Document of The World Bank FOR OFFICIAL USE ONLY Report No: 73700-MZ PROJECT PAPER ON A PROPOSED ADDITIONAL CREDIT IN THE AMOUNT OF SDR 24.2 MILLION (US$37 MILLION EQUIVALENT) TO THE REPUBLIC OF MOZAMBIQUE FOR A HEALTH SERVICE DELIVERY PROJECT December 7, 2012 Health, Nutrition, Population - East and Southern Africa Human Development Department Africa Region This document is being made publicly available prior to Board consideration. This does not imply a presumed outcome. This document may be updated following Board consideration and the updated document will be made publicly available in accordance with the Bank’s Policy on Access to Information. CURRENCY EQUIVALENTS (Exchange Rate Effective November 30, 2012) Currency Unit = Metical (Pl. Meticais) MZM 27.300 = US$1 USD1 = 0.65155 SDR FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AF Additional Financing ANC Ante-natal Care APEs Agentes Polivalentes Elementares (Community Health Workers) BCC Behavioral Change and Communication BFHI Baby Friendly Hospital Initiative BG Beneficiary Group CCS Comites Comunitarios de Saude (Community Health Committee) CIDA Canadian International Development Agency CIFF Children International Fund Foundation CMAM Central Medicine and Medical Supplies CPS Country Partnership Strategy DAF Directorate of Administration and Finance DANIDA Danish International Development Agency DNO District Nutrition Officer DNSP/DN National Department of Nutrition DP Development Partner DPO Development Policy Operation DPS Provincial Directorate of Health ECD Early Childhood Development e-SISTAFE Integrated Financial Management System EU European Union FMR Financial Monitoring Report GAIN Global Alliance for Improved Nutrition GDP Gross Domestic Product GOM Government of Mozambique HSDP Health Service Delivery Project HWMP Health Waste Management Plan IBRD International Bank for Rehabilitation and Development IDA International Development Association IEC Information, Education and Communication IFA Iron-folic Acid Tablet IFR Interim Financial Report INE Mozambique National Statistical Institute INS National Institute of Health IYCF Infant and Young Child Feeding IYCN Infant and Young Child Nutrition M&E Monitoring and Evaluation MICS Multi Indicator Cluster Survey MNP Micronutrient Powder MOH Ministry of Health MPD Ministry of Planning and Development MUAC Mid Upper Arm Circumference NGO Non-Governmental Organization NIM Nutrition Implementation Manual ORAF Operational Risk Assessment Framework ORS Oral Rehydration Salts PARPA Poverty Reduction Strategy in Mozambique PAMRDC Multisectoral Action Plan for the Reduction of Chronic Under Nutrition PDO Project Development Objective RUTF Ready to Use Therapeutic Food SDSMAS District Health, Women and Social Action Services SETSAN Food Security and Nutrition Coordination Secretariat SIL Specific Investment Lending SUN Scale Up Nutrition TTP Third Party Provider UGEA Executive Management Procurement Units UN United Nations UNICEF United National Children’s Fund USAID United States Agency for International Development VMP Vector Management Plan WFP World Food Program WHO World Health Organization Vice President: Makhtar Diop Country Director: Laurence Clarke Sector Director: Ritva Reinikka Sector Manager: Olusoji O. Adeyi Task Team Leader: Ziauddin Hyder REPUBLIC OF MOZAMBIQUE HEALTH SERVICE DELIVERY PROJECT CONTENTS ADDITIONAL FINANCING DATA SHEET ............................................................................................ i I. Introduction ............................................................................................................................................ 1 II. Background and Rationale for Additional Financing and Alternatives Considered .............................. 5 III. The Proposal ....................................................................................................................................... 10 IV. Appraisal Summary ............................................................................................................................ 25 ANNEX 1: Proposed Change to Results Framework ............................................................................... 30 ANNEX 2: Operational Risk Assessment Framework (ORAF)............................................................... 37 ANNEX 3: Revised Estimate of Costs ..................................................................................................... 43 ANNEX 4: Detailed Description of the Revised Components and New Activities ................................. 45 ANNEX 5: Revised Implementation Arrangements and Support ............................................................ 