Mozambique - HIV/AIDS Response Project

Report No. PID11473 Project Name MOZAMBIQUE-HIV/AIDS Response Project (@) Region Africa Regional Office Sector Health (100%) Project ID P078053 Borrower(s) GOVERNMENT OF MOZAMBIQUE Implementing Agency Address NATIONAL AIDS SECRETARIAT, MINISTRIES AND CIVIL SOCIETY Executive Secretariat, National Council to Combat HIV/AIDS Address: Rua Antonio Bocarro 106/144, Maputo, Mozambique Contact Person: Mrs Janet Mondlane, Executive Secretary, National Council to Combat HIV/AIDS Tel: 258 1 495 396 Fax: 258 1 495 395 Email: janet@virconn.com Ministry of Health Address: Av Eduardo Mondlane 1008 Contact Person: Dr. Francisco Songane, Minister of Health Tel: 258 1 313 389 Fax: 258 1 427 133 Email: ffsongane@teledata.co.mz Environment Category B Date PID Prepared March 7, 2003 Auth Appr/Negs Date October 3, 2002 Bank Approval Date March 25, 2003 1. Country and Sector Background Country and Sector Background Mozambique achieved independence in 1975. Since then it has suffered from civil war, flood and drought, while defining and building its economic and social institutions. Since the early 1990's Mozambique has succeeded in creating the institutions necessary to underpin both a democratic form of Government, and an economy based on market principles. This framework has the potential to deliver rapid, sustained and broad based growth. These institutions, however, are weak, due fundamentally to the lack of sufficient qualified and motivated staff. Incomes are low, with GDP per capita in the range of US$ 230. Some 699 of the population consume below a minimum level designated as the 'poverty line', with poverty deeper in rural areas. Indices on literacy (40%), gross primary enrollment (71%) infant mortality (147 per 1,000 live births), maternal mortality (1,083 per 100,000 deliveries) and malnutrition (affecting 41 % of children under 5) are all low by African standards. All of these indicators are  averages. When these averages are opened up they reveal sharp differences across: (i) gender, with women and girls having significantly lower living standards than men and boys; (ii) rural-urban space, where the rural population fares significantly worse than the urban population on all counts; and (iii) provinces, where Maputo city and province are significantly ahead of the rest of the country. Prevalence by Location In 1999 life expectancy at birth in Mozambique was 44 years. Without the AIDS epidemic, this was projected to reach 50 years by 2010. If the current rate of infection with HIV continues, AIDS will cause life expectancy to drop to 36.5 years by 2010. The HIV prevalence rate for adults (ages 15-49) in Mozambique has been recently estimated at 12.2% for the year 2000. The first infection was diagnosed in 1986. By 1988 the prevalence rate in the city of Maputo was 1%, increasing to 9.9% ten years later, and reaching 13% in 2000. The installation of 20 surveillance centers spread across the country in 2000 has permitted a much more reliable estimate of the progress of the disease. The new data reveals dramatic differences in prevalence rates across regions as can be seen from the table below. Adult HIV Prevalence by Province in 2000 The highest prevalence rates are found in three provinces in the center of the country, Tete, Manica and Sofala (19.8%, 21.19 and 18.7 % respectively) where there are active, high volume transport corridors to Zimbabwe, Zambia and Malawi (three countries that have higher levels of HIV prevalence than Mozambique -- the first two are above 20 % ). Gaza, the province which is home to the migrant miners who work in South Africa, has the next highest rate, 16%-. Maputo Province is home to a key transport corridor to South Africa's industrial heartland, and has a prevalence rate of 13%-. Maputo City, the largest urban center, a port, a transport hub, and the highest income levels in the country, has a prevalence rate of 13%. Zambezia, the most populous province with 19% of the population, and extensive links to Malawi and central Africa, has a prevalence rate of 12.7%. The remaining four provinces with 40% of the country's population, are largely rural, with prevalence rates well below the national norm: Inhambane (9.6%), Nampula (5,29), Cabo Delgado (6.4%) and Niassa (6.8%). Geography matters. Mozambique's position as a transport corridor, which worked to its favor in the past, is now a health liability. It is surrounded by countries with prevalence levels well above its own: Swaziland and Zimbabwe at over 259, Zambia and South Africa at 20 %, Malawi at 16% and Botswana, in the center of the continent, at over 35%. Prevalence by Age and Gender Women are more likely to be infected than men, and girls 15-25 are more than twice as likely to be infected as boys. In 2000 it is estimated that the prevalence rate for adult women (aged 15-49) was 13 %, vs 11 % for men. There are also differences within age groups. Young women between the ages of 15 and 29 are much more likely to be infected than their male counterparts. On the other hand, men between the ages of 30 and 44 are more likely to be infected than women of the same age group. -2 -  Overall HIV Prevalence by Age Group in 2000 Awareness and Behavior Change Knowledge of the existence of HIV/AIDS appears, (according to a 1997 survey of adults 15-49), to be almost universal in Mozambique, with 97T of those surveyed recognizing HIV/AIDS as a sexually transmitted disease. Knowledge of two or more means of preventing HIV/AIDS is also high (85w among both men and women. Over half (58%) of all respondents considered AIDS a serious problem for their community and 659 thought the situation would get worse. Knowledge of HIV/AIDS is greatest amongst those in the highest risk categories -- urban men with money and access to mass media outlets. This high level of awareness noted above is contested in other surveys, and doesn't seem to have resulted in changes in sexual behaviour. The main form of infection is an unprotected heterosexual sexual encounter, where women are more vulnerable than men. However, only about one third of all sexually active adults used a condom at some point in the past -- half of the men and one fifth of the women. Young people in the 15-24 age cohort, where women are extremely vulnerable as the above chart indicates, seem to be aware of the dangers of unprotected sex, but their behavior lags behind this knowledge. Recent data from a nationwide survey carried out in 2001 by the National Institute of Statistics on sexual awareness and behavior of people aged 15 to 24 indicates that some 79 % of the men and 82 % of the women in the age cohort had heard of the disease -- with awareness higher in urban areas. A high proportion (85% for men and 70 % for women) of those aware of the disease knew how it was transmitted, and of the measures that could be taken to avoid infection. However, behavior change is not in line with awareness. Condom use is low. As a national average for the age group, only 11% of the young men, and 6% of the young women, said they used condoms in all sexual encounters, with use rates lower in rural areas. The most common behavior change was a shift towards fidelity. The rate of condom use in the first sexual encounter is well below these averages. The main reason given for non-use of contraception was lack of knowledge. Of those young people who were single 25 ? of men and 28? of women said they used a condom in their most recent sexual encounter. A study on sexual behavior among youth (15-24) carried out by the Ministry of Health in 5 provinces and Maputo City in 2000 indicated that the age of sexual debut was 15.7 years, slightly earlier for men and later for women. At sexual debut, 85% did not use a condom (similar ratios for men and women) with the most frequent reason for non-use being lack of knowledge. Non-availability was the second most frequent reason for both sexes. Some 41 % of the youth reported having multiple sexual partners in the past 6 months, with the ratio much higher for men than for women. Regarding their most recent sexual encounter, this was with a non regular partner for 28% of the men, and 4 % of the women. In the most recent sexual encounter, 37T of the men and 18% of the women used a condom. The most frequent reason given for non-use was trust in the partner (for both men and women). PLWHA and Orphans -3-  By late 2000 it is estimated that there were some 1.1 million people living with HIV/AIDS, 57T of them women, and that the number was increasing at the rate of 500 persons a day. During the year 2000, more than 57,000 persons died from complications associated with AIDS. Of these, some 25,000 were women, many of them mothers. Their death has left an additional 60,000 children without a mother (often without any parents at all). By the end of 2001, it is estimated there were some 400,000 children whose mother had died, with half of these deaths attributable to