Implementation of a National Telephone Consultation Service for Clinicians in Mozambique

Abstract

The manuscript outlines the establishment of a remote consultation service for clinicians in Mozambique, highlighting best practices and lessons learned. It discusses the transition to full management by the Ministry of Health and the challenges of sustaining the service post-transition within the MoH Telehealth Program. The program evaluation results focus on the national telephone consultation service for HIV/AIDS care and treatment, which, between 2013 and 2019, received calls from a wide range of health facilities and cadres, including nonmedical prescribers, doctors, clinical assistants, and nurses. A 2017 clinician satisfaction survey indicated high satisfaction rates. Key implementation lessons emphasized the necessity of staffing the consultation line with highly trained clinicians, leveraging training to enhance service awareness and trust, supporting the public health system, maintaining operational flexibility, and strengthening pre-service clinical training.

Introduction

Context and Justification

Mozambique is burdened with a significant HIV/AIDS prevalence, with an adult rate of 12.5% as estimated by INSIDA in 2021. ¹ This is compounded by a critical shortage of healthcare professionals, with World Health Organization (WHO) estimating only 8.14 doctors per 1000 inhabitants, equating to one physician serving approximately 123 individuals in 2021. ² In response, Mozambique implemented a “test and treat” policy in 2016, making all people living with HIV (PLHIV) eligible for antiretroviral therapy (ART). ³ This policy has increased the demand for healthcare professionals skilled in HIV/AIDS care and treatment. ⁴ However, many clinical sites face challenges such as inadequate staffing, limited clinical skills, insufficient opportunities for continuing professional development, and a lack of supervision or technical support from experienced peers. ⁴ The health worker density in Mozambique is among the lowest globally, with only 12.9 health professionals per 10 000 population, far below the WHO's recommendation of 23 per 10 000. ² The scarcity of health workers is exacerbated by their uneven distribution and insufficient competencies to meet the Ministry of Health (MoH)'s objectives for universal access to basic healthcare. ⁴ Concerns persist regarding the quality of health worker training and staff allocation. ⁴ To mitigate the physician shortage, nonmedical prescribers known as “Técnicos de Medicina,” (healthcare professionals, excluding physicians, who possess advanced clinical qualifications and are legally authorized to prescribe medications, dressings, and medical devices ⁵ ), have been assigned the responsibility of managing a substantial number of patients. This effort is supplemented, albeit to a lesser degree, by general and maternal child health nurses. ⁴ Task Shifting, which involves nonmedical prescribers assuming responsibility for HIV/ART care and treatment, presents challenges such as a lack of continuing education and clinical mentoring programs, limited basic training, high costs associated with in-service training, and workplace absences due to training needs. ⁶ Consequently, in rural areas where nonmedical prescribers are predominant, there are limited opportunities to enhance the knowledge and skills of these nonmedical prescribers. ⁶

In addressing the challenges of integrating nonmedical prescribers into HIV care and treatment in Mozambique, the MoH, with support from International Training and Education Center for Health (I-TECH), has launched two pivotal programs to aid frontline clinicians. The first program offers distance learning courses aimed at updating and enhancing clinical knowledge for remote HIV treatment. ⁷ The second program establishes a consultation service to provide clinicians with timely feedback. ⁶ Similar programs have been successfully implemented in other countries, such as Uganda's hotline and warmline, ⁸ and India's warmline, ⁹ to deliver real-time support to clinicians.

The MoH has endeavored to enhance foundational clinical capabilities by providing comprehensive guidelines for AIDS care. ¹⁰ Since the introduction of ART in Mozambique in 2002, ¹¹ continuous professional development programs focusing on HIV/AIDS have been implemented across all provinces. ⁷ Nevertheless, clinical personnel in remote and rural regions frequently face challenges in attending these refresher courses. ⁷ Additionally, funding for in-person training has markedly decreased in recent years, further restricting access to on-site clinical training opportunities. ⁷