63 REPUBLIC OF MOZAMBIQUE HEALTH SERVICE DELIVERY PROJECT ADDITIONAL FINANCING DATA SHEET Basic Information - Additional Financing (AF) Country Director: Laurence Sectors: Health, Nutrition, Population Clarke Themes: Nutrition and Food Security Sector Director: Ritva Reinikka (80%); Child Health (10%); Population Team Leader: Ziauddin Hyder and Reproductive Health (10%) Project ID: P125477 Environmental category: B Expected Effectiveness Date: Expected Closing Date: December 31, April 30, 2013 2016 Lending Instrument: Sector Investment Loan (SIL) Additional Financing Type: Scaling Up Basic Information - Original Project Project ID: P099930 Environmental category: B Project Name: Health Service Closing Date: February 28, 2014 Delivery Project (HSDP) Lending Instrument: Sector Investment Loan (SIL) AF Financing Data [ ] Loan [ X ] Credit [ ] Grant [ ] Guarantee [ ] Other: Proposed terms: The credit would be on standard IDA terms with a total maturity of 40 years including a grace period of 10 years AF Financing Plan (US$m) Source Total Amount (US $m) Total Project Cost: 37.0 Cofinancing: 0.0 Borrower: 0.0 Total Bank Financing: 37.0 IBRD 37.0 IDA 37.0 New Recommitted i Client Information Recipient: Republic of Mozambique Responsible Agency: Ministry of Health Contact Person: Dr. Alexandre J. Manguele, Minister of Health Av. Eduardo Mondlane Maputo, Mozambique Telephone No.: +258 21 311 164 Fax No.: +258 21 321 738 Email: alexandrejaime@tropical.co.mz AF Estimated Disbursements (Bank FY/US$m) FY FY13 FY14 FY15 FY16 FY17 Annual 8 16 8 5 0 Cumulative 8 24 32 37 37 ii Project Development Objective and Description The Health Service Delivery Project’s Original Development Objectives (PDO) are to: (a) reduce child mortality; (b) reduce maternal mortality; (c) reduce the burden of malaria; (d) reduce the prevalence of tuberculosis; and (e) reduce inequity in the access of health services in Mozambique. This Project Paper (PP) proposes additional financing (AF) including restructuring of the Original Project as follows: (a) Change the PDO to better reflect the Original Project and newly added nutrition activities; (b) Revise all Original Project components; (c) Revise Project indicators as follows: increase PDO indicators from 3 to 5 and intermediary indicators from 7 to 11 to reflect the AF; and (d) Reallocate Original Credit proceeds and AF proceeds across the Project components in order to better reflect their contribution to the PDO. The revised PDO will read as follows: • To increase access to, and utilization of, maternal and child health and nutrition services in target areas in the Recipient’s territory. Project description: The revised Project components will be: • Component I: Improvement in service delivery • Component II: Boosting of national malaria control program • Component III: Strategic planning and capacity building • Component IV: Project management and operating costs The proposed AF will finance high impact nutrition interventions, including on-going activities to increase the impact and development effectiveness of the Original Project. iii Safeguard and Exception to Policies Safeguard policies triggered: Environmental Assessment (OP/BP 4.01) [X]Yes [ ] No Natural Habitats (OP/BP 4.04) [ ]Yes [X] No Forests (OP/BP 4.36) [ ]Yes [X] No Pest Management (OP 4.09) [X]Yes [ ] No Physical Cultural Resources (OP/BP 4.11) [ ]Yes [ X ] No Indigenous Peoples (OP/BP 4.10) [ ]Yes [ X ] No Involuntary Resettlement (OP/BP 4.12) [ ]Yes [ X ] No Safety of Dams (OP/BP 4.37) [ ]Yes [ X ] No Projects on International Waterways (OP/BP 7.50) [ ]Yes [ X ] No Projects in Disputed Areas (OP/BP 7.60) [ ]Yes [X ] No Does the project require any waivers of Bank policies? [ ]Yes [ X] No Have these been endorsed or approved by Bank management? [ ]Yes [ ] No Conditions and Legal Covenants: Financing Agreement Reference Description of Date Due Condition/Covenant Article IV – Section 4.01 Nutrition Implementation Effectiveness Manual (NIM) Schedule 2 – Section V A. Except as the Association may 6 months after otherwise agree, the Recipient Effective Date shall ensure that the Independent Verification Agent (IVA) for the Project be hired by no later than six months after Effective Date on the basis of terms of reference satisfactory to IDA. B. The GOM shall submit to IDA evidence satisfactory to IDA 6 months after that the Micronutrient Powder Effective Date (MNP) has been duly registered in accordance with the laws of Mozambique and published in the Official Gazette. iv I. Introduction 1. This Project Paper seeks the approval of the Executive Directors to provide an Additional Credit in the amount of SDR 24.2 (US$37 million equivalent) to the Republic of Mozambique for the Health Service Delivery Project (HSDP) (P099930). It will also include a restructuring of the HSDP to