AIDS. This burden has been absorbed by the extended family, but there are limits to how much support is available. The burden is projected to grow geometrically, as the number of adult deaths from AIDS increases rapidly in the coming years. It is expected there will be some 1 million orphans to be cared for by 2008. Stigma One of the key issues which has affected the momentum of the HIV/AIDS campaign has been the question of stigma. Only a small number of courageous individuals, living in urban areas, have revealed their HIV positive status. They are subject to discrimination and job loss, and are now slowly organizing themselves into associations which can mobilize resources to care for them, and to allow them to contribute to the advocacy campaign. At higher levels of society the issue is taboo. To date no 'leadership' figures have emerged, such as Magic Johnson in the USA, or Nkosi Jonson or Justice Edwin Cameron of South Africa, declaring themselves positive and encouraging the society to act on the epidemic. The situation is improving however. In November 2001 the Mozambique parliament passed a law aimed at protecting workers who are infected with HIV from discrimination at their workplaces. The bill, passed unanimously by both the ruling FRELIMO party and opposition RENAMO lawmakers, makes it illegal to sack workers on the grounds that they carry the HIV virus or suffer from AIDS. The legislation also makes it illegal to carry out HIV tests on workers or job seekers without their consent. The law also makes it clear that no worker is obliged to reveal their HIV status to employers, and health professionals must keep HIV tests results confidential. Heavy fines are planned for breach of the law. While very important, this law is not yet widely known or implemented. Health Care in Mozambique The health system in Mozambique consists of a network of 4 central hospitals, 12 provincial hospitals, 25 rural hospitals, 276 health centers and 736 health posts. It is estimated that about 40 percent of the population have access to basic public preventive and curative health services and live within 10 km of a facility. The National household survey of 1996/7 indicates that the closest medical service is the traditional healer, located an average 1.5 km from the rural household. Doctors on the other hand are on average 46 km away, and a health post 19 km away. Data on where people in the average village receive health care reflect the access data. Traditional healers treat 94 percent of the people in the average village, nurses 179, midwives 20t and doctors only 2 In 1997 about 44 percent of deliveries were assisted by a health - 4 -  professional, and 47 W of children aged 12-23 months received full immunization. While service outputs per capita are increasing, they are unequally distributed with Maputo City residents receiving the best care. Within the provinces, Zambezia (the largest) stands out as the one with the lowest care units per person. The efficiency of the system has been improving gradually, with care units per staff person in 1999 up 12 W over the 1993 level. The quality of care is still low however, as the stark statistics in the previous paragraphs indicate. The public health system in Mozambique is stretched thin, as it attempts to provide coverage for a large, dispersed and poor rural population. Resource allocations have gradually increased, from 9 W of the recurrent budget in 1998 to 13.4 W in 2000. However, coverage will only improve significantly once incomes increase and families are able to finance service delivery from the private sector. Total expenditure on public health in 1997 was $ 140 million, about $ 9.3 per capita. Government Strategy In 1986 the first case of AIDS was verified in Mozambique. In 1988 the Ministry of Health initiated the National AIDS Control Program -- which developed three medium term plans over the course of the next decade, in the battle against HIV/AIDS. In 1988 and 1990 this Ministry led a multisectoral, cross institutional group which included not only Government, but also civil society, NGOs and donors, in the formulation of the first National Strategic Plan to Combat HIV/AIDS and STDs. The Council of Ministers passed the first Strategic Plan to Combat HIV/AIDS and STD in October 1999. It is a three year plan (2000 - 2002) and required an additional US $ 40 million for its implementation. The Plan proposed the creation of an Inter-Ministerial AIDS Commission (a National Council to Combat HIV/AIDS -- CNCS -- was approved in May 2000) and set out Guiding Principles as follows : (i) addressing priority vulnerable groups -- those most vulnerable to infection and impact (young people especially girls, highly mobile adults such as soldiers, miners, prisoners, drivers, and commercial sex workers) and reducing impact for those living with HIV/AIDS. (ii) ensuring relevance -- activities funded should be those identified by the vulnerable groups as contributing most to reducing infection rates and impact of the disease; (iii) involving people living with HIV/AIDS -- recruiting them as activists and giving them status hence reducing stigma; and (iv) focussing action on the three main transport corridors (Maputo, Beira and Nacala) and the communities in and around them. The national response would be to focus on quality and coverage of essential health and care services for the whole population as well as the vulnerable groups. Institutions should be helped to overcome bureaucratic and financial obstacles to action, and a premium would be placed on multisectoral cooperation agreements amongst all actors at various levels to carry out target activities. Emphasis is placed on having this multisectoral approach prevail at the macro and the community level. The HIV/AIDS campaign had been led, since its inception in the late 1980s, by the Ministry of Health which set up the National Program for Combating AIDS. During the initial decade, a broad educational and awareness building program was developed, with wide participation by civil society and NGOs. Condom distribution went up rapidly, reaching 10 million per - 5 -  annum by 2000. In spite of this, infection rates have also increased rapidly, with prevalence going from under 1 W in 1990 to 12 W in 2000. This rapid rate of infection infused new urgency into the program, and caused Government to try and broaden the campaign. The recent approval of the National Strategy, the creation of the National Council and its Secretariat, and the shift in leadership to these new bodies brought a period of change, as the new, broader, multisectoral institutions were put in place. During the first year of implementation, plans were developed for each Ministry and each Province, the Secretariat to the CNCS staffed and located in an office, and a donor Round Table held which yielded commitments of US$ 120 million from donors in support of the National Program (not all of it incremental funding). During the second year, with the new leadership now in place, nationally run activities began to gear up. The focus was on prevention. The Secretariat to the CNCS put professional staff in place in every province, linked to the Governor's office, and began its cross-sectoral advocacy (to "Break the Silence"). It also established coordination functions at all levels and locations of both the Government and the NGOs and private sector activists. A national Coordination Forum was held in March 2001, and again in May 2002. Thematic groups were formed around themes such as prevention, home based care, VCT centers and orphan care. A broad national communication program was launched with assistance from local artists. During the year new associations of People Living With HIV/AIDS were formed in Nampula, Inhambane and Sofala -- now come together in a network of PLWHA in Mozambique. Also during 2000, the coverage of the surveillance centers was greatly expanded -- from 4 to 20 centers -- providing much more accurate assessments of the coverage and severity of the epidemic. The Government has recently adopted a policy on ARV treatment, set out in Ministerial Diploma No 183-A/2001 published December 18, 2001 Under this policy, Government would develop its capability to monitor and support ARV treatment in the general population, while at the same time strengthening its capacity to treat and care for patients with opportunistic infections and diseases which result from AIDS. The Government would charge for the 'reference' services provided in the monitoring of ARV treatment, and the medication would have to be provided by the patient, or some source other than Government. An exception to this is made in the case of preventing Mother to Child Transmission, and in the case of health workers who are infected during the course of their work. Here, the Government finances the cost of ARV treatment, in addition to the follow-up and monitoring costs. The Executive Secretariat to