The University of Washington's I-TECH initiated efforts to enhance Mozambique's health system in 2005.^7,12 Since its inception, I-TECH has provided technical support to MoH, concentrating on mitigating the shortage of healthcare providers through clinical training and curriculum development.^7,12 The organization has also focused on elevating the quality of HIV prevention, care, and treatment services, including ART and voluntary medical male circumcision. ⁷ Additionally, I-TECH has engaged in continuous monitoring and evaluation activities (M&E), offering technical assistance to the MoH to assess the effectiveness of healthcare programs and deliver quality data for informed decision-making and program enhancement.^7,12

In 2013, I-TECH collaborated with MoH to establish a telephonic clinical consultation service for HIV clinicians in Mozambique, referred to as Linha Verde (LV)^7,13. The WHO has prioritized the expansion of telehealth technologies to enhance healthcare delivery in resource-limited settings, aiming to improve access to high-quality health services. ¹⁴ A specific type of telehealth intervention includes telephone consultation services for clinicians, commonly known as warm lines. ¹³ These services enable clinicians to access real-time clinical decision-making consultations from highly trained peer clinicians who operate the phone line. ¹⁵ Implemented in various settings, studies have demonstrated that these services enhance access to quality healthcare and address the shortage of qualified professionals in resource-limited areas.^13–15

Program Purpose, Scope, and Operations

The LV “Warm Line” program was established to deliver real-time, specialist-level technical guidance to clinicians providing care and treatment for PLHIV in remote and isolated areas. Clinicians placed in these regions face limited opportunities for supportive supervision and continuous medical education, and they lack access to specialist-level technical advice for managing complex cases. To address this challenge, I-TECH Mozambique, on behalf of the MoH and funded by HRSA under the USG—PEPFAR Initiative, developed and administered a toll-free, telephone-based consultation service for clinicians.

Structure of Linha Verde

The services comprised the following components: First, three telephone numbers from each of the three mobile service providers in Mozambique. Second, terminals consisting of cell phones and tablets. Third, a computer equipped with a database for recording all incoming calls. The collected information included the caller's name, professional category, health facility, province of origin, a brief transcript of the call's content, and the advice provided by the responder or consultant.

Room or venue of the warm line: equipped with all the relevant books and policies, guidelines, training material (reference manuals and job aids) related to the clinical management of HIV and associated disease from the MoH or approved by the MoH.

Warm line responders’ team: the team managing the warm line consists of highly experienced doctors specializing in HIV patient care. This includes general practitioners with extensive experience in primary health care, including HIV and related diseases, as well as specialists in internal medicine with significant expertise in both primary healthcare and referral hospitals. All consultant doctors possess strong teaching and mentoring skills, having been involved in developing clinical content for training packages and standard operating procedures for HIV care and treatment. They have also served as advisors to the Mozambican MoH's national technical working groups for HIV treatment and have facilitated training, mentoring, and supervision for health providers across various levels of the healthcare system.

How Does Linha Verde Operate?

The LV program provided free clinical consultations and guidance to healthcare professionals delivering counseling and testing services for HIV/AIDS. This support was particularly aimed at care providers in rural and resource-limited settings, as well as those with restricted access to supervision and on-the-job training. Additionally, the program addressed inquiries regarding non-HIV-related conditions whenever healthcare workers required expert opinions from senior clinicians.

The service was staffed by a team of senior physicians with expertise in HIV/AIDS patient care. The team comprised two part-time general practitioners, two part-time internists, and specialists including a pediatrician, a pneumologist, and a dermatologist available as needed. The service operated Monday to Friday, from 8:00 AM to 3:30 PM, and could be accessed via distinct phone numbers for each mobile service provider in Mozambique. Calls were promptly addressed by the on-duty physician.

Calls were categorized into two distinct types based on their content. The first type pertains to the clinical management of individual patients, necessitating the assistance of LV for clinical decision-making. These interactions often culminated in recommendations for additional examinations, therapeutic interventions, hospitalization, or referrals. Additionally, calls may involve the evaluation of dermatologic and pneumology cases through the review of skin and chest X-ray images sent via WhatsApp by clinicians. This process was supported by a specialist, who was consulted by LV staff for expert opinions. During consultations, LV doctors posed questions to supplement the information provided by the caller, ensuring a more informed opinion on the case. In certain instances, multiple calls were arranged to allow the caller to gather further details from the patient's medical records. Complex cases were sometimes discussed internally among LV doctors before providing a response to the caller. Most inquiries from callers were addressed by referencing national protocols, while questions concerning emerging issues not covered in the MoH's guidelines were resolved using research findings and expert opinions.

