Gloyd, Stephen MD, MPH*†; Montoya, Pablo MD, MPH†; Floriano, Florencia BS†; Chadreque, Mariaana Correia MPH†; Pfeiffer, James PhD, MPH*†; Gimbel-Sherr, Kenneth MPH†‡
SYPHILIS INFECTION IN PREGNANCY has long been recognized as a major factor in adverse perinatal and maternal outcomes.1–8 Syphilis can be easily diagnosed with simple laboratory tests,9–14 treatment is cheap, and it is highly effective if given in the first or second trimester of pregnancy.2,15–21 Because the prevalence of adult syphilis infection in Sub-Saharan Africa is quite high, and because the utilization of antenatal care exceeds 70% in Africa, antenatal syphilis screening should be widely and routinely applied in antenatal clinics throughout the continent.
Antenatal syphilis screening is a written national policy in nearly all African Ministries of Health; however, screening is performed sporadically at best. A 1997 survey completed by 22 sub-Saharan Africa countries produced estimates that fewer than 38% of women already attending antenatal care were likely to have been screened.22 Failure to screen for syphilis in pregnancy was estimated to have resulted in at least 1 million missed opportunities annually to have identified and treated pregnant women with active syphilis. The principal obstacles reported were cost of testing and treatment, organization of services, and transport costs to the testing/treatment sites. In areas where screening does occur, its efficacy is limited by late or no treatment among those who screen positive.22 Partner treatment is typically inadequate as well.
Mozambique is one of the many countries in Africa with a high prevalence of syphilis and HIV [approximately 8% rapid plasma reagin/Treponema pallidum haemagglutination (RPR/TPHA) positive and 16% HIV-positive]. Malaria is also endemic. In the mid 1970s, a newly independent Mozambique built a model primary health care system to meet the needs of its dispersed and poor rural population. A major effort was initiated by the Ministry of Health (MOH) to rapidly expand the health workforce to correspond with an expanding network of health facilities. By 1978, antenatal syphilis screening was an official national norm and most women received some antenatal care. However, syphilis screening was often ignored because of inadequate laboratory capacity, lack of supplies, or simply because syphilis screening had not been adequately emphasized in supervision among antenatal care nurses.
During the 1980s and 1990s, the capacity of Mozambique’s emerging primary health care system was undermined by 2 factors. The first was a proxy civil war (1980–1992), initiated and supported by the Apartheid regime of South Africa, in which insurgents terrorized civilian populations and targeted government infrastructure, including hundreds of clinics and their staff. The second factor was the imposition of structural adjustment programs by the International Monetary Fund (IMF) and donors that slashed government budgets. When the war ended in 1992, donor and NGO support helped reexpand the health infrastructure through investment in new facilities and specific programs. However, with IMF mandated spending caps, the expansion of the health workforce and facility maintenance was greatly curtailed. By the late 1990s the economy began to grow, but structural adjustment program-related government spending restrictions continue to constrain expansion of the health system. By 2004, Mozambique had only 2 doctors and 22 nurses per 100,000 population, one of the lowest health worker densities in the world.23 The salary caps imposed by the IMF have kept health worker salaries at poverty levels, contributing to low morale.
With this historical context, the authors, representing the MOH and Health Alliance International (a nongovernmental organization—NGO—with 2 decades of work in Mozambique) have been working to improve access to and quality of antenatal care, including syphilis screening. This article describes factors behind significant improvements in antenatal care and draws on the experience with syphilis testing to illustrate challenges of scaling up new technologies into overburdened health systems.
Experience in Central Mozambique
In 1992, efforts were made to estimate the proportion of antenatal attendees screened for syphilis in the 2 central provinces of Mozambique (population approximately 3 million). Because antenatal cards were often not completed fully, a review of laboratory records demonstrated that the number of women with prenatal tests performed was well under 5% of the numbers of prenatal attendees. MOH officials designed a syphilis screening feasibility assessment in 11 health facilities, supporting training, supervision, and logistics, while introducing a screening registry book at each facility.24 In addition, a small stipend was paid to participating nurses, who at the time were earning the equivalent of $35 USD per month. RPR screening increased to 70% in these facilities during the 18-month study, then gradually dropped to below 40% because of multiple system problems, including charges for RPR and treatment, test shortages, nurse and laboratory technician absences, and poor nurse morale (Fig. 1). Nevertheless, the experience demonstrated that it was feasible to scale up universal RPR screening. The study also identified additional obstacles to effective syphilis screening; including late attendance at antenatal care, transport costs for pregnant women, and mixed quality of RPR testing in the laboratories.
