High impact medical care through mobile outreach
September 23, 2013
Tito Jequicene, MD
RMF’s Mobile Clinic in Mozambique is a new model of health care provision for our organization, conceptualized to reach remote and rural communities with no prior access to health care. Since its inception in 2008 our Mobile Clinic has been hugely successful and remains the only mobile clinic in all of Mozambique. The clinic, a collaboration between RMF, Vanderbilt University’s Friends in Global Health and Medical Mission International, is currently deployed in one of the most populous provinces of Mozambique, Zambézia Province, located in the central coastal region with a population of almost 4 million.
To improve the quality of life and provide access to health services, particularly access to maternal-child healthcare and anti-retroviral therapy (ART) for people living with HIV and AIDS, Tuberculosis and other diseases.
To provide access to healthcare in remote areas of Zambézia Province, Mozambique
To reinforce the expansion of HIV care and treatment services initiated by the Zambézia Provincial Health Directorate (DPS), by providing temporary reinforcement in terms of staff, training, and space for peripheral health units initiating implementation of ART until such time as the DPS can organize the infrastructure and resources necessary for these sites to function independently.
To 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 the targeted areas.
Summary of RMF/MMI-sponsored activities carried out during the reporting period under each project objective:
During the second quarter of 2013 the Mobile Clinic continued visiting the villages of Malei and Mexixine bi-weekly and also covered Malei and Furquia. The main activities of the Mobile Clinic include provision of:
- Primary health care to the populations of Malei, Mexixine and Furquia;
- HIV diagnostics, care and treatment services including integrated TB / HIV services for co-infected patients;
- Antenatal health services and PMTCT to pregnant women;
- Health care services and early diagnosis of HIV in infants born to HIV positive women;
- Diagnostic services, treatment and care of TB
Results and/or accomplishments achieved during this reporting period:
The main results achieved during the reporting period were as follows:
- Design of the service flow of patients at the reception area, the consultation clinic, lab, pharmacy and for those referred to support groups, if necessary;
- Implementation of one-stop models for co-infected TB/ HIV patients (integrated consultation), HIV+ pregnant women and breastfeeding mothers and exposed children, whereby a weekday is chosen for follow-up appointments with this target group, with weekly visits (Thursdays) to the Maternal Child Health clinic. We believe through this strategy, the support groups from mother to mother (MPM) can be easily reinstated, with weekly activities to strengthen membership through testimonials from other mothers and strategic approaches toward issues related to prevention of vertical transmission and positive prevention.
- Guidance to conduct weekly management meetings for clinical service provision that include the entire health unit staff (General Medical Technician, Maternal Child Health Nurse, General Nurse, Preventive Medicine Technician and Health Counselor), the DOTS-C volunteers and the Ogumaniha activists for home visits and care. These meetings take stock of the weekly activities at the health facility, most notably those related to ART Service (discussion on list of indicators to be followed for HAART services) in order to improve the monitoring of HIV+ patients through intersectoral collaboration. With the support provided by volunteers and community activists, we have gained information on adherence to antiretroviral treatment and tuberculosis in the community;
- In addition to clinical refresher trainings and trainings for the pharmacy (management of medicines, especially ARVs) and lab (process of collecting and preserving samples for CD4, CBC, Biochemistry, PCR and BK), training was provided to reinforce adequate completion of clinical forms, records and log books with special attention to the new clinical registers introduced (ART and Pre-ART logbook, daily log of ARVs, pharmacy forms for ARVs and Membership log).
- Refresher training in understanding new instruments for psychosocial support;
- Approach to patient counseling on eligibility criteria for HAART (Highly Active Antiretroviral Therapy), taking into account the need for rapid initiation of treatment;
- Distribution of information to ART-enrolled patients regarding the importance of constant ART management even in the absence of the mobile clinic, through group lectures and individual-level approach;
- Preparation of regular lists of priority patients for home visits and active searches for defaulters;
- Understanding proper completion of psychosocial support logbook
- Training health unit staff on the collection and storage of samples for CD4, biochemistry, hematology, BK and PCR;
- Implementation of a register book for the collection of samples and results of CD4, biochemistry, blood count and smear;
- Implementation of a system for collecting and weekly (Tuesday and Thursday) shipping samples of CD4, biochemistry, hematology, BK and PCR;
- Implementation of standards for requisition of materials and laboratory consumables;
- Implementation of standards for sending samples (drafting of protocols for sending);
- Refresher training for maternal and child health nurse on material referencing PCR samples (collection; adequate completion of books and forms, sending and receiving the results).
