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Mozambique is home to some 26.5 million inhabitants. It is a young population with a median age just over 17 years, largely due to nearly two decades of civil war spanning the mid-1970s through the 1990s. UNAIDS estimates for 2016 indicate that the HIV prevalence rate among adults is 12.2 percent, with about 1.8 million people currently living with HIV or AIDS — including some 13,000 children newly infected with HIV through mother-to-child transmission.
Regional economic developments and employment opportunities are currently expanding, resulting in more migration, more disposable income, a disintegrating family structure, and an increase in the commercial sex industry. Collectively, these factors are compounding infection rates, particularly because the country’s doctor-patient ratio is just 0.04 per 1,000 people.
Mozambique’s health system is further burdened by high risk of infectious diseases, including bacterial and protozoal diarrhea, hepatitis A, and typhoid fever, as well as vector-borne diseases such as malaria and dengue fever.
With support from the US President’s Emergency Plan for AIDS Relief (PEPFAR) and various US Government funding agencies in country, the American International Health Alliance (AIHA) manages capacity building initiatives in Mozambique through our HRSA-supported HIV/AIDS Twinning Center Program through our regional office for Southern Africa based in Pretoria, South Africa.
Click here for a printable overview of our work in Mozambique.
Centro de Aprendizagem em Saude Sexual Reproductiva (AMODEFA) / Children’s Place International
(2016 – Present)
The overarching goal of this partnership is to increase the percentage of Mozambican families that have informed their HIV-positive children and adolescents of their HIV status.
In early 2016, AIHA launched a partnership linking the Associação Moçambicana Para o Desenvolvimento da Familia (AMODEFA) with the Chicago-based Children’s Place International (CPI). Later, the University of Michigan School of Public Health (UM) joined the partnership to provide additional technical assistance and support. The overarching goal of this partnership is to increase the percentage of Mozambican families that have informed their HIV-positive children and adolescents of their HIV status.
Although research indicates that when adolescents living with HIV
do not know their status, they are less likely to adhere to treatment
and more likely to engage in high-risk behaviors, PEPFAR’s 2017 Mozambique Operational Plan estimated that only 58 percent of this population were aware that they were HIV-positive, with just 41 percent of these on ART.
AIHA partners conducted a needs assessment at the onset of the
project, which revealed that caregivers and health workers alike
reported a cultural norm of disclosing HIV status to a perinatally-infected adolescent between the ages of 15-19, well beyond the
average age of sexual debut. This, along with other assessment results, helped inform development of a theory-based, evidence-informed adolescent disclosure intervention called N’tiyiso, which means “truth” in Changana, a local language.
Designed to be delivered by community health workers to parents and caregivers of adolescents between the ages of 10 and 19 who are living with HIV yet do not currently know their status, N’tiyiso is a “home-grown” intervention. A collaborative team of community-based HIV service providers in Mozambique and experts from the US partner institutions used participatory methods that allowed for equitable input from all parties. The result is a 9-session intervention that utilizes a developmentally and culturally appropriate framework to address the pre-disclosure, disclosure, and post-disclosure needs of families with adolescents who are living with HIV.
N’tiyiso features a manual and accompanying implementation resources that provide step-by-step guidance to support
community health workers as they deliver the package of nine structured, one-on-one sessions first to parents or caregivers of adolescents living with HIV, and — once disclosure occurs — to both caregivers and the adolescent.
N’tiyiso utilizes a trauma-informed, empowerment-based participatory approach that focuses on the entire family unit and is integrated into existing systems of care for families impacted by HIV. The intervention package includes a user-friendly facilitators manual, as well as supplementary materials for parents, adolescents, and the healthcare providers who are delivering the intervention. A detailed implementation manual to assist sites in adopting and executing this intervention is currently under development.
