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Thirty years since its first public use in 1980, the phrase structural adjustment remains obscure for many anthropologists and public health workers. However, structural adjustment programs (SAPs) are the practical tools used by international financial institutions (IFIs) such as the International Monetary Fund (IMF) and the World Bank to promote the market fundamentalism that constitutes the core of neoliberalism. A robust debate continues on the impact of SAPs on national economies and public health. But the stories that anthropologists tell from the field overwhelmingly speak to a new intensity of immiseration produced by adjustment programs that have undermined public sector services for the poor. This review provides a brief history of structural adjustment, and then presents anthropological analyses of adjustment and public health. The first section reviews studies of health services and the second section examines literature that assesses broader social determinants of health influenced by adjustment.

The recent expansion of Pentecostalism and independent churches in Africa has generated growing interest among social scientists. This attention parallels a renewed interest among Africanists on witchcraft and occult activities, also believed by many to be increasing. Some suggest the two trends may be related, but it remains unclear how and why. Drawing on a study of Pentecostalism and health in the city of Chimoio, Mozambique, in 2002–03 that focused on attitudes toward recent social change, we argue that structural adjustment economic reforms have deepened economic inequality and exacerbated household stresses that affect men and women differently. Women increasingly seek spiritual help for reproductive health problems from Pentecostal churches, whereas men disproportionately pay traditional healers to engage "occult" practices to manage misfortune related to employment. The increased resort to both spiritual resources reveals social distress caused by economic adjustment, with important implications for health programs.

BACKGROUND: Knowledge 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. METHODS: Using 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. FINDINGS: Under-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. INTERPRETATION: The 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. FUNDING: Doris Duke Charitable Foundation and Mozambican National Institute of Health.

Social support is a key, yet elusive resource for HIV patients living in poverty in Lima, Peru. Despite a greater need for health services and encouragement from others, economic restraints, stigma, and trouble negotiating a fractured health system act as hurdles to accessing support. In this study, 33 people with HIV and 15 of their treatment supporters were interviewed upon initiation of antiretroviral therapy in order to understand changes in social support during this critical time, and how these changes affected their well-being. Everyone's social network underwent dramatic transformation, while some were rejected upon disclosure by people they knew, many successfully trimmed their social circles to a few trusted parties. Treatment supporters were most frequently the first to whom they disclosed their HIV status, and most backed the person with HIV, although sometimes out of obligation. HIV peers became a vital new source of strength. Ultimately, people with HIV who successfully reorganized their social network drew personal strength and self-worth from new and old relationships in their lives.

Loss to follow-up contributes to the low coverage of HIV care interventions among HIV-exposed infants in Beira, Mozambique. This qualitative study explores the perceptions of HIV-infected women and their health care providers regarding the main obstacles preventing women from attending follow-up visits for HIV care, and factors influencing women's decisions about newborn care. Fifty-two in-depth interviews and two focus group discussions were conducted; transcripts were coded and analyzed using ATLAS.ti. Interviewees perceived three major barriers to follow-up: food insecurity, difficulties navigating the health system, and women's familial roles and responsibilities. Our findings unveil the complex context in which HIV-infected women and their children live, and suggest that the structure and function of the HIV care system should be reviewed. Economic empowerment of women is crucial to achieving better compliance with medical care. Integration of mother and child services and more efficient and culturally sensitive medical services may improve follow-up.

