Nampula Health Facility Assessment Report

Baseline Assessment of Facility and District Capacity
Alcançar
Qualidade de Serviços de Saúde para Mulheres e Crianças
Cooperative Agreement Number: 72065619CA00004
Submitted to:
Dulce Nhassico
Agreement Officer Representative
USAID Mozambique
January 31, 2020
This report is made possible by the support of the U.S. Government and American people through the
United States Agency for International Development (USAID), under cooperative agreement
72065619CA00004. The contents of this report are the responsibility of FHI 360 and do not necessarily
reflect the views of USAID or the United States Government.
Table of Contents
Table of Contents ..............................................................................................................................................i
Acronyms and Abbreviations ........................................................................................................................... ii
Acknowledgements ............................................................................................................................................ iii
Executive Summary ............................................................................................................................................ iv
Baseline Assessment of Facility and District Capacity ......................................................................................... 6
1.0 Background/Rationale............................................................................................................................... 6
2.0 Methods .................................................................................................................................................... 6
2.1 Survey design and selection of facilities and respondents ................................................................... 6
2.2 Data collection instruments and pre-testing ........................................................................................ 7
2.3 Recruitment and training of data collectors, and organization of field work ...................................... 8
2.4 Data entry, cleaning and analysis and dissemination ........................................................................... 8
2.5 Quality assurance.................................................................................................................................. 9
2.6 Research ethics ..................................................................................................................................... 9
2.7 Organization of the report .................................................................................................................... 9
3.0 Results ..................................................................................................................................................... 10
3.1 Surveyed health facilities .................................................................................................................... 10
3.2 Facility infrastructure for general service readiness .......................................................................... 12
3.3 Capacity to provide the continuum of pre-pregnancy, delivery, post-partum and newborn care (IR
2.1 and IR 2.2) ........................................................................................................................................... 21
3.4 Capacity to provide child health services including immunizations, integrated management of
childhood illnesses and management of malnutrition (IR 2.1 and 2.2).................................................... 33
3.5 Service statistics and service indicators for maternal, newborn and child health ............................. 38
3.6 Capacity for QI (IR 4.1 and 4.2) and provision of humanized services (IR 2.3) ................................... 46
3.7 Provider knowledge of MNH and Child health services ..................................................................... 58
3.8 Stock outs of key MNH drugs (IR 3.3) ................................................................................................. 66
3.9 Data and data systems for decision-making (IR 3.1) .......................................................................... 68
Acronyms and Abbreviations
ANC Antenatal Care
ANC4 At least 4 ANC visits
CHC Community Health Committee
CSSN Care for Small and Sick Newborns
DOCFR Direct Obstetric Case Fatality Rate
DPS Direcção Provincial de Saúde
EDM Electricidade de Mozambique
EmONC Emergency Obstetric and Newborn Care
FP Family Planning
GIS Geographic Information System
HR Human Resources
IMNCI Integrated Management of Neonatal and Childhood Illness
IYCF Infant and Young Child Feeding
KMC Kangaroo Mother Care
M&E Monitoring and Evaluation
MDSR Maternal Death Surveillance and Response Program
MNCH Maternal, Newborn and Child Health
MCH Maternal and Child Health
MISAU Ministério da Saúde
PAC Postabortion Care
PNC Post-natal Care
PPH Postpartum Haemorrhage
PY/PY2 Program Year/Program Year 2
QA Quality Assurance
QI/QI&H Quality Improvement/Quality Improvement and Humanization
RMC Respectful Maternity Care
SDSMAS Serviço Distrital de Saúde, Género, Criança e Acção Social
SIGLUS Sistema de Informação e Gestão de Logística para Unidades Sanitárias
SIS-MA Sistema de Informação de Saúde para Monitoria e Avaliação
STIs Sexually Transmitted Infections
WASH Water, Sanitation and Hygiene
Alcançar Baseline Assessment of Facility and District Capacity

January 2020 Page ii of 72
Acknowledgements
We would like to acknowledge those that contributed to the successful completion of the baseline
assessment and to express our gratitude to the Nampula Provincial Health Directorate and the District
Health Offices for their support to this effort. We extend special thanks to the data collectors for their
dedication to completing the field work, and to the facility staff for their participation. We would also like to
acknowledge the leadership provided by the Alcançar Monitoring, Evaluation and Learning team including
Joaquim Vilanculos, Vivaldo Nunes Oficiano, Rito Rafael, Jeremias Cândido Tembe and Faizal Motte, and by
Alcançar’s Technical Director, Dr. Fulgencio Sambola Estrada. Finally, we thank FHI 360’s technical support
team including Emily Keyes, Victoria Lebrun, and Virginia Savage.
-Dr. Geoffrey Ezepue, Alcançar Chief of Party

January 2020 Page iii of 72
Executive Summary
The Alcançar Baseline Assessment of Facility and District Capacity was conducted to establish an evidence
base against which to measure project performance and impact over the life of the project and to inform
project priorities and planning. The assessment includes a census of health centers and hospitals in Nampula
province - the population of facilities that the project is expected to influence. Trained data collection teams
interviewed facility and district staff to collect current information on (1) facility infrastructure and policies,
(2) human resources, (3) ordering and management of maternal and child health (MCH) commodities, (4)
provision of MCH services (5) knowledge of MCH care components, and (6) emergency referral capacity.
Additionally, they reviewed and extracted data from facility registers over a 6-month period and observed
antenatal care (ANC) consultations. Data collectors visited each of the district health offices (Serviço Distrital
de Saúde, Género, Criança e Acção Social, SDSMAS) to gather information on district health capacity to provide
clinical mentoring, implement quality improvement and death audits, and manage commodities. This
assessment report presents selected results.
A snapshot of key results:
• Access to a reliable source of electricity remains a key issue throughout Nampula province,
especially among health centers. Almost a quarter of health facilities in Nampula have no source of
electricity. While 42% of health facilities are connected to the national electrical grid (EDM), almost
half of those facilities experienced a power supply interruption of more than two hours in the week
prior to data collection.
• Health centers oversee a significant majority of institutional deliveries throughout Nampula province,
yet in comparison with hospitals, those facilities are much less equipped to provide sufficient beds for
the volume of obstetric patients they receive.
• Nampula has 9 facilities that meet criteria for providing basic or comprehensive emergency obstetric
and newborn care (EmONC). Eight facilities provide the full package of care for small and sick
newborns (CSSN). An additional 52 fully functioning EmONC facilities are needed throughout Nampula
province to meet global guidelines that recommend 5 EmONC facilities per 500,000 population.
• Many health facilities have been successful in maintaining a cold chain to keep vaccinations at an
appropriate temperature, yet nearly one quarter of facilities reported that refrigerator temperature
had fluctuated outside of the acceptable range in the month prior to data collection.
• Vaccinations services are widely available at health centers, hospitals, and through mobile units,
though those services might not be offered daily.
• Our assessment calculated Nampula’s institutional delivery rate at 85%, early initiation of ANC at 5%,
coverage of at least four ANC visits (ANC4), as 42% immediate oxytocin after delivery at 79%, and
postnatal care (PNC) within two days as 77%.
• Our assessment calculated Nampula’s:
o Institutional delivery rate at 85%, early initiation of ANC at 5%, coverage of ANC4 as 42%,
immediate oxytocin after delivery at 79%, and PNC within two days as 77%.
o Premature births rate at 19% of institutional births.
o Pre-discharge newborn mortality rate is 3.7 newborn deaths per 1000 institutional
deliveries, specifically 22.3 for hospitals and 1.6 for health centers.
o Direct obstetric case fatality rate (DOCFR) over the time period was 5% - above the <1%
target.
o One-hundred and ninety-five child deaths due to pneumonia, malaria, diarrhea and of
unknown cause were counted over the 6-month period. The vast majority of these (134)
occurred at health centers, and malaria was the most common cause of death.
• More than half of the facilities included in the baseline assessment have established active quality
improvement and humanization (QI&H) committees, created systems to collect and integrate service
January 2020 Page iv of 72
user input in quality improvement (QI) initiatives, and implemented QI initiatives in the areas of
maternal, newborn, and pediatric services. However, a higher percentage of hospitals than of health
centers had implemented these QI structures.
• Findings highlight a need to strengthen death audit and other surveillance initiatives, particularly
among health centers throughout Nampula province.
• During ANC consultations, more efforts are needed to fulfill women’s rights to information and
consent, through obtaining consent for lab tests and physical examinations, encouraging women to
ask questions, and providing women with information on danger signs during pregnancy.
• Significant knowledge gaps exist among frontline health workers providing essential MNCH care,
particularly regarding:
o When a special birth plan is required
o Observations to monitor during labor, such as maternal vital signs
o Diagnosis of severe bleeding and treatment of post-partum hemorrhage
o Diagnosis and management of sepsis in newborns
o Comprehensive treatment for women who had unsafe abortions and rape victims
• Child health providers had better knowledge of assessment and treatment for sick children than the
delivery of preventive care through well child check-ups.
• Stock outs of key MCH drugs and supplies are common across facilities in Nampula and impact
providers’ abilities to deliver high-quality MCH services to every patient. Alcançar project staff
engaged in activities to strengthen the supply of critical drugs, equipment and supplies can use these
results, complemented by additional information collected in the baseline assessment around
systems and practices for commodities management and ordering, to tailor and target technical
support.
• There are important areas for capacity building around data quality and data use which Alcançar can
prioritize in the second program year (PY2). In most health centers, paper-based registration,
aggregation and reporting remains the standard procedure. SDSMAS reports that all health facilities
are contributing reports to the national health information system (Sistema de Informação de Saúde
para Monitoria e Avaliação or SIS-MA), and most are doing so on time. Priority activities will likely
focus on ensuring health providers understand the proper way to fill the registers, and to aggregate
data into monthly reports. Efforts should be made to ensure facilities have the required registers.

January 2020 Page v of 72
Baseline Assessment of Facility and District Capacity
1.0 Background/Rationale
Alcancar is a five-year USAID-funded project, implemented by a consortium of international and local
partners and led by FHI 360. The project’s overall objective is to reduce maternal, neonatal and child
mortality in Nampula province, and to make Nampula province a model of modern, high-quality, high-
impact, patient-centered health services for mothers, newborns and children. These objectives will be
achieved by direct support to Nampula Provincial Health Directorate (Direcção Provincial de Saúde, or DPS),
the District Health Directorates (SDSMAS) and front-line maternal, newborn and child health (MNCH)
providers to develop individual and organizational capacities enabling them to improve the quality and
efficiency of MNCH services.
The Alcançar Baseline Assessment of Facility and District Capacity was conducted to establish an evidence
base against which to measure project performance and impact over the life of the project. It is intended to
inform project priorities – that is, to identify areas and ways in which Alcançar can most efficiently focus its
resources to achieve its goals. Data collected through the assessment provide a broad perspective on the
status of the health system and services in Nampula, in order to more fully understand the context and the
constraints, and to identify areas even outside of Alcançar’s project scope which are necessary for
stakeholders to address if Nampula is to become a model health system.
The assessment includes a census of health centers and hospitals in Nampula province - the population of
facilities that the project is expected to influence. The data collection tools gathered data necessary to
calculate baseline values for 15 of the 46 indicators included in the project’s Monitoring, Evaluation and
Learning Plan (MELP) results framework (submitted separately). Further, the baseline provides rich
information on facility, provider and district capacity to deliver quality, human-centered MNCH services and
assessed the strength and functioning of key aspects of the health system required to sustainably provide
these services.
2.0 Methods
2.1 Survey design and selection of facilities and respondents
The assessment represents a census of health facilities in Nampula Province that offer MNCH services.
Facilities not expected to offer MCH services were not visited, and neither were facilities that only recently
started providing services (Table 3.1.1 provides details of included facilities).
In each health facility, the data collection teams interviewed the facility in-charge, and persons responsible
and/or most knowledgeable about: (1) facility infrastructure and policies, (2) human resources, (3) ordering
and management of MCH commodities, (4) provision of ANC, services provided in the labor and delivery ward,
immunizations, preventive and curative child health services. Additionally, data collectors interviewed one
provider who performed the most deliveries in the previous month and who was present on the day of the
interview, and one provider who was most experienced providing child health services to assess their level of
knowledge on key MNCH topics. To gather 6-months of facility statistics, data collectors reviewed and
extracted data from facility registers. Further, data collectors obtained consent from providers and clients to
observe one ANC consultation per health facility visited. Data collectors also visited each of the 23 SDSMAS
offices to interview the key district health official to gather information on district health capacity to provide
clinical mentoring and supportive supervision, functioning of quality improvement and death review
committees, use of data for decision-making and commodities management.

January 2020 Page 6 of 72
2.2 Data collection instruments and pre-testing
The assessment tools build on facility assessments that have been used in over 50 countries to monitor
obstetric and newborn services for the past two decades, including twice in Mozambique. These data
collection tools were expanded to include additional questions on routine care such as ANC and post-natal
care (PNC), and preventive and curative care for the child, including integrated care for newborn and child
illnesses (IMNCI), immunization, and nutrition. Indicators that can be calculated from these tools are aligned
with global standards for monitoring outlined in:
• Emergency Obstetric and Newborn Care monitoring framework (WHO, UNICEF, UNFPA and the
Averting Maternal Death and Disability Program (AMDD))
• Every Newborn Action Plan (WHO)
• Survive and Thrive Strategy (newly released by WHO and UNICEF)
• Joint Monitoring Program for WASH in Health Care Facilities and Birth Settings (WHO and UNICEF)
• Service Availability and Readiness Assessment (WHO)
• Service Provision Assessment (USAID)
• DELIVER project’s Supply Chain Assessment (John Snow Inc. (JSI))
• Evaluating Respectful Care (White Ribbon Alliance tools)
In addition to the baseline indicators, the assessment provides information on:
• Access, quality and use of routine care: ANC, PNC, routine delivery, essential newborn care, and
immunizations
• Facility and provider capacity to manage life-threatening complications: emergency obstetric and
newborn care (EmONC), care for small and sick newborns (CSSN), integrated management of
childhood illnesses (IMNCI) including child malaria, pneumonia, and diarrhea
• Facility readiness to provide respectful maternity care/patient-centered care and assessment of
respectful care provision in ANC consultations through observation
• Presence and functioning of policies and structures for maternal, newborn and child death audits,
quality improvement activities, facility and district-level use of routine data, supply chain functioning
and management
• Provider knowledge of key MNCH actions to identify major gaps
• Frequency and quality of mentorship and supportive supervision
The baseline assessment included 9 modules:
• Module 1: Health Facility Identification, Infrastructure, and Emergency Referral Capacity

• Module 2: Human Resources
• Module 3: Essential Drugs, Equipment and Supplies for MNCH Services
• Module 4: Facility Case Statistics (over 6 months)
• Module 5: Performance of Signal Functions and Key Services in Obstetric, Newborn and Child Health
• Module 6a: Provider Knowledge of Obstetric and Newborn Care
• Module 6b: Provider Knowledge of Child Preventive and Curative Services and Immunization
• Module 7: Observation Checklist for Respectful Services during ANC
• Module 8: Interview with District Health Management Team
The Modules were pretested by Alcançar staff in two facilities prior the training of data collectors. After the
pretesting, the technical team corrected inconsistencies and other issues identified to ensure clarity and
consistency, and to ensure alignment with terminology and practices within Mozambique. Modules were
further revised as per corrections identified by data collectors during the field activity during the training.
2.3 Recruitment and training of data collectors, and organization of field work
The Assessment was carried out by a 20-person data collection team, working in 10 teams of two. Data
collectors were recruited according to the following criteria:
• University degree. Masters or professional degree in medicine, midwifery, nursing, demography,

biostatistics, or other social or health sciences preferred.
• Data collection experience
• Familiarity with clinical settings, services related to maternal, newborn and child health, health
facilities, and clinical equipment and commodities.
• Familiarity with obstetric and newborn care and/or child health and immunization
• Ability to speak and write fluently in Portuguese. Additional knowledge of local language(s) in
Nampula.
• Excellent interpersonal and communication skills.
Data collectors were trained over 5 days with a standardized curriculum that included didactic, participatory
and applied learning, including one day of field practice. Alcançar staff used training materials (i.e.
presentation slides, handouts, activities, pre- and post-tests) adapted from the standardized curriculum to
these specific modules. Successful completion of the data collectors’ training was required for the training
participant to engage in field work. Success was measured by an 80 percent or higher score on the post-
training test, and trainer assessment of the participants performance during the training using a standard skills
inventory.
Each data collection team was responsible for an average of 25 facilities. They traveled with an authorization
letter from DPS. Health facilities and SDSMAS offices were officially notified by DPS of the baseline assessment
field work ahead of data collection to facilitate entry to the facilities and participation by providers and district
health management staff.
FHI 360 Alcançar staff provided quality assurance to the teams while in the field via remote and on-site visits,
most intensively in the early days of field work to quickly troubleshoot and resolve any data collection
challenges.
2.4 Data entry, cleaning and analysis and dissemination

The data were double entered into CSPRO v7.3, a data entry program and exported into SPSS v21.0 and Stata
v15. The two data entry attempts were validated within Stata v15 and inconsistencies were corrected by
returning to the paper forms and indicating the correct entry. Final, clean analysis datasets were then analyzed
by Alcançar and FHI 360 staff, and selected results are presented in this report. Additional analyses and data
products will be developed using the baseline data, as needed by Alcançar or as requested by USAID, the
Ministry of Health (Ministério da Saúde, or MISAU), DPS or others. Results will be further disseminated
through various means and materials to facilities, SDSMAS, DPS, local partner organizations and other key
stakeholders – including health facility staff and youth – during formal and informal dissemination events.
Most importantly, the Alcançar team will use results from the baseline assessment to develop a data-driven
strategy and implementation plan for prioritized activities for PY2 and beyond. The data will be merged with
geocoded master facility list to enable mapping and spatial analyses in response to specific DPS, SDSMAS and
programmatic needs over the life of the project.