Over the next few years, reports on the experience were presented at conferences and meetings at provincial and national levels. Further advocacy was conducted through articles and editorials in the national medical journal24,25 and through multiple informal encounters with MOH and donor officials. By 1995, antenatal syphilis screening was made a key element in the national 5-year plan. With strong policy support, the total screening rate among pregnant women in health facilities with laboratories within the 2 central provinces of Manica and Sofala increased to 50%–60%. Nevertheless, nearly half of the women attending antenatal care in these sites were still not getting screened. It was believed that much of this deficit was caused by women who did not go to the laboratory for either blood draw or results. In some cases the laboratory was in a different location, and usually the women had to wait in a second line. To address this, health workers in one clinic initiated a system where blood was drawn directly by MCH nurses at the beginning of the antenatal session to permit batch testing and transport of samples. This method facilitated obtaining of results and treatment on the same day.
The percentage of ANC attendees tested immediately increased to 90%–100% in these health facilities (Fig. 2). However, the proportion of women recorded as treated remained around 70% given that women had to pay for their treatment. With active communication across the provinces, the batch testing practice and the provision of treatment in the antenatal care site quickly spread to other clinics. Advocacy efforts resulted in an MOH policy of free treatment (penicillin G). The introduction of a formal registry system, and a laboratory quality control checklist further strengthened the system and boosted enthusiasm of health workers. Within 1 year, the model was extended to all 32 health facilities in the 2 provinces with or near a functioning laboratory. Testing rates remained over 90%, and more than 50,000 women were tested annually, identifying over 6000 syphilis positive women and over 90% recorded as treated. Syphilis screening had become a habit for all MCH nurses providing antenatal care and within 2 years, the practice was sustained with no further donor or NGO input.26
First antenatal visits of many women were too late in gestation for effective syphilis treatment, even if they were treated on the day of the first visit. Even after several years of community mobilization, only 45% of positive women were treated before 24 weeks of pregnancy. Shortages of RPR tests, syringes, and penicillin became more common as demands for both increased. Introduction of single-use, disposable syringes contributed to the syringe and needle shortages. Inadequate allocation and absences of nursing and laboratory personnel created additional gaps in testing.
Competition among vertical programs in antenatal care began to have an impact in the late 1990s. Special sexually transmitted diseases care programs channeled antenatal syphilis cases to separate clinics for registry and treatment, disrupting the antenatal flow patterns. Prevention of mother to child HIV transmission (pMTCT) programs created additional separate systems (sometimes separate clinics!) of patient flow and monitoring. Intermittent preventive therapy and distribution of insecticide treated nets for malaria created even more separate processes. Each of these distinct vertical programs strained the already stretched workforce and limited space capacity in antenatal care sites.
Partner notification and treatment have been consistently poor. Antenatal care nurses typically counsel their index patients to notify their partners using a standardized card to encourage them to come to the antenatal care clinics where they are treated. The rate of documented partner treatment has remained at about 50% for many years. Without partner treatment, it is likely that reinfection frequently occurs. Some women say that they do not notify their partners because they fear domestic violence and family disruption, their partners are migrant workers, or they are single mothers with casual partners.
Introduction and Impact of the Rapid Syphilis Tests
One of the greatest gaps is the very large number of women who do not get screened because they attend antenatal care in peripheral health facilities without reasonable access to laboratories. In 2003, the MOH, with support from HAI and Program for Appropriate Technology for Health (PATH), with funds from the Bill and Melinda Gates Foundation, introduced a treponemal immunochromatographic strip (ICS) rapid test for antenatal syphilis screening in hopes of bringing screening to these peripheral units. A feasibility study among nearly 5000 pregnant women demonstrated that the ICS performed quite well in Mozambique.9 The ICS was more sensitive (86% vs. 72% for RPR+/TPHA+ cases) and specific (97% vs. 96% for RPR+/TPHA+ cases) than RPR and more reliable than RPR in peripheral health facilities.9 The cost study described by Levin et al.27 demonstrated that the overall average cost per women screened was comparable among the 2 tests ($0.85 with RPR and $0.98 with ICS) despite the greater unit cost of the ICS ($0.40) compared to the RPR ($0.20).
The test was introduced for antenatal screening at all 164 health facilities providing antenatal care in the 2 central provinces. We assessed the introduction of the ICS test in the 132 peripheral facilities without laboratories, and compared the ICS with RPR in the 32 facilities with laboratories. Tests were performed by nurses in the clinics and by laboratory technicians where laboratories were available. In a survey conducted in 27 health facilities, 14/17 laboratory technicians and 27/27 nurses preferred ICS over the RPR because of test performance speed, immediacy of results, ease of interpretation, and antenatal care nurse control over the testing process.9 The number of antenatal care attendees tested nearly doubled (Fig. 3) mostly because testing became available in antenatal care sites without laboratories. In the first year, over 80,000 women were tested, 8000 of whom were syphilis positive and 96% of whom were treated. The proportion of testing increased to 93% in all health facilities (with and without laboratories) providing antenatal care. However, the new test did not make a major difference in antenatal syphilis screening in health facilities with laboratories, largely because the screening levels at those clinics were already more than 90%.
