Mozambique: Mozambique Mobile Clinic Project

 

Impact this project has on the community (who is benefiting and how):
 
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 Mobile Clinic team also provides management support and aids in medication (ARVs, cotrimoxazole, isoniazid, ferrous salt, mebendazole, etc.), and blood sample transport.

During the quarter, supervision activities and TA in the areas of pharmacy and MCH continued.
 
Furquia Health Facility: No changes in the health facility staff; all of them had been oriented in previous quarters and are working in their assigned areas with the support of the Mobile Clinic team and clinical mentoring.
 
During the reporting period the health staff in Furquia benefitted from 3 trainings: Pediatric TB, GAAC and Massive Testing (screening and testing of children in health facility all point of entrance to improve EID and treatment).  Also during this period Malaria prevention, diagnosis and treatment was one of the activities more prioritized facing the future rainy season where malaria cases increase a lot and constitute the first cause of death.
 
HIV testing is also implemented in the vaccination sector following the recommended strategy of testing in every entrance gate 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

Reinforcement of the community clinical linkages during the quarter focused on the coordination with the 3 existing Health Councils (Conselhos de Saude).  4 monthly meetings were held with the Health Councils and health facility staff, with an average number of 10 participants (5 of whom were traditional healers).
 
Consented case finding is supported by 4 activists, and some APES (Polyvalent Elementary Health Agent) that are also acting as TB-DOTS volunteers. N95 masks were provided for health unit staff.
 
Some renovations were done in the Furquia health facility to provide one small space for laboratory and also one room for counseling and testing activities. Improved roof, windows and doors condition (glasses, mosquito nets, etc.), security conditions (locks) and painting.
 
Mbawa Health Facility: 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.
During the reporting period the health staff in Mbawa benefited from 2 trainings: Pediatric TB and GAAC.
 
Also during this period: Malaria prevention, diagnosis and treatment was one of the activities more prioritized facing the future rainy season where malaria cases increase a lot and constitute the first cause of death. HIV testing is also implemented in the vaccination sector following the recommended strategy of testing at every entry point within the health facility.
 
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, they meet twice per month. During the quarter activities focused on coordination of monthly meetings held among the Health Councils and health facility staff with an average number of 36 participants in Mbawa sede and Taioi, and 25 participants in Maroda and Machawa. Consented case finding is supported by 4 Ogumaniha volunteers and 3 DOTS volunteers who are permanently motivated by staff to participate in the weekly Adherence Committee (Comite de Adesão CAD).
 
95 masks were provided for health facility staff (with PEPFAR funding).
 
As in Furquia, the heath facility of Mbawa benefitted from some renovation and set up of the space in order to provide more privacy and confidentiality for patients in the consultation rooms. Also some improvements were done in the pharmacy space to improve security conditions and opening one pane to deliver drugs.  Provision of HIV diagnostic, care and treatment services, including integrated services for TB/ HIV co-infected patients.
Technical support provided by the Mobile Clinic team includes:

• Reinforcement of diagnostic and clinical management of TB (pediatric)
• Screening/assessment of malnutrition
• 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

• 310 new patients were enrolled in clinical care during this quarter.
• From 383 HIV-positive persons receiving care during the reporting period eligible for CTZ prophylaxis, 354 received CTZ prophylaxis (92.4%)
• 245 individuals with advanced HIV infection were newly enrolled on ART; 220 adults (>15 years), 25 children (0-14 years old)
• New care patients who were screened for STIs at the last visit during the reporting period: 267 (86%)
• 706 HIV-positive patients were screened/ assessed for malnutrition; of them, 116 were clinically malnourished. (16.4%)

 Provision of Prenatal & PMTCT services (universal ART) for pregnant and lactating women

• In the period under review, 529 pregnant women were registered at ANC service in the two health units, 247 in Furquia and 282 in Mbawa; 547 pregnant women received HIV counseling and testing with 69 positive results (12.6%).  Due to Option B+, 66 HIV+ pregnant women received ART during this period. Unfortunately, the 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, 167 partners of pregnant women were tested, 37 (22%) 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)
• Transmission of HIV post-natal/ breastfeeding
• Importance of preventing mother-to-child transmission, CPN/ETV, Child-at-Risk clinic, and Follow-up of ART
• HIV Prevention

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

• During this quarter, 44 children were enrolled in the Child At-Risk Clinic (CCR) in Furquia and 56 in Mbawa. To improve adherence of the mothers of CCR patients, two meetings were held with the mothers at both the Furquia and Mbawa health facilities. The meetings addressed the importance of the CCR for the child’s health.
•  During the reporting period, 102 pediatric patients benefited from virological testing with 16 positive results (15.6%) reported. Rapid testing was offered to 44 children (1 of 44 tested HIV+ (2%)).

As a strategy to improve EID, the Provincial Health Department has requested in this reporting period to report weekly the number of PCR and rapid tests done, as well number of children initiating ARV. This is resulting in an increase of the number of children enrolled in the CCR, also in the number of children tested and inclusions in ARV treatment.
Voluntary Counseling and Testing – Children

• During the quarter, 85 children were counseled and tested with 17 (20%) HIV+ results. 16 of them initiated ART.