2.5 Quality assurance
Quality assurance involved multiple steps along a continuum of training, data collection in the field, and data
processing at central level, especially during the first weeks of data collection, with experienced trainers
accompanying the teams to mentor and help problem solve.
Quality assurance began with the recruitment of data collectors and team leaders with a health background.
Data collectors took pre- and post-tests to assess their learning and knowledge of the assessment guidelines
and standards for data collection. Each data collector was given a hard copy manual of the assessment
guidelines.
Team leaders played a critical role in the correct completion of the modules as they reviewed all the
questionnaires. The Alcançar coordinators visited and communicated with teams regularly to provide support
and help when difficulties arose at individual facilities and supervised the teams in the field to ensure
consistency and quality. When needed, the central data managers telephoned facilities for clarification and
to ensure quality.
2.6 Research ethics

During the data collector training, the Alcançar trainers introduced the data collectors to principles of
confidentiality and ethics in data collection. No person’s name (except that of the data collector) was recorded
on any of the modules. Permission to enter each facility, to interview the different employees, and to review
registers was requested from the person in-charge at the beginning of each visit. The response from the
medical director, matron and all other respondents with whom the team had contact was always respectful.
The teams carried with them official letters of cooperation from the DPS. Providers who were interviewed for
Modules 6A and 6B (knowledge interviews in maternal, newborn and child health) granted oral consent prior
to the interview itself, and this oral consent was recorded in the module. Provider names were not recorded,
and results of these knowledge interviews are presented in the aggregated to reduce deductive disclosure of
respondents.
2.7 Organization of the report

Chapter 3.0 present selected results from the analysis. Results are organized into the sub-sections below:
• Section 3.1. This section presents the characteristics of facilities that were included in the assessment.
• Section 3.2. General service readiness including aspects of infrastructure (electricity, water,
sanitation, waste management, and infection prevention), overview of MNCH services offered,
availability of pharmacy, laboratory, blood transfusion and surgical services, and measures of facility
capacity (i.e. beds per deliveries).
• Sections 3.3 Maternal and Newborn Health) and 3.4 Child Health. These sections present selected
results that describe facility capacity to provide specific medical interventions that make up the
packages of MNCH services. Presented results include availability of the minimum required
infrastructure, presence of clinical guidelines, minimum human resources (HR) to provide each
medical intervention, and availability of key drugs, equipment and supplies. We also present recent
provision of specific components of MNCH services (e.g. within the previous 3 months). For section
3.3, we provide an analysis of the availability of EmONC and CSSN services; for Section 3.4 we discuss
planning and implementation of immunization services.
• Section 3.5. Selection of indicators calculated using facility case statistics including indicators of ANC
coverage and use, PNC use, institutional delivery rates and aspects of quality of care, distribution of
maternal complications and deaths, newborn outcomes and number of child deaths by cause.
• Section 3.6: This section present results from across various modules that provide a picture of facility
and district-level capacity to implement QI mechanisms and to deliver humanized services. This
section includes results of the ANC observations (Module 7), which are organized within the standards
of the recent Respectful Maternity Care Charter.
• Section 3.7. This section presents characteristics of providers who participated in the knowledge
interviews of maternal, newborn and child health, and the resulting knowledge score for each
component of care included.
• Section 3.8. This section includes results related to stockouts of key drugs and oxygen supply.
• Section 3.9. Provides a beginning investigation into aspects of the HMIS systems including availability
of computer/internet and registers, practices around classification of deaths, and validation of key
indicators triangulated with SIS-MA data for the same period.
To minimize the length of this report, we do not present district-level results. However, we have analyzed
most results to the district level, which will be used by project staff to inform activities and workplanning.
3.0 Results
3.1 Surveyed health facilities
Master facility lists provided to Alcançar by DPS indicate a total of 241 health facilities in Nampula (Table
3.1.1). Thirteen of these facilities were not visited during the baseline assessment because they no longer
exist (e.g. Cimentos Health Center and Natoa Health Center), were too new to have adequate statistics or
staff, or because they are not expected to provide MNCH services.
Data collection teams visited a total of 228 hospitals and health centers during field work. All modules were
attempted at each visited facility, and modules included filter questions to minimize asking of irrelevant
questions (e.g. if a facility did not have surgical capacity, data collectors were skipped out of detailed
questions about equipment in the operating theater).
Facilities determined to not currently provide maternity services, as per data collected during this assessment,
are excluded from this report. The monitoring and evaluation (M&E) team will later analyze data from these
facilities; however, for the purposes of identifying key gaps in facility capacity, the exclusion of these facilities
is unlikely to substantially influence the interpretation of results.
Therefore, the maximum number of facilities included in the report tables is 200. This includes 9 hospitals and
191 health centers, the overwhelming majority of which are Type II Rural Health Centers (141). Most report
tables collapse facilities into categories as per the groupings shown in Table 3.1.1.:
• Health Centers and Hospitals
• District Groups used by Alcançar to prioritize and phase activities.
o Innovation Districts are the seven districts receiving the most intensive level of contact in PY1
and PY2. The seven Innovation Districts are also the location of the 35 health facilities
(Innovation Facilities) that will launch the Quality Improvement Collaboratives.
o There are six Priority Districts which also receive an intensive level of contact in PY1 and PY2,
but which are not the site of the QI Collaboratives.
o The remaining 10 districts receive a lower intensity of contact in PY1 and PY2, thus they are
referred to as Future Focal Districts.

Table 3.1.1. Distribution of health facilities according to inclusion in the baseline assessment, by facility type and district
Included faciities
Total Hospitals Urban Health Centers Rural Health
Total number Total facilities Total facilities
Total facilities facilities
of health not visited for visited, but Health
visited for the included Total
facilities in the excluded from Centers
assessment in this Hospitals Central General Rural District A B C Tipo I Tipo II
Nampula assessment1 the report2 Total
report
Nampula 241 13 228 28 200 9 1 1 2 5 191 4 7 4 35 141
Distritos
Innovation 96 2 94 12 82 7 0 0 2 5 75 1 3 1 6 64
Angoche 19 0 19 7 12 1 0 0 1 0 11 0 0 0 1 10
Erati 11 0 11 0 11 1 0 0 0 1 10 0 0 0 0 10
Memba 14 0 14 1 13 1 0 0 0 1 12 0 0 0 3 9
Moma 11 0 11 0 11 1 0 0 0 1 10 0 0 0 1 9
Monapo 17 0 17 0 17 1 0 0 0 1 16 0 0 0 0 16
Nacala 14 2 12 4 8 1 0 0 0 1 7 1 3 1 0 2
Ribaue 10 0 10 0 10 1 0 0 1 0 9 0 0 0 1 8
Priority 44 4 40 2 38 0 0 0 0 0 38 0 0 0 10 28
Liupo 3 0 3 0 3 0 0 0 0 0 3 0 0 0 0 3
Meconta 8 1 7 0 7 0 0 0 0 0 7 0 0 0 4 3
Mogovolas 8 1 7 0 7 0 0 0 0 0 7 0 0 0 1 6
Mossuril 12 2 10 1 9 0 0 0 0 0 9 0 0 0 1 8
Nacala-a-Velha 6 0 6 1 5 0 0 0 0 0 5 0 0 0 1 4
Nacaroa 7 0 7 0 7 0 0 0 0 0 7 0 0 0 3 4
Furture Focal District 76 6 70 13 57 2 1 1 0 0 55 3 4 3 10 35

Distrito de Nampula 28 5 23 9 14 2 1 1 0 0 12 2 3 3 2 2
Ilha de Mocambique 5 0 5 0 5 0 0 0 0 0 5 1 1 0 0 3
Lalaua 7 0 7 0 7 0 0 0 0 0 7 0 0 0 2 5
Larde 7 1 6 2 4 0 0 0 0 0 4 0 0 0 0 4
Malema 10 0 10 1 9 0 0 0 0 0 9 0 0 0 2 7
Mecuburi 13 0 13 1 12 0 0 0 0 0 12 0 0 0 2 10
Mogincual 6 0 6 0 6 0 0 0 0 0 6 0 0 0 2 4
Muecate 11 0 11 0 11 0 0 0 0 0 11 0 0 0 5 6
Murrupula 6 0 6 0 6 0 0 0 0 0 6 0 0 0 2 4
Rapale 8 1 7 1 6 0 0 0 0 0 6 0 0 0 2 4
1. Facilities were excluded because they no longer exist or started operating in the last 6 months, because they were private facilities
2. Facilities that were not providing maternity services, as per data collected the baseline assessment, are excluded from this report.

3.2 Facility infrastructure for general service readiness
In this section we present an overview of general service readiness including electrical supply and reliability,
water sources, sanitation services, and availability of MNCH services.
Electricity
Widespread lack of energy access within the health sector in Mozambique, and sub-Saharan Africa generally,
is a persistent barrier to the attainment of universal coverage of quality health services. Without electricity,
many essential and life-saving services simply cannot be provided. The availability of reliable electricity
supply is critical for the provision of quality MNCH health services, the safety of clients and providers alike at
all facility levels.
WHO is developing minimum standards of electric service capacity required to delivery specified packages of
services, and definitions of ‘electric adequacy’ have emerged. To ensure adequate services, electrical supply
must be without gaps, and available throughout service hours to support the cold chain immunizations,
blood and some medications; ensure continuous adherence to infection prevention practices including
sterilization of medical equipment; support continuity of care through timely completion and reporting of
laboratory test results, entry of patient data into the electronic medical record system, and ordering of
commodities via electronic logistics and information systems.1,2
The electricity supply must be of sufficient quality to avoid voltage fluctuations, often characteristic of the
central grid supply that can damage laboratory equipment, refrigerators, and computers. Furthermore,
health providers’ job satisfaction is impacted by their ability to adequately perform their duties as well as the
comfort and convenience of their work environment.3,4 For staff who live in on-site quarters, electricity
access and lighting can contribute to improved satisfaction with living conditions (e.g. allowing electronic
devices to be charged; providing heating, cooling, routine and security lighting, and television), thus
influencing worker retention particularly in rural areas.5
Renewable energy solutions can address most of these challenges. In many countries, including
Mozambique, rooftop solar panels and mini-systems have been used to address the immediate need for
quality lighting and electricity in small facilities; on-site photovoltaic power systems are being installed as
either primary or back-up sources for small health facilities as well as hospitals; and, hybrid solar-diesel
(photovoltaic plus generator) systems can provide additional protections from any intermittent power
interruptions.1,2
In Nampula, almost one-quarter of health facilities are without any source of electricity (Figure 3.2.1). The
primary source of electricity is Electricidade de Mozambique (EDM)’s electric transmission network (the grid)
and 42% of health facilities in Nampula, including all 9 hospitals, are connected. Solar energy is also widely
used by health centers, providing the sole source of energy to 35% of health centers.
Reliability of the EDM electric supply is poor (Figure 3.2.2.). Among the 83 facilities that are connected to
the grid, more than 46% (38) indicated that they were without electric supply for more than 2 hours in the
1
Adair-Rohani, Heather, et al. "Limited electricity access in health facilities of sub-Saharan Africa: a systematic review of
data on electricity access, sources, and reliability." Global Health: Science and Practice 1.2 (2013): 249-261.
2
World Health Organization. Access to modern energy services for health facilities in resource-constrained settings: a
review of status, significance, challenges and measurement. World Health Organization, 2014.
3
Mutale, Wilbroad, et al. "Measuring health workers’ motivation in rural health facilities: baseline results from three
study districts in Zambia." Human resources for health 11.1 (2013): 1.
4
Mbindyo, Patrick M., et al. "Developing a tool to measure health worker motivation in district hospitals in Kenya."
Human Resources for Health 7.1 (2009): 1.
5
Lehmann, Uta, Marjolein Dieleman, and Tim Martineau. "Staffing remote rural areas in middle-and low-income
countries: a literature review of attraction and retention." BMC health services research 8.1 (2008): 1.
week previous week. An additional 12% (10) experienced an interruption that was less than 2 hours.
Infrastructure to mitigate the unreliable power supply is rare, with just 10% of grid-connected facilities
reporting a back-up generator. Among all facilities with a generator (10), one was not ready for use at the
time of the survey, and only three were wired to automatically connect with a loss of power. It is worth
noting that all hospitals were connected to EDM and most (8) had a backup generator ready to be used.
Figure 3.2.1 Availability and sources of electricity, by facility type
Figure 3.2.2 Reliability of supply, among facilities connected to the electrical grid, by facility type
100%
80%
60% No interruption in past week
40% Interruption < 2 hours in last

week
20% Interruption lasting >2 hours in

last week
0%
Nampula Hospitals Health
(n=83) (n=9) Centers
(n=74)
Water and Sanitation

Improved water, sanitation and hygiene (WASH) practices, at home and in health facilities, are critical
determinants for survival. WASH has long been acknowledged as a primary intervention to prevent the two
major causes of childhood deaths globally—diarrhea and acute lower respiratory infection and its role in
preventing negative effects of infectious diseases on child growth and nutrition are well-established. With
the advent of the Sustainable Development Goals, the importance of WASH in institutions – including health
facilities – has come to the fore as a strategy to reduce newborn mortality. Infections account for 14% of
newborn deaths in the early neonatal period and nearly half of late neonatal deaths – many of which are

attributable to inadequate hygiene.6 Expert opinion suggests that 27% of infections among babies born in
hospitals could be reduced with clean delivery practices.7 Puerperal sepsis caused almost one in ten of all
maternal deaths in 2013.8
In Nampula, 15% of health facilities are without a source of water (Figure 3.2.3). All hospitals have a source,
with most (78%) of them reporting piped water into the facility. Just 29% of health centers have piped
water. The most common source of water among health centers is a hand-pump. Variation in water supply
across districts is worth noting – in Moma, Mossuril, Mecuburi, Muecate, and Murrupula districts, more than
30% of all health facilities report no source of water (data not shown). Further, more than 70% of facilities
in Nacala, District of Nampula and Ilha de Mocambique have piped water.
Figure 3.2.3 Availability and sources of water, by facility type
All Nampula hospitals have sanitation facilities for employees and patients and just over half of health
centers have a bathroom or a latrine for employees (54%), while 85% have a bathroom or latrine for patients
(Figure 3.2.4). In hospitals, sanitation facilities are either flush or non-flush toilets (Figure 3.2.5). In health
centers, employee facilities are most likely to be flush toilets, followed by a toilet without a flush; whereas,
patient facilities are most commonly ventilated improved latrines (44%) or traditional improved latrines
(24%).
6
WHO, UNICEF. Water, sanitation and hygiene in health care facilities: status in low and middle income countries
and way forward [Internet]. Geneva: WHO; 2015. Available: http://www.who.int/water_sanitation_
health/publications/wash-health-care-facilities/en/.
7
Blencowe H, Cousens S, Mullany LC, Lee ACC, Kerber K, Wall S, et al. Clean birth and postnatal care
practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation
of mortality effect. BMC Public Health. 2011; 11 Suppl 3: S11. doi: 10.1186/1471-2458-11-S3-S11
PMID: 21501428
8
Kassebaum, Nicholas J., et al. "Global, regional, and national levels and causes of maternal mortality during 1990–
2013: a systematic analysis for the Global Burden of Disease Study 2013." The Lancet 384.9947 (2014): 980-1004.
Figure 3.2.4 Availability of sanitation facilities for patients and employees, by type of facility
Figure 3.2.5 Types of sanitation facilities available for patients and employees, by type of facility
Availability of key RMNCH services by facility type

Across Nampula in general, reproductive and MNCH services are widely available. In the next section (3.3),
we scrutinize facility capacity and readiness to provide important high-impact interventions and components
of these care packages. In this Section, we look generally at broad availability of services.