The second category of calls pertained to matters not directly associated with individual patients. For instance, callers might report shortages of certain medications or seek clarification on prescriptions in line with national guidelines. Beyond telephone consultations, LV clinicians address these general inquiries—encompassing non-clinical topics such as health policy information, procedural protocols, and the supply chain of pharmaceuticals and laboratory materials—by offering guidance through the distribution of educational materials via mail and/or notifying the national competent authority about distribution and drug management system bottlenecks across various levels of the healthcare system.

The LV team engaged in multifaceted collaboration with the MoH, extending beyond merely responding to clinician inquiries. They proactively disseminated information by sending text messages to numerous frontline clinicians and health service providers, thereby announcing or elucidating new MoH policies, treatment standards, and guidelines. The team capitalized on inquiries from callers to establish a surveillance mechanism addressing various issues, including adverse drug reactions, drug shortages, and gaps in clinician knowledge or training requirements. In instances of adverse drug reactions and drug shortages, timely evidence was provided to MoH managers. For knowledge gaps, baseline data was gathered to aid the MoH in policy, protocol, and training material development or updates. Since 2019, LV has supported the National Tuberculosis (TB) Program by facilitating the delivery of mycobacteria culture and antimicrobial susceptibility testing results for suspected drug-resistant cases to clinicians managing TB patients nationwide. The team received laboratory results via email from the National TB Reference Laboratory and ensured delivery to the appropriate clinicians. Additionally, LV offered case reviews and monitoring for complex TB cases, ¹⁶ such as those involving extensively drug-resistant TB. Beyond merely transmitting results, they provided phone consultations with senior specialists to address TB drug resistance cases effectively and promptly.

The manuscript details the findings from a program evaluation of LV, encompassing data on service utilization, provider satisfaction, and insights gained from I-TECH's implementation of the service between 2013 and 2019.

Methods

Setting or Area

The analysis reviewed routine data collected from LV (“warm line”) implemented at national level from 2013 to 2019. The service received calls from most health facilities in Mozambique and by a range of different health cadres, including nonmedical prescribers, doctors, clinical assistants, and nurses.

Evaluation Design and Population

This cross-sectional assessment of routine programmatic data was conducted to guide future program enhancements. Data collection occurred in two phases: initially, routine data from the program spanning 2013 to 2019 was gathered retrospectively. Subsequently, an online close-ended survey was administered prospectively from January 2017 to March 2018.

Potential participants for the caller satisfaction survey were recruited from the caller log book. The survey included approximately 4556 callers from the warm line, representing a distribution across nationwide health facilities. With a 95% confidence level, a 4.5% margin of error, and assuming a population proportion of 50% for those who agreed to participate, the mean sample size was determined to be 355 patients, accounting for 7.8% of the total population.

The satisfaction survey involved 342 randomly selected callers who sought advice from LV, conducted via phone interviews using a structured questionnaire. Survey questions and responses are detailed in Table 1, with responses categorized by professional category, gender, and location. Participants included a diverse range of healthcare professionals, such as nonmedical prescribers, doctors, clinical assistants, and nurses, who consented to participate and completed the questionnaire. Interviewers utilized purpose-designed forms to record responses, and completed questionnaires were entered into Excel and Statistical Package for the Social Sciences (SPSS) databases for analysis. Statistical analysis was performed using the statistical software IBM^® SPSS version 25 (International Business Machines Corporation, IBM corp, Release 2017, https://www.ibm.com/legal/copytrade, USA).

Table 1.

Summary of Caller Satisfaction Survey Results (n = 342).

