Mozambique

Mozambique is located in southern Africa and had a population of 19.4 million in 2004. Mozambique is ranked 18th globally among high-burden TB countries, with an estimated burden of 457/100,000 population for all cases and 190/100,000 for new smear-positive cases. TB/HIV co-infection is estimated to be 49 percent, and Mozambique is beginning to address the special challenges associated with high rates of TB and HIV co-infection. Despite difficulties in the country including inadequate resources, natural disasters and civil unrest, TB case detection and cure rates have improved in recent years. The case detection rate was believed to be 45 percent in 2003, although the accuracy is uncertain. The treatment success rate was 78 percent for the 2002 cohort, and has improved each year since 1995.

TBCTA Project 1 (2000-2006)

TBCTA support in Mozambique was based on the NTLP and National HIV/AIDS Program Medium-term Plans to start the development and implementation of TB/HIV collaborative activities.

Objectives

• Develop a TB/HIV activity implementation plan
• Improve planning and management capacity
• Increase human resource development capacity in TB/HIV in the Integrated Health Networks
• Strengthen the monitoring and evaluation system for TB/HIV in the Integrated Health Networks
• Implement small-scale projects on TB/HIV.
  

Major TBCTA Accomplishments

• Despite many setbacks, TBCTA managed to place TB/HIV collaboration firmly on the agenda of the Ministry of Health and other HIV/AIDS stakeholders. It clearly demonstrated that this area of work needs full-time, dedicated staffing.
• The recruitment of a full-time TB/HIV coordinator immediately resulted in a very successful strengthening of the national team, building relationships with stakeholders in the HIV/AIDS arena, both in Government and non-government sectors. One of the first achievements was the mainstreaming of TB/HIV indicators in the monitoring and evaluation system for the integrated care networks for HIV/AIDS. Later the NTLP revised its recording and reporting system, which now includes the common TB/HIV indicators recommended by the Stop TB Partnership. In addition, a draft TB/HIV technical policy guidelines for adoption by the Ministry of Health were developed.
• The development and implementation of a flexible training course for health workers in the NTP and in the integrated networks was an important TBCTA accomplishment. This course was subsequently and successfully piloted in May 2005 in Nampula. After evaluation and adjustment, the course will undergo national scale-up under TB CAP.

TB CAP Highlights Mozambique

CB DOTS Experience
One of the most significant achievements of TB CAP Mozambique has been introducing CB DOTS implementation in this country beginning in the specifically targeted provinces of Gaza, Sofala and Zambezia. TB CAP Mozambique was approved in October 2006 by the Ministry of Health (MOH) and CB DOTS activities commenced shortly after a national meeting where the CB DOTS strategy was discussed and approved by key government officials. TB CAP’s strategy in Mozambique has focused on working through implementing agencies that have the ability to mobilize and implement at community level. This strategy was effective in the initial pilot in Gaza (Chowe and Chibuto districts) and then expanded simultaneously to Sofala (Nhamatanda and Dondo districts) as well as Zambezia (Milange and Mocuba districts). All implementing agencies trained community based volunteers using training manuals designed by TB CAP to ensure standard messages and practices. In addition, TB CAP has designed, adapted and updated a variety of data collection tools and registration forms for community volunteers to use such as Referral Guides and Monthly Volunteer Summary Forms. CB DOTS implementation in all provinces has had constant technical assistance, supervision, as well as monitoring and evaluation from TB CAP staff to ensure efficient and effective implementation. At present close to 1000 volunteers exist in targeted districts and approximately 5000 people were referred to health centers for clinical examination and diagnosis. CB DOTS has greatly contributed towards strengthening the national programs in the fight against tuberculosis and HIV. The MOH has acknowledged the results and fully supports the efforts of TB CAP. In 2007-2008:

• Approximately 4861 people were referred by community volunteers to health centers with signs and symptoms of TB;
• 386 people (including children and adults) were taken to health centers for observation after being in contact with patients diagnosed TB Ss(+);
• 1004 men and women were diagnosed TB Ss(+), 472 cases diagnosed TB Ss(-) and 87 cases were diagnosed with extra pulmonary TB, a total of 1,563;
• All patients mentioned above began treatment and benefited from CB DOTS and receiving support from a TB treatment supporter (godfather or “padrinho” in Portuguese), activists and community volunteers. It is too early to report treatment outcomes from this entire group of patients.

Due to successful implementation TB CAP with full support from the MOH is expanding activities to increase coverage to additional districts in existing targeted provinces and beginning activities in two additional provinces in the north, Nampula, Niassa and Cabo Delgado.

One of the challenges confronted by TB CAP thus far has been the lack of capacity of implementing agencies. Partners’ ability to manage TB CAP funded project activities is critical to increasing TB diagnosis and treatment adherence. To address the issue, TB CAP has and continues to work diligently to build partners’ capacity technically, administratively and build their financial management skills. This has required a great deal of strategic planning, along with consistent follow-up and monitoring on various trainings TB CAP has provided. Also, TB CAP is developing a specific Terms of Reference for new implementing agencies to better project where strengthening is needed and developing training plan for partners before implementing project activities.

On a macro level, the weak infrastructure and management systems of MOH specifically and throughout the country in general, often causes significant challenges when TB CAP and partners implement activities. TB CAP continues to advocate addressing these issues. One national meeting facilitated by TB CAP Mozambique staff has been held and another is scheduled for the end of 2008 to provide a forum to address key issues where implementing partners and key Ministry Officials come together and exchange experiences and work to offer uniform solutions and responses. In addition, TB CAP has regularly scheduled coordination meetings with the MOH at the district level to ensure consistent collaboration and communication. These strategies have been critical to continue successful implementation of TB CAP supported activities, while advocating in a larger context to MOH the need to address the structural issues required strengthening health initiatives throughout the country.

TB CAP Project Period (2005-2010)

Expected output(s)

• CB DOTS successfully piloted in Gaza province and case detection rate increased from 46% to 70% and the treatment success rate increased from 63% to 85% in three districts of Gaza province.
• Improved access to quality assured laboratory diagnosis.
• TB/HIV collaborative activities expanded and monitored in HIV/AIDS and DOTS services.

Current status

TB CAP introduced community based (CB) DOTS approach, developed CB DOTS & TB-HIV Guidelines, training and educational materials as well as monitoring tools, developed a curriculum for training of health workers and counselors on PICT, started improving the competence of TB/HIV/AIDS health workers in TB/HIV activities. A baseline rapid assessment was completed and a training package prepared that includes all aspects of TB/HIV, including PICT, medical management of patients with both diseases, and recording and reporting.