Health Centers in Nampula widely offer most packages of reproductive and maternal health services
including ANC and PNC, testing and treatment of STIs, and family planning (FP) (Figure 3.2.6). However,
there are gaps in availability of postabortion care (PAC) and cervical cancer screening at health center level.
All hospitals report providing PNC, screening and treatment of STIs, PAC, FP and cervical cancer screening, as
well as obstetric surgery and radiology.
Availability of child health services, including routine vaccinations, growth monitoring and infant and young
child feeding (IYCF), as well as screening and treatment of childhood illnesses and malnutrition, are widely
available at health centers. It is worth noting that not all hospitals offer vaccination of newborns, growth
monitoring or IYCF.
Figure 3.2.6 Availability of key RMNCH services, by facility type

Table 3.2.6. Availability of pharmacy, laboratory, blood transfusion and obstetric surgery,, by facility type
Health
Total Hospitals
Centers
Pharmacy
Among all facilities n=200 n=9 n=191
Facility has pharmacy/drug store 89% 100% 88%
Facility has no pharmacy or store but has a supply of medicines 100% 100% 99%
Number of facilities with either a pharmacy/drug store or a supply of medicines n=199 n=9 n=190
Among those with pharmacy/supply of medicines, drug inventory register exists and is up-to-date 98% 100% 98%
Laboratory
Facility has a laboratory 29% 100% 26%
Among facilities with a laboratory n=58 n=9 n=49
Has set of guidelines for laboratory 88% 100% 86%
Blood transfusion
Facility offers blood transfusion services 19% 100% 15%
Among facilities that offer blood tranfusion n=37 n=9 n=28
Average number of units of blood in stock 6 16 3
Had interruption in the availability of blood in the last 3 months 57% 22% 78%
Blood is always screened for infectious diseases before transfusion* 95% 89% 96%
Surgery
Among all hospitals n=9 n=9 -
Operating room for major surgeries 100% 100% -
Separate operating rooms for obstetric patients only 56% 56% -
*defined as always screening for HIV, Hep b, Hep C and syphillis
Across Nampula Province, most health facilities have a pharmacy or a drug store (89%) and all have a supply
of medicine (even if no pharmacy), and the availability of an up-to-date drug inventory register is almost
universal (98%) (Table 3.2.6). All hospitals have a laboratory, though just over one-quarter of health centers
do. Further disaggregation of laboratory presence by Health Center types might reveal some patterns as to
the which health centers are most likely to have laboratories. Among facilities with a laboratory, all hospitals
had a set of guidelines in place but only 86% of health centers with a laboratory did.
Blood transfusion services are universally available among hospitals, and 15% of health centers offer blood
transfusion. On average, facilities that offer transfusion services have 6 units of blood in stock and 57% of
facilities (including 22% of hospitals) have experienced a stock out of blood supply in the previous 3 months.
Further, almost all (but not all) hospitals or health centers report always screening donated blood for HIV,
Hep B, Hep C and syphilis before transfusion. Regarding surgical capacity, all hospitals offer surgery but not
all have a separate operating theatre for obstetric patients.

Table 3.2.7. Availability of infection prevention supplies in the maternity, by facility type
Health
Total Hospitals
Centers
n=200 n=9 n=191
Basic items
Soap 45% 78% 43%
Antiseptics 80% 100% 79%
Disposable latex examination gloves 81% 100% 80%
Elbow length gloves 78% 89% 77%
Heavy duty gloves 80% 100% 79%
Eye shields 52% 89% 50%
Mask 78% 100% 77%
Non-sterile protective clothing 60% 100% 58%
Decontamination container 83% 100% 82%
Bleach or bleaching powder (chlorine) 70% 89% 69%
Prepared disinfection solution 59% 100% 57%
Regular trash bin 89% 100% 88%
Covered contaminated waste trash bin 89% 100% 88%
Puncture proof sharps container 95% 100% 94%
Mayo stand/table (or equivalent to
41% 89% 39%
establish sterile field)
Surgeon's hand brush with nylon bristles 8% 56% 5%
Surgeon's boots 6% 67% 3%
Disinfectants and antiseptics

Chlorhexidine solution (Savlon) 50% 67% 49%
Ethanol (75%) 32% 100% 29%
Ethanol (95%) 22% 89% 18%
Polyvidone iodine 17% 33% 16%
Alcohol-based rub 71% 100% 70%
1
For hospitals or large health centers, the maternity area was likely to be a
specific room and these questions were related to the items available in that
specific room. Smaller health centres may not have had a specific room
devoted to a maternity and these questions were therefore related to
whether the facility, in general, had the items available.
To ensure the safety of health providers and patients and to prevent the spread of infections, health facilities
must have an adequate and reliable supply of infection prevention equipment and, along with well-defined
standards and procedures, infrastructure to sterilize equipment and properly dispose of hazardous wastes.
Eighty percent or more of health facilities in Nampula had antiseptics, disposable gloves, heavy duty gloves,
decontamination containers, covered waste bins, and sharps container available in the maternity area (Table
3.2.7). Not quite half of health facilities in Nampula had soap available in the maternity ward – whereas, 71%
reported having alcohol-based rub for hand sanitizing. In general, hospitals were better supplied than health
centers, but some hospitals lacked soap, elbow length gloves, a mayo stand, hand brush and boots.
Equipment for sterilization is not widely available (Table 3.2.8). Only 22% of hospitals have an autoclave
devoted to the maternity area. In general, autoclave space is shared across areas of the facility. Many health
centers are without modern sterilization equipment. On the other hand, functioning incinerators and placenta
pits are widely available for final disposal of waste.

Table 3.2.8. Availability of sterilization infrastructure in the maternity
Health
Total Hospitals
Centers
n=200 n=9 n=191
Physical space for autoclave (% distribution)*
Has separate equipment and space 35% 22% 36%
Shares space and equipment with other services 60% 78% 59%
Other 3% - 3%
Sterilization equipment
Autoclave with temperature and pressure gauges 39% 89% 37%
Hot air sterilizer (dry oven) 16% 56% 14%
Steam sterilizer 16% 56% 14%
Steam instrument sterilizer/pressure cooker, electric 13% 56% 11%
Sterilizer/pressure cooker, kerosene heated 21% 33% 20%
Sterilization drum 21% 33% 20%
Sterilization drum stand 16% 33% 15%
Waste management and disposal

Functioning incinerator 73% 100% 72%
Placenta pit 83% 100% 82%
1
For hospitals, the maternity area was likely to be a specific room and these questions were
related to the items available in that specific room. Health centres may not have had a specific
room devoted to a maternity and these questions were therefore related to whether the facility,
in general, had the items available.
*one health center is not included due to missing data (n=187)
Table 3.2.9. Average number of beds per facility and ratio of beds to deliveries
Ratio of Ratio of
Total Todal Average obstetric delivery
Number Total annual Tota number
number of number of number of beds per beds per
of institutional of beds in
obstetric delivery beds per 1,000 1,000
facilities deliveries2 facilities
beds3 beds facility institutional institutional
deliveries deliveries
Nampula 200 232,256 3,770 1,215 425 19.3 5.2 1.8
Type of facility
Hospitals 9 26,274 1,339 253 28 148.8 9.6 1.1
Health Centers 191 205,982 2,431 962 397 14.0 4.7 1.9
District group
Innovation 82 93,714 1,639 511 168 20.2 5.5 1.8
Priority 38 51,820 534 195 92 14.4 3.8 1.8
Future Focal District 80 86,602 1,597 509 165 22.7 5.9 1.9
1
According to the Essential elements of obstetric care at first referral level (WHO, 1991) there should be 24 beds per 1,000 deliveries
in the maternity ward (for both prenatal and postnatal clients). The labour and delivery room should have 6-8 beds. Overall,
therefore, the standard would be approximately 30-32 beds per 1,000 deliveries at a facility that would be considered 'first referral
level.' This is the equivalent to a district level hospital for about 100,000 population.
2
Deliveries from the period of January through June 2019, and doubled to estimate a 12-month volume.
3
For antenatal, postpartum, post-operative, postabortion (etc.) clients.
The estimated annual volume of institutional deliveries in Nampula province is just over 232,000 (Table 3.2.9).
Health centers account for the vast proportion of these deliveries compared to hospitals (205,982 annual
deliveries vs. 26,274) yet the physical capacity to accommodate these patients – at least as described by the
ratio of obstetric beds to institutional deliveries – is inadequate among health centers. Health centers have,
on average, 4.7 beds for every 1000 deliveries they attend, whereas hospitals have 9.6 beds per 1000
deliveries. According to some interpretations of WHO standards, the number of obstetric beds per 1000
deliveries should be just over 20 to adequately accommodate pre-labor, labor and post-partum patients.
It is worth noting that facilities in Alcançar’s Innovation and Priority districts account for 63% of all institutional
deliveries in Nampula Province (145,534 deliveries of 232,253).
Summary of key findings and recommendations

Key Findings:
• Access to a reliable source of electricity remains a key issue throughout Nampula province, especially
among health centers. Almost a quarter of health facilities in Nampula have no source of electricity.
While 42% of health facilities are connected to the national electrical grid (EDM), almost half of those
facilities experienced a power supply interruption of more than two hours in the week prior to data
collection.
• Nampula province health facilities have achieved mixed success in improving WASH practices. Not all
health centers in Nampula have some form of sanitation facility. Most have a sanitation facility for
patients (85%) but just 54% of health centers have a toilet or latrine of some kind for employees to
use. There are significant disparities in access to water according to facility type and district. Of note,
30% of health facilities in Moma, Mossuril, Mecuburi, Muecate, and Murrupula districts report no
source of water.
• MNCH and pharmacy services are widely available across Nampula health facilities, though provision
of PAC, cervical cancer screening, newborn vaccinations, child growth monitoring, and IYCF varies by
facility type.
• Laboratories and blood transfusion services are universally available among hospitals, but much less
prevalent among health centers. Achieving universal screening of blood and reducing stock outs of
blood are key challenges to the provision of optimal care.
• Infection prevention materials were available in most facilities, though critical gaps remain in the
supply of sterilization equipment and soap.
• Health centers oversee a significant majority of institutional deliveries throughout Nampula province,
yet in comparison with hospitals, those facilities are much less equipped to provide sufficient beds for
the volume of obstetric patients they receive.
Recommendations:
• Increased infrastructure is needed to ensure reliable access to electricity and water, especially among
health centers and facilities in Moma, Mossuril, Mecuburi, Muecate, and Murrupula.
• Improvements in facility access to water should be accompanied by increased provision of soap to
promote recommended WASH practices.
• Increased management systems and supplies are needed to ensure the screening of blood for
transfusions and prevent blood supply stockouts.
• Special attention is needed to provide adequate space and patient beds for the high volume of women
receiving care around the time of childbirth in health centers.

3.3 Capacity to provide the continuum of pre-pregnancy, delivery, post-partum and
newborn care (IR 2.1 and IR 2.2)
In this section we present results on the key components of facility MNH readiness including availability of
critical infrastructure, guidelines, minimum staffing, drugs and equipment, provision of routine interventions,
and an analysis of EmONC coverage.
Infrastructure and guidelines

Table 3.3.1. Infrastructure in maternity and L&D areas
Health
Total Hospitals Centers
(n=200) (n=9) (n=191)
Sufficient light source to perform tasks during the day 82% 100% 81%
Sufficient light source to perform tasks at night 53% 100% 51%
Means of ventilation 47% 78% 45%
Functioning toilet for patient use 76% 89% 75%
Heating/heating arrangements 20% 89% 17%
Functional fan/air conditioning 10% 33% 8%
Curtains/means of providing patient privacy 58% 78% 57%
Waiting area for visitors and family 29% 44% 28%
Rest area for health personnel 14% 22% 13%
Functioning toilet for visitors' and family use 48% 78% 46%
Basic infrastructure for maternity and labor and delivery services includes adequate light to complete tasks
during the day and night, bathrooms for patients and their visitors, a source of heat and a fan or air
conditioning, privacy curtains, a waiting area, and a place for facility staff to rest. Overall, infrastructure in
these areas is inadequate. Hospitals are significantly better equipped in the maternity and labor and delivery
areas, yet the majority of Nampula hospitals still lack working fans or air conditioning, waiting areas for visitors,
working bathrooms for visitors, and space where staff can rest. Almost half of health centers are without
adequate lighting to perform tasks at night.
Table 3.3.2. Presence of relevant MNH guidelines

Total Hospitals Hospitals
(n=200) (n=9) (n=9)

Guidelines, protocols, or job aids
National ANC Guidelines 27% 56% 26%
Checklist or guidelines for ANC 35% 33% 35%
TIP checklists and / or guidelines (including graphics) 36% 44% 35%
Provision of respectful maternity care 50% 89% 48%
Prevention of mother-to-child transmission of HIV 74% 100% 72%
Management protocols for selected obstetric topics (for health centers, hospitals) 37% 78% 35%
Infection prevention guidelines 60% 89% 59%
Integrated management of pregnancy, delivery, postpartum and newborn care 54% 78% 53%
Care for premature and low birthweight babies, including KMC 46% 67% 45%
Newborn resuscitation 50% 89% 48%
Integrated management of newborn and childhood illnesses (IMNCI) 37% 56% 36%
Referral and counter-referral norms 63% 78% 62%
Post partum family planning 82% 100% 81%
IMNCI = integrated management of neonatal and childhood illness; KMC = kangaroo mother care; PMTCT = prevention of mother-to-child
transmission (of HIV).
1
For hospitals, the maternity area was likely to be a specific room and these questions were related to the items available in that specific
room. Health centres may not have had a specific room devoted to maternity and these questions were therefore related to whether the
facility, in general, had the items available.
The most commonly available guidelines related to maternal and newborn health were for post-partum family
planning, PMTCT, infection prevention, and referral and counter-referral norms. Notably, only a quarter of
health centers had the national guide for pre-natal care/ANC available on the day of the survey.
Human Resources
Figure 3.3.3. Percent of facilities with at least one provider capable of providing key MNH services, by facility
type

A strategic objective of the health system is to ensure the availability of the right mix of adequately skilled and
motivated staff who are committed to work and stay in a well-managed sector. This includes expanding the
availability of critical human resource categories by scaling-up the training of professionals who are in scarce
supply such as MNCH nurses and APEs - which Mozambique is committed to - and by improving the motivation
and retention of HR through the implementation of evidence-based financial and non-financial incentives.
Data collected during this baseline assessment can help inform health planners in Nampula about the
strengths and gaps in availability and posting of human resources. At each health facility, data collectors asked
facility staff (e.g. human resource or administrative directors, or the facility in-charge) about the availability of
personnel, the training they have received, and the specific medical interventions that each cadre is routinely
providing. Data collectors gathered information on the total number of health workers (in 25 different cadres)
that are currently posted at each facility, how many have recently left, and the total number of male and
female workers (in each cadre). Further, we gathered information on the number of each cadre that have
received training in critical skills packages for MNCH (e.g. EmONC, Helping Babies Breath, Integrated Care for
Childhood Illnesses, Immunization, FP, etc.).
In this preliminary report, we present a summary result indicating the percent of health facilities where at
least one health provider currently posted at that facility can provide critical MNH interventions (Figure 3.3.3).
(Results on the availability of staff who can provide components of child Health services are presented in
Section 3.4).
Hospitals and health centers are at least minimally staffed to provide most routine MNCH services including
normal deliveries, use of the partograph, PNC and post-partum family planning. There are important gaps, in
health centers particularly, in human resources to provide newborn vaccinations.
Health centers and hospitals appear to be minimally staffed to manage most obstetric complications. Ninety
percent or more of hospitals and health centers have staff to provide six of the seven basic emergency
obstetric and newborn care (EmONC) signal functions (i.e. parenteral antibiotics, uterotonics, anticonvulsants,
manual removal of the placenta, removal of retained products of conception and newborn resuscitation).
However, it is worth noting that staffing to provide these critical life-saving interventions is not universally
available at health centers or hospitals in Nampula – an important area for potential improvement. Further,
few facilities have staff to provide assisted vaginal delivery (i.e. delivery of a baby with the use of a vacuum
extractor or forceps). The lack of this emergency intervention further emphasizes the importance of timely
access to surgical delivery for every pregnant woman. All hospitals are at least minimally staffed to provide
caesarean delivery and blood transfusion.
The World Health Organization has recently released a strategy to transform the care of small and sick
newborns (CSSN).9 Results of this baseline assessment indicate important areas for improvement around
staffing for the practices identified as key components of that strategy. An important discussion for Alcançar
to have with MISAU, DPS and others is around identifying the appropriate levels of the health system where
each CSSN practice can and should be delivered. For example, health centers are currently best staffed to
provide newborn resuscitation, antibiotics for preterm, premature rupture of membranes (pPROM),
antibiotics for newborn sepsis, KMC for small babies, and management of newborn convulsions. Currently, in
Nampula, administration of safe oxygen to newborns is predominately within the purview of hospitals.
Further, fewer than 80% of health centers are staffed to provide antenatal corticosteroids, IV fluids to
newborns, or alternative feeding.
9
World Health Organization, 2019. Survive and thrive: transforming care for every small and sick newborn.
Drugs, equipment and supplies for maternal and newborn care
Another critical component of facility capacity to provide quality services is the availability of commodities,
drugs and supplies. Tables 3.3.4A and 3.3.4B present results on the proportion of facilities that had specific
MNH drugs and supplies available on the day of the survey (results related to key child health drugs and
supplies are presented in Section 3.4). Important gaps are noted in the availability of antibiotics, magnesium
sulphate, and oxytocin at health centers.
Table 3.3.4A. Availability of key drugs, equipment and supplies for maternal health services (on the day of the
survey), by facility type
Health
(n=200) (n=9) (n=191)
% % %
Antibiotics (any)
Ampicillin (injection) 51% 78% 50%
Penicillin G (benzyl) 67% 100% 67%
Gentamicin (injection) 58% 100% 56%
Kanaymcin (injection) amp 2g 2% 0% 2%
Metronidazole (injection) 49% 44% 49%
Chloramphenicol (injection) 33% 89% 30%
Cephalosporin (injection) 19% 78% 16%
Anticonvulsants (any)
Magnesium sulphate (injection) 77% 100% 75%
Diazepam (injection) 89% 67% 90%
Antihypertensives (any)
Dihydralazine (injection) 25 mg 33% 100% 30%
Methyldopa 41% 100% 38%
Nifedipine 14% 56% 12%
Oxytocics and prostaglandins (any)

Oxytocin (injection) amp 10UI/MI 87% 89% 87%
Misoprostol (Cytotec), cp 200mg 32% 67% 30%
Ergometrine 13% 33% 12%
Drugs used in emergencies (any)

Adrenaline (epinephrine) 90% 89% 90%
Calcium gluconate 6% 11% 5%
Atropine 15% 78% 12%
Dopamine (injection) 1% 0% 1%
Aminophylline 49% 100% 47%
IV fluids (any)
Dextrose (5%), 1L bottles 78% 100% 77%
Dextrose (30%) 38% 100% 35%
Sodium Bicarbonate 21% 22% 20%
Normal saline, 1L bottles 81% 100% 80%
Dextran or plasma gel 8% 22% 7%
Ringer's lactate 82% 100% 81%
1
If fa ci l i ty reported nei ther a pha rma cy nor a s uppl y of medi ci nes , tha t fa ci l i ty wa s
a s s umed not to ha ve the drug. Mi s s i ng i nforma ti on wa s a l s o ta ken a s not ha vi ng the drug.