The major disadvantage of the ICS is the persistent positivity of the treponemal test, even after treatment. Thus, if the ICS is used as a single test, over the years an increasing proportion of women who were once infected but now healthy will still test positive and be subject to unnecessary treatment, stigma, and other consequences of syphilis test positivity. However, overtreatment also occurs with RPR if the time between pregnancies is short,28,29 and because of false positive results.6,13 Undertreatment is currently a more important issue and local experience has demonstrated that RPR has significantly more false negatives under field conditions than the ICS.9
Over the decade, we noted that the long-term and widespread and functioning syphilis screening may have reduced overall community prevalence of syphilis in these two central provinces of Mozambique. From 1988 to 2005, the antenatal prevalence of syphilis (RPR) positivity in the 32 largest health facilities dropped from approximately 12% to 5%.30 During the same time, of course, other factors may have also contributed, including increased condom use, the introduction of the syndromic approach for treatment of STIs, decreased high-risk behavior as a result of HIV programs, and AIDS mortality.31 However, HIV infections continue to increase.
The Mozambique experience over the past 2 decades has shown that it is possible to scale up and maintain effective antenatal syphilis screening in one of the poorest countries in the world. The experience demonstrated that the RPR can be an effective test on which to base screening programs. However, the rapid ICS test is critical to provide access to testing for the antenatal patients at peripheral facilities without laboratories who had largely been left out of the screening programs. Table 1 summarizes some of the most important health service changes associated with improved screening performance.
Most importantly, the experiences with syphilis screening as an integral part of the antenatal care program show that scale up is substantively different from introduction of new technologies or systems. It requires broad health system strengthening to be effective and sustainable. Persistent policy advocacy at all levels of the MOH is crucial to its success. Finally, the scale-up benefits from continuous monitoring to identify and address the multiple health systems challenges whose improvement is essential to making all of the innovations work. The following discussion outlines the most important of these challenges, which include workforce, facilities, systems of care, community involvement, donor management, and leadership. Although the discussion is derived from Mozambique examples, the issues tend to be major concerns throughout Africa.
The nursing shortage is probably the most important obstacle to the scale up of new programs. In high volume health facilities, midwives already have a high workload. The addition of multiple vertical program activities such as syphilis screening, pMTCT, and malaria create substantially more stress for overworked nurses and adversely affect morale. Low salaries and poor conditions of work add to the morale problem. Huge numbers of new nurses need to be trained, but not without assurance by Ministries of Finance and Health that the health system has the financial capacity to hire and support them. National and international advocacy is necessary to promote an expanded workforce that corresponds to the expanding health care needs.
Much of the current workforce “capacity building” by donors is done through 1–3 week “hotel courses” that tend to focus on specific conditions or programs. In many cases, they can be useful. However, the impact of these courses is frequently limited by the poor working environment, low salaries of nurses, and inadequate supervision. In the case of the training for improving syphilis screening, we noted that the short courses did contribute to the improvement of the quality of care—but only when it was accompanied by frequent postcourse support visits with focused attention to conditions (equipment, supplies) and health worker morale at the health facilities. Integrated supervision of multiple programs can contribute to improving services and help avoid program verticalization. Frequent supervision reinforces the concept that antenatal care naturally includes several key interventions, including universal syphilis screening. Once nurses get into the habit of performing key tasks, these health workers tend to teach newcomers to do the same. When the importance of these critical interventions is understood and internalized, health workers will exert substantial energy to solve supply, logistics, access to care, and patient flow problems.
Every donor and NGO wants to build capacity and create new, innovative systems of care. However, when literally hundreds of donors and NGOs are putting on similar short courses in a country like Mozambique, the system can easily be overwhelmed with capacity building. There are too few managers to select the appropriate candidates and too few health workers to train without creating gaps in services. Short course training must be done judiciously to avoid pulling critical health workers from their jobs without substitution.
Adequate facilities are key to carry out and scale up the essential components of antenatal care. We noted that efforts to improve the clinic environment attracts patients and provides an optimal environment for worker morale. Adequacy of space, including separate rooms for confidential interviews is increasingly important for discussion of sensitive issues relating to HIV and syphilis. Attention to basic maintenance is necessary to ensure meeting minimal conditions for work and client safety. Maintenance of facilities is a recurrent cost that often does not get covered by donors—and lack of maintenance over the past several decades has taken its toll. In addition, in the current age of program-specific, vertical funding, NGOs are often limited to rehabilitation or new construction of a site for a specific activity within a larger facility. In Mozambique, this practice tends to create a sense of separateness of these new programs from traditional programs among health facility managers and health workers. Greater funding and higher salaries among the well funded programs is often resented by those who are left out, and these programs are sometimes sabotaged as a result.