the National AIDS Council has been established under exceptional administrative, financial and personnel management conditions. Standard civil service procedures have been set aside for a more flexible apparatus, which allows for the contracting of staff at market salaries, the design and implementation of a 'purpose built' financial management and program monitoring system, and an openness to measures needed to improve effectiveness, including hiring in functions as needed. An Institutional Assessment was completed in December 2002 and provides a roadmap for building an institution capable of discharging its functions in the expanded program. The Secretariat to date has developed a proposal for a pooling mechanism for donor funds (the Common Fund), a Civil Society Facility for Community Projects, and is formulating a national monitoring and evaluation strategy and a - 6 -  communications strategy (see Section C4). These functions should be underway by the end of 2002, which the CNCS has labeled the year for Quality and Integration. Following a period of stock taking and reorganization into a broader, more multisectoral campaign, with larger more forceful presence in the provinces, the National Council is now ready to launch a much broader and more aggressive campaign. It is for that reason that it has approached IDA (along with the Global Fund) for financial support. The Mozambican strategy and approach to the HIV/AIDS campaign is one which conforms well with access criteria set out by the Bank for its Multi-country AIDS Program for Africa (see Section D4) in that a coherent national campaign strategy has been formulated and is under implementation, a high level council has been established to lead the campaign, and the Government is taking extraordinary institutional measures to ensure effective implementation of the program. 2. Objectives The project will assist the Government of Mozambique to finance the implementation of its National Strategic Plan to Combat STD and HIV/AIDS. The strategy is designed to slow the spread of HIV/AIDS infection and mitigate the effects of the epidemic, through prevention, care, treatment and mitigation activities. The National Strategic Plan is multisectoral in nature, bringing together the efforts of Government, civil society, private sector and communities in a national campaign to slow the rate of infection and provide care for those who suffer from the disease, and for those who depend on them. The effort is led by a National Council to Combat AIDS, chaired by the Prime Minister, which includes key Ministers and leaders in civil society in its membership. The strategy is funded from the National Budget and various local and international bilateral and multilateral contributors, including the United Nations agencies and potentially the Global Fund to Fight AIDS, Tuberculosis and Malaria. The design of the Mozambique strategy is well suited for support by the Bank under its Multicountry HIV/AIDS Program for the Africa Region (MAP II), as it meets all of the strategic and institutional criteria for inclusion (see Section D4). The Bank's MAP II for US $ 500 million was approved at the Board on February 7, 2002 (Doc No. IDA/R2002-4). The project will: (i) improve institutional capacity for planning, delivery and monitoring of HIV/AIDS response interventions through all levels of Government and its line ministries, civil society and the private sector, with a focus on vulnerable groups; (ii) strengthen delivery of health services providing prevention and care, giving priority to the more vulnerable regions of the country, such services to include voluntary testing and counselling services and treatment of sexually transmitted diseases and opportunistic infections related to HIV/AIDS; (iii) enable Government at the national level and regions, as well as through its line ministries, to carry out programs advocating prevention and providing care for its own staff and communities; and (iv) fund a variety of projects led by civil society, including the private sector, and carried out in urban and rural communities, which cover HIV/AIDS related prevention, advocacy, public awareness creation and care for orphans and PLWHA, with a focus on the needs of vulnerable groups. - 7-  3. Rationale for Bank's Involvement The rationale for World Bank involvement includes: The World Bank can add substantially to the resources available to support a broad multi-agent, multi-sectoral program -- particularly in an environment in which the Government is committed to increasing service delivery, outreach and advocacy through a multiplicity of institutions and agencies. The Bank can bring to bear its broad experience in funding HIV/AIDS campaigns around the world, including in Portuguese speaking countries such as Brasil and Cabo Verde, where specific media and communications materials, assessments and operational manuals and expertise can be identified for Mozambican use. The Bank has much experience in the mechanics of such national programs, particularly in dealing with financial and procurement issues affecting Government agencies and communities. This experience, translated into operational guidelines and manuals, can help Mozambique structure its own institutions to manage the campaign and deliver the services. The Bank has access to a broad range of international contacts which (when combined with the networks offered by the UN system and UNAIDS in particular) will enable Mozambique to visit -- be aware of -- and consult with -- those national programs which have been most effective, and which have the closest similarity and applicability to the Mozambican cultural, geographic and economic situation. By virtue of its financial presence, its technical expertise, its multilateral ownership, its close links to the key economic and social sectors in Government, and its global network, the World Bank can assist the Secretariat to the National Council to develop strategic positions and overcome coordination problems -- to the benefit of the campaign. 4. Description The objective of the project is to slow the spread of HIV infection in Mozambique, and mitigate the effects of AIDS, through prevention and care activities. The design process, led by the Executive Secretariat to the CNCS has been transparent and participatory, carried out in frequent consultation with the Ministry of Health and other Government agencies, NGOs, private sector, donors and other stakeholders. The project has five components as described briefly below. Implementation issues are discussed in section C 4. (i) Community and Civil Society Initiatives (- US$ 28 million) -- This component would empower communities to respond effectively to the HIV/AIDS epidemic. A central activity would be mobilizing communities, promoting local initiatives and strengthening the capacity of local actors. A Community and Civil Society Facility held by the CNCS would be created to finance appropriate HIV/AIDS related activities carried out by eligible applicants. These include community and faith-based organizations, NGOs, the private sector, associations and other organizations. The management of the facility would be decentralized to the provincial level, in support of a provincial program to combat HIV/AIDS. Significant resources would be invested at the Province level to strengthen the Secretariat and other organizations -- public, private and NGOs -- to carry out the program. Criteria and procedures for project preparation and approval are specified in the Operational Manual, and cover: (i) the principles of operation; (ii) eligible applicants; (iii) institutional arrangements and facilitating agents; (iv) eligible activities, (v) the allocation of - 8 -  resources by province, and (vi) the features of the project identification, preparation, approval and supervision cycle. Activities to be funded, all of which link to the HIV/AIDS campaign, include dramatic representations, seminars and talks to emphasize prevention, seminars and other kinds of assistance providing guidance and support to care-givers and those providing foster homes for orphans and widows, schemes for generating income to replace losses due to AIDS deaths, and guidance on treatment for oportunistic diseases, and ARVs. The implementation process is designed to be managed in a decentralized fashion, with support and decisions making occurring at provincial level. The process should be open and participatory, with the main stakeholders represented on a provincial Technical Council which will oversee the process. Subprojects would be for two or three year duration. Subprojects valued at less than $ 20,000 would be approved at the provincial level. A maximum project size of $ 100,000 is envisioned. Facilitating Agents, potentially NGOs or private sector entities, would be contracted to work with community agents to foster program identification and project preparation at the community level, and