Materials allocated to the Malei health unit by our Logistics Department during Second Quarter:
- 1 chair for patient
- 1 altimeter for adult
- 2 measuring tapes
- 5 digital thermometers
- 1 adult balance with altimeter (ART)
- 1 locker for clinical process forms (ART)
- 1 glass cabinet for pharmacy
- 1 screen for physical examination
- 1 locker for pharmacy forms for ARVs
- 1 small desk for pharmacy
Note that training in the areas of Pharmacy and Laboratory are very important at this stage, because the health unit does not employ technical staff in these two areas. The monitoring of these activities will be ensured by regular technical support visits by FGH in coordination with the district supervisors of these programs in order to ensure sustainability even in the absence of our team.
Number served/number of direct project beneficiaries:
2,020 people benefited directly from activities implemented by the Mobile Clinic during this reporting period.
It is noted that this is nearly 28% less than the previous quarter; however, this can be explained by the fact that the Malei Health Unit received a Medical Technician, guaranteeing regular daily consultations for patients that were once referred to return the week when the Mobile Clinic was present.
ANNEX A – QUALITY MATERNAL CHILD HEALTH SERVICES
A strategy to increase the number of pregnant women with access to ATS and the number of healthy babies born to HIV+ mothers
Maessa Momade is 30 years old and the mother of five children. Maessa is currently 6 months pregnant, and in the last year had a stillbirth and previously lost two children when they were less than 5 years old. All five of Maessa’s children were born outside of the maternity ward, performed instead by a traditional birth attendant in the local community. According to Maessa, she has always given birth to her children at home, because when the labor pain began it was already too late to travel to a hospital, so a call would be given to the local birth attendant to assist in labor.
Her perspective began to change when after the last stillbirth; Maessa herself had some serious health problems and ended up in the hospital from losing too much blood. She remained in the hospital for two days and, once cured, the nurse on duty explained the advantages of having a health-facility based delivery. The nurse also recommended that as soon as Maessa is pregnant again she should come to the hospital for vaccines and monitoring of the pregnancy.
This time when Maessa became pregnant she came to the health facility as requested and had her first prenatal visit with the SMI nurse and was counseled and tested for HIV to know both her own state of health and that of her baby. Maessa’s test result was seropositive for HIV. Upon receipt of these results it was explained to her the need to take related medication until her child was born and come to consultations every month for observation to ensure the birth of a healthy child.Now, Maessa returns every month for her consultations. She has her weight measured and receives necessary vitamin supplements and medications.
Maessa’s SMI nurse feels that she now knows the benefits of an institutional delivery and that complications can often be treated in time to avoid the suffering experienced by Maessa and countless other women of her community over the years. Maessa shared, "today I am here in the hospital for the second time this month, because I started to feel pain in my lower abdomen. I came to know what's happening with my baby, because I'm afraid of losing my child again.”
The Maternal Child Health (MCH)/ Prevention of Mother-to-Child Transmission Program (PMTCT) aims to improve the quality of service in all health facilities within districts supported by FGH. With a strong emphasis in the areas of MCH and PMTCT, the goal is to ensure that all pregnant women know their serostatus for HIV, to see that eligible HIV+ patients are on ART or at least benefit from ARV prophylaxis, to ensure that any child exposed to HIV is given prophylaxis in the maternity and later enrolled into the child-at-risk clinic and also to ensure that any child with a seropositive HIV result is initiated onto ART.
The general SMI nurse working at the Magiga-Pebane Health Facility shared that with our support she began to improve her skills for collecting PCR samples and ensuring active medication stock in collaboration with the pharmacy at the health center in the district headquarters. She is also able to ensure availability of the apparatus for measuring hemoglobin for pregnant mothers, which provides faster results in order to administer ARVs. FGH has a PMTCT mentorship in the health facilities for new approaches on prevention and to allow for in-service training on the new standards.