When AIHA launched this partnership, there were no existing evidence-based interventions addressing primary HIV
disclosure to adolescents. Partners therefore developed N’tiyiso through an iterative, evidence-informed process to maximize effectiveness and cultural appropriateness. Given the lack of comparable existing interventions, partners conducted a small pilot from March to July 2017, delivering the intervention to 10 families in Maputo to assess feasibility and acceptability of this novel adolescent disclosure project. Outcome data were collected using a mixed-methods (qualitative and quantitative) evaluation to assess feasibility and acceptability of the intervention and gauge its potential impact.
Evaluation results demonstrated that the N’tiyiso intervention is both feasible to implement using community-based health workers and highly acceptable among the families who participated. Families reported increased caregiver knowledge, increased motivation to disclose, and increases in multiple health-promoting behaviors among participants, including increased adherence to ART and increased utilization of HIV medical care and support services. Of the 10 families who participated in the pilot, nine caregivers successfully disclosed HIV status to their adolescents, while one family decided to work toward disclosure in the next year and continues to receive support.
Intervention facilitators and participants reported no unintended negative effects and families provided testimonials of how the intervention not only provided them with the information, motivation, and skills to disclose, but also positively affected their families in terms of communication of HIV status and adherence to ART. Families overwhelmingly asked for the intervention to continue so that other families and adolescents could be similarly supported.
Partners analyzed the evaluation data and identified areas that would benefit from modifications, as well as needs for additional new materials, including an implementation manual, educational brochures, and promotional materials, prior to scaling up the intervention and rolling it out to additional regions.
Partnership to Strengthen Social Work Training to Improve OVC Care and Support
(currently under development)
USAID is supporting this new Twinning Center partnership, which will initially focus on developing in-service training courses to improve the knowledge and skills of social workers who already manage programs local social welfare support programs. It will also support the Ministry of Health’s efforts to decentralize all social work training courses.
HIV/AIDS poses a significant threat to children and young adults in Mozambique, which is home to more than 1.6 million orphans — the equivalent of roughly 16 percent of the country’s child population. More than 600,000 of these children were orphaned due to HIV, and AIDS is a major cause of child mortality. Regardless of cause, however, orphans and other vulnerable children face great difficulty accessing essential needs and services, including healthcare, food,
education, financial and legal support, and psychosocial care. As they grow older, they have limited means of income generation and are more likely to engage in risky or harmful behaviors, such as substance abuse, commercial sex work, and early marriage as a way to survive or, in some cases, support other members of their households.
Having access to a strong social support network can make a world of difference for Mozambique’s vulnerable children, but formal training for social workers that had previously been coordinated by the Ministry of Health and the National Health Institute ceased in 2004. In 2012, the Ministry of Education Reform Program for Professional Training Unity (PIREP) launched a new curriculum and resumed trainings. Unfortunately, this new cadre of trained social workers experienced marked delays — sometimes as long one year — receiving their certifications. Without official certification, they cannot be integrated into the Ministry of Women and Social Action’s remuneration categories and often turn to a different field that has little compatibility with social work.
In response, the Ministry is decentralizing all social work training courses and AIHA is working with closely with local stakeholders, including the Instituto de Ciencias de Saude and the Universidade Eduardo Mondlane to develop district-and provincial-level capacity to implement these changes.
In 2017, AIHA launched a partnership linking a team of social work experts from Tanzania and the Midwest AIDS Training and Education Center at the University of Illinois-Chicago with the Ministry of Gender, Children and Social Action (MGCAS) in Sofala Province. The US and Tanzanian partners shared information about their experience developing the Para Social Worker (PSW) training program in Tanzania, while MGCAS representatives shared information and organized site visits to help the partners better understand the social service delivery context in Sofala. Together,
partners designed a 5-day PSW training program for the province, delivering it to 27 social welfare technicians and officials from Sofala’s 13 district offices in Sofala Province. In addition, the US and Tanzanian partners revised, updated, and adapted the full 9-month PSW training program based on the version they developed and successfully implemented in Tanzania and shared the materials with MGCAS and the 27 individuals trained in the short course.
