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Introduction: In 2004, Mozambique, supported by large increases in international disease‐specific funding, initiated a national rapid scale‐up of antiretroviral treatment (ART) and HIV care through a vertical “Day Hospital” approach. Though this model showed substantial increases in people receiving treatment, it diverted scarce resources away from the primary health care (PHC) system. In 2005, the Ministry of Health (MOH) began an effort to use HIV/AIDS treatment and care resources as a means to strengthen their PHC system. The MOH worked closely with a number of NGOs to integrate HIV programs more effectively into existing public‐sector PHC services. Case Description: In 2005, the Ministry of Health and Health Alliance International initiated an effort in two provinces to integrate ART into the existing primary health care system through health units distributed across 23 districts. Integration included: a) placing ART services in existing units; b) retraining existing workers; c) strengthening laboratories, testing, and referral linkages; e) expanding testing in TB wards; f) integrating HIV and antenatal services; and g) improving district‐level management. Discussion: By 2008, treatment was available in nearly 67 health facilities in 23 districts. Nearly 30,000 adults were on ART. Over 80,000 enrolled in the HIV/AIDS program. Loss to follow‐up from antenatal and TB testing to ART services has declined from 70% to less than 10% in many integrated sites. Average time from HIV testing to ART initiation is significantly faster and adherence to ART is better in smaller peripheral clinics than in vertical day hospitals. Integration has also improved other non‐HIV aspects of primary health care. Conclusion: The integration approach enables the public sector PHC system to test more patients for HIV, place more patients on ART more quickly and efficiently, reduce loss‐to‐follow‐up, and achieve greater geographic HIV care coverage compared to the vertical model. Through the integration process, HIV resources have been used to rehabilitate PHC infrastructure (including laboratories and pharmacies), strengthen supervision, fill workforce gaps, and improve patient flow between services and facilities in ways that can benefit all programs. Using aid resources to integrate and better link HIV care with existing services can strengthen wider PHC systems., Introduction The rapid scale up of antiretroviral treatment (ART) and HIV care across Africa over the past five years has provoked an important and lively debate about the impact of [...]

The challenges facing efforts in Africa to increase access to antiretroviral HIV treatment underscore the urgent need to strengthen national health systems across the continent. However, donor aid to developing countries continues to be disproportionately channeled to international nongovernmental organizations (NGOs) rather than to ministries of health. The rapid proliferation of NGOs has provoked 'brain drain' from the public sector by luring workers away with higher salaries, fragmentation of services, and increased management burdens for local authorities in many countries. Projects by NGOs sometimes can undermine the strengthening of public primary health care systems. We argue for a return to a public focus for donor aid, and for NGOs to adopt a code of conduct that establishes standards and best practices for NGO relationships with public sector health systems. doi:10.2105/AJPH. 2007.125989

The recent expansion of Pentecostalism and independent churches in Africa has generated growing interest among social scientists. This attention parallels a renewed interest among Africanists on witchcraft and occult activities, also believed by many to be increasing. Some suggest the two trends may be related, but it remains unclear how and why. Drawing on a study of Pentecostalism and health in the city of Chimoio, Mozambique, in 2002-03 that focused on attitudes toward recent social change, we argue that structural adjustment economic reforms have deepened economic inequality and exacerbated household stresses that affect men and women differently. Women increasingly seek spiritual help for reproductive health problems from Pentecostal churches, whereas men disproportionately pay traditional healers tO engage 'occult' practices to manage misfortune related to employment. The increased resort to both spiritual resources reveals social distress caused by economic adjustment, with important implications for health programs. [Keywords: Pentecostal, African Independent Churches, Mozambique, inequality, neoliberal]

The concept of 'civil society' has been used by major donors in the world of international development to justify the rechanneling of aid resources away from public sector services to nongovernmental organizations (NGOs) in an era of structural adjustment. Mozambique provides an especially valuable case study of the civil society experiment in Africa, given its dramatic conversion from state-centered development to civil society and free markets over the last decade. The rapid retreat of the state in the lives of ordinary Mozambicans during this period quickly cleared a space for the emergence of an 'independent' civil society that has been quickly filled by two social currents: international NGOs and Pentecostal-influenced churches. This article argues that the NGO presence has intensified already growing social inequality by channeling resources primarily to elites, while the church movements have thrived in poor communities outside the foreign aid world. The enormous popularity of the churches reveals the deepening marginalization of poor communities in the market economy and exposes the inadequacy of the NGO-civil society model to meet the needs of vulnerable populations. Key words: civil society, NGOs, African Independent Churches, Pentecostal, Mozambique

The arguments relating to the social-marketing (SM) techniques in Africa, which is not driven by demonstrated efficacy but is attributable to the promotion of privatization and free markets across the region, are presented. This technique to sell condoms has clashed with ethics of various churches that contrast the message about sexuality and risky behavior in the central Mozambican community.