Table 3.3.4B. Availability of key drugs, equipment and supplies for maternal health services (on the day of the
Health
(n=200) (n=9) (n=191)
% % %
Antimalarials (any)
Coartem (artemether/lumefantrine) 87% 100% 86%
Quinine (injection) 5% 11% 4%
Quinine, oral 59% 100% 57%
Artesunate 47% 89% 45%
Other drugs and supplies

Ferrous sulphate or fumarate 72% 100% 70%
Folic acid 33% 44% 32%
Ferrous sulphate with folic acid 91% 100% 91%
Anti-tetanus serum/TAT 22% 0% 23%
Tetanus toxoid vaccine 92% 89% 92%
Anti-rho (D) immune globulin 10% 11% 10%
ITNs 26% 0% 27%
Mebendazole 92% 100% 92%
Metoclopramide 86% 100% 85%
Equipment
Filled O2 cylinder, carrier, and key 9% 89% 5%
Ultrasound 5% 89% 1%
Cardiotocography (external or internal) 2% 33% 1%
Blood pressure cuff 51% 89% 49%
Stethoscope (for adult) 65% 100% 63%
Stethoscope (for foetus) 86% 78% 86%
Doppler 6% 56% 4%
Thermometer (clinical) 80% 89% 80%
Thermometer (low reading) 29% 33% 28%
Supplies
Suture needles/suture materials 92% 100% 91%
Catheter for IV line (16-18) 83% 100% 82%
IV infusion stand(s) 87% 100% 86%
Urinary catheters 42% 89% 40%
IV cannulae (24 gauge) 50% 100% 48%
Dipstick for urinalysis 5% 33% 3%
Ventilator bag and mask (for adult) 54% 100% 52%
Partograph form 71% 100% 69%
Watch or clock with second hand that can be easily seen 29% 67% 27%
Measuring tape 93% 100% 92%
Obstetric wheel 33% 67% 31%
Tubing for oxygen administration 12% 89% 8%
Pulse oximeter 15% 33% 14%
Apnoea monitor 4% 22% 3%
HIV rapid test kit 93% 100% 93%
1
If fa ci l i ty reported nei ther a pha rma cy nor a s uppl y of medi ci nes , tha t fa ci l i ty wa s a s s umed not to
ha ve the drug. Mi s s i ng i nforma ti on wa s a l s o ta ken a s not ha vi ng the drug.

Table 3.3.5. Availability of key drugs, equipment and supplies for newborn health services (on the day of the
Health
(n=200) (n=9) (n=191)
% % %
Basic newborn care
Baby weighing scale 90% 100% 90%
Cord ties/clips 94% 100% 93%
Thermometer for newborn 46% 56% 46%
Caps or hats to prevent heat loss 17% 67% 14%
Towels/blankets or cloth for newborn 15% 44% 13%
Vitamin K (for newborn) 66% 100% 64%
Chlorhexidine (4% gel) 51% 67% 50%
Phenobarbital 29% 100% 25%
Nystatin (oral, for newborn) 72% 44% 73%
Newborn resuscitation
Neonatal resuscitating corner 49% 89% 47%
Mucus extractor/simple suction 77% 100% 76%
Neonatal face masks (size 0) 43% 89% 41%
Neonatal face masks (size 1) 41% 89% 39%
Neonatal size ambu (ventilatory bag) 87% 100% 86%
Suction catheter (10, 12Ch) 28% 33% 27%
Infant laryngoscope with spare bulb and batteries 3% 11% 3%
Endotracheal tubes (3.5, 3.0, 2.5mm) 5% 44% 3%
Disposable uncuffed tracheal tubes (sizes 2.0-3.5) 12% 56% 10%
Suction apparatus (foot- or electrically-operated) 14% 67% 12%
Mucus trap for suction 8% 33% 7%
Newborn anatomical model (for practice) 29% 89% 26%
Small and sick newborns 0% 0% 0%

Register for sick babies 93% 100% 92%
Daily patient chart 88% 100% 87%
IV fluid (neonatal giving) set 42% 78% 40%
Exchange transfusion set 12% 89% 8%
Umbilical catheter 9% 44% 7%
Syringes (0.5, 1.0ml) 71% 78% 71%
Radiant warmer 22% 78% 19%
Incubator 4% 44% 2%
Designated space or beds for KMC 38% 78% 36%
KMC register 60% 78% 59%
Nasogastric feeding tube (#4) 28% 89% 25%
Cup and spoon for infant feeding 23% 56% 21%
Cup for breast milk expression 13% 44% 11%
Icterometer 1% 11% 0%
Fluorescent tubes for phototherapy to treat jaundice 7% 56% 5%
Oxygen source for newborns 9% 89% 5%
Laryngoscope (newborn size) 1% 11% 0%
Respirator for neonates 7% 78% 3%
CPAP machine 19% 56% 17%
CPAP = continuous positive airway pressure; KMC = kangaroo mother care.

Availability of maternal and newborn health services
In addition to asking about whether facilities were staffed and equipped to provide services, we gathered
information on whether each facility had recently provided specific MNH interventions (report on provision
of child health services are reported under Section 3.4).
Routine services for maternal and newborn care are provided widely in hospitals and health centers (Figure
3.3.6). However, health centers are unlikely to provide alternative feeding to newborns or a surgical method
of family planning, the latter is not surprising and the former mirrors the findings on staffing in health centers
for alternative feeding. Of note is that application of chlorhexidine to the umbilical cord is not universally
available at health centers or hospitals. Clarification around DPS and MISAU objectives regarding
chlorhexidine application may be useful.
Management of complications for newborns and pregnant women, women in labor or in the post-partum
period– i.e. provision of the signal functions of EmONC – appears to be concentrated in hospitals, with the
notable exception of antibiotics and oxytocics. The low provision of anticonvulsants at health centers is worth
investigating as it is a practice that can be decentralized to health center level, thus mitigating the need for
rapid referral of women with severe pre-eclampsia or eclampsia. Manual removal of placenta and removal
of retained products are also life-saving interventions that can be safely provided at health center level – and
many health centers are providing these services. Further analysis of provision of these services that
disaggregates health centers by type may be useful in better understanding the patterns seen here.
Despite what we saw in Figure 3.3.3 which indicated that many health centers were at least minimally staffed
to provide many of the components of care for small and sick newborns, Figure 3.3.6 indicates that in practice,
outside of newborn resuscitation and KMC, health centers are not providing these life-saving services for
babies. This could be an important area for collaborative discussion with MISAU, DPS and USAID and other
stakeholders, to create a clear strategy for ensuring availability and provision of these services.

Figure 3.3.6. Recent provision of key MNH services (in previous 3 months)

Table 3.3.7. Number of facilities providing full and almost full EmONC and CSSN packages, by facility type and
district groups
Emergency Obstetric and Newborn Care Care for Small and Sick Newborns
Fully Almost Performed

Number of Performed all
EmONC EmONC most key
facilities key
functioning (missing 1-2 Other components Other
compoents in
(in last 3 EmONC signal 1
within last 3
last 3 months
months) 1 functions) 2 months2
Nampula 200 9 67 124 8 27 165
Facility Type
Hospitals 9 4 5 0 7 1 1
Health Centers 181 5 62 124 1 26 164
District Group
Innovation 82 3 30 49 6 10 66
Priority 38 0 12 26 0 4 34
Future Focal District 80 6 25 49 2 13 65
1
Almost there indicates those facilities providing some signal functions but missing 1-2 EmONC signal functions/1-2 components of
the Care for Small and Sick Newborn packages.
2
Other indicates those facilities missing more than 2 EmONC signal functions (relative to facility type) or missing more than 3
components of Care for Small and Sick Newborns
EmONC refers to a package of life-saving interventions or signal functions used to treat the direct obstetric
complications that make up approximately 70-80% of maternal deaths globally.10 A facility is classified as
functionally basic EmONC if the first seven signal functions have been performed at that facility in the 3 months
prior to the assessment (parenteral antibiotics, oxytocics and anticonvulsants, manual removal of placenta,
removal of retained products, assisted vaginal delivery and newborn resuscitation). 11 A facility qualifies as
functionally comprehensive EmONC if caesarean delivery and blood transfusion services have been provided
in addition to the seven basic signal functions.
The baseline assessment collected information from each facility on the recent provision of each signal
function, and we classified facilities as either fully EmONC functioning (basic EmONC for health centers or
comprehensive EmONC for hospitals) or as almost fully EmONC (i.e. they are missing one or two signal
functions) (Table 3.3.7). Facilities that do not meet these critieria are included under Other. The seven
interventions included under CSSN have not yet been organized into basic or comprehensive packages;
therefore, we classified facilities as recently performing all components of the CSSN package, or most
components of the package (i.e. 5 or 6). Facilities that do not fall into those two categories are included in
Other.
Nampula has 9 facilities that are functioning as either fully Basic or fully Comprehensive EmONC, and an
additional 67 facilities that are almost doing so. Similarly, just 8 facilities provided the full package of CSSN,
including 7 hospitals. An additional 27 facilities (mostly health centers) are providing almost the entire
package.
It is useful to quantify the number of facilities that are ‘almost’ providing the full package in order to more
efficiently target efforts to raise the capacity of those facilities to expand coverage of these life-saving services.
10
Austin A, Langer A, Salam RA, Lassi ZS, Das JK, Bhutta ZA. Approaches to improve the quality of maternal and newborn health care:
an overview of the evidence. Reprod Health 2014, 11 Supple 2:S1.
11
WHO, UNFPA, UNICEF, AMDD. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization; 2009.
While population-based targets for the appropriate level of coverage of CSSN have not yet been developed,
they are well-established for EmONC services (Table 3.3.8).
Table 3.3.8. EmONC coverage per population (relative to WHO Guidelines)

Comprehens i ve a nd Ba s i c EmONC
Comprehens i ve EmONC fa ci l i ties
fa ci l i ties
Total
Recommended (Ga p) Recommended (Ga p)
popul a tion 2 Actua l 2 Actua l
Surpl us Surpl us
N N N N N N
Na mpul a 6,102,867 61 9 (52) 12 4 (8)
Di s tri tos
Innova tion
Angoche 399,092 4 0 (4) 1 0 (1)
Era ti 372,844 4 1 (3) 1 1 0
Memba 313,507 3 0 (3) 1 0 (1)
Moma 310,706 3 0 (3) 1 0 (1)
Mona po 413,694 4 0 (4) 1 0 (1)
Na ca l a 225,034 2 1 (1) 0 1 1
Ri ba ue 290,244 3 1 (2) 1 1 0
Pri ori ty
Li upo 174,278 2 0 (2) 0 0 (0)
Meconta 250,425 3 0 (3) 1 0 (1)
Mogovol a s 415,407 4 0 (4) 1 0 (1)
Mos s uri l 142,787 1 0 (1) 0 0 (0)
Na ca l a -a -Vel ha 241,536 2 0 (2) 0 0 (0)
Na ca roa 145,643 1 0 (1) 0 0 (0)
Furture Foca l Di s tri ct

Di s tri to de Na mpul a 743,125 7 3 (4) 1 1 (0)
Il ha de Moca mbi que 65,712 1 0 (1) 0 0 (0)
La l a ua 102,890 1 1 (0) 0 0 (0)
La rde 85,971 1 0 (1) 0 0 (0)
Ma l ema 223,791 2 2 (0) 0 0 (0)
Mecuburi 283,984 3 0 (3) 1 0 (1)
Mogi ncua l 337,207 3 0 (3) 1 0 (1)
Mueca te 175,075 2 0 (2) 0 0 (0)
Murrupul a 215,208 2 0 (2) 0 0 (0)
Ra pa l e 174,707 2 0 (2) 0 0 (0)
1. Source of the population estimate is INE - National Institute of Statistics, CENSO, 2017 " Relatório Preliminar''.
2. WHO, UNFPA and UNICEF recommend a minimum of 5 fully-functioning EmONC facilities per 500,000 population where at
least one is a fully functioning Comprehensive EmONC facility (Monitoring emergency obstetric care: a handbook, 2009).
WHO, UNICEF, and UNFPA recommend a minimum of 5 fully functioning EmONC facilities per 500,000
population, where at least one is a fully functioning Comprehensive EmONC facility. This target is useful for
high-level planning of services, perhaps at the provincial level. Table 3.3.8 provides the recommended number
of EmONC facilities for each district in Nampula. These district-level results only guide health planners and
identify potential geographic gaps in services. However, a province-wide strategy to ensure universal timely
access to emergency obstetric and newborn care service must consider geographic placement of these
facilities relative to population centers, navigable roads, and should arrange systems and mechanisms for
referral between communities and facilities, and between lower and higher-level facilities. At the provincial
level, Nampula needs an additional 52 fully functioning EmONC facilities – 8 comprehensive EmONC facilities
and the remaining providing at least Basic EmONC. It would be worth investigating whether the 67 facilities
that are “almost EmONC” (Table 3.3.7) are appropriate candidates for capacity and service strengthening to
upgrade to fully functioning, and if by doing so Nampula would achieve an efficient geographic coverage of
emergency services.
The most commonly missing signal function (Table 3.3.6) is assisted vaginal delivery (AVD) with vacuum
extraction or forceps. In some cases, countries have opted to eliminate pre-service training in this skill or have
developed strategies that do not encourage AVD at health center level. In that case, one might re-think the
definition of basic EmONC by excluding that signal function from the definition. If we were to exclude AVD as
a basic signal function, Nampula would have 38 fully functioning basic EmONC facilities. Of course, eliminating
health center access to that life-saving intervention will have implications – namely, increasing the importance
of a functioning emergency referral system and timely access to surgery.
Key findings:
• In comparison with hospitals, health centers are less equipped with basic infrastructure for
maternity and labor and delivery services. A high proportion of health centers lack infrastructure to
provide sufficient lighting for performing tasks at night, means of privacy, ventilation, heating, and
rest areas for facility personnel.
• Over half of Nampula facilities have available guides or protocols related to post-partum family
planning, infection prevention, PMTCT, referral norms, and integrated management of pregnancy,
delivery, postpartum and newborn care. Similar materials for ANC, and RMC, among others were
found in a smaller number of facilities.
• Almost all facilities have at least one provider able to perform key components of routine MNH
services and EmONC signal functions. However, the provision of these services is more prevalent in
hospitals, with the exceptions of providing antibiotics and oxytocics. Among both types of facilities,
there is a need for personnel able to perform assisted vaginal deliveries.
• Results indicate critical gaps in the availability of antibiotics, magnesium sulphate, and oxytocin at
health centers. Chlorhexidine for umbilical cord care is not universally available at either health
centers or hospitals.
• Nampula has 9 facilities that meet criteria for being fully Basic or fully Comprehensive EmONC. Eight
facilities provide the full package of CSSN. An additional 52 fully functioning EmONC facilities are
needed throughout Nampula province to meet global guidelines that recommend 5 EmONC facilities
per 500,000 population. There are 67 health facilities that are missing just one or two of the EmONC
signal functions, and therefore are potential candidates for service strengthening to meet the target.
Recommendations:
• Overall, more efforts are needed to better equip health facilities to perform EmONC functions. Initial
efforts could investigate the state of “almost EmONC” facilities and determine best strategies to
upgrade those facilities to fully functioning. There are 67 health facilities that are missing just one or
two of the EmONC signal functions, and therefore are potential candidates for service strengthening
to meet EmONC coverage targets.
• More efforts are needed to improve the availability of personnel and services to provide care for
small and sick newborns. More specifically, we recommend increased discussion to determine the
rollout of the CSSN strategy at different types of health facilities, and more initiatives needed to
ensure the delivery of lifesaving newborn health services at health centers.
• We recommend the expansion of lighting, ventilation, and other basic infrastructure to provide
optimal care for women giving birth at health facilities and their newborns.
• More research is needed to determine the causes detracting from the provision of anticonvulsants
and other life-saving interventions at health centers.

• Supply chain initiatives are recommended to ensure the availability of lifesaving drugs at health
centers.
• More investigation and programs are warranted to examine why few personnel are trained to
perform assisted vaginal deliveries and increase capacity in that area.