the preparation of project proposals to be funded by the Community and Civil Society Facility. One set aside of US$ 5 million from the CCSF is allocated to support large NGOs providing voluntary counselling and testing services and supplementary health care services related to HIV/AIDS in collaboration with, and under the supervision of, the Ministry of Health. A second set aside of US$ 2 million will be used to support HIV/AIDS initiatives to be carried out by the private sector, under conditions set out in the Operations Manual. (ii) Capacity Building for the Civil Society HIV/AIDS Response (- US$ 5.5 million) -- this component will support efforts to create AIDS competent communities by improving skills and increasing implementation capacity for the implementers, supporters, and target groups active under the Community and Civil Society Initiatives. Activites to be funded would include (i) hiring and training 'Facilitating Agents' who would take the lead, in each province, in identifying and training up organizations for community mobilization; (ii) courses and activities to build awareness development and build capacity for leadership in the public sector, civil society and the private sector, and (iii) and the formulation of training modules in HIV/AIDS awareness for use in public and private sector enterprises. Specialized packages of Information, Education and Communications (IEC) materials would be developed and distributed through this effort. (iii) Government Multisector Response (- US$ 7 million) -- Ministries and subordinate institutions will be supported under this component in the development and implementation of HIV/AIDS related programs directed toward their own personnel (particularly high risk staff such as soldiers, police, extension agents, teachers, health workers) and their families, as well as programs directed toward their clients. Under this component, ministries are encouraged to expand their activities in the area of HIV/AIDS according to the National Strategic Plan for combating HIV/AIDS and the Ministerial Plans. The program will therefore concentrate on non-health ministries and other key public sector institutions to effectively respond to the epidemic. Emphasis will be made on prevention and care for infected and affected families. The activities included in the program for financing are categorised in two parts: part (i) will focus on staff and their families by providing them with HIV/AIDS education, training, condoms, support for caring for infected and -9-  affected, encouraging behavioural change, and destigmatizing the illness at the work place; and part (ii) will focus on the external clients of the respective ministries. It is envisaged that the second part activities will have a close link with activities to be implemented under the civil society component. Support will be provided to facilitate respective outreach programs of various ministries. These would include community based activities involving youth associations, sporting clubs, cultural groups, farmers clubs, women's groups, street children, orphans, teachers, school councils, parents-teacher associations, activists, and any other groups as may be identified with relevant agencies. In each of the line ministries, a Focal Point will be identified who will be supported by ministerial and/or departmental management committees designated to oversee the design and carrying out of HIV/AIDS related policies and action plans. The Focal Points will receive training and day-to-day guidance of their roles and responsibilities form the Ministry Response Coordinator situated at CNCS head office. As the case may be, the project will facilitate the operations of the Focal Points through ensuring availability of basic office equipment, facilities, and incremental operating costs. With guidance from the Provincial Government and the Ministry of State Administration, District Administrators would be engaged to foster the development of District HIV/AIDS plans. (iv) Strengthening and Scaling Up Health Sector Services for HIV/AIDS (~ US$17.5 million) -- With the objective of scaling up the response of the health sector to the HIV/AIDS epidemic and to provide technical leadership on treatment and care for people living with HIV/AIDS, this component would include: (i) the strengthening of the Integrated Health Network providing voluntary counselling and testing and HIV/AIDS related services in the four provinces in the center of the country (Tete, Manica, Sofala and Zambezia) where prevalence rates are highest, and where there is still no significant upscaling program underway; (ii) increasing the supply of HIV/AIDS related drugs and materials, such as the supply of condoms, drugs to treat opportunistic infections, anti-retrovirals for the reduction of MTCT and post exposure prophylaxis; (iii) strengthening clinical laboratory capacity to enable diagnosis and monitoring of HIV therapy including those for CD4 monitoring and diagnosis of opportunistic infections; (iv) measures to enhance bio-security; (v) measures to enhance blood safety; (vi) training and antiretroviral drugs for post-exposure profilaxis for health sector workers; (vii) improved management of opportunistic infections, focussing on their prevention via prophylaxis, as well as their treatment as mentioned; and (viii) improved management monitoring and evaluation of the component and the overall progress of the epidemic. In line with Government priorities, and consonant with the distribution of current efforts to combat the epidemic, the project would support the strengthening of a network of health centers in the center of the country, in order to respond to the high prevalence rates and density of vulnerable groups. These centers would be specialized in providing voluntary counselling and testing for HIV, treatment for STDs, guidance and training for individuals and associations in ARV treatment, and guidance in Home Based Care for PLWHA and their families, and orphans. They would be established under the guidelines and with overall supervision and monitoring from the Ministry of Health. Modern health care in Mozambique is heavily reliant on public sector delivery in urban areas. In rural areas, the public sector is the only source of modern health care, with few exceptions. The component would focus on - 10 -  strengthening the strategic planning and monitoring capabilities of the Ministry, as well as its capacity to deliver care. However, due to current capacity limitations in the Ministry, operations linked to HIV/AIDS such as voluntary counselling and testing and support for home based care, would be contracted out initially to NGOs and other partners. These contracts are costed under the Community and Civil Society Initiatives component, as they will be funded from the Community and Civil Society Facility. The World Bank has supported the development of the health care system in Mozambique since 1995 through the Health Care Recovery Project. This component, focussing on HIV/AIDS related care, will build on the accomplishments in the prior operation. Results and achievements under the Health Care Recovery Project are reviewed in section D2. (v) Institutional Development for Program Management (- US$ 6 million) -- This component would target the Executive Secretariat of the National Council, strengthening its capacity to lead the country in the campaign. The CNCS Secretariat is one of two implementing agencies for the IDA Grant, the other being the Ministry of Health. Under this component the CNCS will significantly improve its capacity to coordinate the National HIV/AIDS Program and carry out project management. This includes carrying out overall planning, budgeting and coordination of the National Aids Program, catalyzing greater involvement by society in the HIV/AIDS response, channeling of funds to implementing agents and monitoring of program execution to ensure compliance with Program objectives and fiduciary responsibilities. A major objective is to build the capacity of the CNCS provincial nucleos to undertake responsibility for planning, mobilizing and channeling resources, and coordinating and monitoring of HIV/AIDS activities in a particular province. Institutional development efforts include: (i) capacity building for the CNCS Board and the Executive Secretariat; (ii) strengthening organizational arrangements and financial management at the center and province; (iii) strengthening monitoring and evaluation; (iv) formulation and monitoring of a national communications strategy; (v) creation of a supportive regulatory environment and (vi) building a strong coalition across civil society and donors at national and provincial level in support of a multi-agent, multi-faceted community based approach to HIV/AIDS prevention, care and treatment in Mozambique. A key principle of the HIV/AIDS program is that the Secretariat is charged with coordination and oversight, but