better reflect its objectives. This additional financing (AF) will be used to scale up priority nutrition activities in the 3 Northern provinces, namely, Cabo Delgado, Nampula, and Niassa under this project. These activities are important elements that will enhance the impact and development effectiveness of the HSDP, and cannot be financed from the Original Credit. The proposed closing date for the AF is December 31, 2016. This will provide adequate time for implementation of new activities and is within the 3 years maximum allowed timeframe from the closing date of the Original Project (February 28, 2014) as provided under OP/BP 13.20 (Additional Financing for Investment Lending). a. Context 2. The proposed restructuring and AF for nutrition are consistent with the Mozambique Country Partnership Strategy (FY2012-2015) and the Government’s poverty reduction plan and development agenda. The Bank’s Country Partnership Strategy (CPS) has as one of its 3 pillars “vulnerability and resilience”, which along with the Government’s “Plano de Acção para a Redução da Pobreza Absoluta” (PARPA II), recognize the importance of addressing the under- served health and nutrition needs of women and children, especially in promoting equal access to care, and expanding outreach to these groups. Furthermore, the Government has embarked on a decentralization process, which is supported by the CPS, and will mean that responsibilities for the management of service provision will be closer to the targeted beneficiaries, and warrants the need for significant capacity enhancement. 3. Although many of Mozambique’s economic and health indicators have improved in recent years, the country remains one of the poorest, posing significant threats to human development outcomes. Over the past 2 decades, Mozambique has emerged from a devastating civil war and a series of natural disasters, demonstrating remarkable economic growth, with per capita GDP projected to have reached 7.2 percent in 2011. Over the same time, there has been a decline in the poverty headcount index of 15 percentage points. Subsequent growth has not been at the same pace, but nonetheless, has been impressive. Several factors have contributed to this economic progress, notably post-war reconstruction projects, enhanced macroeconomic stability, policy reforms, agricultural growth, and support from Development Partners (DP). Despite this advancement, Mozambique continues to be one of the poorest countries in the world (4th from the bottom), ranking 184th out of 187 countries on the 2011 Human Development Index 1. It also has the 5th lowest ratio of health workers to population. 1 Human Development Report 2011. Sustainability and Equity: A Better Future for All (UNDP, 2011). 1 4. Chronic under nutrition remains a serious public health problem, accounting for at least one-third of under-5 child deaths 2. In Mozambique, approximately 44 percent of children under-5 suffers from chronic under nutrition 3, a rate that has remained virtually unchanged since 2003 and is considered “very high” by the World Health Organization (WHO) standards. The provinces of Cabo Delgado and Nampula have the highest rate (>50 percent), followed by other northern provinces, including Niassa (45 percent). Similar concerns exist with respect to poor maternal health and nutrition indicators. Fifteen percent of newborns have low birth weights, an important indicator of maternal and newborn health and nutrition. Vitamin A deficiency affects 69 percent of children 6-59 months of age and 14 percent of pregnant women. Furthermore, anemia affects nearly 75 percent of children 6-24 months of age and over half of pregnant women. 5. Even in the richest quintile, 25 percent of Mozambican children are stunted. These data suggest that high prevalence of under nutrition in Mozambique is not simply a result of a lack of food per se, but due to a combination of suboptimal infant and young child feeding and caring practices, deficiencies of essential vitamins and minerals, and inadequate prevention and management of illnesses that are driving factors behind the persistent high stunting rates. One- third of all newborns do not receive breast milk within the first one hour of birth, only 37 percent of infants under the 6 months of age are exclusively breastfed, and only 16 percent of infants between 6 and 9 months of age are appropriately fed with breast milk and nutrient-dense complementary foods. As a result, stunting rates are very high, posing unacceptably high costs to individuals, households and the economy. The most critical window of opportunity to intervene for the prevention of stunting, including vitamin and mineral deficiencies, is -9 months to +24 months of age, the first 1000 days of a child’s life. 6. Severe acute malnutrition 4, also known as wasting, remains a public health concern in Mozambique as it affects 4 percent of the under-5 children, increasing their risk of mortality. In 2011, the MOH identified approximately 21,000 under-5 children with severe acute malnutrition, of which about one third needed in-patient care while the rest were treated as out-patients with Ready-to-Use Therapeutic Foods (RUTF). 