Mozambique: Mozambique Mobile Clinic Project

Project Goal:

• Improve quality of life and provide access to health services, particularly maternal and child health and antiretroviral treatment to people living with HIV/ AIDS, tuberculosis and other diseases.
• Provide access to health services in remote areas of the province of Zambézia, Mozambique.
• Reinforce the expansion of services for care and treatment of HIV, initiated by the Provincial Health Authority of Zambézia.
• Provide clinical support and technical assistance to temporary peripheral health units with the potential of implementing antiretroviral treatment in the near future.

Photo: Mobile Clinic presence at the Ronda Resettlement Center

Project Objectives:
 
Increase the number of people with access to health services, as well as the number of patients enrolled in HIV care and treatment services in areas supported

Summary of RMF/MMI-sponsored activities carried out during the reporting period under each project objective:

During the first quarter of 2015, the Mobile Clinic continued implementation of the strategy presented in January 2012. The main activities of the Mobile Clinic include provision of:

1. Primary health care to the populations of Furquia and Mbawa;
2. HIV diagnostic, care and treatment services including integrated TB/HIV services for co-infected patients;
3. Antenatal health services and universal ART to pregnant and lactating women;
4. Health care services and early diagnosis of HIV in infants born to HIV positive women;
5. Diagnostic services for TB and TB/HIV co-infected patients’ treatment and care;
6. Transport of extra stock of medicine and medical supplies in preparation for potential flooding (and subsequent HF isolation) during the rainy season.

During this reporting period, specifically between the dates of January 12^th to March 28^th, 2015, Zambézia province was impacted severely by massive flooding/heavy rains, which caused disruptions in technical assistance/service delivery in FGH-supported districts. Based on official information from the Operational Center for Emergencies (COE) received on March 4^th, approximately 96,000 persons were temporarily displaced province-wide, approximately 7,013 of which resided in Namacurra district.   The Mobile Clinic team, in collaboration with the FGH multidisciplinary team based in the Namacurra, provided technical assistance and support to the DDS/DPS to address the following essential service/support areas:

• Supply chain support (essential medication and relief item transport)
• Patient evacuations
• Direct clinical assistance for displaced persons residing temporarily in accommodation/ displaced person camps in Furquia (Ronda camp) and in Birigodo (Mbawa area)
• Information, education, and communication (IEC) activities (HIV prevention, GBV, diarrhea, malaria, etc.) in all the displaced person camps Furquia and Mbawa.

The Mobile Clinic team provided technical assistance to prevent the disruption of clinical HIV services (care and treatment) among displaced persons. 

Number served/number of direct project beneficiaries (for example, average number treated per day or month and if possible, per health condition):

8,242 people benefited directly from activities implemented by the Mobile Clinic during this reporting period. After DPS orientation, all the clinical activities for patient care and treatment provided by the Mobile Clinic staff are fully integrated in the Health Facility and are registered jointly with the clinical activities performed by the HF staff.

Results and/or accomplishments achieved during this reporting period:

The main results achieved this reporting period were related to peripheral health unit support:
 

 
Following DPS orientation, all the clinical activities for patient care and treatment provided by the Mobile Clinic staff are fully integrated into the Health Facility (HF) and are registered jointly with the clinical activities performed by the HF staff.
 

Provision of primary health services to Furquia & Mbawa communities:

The Mobile Clinic team continues to strengthen the technical and logistical capacities of local personnel through clinical mentoring activities and on-the-job training. In addition to daily lectures given on disease prevention, community members benefit from health counseling and testing in screening rooms where, on a voluntary basis, individuals can be screened for malaria, TB, STI, HIV, etc. The MC team also provides management support and aids in medication (ARV’s, cotrimoxazole, isoniazid, ferrous salt, mebendazole, etc.) and blood sample transport.
During the quarter, supervision activities and TA in the areas of C&T, Pharmacy and MCH continued.
During this period Mobile Clinic and FGH teams were helping health staff from the health facility to attend displaced people in the Ronda Camp.
 
Furquia Health Facility:
 
There were no changes in the health facility staff; all of them had been oriented in previous quarters and are working in their routine areas with the support of the Mobile Clinic team and clinical mentoring.
 
With the integration of the new FGH District Community Health Supervisor (PEPFAR supported), community activities increased during this period, and new GAACs were constituted during this quarter in Furquia. 7 active GAACs are currently in Furquia with a total of 18 patients.
 
