Partnership for HIV-Free Survival Community Demonstration Project in Gaza, Mozambique
Beginning in late 2013, the USAID ASSIST Project began to provide technical support for community-level improvement of elimination of mother-to-child transmission (EMTCT) services to the Ministry of Health of Mozambique as part of the PEPFAR-funded Partnership for HIV-Free Survival (PHFS). The project took place in Bilene District in Gaza, Province in three health centers (Licilo, Chissano and Incaia) and their associated catchment areas which included 15, 11 and 13 bairros (communities) respectively. The goal of the PHFS Community Demonstration Project was to contribute to EMTCT through increased community awareness, improved community-facility linkages, and increased access to services for pregnant women. The project focused on increasing the number of pregnant women identified by the community who sought antenatal care (ANC) at the health center and who were tested for HIV. This demonstration project employed the community health system strengthening model to improve the quality of PHFS services at the community level.
In each of the 39 bairros, bairro committees were formed of community group representatives whose responsibility it was to support activistas (community health workers) in their work, pass on health messages from the health center to the household level, collect data, follow up with clients, and discuss strategies for improving care.
The primary change that took place in each of these communities was the design of a new system for information and data exchange between existing community groups and the health facility through the coordinated activities of the bairro committees and the Health Committee. Since the nurses at the health center were unable to travel to each bairro due to workload, the meetings of the Health Committee provided a forum through which to review the pregnant women identified in each community, compare the list of identified women with those who went to the health center for ANC, and discuss strategies to encourage pregnant women to come to ANC. The Health Committee also served as the mechanism for the nurse to share critical health messages for community members. The nurse at each health center, district staff, and ASSIST staff provided training on key health messages around the importance of ANC for pregnant women and treatment for HIV-positive pregnant women to prevent transmission to their children. Health Committee members brought this information to bairro committee members who in turn brought it to their respective community group members and their families.
The results from the three health centers were mixed. In Licilo, 95 community groups identified 896 women between March 2014 and February 2015. They increased the percent of community-identified pregnant women receiving ANC in the same month from 36% in March 2014 to 97% in February 2015. Additional data collection in Licilo Health Center revealed that they also increased the percentage of women coming to ANC earlier in their pregnancy. Chissano identified 715 pregnant women between June 2014 and February 2015, but the increase in pregnant women attending ANC overwhelmed the health center. The percent of identified pregnant women receiving ANC in the same month fell from 87% in July 2014 to 57% in February 2015. In Incaia, 77 community groups identified 409 pregnant women between June 2014 and February 2015. Inconsistent data made a baseline determination difficult, but they ended in February 2015 with 99% of identified women receiving ANC in the same month. All three sites had consistently high rates of HIV testing and getting women found to be HIV-positive on treatment.
The community health system strengthening model was adapted successfully to the Mozambique context, eventually creating excitement in community groups around helping support the work of health facility staff and activistas and resulted in more pregnant women being connected with care earlier in pregnancy. While it is difficult to predict the sustainability of these efforts, the ease with which pre-existing community groups were able to incorporate the improvement approach and health issues into their ongoing meetings suggests the groundwork for a sustained approach. The experience of Chissano health center points to the importance of linking community-level demand generation with facility-level improvement work to accommodate the demand.