To promote program sustainability, AIHA is currently engaging with other implementing partners in Mozambique to share the PSW training materials and expand the reach of this vital community-based cadre throughout the country.
Mozambican National Nursing Association (ANEMO) / African Palliative Care Association
(2006 – 2008)
This south-south partnership focused on building the institutional capacity of ANEMO, strengthening its capacity as a member organization to help improve HIV-related nursing care throughout Mozambique.
The Associação Nacional dos Enfermeiros de Moçambique (ANEMO) — the Mozambican National Nurses Association — collaborated with the African Palliative Care Association (APCA) based in Kampala, Uganda, to strengthen ANEMO’s expertise and capacity to implement, monitor, and evaluate programs that mitigate the spread of HIV and improve the ability of nurses in Mozambique to provide quality patient care. This south-south partnership graduated from the HIV/AIDS Twinning Center’s technical assistance program in December 2008.
The overall goal of the partnership was to strengthen ANEMO’s human and institutional capacity to effectively contribute to the fight against HIV/AIDS in Mozambique by developing its organizational capacity.
At the partnership’s close, AIHA reported that the ANEMO/APCA alliance exceeded its target results for all indicators, training 196 individuals in HIV/AIDS policy development and providing related technical assistance to 24 local organizations. Partners also trained 181 people in HIV/AIDS institutional capacity building and provided related technical assistance to 20 local organizations.
Partners jointly reviewed ANEMO’s governance structure, including the existing councils, and identified areas of improvement at both the governance and secretarial level. Human resource and financial policies were also reviewed and recommendations were given to best serve ANEMO’s needs. A new governance structure was developed, which allowed for easier operating procedures for ANEMO. This allowed for the beginning of the strategic planning meetings and a clear vision and mission for ANEMO. During the partnership, partners jointly ratified ANEMO’s constitution, translated it into Portuguese, and presented it to ANEMO’s board.
Partners conducted strategic planning workshop for ANEMO board members, which assisted Board members and ANEMO staff to better understand the organization’s strategic direction. Additionally, it allowed ANEMO to implement objectives, measure the Board’s competencies, and to better understand the organization’s overall structure. Strategic planning workshops were also conducted for ANEMO’s provincial members and the General Assembly, to determine how to best execute ANEMO’s activities to maximize the outcomes for ongoing and future activities.
Throughout the course of the partnership, partners planned and conducted professional exchanges and study tours to learn about palliative care initiatives in Uganda. ANEMO representatives gained practical exposure to palliative care delivery services through home-based care to integrate this within trainings offered in Mozambique. While in Uganda, partners visited palliative care associations and hospices to learn about activities that could be adapted and mirrored in their own settings.
In accordance with ANEMO’s objective of expanding its services beyond Maputo, partners conducted monitoring and capacity-building visits to provincial delegations to provide support to local authorities and strengthen membership recruitment. They implemented trainings of provincial trainers on various topics related to home-based care, including technical support, WHO self-awareness checklists, and the development of a national action plan for ANEMO.
Partners identified strategies to improve access to essential pain medicines in Mozambique. They jointly reviewed draft strategies, carried-out assessment of contributing factors to the current opioids situation in Mozambique, identified reasons for unavailability and/or lack of accessibility of opioids in Mozambique, identified possible solutions to roll-out barriers, and potential funding sources. They also formed three groups to examine the current status of the WHO pillars for a palliative care program — policy, education, and training — as well as drug availability. Task force members drafted and finalized an action plan, which was shared with the Mozambican Ministry of Health and development partners.
With the overall goal of increasing the sustainability of ANEMO, the partners developed clear strategies to increase the organization’s visibility throughout Mozambique. Meetings were conducted with ANEMO staff, including those in the provinces, to determine the best methods of successfully rolling out effective communication messages. An ANEMO newsletter was developed, which assisted with bolstering membership. Partners also hired a consultant to begin work on the official ANEMO Web site. At the conclusion of the partnership, the site was operational, allowing for increased communication between ANEMO and the organizations with which it partners.