Reason to use the LV Services:	N	%
I needed help to clarify clinical doubts	292	85%
Quality of consultation:
Service is helpful in the care of the patients	329	96.3%
Response given in a timely manner	298	87%
I am pleased with the cordially service	332	97.1%
Quality of clinical information:
The clinician to whom I presented my doubt had deep knowledge about the topic	318	93%
The services recommendations/information were useful	318	93%
I did not have difficulty implementing the recommendations received in my setting	295	87%
Future use of services
I would use the services again	341	99.7%
I am likely to recommend the LV services to my colleagues	341	99.7%

Results

Descriptive Characteristics of Linha Verde Calls and Services

From 2013 to 2019, LV provided expert consultation through 12 603 calls to clinicians from 1326 out of 1546 health facilities (86%) of all eleven provinces of Mozambique including rural and urban areas. Most calls (76%) came from health facilities offering primary healthcare. Calls were made from 4556 mobile numbers, of which 44% were used more than once. Frequently used numbers averaged five calls each with a range of 2-70 calls. There were 252 phone numbers that used the services more than nine times. Most callers were clinicians with a critical role in the management of PLHIV including técnicos de medicina (46.2%), physicians (35.4%), nurses (11%), and agentes de medicina (clinical assistants) (4%) (Table 2).

Table 2.

Descriptive Characteristics of 12 603 Warmline Calls Received, (2013-2019).

Calls by facility type	N	%
Health facilities offering primary health care	11 192	89%
Referral health facilities (not offering PHC)	1411	11%
Frequent or first-time caller
First time	2538	55.7%
Frequent callers (more than two calls)	2018	44.3%
Calls by provider
Physician	4465	35.4%
Nonmedical prescribers (Técnico de Medicina)	5818	46.2%
Nurse	1380	11%
Clinical assistant (Agente de Medicina)	516	4%
Others	424	3.4%

Since its launch in 2013 to 2019, there was considerable increase in calls per year, from 834 in 2013 to 2848 in 2019 (Figure 1). Meanwhile, the number of phone numbers accessing the LV increased from 475 to 1359 during the same period.

Figure 1.

Increase in number of call since the inception of the program in 2013. Note: Data included from February 1, 2013 through end of December 2019.

Although the LV service was initially meant to focus on the needs of basic-level health professionals working in remote health facilities, the LV team received calls from a range of clinicians (physicians including specialists from different areas, nonmedical prescribers, nurses, and clinical assistants) and from both primary healthcare level and referral hospitals. This indicates that the LV responded to a generalized demand rather than a specific or localized one, as it was thought when the service was established.

Most of the calls (92%, 11 613/12 603) were related to the management of clinical cases, and 81% of them (9355/11 613) were linked to HIV/AIDS (Figure 2). Asked topics were often related to the ART, including new ART regimes (26%), adverse effects to ART and other medicines (11%), or ART failure (10%). Questions related to opportunistic infections in patients with AIDS were focused on clinical aspects of TB and associated conditions (11%), TB treatment, including multi and extremely drug-resistant (6%), and dermatologic cases (7%). Other questions were related to counseling and testing for HIV (2%) and diagnosis of pediatric HIV infection (5%). Questions related to new ART regimes including Dolutegravir, which was gradually introduced starting April 2019, were asked in 17% of 2043 calls received between May and October 2019. As indicated above, the range of topics addressed by callers was very broad and the level of complexity of the questions varied substantially. Some questions were so basic to suggest that the callers had neither been formally trained in HIV/AIDS care or they had not retained the basic content of their trainings. Other cases were very complex and illustrated how even good clinical manuals cannot anticipate all possible clinical scenarios.

Figure 2.

Services offered by the warn line.

Of the clinical cases unrelated to HIV/AIDS (2258), the most frequent questions concerned dermatology (36%), TB, including multi and extremely drug-resistant cases (18%), and sexually transmitted infections (4%). LV also answered calls related to gender-based violence (340). Drug stock-outs (313, 2% of total) were reported from 143 health facilities, with questions regarding alternative therapies. Stock-outs were relayed to the provincial and national warehouses responsible for the solution of the case. The most frequently mentioned medicines that were running out were pediatric ART.

Through the LV WhatsApp services, 1422 dermatological images from patients were received and responded, as well as 10 chest x-rays. For all these cases, the LV provided technical assistance, including diagnosis and clinical conduct (Figure 2). Since May 2019-present, the LV service has delivered 3617 mycobacterium TB culture and drug-sensitivity test results from the National TB Reference Lab to the attending clinicians. One hundred and seventeen (117) batches of text messages were sent to 11 697 healthcare workers attending PLHIV (Figure 2). Recipients included physicians, nonmedical prescribers, nurses, and other cadres. Topics included information on how to address baseline knowledge gaps, clinical issues identified by the LV calls, and refresher training on policies and therapeutic protocols.

