges, and implementation adaptations that the investigators have observed far.) The first is that decentralization is not a linear or sequential process, and often it is not clear which activities are within the scope of control of district, provincial, or national managers. The PHIT Partnership has encountered challenges in building leadership capacity at scale, which requires an intensive process using skilled mentors to train individual health system managers. Collaboration and ownership by provincial and district Ministry of Health authorities Embedded technical and financial support has built ownership of the PHIT activities by health system leadership, which has led to refinements in PHIT tools to be contextually appropriate in design, accelerate the pace of implementation in the province, and provides an avenue for further scale-up. By providing evidence on the effect of efforts to improve data quality coupled with the introduction of tools, training, and supervision to improve evidence-based decision making, we expect to contribute to the knowledge base on what works to enhance health systems in an African context and potentially in other LMICs. we expect to contribute to the knowledge base regarding how to design and conduct impact evaluations for large-scale, complex interventions in real-world implementation settings. Competing interests The authors declare that they have no competing interests
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