achieving effective implementation of new roles in primary care ... · misau: o nosso maior valor...

Ministério da Saúde

República de Moçambique────

Achieving Effective Implementation of New Roles in Primary Care: Country experience –Mozambique

Fourth Global Forum on Human Resources for Health

15 November 2017Dublin, Ireland

Martinho Dgedge, MD; Msc; PhDGeneral Inspector of Health – Ministry of Health- [email protected]; [email protected]

MISAU: O nosso maior valor é a vida

MISAU

Outline of the Presentation

1. Introduction

2. Mozambique general information

3. Primary Health Care Package and respective competencies

4. Primary Health Care Workforce

5. Key examples of increased health services coverage

6. Final considerations

212/7/2017


MISAU

Introduction

• The National Health Service operates mostly with mid-level cadre since the

independence in 1975.

• Therefore, for us, those new roles are not really new.

• What is new are the new tasks that these cadres perform

�Task shifting for HIV and AIDS Care and treatment from doctors to mid-

level clinicians, nurses and midwives

� Tuberculosis treatment by mid-level nurses

�Basic treatment and preventive interventions by Community Health

Workers

312/7/2017


MISAU

Mozambique General Information (1)

Socio-Demographic information

Population Close to 27 millions

Maternal Mortality Rate 408/100,000 live

births

Infant Mortality Rate 93/1,000 live births

GDP/Capita Close to 900 USD


MISAU

07/12/2017

5

Malaria Prevalence HIV Prevalence

Mozambique General Information (2)


MISAU Quaternary

Level

4 Central Hospitals

2 Specialized Hospitals

Quaternary

Level

4 Central Hospitals

2 Specialized Hospitals

Terciary Level: 8 (0.5%) 8 Provincial Hospitals

Total of HRH: 4,689 (12%)

Health Workers: 2,422 (11%)

Terciary Level: 8 (0.5%) 8 Provincial Hospitals



Secundary Level: 50 (3%)

21 Rural Hospitals, 23 Distrital Hospitals, 6 General

Hospitals



Secundary Level: 50 (3%)

21 Rural Hospitals, 23 Distrital Hospitals, 6 General

Hospitals



Primary Level: 1,530 (96%)162 Urban Health Centres,

1,238 Rural Health Centres and 130 Health Posts

Total of HRH: 19,350 (50%)


Primary Level: 1,530 (96%)162 Urban Health Centres,

1,238 Rural Health Centres and 130 Health Posts

Total of HRH: 19,350 (50%)


Health Workforce and Health Facility Distribuition per level of care, National

Health Service, Mozambique, 2016

PH

C

Total of Health Facilities: 1,595

Health Workforce Stock in Health FacilitiesTotal HRH: 39,055Health Workers: 21,908

Source: MoH/HRD/HRIS (eSIP-Saúde)

Quaternary levelTotal of HF: 6 (0.4%)Total of HRH: 7,188 (18%)Health Workers: 3,077 (14%)

6


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7

Health Workforce by Occupational Categories, NHS, 2016

Source: MOH/HRD/HRIS (eSIP-Saúde)

[VALUE] (0,1%)

[VALUE] (0,1%)

[VALUE] (0,2%)

[VALUE] (0,2%)

[VALUE] (0,3%)

[VALUE] (0,5%)

188 (0,7%)

257 (0,9%)

287 (1,0%)

387 (1,4%)

483 (1,7%)

[VALUE] (1,7%)

493 (1,7%)

512 (1,8%)

1.845 (6,5%)

2.087 (7,4%)

2.149 (7,6%)

5.485 (19,4%)

5.517 (19,5%)

7.660 (27,1%)

