Introduction: While there is growing consensus within the global health community on the importance of health systems strengthening (HSS) to improving service delivery and health outcomes, evidence linking HSS interventions to such outcomes is only beginning to emerge. This study sought to examine the relationships between the District Approach intervention in Mozambique and HIV service delivery outcomes, as well as the relationship between strengthened district health systems and HIV service delivery outcomes.
Intervention: The Clinical HIV/AIDS Services Strengthening Project in Sofala, Manica, and Tete provinces (CHASS-SMT) designed the District Approach to address key weaknesses that lead to underperformance of districts on HIV service delivery: low managerial capacity; scarcity of resources; and sub-optimal systems and
processes. District Approach interventions included the Graduation Path, district sub-agreements, and clinical tutoring. The goal of the Graduation Path was to improve the capacity of districts to manage systemic functions (planning, information systems, human resources, financing, supply and logistics) and services
functions (health programs, laboratory, community mobilization). The Graduation Path included a periodic, quantitative assessment of district management capacity based on process indicators.
Methods: CHASS-SMT implemented the District Approach differently among the 36 districts in Sofala, Manica, and Tete: twelve high-priority districts (HPDs) received the full package, including the Graduation Path, and the remaining 24 non-priority districts (NPDs) received a less intensive form of the District Approach, which did not include the Graduation Path. We used the Graduation Path scores to measure changes in district management capacity, and six facility-level HIV services indicators to measure service delivery outcomes: three quality indicators and three access indicators. We used both bivariate (mean comparison) and multivariate analyses to answer the study’s two research questions. We also carried out key informant interviews to examine the changes that occurred in districts and health facilities after the implementation of the District Approach.
Results: The analyses showed that the District Approach is associated with better performance on two of the three quality indicators, and with lower performance on the third quality indicator and on one access indicator. Further analyses detected positive, statistically significant relationships between improvements in district capacity to manage services functions and improvements in five of the six service delivery outcome indicators. Results for systemic functions were mixed: there were negative associations with two access indicators and with one quality indicator, and a positive association with one quality indicator.
Conclusions: Although the study design presents limitations, we conclude that the District Approach may be positively associated with improved HIV service quality, and that improvements in district capacity to manage systemic functions may be positively associated with improved quality and access of HIV services. More research is needed to establish stronger links between HSS interventions, strengthened health systems, and service delivery outcomes.

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