Abstract Background Since the rapid scale-up of antiretroviral therapy (ART) programs in sub-Saharan Africa, electronic patient tracking systems (EPTS) have been deployed to respond to the growing demand for program monitoring, evaluation and reporting to governments and donors. These routinely collected data are often used in epidemiologic and operations research studies intended to improve programs. To ensure accurate reporting and good quality for research, the reliability and completeness of data systems need to be assessed and reported. We assessed the completeness and reliability of EPTS used in 16 HIV care and treatment clinics in Manica and Sofala provinces of Mozambique. Methods We conducted a cross-sectional study to assess the completeness and reliability of key variables in the electronic data system for patients enrolling in 16 public sector HIV treatment clinics between 1 July 2004 and 30 June 2008. Data from the electronic database was compared with data abstracted from a stratified random sample of 520 patient charts. Percent agreement, kappa scores and concordance correlation coefficients were calculated for specified variables. Percentile bootstrap confidence intervals were calculated to account for the stratified nature of our sampling. Results A total of 16,149 patients with a median age of 33 years and a median CD4 count of 151 enrolled in these 16 clinics between 1 July 2004 and 30 June 2008. The level of completeness was high for most variables with height (18.6%) and weight (11.5%) having the highest amount of missing data. The level of agreement for available data was also high with reliability statistics of 0.95 (95% CI: 0.92-0.98) for gender, 0.91 (95% CI: 0.80-1.00) for pre-ART CD4 value and 0.97 (95% CI: 0.95-0.99) for patient retention. Conclusions Electronic patient tracking systems have been deployed to respond to the growing monitoring, evaluation and reporting requirements. In our cross-sectional study of clinics in Manica and Sofala provinces of Mozambique, we found high levels of completeness and reliability for key variables indicating that these electronic databases provided adequate data not only for monitoring and evaluation but also for research. Routine evaluations of the completeness and reliability of these databases need to occur to ensure high quality data are being used for reporting and research.

IntroductionIn 2004, Mozambique, supported by large increases in international disease‐specific funding, initiated a national rapid scale‐up of antiretroviral treatment (ART) and HIV care through a vertical "Day Hospital" approach. Though this model showed substantial increases in people receiving treatment, it diverted scarce resources away from the primary health care (PHC) system. In 2005, the Ministry of Health (MOH) began an effort to use HIV/AIDS treatment and care resources as a means to strengthen their PHC system. The MOH worked closely with a number of NGOs to integrate HIV programs more effectively into existing public‐sector PHC services.Case DescriptionIn 2005, the Ministry of Health and Health Alliance International initiated an effort in two provinces to integrate ART into the existing primary health care system through health units distributed across 23 districts. Integration included: a) placing ART services in existing units; b) retraining existing workers; c) strengthening laboratories, testing, and referral linkages; e) expanding testing in TB wards; f) integrating HIV and antenatal services; and g) improving district‐level management. Discussion: By 2008, treatment was available in nearly 67 health facilities in 23 districts. Nearly 30,000 adults were on ART. Over 80,000 enrolled in the HIV/AIDS program. Loss to follow‐up from antenatal and TB testing to ART services has declined from 70% to less than 10% in many integrated sites. Average time from HIV testing to ART initiation is significantly faster and adherence to ART is better in smaller peripheral clinics than in vertical day hospitals. Integration has also improved other non‐HIV aspects of primary health care.ConclusionThe integration approach enables the public sector PHC system to test more patients for HIV, place more patients on ART more quickly and efficiently, reduce loss‐to‐follow‐up, and achieve greater geographic HIV care coverage compared to the vertical model. Through the integration process, HIV resources have been used to rehabilitate PHC infrastructure (including laboratories and pharmacies), strengthen supervision, fill workforce gaps, and improve patient flow between services and facilities in ways that can benefit all programs. Using aid resources to integrate and better link HIV care with existing services can strengthen wider PHC systems.