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000

Otolaryngology

Orthroprotesia

Surgery

Health Statistics

Others Professionals

Ophthalmology

Anesthesiology

Radiology

Instrumentation

Physical Medicine and Rehabilitation

Hospital administration

Nutrition

Psychiatry and Mental Health

Dental care

Laboratory

Pharmacy

Environ, and public health professionals

Healing Medicine

Midwifery

Nursing


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Accessibility: Ratios of Inhabitants per Primary Health Care Facility and per Primary Health Care Workers, NHS, 2014

8


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Primary Health Care Workforce (regulated by –Ministerial Decree127/2002)

• Generalist Doctors

• Basic/Mid level Paramedical Practioners

• Basic/Mid level nurses

• Basic/Mid level Midwifery Professionals

• Basic/Mid level Dental assistants

• Basic/Mid level Laboratory Practioners

• Basic/Mid level Pharmaceutical Practioners

• Basic/Mid level Nutricionist practioners

912/7/2017


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10

Staffing Norms by Health Facility Type, Ministerial Decree 127/2002 (1)

Health Facility Type Category DM 127/2002Staffing

Norms

Rural Health Center Type II 4

Mid-level Paramedical practitioners or Mid-level Nursing

professionals or Nursing associate professionals1

Mid-level Midwifery professionals or Midwifery associate

professionals1

Mid-level Nutrition professionals 1

Health support staff 1

Rural Health Center Type I 14

Mid-level Paramedical practitioners 1

Mid-level Environ, and public health professionals 1

Mid-level Dental assistants and therapists 1

Mid-level Nursing professionals or Nursing associate

professionals2

Mid-level Midwifery professionals or Midwifery associate

professionals2

Mid level Medical and pathology laboratory technicians 1

Mid-level Medical imaging and therapeutic equipment

operators1

Mid-level Pharmaceutical technicians and assistants 1

Health management workers/Skilled administrative staff

(Hospital Administration Agent)1

Health support staff 3



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11

Health Facility Type Category DM 127/2002

Staffing

Norms

(without

maternity)

Staffing

Norms

(with

maternity)

Urban Health Center 25 31

Physicians and Mid-level Paramedical practitioners 3 3

Mid-level Environ, and public health professionals 1 1

Mid-level Dental assistants and therapists 1 1

Mid-level Nursing professionals 4 4

Mid-level Midwifery professionals or Midwifery

associate professionals5 5

Mid level Medical and pathology laboratory

technicians1 1

Mid-level Medical imaging and therapeutic

equipment operators1 1

Mid-level Pharmaceutical technicians and assistants 1 1

Health management workers/Skilled administrative

staff (Hospital Administration Assistant)1 1

Health management workers/Skilled administrative

staff (Clerk - Typist)2 2

Other health support staff 5 11


Staffing Norms by Health Facility Type, Ministerial Decree 127/2002 (2)


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12

Primary Health Care Workforce Distribution by Health Centre Type, National

Health Service, Mozambique, 2016 (1)


