Introduction

Non-communicable diseases (NCDs) are considered a global health challenge. The World Health Statistics (2023) estimated that of the 55.4 million deaths from all causes in 2019, 74% deaths were from NCDs [1]. Global deaths projections indicate that by 2048 there will be nearly 90 million annual deaths, with a 90% increase in the deaths attributable to NCDs from 2019 [1].

The major burden of NCDs occurs in low-and middle-income countries (LMIC) [2]; which registered 77% of the approximately 41 million deaths attributed to NCDs in 2021 [3]. LMICs, including countries in Sub-Saharan Africa (SSA), are expected to register a greater increase of the NCD burden due to their population ageing and rapid urbanization [4]. This is a major problem as LMIC healthcare services are predominantly oriented towards acute conditions and infectious diseases. Globally, international donors have the notion that investment should first go to communicable diseases before they start focusing on NCDs, and locally, health systems base their prevention and control measures on infectious diseases [5].

The demands imposed by the rising NCD burden on LMIC health systems including diagnosis, management and treatment, will require a reorientation of healthcare systems to improve their responsiveness and address the new challenges accordingly [6]. Overall health system strengthening has been identified as a critical strategy in addressing the NCD burden [6, 7]. Health system strengthening requires allocation of adequate numbers of qualified human resources (HR), one of its key building blocks. One of the most pressing challenges of LMICs’ health systems is the HR scarcity. In 2019 it was estimated that in SSA there were 2.9 physicians per 10,000 inhabitants in contrast to 6.5 physicians per 10,000 inhabitants in South Asia. Similarly, nurse and midwifery personnel ranged from 9.7 per 10,000 inhabitants in South Asia to 18.3 per 10,000 inhabitants in SSA [8]. These figures are up to 5 to 10 times less than the estimates for high-income countries’ physicians (33.4 per 10,000 inhabitants) and 6 to 11 times fewer nurses and midwifery personnel (114.9 per 10,000 inhabitants) for the same year [8]. This scarcity is further aggravated by factors such as training, mentoring and other supporting measures from health systems, which are largely shaped by health sector priorities [9].

In Mozambique, NCD have received some prominence since the early 2000s when reports started to identify a significant burden that has worsened over time. For example, in 2001, mortality from NCD ranged from 13 to 24% [10], then rose to 28% in 2012 [11]. Similarly, the estimated prevalence of hypertension and type 2 diabetes increased from 33% to 39% and 2.9% to 7.4%, respectively, from 2005 to 2015 [12–15]. This increase in prevalence was accompanied by a deterioration in other NCD health parameters, such as fewer people being 1) aware of their disease, 2) being in treatment, and 3) with their diseases controlled [14–16].

In recognition of the burden of NCD in Mozambique, particularly of hypertension and diabetes, NCD were included in national level health and priority policy documents, such as the Poverty Reduction Action Plan (PARPA II), which declared NCD as a priority in 2006, and later in 2008, the first National Strategy for Prevention and Control of NCD [17] was developed. The strategy aimed to reduce exposure to NCDs risk factors and associated morbidity and mortality by increasing awareness about NCDs, strengthening and integrating NCD-related training, improving access and quality of NCD prevention and care services, and strengthening NCD surveillance, monitoring and evaluation [10]. However, the reported HR shortage in Mozambique’s health system is severe, with less than one doctor per 10,000 people and approximately three nurses per 10,000 people [18, 19], which poses a significant challenge to the effort to strengthen the health system.

This study’s aims were: (i) to explore self-reported training and competencies of NCD-related healthcare providers, and (ii) to assess the perceived challenges posed by the current health system structuring in the health sector context of the country. By documenting the perceived challenges to managing diabetes and hypertension, the study team expects to contribute to informing the healthcare workers’ training requirements and healthcare services structuring to provide NCD-related services tailored to the needs of Mozambique’s and similar health contexts.

Material and methods

Data management and analysis

The audio recordings were transcribed verbatim in Portuguese and NVivo software (NVivo 12, QSR International) was used to facilitate coding (thematic analysis).

