Improving the management of the health system in Mozambique

Despite global efforts, we still see 289,000 maternal deaths and 2,762,592 preventable newborn deaths each year (UNICEF 2013). Antenatal care is a critical building block for maternal and newborn health care. Access to affordable, high quality antenatal care (ANC) offers the opportunity to inform women about potential danger signs to look for during their pregnancy, identify and treat illnesses such as malaria or tuberculosis, and promote healthy behaviours such as healthy nutrition and breastfeeding. With improvements to coverage in antenatal care, an estimated 160,000 newborn lives could be saved each year.

And yet, women still face significant barriers to consistent attendance of ante-natal care, particularly in low-income countries. In Mozambique, where our study takes place, while the vast majority (91%) of women do seek some antenatal care, only half of pregnant women receive the recommended four antenatal care visits. Even when women receive the recommended number of antenatal care visits, they do not always receive high quality care. In fact, only 43.6% of women receive the necessary 3 doses of intermittent preventative treatment for malaria. As of 2011, only 51% of HIV+ pregnant women were receiving treatment across Mozambique, and only 18.6% of HIV positive pregnant women were receiving care that ensures the prevention of mother to child transmission of HIV.

One of the key challenges in accessing ANC is the fact that it often requires waiting in long queues. In fact, according to survey data from Sub-Saharan Africa as a whole in 2012, 74% of individuals report that they have experienced very long wait times in public clinics. Like most developing countries, public health care in Mozambique is not scheduled with appointments. Instead, women wait in queues to receive care: they arrive early in the morning at clinics and may have to wait all day for services, without any guarantee that they will actually be seen that day. Queues may therefore explain low rates of completion of the recommended ANC schedule since mothers attending ANC likely have numerous other responsibilities -- the average woman in Mozambique has 5.6 children. Since ANC is often the first interaction a pregnant woman has with the health centre, the initial experience of waiting all day is likely to have significant negative effects later in time. Queues can not only reduce demand for ANC but they can also have significant negative effects on the quality of service delivery. If health providers have to see an overwhelming number of patients, they may neglect key procedures for diagnosing risky conditions during pregnancy when rushing to handle a large volume of patients. Furthermore, long lines and disgruntled patients waiting may lead to health workers becoming overstressed, which could lead to inefficient and disrespectful care. The perception of non-responsive care may weaken the relationship between patient and provider, leading mothers to be less likely to comply with medical advice and less likely to return for delivery in the facility.

This study tests the impact of an intervention that significantly reduces waiting time in access to antenatal care on the health outcomes of mothers and infants in Mozambique. In collaboration with the Institute of National Health, the National Directorate of Public Health and the Ministry of Health in Mozambique, we propose to test the impact of introducing a scheduling system that spreads patient attendance across the day and across the week in 100 public clinics in Mozambique. We will then assess the impact of introducing this scheduling system on demand for antenatal care, and on the quality of supply (specifically the number of essential procedures that occur during antenatal care and the incidence of disrespectful care). The results from this study can then motivate and inform the scale-up of the scheduling system to other clinics in Mozambique and to other types of primary health care services that they provide.