Satisfaction Survey

A total of 445 callers were initially approached for satisfaction survey. Of these, 91 individuals (20.4%) were unreachable due to uncontactable numbers, and 12 individuals (2.7%) either declined participation or were unavailable. In such instances, interviewers sought alternative participants matching the same criteria—province, professional category, gender, and location area—to ensure the completion of the sample size, ultimately achieving a total of 342 interviews.

Overall, callers who answered the satisfaction survey indicated that they used the LV services to clarify clinical doubts and found the service practical for solving the cases, as recommendations given were useful and easy to implement (87%). Nearly all the respondents would use the service again and would recommend the LV to colleagues. Professional experience in patient's care among respondents was less than 3 years in 63 (25%), 3-10 years in 254 cases (74%) and over 11 years in 25 (10%) cases.

Lessons Learned

Drawing upon more than 6 years of experience with LV and the outcomes achieved, the authors have extracted essential insights that could enhance programs seeking to implement analogous services in diverse settings.

Proper Selection of Clinical Staff

Selecting clinicians with extensive training and experience is essential for staffing the consultation service. It is crucial to have strong experience and clinical practice across various levels of the health system, such as primary healthcare in both rural and urban settings, as well as referral hospitals, to comprehend the professional context of the diverse range of callers utilizing the service. In addition to clinical competencies, possessing instructive and pedagogic skills, along with interpersonal communication abilities, is vital. While these interpersonal skills are often innate, they can be enhanced through experience and mentorship from other clinicians within the service. A trial period in the role has proven to be significant. Given the expertise and experience required, staff continuity is also critical. The LV staff maintained stability over 7 years, contributing to the sustained quality of the service.

Learning by Experience

An effective on-call consultant clinician is developed through experience. The limited information provided by callers requires careful analysis and interpretation. Identifying weaknesses in the caller's presentation is crucial. Additional clinical data is often necessary. Continuous practice enhances the ability to extract information from callers. Patience, gentleness, and common sense are essential to avoid judgments when consultations reveal significant unmet needs at the patient or provider level. They also play a proactive role in guiding case follow-ups across various levels of care and services.

Collaboration with the Public Health System

LV personnel possessed expertise not only in the clinical dimensions of HIV/AIDS and TB but also demonstrated comprehensive knowledge of national guidelines and policies. They were well-acquainted with the system's operations, identifying its bottlenecks and inefficiencies. The team actively participated in the MoH's technical working groups, contributing significantly to the development of protocols and manuals related to HIV/AIDS and TB. Given that health workers in remote areas frequently depend on these resources, numerous inquiries pertain to the interpretation of specific sections of governmental treatment guidelines. A thorough understanding of these manuals is crucial for offering guidance to callers regarding these guidelines. The interaction with clinicians interpreting the guidelines enabled LV staff to assist in the review and revision of national treatment guidelines and the creation of job aids, leveraging their unique insights into the challenges clinicians face in adhering to policies and protocols.

Operational Flexibility

The LV was intricately aligned with the MoH's programs, especially in managing TB and HIV/AIDS. However, due to its implementation by I-TECH, LV retained its administrative and operational independence. This autonomy facilitated pragmatic and efficient management, ensuring seamless operations, the flexibility to hire specialized consultants, adjust compensation structures, and schedule callbacks at optimal times.

Participation in Continuing Professional Development

LV physicians have established a robust technical reputation through the implementation of numerous interactive distance education training programs, primarily focused on the clinical management of HIV/AIDS. These programs have engaged hundreds of healthcare professionals nationwide. Regular involvement in supervision and on-the-job training across the country has further enhanced their credibility among clinicians utilizing the service. Additionally, consistent engagement with clinicians nationwide has afforded the LV team valuable insights into prevalent knowledge gaps, which can be leveraged to design targeted on-the-job training sessions.

