IGC Mozambique jointly hosted a workshop with the National Institute of Health on research into primary healthcare, and more specifically on how to generate evidence to support policymaking in the health sector.
This workshop included an opening speech by Eduardo Samo Gudo (Scientific Director, National Institute of Health), as well as presentations by Dr Laura Poswell (Executive Director, JPAL Africa) on lessons from JPAL on partnerships between researchers and government for evidence-based policymaking, Dr Marcos Vera Hernandez (University College London) on scientific research in the area of primary healthcare, Dr Damien de Walque (World Bank) on community-led interventions and the improvement of primary healthcare, Dr Sergio Chicube (National Institute of Health) on the evaluation of the implementation of the esential functions of the public health service at the district level, and Dr Sandra Sequeira (LSE and IGC) on the IGC project on management interventions at the clinic level to improve antenatal care in Mozambique. The detailed programme can be found below.
Eduardo Samo Gudo (National Health Institute, Ministry of Health of Mozambique) delivered the opening speech, welcoming the opportunity to discuss economic research on the management of the health system. He stressed that most of the research carried out by the Ministry is of a clinical nature, and expressed his hope that the workshop would result in more partnerships for research on aspects of health management in Mozambique.
Laura Poswell (Executive Director, JPAL South Africa) discussed ways to improve health worker productivity and attendance, and referred to a study conducted in India aimed at improving the attendance of health workers through performance pay incentives. This study showed that the problem is not the incentives themselves, but rather the way they are implemented: incentives can work to change modes of behaviour, but the specific design of how these incentives are delivered and administrated may be the obstacle. In this case, the relationship between the nurses and the members of staff responsible for monitoring attendance served to hinder any potential impact of increased worker attendance because the monitors were reluctant to deduct nurses’ pay. In a different intervention, an alternative approach to monitoring teachers’ attendance proved very successful: to request teachers to take pictures of themselves with their students twice during the school day, using cameras with a timestamp feature. Dr. Poswell highlighted that incentive programmes can work if administered effectively but that the design is key to ensure success.
Dr. Poswell also discussed the effect of community monitoring and community participation programmes that aim to improve health worker productivity and attendance, explaining that, generally, such programmes are not very effective. In contrast, career incentives at the recruitment stage can have a positive impact on worker productivity by selecting more productive health workers, as shown by a study conducted on recruiting and motivating community health assistants in Zambia.
Marcos Vera-Hernandez (UCL) emphasised the importance of child nutrition and its impact on a child’s development, especially during the early years. He explained that the causes of malnutrition are complex and diverse, and gave examples of deeply rooted ‘unhealthy norms’ that exist in parts of Africa, such as the idea that eggs are unhealthy for children to consume. Dr. Vera-Hernandez argued that intensive communication strategies are required in order to break these norms that have been passed down from generation to generation. He explained that home visits in Malawi seem to have promising and positive effects on changing norms and practices. He compares this to an alternative strategy using women’s groups; such groups for child and maternal health issues have been seen to work well in Nepal and India. This could be a more effective way to break norms, allowing for stronger collective action. However, as Dr. Vera-Hernandez mentions, the drawback of such a strategy is that it relies on women attending the group rather than the health worker making the home visit. He suggests that a study is needed to compare both approaches and their effectiveness, and that perhaps a combined approach should be introduced.
Dr. Vera-Hernandez also discussed health insurance as a way to build effective and responsive health systems, highlighting that the percentage of the population with health insurance is increasing in many parts of the world with a big push in the international community for greater health care coverage. He compares insurance-based and zero fee health systems, explaining that in the former, money follows the patient so that the patient is empowered and can choose which health facility to go to. In a zero-fee system, on the other hand, the money follows the facility and therefore the facility does not have an incentive to work hard to increase the number of patients utilising its services. The Colombian experience with universal health insurance shows positive results, demonstrating increases in curative and preventative care visits and a fall in health expenditure.
Damien de Walque (World Bank) discussed community-led interventions and the improvement of primary healthcare. He explained that one prominent idea to improve public service provision is to enhance beneficiary involvement, empowering users of public services. He compares the impact of two alternative interventions in Uganda that shared a similar package of process-based components aimed at enhancing beneficiary involvement. This included the facilitation of meetings between the provider and the user (health facilities and community groups) with the final outcome being a joint action plan identifying issues to be addressed and how to address them. The two different interventions were a ‘participation only’ and a ‘participation and information’ intervention where in the latter, quantitative information on health facilities and staff performance was disseminated as part of the process of agreeing on a joint action plan. The results showed that the ‘participation only’ intervention yielded no significant differences in outcomes, whereas the ‘participation and information’ intervention resulted in large and long run improvements in both service provision and health outcomes. Therefore, the results suggest that unless the community has access to objective information on staff performance, community involvement is not likely to have much of an impact. Dr. de Walque explains the results by describing the role of information as allowing clients to distinguish between the lack of effort of the provider (local level) and a lack of resources assigned to the facility (higher level). He explains that it addresses information asymmetries and allows for action plans to focus on activities actionable at the local level. He finds that the percentage of local actions is much higher in the joint action plans of those facilities receiving information.
Sérgio Chicumbe (INS – Ministry of Health) presented on a pilot to evaluate the performance of the health system in Mozambique in the delivery of its core functions at the district level. The pilot was based on the Essential Public Health Functions (EPHF) framework, which defines eleven core functions of national health systems. This approach was found to be helpful for identifying the core functions that present most scope for improvements at the level of each particular district. Furthermore, it promoted much more active participation by health staff members themselves in the evaluation process than is common in regular supervision visits carried out by the Ministry of Health. This was found to stimulate self-reflection of district-level health officials on their strong points, their weak points and opportunities for improvements.
Sandra Sequeira (LSE) presented on managing primary healthcare resources, and in particular scheduling medical appointments for ante-natal care (ANC) visits in Mozambique. Dr. Sequeira explained that universal access to health care and free maternal care raises the question of how to deal with large patient flows, particularly in the context of health care worker shortages. These forces can generate long queues and waiting times that carry significant costs, both from the demand side and the supply side. The demand for health care services can be directly impacted by long waiting times. Furthermore, when health workers have to operate with large queues of patients waiting outside, the resulting pressure can lead to a deterioration of the quality of the health services provided.
Dr. Sequeira presented a research project where a simple scheduling system for maternal care visits will be introduced at the clinics in the treatment group. The research is designed to test the impact of this low cost intervention in the management of patient flows on the quantity and quality of health care services demanded by patients and provided by health care workers.