3.4 Capacity to provide child health services including immunizations, integrated
management of childhood illnesses and management of malnutrition (IR 2.1 and 2.2)
In this section we present results on the key components of facility child health readiness including
availability of critical infrastructure, guidelines, minimum staffing, drugs and equipment, provision of routine
interventions.
Infrastructure and guidelines
Table 3.4.1 Immunization infrastructure

Health
Total Hospitals
Centers
(n=200) (n=9)
(n=191)
% % %
At least one refrigerator / freezer in operation and available for EPI 93% 67% 94%
Energy used to operate the refrigerator
Electricity (EDM) 38% 78% 36%
Solar (with or without batteries) 30% 0% 31%
Gas 29% 0% 30%
Generator (Gasoline / Diesel) 0% 0% 0%
Power supplied to the refrigerator 24 hours a day, 7 days a week 83% 78% 83%
On the day of the survey, the temperature of the refrigerator / glacier was monitored by:
Thermometer 81% 44% 82%
Continuous temperature recorder 49% 67% 48%
The temperature log was completely filled in the last 30 days 77% 56% 78%
The temperature was out of range ing the past 30 days
yes 24% 33% 24%
not available/ no register 14% 33% 13%
no 63% 33% 64%
Ensuring the integrity and effectiveness of vaccinations requires a reliable cold-chain. In Nampula,
refrigerators used to keep vaccinations at the proper temperature are widely available (though, notably
three hospitals reported not having one). Health centers used a diversity of electricity sources to operate
the EPI refrigerator, including the grid (36%), solar (31%) and gas refrigerators (30%). More than 80% of
health facilities indicated that power was supplied to the refrigerator constantly, however almost one-
quarter of facilities indicated that the temperature had been out of acceptable range in the previous 30 days
posing risk to the integrity of the vaccine supply.
Table 3.4.2. Presence of relevant child health guidelines
Health
Total Hospitals
Centers
(n=200) (n=9)
(n=191)
% % %
Guidelines, protocols, or job aids
The national guide for routine childhood vaccination (noted) 55% 44% 54%
IMCI guidelines for the diagnosis and treatment of childhood illnesses 39% 56% 38%
Checklist or guidelines for the management of childhood illnesses 31% 44% 30%
National guide for growth monitoring 51% 67% 50%
Important guidelines for child health include national guide for vaccinations, IMCI guidelines and checklists,
and the national guide for growth monitoring. However, these important guidelines are not widely available
with 55% or fewer of facilities having them.
Human Resources
As mentioned in Section 3.3, the right mix of adequately skilled and motivated staff, and the thoughtful
expansion of critical human resource categories is an important strategy for the health sector to achieve its
health targets and to sustain them.
As for maternal and newborn health, we present the percent of health facilities where at least one health
provider currently posted at that facility can provide critical child health interventions (Figure 3.4.3). Data
collected during this baseline assessment can provide further insight into the gaps, turnover, training, and
sex-ratio of staff. We will analyze and share these data at a later date.
Figure 3.4.3. Availability of at least one provider to provide key components of child health services, by facility
type
Hospitals and health centers are at least minimally staffed to provide IMNCI and ORS, diagnose and treat
pneumonia, screen for malaria, provide growth monitoring, and counsel on exclusive breastfeeding. Health
centers are also minmally staffed for screening of malnutrition. Slightly fewer health centers are able to
treat acute malnutrition, but 100% of hospitals are staffed to do so. There are some notable gaps in
minimum staffing at health centers for several vaccines: polio, measles (MCV1 and MCV2), and pentavalent.

Drugs, equipment and supplies for child health and immunization
Table 3.4.4. Availability of key drugs, equipment and supplies for child health (on the day of the survey), by
facility type
Total Hospitals Health Centers
(n=200) (n=9) (n=191)
% % %
Supplies for child health consultations
Watch or clock with second hand 29% 67% 27%
Clinical thermometer 80% 89% 80%
Newborn/infant scale 90% 100% 90%
Measuring tape 93% 100% 92%
Child growth curve charts 63% 78% 62%
23-25 gauge needles 61% 89% 60%
Seringes (1 ml, 2 ml, 5 ml, 10 ml, 15 ml) 92% 100% 91%
Child health medicines

Paracetamol 94% 89% 94%
Artemeter⁺Lumenfatrina (Coartem) 87% 100% 86%
Artesunato (inj) 47% 89% 45%
Oral rehydration solution 97% 100% 97%
Salbutamol 37% 89% 35%
Mebendazol 92% 100% 92%
Ferrous sulfate 72% 100% 70%
Ampicilin 51% 78% 50%
Penicillin G/ Benzylpenicillin 67% 100% 65%
Gentamicin 58% 100% 56%
Quinine EV/IM. 5% 11% 4%
Diazepam 89% 67% 90%
Vaccines
Pentavalent vaccine (DTP-HepB-Hib) 84% 56% 85%
Polio vaccine 87% 89% 87%
Vaccine against measles and the diluent 90% 56% 91%
BCG vaccine and the diluent 91% 89% 91%
Anti-tetanus serum/TAT 22% 0% 23%
Tetanus toxoid vaccine 92% 89% 92%
Most facilities had supplies for child health consultations, except for child growth curve charts and needles.
Several medicines important for the treatment of childhood illnesses were not widely available including
salbutamol to treat respiratory illness; drugs used for the treatment of infections and pneumonia such as
ampicillin, penicillin G., and gentamicin; and the antimalarials artesunate and quinine. Anti-tetanus serum
was only present in one-fifth of health centers and not at all in hospitals.
Availability of child health services

In Table 3.4.5, we provide detail on methods used to diagnose and treat malnutrition, as well as recent
diagnosis or treatment. Eighty-nine percent of hospitals and 93% of health centers had diagnosed
malnutrition in the 3 months before the assessment, and slightly more report treating a child with
malnutrition. For hospitals and health centers, the most widely used methods to diagnose malnutrition
were mid-upper arm circumference (MUAC), followed by weight for age, and weight for height. Far fewer

facilities use cranial circumference or BMI measurements. Reported methods for treating malnutrition vary
widely across all facilities.
Figure 3.4.5. Provision of child health services

Total Hospitals Health
(n=200) (n=9) Centers
% % %
Child health services
Methods to diagnose malnutrition
Arm circumference (MUAC) 87% 100% 86%
Weight for Age 82% 78% 82%
Cranial circumference 34% 44% 33%
Weight for height 75% 78% 74%
BMI for Age 47% 56% 46%
Clinical Diagnosis 43% 56% 42%
Height for age 54% 67% 53%
Diagnosed malnutrition in the last 3 months 93% 89% 93%
How do you treat acute malnutrition in this facility?
Provide vitamin A 36% 56% 35%
Provide iron 28% 33% 27%
Provide oral rehydration salts 30% 56% 29%
Provide zinc 24% 56% 23%
Growth monitoring 38% 67% 36%
Provide antibiotics 28% 67% 26%
Administration of therapeutic milk (LOA) 29% 56% 28%
Treated a child who suffered from malnutrition in the last 3 months 92% 100% 92%
Vitamin A Supplementation 94% 100% 93%
Iron Supplementation 89% 100% 88%
Zinc supplementation for any child with diarrhea 83% 100% 82%
Growth curve monitoring 94% 89% 94%
Treated a child suffering from pneumonia or respiratory infection 90% 100% 89%

Table 3.4.6. Provision and planning of immunization services, by facility type
Health
Total Hospitals
Centers
% % %
Has vaccination services 99% 78% 99%
Offered services on the day of the survey 73% 78% 72%
Participated in the last vaccination coordination meeting
66% 67% 66%
with SDSMAS
Of facilities with vaccination services

Birth doses (hepB0, BCG, OPV0)
Not offered 0% 0% 0%
Offered
In the facility and mobile units 85% 33% 87%
In the facility only 14% 44% 12%
In mobile units only - - -
Vaccination of infants >1 year old

Offered
In mobile units only - - -
Vaccination of adolescents/adults (HPV, tetanus, flu)

Offered
In mobile units only 3% 11% 2%
Vaccination sessions in facilities planned last month 3127 145 2982

Vaccination sessions conducted in facilities last month 3402 163 3239
Mobile vaccination sessions planned last month 721 12 709
Mobile vaccination sessions conducted last month 385 3 382
Nampula has achieved great gains in vaccination coverage and currently has coverage rates of 100% (or
higher) for polio 1 and polio 3; measles at 9 months; and Bacille Calmette Guerin (BCG), Hepatitis B and oral
polio vaccine (OPV0) during the first month of life. Measles containing vaccine by 18-months of age (MCV2)
is 75% (data from another source). In a decentralized system like that of Mozambique, immunization
services are typically provided at the local level, which is reflected in the assessment findings. Virtually all
health centers and seven out of nine hospitals provide vaccinations at birth as well as for infants,
adolescents, and adults. Mobile unit coverage also appears strong, with about 85% of facilities employing
mobile units for vaccination. However, services may not be offered every day. On the day of the survey, only
72% of health centers had vaccination services available. It is interesting to note that hospitals and health
centers conducted more facility-based vaccination sessions than they had planned in the last month.
However, health centers conducted about half of the mobile vaccination sessions that had been planned and
hospitals conducted one quarter of planned mobile sessions, an indication of the difficulty in arranging
adequate staffing, supplies, transportation and fuel for these mobile brigades. Further, just two-thirds of
facilities participated in coordination meetings of immunization services with the district. Participation is

often hindered by lack of financial support, or staff available to participate, or potentially inefficient
communication about this timing of the meeting.

Key Findings:
• Many health facilities have been successful in maintaining a cold chain to keep vaccinations at an
appropriate temperature, yet nearly one quarter of facilities reported that refrigerator temperature
had fluctuated outside of the acceptable range in the month prior to data collection.
• National guidelines related to child health are not widely available at health facilities.
• A large majority of health facilities have at least one provider able to perform key components of
child health services, though a few gaps remain in personnel capacity to treat acute malnutrition and
provide various vaccines among health centers.
• At both hospitals and health centers, there are notable shortages of essential medicines to treat
respiratory illnesses, pneumonia, malaria, and tetanus.
• Services to diagnoses malnutrition are widely available at hospitals and health centers, though
treatment methods vary across facilities.
• Vaccinations services are widely available at health centers, hospitals, and through mobile units,
though those services might not be offered daily and there are gaps between planned and
implemented mobile campaigns.
Recommendations:
• Infrastructure improvements are needed to ensure proper refrigeration for vaccines at all facilities.
• We recommend increased dissemination of national child health guidelines.
• Key areas for action are supply chain efforts to ensure the availability of essential medicines for
children at all health facilities.
• We recommend additional training to increase health center personnel capacity to provide the full
range of essential vaccines.
• Technical, logistical and planning support to ensure improved planning and implementation of
mobile immunization campaigns.
3.5 Service statistics and service indicators for maternal, newborn and child health
In this section, we present a selection of indicators that have been calculated using facility case statistics
including indicators of ANC coverage and use, PNC use, institutional delivery rates and aspects of quality of
care, distribution of maternal complications and deaths, newborn outcomes. and number of child deaths by
cause.
Data collectors extracted facility case statistics from facility registers to calculate important indicators of
MNCH coverage and quality. In this preliminary report, we present a selection of indicators at the
population- and institutional-levels including the number of deliveries, obstetric complications, caesarean
deliveries, maternal deaths, stillbirths, and pre-discharge early neonatal deaths, number of child death. In all
cases, statistics were collected over a 6-month period and in some cases 6-month sums are multiplied by 2
to estimate annual totals.

Table 3.5.1. Indicators of ANC coverage and use, institutional delivery and aspects of quality of intrapartum and newborn care, and PNC coverage of 6-month
period, by district groups
District Group
Nampula
Innovation Priority Future Priority
Total Total Total Total
number Rate number Rate number Rate number Rate
Total population 6,102,867 2,325,121 1,370,076 2,407,670
Total expected pregnancies over 6 months period* 152,572 58,128 34,252 60,192
Total expected deliveries over a 6 months period** 137,315 52,315 30,827 54,173
Amonge expected pregnancies in the population

Pregnant women who initiate ANC early (<12 weeks) (MEL Indicator) 7,844 5% 3,338 6% 1,221 4% 3,285 5%
Pregnant women who complete at least ANC 4 (MEL Indicator) 63,470 42% 23,483 40% 18,188 53% 21,799 36%
TIP2 coverage 107,512 70% 43,861 75% 24,228 71% 39,423 65%
TIP3 coverage 80,764 53% 31,132 54% 20,013 58% 29,619 49%
TIP4 coverage 55,992 37% 20,443 35% 16,073 47% 19,476 32%
Among expected deliveries in the population

Institutional delivery rate (MEL Indicator) 116,128 85% 46,857 90% 25,971 84% 43,301 80%
Post partum women receiving contraceptive method 31,615 23% 15,842 30% 5,818 19% 9,955 18%
Cesarean delivery rate (MEL Indicator) 2,881 2% 1,204 2% 60 0% 1,617 3%
Mothers accompanied to delivery 108,339 79% 44,815 86% 24,934 81% 38,590 71%
Women receiving AMTSL (immediate oxytocics) (MEL Indicator) 108,300 79% 43,744 84% 24,027 78% 40,529 75%
Newborns with severe breathing difficulties 727 234 100 393

Newborns resuscitated 714 98% 264 113% 91 91% 359 91%
Among institutional deliveries

Total PNC registrations over 6 months and rate among institutional
99,276 85% 41,711 89% 24,025 93% 33,540 77%
deliveries
Newborns receiving postnatal health check within two days of birth
89,129 77% 36,339 78% 22,593 87% 30,197 70%
(MEL Indicator)
* expected pregnancies over 6-months = population * 5% divided by 2
* expected deliveries over 6-months = population * 4.5% divided by 2

Figures 3.5.2A and 3.5.2B. Distribution of maternal complications by cause and facility type
Figures 3.5.2A and 3.5.2B show the distribution of all obstetric complications treated at any facility in Nampula over a 6-month period, by facility type. The
most striking difference between hospitals and health centers, aside from the volume of complications – hospitals treated twice as many complications as
health centers despite health centers accounting for 89% of all institutional deliveries over the same time period –, is the proportion of indirect
complications. Thirty-eight percent of all obstetric complications treated at health centers are due to indirect causes (malaria, HIV, anemia, and
tuberculosis), whereas among hospitals the percentage is 12%. Among direct obstetric complications, post-partum hemorrhage accounts for approximately
the same proportion of complications regardless of location (~16%).

Figures 3.5.3A and 3.5.3B. Distribution of maternal deaths by cause and facility type
Figures 3.5.3A and 3.5.3B present the proportion of all institutional maternal deaths in Nampula (excluding those that occurred in the Central Hospital) over
a 6-month period.12 A total of 90 maternal deaths were counted over the period, with 28% of deaths among women in health centers attributed to post-
partum hemorrhage, and 38% due to indirect complications (i.e., malaria, tuberculosis, HIV and anemia). At hospitals, abortions with grave complications
account for almost one-quarter of deaths. Of course, the Central Hospital treats a large volume of maternal complications (588 over the 6-month period
were counted in our assessment, or 43% of total complications), and receives the most complicated cases; therefore, we would expect a high number of
obstetric deaths to occur there as well. Thus, these results should be considered representative of General, Rural and District Hospitals only.
12
Maternal deaths that were counted at the Central Hospital in Nampula are excluded from Figure 3.5.3A because the number and classifications of the deaths need to be
further validated.
Table 3.5.4. Cause-specific case fatality rates for maternal death
Number of Number of
women with women who
direct died of direct Cause-specifc
1
complications complication mortality rate
Total direct obsetetric case fatality rate (MEL Indicator) 1164 59 5%
Cause-specific case fatality rates
Antepartum hemorrhage 160 4 3%
Postpartum hemorrhage 339 22 6%
Prolonged/obstructed labor 139 5 4%
Severe pre eclampsia\eclampsia 147 8 5%
Postpartum sepsis 13 1 8%
1
Abortions with serious complications (sepsis, hemorrhage) 61 8 13%
Ectopic pregnancy 305 11 4%
1 Women with uncomplicated abortions are not included. If the woman died of an abortion, by
definition she died from a severe complication
The direct obstetric case fatality rate (DOCFR) is the proportion of women with major direct obstetric
complications in facilities who die before discharge. It is an indicator of the quality of how these
complications are managed. The international benchmark is less than one percent. An accurate estimate of
the DOCFR depends on the correct diagnosis, complete recording of obstetric complications, maternal
deaths, and causes of death. The results presented here should be interpreted with caution, yet they
provide an important benchmark for both improvements service quality and in data quality.
The DOCFR over the time period was 5%, higher than the <1% target. Cause-specific case fatality rates for all
causes are higher than one would hope.
It is worth noting that obstetric deaths counted at the Central Hospital in Nampula are excluded from the
calculations in Table 3.5.4, though the Hospital’s complications are included. Therefore, the actual case
fatality rates are likely higher than this. We excluded the Central Hospital deaths because the numbers and
classifications of the deaths need to be further validated.