7. The Government of Mozambique (GOM) recognizes the urgency of the nutrition situation. A 5-year (2011-2015), “Multisectoral Action Plan for the Reduction of Chronic Malnutrition” (PAMRDC), was developed in collaboration with UN agencies, bilateral DPs, and key Non-Governmental Organizations (NGOs), and includes a Declaration of Commitment signed by 12 Ministers, including health, agriculture, education and planning and development ministers. The PAMRDC was launched in July 2010 and incorporates the priority interventions 2 Pelletier, Frongillo, and Habicht (1994); Caulfield and others (2004); Bryce and others (2005). 3 Chronic undernutrition (or stunting): Failure to reach linear growth potential because of inadequate nutrition or poor health. Chronic undernutrition implies long-term undernutrition and poor health and is measured as height for age that is two z-scores below the international reference. This measure is usually a good indicator of long-term undernutrition among young children. For children under 12 months, recumbent length is used instead of height. 4 Acute malnutrition (or wasting): Weight (in kilograms) divided by height (in meters squared) that is two z-scores below the international reference. Acute malnutrition describes a recent or current severe process leading to significant weight loss. 2 recommended by the Lancet Nutrition Series, Scaling Up Nutrition: A Framework for Action 5, and the World Bank’s Repositioning Nutrition as Central to Development 6. The general objective of the PAMRDC is to accelerate the reduction of chronic under nutrition among under- 5 children from 44 percent in 2008 to 30 percent in 2015 and 20 percent in 2020. In addition, it targets adolescent girls 11-19 years of age since early pregnancy is common in Mozambique, with consequent vulnerability for the mother and newborn. The strength of the PAMRDC is that it recognizes the multi-dimensional causes of under nutrition and the need to implement multiple interventions targeted to -9 to +24 months of age to effectively tackle the problem. 8. The Ministry of Health (MOH) has prioritized a set of evidence-based direct nutrition interventions targeted primarily at pregnant and lactating women, adolescent girls and children up to 24 months. Following the launch of the PAMRDC, the World Bank provided technical assistance to the MOH to further refine these interventions, and the inputs required to deliver them. While recognizing the potential role of other sectors (e.g., agriculture, education and social protection) to address multiple causes of chronic under nutrition, the health sector was tasked by the Government of Mozambique to take an initial lead in delivering this package of high impact evidence-based nutrition-specific interventions. Simultaneously, the MOH is also working with the other sectors to support the delivery of complementary “nutrition-sensitive” interventions through the education, agriculture, industry and social protection sectors. 9. Community involvement in provision of health and nutrition services is increasingly on the agenda of the MOH over the last years. To complement the PAMRDC, the Community Mobilization Strategy, developed by the government in 2010, also prioritizes nutrition as one of the services that can effectively be offered at community level through the Community Health Workers or Agentes Polivalentes Elementares (APEs), the Community Health Committee or Comites Comunitarios de Saude (CCS) and community volunteers. Furthermore, the Strategy envisions the establishment of partnerships with other sectors, institutions, NGOs and Civil Society to implement and sustain health promotion activities. It includes subcontracting NGOs in short and medium terms that will ensure quick start to urgent nutrition interventions in order to tackle high levels of stunting in the provinces. 