As this partnership with APCA was approaching its end in late 2008, AIHA launched a second partnership with ANEMO, pairing the organization with St. Luke’s Hospital School of Nursing at Moravian Collage in Pennsylvania.
Namaacha Health Center and Esperanza-Beluluane VCT Center / University of California – San Francisco School of Nursing
(2006 – 2010)
Partners successfully implemented “prevention with positives” programs in two distinct community-based settings: a healthcare clinic and a VCT and peer support center. They also expanded these successful prevention services to Mozambique’s Sofala and Zambezia provinces.
As ARV medicines become more widely available in Mozambique, people living with HIV are living longer and feeling healthier. This necessitates the expansion of prevention messages beyond the traditional target of uninfected individuals.
In 2006, AIHA established a partnership linking Namaacha Health Center and Esperanza-Beluluane Voluntary Counseling and Testing Center with the University of California – San Francisco School of Nursing to implement clinic- and community-based prevention messages that target people who are living with HIV. This partnership graduated from AIHA’s HIV/AIDS Twinning Center technical assistance program in 2010.
The objective of the “prevention with positives” programs implemented by partners was to prevent re-infection and co-infection of HIV among those already living with the virus, as well as among sero-discordant couples.
Some of their key partnership activities included:
- Training healthcare workers to conduct short risk-reduction interventions with HIV-positive patients;
- Developing a provider-based prevention with positives intervention;
- Developing a client-led prevention with positives intervention; and
- Expanding interventions to Mozambique’s Sofala and Zambezia provinces.
Partners also developed a training curriculum and conducted a series of professional exchanges, as well as secured approval of a set of monitoring and evaluation instruments from the Mozambique Bioethics Committee.
Catholic University of Mozambique / University of Pittsburgh
(2006 – 2014)
Partners collaborated to support the Mozambican Ministry of Health’s goal of strengthening the healthcare workforce by providing in-service training in HIV/AIDS care to mid- and lower-level caregivers, as well as opening a model clinic that also serves as a practical training site. By 2013, this highly successful twinning partnership had sufficiently built the institutional and human resource capacity at Catholic University’s campus in Beira to allow AIHA to graduate the University of Pittsburgh and continue providing direct funding and support for the Mozambican partner’s medical education and treatment and care activities through the fall of 2014.
Mozambique faces a severe shortage of human resources for health that has long been hindering its ability to rapidly scale up efforts to provide ART and other essential treatment and care services to PLHIV. Adding to the complexity of the situation is that fact that some 17 percent of the public healthcare workforce is also living with HIV and in need of care themselves.
Mozambique’s Ministry of Health recognizes the need to train additional healthcare workers and has been targeting in-service training, particularly for mid- and lower-level healthcare workers, as a key component of its national HIV/AIDS Strategic Plan.
In support of this initiative, in 2006 AIHA launched a twinning partnership linking Catholic University of Mozambique with the University of Pittsburgh in Pennsylvania. The overall goal of this partnership was to increase the availability of quality HIV services in Mozambique’s Sofala Province, with specific objectives to expand the number of healthcare workers and to create a model clinic that provides high quality HIV-related treatment and care services while at the same time serving as a clinical training site for students and healthcare professionals.
In June 2009, partners opened the São Lucas Health Center at Catholic University of Mozambique’s campus in Beira. Since then, staff have treated more than 50,000 patients, averaging about 1,200 consultations each month. Between October 2013 and March 2014 alone, São Lucas staff provided counseling and testing services to an average of 458 patients each month, enrolling 42 in pre-ART care and 36 in ART monthly. São Lucas Health Center is currently tracking treatment progress via the ICAP ART reporting database.
