Facilitators of successful implementation
The main facilitator of successful implementation of the intervention, regardless intensive or sustainment), was compatibility of the intervention with organizational structures, processes, and priorities of Mozambique’s health system at the district and health facility levels (Table 3).
Table 3
Facilitators of successful implementation of SAIA-SCALE, across two intervention waves in Mozambique, 2018–2020
Facilitators in both implementation waves (2018–2019 and 2019–2020) |
Inner setting domain |
Compatibility (subconstruct of implementation climate) | SAIA compatibility with organizational structures, processes, and priorities of national health service at district and facility levels |
Facilitators in the second implementation wave (2019–2020) |
Intervention characteristics domain | |
Relative advantage construct | Relative advantage to MCH and PMTCT cascade at health facility |
Outer setting domain | |
External policy and incentives construct | Support and pressure that provincial managers exerted over district and facility managers and personnel |
Inner setting domain | |
Relative priority (subconstruct of Implementation climate) Leadership engagement (subconstruct of readiness for implementation) | Relative priority of intervention at district and facility levels, supported by PMTCT being a national priority in Mozambique District managers’ active involvement in intervention activities: health facility supervision, technical support, and solving logistical issues |
Implementation process domain | |
Executing construct | Implementation of intervention as originally planned, with high quality methods and committed personnel |
Some participants reported that the intervention helped implement or improve the implementation of already planned activities at the health facility and did not conflict with activities underway at district and health facility levels. This made frontline nurses and managers look at the intervention as part of their “routine and a necessary activity – this is our daily bread” [Nurse manager, March 2020]. Other interviewees described that the intervention was a good fit because – by consulting with community leaders – it respected the community engagement principle that is central to Mozambique’s health system. Participants echoed these thoughts as follows:
The intervention is compatible with how the health facility works because it doesn’t interfere; it helps us improve and see our weaknesses. For instance, in the maternity ward we were not able to meet our target of bringing mothers to the maternity. They [intervention leaders] gave us tips and we are meeting our targets - Frontline Nurse, Urban Health Facility, April 2019.
The intervention is compatible because nurses don’t feel that it is something that was added to their work; they view SAIA as a normal activity - Frontline nurse, Rural Health Facility, March 2019.
Facilitators of successful implementation of the intervention that were limited to a year after implementation (intensive phase alone) were related to the relative advantage of the intervention, external policy and incentives, the relative priority of the intervention, and the quality with which the intervention was implemented.
Study participants mentioned that the intervention’s advantages to the MCH program and to the PMTCT continuum of care at health facilities, included improving MCH managers and frontline nurse awareness of the need to conduct data quality assessments, to improve MCH data quality and PMTCT indicators such as early enrollment of mothers into antenatal care, early collection of blood samples for early infant diagnosis testing, and retention of mothers and their children in the PMTCT continuum of care. They also noted that the intervention improved frontline nurse and district manager competencies for independently identifying and solving problems in a timely fashion, which also promoted nurse performance and self-evaluations. Finally, participants added that the small grant funding provided to the districts helped improve the quality of MCH services at health facilities because it helped purchase medical equipment and furniture, patient clothing and other items. They summarized that the intervention helped improve humanization of services, because it inspired frontline nurses and managers to focus more on the health of mothers and their HIV-exposed babies. As expression of the role of external policies and incentives as a facilitator were support and pressure that provincial managers exerted over district and health facility managers and other personnel. Study participants mentioned the financial support that their health facilities received through small grants awarded to the districts, as well as logistical support in the form of transportation, snacks for monthly meetings held at the health facility, and office supplies. They noted that both study nurses and provincial MCH and PMTCT managers provided technical support and were rigorous in demanding professional excellence from frontline nurses and MCH nurse managers.
The project is being implemented by people with knowledge, competencies and who use adequate methods – [study] nurses and district managers. The methods they use [include] respect, demand [for excellence], patience, and tips so we can improve our work. This method is different from the method used by [another NGO] workers, who are solely concerned with whether there is data, they demand from us and shout at us, forgetting that nurse’s salary is paid for by the State [government], not by [the NGO] - Frontline nurse, Rural Health Facility, March 2019.
They highlighted that while study nurses provide technical support whenever health facility nurses and managers asked for it, they had a participatory leadership style that helped frontline nurses improve their own leadership skills. Specifically, they noted that study nurses always gave health facility nurses the opportunity to chair monthly health facility meetings. They added that the provincial MCH and PMTCT managers conduct weekly monitoring of PMTCT indicators, thanks to data they receive through the provincial MCH WhatsApp group. The provincial MCH manager supplements weekly monitoring with surprise visits to health facilities, during which she always communicated her presence to the district manager when she arrives at the district.