actual implementation of programs would be contracted out to NGOs or private sector or other civil society agents, or invested in line agencies. Further information on these tasks is provided in Section E 4. Indicative Project Costs are listed below: Community and Civil Society Initiatives Capacity Building for Civil Society HIV/AIDS Response Government Multisectoral Response Strengthening and Scaling Up Health Sector HIV/AIDS Institutional Development for Program Management 5. Financing Total ( US$m) BORROWER/RECIPIENT $9.00 IBRD IDA  IDA GRANT FOR HIV/AIDS $55.00 Total Project Cost $64.00 6. Implementation Implementation Period -- 5 years Government Institutions The National Council to Combat HIV/AIDS was approved by the Council of Ministers in 2000 -- as part of the National Strategy. The members of the Council and its Executive Secretary were in place by mid 2000. The National Council is headed by the Prime Minister (President), and includes: (i) Government : Six Ministries as follows: Minister of Health (Vice President), Minister of Foreign Affairs and Cooperation; Minister of Finance and Planning, Minister of Women and Social Action, Minister of Youth and Sports; and Minister of Education; (ii) Nongovernment Organizations: Five NGOs as follows: MONASO (the umbrella NGO for AIDS), Kindlimuka (the largest NGO for PLWHA), AMODEFA (provides health care), OMM (present in almost every community), ADPP (with Danish affiliation, involved in education); (iii) Individuals from Civil Society a Frelimo Parliamentarian; the Rector of the Catholic University, and the Head of a prominent Youth Association. The Executive Secretariat to the National Council has been given the mandate to lead, catalyse, coordinate and monitor all activities in support of the National Strategy -- while not involving itself in the actual implementation of programs. It functions in close cooperation with the Ministry of Health. The Secretariat has established a National Office in Maputo, and a Provincial Nucleus in each of the ten provinces. Headed by the Executive Secretary, the agency is divided into a Planning and Budgeting Unit, a Technical Unit, and a Project Support Unit. Over the past two years, a network of HIV/AIDS focal points has been created across Government and the Provinces. Every Ministry has named an AIDS focal point, and while some Ministries have developed an indicative Ministry Plan to Combat HIV/AIDS -- few of these are actually being implemented. Focal point functions remain incipient, and weak in influence and power. In addition, the Secretariat has worked with each Province to formulate a Provincial Plan to Combat HIV/AIDS --- in an effort to mobilize provincial Government and civil society within the province. Many of these plans are still dormant, for lack of funding and leadership. The Executive Secretariat has also convened two National Fora to review the status of the HIV/AIDS Campaign -- one in March 2001, and a second in May 2002. This event, which is expected to continue to occur annually, brings together all the key institutions active in the HIV/AIDS campaign, from both Government and civil society, for two days of review, reflection, guidance and training. Civil Society Institutions Civil society has formed an umbrella NGO, to lead on all aspects of the campaign: MONASO. While they have limited capacity at the national level, they are well recognized in the large urban centers, including Maputo, and they serve as a center for discussion and coordination for AIDS related topics with NGOs. A society of PLWHA -- Kindlimuka -- plays a lead advocacy role, mainly in the South of the country. In addition, there are a large number of local and international NGOs who, working collaboratively, are active in the HIV/AIDS field. The international NGOs have grouped themselves into an association called NAIMO, and include Medecines Sans Frontiers, PSI, CARE, ADPP, World Vision and others. The CNCS Executive Secretariat is also active in coordinating - 12 -  the activities of civil society at a national level. A series of four thematic groups have been created, to bring together the many NGOs, donors and private sector participants engaged in HIV/AIDS awareness building or care activities. These groups cover: (i) Prevention; (ii) Home based Care; (iii) Voluntary Counselling and Testing; and (iv) the care of child Orphans. The level of involvement of the NGOs in the campaign depends on the activity and the Province. Associations of Persons Living With HIV/AIDS have been formed in Maputo (Kindlimuka) and are in the process of being set up in Inhambane (UTOMI), Nampula (Nivenyee), Sofala (Kulupira) and Manica (Kubatsirana). The CNCS Provincial Coordinators in Niassa, Cabo Delgado, Nampula, Zambezia, Tete, Manica, Sofala, Inhambane, Gaza, Maputo Province and Maputo City have brought together groups of NGOs, churches, private companies and other actors to carry forward the campaign. Funding for these activities is largely provided from own sources, or from donor funds designated for the purpose, and such funding has been scarce. A Civil Society Fund is proposed under the project, to respond civil society's needs. Donor Support To date, the donors have channelled most of their support through NGOs, the UN System, or civil society organizations. Due to the diversity of implementation channels and contracting mechanisms, it is difficult to track all the activities, or account for all the donor funds being used in the campaign. The donors with the largest program commitments (multi-year data, which makes comparisons difficult) include DFID with US$ 30 million, the USAID (and CDC) with some US$ 28 million, followed by Denmark with US$ 11 million, the UN system with $ 10 million (where UNFPA and UNICEF provide over half the total, and where there may be some double counting of donor contributions), Norway with US$ 7 million, the European Union with US $ 6 million (for Mozambique, out of a larger allocation for regional SADC and Africa wide initiatives), Germany with $ 5 million, and then Canada, Australia, France, Italy, and Netherlands with between $1 and $3 million each. Ireland and Spain made contributions as well. The donors have a group which meets regularly to coordinate HIV/AIDS and Health activities. The CNCS Secretariat is also active in donor coordination and resource mobilization. In November 2000 and again in November 2001, the Executive Secretariat organized a Donor round table in Maputo, to report on the Government's activities in the implementation of the National Plan, and to raise funding. The first Roundtable in 2000 raised commitments from of donors of $ 120 million (for multiyear implementation). In the second Roundtable in 2001, the Common Fund was introduced, as a mechanism for pooling donor funds received in support of all activities in the HIV/AIDS campaign. This event raised in the order of US$ 10 million from donors as a contribution to the Common Fund. It is the hope of the Executive Secretariat that, once the issues regarding review and governance procedures and the financial management and reporting systems have been ironed out, donors will see fit to channel an increasing share of their support via the Common Fund. Implementation of the IDA Funded Activities At the national level the CNCS Executive Secretariat would coordinate implementation of all the activities funded under the project. The Secretariat has been building up the capacity to operate in a decentralized fashion over the past two years. An office has been established in each Province, and staffed with a Provincial coordinator and a financial specialist. Financial management and monitoring systems have been designed. However, very few programs have been funded through - 13 -  the CNCS Secretariat to date, for lack of own funds. During preparation for the IDA project, an Institutional Assessment has been carried out, and will be used to recommend on ways to strengthen the Secretariat, to the CNCS Board. The assessment will also guide IDA's investments under the Program Coordination component, and its recommendations for project implementation. The implementation of the PPF, due to be initiated in October, 2002, will enable the Secretariat, and other implementing agencies, to test different insitutional modalities, thresholds, preparation and review procedures, which will be included in the final consolidated Operational Manual. Under this umbrella, there would be two coordination foci: (i) the Executive Secretariat, which would hold two Special Accounts, one to finance the Civil Society Facility, and a second one to finance the remaining components, with the exception of the health component; and (ii) the Ministry of Health, which would receive its funds directly from IDA via a third Special Account, and would implement its agreed workplan for the Health Sector component. Project implementation, financial management, procurement, monitoring and