Table 3.5.5. Newborn outcomes including prematurity rate and KMC coverage, perinatal and pre-discharge mortality rates over the 6-month period
Facility Type District Group
Health
Total Hospitals
Centers Innovation Priority Future Priority
Total live births plus stillbirths 105,821 11,019 94,802 42,841 24,435 38,545
Live births
>2500g 104,590 10,286 94,304 42,147 24,368 38,075
2000 - 2499g 4,367 1,196 3,171 1,374 713 2,280
<1999 g 1,404 465 939 455 185 764
Live births with unspecified weight 1,491 40 1,451 489 40 962
Live births premature (<37 weeks or <8 months) 19,531 1,898 17,633 6,544 4,827 8,060
Prematurity rate (among live births) 19% 18% 19% 16% 20% 21%
Small babies (<2000 g) with immediate skin-to-skin contact or KMC initiated 2,615 411 2,204 1,632 182 801
KMC coverage (among live births<1999 g and unspecified weight) 90% 81% 92% 173% 81% 46%
Pre-discharge neonatal mortality 382 229 153 78 20 284

>2500g 167 67 100 40 20 107
<2000g 180 147 33 17 0 163
Unspecified birth weight 35 15 20 21 0 14
Pre-discharge neonatal mortality rate per 1000 live births (MEL Goal Indicator 3) 3.7 22.3 1.6 1.9 0.8 7.5
Stillbirths2 1,231 733 498 694 67 470
Intrapartum stillbirths (stillbirths with heartbeat upon admission) 63 31 32 21 0 42
Macerated stillbirths 260 114 146 122 23 115
Stillbirths with timing not specified 908 588 320 551 44 313
Perinatal deaths (intrapartum stillbirths and newborn deaths before discharge) 445 260 185 99 20 326
Institutional perinatal mortality rate (perinatal deaths/100 0total births) (MEL Goal Indicator 4) 4.2 23.6 2.0 2.3 0.8 8.5
1. Pre-discharge neonatal death is defined as deaths that occur within 24 hours after delivery or before discharge
2. Total stillbirths = macerated stillbirths + intrapartum stillbirths (with heartbeat upon admission) + unspecified stillbirths
3. Intrapartum and early neonatal fetal death rate = (intrapartum deaths + early neonatal deaths) / (Number of deliveries)

For the 6-month period of February 2019-July 2019, data collectors extracted from facility registers
information on newborn outcomes, weights, and gestational age to calculate important indicators of
newborn health and survival (Table 3.5.5). Over the period, just over 105,800 births occurred in health
facilities in Nampula. The vast majority (99%) were live and of normal birth weight. A small number of live
births did not have their weight recorded (1%) but for the purposes of later indicators, we have assumed
these were of low-birth weight.
Nineteen percent of institutional births were premature, and this rate varies slightly across district groups,
from 16% among Innovation Districts to 21% among Future Priority Districts (though, this latter rate is likely
influenced by the presence of the Central Hospital in that group of Districts).
We calculated KMC coverage out of small babies (i.e. those under 2000 grams at birth). The Province-wide
coverage rate is 90%, yet the variation across district groups is worth noting. Innovation Districts indicated
more than 1,600 babies received immediate skin-to-skin (a proxy for KMC); but there were under 1000 small
babies recorded. We will look into this anomaly to determine if there is a misunderstanding of the register
indicator. It is worth noting that hospitals and Future Focal Districts have the lowest KMC coverage rates.
The pre-discharge newborn mortality rates is 3.7 newborn deaths per 1000 institutional deliveries for
Nampula, 22.3 for hospitals and 1.6 for health centers. The high rate in hospitals is likely due to the high
proportion of complicated cases they receive, yet further investigation is warranted to better understand if
there are other contributing factors.
The institutional perinatal mortality rates mirror the pattern seen among the pre-discharge newborn
mortality rate.
Table 3.5.6. Numbers of child deaths February 2019 – July 2019

Institutional child deaths over 6 month period
(Feb 2019 - Jul 2019)
Deaths due to Deaths due Deaths due Unknown

pneumonia to malaria to diarrhea cause
Total
Nampula 195 28 104 14 49
Facility Type
Hospitals 61 6 34 3 18
Health Centers 134 22 70 11 31
Distritos
Innovation 58 9 39 6 4
Priority 29 5 21 1 2
Furture Focal District 78 14 44 7 13
One-hundred and ninety-five child deaths due to pneumonia, malaria, diarrhea and of unknown cause were
counted over the 6-month period. The vast majority of these (134) occurred at health centers, and malaria
was the most common cause of death.

• Our assessment calculated Nampula’s institutional delivery rate at 85%, early initiation of ANC at 5%,
coverage of ANC4 as 42%, immediate oxytocin after delivery at 79%, and PNC within two days as
77%.
• Nineteen percent of institutional births were premature
• The pre-discharge newborn mortality rates is 1.7 newborn deaths per 1000 institutional deliveries
for Nampula, 22.3 for hospitals and 1.6 for health centers.
• The DOCFR over the time period was 5%, higher than the <1% target. Cause-specific case fatality
rates for all causes are higher than one would hope.
• One-hundred and ninety-five child deaths due to pneumonia, malaria, diarrhea and of unknown
cause were counted over the 6-month period. The vast majority of these (134) occurred at health
centers, and malaria was the most common cause of death.

3.6 Capacity for QI (IR 4.1 and 4.2) and provision of humanized services (IR 2.3)
This section present results from across various modules that provide a picture of facility and district-
level capacity to implement quality improvement (QI) mechanisms and to delivery humanized
services. This section includes results of the ANC observations (Module 7), which are organized
within the standards of the recent Respectful Maternity Care Charter.
Facility capacity for quality improvement and environment to provide humanized services
Numerous facilities in Nampula have established at least some QI&H structures and practices (Table
3.6.1). Overall, 67 percent of facilities throughout the province have established QI&H committees,
and 64 percent had committees that had met within the six months prior to the baseline
assessment. Committee establishment and activity varied significantly by facility type; while 100
percent of hospitals had achieved these indicators, only 66 percent and 62 percent of health centers
had established committees and had active committees, respectively. Nevertheless, in comparison
with hospitals, a higher percentage of health centers were implementing QI initiatives in maternal
and newborn health, as well as in child health at the time of the baseline assessment. Overall, 80
percent of total facilities were implementing initiatives to improve the quality of maternal and
newborn care, and 74 percent were implementing QI initiatives for pediatric services. In the area of
pediatric care, there is a need to expand QI initiatives in Innovation districts where only 62% of
facilities were implementing QI approaches in comparison to 84 percent and 80 percent of facilities
in priority and future focal districts, respectively.
Overall, most facilities (65 percent) had implemented systems to collect and incorporate service user
suggestions in QI initiatives. However, these systems were more prevalent in hospitals and in
Innovation district facilities. Whereas 89 percent of hospitals had implemented user input systems,
only 64 percent of health centers had established those mechanisms. Additionally, despite efforts to
promote humanized services, a minimal number of facilities had a Guide for Humanized Care that
was observed to be available to service users. Only 16 percent of total facilities promoted this Guide
to service users, though that figure was higher among hospitals, 67 percent of which had a guide
available.
Activities to monitor maternal, neonatal, and pediatric deaths were also prevalent among a higher
percentage of hospitals than health centers. Sixty-seven percent of hospitals had an active maternal,
perinatal, and neonatal death audit committee, in contrast with 9 percent of health centers. No
significant differences were found by district type. Similarly, 89 percent of hospitals were using the
MPDSR system in comparison with 42 percent of health centers. Overall, 44 percent of total
facilities were using the MPDSR system and 12 percent had an active committee performing death
audits. Less than half of total facilities conducted maternal, neonatal, and pediatric death audits.
These findings highlight a need to strengthen death audit initiatives and systems to promote service
user input among health centers throughout Nampula province.

Table 3.6.1. Presence and functioning of key QI&H structures and practices within the health facility
Quality Improvement User input Death Audits
Facility has
Facility has a # of hospitals and health
QI&H Facilities with Facility has a Have Comite
Facilities Facilities Facility has a Guide for centers conducting
body/committee active1 QI&H system to Use the de Auditoria Faciliites with Met last time
implementing implementing mechanism to Humanized
US Total established to committees respond to MPDSR de Morte an active1 there was a maternal, neonatal &
MNH QI QI for child collect patient Care that is
monitor and (MEL user system Materna, Peri committee death pediatric death audits (MEL
activities health suggestions promoted to
support QI&H Indicator) suggestions e Neonatal
service users Indicator)
(MEL Indicator)
% % % % % % % % % % % maternal newborn child

Nampula 200 67% 64% 80% 74% 65% 65% 16% 44% 20% 12% 6% 91 89 63
Tipo de US
Hospitals 9 100% 100% 78% 67% 89% 89% 67% 89% 89% 67% 22% 9 9 7
Health Centers 191 66% 62% 80% 74% 64% 64% 14% 42% 16% 9% 5% 82 80 56
Distritos
Innovation 82 68% 65% 74% 62% 67% 71% 15% 32% 16% 9% 6% 33 34 21
Priority 38 66% 63% 87% 84% 58% 58% 13% 55% 18% 11% 5% 20 20 13
Future focal districts 80 66% 63% 83% 80% 66% 63% 19% 51% 24% 15% 5% 38 35 29

Table 3.6.2. Presence and functioning of key QI/QA structures and practices within the district health office

Results indicate that districts have achieved some progress in the implementation of quality improvement
(QI) and quality assurance (QA) initiatives, though more work is needed in this area (Table 3.6.1). Overall, 16
(70 percent) of the 23 districts had implemented QI initiatives in the fiscal year prior to the baseline
assessment. Nearly half of the districts (44 percent) had created specific QI departments or units at the
district health office. While only 17 percent of districts had established Quality Officers in all facilities, 52
percent or 12 districts had installed Quality Officers in at least some facilities.
Seventeen (74 percent) of the 23 districts also reported regular execution of QA activities. Of those districts,
77 percent (13 districts) and 88 percent (15 districts) had systems to recognize best performing facilities and
best performing individuals, respectively. In the area of MNH services, districts most often reported
conducting morbidity audits as key QA activities. Also related to surveillance, MDSR (maternal death
surveillance and response) was implemented to some extent in every district, with 15 districts (65 percent of
the total) reporting the operation of MDSR in every facility, and 8 districts (35 percent) reporting the
integration of MDSR in at least some facilities. SDSMAS was reported to actively contribute to MDSR
activities and was involved in maternal death reviews and review meetings in 87 percent and 83 percent of
districts, respectively. Though the type of participation varied by district, all respondents reported that
SDSMAS was involved in at least some MDSR activities.
More initiatives are needed to promote the inclusion and active participation of community members and
groups in facility QI activities. Though 20 (87 percent) of 23 facilities mentioned the existence of community
QA committees, every district reported that communities were not involved in all QI activities. More active
and inclusive participation of community members is recommended to improve equity, service utilization,
and success of QI initiatives.

Table 3.6.3. Facility structural readiness to provide respectful maternity care and services
Nampula Hospitals Health
n=200 n=9 n=191
% % %
Financial accessibility
Fee structure for services posted in a visible and public place 23% 78% 20%
Women bring their own supplies or medicines to receive assistance during labor or delivery 4% 0% 4%
Women bring their own supplies or medicines to receive attention for newborn 2% 0% 2%
Supportive environment
Standard length of stay after normal delivery at least 24 hours 97% 89% 97%
Standard length of stay after assisted vaginal delivery at least 48 hours 13% 56% 11%
Standard length of stay after cesarian delivery at least 72 hours, reported by hospitals only 78% 78% -
Women allowed female companion during labor 96% 100% 96%
Women allowed female companion during normal delivery 95% 89% 95%
Women allowed female companion during cesarean delivery, reported by hospitals only 11% 11% -
Women allowed to ambulate during labor 97% 100% 97%
Women allowed position of choice during labor/delivery 83% 100% 82%
Women allowed to consume food and liquids during labor 94% 100% 93%
Adequate space. In last 3 months,

Delivery patients have never shared beds 47% 33% 48%
Delivery patients have never slept on the floor 74% 89% 73%
Delivery patients have never delivered on the floor, in the hall, or bathroom 77% 78% 76%
Facility Monitoring of Humanized Care

Facility has a QI&H Committee that has met within the past six months 64% 100% 62%
Facility has a system to incorporate service user suggestions in Quality Improvement 65% 89% 64%
Facility has a Guide for Humanized Care that is promoted to service users* 16% 67% 14%
All facility personnel are trained according to Guide for Humanized Care** 21% 44% 20%
*these values represent facilities where data collectors observed the Guide
**facilities where all personnel are trained according to the guide
All women have the right to high quality, humanized maternity care. The Global Respectful Maternity Care
Council’s 2019 Charter defines respectful maternity care (RMC) as comprising ten fundamental rights to which
women and children are entitled: (1) the right to freedom from harm and ill-treatment, (2) the right to
information, informed consent, and respect for choices and preferences; (3) the right to privacy and
confidentiality; (4) the right to dignity and respect; (5) the right to equality, freedom from discrimination and
equitable care; (6) the right to health care and the highest attainable level of health (7) the right to liberty,
autonomy, self-determination, and freedom from arbitrary detention; (8) the rights of children to be with their
parents and guardians; (9) the right to an identity and nationality; and (10) the right to nutrition and clean
water. Fulfilling these rights requires action not only from health care providers, but also from health facilities
to create policies and structures that enable the provision of respectful maternity care and demand
accountability for instances of disrespect and mistreatment. Given its multi-level nature, the Alcançar baseline
assessment integrated RMC items throughout different modules focusing on facility infrastructure, policies,
and provider knowledge. Also included was an observation checklist for RMC practices performed during ANC
consultations at each facility.
Table 3.6.3 displays results from the assessment of facility readiness to provide respectful care and services.
These results highlight, in some cases, significant differences between hospitals and health centers in the
achievement of readiness. For example, while 78% (seven of nine) of hospitals had made their fee structure
visible to service users, only 20 percent of health centers had achieved this transparency. Also, in the area of
financial accessibility, a few health centers reported that women needed to bring their own supplies for labor,
delivery, and newborn care, whereas such conditional care was not reported by hospitals.

Similar disparities between hospitals and health centers were found in facility monitoring of humanized care.
Whereas all nine hospitals throughout the province had an active Quality Improvement & Humanization
(QI&H) committee, only 62 percent of health centers had a similar committee that had met within the six
months prior to the assessment. In comparison with health centers, a higher percentage of hospitals had also
implemented systems to incorporate user suggestions and promote the Guide for Humanized Care (see Table
3.6.1 for more details by district type). Overall, more efforts are needed to train facility personnel according
to the Guide for Humanized Care, though such training was reported in a higher number of hospitals.
Both hospitals and health centers had instituted policies to promote a supportive environment for women
seeking maternity care. On average, most hospitals and health centers did not discharge patients for at least
24 hours following normal deliveries. Seven of nine hospitals reported that women undergoing cesarean
deliveries were able to stay at least three days before being discharged on average. Overall, most facilities had
also established policies permitting women to ambulate during labor (97 percent of facilities), consume food
or liquids during labor (94 percent), and be accompanied by a female companion during labor and normal
delivery (96 and 95 percent, respectively). Additional policies are needed to allow the presence of a female
companion during cesarean deliveries and to promote women’s choice of position during labor and delivery.
While all hospitals permitted women to choose their preferred position during childbirth, only 82 percent of
health centers had similar policies.
A key area for improvement is the provision of adequate space for women receiving delivery care. Less than
half (47 percent) of facilities overall reported that patients had not shared beds in the three months prior to
the baseline assessment. Overcrowding appears to be of particular issue in hospitals where only 33 percent
(three of nine) facilities had never required patients to share beds. It is possible that this issue might be
associated with higher volumes of women seeking care at hospitals. Additionally, more than 20% of facilities
overall indicated that patients may have slept on the floor, or given birth in the hall, bathroom, or floor in the
past three months. Overall, more efforts are needed to ensure women giving birth have adequate space and
fulfill their rights to privacy and dignity.
ANC observations
As described previously, this baseline assessment included directed observations of ANC consultations at
facilities in each district. These observations sought to evaluate the extent to which pregnant women receive
humanized treatment from health care providers and facilities while seeking ANC. To be included in the
observations, facilities had to be offering ANC consultations the day of data collection, and data collectors
were required to obtain informed consent from both the health care provider and service user participating
in the consultation before conducting an observation. No more than one observation was conducted at each
facility.

Table 3.6.4. Response rate for ANC observations
Percent of total Percent of facilities

Proportion of all
facilities that were providing ANC where
Total facilities where ANC
providing ANC providers and women
facilities consultations were
consults on day of consented to
observed
visit observation
# % % %
Nampula 200 81% 96% 77%
Tipo de US
Hospitals 9 67% 100% 67%
Health Centers 191 81% 96% 77%
Distritos
Innovation 82 77% 100% 77%
Priority 38 92% 100% 89%
Future priority 80 79% 89% 70%
Table 3.6.4 shows the final sample of ANC consultation observations. Of the 200 facilities included in the
baseline assessment, 161 (81%) were offering consultations on the day of data collection. Only four percent
of providers and service users at those facilities declined to have their consultation observed. Ultimately,
observations were conducted at 153 facilities, 77 percent of the total facilities in the baseline assessment.
These facilities comprised six hospitals and 147 health centers. Of note, observations were collected from a
high percentage (89 percent or 34 facilities) of the facilities in priority districts, and from 77 percent and 70
percent of facilities in the innovation and future priority districts, respectively.