In keeping with the neo-liberal emphasis on privatization, international aid has been increasingly channeled through non-governmental organizations (NGOs) and their expatriate technical experts to support primary health care (PHC) in the developing world. Relationships between international aid workers and their local counterparts have thus become critical aspects of PHC and its effectiveness. However, these important social dynamics of PHC remain understudied by social scientists. Based on three years of participant-observation in Mozambique, this paper presents an ethnographic case study, of these relationships in one central province. The Mozambique experience reveals that the deluge of NGOs and their expatriate workers over the last decade has fragmented the local health system, undermined local control of health programs, and contributed to growing local social inequality. Since national health system salaries plummeted over the same period as a result of structural adjustment, health workers became vulnerable to financial favors offered by NGOs seeking to promote their projects in turf struggles with other agencies. It is argued that new aid management strategies, while necessary, will not be sufficient to remedy the fragmentation of the health sector. A new model for collaboration between expatriate aid workers and their local counterparts in the developing world is urgently needed that centers on the building of long-term equitable professional relationships in a sustainable adequately funded public sector. The case study presented here illustrates how the NGO model undermines the establishment of these relationships that are so vital to successful development assistance. Keywords: NGOs; Mozambique; International aid; Primary health care; Social inequality

Introduction: Effectiveness of the rapid expansion of antiretroviral therapy (ART) throughout sub-Saharan Africa is highly dependent on adequate enrolment and retention in HIV care. However, the measurement of both has been challenging in these settings. This study aimed to assess enrolment and retention in HIV care (pre- ARTand ART) among HIV-positive adults in Central Mozambique, including identification of barriers and facilitators. Methods: We assessed linkages to and retention in HIV care using a mixed quantitative and qualitative approach in six districts of Manica and Sofala provinces. We analyzed routine district and health facility monthly reports and HIV care registries from April 2012 to March 2013 and used single imputation and trimmed means to adjust for missing values. In eight health facilities in the same districts and period, we assessed retention in HIV care among 795 randomly selected adult patient charts (15 years and older). We also conducted 25 focus group discussions and 53 in-depth interviews with HIV-positive adults, healthcare providers and community members to identify facilitators and barriers to enrolment and retention in HIV care. Results: Overall, 46% of the monthly HIV testing reports expected at the district level were missing, compared to 6.4% of the pre-ART registry reports. After adjustment for missing values, we estimated that the aggregate numbers of adults registered in pre-ART was 75% of the number of persons tested HIV-positive in the six districts. In the eight health facilities, 40% of the patient charts for adults enrolled in pre-ART and 44% in ART were missing. Of those on ART for whom charts were found, retention in treatment within 90 and 60 days prior to the study team visit was 34 and 25%, respectively. Combining these multiple data sources, the overall estimated retention was 18% in our sample. Individual-level factors were perceived to be key influences to enrolment in HIV care, while health facility and structural-level factors were perceived to be key influences of retention. Conclusions: Efforts to increase linkages to and retention in HIV care should address individual, health facility, and structural level factors in Central Mozambique. However, their outcomes cannot be reliably assessed without improving the quality of routine health information systems. Keywords: linkages; retention; HIV care; treatment; Mozambique., Introduction In the past decade, Mozambique has expanded access to HIV testing services and antiretroviral therapy (ART) and has integrated them into the primary healthcare system [1-4]. Still, the proportion [...]

Introduction: Effectiveness of the rapid expansion of antiretroviral therapy (ART) throughout sub‐Saharan Africa is highly dependent on adequate enrolment and retention in HIV care. However, the measurement of both has been challenging in these settings. This study aimed to assess enrolment and retention in HIV care (pre‐ART and ART) among HIV‐positive adults in Central Mozambique, including identification of barriers and facilitators. Methods: We assessed linkages to and retention in HIV care using a mixed quantitative and qualitative approach in six districts of Manica and Sofala provinces. We analyzed routine district and health facility monthly reports and HIV care registries from April 2012 to March 2013 and used single imputation and trimmed means to adjust for missing values. In eight health facilities in the same districts and period, we assessed retention in HIV care among 795 randomly selected adult patient charts (15 years and older). We also conducted 25 focus group discussions and 53 in‐depth interviews with HIV‐positive adults, healthcare providers and community members to identify facilitators and barriers to enrolment and retention in HIV care. Results: Overall, 46% of the monthly HIV testing reports expected at the district level were missing, compared to 6.4% of the pre‐ART registry reports. After adjustment for missing values, we estimated that the aggregate numbers of adults registered in pre‐ART was 75% of the number of persons tested HIV‐positive in the six districts. In the eight health facilities, 40% of the patient charts for adults enrolled in pre‐ART and 44% in ART were missing. Of those on ART for whom charts were found, retention in treatment within 90 and 60 days prior to the study team visit was 34 and 25%, respectively. Combining these multiple data sources, the overall estimated retention was 18% in our sample. Individual‐level factors were perceived to be key influences to enrolment in HIV care, while health facility and structural‐level factors were perceived to be key influences of retention. Conclusions: Efforts to increase linkages to and retention in HIV care should address individual, health facility, and structural‐level factors in Central Mozambique. However, their outcomes cannot be reliably assessed without improving the quality of routine health information systems., Introduction In the past decade, Mozambique has expanded access to HIV testing services and antiretroviral therapy (ART) and has integrated them into the primary healthcare system [1–4]. Still, the proportion [...]