The organizational (or inner) setting had a positive influence on successful implementation because stakeholders at the health facility and district level regarded the intervention as a priority, and intervention leaders and other managers at the health facility and district level were actively involved. That the intervention addresses PMTCT, a national priority in Mozambique, might influence it being regarded as a priority at lower levels of the country’s health system. For instance, community members were engaged in community mobilization through health committees and joint management committees that gave biweekly talks at the community on various topics, including on the need for male partner involvement in MCH consultations at the facility which, given gender power relations could contribute to increasing women’s access to MCH services. Additionally, study participants noted that all MCH personnel at the facility and district levels continued to be involved in the intervention, including nurses, managers, clinicians, and health facility managers. Study participants noted, however, that antenatal care managers seemed to be more active, perhaps because that section is the point of entry for mothers and babies at the MCH program. District managers also continued to be involved in the intervention, by conducting health facility supervisions, providing technical support, and finding solutions for logistical challenges that could affect intervention implementation, such as facilitating access to transportation for supervision visits. Study participants found the involvement of chief medical officers particularly important because that had not been planned for in the intervention. However, in some districts, the intervention seemed to be less of a priority for part of the administrative personnel, whom some participants noted did not always ensure timely disbursement or use of the small grant funds provided to districts. Study respondents noted that program personnel (e.g. district MCH supervisors) had limited influence on administrative decisions at the district level (including use of the small grant funds).
Finally, the implementation process positively influenced implementation of the intervention through staff involved in program execution as planned in the protocol. Study participants noted that the intervention used appropriate methods and was implemented by highly qualified and committed personnel (PMTCT and MCH district supervisors and study nurses) who displayed an exemplary work ethic. They noted that all district managers were competent in using intervention tools, such as the cascade analysis tool, and they coupled solidarity and respect for health facility managers and nurses with demands for professional excellence. An instance of solidarity that frontline nurses mentioned was that whenever study nurses and district managers visited health facilities for the monthly meeting, before conducting intervention specific activities, they helped health facility staff find solutions for problems identified through the facility action plan, and helped nurses manage the patient flow.
We go to the health facility very early [in the morning]. We provide technical support, [which includes] working to try and reduce [patient] flow, so we can manage to have her [nurse] participate in the meeting. So, after our work, we go ahead, we register, we collect the monthly data. We register monthly data in the giant paper. Only they [nurses] come. We register data in the PCAT when all of them are in the meeting and we write the work plan in that paper – District manager, March 11, 2019.
Barriers to successful implementation
Barriers to intervention implementation regardless of intervention wave and phase were related to the lack of adequate health facility infrastructure and resources to satisfy the needs of patients who seek MCH or PMTCT services at health facilities, and to challenges that some districts had in managing the small grants provided by the intervention (Table 4).
Table 4
Barriers to successful implementation of SAIA-SCALE, across two intervention waves in Mozambique, 2018–2020
Barriers in both implementation waves (2018–2019 and 2019–2020) |
Outer Setting domain | |
Needs and resources of those served | HIV-positive mothers do not show up for institutional births because of inadequate health facility and road infrastructure |
Inner Setting domain Compatibility (subconstruct of implementation climate) | Challenges that some districts had in managing the small grants provided by the intervention |
Available resources (subconstruct of readiness for implementation) | Inadequate health facility infrastructure: small rooms, lack privacy lack of registries and medical and hygiene suppliers and child delivery medical equipment Some health facilities did not have running water and health workers interrupted work to fetch water |
Barriers in the second implementation wave (2019–2020) |
Inner Setting domain |
Available resources (subconstruct of readiness for implementation) | Stockouts of medicines for HIV prophylaxis and ART at facility and district prevent meeting PMTCT targets |
The lack of adequate health facility and road infrastructure, and distance between health facilities that reduce HIV-positive mothers’ access to MCH and PMTCT services at the health facility level, was identified as an important barrier. Specifically, the small size and lack of quality of pregnant mothers’ waiting homes [casa de espera da mãe grávida] and the lack of privacy during MCH consultations discourages mothers from seeking institutional births. This was compounded by the distance between the residences of those mothers and the health facility and the poor road quality. Some health facilities lack running water, and frontline nurses often interrupt their work to fetch water, which distracted healthcare workers from focusing on improving the quality of data and of healthcare service provision.
Additionally, the distance from health facilities to residential areas and lack of transportation support from the district health authorities prevented health workers from conducting community outreach work that study participants believe could contribute to increasing mother’s access to MCH and PMTCT services. Study participants also mentioned that some districts had challenges in managing and disbursing funds from the small grants provided by the study:
It takes about three months to have those funds released [intervention small grants]. What we would like to ask in the management of those materials is that when they go and purchase them, the person responsible for maternity wards at the district level should be part of the team that purchases the material along with the administrative person, so we can have materials with quality. Because usually you ask for a basin and they bring you a basin to wash hands when you need a basin for the delivery. So, this is not helpful. […]. You ask for a trash bin and they bring you a backet That doesn’t make any sense. They shouldn’t include the nurse only when they go shopping. They should also include her when they do [procurement] to identify which items have quality. [Otherwise, the] administrative person can think in his/her head that the basins he/she has chosen are the same. This is what happens when materials and supplies are purchased – FGD with maintenance phase nurses from four districts, March 14, 2020.
The only barrier to successfully implementing the intervention after a year of implementation was related to constant stockouts in the ART combination of Nevirapine and Azidothymidine (AZT) that is used for prophylaxis and treatment of HIV in babies that were being assisted in the PMCT continuum of care. Study participants noted that these stockouts could make prophylaxis ineffective and compromise prevention of vertical transmission of HIV, one of the main intervention targets. Study participants noted that these stockouts happened at both health facility pharmacies and at the district depots.