A codebook with a predetermined list of themes (categories) and sub-themes (sub-categories) was developed and a deductive perspective used for data analysis. These themes were identified by drawing on the adapted model shown below (Fig 1), which puts healthcare providers’ capacity building as the core asset for adequate provision of NCD-related care. We used a phenomenological approach to explore healthcare providers and their manager’s perceptions of how the structure of the health system influences how they are prepared to respond to the NCD service’s needs, and the additional investment on diagnostic tools, equipment, supplies, and medicines necessary to provide quality services under the policy prioritization context it functions.

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Fig 1. Study’s data analysis model.

https://doi.org/10.1371/journal.pone.0297676.g001

The lead and second authors conducted a parallel coding guided by the developed codebook. After concluding the process individually, they jointly compared the coded transcripts. They reviewed all coded transcripts to reach a consensus on which quotes to present that best captured respondents’ perspectives and responded to the analysis domains. After being sorted by theme (category), data was summarized, synthesized, and abstracted in each category. Translation of the relevant sections of the transcriptions to English language was done at the time of writing this manuscript.

Results

For both diseases, hypertension, and type 2 diabetes, we describe the findings following the three domains identified on the model: providers capacity building, health system, and policy. Within each domain we identified common barriers (Table 1) across the two districts and all four health facilities, which were: (i) inadequacy of NCD’s healthcare providers training and poor guidance to enhance providers skills; (ii) disrupted referral system, poor availability of diagnostic meansand medicines; and (iii) low NCDs’ priority.

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Table 1. Structured themes and subthemes from the interviews by level of analysis.

https://doi.org/10.1371/journal.pone.0297676.t001

Discussion

Although the reviewed cadres’ training curriculum incorporates NCD-related content, the findings from this study suggest that nurses and non-physician clinicians rarely engage in diagnosing and managing NCDs at the PHC level due to limitations in their pre-service training. The healthcare sector of Mozambique lacks diagnostic equipment, tools and supplies, and medicines which constitutes an additional barrier to healthcare providers ability to manage NCDs appropriately; and, there is a lack of guidelines and training in their use to improve providers’ skills.

The training models adopted by health training institutions in LMIC, which have a significant practical component completed within the health facilities, are shaped by the health sector´s priorities [9]. Although both infectious diseases and NCDs co-exist, attention is much more directed towards responding to the former, more specifically to HIV, tuberculosis and malaria. This is frequently driven by donor funding, as shown by the high level of investment and the amount of existing supporting resources (guidelines, diagnostic equipment and supplies, medicines, patient registries, to name some) in health facilities [28–30]. Therefore, health students are much more likely to practice and learn about infectious diseases, while the NCDs lag behind. Secondly, there is a well documented investment in short in-service trainings targeted towards doctors, non-clinician health technicians, and nurses that mainly focuses on three priority diseases, HIV, tuberculosis and malaria [29]. Funders are interested in this type of training to show results within the time frame of specific grants by continuously adapting to the local needs, ensuring providers are up-to-date on the latest approaches and international guidelines and improving their performance against pre-determined indicators [9, 29]. In Mozambique, external institutions supporting the large programs for HIV, TB and malaria will frequently provide professionals with technical skills that are available to provide mentorship and guidance to the frontline providers in case they need it [9]. However, this same level of technical support has not yet prioritized NCD care.

Apart from the healthcare workers’ limited exposure to NCD-related knowledge and practice during their pre-service training, after their integration into the healthcare system they face additional challenges. The necessary equipment and tools to support them with their activities were neither sufficient nor adequate to help them improve the quality of services they offer. For example, the diagnostic equipment required to screen for and diagnose both diabetes and hypertension was revealed to be unreliably available [31]. When available, the equipment often did not correspond to the actual needs of patients, such as those needing extra-large BP cuffs even though obesity is a common risk for diabetes [15].

Moreover, providers could benefit from using MOH produced clinical guidelines to improve their management of diabetes and hypertension. Apart from supporting healthcare providers, the guidelines serve other purposes, including harmonization of clinicians’ approaches [32], improving the confidence of clinicians who are unsure on how to proceed, and reversing clinicians’ beliefs adapted to outdated practices [33]. However, some mid-level providers perceive their use as an additional burden to the providers’ complex working environment.

