Mozambique
Country Profile
Jhpiego in Mozambique
Background
Quick Facts Mozambique has undergone substantial developmental growth and change since achieving
Estimated total population:1 independence in 1975 and has seen strong economic growth in recent years. The
21.9 million
government has made a commitment to health care reform and improvement in all health
and human service sectors. This initiative offers great promise of success, as evidenced by
Maternal mortality ratio:2
550 per 100,000 live births recent encouraging improvements in various health indicators. Data from the 1997 and
2003 Demographic and Health Surveys and 2008 Multiple Indicators Cluster Survey, as
Infant mortality rate:2 well as routine Ministry of Health (MOH) data from 2008, indicate reductions in
64 per 1,000 live births maternal, neonatal and child mortality between 1999 and 2008. Immunization coverage
increased to a sustained rate of 95%, while the institutional birth rate increased from 49%
Under-five mortality rate:2 in 2005 to 54% in 2007 and 58% in 2008. There has been a reduction in the malaria
97 per 1,000 live births mortality rate, expansion of access to tuberculosis (TB) treatment and a significant increase
in the number of persons benefiting from antiretroviral treatment. Nevertheless,
Total fertility rate:3
substantial challenges remain, including high rates of neonatal and infant mortality and
5.9
high risk for HIV and other infectious diseases.
Contraceptive prevalence:3
11% (modern methods) Jhpiego has been working in Mozambique since 2004, initially on prevention of medical
12% (all methods) transmission of HIV/AIDS in hospitals under the University Technical Assistance
Project (UTAP), funded by the Centers for Disease Control and Prevention (CDC)
HIV prevalence:4 through the U.S. President’s Emergency Plan for AIDS Relief. Since then, Jhpiego’s role
11.5% has expanded exponentially, with multiple HIV-related interventions and an office in
Maputo with more than 100 staff. In June 2009, prior to the end of UTAP, Jhpiego was
Births with skilled provider:2
awarded a five-year cooperative agreement by CDC with a scope of work that continues
54.3%
and expands HIV/AIDS efforts.
Sources:
1
Instituto Nacional de Estatística Web In 2005, Jhpiego also began working in Mozambique to strengthen maternal and newborn
site, 2010 projection; health services as a partner under FORTE Saúde (Fostering Optimization of Resources
2
Mozambique 2011 Demographic and
Health Survey;
and Technical Excellence for National Health), a project funded by the U.S. Agency for
3
Population Reference Bureau 2013 International Development (USAID). With the end of this project in early 2009, Jhpiego
World Population Data Sheet; launched a new partnership with USAID under the global Maternal and Child Health
4
National HIV Survey 2009. Integrated Program (MCHIP) to work with the MOH to improve the quality of maternal
and newborn health services through the implementation of a national “Model
Maternities” Initiative (MMI). This initiative focuses on scaling up humanized care and
high-impact interventions for maternal and neonatal health and key preventive
reproductive health/family planning (RH/FP) services, including breast and cervical cancer
prevention. A second phase of MCHIP began in early 2011 to further expand the MMI
and the national breast and cervical cancer prevention program, to develop and roll out an
integrated services package for maternal, newborn and child health (MNCH) and RH/FP
services, and to broaden the use of a quality improvement approach based on Jhpiego’s
Standards-Based Management and Recognition (SBM-R®) methodology.
In addition to working with funding from CDC and USAID, Jhpiego in Mozambique
received funding from BHP Billiton, in conjunction with its Mozal Project, to improve
l_m
community access to quality HIV and other essential maternal and newborn health services in two health facilities in the Boane
District of Mozambique. Under this award, Jhpiego is partnering with and strengthening the capacity of a local community-based
organization, Irmãs Franciscanas, to address HIV/AIDS in Boane District. Implemented as a natural extension of Jhpiego’s current
efforts, and in accordance with the Mozal Community Development Trust and Boane District health priorities, this project uses a
two-pronged approach that focuses on community engagement, while also strengthening health services at health centers.
All three of Jhpiego’s current projects in Mozambique are described in more detail below.