evaluation would be operated through the institutional management and accounting systems of the Executive Secretariat and of the Ministry of Health. All aspects of implementation of the program, and the Bank funded project are set out in the Operational Manual. The manual sets out performance objectives, institutional modalities, criteria and processes. It also has model forms and contracts to guide the various actors during the implementation period The manual has been prepared in a participatory fashion, led by the CNCS, and will be reviewed and agreed on with the the Government and stakeholders prior to Grant effectiveness. Procedures and institutional arrangements set out in the Manual are to be tested under the IDA funded Project Preparation Facility of $ 880,000. Implementation of the Community and Civil Society Initiatives and the Civil Society Capacity Building components would be delegated to a large number of insititutions, in the NGO, private and public sector, best placed to lead HIV/AIDS campaign activities in their particular community. These organizations would be appraised by the Secretariat, or institutions contracted to the Secretariat, prior to entering into funding agreements with them. A training and strengthening building program would be put in place to strengthen administrative capacity for local institutions with the mandate, interest and community relationshios needed to carry out HIV/AIDS related activities. The activities under this, the largest component, would be carried out following the procedures and criteria set out in the Operational Manual. Promotion, preparation, review and approval procedures and thresholds and structures are based on a decentralized management structure. They have been designed based on experience to date with this kind of program in country, and in other parts of Africa. The structure and approval points and thresholds will be tested under the PPF, and may need to be revisited by the CNCS management. IDA would need to be consulted on any changes in such thresholds and procedures. In addition, certain financial and monitoring activities may need to be outsourced by the Secretiariat. An assessment of potential workload and number of transactions should guide the capacity building and the decisionmaking on the option of in-house as opposed to out sourcing. We recognize the overall shortage of professionals in financial management in the country and recommend a careful workload assessment and decision making as to how much capacity should be built in-house and how much should be targeted for out sourcing. - 14 -  The component supporting the Government Multisectoral Response would be implemented by each of the sectoral ministries, making use of their internal management and financial systems, strengthened to carry the HIV/AIDS related activities with funds provided under the project. Ministries would not be funded unless they had an HIV/AIDS action plan approved by the CNCS, with a focal point and an HIV/AIDS office in place. The Ministry of Health would implement the Scaling Up of Health Care Services component by making use of management systems developed in the course of implementing the Bank funded Health Recovery Project (Cr 27880). Recently, the MOH has developed a financial management system and an epidemiological monitoring system which are already operational. Project coordination would be the responsibility of the CNCS Secretariat. The Secretariat is receiving support for institutional strengthening under a project funded by USAID which includes technical assistance, hardware and training for the design and installation of a purpose built financial management system, and a national database of HIV/AIDS related activities. These will result in the production of all procedures manuals and training in the operation of the systems. Technical assistance on the financial side is provided by two internationally recognized management consulting and auditing firms. Technical assistance on the activities database and monitoring is provided by the Centers for Disease Control. Design of these systems has been completed, and training is underway. The CNCS is also in the process of recruitment of accountants and internal auditors based on the proposed design and structure of the internal control systems. The UNDP is also funding a capacity strengthening program for the CNCS, which is in its first year. This project will provide technical assistance to support internal training programs, and staff to strengthen the coordination of the Civil Society Initiatives component at Provincial level. The Bank funded project would provide additional financial, procurement and program staff, along the the requisite hardware and training, as needed to enable the decentralized coordination of the growing HIV/AIDS program. Financial Management, Accounting and Auditing As noted above and described more fully in Annex 6, the Secretariat would be responsible to the Government, the Bank and other donors for ensuring that sound financial management principles were used in support of program implementation. Significant resources (provided by USAID) have been invested in the design and setup of financial management and administrative systems for the Secretariat. A management consulting and auditing firm of international repute has been contracted to carry out these tasks. After over a year of effort, a purpose designed accounting system is in place (which is designed to respond to the reporting needs of both the donors and the Government), the hardware has been purchased and installed at the center and all provincial offices, financial management staff have been hired for all locations, and comprehensive training programs are underway. The Secretariat has an Administrative Manual, which establishes personnel management policies and the procedures for maintenance and management of its assets. A separate contract has been entered into with another international management consulting and auditing firm, to design and put in place a financial system for tracking funds received from donors for use in - 15 -  support of Community and Civil Society Initiatives. This system is now operational, and being used for the funds received to date from the Irish Government and the DFID. An internal auditing function for the Secretariat has been designed, and two auditors have been hired to provide continuous visits to the provincial offices to ensure procedures are being followed. Executing agencies of the project include the Secretariat and its eleven Provincial Nuclei, the Ministry of Health, the various Ministries which receive support for their HIV/AIDS programs, the larger NGOs who lead in the civil society initiatives, and a multitude of recipients of funds at the local and community level (including NGOs, CBOs, and Private Sector companies). Agents responsible for the use of funds provided under the project will be appraised by the Secretariat prior to entering into funding arrangements with them. Forms and procedures are spelled out in the Operational Manual. A capacity building program has been designed to bring agents under the project up the appropriate level of financial and administrative sophistication (this will vary by the magnitude of the funding involved) prior to providing implementation responsibility. The program will rely on other sources to strengthen agents' internal control structures. The Government is improving its own financial and administrative structures under the SISTAFE program supported by the Bank's Public Sector Reform project. A number of NGOs receive support from donors, or from their international affiliates, and will be required to provide assurances of good fiduciary practices. In particular, there will be a number of large NGOs (most of them of international origin) who will carry out voluntary counselling and testing, training in home based care, and treatment for opportunistic diseases -- under the technical supervision of the Ministry of Health -- who will be financed from the Civil Society Initiatives fund. Specific forms and procedures will be designed under the PPF for use in this activity, which has been budgeted at up to $ 5 million over the project period. The Ministry of Health would be responsible for the implementation of the Upscaling of Health Services component. Due to the volume of funds to be managed under this component, a separate Special Account will be established for the Ministry of Health. Voluntary counselling and testing and other health care functions, contracted out initially to large international NGOs with sufficient capacity and expertise, will be supervised by the Ministry of Health, but funded by the Secretariat under the civil society initiatives component. The Project Management Office (GACOPI) in the Ministry of Health which has supported the implementation of the IDA funded Heath Sector Recovery Project (IDA Credit 27880) since 1996, will