Lastly, the NCDs referral system does not consider the uneven distribution of resources between levels of care, further aggravating the perceived barriers at the PHC level. The nature of the NCDs discussed here requires the same core type of resources for their management when there are no complications. Therefore, it would be needed to ensure the availability of similar types of resources, including qualified providers, laboratory equipment and consumables, and medicines, at the different levels, including the PHC where the demand is higher and there are competing priorities.

Although there are apparent efforts from the government to change the current scenario, early detection, treatment, and control of diabetes and hypertension is unsatisfactory in Mozambique’s health care system, similar to other countries in the African region, which results in frequent and severe complications and sequelae, along with premature deaths [14, 16, 34]. For more than a decade now, Mozambique has taken decisive steps in recognizing the importance of NCDs in the national epidemiological profile by highlighting them in the government’s guiding documents, developing NCDs specific strategic plans, and investing in medicines and laboratory consumables for NCDs to provide them to the public at no cost. The introduction of reforms in the system to tackle the NCD burden and ensuring a thorough implementation of the plans would enable an appropriate response from the health services, but this is not visible. A similar observation was made in a recent study by Heller et al. [35], who concluded that policies, strategies and effective interventions to NCD control exist, but their applicability is questionable, especially in LMICs. In fact, the National Health Service has theoretically adopted integrated management of diseases to allow a comprehensive provision of health care. However, most of the programs, including HIV, TB, and malaria, still function vertically, which further affects the availability of other less prioritized services [36], such as the NCDs. This leads to uneven access to resources and services, contributing to the system’s inefficiencies [36, 37].

There were some limitations in this study. First, the NCD-related skills reported relied mainly on self-reported assessment, which could affect the reliability of the study findings. A strength was that we used data triangulation to enhance the study findings, validity, and credibility. Second, in Mozambique there are several independent health training institutions graduating students, that are then placed within the health system which may mean that some health professionals were not trained under any of the assessed curricula. Further, we did not conduct an in-depth evaluation of the content of the training curricula since this was not the aim of the study. We only visited a limited number of health facilities for this study, all located in a relatively resources favored provinces (Maputo Province and City). This may have biased our findings by underestimating the level of resource scarcity in the PHC-level health facilities.

The health system needs to adapt to offer effective treatment, self-management support, and regular follow-up to NCD patients [38–40]. Some tasks, such as counselling for self-management, are needed to manage NCDs but are only learned by practice. Unfortunately, most of the time, the workload of clinicians does not allow them sufficient time to provide adequate counselling to patients and their families. Tasks like this can be shifted to non-clinicians, such as lay counsellors, who have been successfully used in other health programs. Thus, comprehensive NCD care can be provided to patients by providing appropriate training and evidence-based skills, as well as organizing health care providers into team care models for managing chronic health problems [38]. This approach would reduce the number of trained professionals needed to achieve satisfactory results of NCDs control [41–43] by restructuring the few existing providers and ensuring an even resources distribution among the types of health problems facing the healthcare system.

Conclusions

Mozambique´s health strategic and policy documents reflect the concern at national governmental level about NCDs, however this has not translated into practice. There is a gap in health resources, including human, financial, and material, to respond to the needs faced by the country’s health system. This is more significant for NCDs as they need to compete with the major infectious diseases, which overall are better funded by external partners. The healthcare workers available to provide NCD-related care and management at the PHC level of Mozambique’s health system are inappropriately skilled. In addition, these professionals face a lack of diagnostic equipment and tools to adequately respond to NCD-related needs, particularly at the primary care level. Any increase in global and national responses to the NCD challenge must include investments in human resources and appropriate equipment.

Acknowledgments

The study team would like to thank the following individuals and institutions: the Mozambique MOH; the Maputo Province and City, and Nlhamankulu and Moamba Districts Directorates of Health; the health facilities managers and providers for granting permission to conduct the study and for their personnel contributions through interviews; the COHESION study group for working on different stages of the study conceptualization, field work preparation, data collection and data management; Dr Troy Moon for editing and polishing the manuscript and for providing insightful comments to improve its clarity and readability.