Malaria prevention, diagnostics and treatment were prioritized during the rainy season (when malaria cases increase).
 
Information, education, and communication (IEC) activities (HIV prevention, GBV, diarrhea, malaria, etc.) were disseminated in the displaced camps of Furquia and Mbawa areas.
 
HIV testing is also implemented in the vaccination sector following the recommended strategy of testing at every entry point to the health unit.
 
Current staff working in the health unit include:

• 1 General Medical Technician
• 1 Maternal Child Health Nurse (mid-level)
• 1 General Nurse (mid-level)
• 1 Preventive Medicine Technician
• 1 Lab Technician
• 1 Elementary Nurse
• 2 Health Counselors
• 1 Cleaner

 Continuous coordination is maintained with the 3 existing Health Councils (Conselhos de Saude) with 4 monthly meetings held among Health Councils and health facility staff, each averaging 25 participants (Traditional Birth Attendants, Community Leaders, DOT Volunteers, Health Council Volunteers, Polyvalent Health Agents, Religious Leaders, FGH District Community Health Officer, and other volunteers from Ogumaniha and other partners).
Overall, there are 7 support groups helping in Furquia, as follows:

• Home Based Care: Visits for home base care
• Mothers to Mothers groups: Nutritional education, demonstrations, etc.
• Traditional Birth Attendants: Pregnant women referral to Health Unit, information in the community about HIV test, breastfeeding, nutrition, family planning, PMTCT, etc.
• Traditional Healers: Referral of TB suspect patients to Health Unit, counseling and sensitization of chronic patients to do HIV testing,
• DOTs Volunteers: Sputum sample collection of suspected patients, follow up of TB patients in the community and referrals to Health Unit for HIV counseling and testing.
• ETC (Epidemic Total Control – a partnership between FDC and ADP since October 2014) Volunteers that help in home visits and consented case finding, HIV counseling and testing in the community, case referral to Health Unit, ART adherence reinforcing.   
• APES (Polyvalent Elementary Health Agent): Health promotion, primary health care and some consented case finding.

During the reporting period, weekly meetings (4 per month) were held with every support group (with an average of 7 participants per group); Mobile Clinic Counselors jointly with HF staff participate in those meetings.
Ogumaniha volunteers are still providing support in the identification and referral of malnourished children and in the preparation of enriched foods.
 

Photo: Mbawa Health Center

Mbawa Health Facility:
 
There were no changes in the health facility staff; all of them had been oriented in previous quarters and are working in their routine areas with the support of the Mobile Clinic and clinical mentoring teams.
 
Due to heavy flooding, numerous roads and bridges were impassable, which significantly limited mentoring activities as well as clinical, laboratory, and pharmacy/supply chain support and caused sample transport limitations. From 12 January to 27 February, the road to Mbawa was not passable and consequently the Mobile Clinic team was not able to provide any assistance to this health facility with the exception of one week where one motorbike was able to pass and supply some essential drugs and relief items. 
 
20 Active GAACs exist in Mbawa with a total of 56 patients. 
 
As in Furquia, malaria prevention, diagnostics and treatment were prioritized during the rainy season (when malaria cases increase).
 
HIV testing in the vaccination sector and other entry points within the health facility was implemented following the recommended strategy of “massive” testing from the DPS.
 
Current staff in the health unit:

• 1 Maternal Child Health Nurse (mid-level)
• 1 General Nurse (mid-level)
• 1 Preventive Medicine Technician
• 1 Health Counselor
• 1 Cleaner 

There are 4 existing Health Councils (Conselhos de Saude), in Mbawa sede, Tatioi, Maroda and Machawa similar to Furquia, for reinforcement of the community clinical linkages, and they meet four times per month.  During the quarter, activities focused on coordination of monthly meetings held among the Health Councils and Health facility staff (and participants are Traditional Birth Attendants, Community Leaders, DOTs Volunteers, Health Council Volunteers, APEs, Religious Leaders, FGH District Community Health Officer and Health Technicians) with an average number of 60 participants in Mbawa sede and Taioi, and 25 participants in Maroda and Machawa. Consented case finding is supported by 4 ETC volunteers and 3 DOTS volunteers who participate in the weekly adherence committee (Comite de Adesão-CAD).