Provide diagnostic services for TB care and treatment

• During the quarter, 27 patients were enrolled into TB care and treatment in the two health units.
• All underwent counseling and testing for HIV, with 16 positive results (59.2%). During the quarter, 13 of these co-infected patients started antiretroviral treatment[2].

Consented case finding
 
In the last quarter 396 defaulted patients (236 Furquia and 160 Mbawa) were visited and 264 (Furquia 183 and in Mbawa 81) were found (66.6%), of them 143 (97 in Furquia and 46 in Mbawa) returned for consultation (54%).
 
Home visits to priority groups
 
In order to improve adherence to HIV care and treatment program, patient with low HIV care adherence, HIV exposed  children without PCR test, patients initiating ART and post-partum HIV positive women 179 (136 in Furquia and 43 in Mbawa) were visited and 121 (88 in Furquia and 33 in Mbawa) found (67.5%).
 
Counselors reinforced the patient support group creation, facilitation of monthly meetings and follow up.  A total of 8 meetings were held during the quarter, 4 Mother to Mother (81 participants), 2 Positive Teas (47 participants) and 2 Parents and Caretakers (9 participants).  Identification and reference of malnourished children, as well as orientation for preparation of nutritious foods is done with Ogumaniha volunteer support.
Although the collaboration between UNICEF, ICS (Instituto de Comunicação Social) and FGH was reinstated in Q1 to ensure timely Community Health Promotion, Information and Mobilization in sites supported by the Mobile Clinic including Namacurra District, it has not been well coordinated. A meeting with UNICEF/ICS is being organized to discuss eventual constraints and improve collaboration.
Other groups like Traditional Birth Attendants, Traditional Healers, Home Based Care volunteers provide information and health promotion among the community and refer pregnant women and other patients to the health units.

Number served/number of direct project beneficiaries (for example, average number treated per day or month and if possible, per health condition):
9,038 people benefited directly from activities implemented by the Mobile Clinic during this reporting period. From the previous quarter and following DPS orientation, all the clinical activities for patient care and treatment provided by the Mobile Clinic staff were fully integrated in the health facility and are registered jointly with the clinical activities performed by the HF staff.

Success story(s) highlighting project impact:
 
Mobile Clinic support improves laboratory system in Mbaua Health Unit
 
October 2014
Namacurra district –Mbaua locality
 
Vatimita Nomeada, 35, is married and lives in the town of Mbaua with her husband and their 3 children. With the initial arrival of the Mobile Clinic, she admits she was not fully aware of the new clinic’s purpose and was afraid to go there. However, after hearing announcements that the Mobile Clinic provided similar services to a normal hospital she came to better understand. After a consultation at the Mbaua Health Unit, Vatimita was directed to the Mobile Clinic for testing related to her anti-retroviral treatment. She was surprised when asked to wait around after the test, as results would be available that same day. Same-day results were not possible before, so Vatimita previously had to make the trek to the facility again at a later date, sometimes for additional testing as well.

Vatimita explained that, “before the arrival of the Mobile Clinic I sought consultation at the Macuse Health Center. Now, with the Mobile Clinic, the Mbaua Health Unit has been able to improve my health, not only with the available testing and fast delivery of results but also because I do not have to travel to a distant hospital for medication.”

“The Mobile Clinic has introduced a new dynamic in laboratory services,” explained Elévio, the lead Mobile Clinic technician. He added that, “with the use of PIMA, a point of care device that tests a patient’s level of CD4 cells in about 20 minutes, immediate results enable clinicians to make faster decisions regarding whether or not to start treatment.” From September 2013 to September 2014, with the Mobile Clinic operating in the Mbaua Health Unit, 956 CD4 analyses have been processed with the PIMA.
 
Previously, patients requiring CD4 testing had to come to the facility several times for the collection of blood samples, receipt of test results, and regular clinical consultations. In many cases, patients would spend up to a full day for each visit, resulting in expensive travel costs and many lost hours of work. Furthermore, the long wait time for test results delayed clinical decisions in terms of necessary care and treatment, and some patients were lost in the process. Now with the Mobile Clinic support, Mbaua Health Unit is able to reduce this burden, offering more efficient consultations and testing; increasing the potential for retaining more patients along the cascade of care and treatment.
 

Featured: Vatimita Nomeado, after CD4 analysis at Mbaua Health Unit
Photograher: Etelvina Sousa
Consent: Verbal and written consent received at time of photo, October 2014
 

Featured: Patients awaiting consultation at the Mbaua Health Center
Photograher: Etelvina Sousa
Consent: Verbal and written consent received at time of photo, October 2014

Featured: Mobile Clinic technician, Elévio, following a patient consultation
Photograher: Etelvina Sousa
Consent: Verbal and written consent received at time of photo, October 2014
 
Mobile Clinic improves support to malaria services and activities in Mbaua Health Unit
 
October 2014
Namacurra district –Mbaua locality
 
Emilia Damiano, 38, is married with four children and lives in the town of Mbaua. She has always used the Mbaua Health Unit for health consultations. Currently, Emilia is 5 months pregnant, and at her first prenatal appointment she learned she was HIV positive. However, thanks to the expansion of life-saving antiretroviral treatment in the region, she was able to be enrolled and immediately begin treatment at the clinic.

