Table 2.

Lessons Learned and Next Steps for FGH and Rural Implementation in Zambézia

	Lessons Learned	Next Steps
Human Resources	Human capacity development requires ongoing support and creative ideas to maximize pre-service and in-service training. Increased human resources are required to address increasing number of patients. Health worker motivation plays a big role in the provision of quality HIV services.	On-the-job clinical mentoring that focuses on delivery of quality care and services. Improved M&E indicators and methodologies that evaluate the impact of training (not only numbers of persons trained). Expanding the number of pre-service training courses for key health care staff through 1) increased dedicated funding of courses and curriculum development and 2) simultaneous investments in infrastructure, number of professors, and capacity of professors to improve pre-service institution capacity to cope with the increased number of courses. Advocacy with Government bodies to create place for essential positions within Ministry of Health organizational structures. Advocacy with Government and donor countries to increase investments in health care worker salaries.
Infrastructure	Physical Infrastructure Increasing space is essential when increasing patient volume. Rural health centers need basic necessities required for health care delivery, including steady water and electricity supplies.	Prioritize renovations and improvements of existing health infrastructure to allow for expansion of HIV services into the periphery.
	Supply Chain Management ART roll-out has been severely affected by shortages in essential medicines and basic lab tests.	Focus on improving the logistical legs of the supply chain system within the province (e.g., warehousing, transport, and forecasting) while working with government and donor agencies towards an improved supply chain system.
	Laboratory Diagnostics HIV/AIDS and other chronic disease programs, delivered with quality, require access to regular laboratory monitoring and opportunistic infection diagnostics.	Advocate for Point of Care CD4 testing Expand rehabilitation of laboratories to provide basic lab testing and machine installation, e.g., hematology, biochemistry Advocacy for funds to support provincial and district opportunistic infection diagnostics with priority focus on TB diagnosis.
	Health Information System HIV services and chronic disease management generates a larger amount of paperwork than does an acute care program. Use of documentation tools in a vertical fashion, without planning for integration, creates large inefficiencies in management and utilization of patient data. Development of data collection tools based on government and program specific reporting requirements allows for limited patient and program analysis. Information technology infrastructure to support robust health information systems at the facility level requires creativity and short-term financial investments.	Utilize current information technology investments made for program specific databases as a platform to build integrated systems which incorporate reporting requirements and patient management tools. Advocacy for broader use of patient data in the day-to-day management of patients as well as program reporting. Highlight the advantages of electronic medical records in patient management, information utilization, and efficiency for health staff. Expand both pre-service and in-service training opportunities for national health workers focusing on quality assurance, data collection, and data utilization by 1) advocating at national level for the incorporation of data entry staff into the national cadre of recognized health personnel 2) improving training in monitoring and evaluation for the persons who are currently identified as M&E staff by the national health system, and 3) developing appropriate curricula and practical training sites within the national training institutions. In Mozambique, non-health related information technology infrastructure investments (laying of fiber optic lines) is happening relatively fast. Expand investments in appropriate short-term solutions such as satellite internet in order to scale-up health information systems in the interim.
Integration of Services	Inequities created by large vertically funded programs include 1) decreased health worker motivation in other service areas; 2) diminished focus on combating other diseases that may have higher morbidity/mortality; 3) creation of inefficiencies and duplications in management and monitoring systems.	Advocacy with government and donor agencies for fund utilization which is broader in scope. Highlight the need for existing funds to be leveraged with other development funding to create wrap-around projects.
Stigma Reduction	Communities with low HIV prevalence and that do not have adequate or correct information about a disease fuel stigma. Stigma has a severely negative impact on care and treatment roll-out.	Emphasize social support amongst people living with HIV (PLWHA) by increasing investments in government-authorized associations for PLWHA and, community- and clinic-based support. Incorporate PLWHA into the health system and the community level activities as peer educators to increase awareness and provide an opportunity for sharing experiences and knowledge Focused, locale driven studies which improve understanding of the socio/cultural dimensions of stigma in a particular community need to be conducted and used to target resources and activities.
Bridging Educational Development with Health Education	Poor education level of a community and literacy can negatively impact on treatment understanding and adherence.	Ensure that health care providers have appropriate and tested teaching tools that are available in both local language and in graphic designs. Advocacy for investments in rural educational development.
Increased Sense of Health System Ownership	Implementation of rural services under an “emergency” mandate required dependence on a large percentage of expatriate clinicians and advisors, particularly due to the human resource constraints. It is desirable to replace expatriate staff with nationals expeditiously.	Programmatic support approaches will be modified at the district and health facility levels to increase implementation capacity and accountability of local health systems (i.e., direct financing from NGO partner organizations to district health authorities for program implementation through sub-agreements) Long-term health program sustainability in rural Mozambique benefits from economic, educational, and agricultural capacity-building.