Technical support provided by the Mobile Clinic team includes:

• Reinforcement of diagnostic and clinical management of TB (pediatric)
• Screening/assessment of malnutrition
• Creation of GAACs
• Refresher sessions for PCR sample collection, registration and sample transport
• Clinical mentoring
• Data registration and clinical patient record data collection
• Clinical patient record organization
• Pharmacy inventory
• Update and organization of individual patient forms for receiving ARVs (FILAS
• Update of lost-to-follow-up in the data base and lists for active case finding
• Refresher sessions on clinical protocols and MOH HIV/AIDS clinical orientations
• Job aids and algorithms distributed. 

Health care services and ART (PEPFAR supported):

• 135 new HIV patients were enrolled in clinical care during this quarter.
• From 448 HIV-positive persons receiving care during the reporting period eligible for CTZ prophylaxis, 364 received CTZ prophylaxis (81.2%)
• 134 individuals with advanced HIV infection were newly enrolled on ART; 116 adults (>15 years), 18 children (0-14 years old)
• New care patients who were screened for STIs at the last visit during the reporting period: 103 (76.2%)
• 563 HIV-positive patients were screened/ assessed for malnutrition; of them, 118 were clinically malnourished (21%).

NOTE: As a consequence of the floods and the subsequent isolation of Mbawa and high number of displaced people who were not able to come to Mbawa health unit, there is a general decrease in the number of beneficiaries reported this quarter compared to previous reports. On the contrary, the number of pregnant women and children receiving services is higher than the previous quarter. One possible explanation for this could be that more women and children remained in the displaced persons camp of Furquia (as they don´t have farms to work because they were destroyed) while men went out for other business.
Provision of Prenatal & PMTCT services (universal ART) for pregnant and lactating women:

• In the period under review, 710 pregnant women were registered at ANC service in the two health units, 387 in Furquia and 323 in Mbawa; 648 pregnant women received HIV counseling and testing with 70 positive results (10%).  Due to Option B+, 60 HIV+ pregnant women received ART during this period (86%). Unfortunately, MOH does not have longitudinal books to follow Pregnant Women in their clinic visit. ANC log books are organized by consultation, and for this reason we have some constraints to register patients properly if a pregnant patient does not receive counseling and testing in the first consultation and decides to test in the following month. In this case, the numerator might be overestimated and proportion will be more than 100%. The same happens if a positive woman does not initiate her prophylaxis in the same month.
• Efforts to strengthen ART adherence counseling and follow-up of female patients’ children in the CCR are on-going.

• Partner testing continue being reinforced through “palestras” (lectures) in the HF and communities for men to accompany their pregnant partners. During the period, 197 partners of pregnant women were tested, 23 (12%) being diagnosed HIV positive and referred for ART care and treatment.

• Health Facilities supported by the Mobile Clinic now count on Mother-to-Mother support groups to improve adherence. Currently women meet once per month to share experiences and receive orientation from the MCH nurse and trained TBAs. After the meeting, HIV positive women join the larger group to participate in the demonstration of nutritional food preparation for children. During this quarter, the subjects discussed included:

• HIV Counseling & Testing
• Living Positively with HIV
• Transmission of HIV from pregnant women to their babies (antenatal)
• Postnatal transmission of HIV (breastfeeding)
• Importance of preventing mother-to-child transmission, CPN/ETV, Child-at-Risk clinic, and follow-up of ART
• HIV Prevention
• Malaria and diarrhea prevention facing the raining season

Provision of health care services and early HIV diagnosis in infants born to HIV+ women:

• During this quarter, 19 children were enrolled in the Child-At-Risk Clinic (CCR) in Furquia and 14 in Mbawa.
• During the reporting period, 41 pediatric patients benefited from virological testing with 19 positive results (46.3%) reported. Rapid testing was offered to 21 children, 2 were positive (9.5%).

Voluntary Counseling and Testing – Children:

• During the quarter, 78 children were counseled and tested with 36 (47%) HIV+ results. 26 of them initiated ART (74%).

Provide diagnostic services for TB care and treatment:

• During the quarter, 12 patients were enrolled into TB care and treatment in the two health units.
• All underwent counseling and testing for HIV, with 10 positive results (83.3%) During the quarter, all of these co-infected patients started antiretroviral treatment (100%)

Consented case finding (USAID and PEPFAR supported):
 
With the incorporation of the new District Community Health Officer, the community health activities were reactivated and the number of consented case finding increased during this quarter.
 