Current Program Highlights
Under the CDC bilateral award, Jhpiego is currently working to accomplish the following goals by the end of the project:
Improve compliance with infection prevention and control (IPC) measures for TB in 43 health care settings
Increase the number of Mozambicans who know their HIV status by more than one million through community-based
counseling and testing
Reduce medical transmission of HIV and other blood-borne pathogens by increasing compliance with basic IPC best
practices in up to 200 health facilities
Build MOH capacity to improve the quality of pre-service education by implementing new nursing curricula in 13 training
centers, reaching approximately 500 new graduates
Improve health workforce performance through in-service training and task-shifting for 1,500 ancillary workers in HIV-
related care, including stigma and discrimination, post-exposure prophylaxis (PEP) and health worker protection, through the
implementation of MOH-approved workplace safety and health guidelines nationwide
Expand the nationwide Web-based Training Information and Monitoring System (TIMS©, known in Mozambique as SIFo)
and develop and implement a pre-service information system (SIFIn)
Improve services that address gender-based violence (GBV) by equipping 42 sites to provide comprehensive care for GBV,
including HIV PEP, emergency contraceptives, treatment for sexually transmitted infections, counseling and referrals to
support groups for GBV victims
Assess the current continuing education system and provide support to develop a national strategy for continuing education
Assess the human resources information system and make recommendations to improve it
Establish and expand safe and effective integrated voluntary medical male circumcision/minor surgery (VMMC/MS) services
in several fixed, temporary and mobile sites, serving more than 400,000 individuals
Under MCHIP in Mozambique, Jhpiego is supporting the MOH to:
Create an enabling environment to support nationwide delivery of integrated, high-quality community- and facility-based
high-impact MNCH and RH/FP interventions
Strengthen the national health information system by supporting the rollout of new integrated MNCH/RH/FP registers
Expand national coverage of high-impact MNCH interventions by scaling up the MMI in collaboration with U.S.
Government partners in every province
Strengthen the development of human resources for health service delivery in basic and comprehensive emergency obstetric
and neonatal care and RH
Expand cervical cancer prevention activities using the single visit approach and assist in the implementation of the MOH
“Action Plan to Strengthen and Scale-up Breast and Cervical Cancer Prevention and Control Services”
Develop and implement preventive RH/FP services, management and referral to appropriate facilities in selected health care facilities
Develop and strengthen partnerships to promote nationwide the delivery of integrated, high-quality community- and facility-
based high-impact MNCH interventions through MOH and all U.S. Government partners
Define, implement and monitor standards of care at the point of delivery in key service areas
Under the award from BHP Billiton, Jhpiego expects the project to achieve the following objectives:
Implement an integrated, community-based health program through well-trained lay counselors and health committees who
will work hand in hand with health facilities
Improve the quality of maternal, newborn and reproductive health services, including HIV counseling and prevention of
mother-to-child transmission (PMTCT) services at two health centers, using competency-based training and performance
standards
Increase utilization of services at the Boane and Beluluane Health Centers, including VMMC and PMTCT, as well as
antenatal care, institutional deliveries and family planning
Establish a clear referral and counter-referral system between communities and health facilities
Key Accomplishments
Under the CDC bilateral award, results include:
All 30 health facilities involved in the rapid assessment have developed and are using a plan for infection and control
measures for TB. Through the implementation of simple but effective IPC measures, these efforts will ensure that facility
patients are better protected and the workplace is a safer environment.
With Jhpiego’s support, provider-initiated testing and counseling (PITC) at MOH facilities is being consolidated to ensure
that clients are offered HIV counseling and testing services at all encounters with a given facility. From July 2011 through
June 2013, a total of 41,239 patients were counseled and tested through PITC at Jhpiego-supported sites. Of these, 9,390
tested HIV-positive (22.8%).
As of June 2013, 1,375,360 individuals have been counseled in community settings, and 1,121,060 of these individuals were
tested for HIV (35,886, or 3.2% tested positive). The integration of other program components into community-based
counseling and testing (i.e., TB, VMMC, GBV, PITC and PMTCT) continues to be strengthened to ensure the most
efficient capture of HIV-positive individuals as well as appropriate referrals and follow-up for various issues, including
antiretroviral therapy. Conditions are being created to integrate screening for breast and cervical cancer.
IPC is being implemented in 140 facilities in Mozambique, including all hospitals and major health centers. The internal
assessment of facility performance in IPC is now a self-sustained process, with Jhpiego investing mainly in support of external
assessments, increasing the number of health professionals trained on IPC and working with provincial health managers and
clinical partners to expand the coverage of IPC to new facilities.
Under the pre-service strengthening initiative, Jhpiego is implementing revised, updated and competency-based training for
maternal and child health (MCH) and general nursing students. As part of this initiative, faculty improved their technical
capacities through training on effective teaching skills. A comparative assessment of the new curricula is currently under way.
In addition, SBM-R has been institutionalized by the MOH at all 15 training institutes; they are now implementing all the
performance standards, including for administration and finance. The Model In-Patient Ward methodology is being
implemented in 66 wards in all provinces. Significant progress toward reaching the pre-defined performance standards has
been made in all wards.
As a result of the PEP initiative, from October 2009 through June 2013, 2,106 health workers were documented with
exposure to blood fluids, and 1,916 of these workers received PEP. Occupational PEP is now being offered in 176 facilities
across the country.