N %

Generalist medical practitioners 44 136 87 2 269 1,5%

High level Paramedical practitioners 0 5 3 0 8 0,0%

Mid-level Paramedical practitioners 1.352 1.044 736 213 3.345 18,5%

High level Nursing professionals 15 43 29 2 89 0,5%

Mid-level Nursing professionals 635 1.139 451 134 2.359 13,0%

Nursing associate professionals 93 111 86 36 326 1,8%

High level Midwifery professionals 4 9 5 0 18 0,1%

Mid-level Midwifery professionals 1.046 779 680 174 2.679 14,8%

Midwifery associate professionals 99 93 86 22 300 1,7%

Pharmacists 1 12 7 1 21 0,1%

Mid-level Pharmaceutical technicians 231 346 263 23 863 4,8%

Pharmaceutical assistants 10 18 21 4 53 0,3%

High level Medical and pathology laboratory technicians 0 9 6 0 15 0,1%

Mid-level Medical and pathology laboratory technicians 138 341 174 6 659 3,6%

Medical and pathology laboratory associate professionals 8 15 13 0 36 0,2%

Dentists 9 30 25 0 64 0,4%

Mid-level Dental assistants 27 109 49 0 185 1,0%

Mid-level Medical and dental prosthetic technicians 0 3 0 0 3 0,0%

Grand TotalUrban

Health

Centre

Rural

Health

Centre

Type I

Rural

Health

Centre

Type II

Professional CategoriesHealth

Post


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13


N %

Physiotherapists 0 2 0 0 2 0,0%

Mid-level physiotherapy assistants 4 39 7 0 50 0,3%

Physiotherapy associate professionals 1 0 0 0 1 0,0%

Mid-level Opticians 7 30 15 0 52 0,3%

Mid-level Medical imaging and therapeutic equipment

operators8 25 3 0 36 0,2%

Subtotal Mid-level Health Professionals 3.448 3.855 2.378 550 10.231 89,5%*

Subtotal Health Professionals 3.732 4.338 2.746 617 11.433 63,2%

High level Health management workers/Skilled

administrative staff.9 37 63 3 112 0,6%

Mid-level Health management workers/Skilled

administrative staff.239 464 415 24 1.142 6,3%

Health management workers/Administrative Assistant staff. 23 64 35 22 144 0,8%

Other health support staff 1.862 2.676 1.623 358 6.519 36,0%

Grand Total 5.617 7.078 4.404 997 18.096 100,0%

* 89.5% of the health professionals were mid-level health professionals at the primary health care level

Grand TotalUrban

Health

Centre

Rural

Health

Centre

Type I

Rural

Health

Centre

Type II

Professional CategoriesHealth

Post

Primary Health Care Workforce Distribution by Health Centre Type, National

Health Service, Mozambique, 2016 (2)


MISAU

Primary Health Care Workforce Ratio, National Health Service, Mozambique, 2016

Total Ratio Per Primary Health

Facility

Ratio Per doctor

Ratio per Non Phycisian clinicians

Primary Health Facility

1530

Doctor 269 0,2

Non Physician clinicians

3345 2,2 12,4

Midwifery 2979 1,9 11,1 0,9

Nurses 2685 1,8 10 0,8

1412/7/2017


MISAU

• Antenatal and post natal consultations (incluing ART/B+,

Intermittent Preventive treatment of Malaria).• Prescription and apply non-definitive Family Planning Methods

(oral and injection contraceptives...).• Delivery of pregnant women and care to new borns.

Competencies Cadre

• Mid-level Midwife

• Mid-level Environmentand Public Health

Technician


• Mid-level Nutritiontechnician


• Planning and implementation of educational programes in the

community for health promotion and dissemination of preventativemeasures of HIV-SIDA and other endemic diseases.

• Implementation of the national programme on immunization• Promotion of environment health interventions.

• Nutritional promotion for healthy child development: exclusive

breast feeding and supplementary feeding.• Promotion of local food production and consumption of required

food according to endemic disease (TB and AIDS).15

Skill mix for the Implementation of Primary Health Care Package-Preventive Interventions


MISAU

• Delivery of obstetric care.

• Diagnostic and treatment of hypovolemic shock before transfert of patient.

Competencies Cadre


• Mid-level paramedicalpracticioners


• Evaluation, classification and treatment of most frequent child

diseases according to IMCI protocols and transfert whennecessary.

• Diagnostic and treatment of pediatric HIV.

16

Skill mix for the Implementation of Primary Health CarePackage- Curative Interventions

• Diagnostic and treatment of more commun diseases:

pneumonia, diarrheia, acute malnutrition aguda, Malaria, TB,HIV.

• Little surgery (treatment and/or stitches of superficial wounds,abcess drainage, stitches removal, extraction of foreign bodies,

etc.).