Table 3.6.5. Demographics of women observed during ANC
Type of health facility District group
ANC Health Future
Innovation Priority
observations Hospitals Centers priority
(n=63) (n=34)
total (n=153) (n=6) (n=147) (n=56)
Age (in years)
14-18 22% 17% 22% 21% 26% 20%
19-34 67% 83% 67% 70% 65% 66%
35+ 9% 0% 9% 8% 6% 11%
Unknown 3% 0% 3% 2% 3% 4%
Parity
Zero (first pregnancy) 29% 33% 29% 29% 26% 32%
One 15% 17% 15% 11% 29% 11%
Two 17% 50% 16% 13% 26% 16%
Three 12% 0% 12% 13% 12% 11%
≥Four 26% 0% 27% 33% 6% 30%
Previous ANC Consultations

Zero (first visit) 61% 67% 61% 60% 68% 57%
One 5% 0% 5% 3% 0% 11%
Two 22% 33% 22% 19% 21% 27%
Three 9% 0% 9% 11% 6% 7%
≥Four 2% 0% 2% 5% 0% 0%
Gestational Age
<14 weeks / <4 months 7% 0% 8% 5% 12% 7%
14-28 weeks / 4-6 months 36% 17% 37% 29% 50% 36%
>28 weeks / >7 months 19% 0% 20% 16% 18% 23%
Table 3.6.5 displays demographic information of women participating in the observed ANC consultations.
The ages of women seeking ANC consultations ranged from 14 to 40 years. The average age among women
was 23.6 years, and two thirds of those participants were between 19 to 35 years old. Overall, more than a
fifth of participants were adolescents. In priority districts, adolescents comprised more than a quarter (26
percent) of participants. Conversely, in future priority districts, nearly 11 percent of the women participants
were over 35 years old. These figures are significant given that both adolescents and women over 35 years
of age may be at higher risk for complications during pregnancy and delivery and may therefore need more
specialized ANC.
Nearly 30 percent of women were seeking ANC for their first pregnancy. Reflective of Nampula provinces’
fertility rate of 5.2 [DHS 2015], another quarter of women (26 percent) seeking care had given birth at least
four times prior to their current pregnancy. However, this percentage differed at hospitals and at facilities in
priority districts where no women and only six percent of women, respectively, had at least four prior births.
Current WHO guidelines advise women to seek ANC within the first 12 weeks of their pregnancy and achieve
at least eight contacts with healthcare providers prior to childbirth [WHO 2016]. Among service users
participating in the baseline assessment, 93 women (61 percent of the total) reported the observed
consultation as their first ANC visit for their current pregnancy. Only three women overall (zero seeking care
in hospitals, priority districts, and future priority districts) had received four or more ANC consultations prior
to the observed visit. Additionally, only seven percent of participants were 12 or fewer weeks pregnant at the
time of seeking the consultation. The average gestational age of participants was 23.7 weeks with a minimum
and maximum of 4 weeks and 40 weeks, respectively. While more research is needed, these figures indicate
potential gaps in promoting the uptake of early ANC and at least eight ANC visits. It also should be noted that
the module did not ask specifically if women had previously sought ANC from traditional birth attendants or
individuals outside of the formal health system.
Table 3.6.6. Characteristics of the consultation
As displayed in Table 3.6.6, none of the observations included in the assessment were attended by OBGYNs
or other physicians. SMI nurses with medium level of training attended the vast majority of consultations
(100 percent of consultations in hospitals and 82 percent overall). Additionally, observations indicated that
ANC consultations were brief with 60 percent or 91 consultations lasting less than 20 minutes. The average
consultation length was 20.3 minutes and the median time was 17 minutes. Only five consultations (three
percent of the total) lasted longer than 40 minutes, none of which occurred in facilities in priority districts.
The brevity of consultations is notable given that around 50 percent of women experienced delays of 10 or
more minutes during their consultation, as described in Table 3.6.7 below. More investigation is warranted
to examine possible associations between shorter consultation lengths and volume of service users
attending facilities, number of health care providers at the facilities, risk categorization or complications of
pregnancies, and other elements of respectful care explored in Table 3.6.7.

Table 3.6.7 Respectful Maternity Care Charter fulfilment during ANC consultations
Table 3.6.7 displays observations of respectful maternity care practices as categorized by rights defined in
the White Ribbon Alliance’s Respectful Maternity Care Charter. Practices related to (7) the right to liberty,
autonomy, self-determination, and freedom from arbitrary detention; (8) the rights of children to be with
their parents and guardians; and (9) the right to an identity and nationality were determined to be of greater
relevance to delivery and neonatal care than to ANC, and consequently were not included in observations.
Items related to (10) the right to nutrition and clean water were not observed during ANC consultations but
are detailed in Table 3.2.3 and in several places in section 3.4.

Overall, observations revealed a high level of respectful care delivered during ANC consultations. Data
collectors observed the fulfillment of women’s rights to dignity and respect, with 90 percent of women
receiving friendly treatment. Similarly, in only four percent of observations were women or their support
person interrupted by providers. Three women (two percent of the total) were subjected to threats, insults,
shaming or other actions that might constitute verbal abuse. Similar success was noted in the fulfillment of
women’s rights to equitable care and freedom from discrimination, with 95 percent of consultations
conducted in an appropriate language for the service user. Data collectors recorded eight instances (five
percent of consultations) in which providers rejected women’s beliefs or fears, though this percentage was
higher in priority district facilities where those instances occurred in nine percent of observations.
Fulfillment of women’s rights to information, consent, and choice of companion was less consistent. A high
level of information was delivered to women receiving lab tests during their consultations, with 98 percent
of women receiving information on lab test procedures and results. However, consent for lab tests was
provided by only 86 percent of participants, and only 80 percent of participants in innovation district
facilities. Only 72 percent of women provided consent for physical examinations and 73 percent received
explanations of those examinations. While only 59 percent of participants were encouraged to ask
questions, 100 percent of women who asked questions received answers. Finally, whereas 95 percent of
women received instructions on follow-up care, only 54 percent of women received information on danger
signs during pregnancy.
Only 58 percent of women were joined by a friend, family member, or other support person during their
consultation. As shown in Table 3.6.6, this individual was most often a partner. Of note, data collectors did
not record why women did not have a companion during their consultation, and thus more data is needed to
determine if attending ANC alone resulted from facility policies, women’s preference, or other reasons.
Observation results highlight the need for more initiatives to ensure women’s rights to privacy and
confidentiality, as well as their right to the highest attainable level of health. Protecting patient privacy and
confidentiality is critical to promoting trust and acceptability of health services, yet only 87 percent of
consultations occurred in a private setting and only a quarter of women receiving examinations were
covered with a sheet. These figures were even lower in future priority district facilities where 77 percent of
visits occurred in private settings and 21 percent of women were covered during examinations. Additionally,
only 20% of providers overall and 10 percent of providers in priority district facilities washed or disinfected
their hands before performing examinations. Delays were also frequent with about half of participants
experiencing delays of more than 10 minutes during their consultations.
Finally, data collectors observed two consultations, in which providers used physical force against services
users, thus violating their rights to freedom from ill-treatment. Though these instances were observed in
only one percent of all consultations, increased efforts are needed to ensure that no woman is subjected to
ill-treatment or potential physical harm.
Key findings:
• More than half of the facilities included in the baseline assessment have established active QI&H
committees, created systems to collect and integrate service user input in QI initiatives, and
implemented QI initiatives in the areas of maternal, newborn, and pediatric services. However, a
higher percentage of hospitals than of health centers had implemented these QI structures.

• In comparison with health centers, a significantly higher percentage of hospitals had established
active maternal, perinatal, and neonatal death audit committees, and had integrated the MPDSR
system.
• MDSR is implemented to some extent in every district, and SDSMAS has been widely involved in
maternal death reviews and death audits.
• 20 (87%) of 23 districts had established community QA committees, though every district reported
that community was not involved in all aspects of QI.
• Overall, results indicate a high level of facility readiness to ensure humanized maternity care,
particularly in the creation of a supportive environment. However, in comparison with health
centers, a higher percentage of hospitals had improved financial accessibility of services and
established systems to monitor humanized care.
• During ANC consultations, most service users experienced friendly treatment in the appropriate
language, with minimal instances of being interrupted, having their fears or concerns dismissed, or
verbal abuse. Similarly, high percentage of women received information regarding lab tests and
physical examinations being performed.
Recommendations:
• More efforts are needed to train all facility personnel according to the Guide for Humanized Care
and promote that guide to facility service users.
• Findings highlight a need to strengthen death audit and other surveillance initiatives, particularly
among health centers throughout Nampula province.
• More work is needed at the district level to implement QI and QA initiatives, especially those
including the establishment of facility Quality Officers and district QI departments.
• More initiatives are needed to promote the inclusion and active participation of community
members and groups in facility QI activities.
• Additional policies are needed to allow the presence of a female companion during cesarean
deliveries and to promote women’s choice of position during labor and delivery.
• Increased efforts are needed to reduce overcrowding of facilities and provide women with their own
facility bed around the time of childbirth.
• It is possible that there is a need for more time to be allocated to ANC consultations.
• During ANC consultations, more efforts are needed to fulfill women’s rights to information and
consent, through obtaining consent for lab tests and physical examinations, encouraging women to
ask questions, and providing women with information on danger signs during pregnancy.
• Increased efforts are needed to ensure privacy and sanitation during ANC consultations.

3.7 Provider knowledge of MNH and Child health services
This section presents characteristics of providers who participated in the knowledge interviews of maternal,
newborn and child health, and the resulting knowledge score for each component of care included.
Provider knowledge of key aspects of ANC, routine delivery, complication management, essential newborn
care, and newborn resuscitation
Overall, 196 providers participated in anonymous interviews about their knowledge of maternal and
newborn care (9 at hospitals and 187 at health centers). Data collectors were instructed to select the
provider who had attended the most deliveries in the last month. In most cases, this was an Enfermeiro SMI
(MCH Nurse). Enfermeiro SMI Medio (MNCH Nurse Medio) or a general nurse with about 2 years of formal
training. Enfermeiro SMI Medio are nurses who specialize in MNCH care, who typically stay at the facility and
are on call 24/7 for deliveries in addition to providing ANC, newborn and postpartum care. Seven doctors or
other cadres with 4 or more years of training were interviewed, and 27 basic level nurses with 1-2 years of
professional training were interviewed. In the following section, these categories are used to describe the
knowledge level of the three types of health professionals. Two providers were interviewed who were P.
Traditional (traditional birth attendants), but they are not included in the following figures and tables
because they are not officially part of the health system and would only provide facility-based services in
cases where there are no other staff available.
On average, interviewed providers had about 3.5 years of experience working in their professional role. The
average number of deliveries attended in the past month was 63, which reflects the high delivery
attendance by the MNCH specialty nurse cadres (SMI medio and SMI basico). Doctors attended just 4
deliveries in the past month on average.
Table 3.7.1. Demographic characteristics of respondents to MNH knowledge survey
Professional experience
Number of Number of
Number of
Providers years since providers who
deliveries
interviewed receiving have had
attended in
professional qualification
past month
qualification for ≥3 years
n mean mean %
Nampula 196 62.8 3.6 42%
Facility type
Hospital 9 96.9 6.4 89%
Health Center 187 61.1 3.4 40%
Health worker cadre

Doctor/Tecnico
Médico obstetra 0 0.0 0.0 -
Médico generalista 1 0.0 2.0 0%
Técnico médio de Medicina 6 4.2 2.7 50%
Anestesiologista 0 0.0 0.0 -
Enf SMI (superior/medio/geral)
Enf. SM superior 2 11.5 5.0 50%
Enf. SMI médio 153 65.6 2.9 35%
Enfer. Geral 5 19.0 2.6 20%
Enf SMI (basico, elementar)
Enf. SMI básico 24 69.3 7.2 88%
Enf. Elementar 1 20.0 25.0 100%
Agente Servico 2 42.0 4.0 50%
Others
P. Tradicional 2 33.5 0.0 0%

Providers were asked about several beliefs and practices related to respectful maternity care. Nearly all
providers said women were allowed to labor in a position they prefer, bring a companion into the delivery
room, have tea in the delivery room, and walk around while in labor (Table 3.7.2). This reflects the policies
related to humanized care that have been instituted at most facilities and are described in Table 3.6.3. The
vast majority of providers also believe it is worthwhile to explain what is happening to woman in labor,
though a few basic level nurses did not agree. The greatest areas for improvement are related to a woman’s
right to elect or refuse a medical intervention. Only one in ten providers said women have the right to pain
medication and four in ten said a woman can refuse a medical procedure. Further, providers were asked
about things they can do if a woman disagrees with a recommended procedure. Most answered that they
can explain why the procedure is important and about one-fifth said they can ask a colleague to help explain.
Very few providers (5%) said the woman has no choice or ‘I have to do the procedure anyway’.
Table 3.7.2. Provider beliefs and practices related to respectful maternity care
MCH Nurse and

MCH Nurse and
Nurse
Total Doctor/Tecnico Nurse (basico,
(superior/medio/
elementar)
geral)
n=196 n=7 n=160 n=27
Pregnant women are allowed to choose:
The position they prefer during labor 93% 100% 94% 93%
Whether to use pain medication 11% 14% 11% 11%
Whether someone accompanies her in the delivery room 95% 100% 97% 93%
Whether she will breastfeed or not 71% 71% 78% 37%
Whether to have tea in the delivery room 97% 100% 99% 93%
Walking / walking inside the maternity enclosure during labor 96% 100% 99% 89%
To refuse a medical procedure or medication 39% 71% 39% 30%
It is worth explaining to pregnant women what is happening during

96% 100% 99% 85%
labor / delivery
If she doesn't agree with any procedure I recommend

It never happens 15% 14% 16% 15%
She has no choice / I have to do it anyway 5% 14% 4% 7%
I explain why the procedure is important 83% 86% 84% 81%
I call another colleague to explain 22% 29% 24% 15%
*multiple responses allowed
MNCH knowledge was assessed by asking providers multiple response questions about routine steps of care
and signs or symptoms of complications. Composite knowledge scores were calculated as a percent of the
total number of items spontaneously mentioned. For example, actions taken during ASTML includes three
items: immediate uterotonic, controlled cord traction, and check uterine tone and massage if soft. Providers
were asked “what actions do you do during the active management of the third stage of labor?” Providers
received a score of 33%, 66%, or 100% for mentioning one, two, or all three items, respectively. The
spontaneous recall method of evaluating knowledge means that scores of 100% are not a reasonable
expectation or benchmark. In most cases, composite scores of 70-80% would indicate adequate knowledge
of the topic area.

Figure 3.7.3. Provider knowledge scores on key aspects of ANC, routine intrapartum care and management of
obstetric complications
0 20 40 60 80 100
Primary aspects of focused ANC
Characteristics of women requiring a special birth plan
Signs of labor
Observations to monitor labor
Actions of AMTSL
Signs of severe bleeding
Management of heavy bleeding after delivery
Management of retained placenta
Total respondents (n=196) Doctor/Tecnico (n=7)

Superior/Medio MCH Nurse (n=160) Basic MNCH Nurse (n=27)
Knowledge of key aspects of ANC, intrapartum care, and obstetric complications shows room for
improvement. Average scores were all below 80% and some were as low as 40% (Figure 3.7.3). Provider
knowledge was highest for labor signs and actions taken during the active management of the third stage of
labor. Mean knowledge scores were lowest for naming the characteristics of women requiring a birth plan,
signs of severe bleeding, and steps involved in the management of retained placenta. For women who
require a birth plan and signs of severe bleeding scores for individual items were low in general, but under
retained placenta, there was significant variation in levels of knowledge among the 10 items included in the
score. Most providers mentioned giving oxytocin, manual removal of the placenta, and administering IV
fluids but only half mentioned examining whether the uterus is well contracted and hardly any respondents
mentioned blood typing or preparing to operate. These detailed results will be useful for identifying specific
areas for improvement of provider knowledge.

Figure 3.7.4. Provider knowledge scores on key aspects of routine newborn care and management of
newborn complications
Knowledge of aspects of newborn care and how to manage newborn complications ranged from 44% to 64%
on average (Figure 3.7.4). Composite knowledge scores were highest for immediate newborn care: providers
correctly identified about 7 or 8 of the 11 things to do for newborns following delivery, on average.
Knowledge of the correct diagnosis and management of newborn sepsis and asphyxia is lacking, with
average scores around 50% or less. Providers were asked to list seven steps of neonatal resuscitation in
order and they named three or four, on average. Only 16% of providers mentioned the steps in sequential
order.

Figure 3.7.5. Provider knowledge of PAC and gender-based violence
Provider knowledge of aspects of PAC is somewhat lower than their knowledge of ANC, intrapartum care,
and newborn care, ranging from 43% to 59% on average (Figure 3.7.5), with the highest scores for
information provided to clients treated for an unsafe or incomplete abortion and the lowest scores for
management of women presenting with complications resulting from abortion. Within these categories, the
most commonly mentioned items were providing FP counseling and services to women who had had an
unsafe or incomplete abortion and providing counseling for HIV testing to rape victims. Few respondents
spontaneously recalled that shock and genital and abdominal injuries can result from an unsafe abortion;
that treatment for abortion complications should include taking vital signs, a vaginal exam and assessment
of vaginal bleeding, counseling, referral, and evacuation with curettage; or that labs should be requested
and referrals provided to victims of rape (data not shown). Doctors had better knowledge of what to do
when a client has been a victim of rape.