be strengthened in order to have it continue to provide both procurement and financial services to the Ministry of Health and the Secretariat (for large international purchases) under the proposed project. Consistent with guidelines issued by the Financial Management Board to ensure compliance with OP/BP 10.02, during the appraisal mission a Bank AFTQK team carried out its assessment of financial systems, procedures and capacities to determine whether, when project implementation starts, there will be adequate financial management systems and capacity in place to ensure the production of reliable and useful reports on the project resources and expenditures and other useful information on a timely manner. The conclusions of this assessment are in Annex 6. A final - 16 -  review of the financial management system and capacity will be carried out by the Bank staff to assess readiness, before the Grant is declared effective. Planning and Budgeting The planning and budgeting cycle has been designed to fit the National Budget. Annual budget requests would be prepared at the provincial level by mid-year, within ceilings provided by the Secretariat. Allocations for the annual funding of community and civil society activities for each province would be arrived at following criteria based on population, prevalence and prior year performance. The budget requests would be reviewed at provincial and central level, and then consolidated for presentation to the Ministry of Planning and Finance. Approval of the final allocaation and spending authority from the National Budget would be received prior to the start of the fiscal (calendar) year. In addition, the budget request would be submitted to the Bank and donors for comment and review, at an annual event to be organized in a fashion which follows successful precedents set in the Sector Wide Approach used for Agriculture, Health and Education in Mozambique. The approvals for civil society initiatives would be carried out over the course of the year, using procedures, criteria and thresholds provided in the Operations Manual. Support for the Community and Civil Society Initiatives component, and the Civil Society Capacity Building component would be through a decentralized, province-based program management system. The planning and budgeting exercise for these components was initiated in the 2002 budgeting cycle. The provincial plans have been carried to a reasonable level of detail, although further work will be needed before they can be implemented. The formulation of consolidated Provincial plans has been well executed, and will provide an excellent basis for a decentralized planning and implementation process. The planning and budgeting for the Multisectoral Ministry Response component takes place at the central level. Indicative ministerial plans had been prepared a year ago. The Secretariat is working with each of the ten key Ministries in the formulation of a much tighter, targeted, program, to fit within the available resources. So far the Ministry of Agriculture and Rural Development has presented a coherent proposal, and the ministries of Education, Health and Youth and Sports are not far behind. While the planning and budgeting procedures have been set out and discussed at the central level, much further training and documentation is needed at the Province level to put in place participatory systems which will produce plans which reflect local capacity, and can indeed be implemented. These needs will be addressed under the project. Procurement The Secretariat has defined positions and is hiring staff to carry out the procurement process to be used in each of the components, in a manner consistent with the appropriate Bank guidelines. The Secretariat intends to rely on the office of GACOPI in the Ministry of Health for any large procurement procedure, including any international competitive bidding. A Procurement Plan has been prepared as part of the draft Project Implementation Plan -- and procedures and thresholds for each item have been set out in Annex 6 and the draft Operational Manual. A large share of the project will be used as grants in support of a large number of small community development subprojects, and will be subject to simplified procedures specified in the Operational Manual. Monitoring and Evaluation - 17 -  The current M and E framework is characterized by one component that is well developed (the biological subcomponent of the surveillance system), one component that is under active development (financial monitoring) and two components that require further attention (the overall M and E architecture and program activity monitoring). The status of the system as a whole is described in more detail in Annex 2. The design of the overall M and E architecture is well advanced. The M and E manuals and the Country Response Information System (CRIS) represent major contributions. The indicator sets that have been developed are of high quality, and reflect intensive commitment and consultation. However, these indicators may be too complex to be implemented initially, and a more simple set has been agreed on for startup. In addition, to bring the system architecture to a position where implementation can be initiated, there is a need for: (i) a single governing flowchart and database, to ensure that all information is captured in a single structured form; and (ii) a single unitary system, based on nationally agreed data collection forms and pathways, leading to a single data base. External consultants will be hired under the project to work on further refinement of the system, and assist in startup activities. Periodic assessments of key aspects of the program will be organized by the Secretariat and carried out under contract. These will provide the background and material for annual Learning Events and Progress Reviews by all stakeholders, starting at the provincial level and leading to a National Assessment. Other learning events and study tours would be built into the program. Operations Manual A draft Operations Manual has been prepared, in close consultation with the Secretariat, and is under discussion. During appraisal the review was extended to donors, NGOs and other stakeholders who are likely to make use of the procedures spelled out therein. An effort has been made to define the general institutional framework for the program, and to delineate the strategies, policies and procedures for financial management and procurement to be followed by the Secretariat in coordinating implementation of the program as a whole. Separate sections have then been set aside to describe the procedures required by particular donors, with a special section for the World Bank. The manual covers not only the financial management and procurement procedures required by the Banks fiduciary regulations, but also the appraisal procedures, thresholds, guidelines, criteria, and forms, as well as contractual and supervision procedures to be used in the implementation of the Community and Civil Society Initiatives component --- the component with the largest financial allocation, and the largest number of participating institutions, under the project. The Operations Manual will include (and be consistent with) overlapping sections of the Administrative Manual, and the Financial Systems Manual (mentioned above). The draft Operations Manual will be the focus for an extended process of consultation and review within the Secretariat, the CNCS Board, the donors, and the larger NGOs who will be called on to follow the procedures. A final version of the manual, satisfactory to the Bank, will be ready prior to Grant effectiveness. - 18 -  7. Sustainability In order to be sustainable and effective the following conditions should hold: (i) the social and cultural environment will have to change in order to: (i) reduce the social stigma associated with HIV/AIDS, (ii) increase the openness and freedom to talk freely about sexual behavior -- and the risks of promiscuity, and unprotected sex; and (iii) increase the power of women to determine their sexual choices and behaviour. (ii) the legal and regulatory environment will have to be maintained, or improve, to avoid discrimination against those who are HIV positive; (iii) the management of the project (and the National HIV/AIDS program) will have to maintain and continue to demonstrate its financial accountability and programatic integrity -- so that additional resources can be mobilized from local and international sources in support of a centrally directed campaign (iv) capacity building for local NGOs, CBOs and Private business will have to be successful -- as the program will only be sustainable, and have an impact, if those few institutions receiving strengthening and capacity building programs are in fact made more effective and aggressive -- and capable of mobilizing resources on their own account. They in turn will then be able to go out to create management capacity and implementation capability in community institutions -- which can then mobilize resources from the communities themselves to sustain their activities.. (v) Government should sharply increase the local resources devoted to the campaign. Its reliance on donor funding for upscaling seems to indicate that it is leaving the funding for this very high priority battle to the whims of international financial agencies and donors. (vi) The expansion of health services and the training and skills enhancement of healthcare workers will have to be in place. 