In the last quarter 218 defaulted patients (150 Furquia and 68 Mbawa) were visited and 197 (Furquia 150 and in Mbawa 47) were found (93.3%), of them 62 (42 in Furquia and 20 in Mbawa) returned for consultation (31.4%).
 
Home visits to priority groups (USAID and PEPFAR supported):
 
The arrival of the new District Community Health Officer increased the community activities and the number of visits for priority groups is much higher than in the previous period.  In order to improve adherence to the HIV care and treatment program, patients with low HIV care adherence, HIV exposed  children without PCR test, patients initiating ART and post-partum HIV positive women 168 (128 in Furquia and 40 in Mbawa) were visited and 133 found (79.1%).
 
As in previous reports, other groups like Traditional Birth Attendants, Traditional Healers, Home-Based Care Volunteers continue to provide information and health promotion among the community and refer pregnant women and other patients to the health units.

Success Stories
 

Furquia, Namacurra –Ronda Resettlement Center
January-March 2015
 
TB/ HIV screening

Due to the extreme flooding throughout Zambézia province this rainy season, twenty-year-old Costa Manuel Soares, a young man from Furquia in Namacurra district, is currently residing in the Ronda resettlement center. Costa was identified by the Mobile Clinic team through their collaboration with local leaders working at the resettlement center in Ronda. He was in a critical health situation, complaining of a bad cough and weight loss for more than a month. Through the Mobile Clinic team assistance, Costa was tested and diagnosed with pulmonary tuberculosis (TB). As TB is often associated with HIV, the team also conducted an HIV test for Costa.

Costa during his consultation at the Mobile Clinic supporting the Ronda Resettlement Center

Costa recounts:
"I was very ill and unable to even walk to the bathroom, constantly coughing with mouth sores and total fatigue. With the support of DOT-C volunteers I was referred to the Mobile Clinic in the resettlement center, directly to the office of health counseling and testing. I received a consultation by the Tecnico, since my case was suggestive of TB, and he had to take a sample of my sputum. After the arrival of the results, it was concluded that I should immediately start the treatment of tuberculosis, but since TB is associated with HIV I also received an HIV test. It was positive. I did everything according to medical recommendations (for TB treatment), and two weeks later I started with anti-retroviral treatment (ART). Now I feel much better, since I can do some activity every day, just two months into treatment. My younger 5-year-old sister who lives with me is also taking preventive treatment with isoniazid to prevent TB. I also receive regular home visits from health activists, which makes me more secure. "

Patient awaits results of malaria rapid test; (upper right) Patient receives instructions for medication; (lower right) Patient accepts ART medication.
  
Follow-up of ART patients at Ronda Resettlement Center:

Tonito Pedro is a 33-year-old resident of Nante in Maganja da Costa district, the lowlands across the bank of the Licungo River. Tonito is living with HIV and has been supported for ART at the Nante Health Center since 2013. However, with recent flooding blocking access to Nante, much of the population was forced to take refuge in the town of Furquia. Tonito was among these community members stranded in Furquia, and he soon began to worry about his lack of access to ART. This was compounded by the fact that he had none of his hospital documents handy.

The timely intervention of the Mobile Clinic at the Ronda Resettlement Center in Furquia helped establish a flowchart for care of the displaced patients via lists containing the names of patients enrolled on ART services from surrounding health facilities for the rapid identification and monitoring thereof.

After taking part in health lectures given by the Mobile Clinic health counselors at the resettlement center, Tonito gave the following testimony:
"I found myself stranded at the farm on the banks of the Licungo River, where I cultivate my crops during most evenings. I realized the rising flow of the river, which ultimately led to floods, causing a roadblock to access the location of Nante in Maganja da Costa district. I had to take refuge to another side of the Licungo river bank, the location of Furquia, along with others. On our arrival we were directed to the Ronda Resettlement Center. After attending a lecture given by health personnel from the Mobile Clinic, I approached them and identified myself as a patient on ART. They informed me that they could help keep me on track with ART, and their team referred me to the Furquia Health Unit, where I was attended to promptly, received my drugs and was given a new ID card. I was happy to be serviced, because it was impossible for me to go to the Nante Health Center for my medication. In my most recent visit, I was informed that I could now return to Nante, and they gave me documentation to present the Nante Health Center that would justify the continuation of my treatment even being absent from their perspective."

Tonito receiving his treatment continuation documentation

Tonito happily completes his final clinic visit
 

Another ART patient from the Ronda Resettlement Center receives his medication