ANNEX B – MOBILE CLINIC SUCCESS STORIES
Impact of Mobile Clinic services in Malei Health Unit of Namacurra
Strengthening the health system in peripheral health units
Nico is an HIV-positive 12-year-old boy, the youngest of five siblings who have lost both their parents to HIV – first their mother in 2011, then their father in 2012. After the death of his parents, Nico lived with one of his sisters, age 19, and his brother-in-law, but after some mistreatment from this brother-in-law, decided to leave and live with his maternal grandfather, where he joined with his four brothers. For support in following his HAART regimen, Nico relies on the DOTS-C volunteer and activist visits and consented house searches in his area, which help control his intake of ARVs and accompany Nico to the Malei Health Unity for consultations and pharmacy visits.
An activist, Gruveta, recounts:
“I met Nico when he was still small, back in 2010, still together with his parents here in the area where I live. I typically do home visits to families with suspected illness that do not go to the health unit. As I was trained to screen patients with tuberculosis (suspected patients with cough for more than three weeks), I once visited the parents of Nico, and I noticed that they were coughing a lot and the mother was very ill. I advised them both to go immediately to the hospital for treatment, but at that time there were no ART services in Malei to test them, and they would have to go to the hospital at the Namacurra district headquarters to start treatment. And, as Nico’s father was a traditional healer, he did not accept this and said he could be treated with the roots he had. This was until the health of Nico’s mother worsened, and she eventually lost her life in 2011. It was then when I came back to advise the family that they should go to the Malei Health Unit to know their health status. After long insisting, one day I came back and explained that there is now a Mobile Clinic in Malei that comes to the Health Unit. I took Nico and his father to the Malei Health Unit during the week that the Mobile Clinic was operating. Both were counseled and tested for HIV with positive results. Afterward, we took samples for tuberculosis, which also came back positive. So Nico and his father initiated ART and TB treatment, and I've been following them ever since. As the father of Nico never accepted his illness, he was not adherent, and continued to worsen, losing his life last year. When this happened, I started to give more assistance to Nico, to ensure that he would continue with the treatment. Nico was cured of tuberculosis, and today he continues to receive HAART from the Malei Health Unit, now that these services are readily available.”
The Mobile Clinic has been operating in the locality of Malei for more than six months. With the introduction of the Mobile Clinic, the Malei Health Unit has benefited from Maternal Child Health services, including Prevention of Mother-to-Child Transmission of HIV, HIV Counseling and Testing services and ART enrollment for eligible patients.
A volunteer named Felix, who also supports the Malei Health Unit as a DOTS-C activist said:
“I started working as an activist here in Malei 10 years ago. I always made visits to patients suspected of having tuberculosis, and I accompanied them to the health facility. When patients could not go, I would even collect samples and transport them tothe health facility. Later I was trained to conduct clinical home visits and consensual home searches for patients lost-to-follow-up, providing support to identify non-adherent ART patients. Before the mobile clinic arrived it was very difficult to recover these patients because we had to refer them to the Namacurra Central Hospital and because of the distance and lack of means, they did not venture there for to treatment. Thus, patients ended up being lost even after having been identified by the outreach team. With the arrival of the Mobile Clinic, the process became much easier, because many patients transferred their paperwork to here in Malei, and it became easier to recover lost patients. We activists also participated in all four meetings of the Membership Committee (CAD) here at the Malei Health Unit and received lists of defaulters to treatment for HIV/AIDS and TB. We often already know the patients and can easily locate them, because we live in the same community. We also explain to patients about how ART services are now available."
The Maternal Child Health nurse of the Malei Health Unit also explained that before the arrival of the Mobile Clinic it was very difficult to monitor HIV-positive mothers after childbirth.
“We had to refer them to the main district hospital for ART initiation and to continue with treatment. Because of the difficulties with transportation and the long distance, most of these patients abandoned treatment. With the arrival of the Mobile Clinic, we now test pregnant mothers and, if the result is seropositive, we are able to begin the necessary paperwork right here and follow up that patient through to ART initiation if eligible. Now that we have the ART services in the Malei Health Unit, patient flow increased because we have consultations every day.”