Partners also launched a training program for Agentes de Medicinas and medical students, serving as a clinical rotation site focusing on quality HIV care and patient management for six final year students, five penultimate year students, two clinical psychology students, and one hospital administration student in 2013. In addition, partners initiated mandatory rural site visits for 5th and 6th year medical students and are establishing clinical rotations to provide medical students the opportunity to gain critical patient care skills.
In the fall of 2013, AIHA transitioned this partnership to its sustainability phase by graduating the University of Pittsburgh and providing Catholic University of Mozambique with a subgrant to support daily activities during its final year of technical assistance. In the fall of 2014, Catholic University of Mozambique graduated from AIHA’s Twinning Center Program and now operates independently of AIHA support.
Mozambican National Nursing Association (ANEMO) / St. Luke’s Hospital School of Nursing at Moravian College
(2008 – 2012)
Partners collaborated to strengthen ANEMO as a professional association and increase membership programs related to HIV prevention, care, and treatment.
Associação Nacional dos Enfermeiros de Moçambique (ANEMO) — the National Association of Mozambican Nurses — collaborated with St. Luke’s Hospital School of Nursing at Moravian College in Pennsylvania between 2008 and 2012 to strengthen ANEMO’s capacity as the leading autonomous professional nursing association in the country.
The American Organization of Nurse Executives (AONE) also supported the work of this partnership, providing technical assistance on nursing leadership, including the implementation of the Mozambican Nursing Leadership Institute (MNLI).
Other key objectives of this partnership were to increase ANEMO’s organizational capacity and infrastructure and to elevate the association by strengthening the relationships, linkages, and visibility among both national and international stakeholders.
The successful completion of the year-long pilot MNLI program in 2010-2011 represented a major achievement of this partnership. Some 43 Mozambican nurses — along with a small number of international participants — graduated from MNLI in August 2011 and ANEMO faculty who had been trained through the process conducted the first training for the second, locally facilitated MNLI session.
In addition, both U.S. and Mozambican partners attended and co-facilitated workshops and presentations during ANEMO’s regional Inhambane general assembly meeting. They also completed development of ANEMO’s website and began disseminating quarterly newsletters to ANEMO members.
At the time of graduation from AIHA’s Twinning Center Program, ANEMO staff were planning to conduct local nursing events during International Nursing Week and National Nursing Week; facilitate two additional MNLI sessions; and participate in AONE’s annual meeting. They also planned to conduct health fairs and other community service projects to raise the profile of the nursing profession and help improve public health throughout the country.
Eduardo Mondlane University / University of California – Los Angeles
(2011 – 2014)
This university-to-university partnership focused on overall quality improvement at Eduardo Mondlane, with a specific emphasis on improving pediatric services.
Mozambique’s dearth of trained human resources for health is even more pronounced in clinical specialties, especially when it comes to pediatrics and neonatal care.
In response, AIHA launched a university-based partnership linking Edward Mondlane University and Maputo Central Hospital with the University of California Los Angeles (UCLA) School of Medicine in 2011. The overall goal of this partnership — which was graduated from AIHA’s Twinning Center Program in the fall of 2014 — was to improve quality of care at Maputo Central Hospital with a particular focus on pediatric services.
Key objectives were to improve newborn care and pediatric surgical care, as well as to strengthen the institution’s capacity to care for critically ill children.
To accomplish this, partners jointly assessed the hospital’s HIV services, including observations of the HIV clinic, HIV testing routine on the wards, initiation of ART on the wards, and PMTCT protocols.
Maputo Central Hospital staff also met with local HIV care leadership to determine where gaps exist, including linkages to HIV care for individuals who are newly diagnosed with HIV. Working closely with hospital and medical school leadership, the UCLA Global Health team supported both the clinical and
educational programs in pediatrics at Eduardo Mondlane University and Maputo Central Hospital, creating training programs for Mozambican clinicians working in newborn medicine, critical care pediatrics, transfusion medicine, infection control, and pediatric surgery.