Strengthened systems of care and logistics are essential to any scale up process. Simple management systems to prevent stock outs of tests, blood drawing materials, treatment medications, and needles/syringes for treatment are key. Adequate provision of basic supplies and equipment improves morale of health workers and helps sustain the work habits for consistent testing and treatment. Improvement of support systems (logistics, planning, management, supervision) will require increased administrative and logistic staffing. Workforce constraints are, of course, a key barrier to this.
The current fragmentation of antenatal care demonstrates the need to simplify and integrate the older elements of antenatal care (e.g., syphilis, neonatal tetanus prevention, and anemia screening) with new interventions [e.g., pMTCT and malaria preventive treatment, TB screening (new or old?)]. Competing components of antenatal care need to be integrated at the clinic level, both for efficiency and to ensure an understandable service for users. The components need to be integrated at the national and international levels to create simple and coherent norms of care and feasible monitoring systems. Monitoring systems demonstrate to health workers and their supervisors (at all levels) which activities are priorities. Historically, monitoring and performance targets of immunization programs were extremely effective in focusing health workers to reach and maintain a high level of activity. Performance targets for integrated programs should be designed to encourage provincial and national level officials to focus on logistics, distribution, and workforce allocation. When the system is up and running, frequent district level program monitoring, accompanied by operations research is very helpful to identify and solve problems before they become endemic. Monitoring visits provide opportunities for the nurses and laboratory technicians to contribute their expertise as field-level practitioners into the design of protocols and other implementation efforts.
New technologies are a significant part of the system of care and can be a lever for improving performance at the clinic level. However, new diagnostics only make a difference when the system is functioning well, with good access, treatment, and reasonable adherence among those testing positive. Regarding the selection of the optimal test, our experience demonstrated that a treponemal (ICS) test is an excellent option for facilities without laboratories. ICS alone as the primary diagnostic test for syphilis is a concern because of the false positivity among previously positive but treated women. We believe that the risks associated with overtreatment are outweighed by the potential benefits of expanding syphilis screening coverage that is only possible through use of the ICS. Furthermore, distribution of treatment cards or other patient held record systems might reduce overtreatment.
Community, Gender, and Patient Issues
Early antenatal care attendance is critical to improving the efficacy of antenatal care, whether for syphilis, HIV, malaria, anemia, or nutritional screening and treatment. Understanding traditional beliefs about pregnancy, cultural and economic barriers to care, and community perceptions of the health system all contribute to the effectiveness of syphilis screening. Low partner involvement in reproductive health programs creates enormous missed opportunities and overburdens women with the responsibility of having the first contact with the health system for these interventions. Adherence to programs, especially pMTCT, syphilis treatment, and malaria preventive treatment, is increasingly important, not simply to improve effectiveness, but also to reduce resistance to medication. Qualitative research can be helpful to better understand community concepts, adapt health services offered, and to link the health services with the community.
Donor and NGO Support
Donor and NGO support can be valuable, and sometimes essential—but it is most effective when provided to MOH activities rather than to parallel programs implemented by NGO staff. NGOs come and go, depending on funding—and their selection of activities also tends to be driven by donors, often without consideration for overall system needs. Many donors will fund vertical pMTCT or IPT programs; however, few donors fund programs whose objective is to strengthen antenatal care as a service. Implementing NGOs sometimes achieve faster and more identifiable short-term results by creating separate or semiseparate systems of care. But this kind of achievement does not necessarily strengthen the system as a whole. Because most donors have time-limited funding and changing priorities, and because most NGOs depart when funding ends, dependency on donors and NGOs often creates unpredictable expansions and contractions with spotty long-term consequences.
Our experience with syphilis testing revealed that systems of care are the principal determinants of success in scaling up antenatal syphilis screening and treatment. New technologies can make a big difference, but only to the extent that systems are adequately functioning. Strong leadership by MOH officials is critical to create the systems; through clear policies, measurable targets, and flexible strategies for implementation. Changing systems of service delivery is often a slow process and usually requires advocacy and support at all levels. Repetitive reminders, published examples of good practices, information about missed opportunities all help. Patience and continued perseverance are necessary. New policies need to be disseminated widely. Planning needs to include facility improvement and allocation of appropriate numbers of health workers. Finally, health leaders need to address cross-cutting issues such as relative resource scarcity, intragovernmental allocations, debt reduction, reversal of structural adjustment policies, and overall expansion of public spending. These issues are central to scaling up and integrating antenatal syphilis control in the context of strengthening effective and sustainable health systems.
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