8. Lessons learned from past operations in the country/sector This project will incorporate in its design the lessons learned in the course of designing and supervising implementation of the eleven projects which have been approved under Multicountry HIV/AIDS Programs 1 and 2. The main lessons learned are set forth in pages 11-13 of the MAP 2 Report P 7497 AFR and are summarized below: The MAP projects were designed and launched too rapidly to build effective implementation mechanisms -- and momentum slowed considerably after launch. It is important that (i) operation manuals and first year implementation plans be completed, following a participatory process involving all stakeholders; (ii) pilot activities be tested prior to launch under PPF or PHRD funding; (iii) program targets be defined quarterly for the first year; (iv) mechanisms be put in place to keep civil society advocates involved during implementation; (v) extensive technical assistance be provided to NGOs and CBOs to improve the absorptive capacity of civil society, and (vi) the role of the Ministry of Health be re-asserted in the definition of medical policy, and the procurement of medical supplies. - 19 -  Eligibility criteria for access to MAP funds were appropriate, but more emphasis should be placed on Government adopting "exceptional" implementation arrangements -- including wide scale contracting out in those areas where Government lacks capacity, but needs immediate and effective results. Program implementation is more successful in countries where the national AIDS council has defined its role as "facilitation" and "coordination" rather than as "control" and "implementation". It is important that the secretariat to the Council lead and coordinate from a position of competence, with mechanisms for monitoring performance and providing accountability to civil society and the campaign participants as a whole. The formation of a Civil Society Review Board is a potential mechanism for creating this accountability -- if necessary. Priority to fiduciary mechanisms (financial management, accounting, procurement, review and approval procedures) should not detract from attention to monitoring of program implementation and evaluation of program impact. Design of such systems, and even execution can be contracted in as needed so that they do not lag behind the implementation process. Priority should be given to the 'software' side of the program -- giving attention to getting the right people for the task, and paying them and motivating them appropriately. Procurement of the 'hardware' -- buildings and equipment -- can then follow its normal course without affecting the startup of activities. Mozambique can learn from "best practices" developed both in country, regionally and internationally. Resources should be channelled to creating Technical Theme Groups at all three levels, to connect into and learn from external experiences. In addition, the monitoring and evaluation system to be established for Mozambique should be pressed to provide assessments and guidance on the successes and failures of the national program. Commitment from public sector Ministries and agencies to the program can be hastened and deepened by undertaking an assessment of the impact of the disease on agency staff and their families, and on agency capacity for service delivery, in light of an accellerating loss of experienced staff, and the high cost of finding and training up replacement staff. The practice of carrying out a social assessment, by program and geographic area, can help civil society institutions ensure that their activities are relevant to social needs and can generate stakeholder commitment. 9. Environment Aspects (including any public consultation) Issues The Assessment The most important environmental issue arising from this project relates to the management of medical waste -- which may contaminate health workers, and others who may come in contact with it such as municipal workers who handle collection and disposal, poor families whose income is derived from triage and recycling of waste products, and the general public who may be exposed to contaminated products if they are not safely contained and protected. An international consultant was employed in June 2002 to work with stakeholders in the assessment of the situation, and the preparation of a health care waste management plan. The assessment and the draft plan cover all waste products from the Mozambican public health care system -- estimated at 2.2 tons per day -- and covers syringes, - 20 -  needles, empty bottles for injection liquid, plastic objects (gloves, blood pockets, urine pots, tubes), cotton, compresses, empty bags, and other human waste. The focus is on the public health care system, which provides all health care in rural areas, and the large majority of service in urban areas, except for the small proportion of high income families able to afford private clinics. Issues Issues involved include: (i) the lack of efficient selection of health care waste; (ii) the carelessness of the medical staff and their lack of training in management of health care waste; (iii) the staff dealing with health care waste, including nurse's helpers, lack any type of qualification; (iv) the mingling of health care waste with normal household litter; (v) there are insufficient quantities of pre collection baskets (for needles, cotton, etc); (vi) there are insufficient containers for provisional litter stocks; (vii) their is a lack of security equipment for staff responsible for cleaning of the hospitals, and for the collectors of waste; (viii) there is no efficient treatment system in general use -- 90- of the hospitals dispose of their wastes inside the hospital, 7t transport their wastes to a municipal landfill and 15t use incineration. Stakeholders Stakeholders include: Regulatory Agents: Ministry of Public Health and Ministry of Environment, responsible for environmental and healthcare policy -- they generally have at their disposal competent human resources, and master the management techniques, but their scope of action is a bit limited because of lack of material and financial means to carry out their mission; Health care facilities : are the principal HCW generators, but the healing staff has little concern for the daily management of the HCW, which is considered a second priority besides the huge medical emergencies; Litter gatherers: Municipalities are responsible for the gathering of household litter, but their landfills often receives health care waste. Their help in the handling and cleaning is somewhat weak. The private sector intervenes in the gathering of litter from some institutions, and even some healthcare facilities; but is not yet motivated enough to get involved in the management of health care waste; NGOs: Many of whom intervene in the environmental and health field. They constitute an opportunity to be seized by the project for partnership; Community Organizations: have the advantage of residing in the locality, and enjoy the trust of local populations. Many of them are active in the environment and sanitary field; The scavengers: the level of poverty (70- of the population overpassed the margin of monetary poverty) and the lack of economic alternatives push the populations towards survival strategies, mainly in urban zones. In this framework, informal scavenging or recycling activities at the level of littering disposals, are opportunities for the poor to earn a living. With the health care waste, the sector of pre-collection is too lucrative, to justify much interest; The Donors : most of them intervene in the field of health. Even if all of them recognize the importance and the interest linked with HCW, and the necessity to lead actions in this way; very few of them have specific programs for health care waste. - 21 -  10. Contact Point: Task Manager James H. Coates The World Bank 1818 H Street, NW Washington D.C. 20433 Telephone: 1 202 473 9095 Fax: 1 202 477 0515 11. For information on other project related documents contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 Web: http:// www.worldbank.org/infoshop Note: This is information on an evolving project. Certain components may not be necessarily included in the final project. This PID was processed by the InfoShop during the week ending March 28, 2002. - 22 -