Introduction In 2004, Mozambique, supported by large increases in international disease-specific funding, initiated a national rapid scale-up of antiretroviral treatment (ART) and HIV care through a vertical 'Day Hospital' approach. Though this model showed substantial increases in people receiving treatment, it diverted scarce resources away from the primary health care (PHC) system. In 2005, the Ministry of Health (MOH) began an effort to use HIV/AIDS treatment and care resources as a means to strengthen their PHC system. The MOH worked closely with a number of NGOs to integrate HIV programs more effectively into existing public-sector PHC services. Case Description In 2005, the Ministry of Health and Health Alliance International initiated an effort in two provinces to integrate ART into the existing primary health care system through health units distributed across 23 districts. Integration included: a) placing ART services in existing units; b) retraining existing workers; c) strengthening laboratories, testing, and referral linkages; e) expanding testing in TB wards; f) integrating HIV and antenatal services; and g) improving district-level management. Discussion: By 2008, treatment was available in nearly 67 health facilities in 23 districts. Nearly 30,000 adults were on ART. Over 80,000 enrolled in the HIV/AIDS program. Loss to follow-up from antenatal and TB testing to ART services has declined from 70% to less than 10% in many integrated sites. Average time from HIV testing to ART initiation is significantly faster and adherence to ART is better in smaller peripheral clinics than in vertical day hospitals. Integration has also improved other non-HIV aspects of primary health care. Conclusion The integration approach enables the public sector PHC system to test more patients for HIV, place more patients on ART more quickly and efficiently, reduce loss-to-follow-up, and achieve greater geographic HIV care coverage compared to the vertical model. Through the integration process, HIV resources have been used to rehabilitate PHC infrastructure (including laboratories and pharmacies), strengthen supervision, fill workforce gaps, and improve patient flow between services and facilities in ways that can benefit all programs. Using aid resources to integrate and better link HIV care with existing services can strengthen wider PHC systems., Authors: James Pfeiffer (corresponding author) [1,2]; Pablo Montoya [1,2]; Alberto J Baptista [3]; Marina Karagianis [4]; Marilia de Morais Pugas [5]; Mark Micek [2]; Wendy Johnson [1,2]; Kenneth Sherr [1,2]; [...]

The attempt of African Independent Churches (AIC) in Mozambique to heal the problems of inequality connected with the rapid growth of income disparity is discussed. Women in poor families regard reproductive health problems as coming from witchcraft and turn to the AICs for treatment since traditional healers are viewed as dangerous and too expensive.

This study examines the effect of intrahousehold cash income control and decision-making patterns on child growth in the rural town of Sussundenga in Manica Province, Mozambique. A case-control study design was used to examine the influence of men's and women's disaggregated cash incomes on child growth. The research tested whether greater maternal share of household cash income was associated with (1) increased maternal decision-making and bargaining power in the household, and (2) better child growth. Fifty case households, with children 1-4 years old exhibiting poor growth, were matched with 50 control households of similar socioeconomic status in which all children under five demonstrated healthy growth. Data were gathered on gender-specific income generation and expenditure, specific intrahousehold allocation processes, diet, and sociodemographic variables using a formal survey. Key informant interviews, focus groups, and observation over one year provided ethnographic context for the case-control findings. Case-control differences were analyzed using McNemar's test, paired t-test, and conditional logistic regression. In spite of matching households for socioeconomic status, control household incomes were still slightly greater than cases. Male spouse income was also higher among controls while maternal income, and maternal proportion of household income, were not significantly different. Household meat, fish and poultry consumption, and maternal education were significantly greater among control households than cases. Greater maternal share of household income was not associated with greater maternal decision-making around cash. However, mothers must spend what little cash they earn on daily food supplies and usually request additional cash from spouses to cover these costs. There is evidence that if mothers earn enough to cover these socially prescribed costs, they can spend cash for other needs. Above this threshold, women's earnings may confer more bargaining power. The research also revealed a nuclearization of households, attenuation of community bonds of mutual aid, and increasing importance of cash for survival. Keywords: Intrahousehold resource allocation; Child nutrition; Income; Gender; Case-control study; Mozambique