Extending lifesaving HIV services by expanding community health counseling and testing in Mozambique
Author: Ministry of Health, Mozambique and Jhpiego-Mozambique
An extreme shortage of human resources in the health sector and the long distance of rural communities from health facilities were major barriers to the expansion of HIV counseling and testing (CT) and other health services in Mozambique. While the Ministry of Health was committed to the expansion of CT, skilled healthcare workers had their hands full responding to many other health challenges. In addition to its high rate of HIV, Mozambique is burdened by TB and malaria; maternal and child mortality is also high. According to the World Health Organization, there are just 548 doctors available to serve a population of some 22 million.
In 2007, the Ministry of Health (MoH) and the National AIDS Commission (NAC), with the support of Jhpiego and funding from President′s Emergency Plan for AIDS Relief (PEFPAR), began working on the design of a strategy for implementing CT at the community level. Given the severe shortage of skilled health workers, the central idea was to train lay counselors from local non-governmental and faith-based organizations to provide CT. Lay counselors for HIV testing was a new idea in Mozambique and one which needed to be carefully field-tested during a small pilot phase before a decision could be made on a possible scale-up. Moreover, the MOH wanted to implement HIV CT as part of an integrated health community counseling and testing, including TB, hypertension, malaria and diarrhoeal disease.
Once the MOH and NAC gave approval for the pilot project, five organizations were selected for the implementation phase and they recruited lay counselors, who were trained by Jhpiego. The lay counselors had to be able to read and write in Portuguese and to speak the relevant local language(s) of their geographic area and have a minimum education of grade 7. Training consisted of two weeks of classroom training plus a four week practicum with an experienced counselor. The Ministry of Health agreed to supply the local NGOs with test kits and Jhpiego provided other consumables (gloves, lancets, capillary tubes, etc.)
During the pilot phase, more than 9,094 people were counseled and 8,975 were tested; 11.2% tested positive and were referred to health units for HIV clinical care. Proficiency testing on a representative sample was conducted by the national reference laboratory as external quality assurance. Test results from four of the five NGOs had 100% concordance with the national reference lab; test results from the remaining NGO showed 98% concordance with the national lab. Given the tremendous success of the pilot, the MOH decided that home and community health counseling and testing conducted by trained lay counselors working for NGOs should be expanded nationwide.
The community counselors have proven to be an extremely productive and efficient workforce. At present there are 163 counselors and 11 supervisors working with the Jhpiego-supported NGOs. Between September 2008 and August 2010, they provided health and HIV education and counseling to 307,756 people, of whom 230,592 were tested for HIV, many of them as couples or families.
The experience of the Home and Community Counseling and Testing for Health programme demonstrates that NGOs can effectively partner with government health systems to expand the health workforce and provide lifesaving services at scale, increasing access for rural communities. The experience also shows that a relatively small number of providers - trained, supported, and supervised effectively and efficiently - can make an important difference in some critical areas of healthcare.