Partners also facilitated a refresher training on hand hygiene and began curriculum development for a one-week training on infection control. In support of these efforts, AIHA established in 2013 a Knowledge Management Center (KMC) at the hospital’s Pediatrics Department to facilitate access to evidence-based medical resources as a way to strengthen education and training and improve quality of care.
Mozambique Open Architectures, Standards, and Information Systems (MOASIS) / JEMBI Maternal and Child Mortality Data Monitoring System
(2011 – 2014)
This south-south partnership worked to strengthen Mozambique’s access to international health resources through the correct use and implementation of e-health and health information systems.
From 2012 to 2014, partners at the Mozambique Open Architectures, Standards, and Information Systems (MOASIS) worked with the South Africa-based NGO JEMBI to strengthen Mozambique’s access to international health resources through the correct use and implementation of e-health and health information systems.
Key objectives of this partnership were to support JEMBI as a social enterprise and investigate sustainable models to grow the organization in the future. Partners also worked to build the organizational capacity of MOASIS, bolster performance of the Ministry of Health’s human resources development activities, and support collaboration of the principles with other key stakeholders.
One of the significant accomplishments of this partnership was the implementation of SIS Compact Stations, fully embedded stations complete with a touch screen micro-computer powered by open-source software that enables the function of approved applications. Data can be easily entered using a variety of means then transferred to the district, provincial, and central levels via email. This information is subsequently used to generate daily, weekly, or monthly reports from the SIS Compact Station that allow not only complex data analysis, but also building a reference and patient record system.
The SIS Compact Station prototypes were piloted at General Hospital of Jose Macamo and Mavalane, with eight prototypes of the u-Data Capture Device built; these were then successfully tested at rural health sites. In preparation for partnership graduation, members rolled out the SIS Compact Stations to 10 additional sites.
Together, partners worked on a strategic plan detailing concrete short- and long-term objectives for MOASIS. They worked together to develop the organizational capacity of MOASIS, drafting a business model, strengthening its ongoing ability to attract project-based funding, and creating a framework to sustain health information systems projects in partnership with the Mozambican Ministry of Health and other national stakeholders.
Eduardo Mondlane University / University of California at San Diego
(2011 – 2014)
Partners collaborated to improve trauma care training and practices through faculty and curriculum development.
AIHA launched a second partnership with Edward Mondlane University and Maputo Central Hospital in 2012, linking these institutions with the University of California San Diego (UCSD). The overall goal of this partnership, which was graduated from the Twinning Center Program in the fall of 2014, was to support the provision of quality trauma care throughout Mozambique by strengthening related training and certification courses.
To this end, partners collaborated to develop a postgraduate trauma education curriculum that conforms to international best practices while remaining responsive to the local care context.
They worked to make Maputo Central Hospital a national center of clinical excellence in trauma care, initiating discussions with a successful trauma training center in Ghana, as well as with the WHO Essential and Emergency Surgery Program Director, about adapting the WHO trauma training curriculum for the purposes of this project. They also identified key textbooks and other necessary training resources and worked to establish a trauma center at the hospital.
With support from the UCLA partners, the UCSD team successfully provided technical assistance to Edward Mondlane faculty, helping them to develop a basic framework for locally-delivered trauma course that integrated a broad range of resources drawn from UCSD, including training videos on treating injuries due to trauma and burns.
The UCSD team also supported efforts of Edward Mondlane University’s Department of Surgery to successfully achieve accreditation for its surgery training program under the College of Surgeons of East, Central, and Southern Africa (COSECSA). As accredited members, they now have access to training materials and instructors from neighboring countries with similar health systems and surgical training programs.
As this partnership moved closer to graduation from AIHA’s technical assistance program, the UCSD partners helped their Mozambican counterparts develop a plan describing the long-term vision of the trauma service and identifying other potential development partners. This approach included development of a national program to train other cadres of trauma care providers.