Provider knowledge of child health service provision
To assess child health knowledge, providers who routinely provide pediatric care services were asked to
participate in a brief anonymous survey that was structured and scored similarly to the maternal and
newborn health knowledge portion of the assessment. In total, 198 providers participated (Table 3.7.6). As
with the respondents to the maternal and newborn health knowledge module, the largest cadre among
respondents to the child health module was MNCH nurses, accounting for nearly 50% of respondents for this
portion of the assessment. Together with general nurses, this category of health professionals, all of whom
have about 2 years of formal education, makes up 60% of respondents. An additional quarter of respondents
were medical technicians, who have more education, and about 10% were basic nurses or lower level
cadres. A few other cadres responded but they are excluded from the knowledge analysis that follows
because they have little formal health education. On average, child health providers interviewed have 4.5
years of experience in practice. This is influenced by a handful of providers who have practiced for over 20 or
30 years. About half obtained their medical qualification more than 3 years ago.
Table 3.7.6. Demographic characteristics of respondents to child health knowledge survey

Providers Professional experience
interviewed Mean number of years Providers who have
since receiving qualification for ≥3
professional years
n mean %
Nampula 198 4.5 48%
Facility type
Hospital 9 6.3 67%
Health Center 189 4.4 50%
Health worker cadre

Doctor/Tecnico
Médico generalista 4 2 25%
Técnico Médio de Medicina 45 4 47%
Técnico Basico de Medicina 4 5 100%
Enf SMI (superior/medio/geral)
Enf. SMI superior 1 2 100%
Enf. SMI médio 95 3 34%
Enf. Geral Superior 2 6 50%
Enf. Geral Medio 26 4 50%
Enf SMI (basico, elementar)
Enf. SMI Básico 11 7 100%
Enf. Geral Basico 4 4 100%
Others
Ag. Servico 3 20 33%
Aux. Tec. Saude 1 20 100%
Ag. Voluntario 1 4 100%
Ag. Medicina 1 7 100%

Figure 3.7.7. Knowledge scores on key aspects of child health, by provider cadre
Vaccines given at birth
Medications for facility administration
Oral medications for home use
Pediatric warning signs
Pediatric symptoms
Pediatric check up items
0 10 20 30 40 50 60 70 80 90 100
Basic MNCH Nurse (n=27) Superior/ Medio MCH Nurse (n=160)

Doctor/ Tecnico (n=7) Total respondents (n=198)
Provider knowledge of child health was generally good, especially for pediatric medications and vaccines
given at birth: knowledge of the two vaccinations given at birth was over 90%. Provider knowledge of
warning signs includes if the child eats, is vomiting, has convulsions, and whether the child plays; the last
item was not commonly mentioned. The score for symptoms was also good except that very few providers
mentioned that they ask about ear problems (data not shown). There is room for improvement on the
components of a pediatric check-up, notably verifying the child’s HIV status, and asking about vitamin A and
deworming/parasitic infection (data not shown). The higher-level cadres performed particularly poorly on
knowledge of pediatric check-up items.
Summary of key findings and related recommendations

Key Findings
• In Nampula health facilities, the maternal and newborn health provider who attends the most
deliveries has over 3 years of experience on average and attends over 60 births per month (more
than 2 births/day).
• Providers generally have a good knowledge and acceptance of respectful delivery services, except
that few providers believe that a woman in labor has the right to pain medication and some do not
believe a woman can refuse a procedure
• Significant knowledge gaps exist among frontline health workers providing essential MNCH care,
particularly regarding:
o When a special birth plan is required
o Observations to monitor during labor, such as maternal vital signs
o Diagnosis of severe bleeding and treatment of post-partum hemorrhage
o Diagnosis and management of sepsis in newborns
o Comprehensive treatment for women who had unsafe abortions and rape victims
• Child health providers had better knowledge of assessment and treatment for sick children than the
delivery of preventive care through well child check-ups.

Recommendations
• Raise awareness among providers about joint patient-provider decision making and the patient’s
role in deciding what medical interventions are performed
• Referral was a component of treatment for several health problems that was less commonly recalled
by providers. Refresher trainings on referral for mothers, newborns, and rape victims are needed to
close knowledge gaps about when referral is recommended.
• Build skills of staff who attend deliveries on how to assess severe bleeding and manage post-partum
bleeding.
• Low scores on assessing and treating abortion complications may reflect stigma and a general lack of
attention to this issue, which should be further explored to ensure that comprehensive, humanized
care is given to women who have had unsafe or incomplete abortions.
• Additional training on the diagnosis and management of sepsis in newborns is recommended

3.8 Stock outs of key MNH drugs (IR 3.3)
This section includes results related to stockouts of selected MCH drugs and oxygen supply.
One module administered by the data collectors examined the availability of medications, equipment, and
supplies available in multiple service points within each health facility (e.g. labor and delivery, outpatient
preventative and curative childcare, laboratory services). This module also gathered rich information about
infrastructure, equipment and commodities available in the operating theater. We gathered information on
the pharmacy management systems in place, stock ordering and monitoring practices, as well as the
availability of key drugs, equipment and supplies on the day of the survey. Information gathered will inform
Alcançar priorities for IR 3.3 around improved supply chain and MCH commodities management. Below we
present results related to stock-outs of key drugs (Table 3.8.1).
Table 3.8.1. Stock outs of key MCH drugs in the 3 months prior to the survey
Health
Hospitals
Total (n=200) Centers
(n=9)
(n=191)
% % %
Gentamicina (injec) 40% 11% 41%
Magnesium sulfate 34% 33% 34%
Ketamina 67% 67% 67%
Dexamethasona 64% 67% 64%
Antiretrovirais (ARV) 23% 22% 23%
ORS 12% 11% 12%
Zinc 51% 78% 49%
Amoxicilina Oral 20% 0% 20%
Arteméter-Lumefantrina 33% 22% 33%
Artesunato-Amodiaquina 63% 100% 61%
Quinina oral 48% 22% 49%
Vacina pentavalente (DPT-Hib-HepB) 31% 44% 30%
Vacina contra sarampo e diluente 20% 33% 19%
Vacina BCG 25% 22% 25%
Vacina contra Tétano 17% 22% 17%
Siringas 36% 33% 36%
Luvas 40% 33% 40%
Oxytocin 15% 22% 15%
Among facilities with stockout of oxytocin (n=30) (n=2) (n=28)
Stock-out of oxytocin was due to interruption in the cold chain 70% 50% 71%
Average length of rupture (days without oxitocina) 12.0 6.0 12.0
Every one of the 18 key MCH drugs had been stocked out at one or more facilities in the three months prior
to the survey, and several drugs had been stocked out at over half of Nampula facilities, including ketamine,
dexamethasone, zinc, and artesunate amodiaquine. Oxytocin had been stocked out in the previous three
months at 15% of facilities, including 2 hospitals. Among those experiencing a stockout, most indicated the
rupture in supply was due to an interruption of the cold chain. The average number of days without
oxytocin ranged from 6.0, among hospitals, to 12.0 among health centers.

Table 3.8.2. Interruption of oxygen supply in L&D, neonatal and paediatric wards in the 12 months prior to the
survey
Health
Hospitals Centers
Total (n=200) (n=9) (n=191)
% % %
Labour and delivery ward
Has safe supply of oxygen 11% 78% 7%
Of those with oxygen, has had interruption in last 12 months 19% 14% 21%
Neonatal ward
Paediatric ward
Among those with any interruption, interruption due to electricity supply (% yes) 67% 50% 75%
Availability of oxygen in key service points is not universal among hospitals and is rare within health centers
(Table 3.8.2). Just 7% of (or 13) health centers had a supply of oxygen in the labor and delivery ward, 7% in
the neonatal ward (or neonatal area) and 7% in the pediatric ward. Among hospitals, oxygen supply was
available in the labor and delivery ward and the newborn ward/area in 7 of the 9 hospitals, and 6 hospitals
had a safe oxygen supply in the pediatric ward. Among those few facilities with a safe oxygen supply,
between 20% and 32% had experienced an interruption in the previous 12 months, and interruption in the
electricity supply was a substantial contributor to the rupture in supply.

Stock outs of key MCH drugs and supplies are common across facilities in Nampula and impact providers’
abilities to deliver high-quality MCH services to every patient. Alcançar project staff engaged in activities to
strengthen the supply of critical drugs, equipment and supplies can use these results, complemented by
additional information collected in the baseline assessment around systems and practices for commodities
management and ordering, to tailor and target technical support.

3.9 Data and data systems for decision-making (IR 3.1)
Begins an investigation into aspects of the HMIS systems including availability of computer/internet and
registers, practices around classification of deaths, and validation of key indicators triangulated with SIS-MA
data for the same period.
3.9.1 Availability of health information systems and characteristics

Health
Nampula Hospitals
Centers
n=200 n=9 n=191
Have a data manager who is responsible 30% 100% 27%
Facility has:
Computer 27% 100% 23%
Internet 11% 78% 8%
Facility regularly calculates:

Institutional births rates 93% 100% 92%
Stillbirth rate 77% 100% 76%
Vaccination coverage rate (DPT3) 94% 89% 94%
Coverage rate of fully vaccinated children 94% 89% 94%
Facility uses ICD 101 to classify deaths 89% 89% 90%

Regularly share indicators with community 50% 56% 50%
Uses SIGLUS to monitor and report stock data 56% 0% 58%
As reported by SDSMAS
Facilities that send data for SIS-MA 100% - -
Facilities that submitted reports on-time, last month 79% - -
1. ICD 10 = International Statistical Classification of Diseases and Related Health Problems v. 10
One pillar of Alcançar’s technical strategy is to support all levels of the health system to use accurate data to
identify problems and implement solutions that strengthen the system. The quality of data reported into
routine health information systems, electronic logistics management systems, and into other systems is not
only critical to accurately inform health planning, but also to build trust among data users in the data’s
reliability, and thus contribute to a culture of data use.
Hospitals are reasonably well-prepared to use and optimize data systems – all have a data manager
responsible for managing the process, and all have at least one computer (though just 78% have internet
access). Health centers, on the other hand, are less prepared to use electronic information systems. Most
facilities report regularly calculating key indicators and are using the International Classification of Diseases,
Tenth Revision, better-known as ICD 10, to classify deaths (one of the proposed Disbursement Linked
Indicators for the anticipated performance-based financing scheme). However, engagement with the
community – through sharing of indicators – was reported by only 50% of facilities. This is clearly an
important area for improvement.
From interviews with SDSMAS staff, all facilities are sending information to be entered into SIS-MA, and 79%
submitted their last monthly report on-time.

3.9.2. Availability of MNCH registers
Nampula Hospitals Health Centers
(n=200) (n=9) (n=191)
% % %
Death certificates 29% 100% 25%
Referral Register 90% 89% 90%
Operating Room Registration* 100% 100% -
Family Planning Consultation Register 99% 100% 98%
Antenatal Register (ANC) 98% 100% 99%
Maternity Admission Register 98% 100% 97%
Maternity Register 98% 100% 97%
Kangaroo Mother Care Register 28% 33% 27%
Postpartum Consultation Register 99% 100% 98%
Gynecology Emergency Admissions 95% 100% 94%
Newborn Register 30% 78% 27%
Immunization Register 92% 67% 93%
Well Child Visit Register (CCS) 96% 67% 97%
Sick Child Consultation Book (CCD) 92% 78% 92%
Pediatric Inpatient Register 26% 78% 23%
Child at Risk Consultation Register 96% 67% 97%
*Only among hospitals
The quality of data reported begins with proper completion of the numerous registers and recording tools
available for MCH services. Many of these registers are essentially universally available; though, it is
concerning that even a few health centers are without key tools such as an FP register, ANC register,
maternity admissions and labor register, well and sick child consultation registers. Registers the least
available are pediatric inpatient registers (however, re-calculating this among only those facilities that have
pediatric inpatient services would be a better measure), newborn registers and KMC registers. Just 29% of
health centers have a death certificate register.

3.9.3. Validation of two key indicators with SIS-MA data
Total number of deliveries Total number of maternal deaths
(Feb 2019 - July 2019) (Feb 2019 - July 2019)
Percent
difference
relative to Absolute
SIS-MA Alcançar SIS-MA SIS-MA Alcançar difference
Nampula 117,400 116,123 -1.1% 94 230 136
Facility Type
Hospital Central 4,048 4,472 10.5% 140 -
General, Rural and District Hospitals 8,443 8,665 2.6% 30 -
Health Centers 104,909 102,991 -1.8% 60 -
Districts
Angoche 6,644 6,748 1.6% 2 4 2
Distrito de Nampula 15,638 16,046 2.6% 53 168 115
Erati 6,082 6,048 -0.6% 2 2 0
Ilha de Mocambique 1,620 1,627 0.4% 2 13 11
Lalaua 1,895 1,774 -6.4% 0 1 1
Larde 1,751 1,855 5.9% 0 0 0
Liupo 2,371 2,357 -0.6% 0 0 0
Malema 4,804 4,403 -8.3% 1 0 (1)
Meconta 4,401 4,349 -1.2% 1 1 0
Mecuburi 4,410 4,351 -1.3% 1 1 0
Memba 5,243 5,262 0.4% 3 20 17
Mogincual 2,399 2,371 -1.2% 0 0 0
Mogovolas 10,022 9,789 -2.3% 1 0 (1)
Moma 6,330 5,938 -6.2% 4 7 3
Monapo 9,478 9,579 1.1% 0 3 3
Mossuril 3,545 3,124 -11.9% 0 0 0
Muecate 3,488 3,276 -6.1% 1 0 (1)
Murrupula 3,282 3,240 -1.3% 2 0 (2)
Nacala 7,007 6,935 -1.0% 10 1 (9)
Nacala-a-Velha 2,779 2,761 -0.6% 2 0 (2)
Nacaroa 3,507 3,590 2.4% 0 0 0
Rapale 4,295 4,358 1.5% 0 2 2
Ribaue 6,409 6,347 -1.0% 9 7 (2)
The data we collected via extraction from facility registers allows the Alcançar team not only to calculate
baseline indicators, but also to validate the data entered into SIS-MA. Table 3.9.3 show the results of that
validation for institutional deliveries and institutional deaths. The baseline assessment data’s concurrence
with SIS-MA on deliveries is very high – with a 1% overall difference. The district-level breakdown helps to
highlight districts, and eventually facilities, where data quality TA may be most critical.
Regarding deaths, the data collected in the assessment varies substantially with what is in SIS-MA. Our data
collectors counted substantially more maternal deaths than were reported into SIS-MA during the same
period. The Monitoring and Evaluation team is already investigating the source of these differences. One
important area to scrutinize is the cause of the difference between deaths reported into SIS-MA at the
Central Hospital and deaths counted during our assessment. Please note that while overall we found
substantially more deaths than SIS-MA reports, there are some districts that reported more deaths than we
found. This could mean that we failed to review all the proper source material (i.e. registers) or perhaps we
did not have access to all the proper registers. Because institutional mortality is a primary indicator that we
will use to measure the success of the project, we must work to improve the quality and consistency of the
SIS-MA data. Regarding death reporting, there are many factors that can impact accurate reporting
including incentives to under-report and providers’ fear of

There are important areas for capacity building around data quality and data use which Alcançar can
prioritize in PY2. In most health centers, paper-based registration, aggregation and reporting remains the
standard procedure. SDSMAS reports that all health facilities are contributing to their data, and most are
doing so on time. Priority activities will likely focus on ensuring health providers understand the proper way
to fill the registers, and to aggregate data into monthly reports. Efforts should be made to ensure facilities
have the required registers.
A thoughtful strategy to improve death reporting in SIS-MA is necessary and can coincide and be informed
by our engagement with the Provincial and District death audit committees, and through the facility-level QI
and MPDSR strengthening.


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Baseline Assessment of Facility and District Capacity

Cooperative Agreement Number: 72065619CA00004

January 31, 2020

Alcançar Baseline Assessment of Facility and District Capacity

-Dr. Geoffrey Ezepue, Alcançar Chief of Party

Alcançar Baseline Assessment of Facility and District Capacity

A snapshot of key results:

Alcançar Baseline Assessment of Facility and District Capacity

Alcançar Baseline Assessment of Facility and District Capacity

In addition to the baseline indicators, the assessment provides information on:

The baseline assessment included 9 modules:

• Module 1: Health Facility Identification, Infrastructure, and Emergency Referral Capacity

• University degree. Masters or professional degree in medicine, midwifery, nursing, demography,

2.4 Data entry, cleaning and analysis and dissemination

Alcançar Baseline Assessment of Facility and District Capacity

2.6 Research ethics

2.7 Organization of the report

Alcançar Baseline Assessment of Facility and District Capacity

Nampula 241 13 228 28 200 9 1 1 2 5 191 4 7 4 35 141

Furture Focal District 76 6 70 13 57 2 1 1 0 0 55 3 4 3 10 35

Alcançar Baseline Assessment of Facility and District Capacity

Figure 3.2.1 Availability and sources of electricity, by facility type

60% No interruption in past week

40% Interruption < 2 hours in last

20% Interruption lasting >2 hours in

Water and Sanitation

Alcançar Baseline Assessment of Facility and District Capacity

Figure 3.2.3 Availability and sources of water, by facility type

Availability of key RMNCH services by facility type

Alcançar Baseline Assessment of Facility and District Capacity

Figure 3.2.6 Availability of key RMNCH services, by facility type

Alcançar Baseline Assessment of Facility and District Capacity

Alcançar Baseline Assessment of Facility and District Capacity

Disinfectants and antiseptics

Alcançar Baseline Assessment of Facility and District Capacity

Waste management and disposal

Summary of key findings and recommendations

Alcançar Baseline Assessment of Facility and District Capacity

Infrastructure and guidelines

Table 3.3.2. Presence of relevant MNH guidelines

(n=200) (n=9) (n=9)

Alcançar Baseline Assessment of Facility and District Capacity

Oxytocics and prostaglandins (any)

Drugs used in emergencies (any)

Alcançar Baseline Assessment of Facility and District Capacity

Other drugs and supplies

Alcançar Baseline Assessment of Facility and District Capacity

Small and sick newborns 0% 0% 0%

Alcançar Baseline Assessment of Facility and District Capacity

Alcançar Baseline Assessment of Facility and District Capacity

Alcançar Baseline Assessment of Facility and District Capacity

Fully Almost Performed

Table 3.3.8. EmONC coverage per population (relative to WHO Guidelines)

Furture Foca l Di s tri ct

Summary of key findings and recommendations

Alcançar Baseline Assessment of Facility and District Capacity

Alcançar Baseline Assessment of Facility and District Capacity

Infrastructure and guidelines

Table 3.4.1 Immunization infrastructure

Table 3.4.2. Presence of relevant child health guidelines