Routine health information systems (RHISs) are in place in nearly every country and provide routinely collected full-coverage records on all levels of health system service delivery. However, these rich sources of data are regularly overlooked for evaluating causal effects of health programmes due to concerns regarding completeness, timeliness, representativeness and accuracy. Using Mozambique's national RHIS (Módulo Básico) as an illustrative example, we urge renewed attention to the use of RHIS data for health evaluations. Interventions to improve data quality exist and have been tested in low-and middle-income countries (LMICs). Intrinsic features of RHIS data (numerous repeated observations over extended periods of time, full coverage of health facilities, and numerous real-time indicators of service coverage and utilization) provide for very robust quasi-experimental designs, such as controlled interrupted time-series (cITS), which are not possible with intermittent community sample surveys. In addition, cITS analyses are well suited for continuously evolving development contexts in LMICs by: (1) allowing for measurement and controlling for trends and other patterns before, during and after intervention implementation; (2) facilitating the use of numerous simultaneous control groups and non-equivalent dependent variables at multiple nested levels to increase validity and strength of causal inference; and (3) allowing the integration of continuous 'effective dose received' implementation measures. With expanded use of RHIS data for the evaluation of health programmes, investments in data systems, health worker interest in and utilization of RHIS data, as well as data quality will further increase over time. Because RHIS data are ministry-owned and operated, relying upon these data will contribute to sustainable national capacity over time.

SummaryBackgroundKnowledge of the relation between health-system factors and child mortality could help to inform health policy in low-income and middle-income countries. We aimed to quantify modifiable health-system factors and their relation with provincial-level heterogeneity in under-5, infant, and neonatal mortality over time in Mozambique.MethodsUsing Demographic and Health Survey (2003 and 2011) and Multiple Indicator Cluster Survey (2008) data, we generated provincial-level time-series of child mortality in under-5 (ages 0–4 years), infant (younger than 1 year), and neonatal (younger than 1 month) age groups for 2000–10. We built negative binomial mixed models to examine health-system factors associated with changes in child mortality.FindingsUnder-5 mortality rate was heterogeneous across provinces, with yearly decreases ranging from 11·1% (Nampula) to 1·9% (Maputo Province). Heterogeneity was greater for neonatal mortality rate, with only seven of 11 provinces showing significant yearly decreases, ranging from 13·6% (Nampula) to 4·2% (Zambezia). Health workforce density (adjusted rate ratio 0·94, 95% CI 0·90–0·98) and maternal and child health nurse density (0·96, 0·92–0·99) were both associated with reduced under-5 mortality rate, as were institutional birth coverage (0·94, 0·90–0·98) and government financing per head (0·80, 0·65–0·98). Higher population per health facility was associated with increased under-5 mortality rate (1·14, 1·02–1·28). Neonatal mortality rate was most strongly associated with institutional birth attendance, maternal and child nurse density, and overall health workforce density. Infant mortality rate was most strongly associated with institutional birth attendance and population per health facility.InterpretationThe large decreases in child mortality seen in Mozambique between 2000 and 2010 could have been partly caused by improvements in the public-sector health workforce, institutional birth coverage, and government health financing. Increased attention should be paid to service availability, because population per health facility is increasing across Mozambique and is associated with increased under-5 mortality. Investments in health information systems and new methods to track potentially increasing subnational health disparities are urgently needed.FundingDoris Duke Charitable Foundation and Mozambican National Institute of Health.

Adolescent sexual and reproductive health gained particular traction in Mozambique following the 1994 International Conference on Population and Development leading to the inception of Programa Geração Biz (PGB), a multi-sectoral initiative that was piloted starting in 1999 and fully scaled-up to all provinces by 2007. We conducted a systematic review of the literature to gather information on PGB and analyzed how it planned and managed the scale-up effort using the WHO-ExpandNet framework. PGB’s activities comprised a clear and credible innovation. Appropriate resource and user organizations further facilitated national scale-up. Challenges relating to the complex nature of the multi-sectoral approach and resistance due to norms about adolescent sexual and reproductive health hindered scaling-up in some geographic areas. The national government exhibited commitment and ownership to PGB through budgetary support and integration into multiple policies. This study adds to the documentation of successful scaling-up strategies that can provide guidance for policy makers and programme managers.

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