Need to Strengthen Pre-Service Clinical Training

The utilization of LV services highlights deficiencies in the clinical training of health workers in Mozambique, particularly among Técnicos de Medicina, whose pre-service training spans only 2.5 years. This suggests that the training may not adequately equip them with the necessary physiopathology and pharmacological knowledge to address complex clinical issues, especially in the dynamic field of HIV/AIDS, where clinical standards frequently evolve. The existing gaps in training curricula, coupled with the intricate nature of HIV treatment protocols, underscore the ongoing need for technical support. Addressing these structural challenges at a macro level is essential, yet a telephone consultation service could enhance providers’ technical expertise, self-esteem, confidence, and motivation, thereby improving their overall performance.

Caller Engagement with Linha Verde

Our findings presented a majority, more than half 55.7% (2538 out of 4556) of callers had a unique call, whereas 44.3% (2018 out of 4556) of callers had two or more calls. These data provided highlights following key insights regarding caller engagement with the LV: First—Single Call Satisfaction—The observation indicating that 55.7% of callers made only one call implies that the service is highly effective in addressing caller needs in a single interaction, reflecting a significant level of satisfaction with the first call. Second—Frequent Caller—A notable 44.3% of callers engaged in two or more calls, indicating a substantial portion of callers find value in revisiting the service. This trend may signify continuous support needs or a high degree of trust and satisfaction with the LV. Third—Engagement levels—The equitable distribution between single and multiple calls reflects a balanced level of engagement. This indicates that while a significant portion of callers are satisfied with a one-time call, a substantial number rely on the service for ongoing support. Therefore, this data highlights the LV's efficacy in providing prompt support and serving as a reliable resource for continuous assistance.

Barriers to Caller Engagement in Linha Verde use

Healthcare professionals may face several challenges when accessing LV services, including: First—Lack of Awareness—Certain providers might lack awareness regarding the availability or advantages of LV services. ¹⁷ Second—Time Constraints—The demanding nature of healthcare professionals’ schedules and workloads often poses challenges in allocating time to utilize these services. ¹⁸ Third—Stigma and Confidentiality Concerns—Concerns regarding confidentiality and the stigma linked to HIV may discourage providers from seeking guidance or support. ¹⁸ Fourth—Perceived Complexity—Some providers might perceive the process of using LV services as complex or cumbersome. ¹⁷ Fifth—Limited Training—Limited training for providers on the effective utilization of LV services may result in their underutilization. ¹⁸ Therefore, to overcome these obstacles, it is essential to enhance awareness, streamline access, guarantee confidentiality, and offer comprehensive training to healthcare professionals

Conclusions

The objective of this paper is to detail the establishment and management of a remote consultation service for clinicians in Mozambique, highlighting best practices and lessons learned. It also addresses the transition to full management by the MoH and the challenges of sustaining the service post-transition as it integrates into the MoH Telehealth Program.

Our analysis indicates that the findings align with the primary objectives of the LV program. The complexity of HIV/AIDS care, even for skilled health professionals, is compounded by the shortage of full-time experienced physicians in many health facilities. The role of a telephone consulting clinician, while demanding in terms of labor and expertise, is crucial to the initiative's success due to the significant “human factor” involved. The effectiveness of a telephone consultation service is contingent upon having staff who are not only experienced and credible but also well-regarded by their peers and possess exceptional communication skills. The user satisfaction survey results demonstrate that clinicians value LV for its ability to provide timely expert advice on managing HIV/AIDS patients, particularly in environments lacking alternative sources of immediate expert consultation.

The LV in Mozambique demonstrated its effectiveness and efficiency as a communication mechanism for transmitting crucial data between healthcare providers and the MoH. It enabled the swift exchange of information, such as medicine stock-outs and updated clinical guidelines, and facilitated the rapid transmission of clinical data, including viral load results, mycobacteria cultures, and sensitivity tests.

The engagement of health workers with LV demonstrates their commitment to making informed decisions for patient care by independently seeking additional resources beyond their facilities. This is particularly encouraging given the ongoing issues of insufficient wages and widespread absenteeism. Our experience indicates that maintaining and expanding telephone consultation services like LV in Mozambique is an effective strategy to harness this potential.