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Thirty years since its first public use in 1980, the phrase structural adjustment remains obscure for many anthropologists and public health workers. However, structural adjustment programs (SAPs) are the practical tools used by international financial institutions (IFIs) such as the International Monetary Fund (IMF) and the World Bank to promote the market fundamentalism that constitutes the core of neoliberalism. A robust debate continues on the impact of SAPs on national economies and public health. But the stories that anthropologists tell from the field overwhelmingly speak to a new intensity of immiseration produced by adjustment programs that have undermined public sector services for the poor. This review provides a brief history of structural adjustment, and then presents anthropological analyses of adjustment and public health. The first section reviews studies of health services and the second section examines literature that assesses broader social determinants of health influenced by adjustment.

IntroductionIn 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 DescriptionIn 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.ConclusionThe 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 Access to antiretroviral treatment (ART) has expanded dramatically in resource-limited settings. Evaluating loss to follow-up from HIV testing through post-ART care can help identify obstacles to care. Methods Routine data was analyzed for adults receiving services in two public HIV care systems in central Mozambique. The proportion of people passing through the following steps was determined: (1) HIV testing, (2) enrollment at an ART clinic, (3) CD4 testing, (4) starting ART if eligible, and (5) adhering to ART. Results During the 12-month study period (2004–2005), an estimated 23,430 adults were tested for HIV, and 7,005 (29.9%) were HIV-positive. Only 3,956 (56.5%) of those HIV-positive enrolled at an ART clinic ≤30 days after testing. CD4 testing was obtained in 77.1% ≤30 days of enrollment. Of 1,506 eligible for ART, 471 (31.3%) started ART ≤90 days after CD4 testing. Of 382 with ≥180 days of potential follow-up time on ART, 317 (83.0%) had pharmacy-based adherence rates ≥90%. Discussion Substantial drop-offs were observed for each step between HIV testing and treatment, but were highest for referral from HIV testing to treatment sites and for starting ART. Interventions are needed to improve follow-up and ensure that people benefit from available HIV services.

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.

objectives To assess the relationship between health system factors and facility-level EHP stock-outs in Mozambique. methods Service provisions were assessed in 26 health facilities and 13 district warehouses in Sofala Province, Mozambique, from July to August in 2011–2013. Generalised estimating equations were used to model factors associated with facility-level availability of essential drugs, supplies and equipment. results Stock-out rates for drugs ranged from 1.3% for oral rehydration solution to 20.5% for Depo-Provera and condoms, with a mean stock-out rate of 9.1%; mean stock-out rates were 15.4% for supplies and 4.1% for equipment. Stock-outs at the district level accounted for 27.1% (29/107) of facility-level drug stock-outs and 44.0% (37/84) of supply stock-outs. Each 10-km increase in the distance from district distribution warehouses was associated with a 31% (CI: 22–42%), 28% (CI: 17–40%) or 27% (CI: 7–50%) increase in rates of drug, supply or equipment stock-outs, respectively. The number of heath facility staff was consistently negatively associated with the occurrence of stock-outs. conclusions Facility-level stock-outs of EHPs in Mozambique are common and appear to disproportionately affect those living far from district capitals and near facilities with few health staff. The majority of facility-level EHP stock-outs in Mozambique occur when stock exists at the district distribution centre. Innovative methods are urgently needed to improve EHP supply chains, requesting and ordering of drugs, facility and district communication, and forecasting of future EHP needs in Mozambique. Increased investments in public-sector human resources for health could potentially decrease the occurrence of EHP stock-outs.

BackgroundPrimary health care is recognized as a main driver of equitable health service delivery. For it to function optimally, routine health information systems (HIS) are necessary to ensure adequate provision of health care and the development of appropriate health policies. Concerns about the quality of routine administrative data have undermined their use in resource-limited settings. This evaluation was designed to describe the availability, reliability, and validity of a sample of primary health care HIS data from nine health facilities across three districts in Sofala Province, Mozambique. HIS data were also compared with results from large community-based surveys.MethodologyWe used a methodology similar to the Global Fund to Fight AIDS, Tuberculosis and Malaria data verification bottom-up audit to assess primary health care HIS data availability and reliability. The quality of HIS data was validated by comparing three key indicators (antenatal care, institutional birth, and third diptheria, pertussis, and tetanus [DPT] immunization) with population-level surveys over time.Results and discussionThe data concordance from facility clinical registries to monthly facility reports on five key indicators--the number of first antenatal care visits, institutional births, third DPT immunization, HIV testing, and outpatient consults--was good (80%). When two sites were excluded from the analysis, the concordance was markedly better (92%). Of monthly facility reports for immunization and maternity services, 98% were available in paper form at district health departments and 98% of immunization and maternity services monthly facility reports matched the Ministry of Health electronic database. Population-level health survey and HIS data were strongly correlated (R = 0.73), for institutional birth, first antenatal care visit, and third DPT immunization.ConclusionsOur results suggest that in this setting, HIS data are both reliable and consistent, supporting their use in primary health care program monitoring and evaluation. Simple, rapid tools can be used to evaluate routine data and facilitate the rapid identification of problem areas.

BackgroundLarge increases in health sector investment and policies favoring upgrading and expanding the public sector health network have prioritized maternal and child health in Mozambique and, over the past decade, Mozambique has achieved substantial improvements in maternal and child health indicators. Over this same period, the government of Mozambique has continued to decentralize the management of public sector resources to the district level, including in the health sector, with the aim of bringing decision-making and resources closer to service beneficiaries. Weak district level management capacity has hindered the decentralization process, and building this capacity is an important link to ensure that resources translate to improved service delivery and further improvements in population health. A consortium of the Ministry of Health, Health Alliance International, Eduardo Mondlane University, and the University of Washington are implementing a health systems strengthening model in Sofala Province, central Mozambique.Description of implementationThe Mozambique Population Health Implementation and Training (PHIT) Partnership focuses on improving the quality of routine data and its use through appropriate tools to facilitate decision making by health system managers; strengthening management and planning capacity and funding district health plans; and building capacity for operations research to guide system-strengthening efforts. This seven-year effort covers all 13 districts and 146 health facilities in Sofala Province.Evaluation designA quasi-experimental controlled time-series design will be used to assess the overall impact of the partnership strategy on under-5 mortality by examining changes in mortality pre- and post-implementation in Sofala Province compared with neighboring Manica Province. The evaluation will compare a broad range of input, process, output, and outcome variables to strengthen the plausibility that the partnership strategy led to health system improvements and subsequent population health impact.DiscussionThe Mozambique PHIT Partnership expects to provide evidence on the effect of efforts to improve data quality coupled with the introduction of tools, training, and supervision to improve evidence-based decision making. This contribution to the knowledge base on what works to enhance health systems is highly replicable for rapid scale-up to other provinces in Mozambique, as well as other sub-Saharan African countries with limited resources and a commitment to comprehensive primary health care.