Forty-two facilities in seven provinces are providing integrated care to victims of GBV. Since efforts began in September
2010, a total of 1,378 victims of sexual violence have been provided with integrated post-GBV care, including PEP, in
Jhpiego-supported facilities. Jhpiego has initiated community interventions related to GBV as a strategy to improve awareness
and information about GBV as a public health issue, legal knowledge about GBV and access to GBV care; additionally, GBV
is being integrated with VMMC as a strategy to engage men in the prevention of GBV.
The VMMC/MS program includes 28 sites (19 fixed and nine temporary) in Maputo City as well as the provinces of
Maputo, Gaza, Sofala and Manica. From November 2009 to July 2013, more than 170,000 VMMC procedures were
performed, with an average complication rate of less than 0.5%. Satisfaction of the clients with VMMC services, including
counseling and testing, has been continuously monitored and has remained above 95%. In July 2013, 18,085 VMMC
procedures were performed, the highest monthly number to date.
To rapidly introduce training for nurses in antiretroviral therapy, Jhpiego helped the MOH to integrate an HIV module into
the MCH nurse training course and also successfully implemented training in antiretroviral therapy for 491 newly graduated
MCH nurses.
With Jhpiego support, the MOH is pursuing an innovative approach in the development of its human resources information
system. Close internal coordination within the MOH has allowed the identification of opportunities for joint development of
key pieces of the MOH information architecture, such as the facilities database. Jhpiego is providing technical support to the
MOH to develop a national strategy for retention of health care workers.
Major accomplishments under the MCHIP Associate Award, from the period October 2012 through June 2013, include:
The MMI has expanded from 34 to 95 health facilities, as of June 2013. Indicators for all five of the prioritized high-impact
maternal and newborn health practices (completely filled in partograph, active management of the third stage of labor,
treatment of pre-eclampsia/eclampsia with magnesium sulfate, immediate skin-to-skin contact with the newborn and
breastfeeding within the first hour after delivery) show a positive trend.
As of June 2013, a total of 216 Health Committees have been created or revitalized and are currently functioning with
support of the project. Of these, 195 (90%) are actively identifying, analyzing and proposing solutions for problems in their
communities. In addition, MCHIP has created 87 Co-Management Committees, composed of community members and
health workers, all of which have developed community-facility action plans to address the identified gaps/challenges, and are
beginning to implement key actions.
Cervical cancer prevention program activities are integrated into existing RH services, leading to the creation of a package of
integrated RH outpatient services that includes: counseling and services for family planning, cervical cancer prevention, HIV
services, sexually transmitted infection services, GBV support and infertility treatment, as well as screening, treatment or
referral for other gynecological conditions. By the end of June 2013, the number of health facilities offering integrated RH
services increased from 17 to 89.
MCHIP finalized the report of the study, “Health Facility Survey for Quality and Humanization of Care in Mozambique’s
Model Maternity Facilities.” The report summarizes the findings from observations of 525 deliveries and 303 antenatal
consultations in 46 facilities (17 facilities currently participating in MMI and 29 in the future expansion plans for the
initiative). Findings have been used to prioritize urgent needs (e.g., material improvements, improvement in use of the
partograph and emergency readiness measures) and recommendations incorporated in the project’s work plan.
Partners/Donors
Jhpiego’s two donors in Mozambique are CDC and USAID.
Jhpiego works closely with the MOH, Ministry of Finance, Ministry of Women and Social Action and the National AIDS
Council, as well as coordinating with other partners active in Mozambique, such as the World Health Organization (WHO),
Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Population Fund (UNFPA), national and
international NGOs, local community counseling and testing NGOs, and others.
References
Instituto Nacional de Estatística, Ministério do Plano. População Projectada Total, Moçambique, 1997-2020. At: http://www.ine.gov.mz
Joint United Nations Programme on HIV/AIDS (UNAIDS) Country Responses. At: http://www.unaids.org/en/CountryResponses/Countries/mozambique.asp
Ministério da Saúde, Instituto Nacional de Saúde. 2009. Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique.
Maputo, Mozambique.
Ministério da Saúde, Instituto Nacional de Estatística. 2003. Moçambique Inquérito Demográfico e de Saúde. Maputo, Mozambique.
National Statistics Institute. 2009. Mozambique Multiple Indicator Cluster Survey 2008: Summary. Maputo, Mozambique.
Population Reference Bureau. 2013 World Population Data Sheet. Washington, D.C.
Ministerio da Saude (MISAU), Instituto Nacional de Estatística (INE) e ICF International (ICFI). Moçambique Inquérito Demográfico e de Saúde 2011.
Calverton, Maryland, USA: MISAU, INE e ICFI.