In this process, with the support of the Mobile Clinic, Emilia also began to learn about the necessary steps toward preventing malaria and available services. She received a mosquito net, was tested for malaria with a rapid test and was happy to know that she was malaria free. Through Mobile Clinic support, the importance of malaria prevention and avoidance of complications during pregnancy was explained to Emilia and how such measures could potentially prevent the loss of her child.

With the arrival of the Mobile Clinic at the Mbaua Health Unit, a greater focus was placed on ensuring proper consultations for the prevention and treatment of malaria, including consistent availability of rapid tests and anti–malarial drugs. The Mobile Clinic has enhanced awareness and community mobilization on the topic, highlighting the importance of preventive malaria prophylaxis for pregnant women and screening with the use of rapid testing for malaria. The clinical intervention also includes provision of cotrimoxazole to all HIV-positive pregnant women, which has an acting component for malaria prevention.
 
In addition to pregnant women, children that come for nutritional/ weight consultations are also screened for malaria through Mobile Clinic support, whereby children testing positive receive the first treatment dose immediately after the consultation and continue with remaining treatment at home. Elévio, the Mobile Clinic medical technician working in the Mobile Clinic, shared that 1,269 malaria screenings have been made during Mobile Clinic consultations from October 2013 to September 2014. The Mobile Clinic’s Maternal Child Health Nurse said that, “with the onset of Mobile Clinic support, pregnant women have begun to better understand the dangers of malaria through the awareness raised in prenatal visits.”

 
Featured: Emília Damião after her pre-natal consultation at the Mbaua Health Center
Photograher: Etelvina Sousa
Consent: Verbal and written consent received at time of photo, October 2014
 
Featured: Mobile Clinic technician, Elévio, consulting with a mother and child regarding malaria at the Mbaua Health Center
Photograher: Etelvina Sousa
Consent: Verbal and written consent received at time of photo, October 2014

Featured: Mobile Clinic where analysis is conducted at Mbaua Health Unit
Photograher: Etelvina Sousa
Consent: Verbal and written consent received at time of photo, October 2014
 
Mobile Clinic improves support in strengthening pharmacy services in the Mbaua Health Unit
 
Mobile Clinic program in Namacurra
Namacurra district –Mbaua locality
 
Mobile Clinic support in pharmacy strengthening at Mbaua Health Center
 
Juvêncio is the technician responsible for pharmacy services for the Mobile Clinic operating in the Mbaua Health Center where he dispenses medicine and offers related counseling to patients. He explained that one of facility’s biggest problems has been stock rupture of medicines for all services, and with the arrival of the Mobile Clinic this is being addressed more effectively. The Mobile Clinic operates for a week at the Mbaua Health Center, and prior to moving on to the other peripheral health unit, the Mbaua staff provide stock reports and make requests for the pharmacy team for all the necessary items. “With our trip to the Namacurra District Health Center, we always guarantee replacement of stock on time,” Juvêncio remarked.

The technician in charge of the Mbaua Health Center, Atanásio, shared that before the arrival of the Mobile Clinic, the work there was very complicated. “There were times when we would reach a point of having nearly no medications at all, due to delays in shipment or transportation difficulties. This meant that patients did not come for our services, because there was an impression that the necessary drugs were not available. With the support of the Mobile Clinic, today we no longer have these problems," Atanásio stated.

Juvêncio further explained that with the Mobile Clinic at the Mbaua Health Center, services for individual patient registration for antiretroviral medication via pharmacy forms, or “FILAs”, has vastly improved. Before its arrival there was no specific pharmacy space with a pharmacy technician to dispense drugs. All of the medications were managed by clinicians who first met with patients for clinical visits and then reserved a time to dispense medicines. For this reason, FILA registration of patients for medications was often delayed to another day, with some patients complaining of delays in treatment as well.

One of the Mobile Clinic patients, Hortênsia Pedro, 41, lives in the town of Mbaua and says that with the arrival of the Mobile Clinic she was able to transfer from previous treatments in Macuse locality. She explained that before the Mobile Clinic’s arrival, most Mbaua residents traveled nearly 30 km to the Macuse Health Center, despite the distance, because of fears of not finding the necessary drugs in Mbaua. Hortênsia expands that, “now I am happier because everything is close. I can access all medications here at the Mbaua Health Center and do not face the struggles of getting to the district hospital.”
 

Featured: Mobile Clinic pharmacy technician, Juvêncio, at the Mbaua Health Center
Photograher: Etelvina Sousa
Consent: Verbal and written consent received at time of photo, October 2014

 
Featured: Atanásio, techician in charge of the Mbaua Health Center
Photograher: Etelvina Sousa
Consent: Verbal and written consent received at time of photo, October 2014
 

Featured: Hortência P. Gomes after her Mobile Clinic consultation at the Mbaua Health Center
Photograher: Etelvina Sousa
Consent: Verbal and written consent received at time of photo, October 2014