Mozambique: Mozambique Mobile Clinic Project

photo:

A crowd of local community members greet the Mobile Clinic for a health fair

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.

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 second 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.

After severe rains and flooding during the previous period, which caused disruptions in technical assistance/service delivery in FGH-supported districts, the Mobile Clinic team resumed normal activities. Most of the displaced population around Furquia HF has already returned to their previous living area with only one small group of people who decided to remain at the resettlement camp.   

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.

Impact this project has on the community (who is benefiting and how):
 
Provision of primary health services to Furquia & Mbawa communities:
The MC 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 (ARVs, cotrimoxazole, isoniazid, ferrous salt, mebendazole, etc.) and blood sample transport.

During the quarter, clinical mentoring, supervision activities and TA in the areas of C&T, Pharmacy and MCH continued.

Until end of April 15, the Mobile Clinic and FGH teams were helping health staff from the health facility to attend displaced people in the Ronda Camp. From May15 all the health care for the people remaining in the camp was again provided at Furquia HF level.
 
Furquia Health Facility:
 

photo: TBA Rosa Lazaro at the Furquia Health Center

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.
 
Community activities continued to increase during this period with new GAACs constituted. At the end of this quarter, there are 11 active GAACs currently in Furquia with a total of 22 patients.
 
Malaria prevention, diagnostics and treatment were also prioritized during this period.
 
FGH community health staff (Peer Educators and Counselors) continued to provide information, education, and communication (IEC) on HIV prevention and testing, GBV, treatment adherence, diarrhea, malaria, etc. among the community and patients waiting for consultation at Furquia and Mbawa Health Facilities.
 
HIV testing is also implemented in the vaccination sector and other points of entry to the HF (emergency area), following the recommended strategy of testing at every entry point to the health unit.
 
Current staff working in the health unit include:

• 01 General Medical Technician
• 01 Maternal Child Health Nurse (mid-level)
• 01 General Nurse (mid level)
• 01 Preventive Medicine Technician
• 01 Lab Technician
• 01 Elementary Nurse
• 02 Health Counselors
• O1 Cleaner

 
Continuous coordination is maintained with the 3 existing Health Councils (Conselhos de Saude) with 4 monthly meetings (every Thursday) held among Health Councils and health facility staff, each averaging 50 participants (Traditional Birth Attendants, Community Leaders, DOT Volunteers, Health Council Volunteers, Polyvalent Heath Agents, Religious Leaders, FGH District Community Health Officer, and other volunteers from Ogumaniha and other partners). After the rainy season, the number of participants in those meetings has increased.
 
Overall, there are 7 support groups helping in Furquia, as follows:

• Home Based Care: home visits
• Mothers to Mothers groups: nutritional education, demonstrations, etc.
• Traditional Birth Attendants: Pregnant women referral to Health Unit, information in the community about HIV testing, breastfeeding, nutrition, family planning, PMTCT, etc.
• Traditional Healers: Referral of suspected TB 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 references to Health Unit for HIV counseling and testing
• ETC (Epidemic Total Control – a partnership between FDC and ADP since October 2014): 4 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: The Furquia Health Center conducting an STI awareness presentation to a group of community members

photo: A young couple is jointly counseled on STI prevention and treatment

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.
 
Following heavy flooding in January and February, the road to Mbawa has been passable again since March 15, and the Mobile Clinic team was able to provide assistance to the health facility.
 
35 Active GAACs exist in Mbawa with a total of 88 patients. 
 
As in Furquia, malaria prevention, diagnostics and treatment were also prioritized during this period.
 
HIV testing in the vaccination sector and other entry points within the health facility were implemented following the recommended strategy of “massive” testing from the DPS.
 
Current staff in the health unit:

• 01 Maternal Child Health Nurse (mid-level)
• 01 General Nurse (mid level)
• 01 Preventive Medicine Technician
• 01 Health Counselors
• 01 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 (Comité 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) [1]
• 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):

• 287 new HIV patients were enrolled in clinical care during this quarter.
• From 618 HIV-positive persons receiving care during the reporting period eligible for CTZ prophylaxis, 574 received CTZ prophylaxis (92.8%)
• 232 individuals with advanced HIV infection were newly enrolled on ART; 213 adults (>15 years), 19 children (0-14 years old)
• Newly enrolled patients who were screened for STIs at the last visit during the reporting period: 249 (27.5%)
• 790 HIV-positive patients were screened/ assessed for malnutrition; of them, 130 were clinically malnourished (16.5%)

NOTE: As a normalization of the health activities in Mbawa health unit after the rains, there is a general increase in the number of beneficiaries reported this quarter compared to the previous report.
 
Provision of Prenatal & PMTCT services (universal ART) for pregnant and lactating women:

• In the period under review, 754 pregnant women were registered at ANC service in the two health units, 379 in Furquia and 375 in Mbawa; 744 pregnant women received HIV counseling and testing with 98 positive results (13%).  Due to Option B+, 60 HIV+ pregnant women received ART during this period (86%). Unfortunately, the MOH does not have longitudinal books to follow Pregnant Women in their clinic visits. 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 continues to be reinforced through “palestras” (lectures) and with the “Male Champion Strategy” in the HFs and communities to motivate men to accompany their pregnant partners. During the period we observed an increase in the number of partners tested, 256 partners of pregnant women were tested, 26 (10.2%) 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 (especially during rainy season)

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

• During this quarter, 48 children were enrolled in the Child-At-Risk Clinic (CCR) in Furquia and 25 in Mbawa
• During the reporting period, 79 pediatric patients benefited from virological testing with 22 positive results (27.8%) reported. Rapid testing was offered to 37 children, 1 was positive (2.7%).

Voluntary Counseling and Testing – Children:

• During the quarter, 64 children were counseled and tested with 12 (19%) HIV+ results. 10 of them initiated ART (83%).

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.
• 11 patients were counseled and tested for HIV, with 6 positive results (55%). During the quarter, 4 of the patients started antiretroviral treatment (67%)[2].
   

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 234 defaulted patients (151 Furquia and 83 Mbawa) were visited and 95 (Furquia 61 and in Mbawa 34) were found (40.6%), of them 72 (49 in Furquia and 23 in Mbawa) returned for consultation (75.8%)
 
Home visits to priority groups (USAID and PEPFAR supported):
 
With the arrival of the new District Community Health Officer in the previous reporting period, community activities and the number of visits for priority groups are now 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 were referred for visits. A total of 228 patients were referred for visits, of which 156 (66 in Furquia and 90 in Mbawa) were visited, and 68 (11 in Furquia and 57 in Mbawa) found (29.8% of total referred for visits).
 
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.