IntroductionEffectiveness of the rapid expansion of antiretroviral therapy (ART) throughout sub‐Saharan Africa is highly dependent on adequate enrolment and retention in HIV care. However, the measurement of both has been challenging in these settings. This study aimed to assess enrolment and retention in HIV care (pre‐ART and ART) among HIV‐positive adults in Central Mozambique, including identification of barriers and facilitators.MethodsWe assessed linkages to and retention in HIV care using a mixed quantitative and qualitative approach in six districts of Manica and Sofala provinces. We analyzed routine district and health facility monthly reports and HIV care registries from April 2012 to March 2013 and used single imputation and trimmed means to adjust for missing values. In eight health facilities in the same districts and period, we assessed retention in HIV care among 795 randomly selected adult patient charts (15 years and older). We also conducted 25 focus group discussions and 53 in‐depth interviews with HIV‐positive adults, healthcare providers and community members to identify facilitators and barriers to enrolment and retention in HIV care.ResultsOverall, 46% of the monthly HIV testing reports expected at the district level were missing, compared to 6.4% of the pre‐ART registry reports. After adjustment for missing values, we estimated that the aggregate numbers of adults registered in pre‐ART was 75% of the number of persons tested HIV‐positive in the six districts. In the eight health facilities, 40% of the patient charts for adults enrolled in pre‐ART and 44% in ART were missing. Of those on ART for whom charts were found, retention in treatment within 90 and 60 days prior to the study team visit was 34 and 25%, respectively. Combining these multiple data sources, the overall estimated retention was 18% in our sample. Individual‐level factors were perceived to be key influences to enrolment in HIV care, while health facility and structural‐level factors were perceived to be key influences of retention.ConclusionsEfforts to increase linkages to and retention in HIV care should address individual, health facility, and structural‐level factors in Central Mozambique. However, their outcomes cannot be reliably assessed without improving the quality of routine health information systems.

Frontmatter -- Contents -- Figures -- Foreword / Navarro, Vicente -- Acknowledgments -- Part I. Health Comrades in Context -- Chapter 1. Introduction: Health Comrades, Abroad and at Home / Birn, Anne-Emanuelle / Brown, Theodore M. -- Chapter 2. The Making of Health Internationalists / Brown, Theodore M. / Birn, Anne-Emanuelle -- Part II. Generation Born in the 1870s–1910s -- Chapter 3. The Perils of Unconstrained Enthusiasm: John Kingsbury, Soviet Public Health, and 1930s America / Gross Solomon, Susan -- Chapter 4. American Medical Support for Spanish Democracy, 1936–1938 / Lear, Walter J. -- Chapter 5. Medical McCarthyism and the Punishment of Internationalist Physicians in the United States / Brickman, Jane Pacht -- Part III. Generation Born in the 1920s–1930s -- Chapter 6. Contesting Racism and Innovating Community Health Centers: Approaches on Two Continents / Geiger, H. Jack -- Chapter 7. Barefoot in China, the Bronx, and Beyond / Sidel, Victor W. / Sidel, Ruth -- Chapter 8. Medical Internationalism and the "Last Epidemic" / Lown, Bernard -- Part IV. Generation Born in the 1940s–1960s -- Chapter 9. Social Medicine, at Home and Abroad / Waitzkin, Howard -- Chapter 10. Find the Best People and Support Them / Braveman, Paula -- Chapter 11. Cooperantes, Solidarity, and the Fight for Health in Mozambique / Gloyd, Stephen / Pfeiffer, James / Johnson, Wendy -- Chapter 12. From Harlem to Harare: Lessons in How Social Movements and Social Policy Change Health / Travis Bassett, Mary -- Part V. Generation Born in the 1960s–1970s -- Chapter 13. Brigadistas and Revolutionaries: Health and Social Justice in El Salvador / Terry, Michael / Turiano, Laura -- Chapter 14. Health and Human Rights in Latin America, and Beyond: A Lawyer's Experience with Public Health Internationalism / Yamin, Alicia Ely -- Chapter 15 History, Theory, and Praxis in Pacific Islands Health / Yamada, Seiji -- Chapter 16. Doctors for Global Health: Applying Liberation Medicine and Accompanying Communities in Their Struggles for Health and Social Justice / Lanford Smith, Lanny Clyde / Kasper, Jennifer / Holtz, Timothy H. -- Chapter 17. Doctors Across Blockades: American Medical Students in Cuba / Remen, Razel / Bondi-Boyd, Brea -- Part VI Conclusion -- Chapter 18 Across the Generations: Lessons from Health Internationalism / Birn, Anne-Emanuelle / Brown, Theodore M. -- Notes on Contributors -- Index