• Mid-level Nurse

• Mid-level paramedicalpracticioners


MISAU

Key examples of increased health services coverage (1)Outpatient and Institutional Deliveries Distribution per Health Facility type, National Health Service, 2014

1712/7/2017

14%

86%

0%

25%

50%

75%

100%

Hospitais Centros de Saúde

Outpatient

21%

[VALUE]

Hospitais Centros de Saúde

DELIVERIES

Hospitais

Centros de

Saúde


MISAU

Key examples of increased health services coverage (2)HIV Counceling and Testing per Activity Sector and Province, 1st

Semester 2017


MISAU

Key examples of increased health services coverage (3)Evolution of Number on Health Facilities providing ART, 2003 - 1st

semester 2017


MISAU

Key examples of increased health services coverage (4)Coverage and number of Patients on ART, 2003 -1º Sem 2017


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Key examples of increased health services coverage (4)Evolution of Pediatric TB cases notification,NHS, 2010-2016

34493214

36893890

5776

6726

9254

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

2010 2011 2012 2013 2014 2015 2016

Nú

mero

de c

aso

s n

oti

ficad

os

PEDIATRIC TB


MISAU

COMMUNITY HEALTH WORKERS

12/7/2017

22


MISAU

� Revitalization of community health workers programme in 2010

� To provide health care to communitinities of 500 to 2000 inhabitants in a distance of 8 to 25 Km of the health center;

�20% limited curative care and treatment;

�80% preventive and health promotion activities.

Community Health Worker Programme (1)


MISAU� Revision of CHW’s profile and introduction of new community –based

interventions in 2014

o Delivery of modern methods of family planning

o Prevention of of post-partum haemorragy

o Supplement of Vitamin A for children 6-59 months old

o Treatment adherence to HAART, PMTCT and TB

o Malaria Diagnosis and treatment

o 3.380 CHWs trained in 2015 and 2016

Community Health Worker Programme (2)


MISAU

Evolution of CHWs’ activities, 2015-2016 (1)

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Maláriaconfirmada

Malária Clínica Diarreia Pneumonia MaláriaConfirmada

Malária Clínica Diarreia

Diagnóstico de casos (2meses -5anos) Diagnóstico de caso ( ≥ 5anos)

Diagnoses of Malaria, Diarrhoea, Respiratory Infections

2015

2016


MISAU

Evolution of CHWs’ activities, 2015-2016 (2)

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

RN (0-28dias)

Vacinaçãoincompleta

CPN CPP PF DAG, graveou mod

Sinal geralde perigo

Transfer to Health Facilities

2015

2016


MISAU

Redution of Health Unit pressure

Potential Complementarity of CHWs

651316

(22%)

2318628

(78%)

Malaria cases 0-4 anos

APE's US's

524606

(17%)

2649125

(83%)

Malaria cases >5 anos

APE's US's


MISAU

Family Planing

Potential Complementarity of CHWs

597363

(94%)

757145

(97%)

38429 (6%)

21475 (3%)

0

100000

200000

300000

400000

500000

600000

700000

800000

900000

Utentes que escolheram

Pílulas

Utentes que escolheram

Depo

US's APES

%

Contribuição dos APEs no PF

34

269

353

255

75 66 27 22 6 33

148

66

128

58

54 5692

38 6944

Maternal Deaths reported by The Health Information System

2016

MM reportadas APEs MM reportadas US's


MISAU

1. The ministerial decree describes the skill mix needed for the implementation of primaryhealth care services

• However, due to the limited number of mid-level medical practitioners, strategies toincrease health interventions coverage were:

� Task-shifting to mid-level nurses and mid-level midwives who are the second mostrepresented category in primary health care

� Increase of Mid-level midwives competencies scope, implementing a wide range ofinterventions from maternal and neonatal to adolescent care

� Increase of Community Health Workers competencies to widen the range of primaryhealth care services offered to the population

2. Training of more mid-level clinicians is necessary to reduce the workload of mid-levelmidwives 29

Final Considerations


MISAU

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achieving effective implementation of new roles in primary care ... · misau: o nosso maior valor...

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