10. APEs represent a “fourth” and formal element of the Mozambique health systems pyramid but they cannot be burdened further with concentrated nutrition social mobilization and education efforts. Experience with this cadre has shown that they are a valuable support element to the health system, principally in providing basic health support. An objective that has not been possible to achieve heretofore with the APE program was “the number of people reached through outreach teams and teams of APEs providing basic health services in the provinces of Cabo Delgado, Nampula, and Niassa” 7. Nor could they concentrate sufficiently on preventive health services, including nutrition wellbeing and health promotion, given other priorities. While an expansion of the APE program is envisioned, what cannot be increased is 5 Scaling Up Nutrition: What Will It Cost? The International Bank for Reconstruction and Development/The World Bank, 1818 H Street, NW, Washington, DC 20433 USA, 2006. 6 Repositioning Nutrition as Central to Development A Strategy for Large-Scale Action. The International Bank for Reconstruction and Development/The World Bank, 1818 H Street, NW, Washington, DC 20433 USA, 2006. 7 APEs Program Self-Evaluation FY08-FY11. 3 adding concentrated social mobilization and education efforts for nutrition. By engaging NGOs at community level, and having them coordinated with the APEs, many more households will be reached, without creating a new public sector workforce. 11. Third Party services Providers (TPPs), such as NGOs, have been a strong and active presence in Mozambique for many years. Before and since independence, non-governmental and faith-based organizations have been engaged in providing support to communities in their human and social development improvement efforts. NGO networks have been tested and are experienced in working in most Provinces and many Districts in the country, in health, agriculture, nutrition, education and social protection. Their role and contribution are well accepted by the GOM and its citizens. They work closely with both central and provincial health authorities and are seen as integral contributors to improving human development indicators, specifically health and nutrition, in the country. 12. NGOs in Mozambique have also long standing experience in implementing maternal and child health activities using a volunteer-based Beneficiary Group (BG) methodology, and they are playing a significant role in supporting the implementation of the Community Mobilization Strategy by establishing CCS, facilitating the identification of APE, and supporting training, supervision and provisions of supplies. The BG methodology uses an ”Activista” to equip a group of female Volunteers with health promotion messages, and each Volunteer further communicates these messages to an additional 10-15 mother-beneficiaries in surrounding households. The health promotion messages focus on issues, such as nutrition, water treatment, sanitation and hygiene; danger signs during pregnancy for which health care should be sought, disease prevention (e.g., Insecticide Treated Nets for malaria), immunizations and prenatal care, and the importance of giving birth at a health center. Evaluations of this model in Sofala Province in 2010 documented promising health and nutrition outcomes that were cost-effective 8. Similar community-based models have delivered impressive results in countries such as Bangladesh, Senegal, Madagascar, and Nepal. b. Multi-sectorality and Partnership Arrangements 13. The proposed AF will complement Bank-supported interventions in other sectors in Mozambique. Through the Education Sector Support Project, the AF is designed to scale up community-based early childhood development activities with interventions focusing on children between ages 3 and 5 years in poor rural areas. The synergies between improved nutrition 9 months before birth and 24 months thereafter, and the benefits in terms of physical and mental development, school readiness, and educational outcomes, are well documented. Studies have shown that, in countries such as Mozambique, the percentage of children completing primary schools dropped by 7.9 percent for every 10 percent increase in stunting. Furthermore, there is complementarity with the planned social protection project, which aims to increase social safety 8 1. Freeman P, Perry H, Gupta SK, Rassekh B. (November 2009). Accelerating progress in achieving the millennium development goal for children through community-based approaches. Global Public Health. 2. Edward A, Ernst P, Taylor C, Becker S, Mazive E, Perry H. (February 2007). Examining the evidence of under- five mortality reduction in a community-based program in Gaza, Mozambique. Transactions of the Royal Society of Tropical Medicine and Hygiene. 4 net services to those vulnerable populations, most likely to have higher rates of stunting, from 80,000 in 2011 to 815,000 in 2015. Such complementary investments are keys to ensuring that multiple causes of under nutrition (both underlying and immediate) are adequately addressed to achieve and sustain results. Likewise, additional nutrition support would contribute to increased development effectiveness of the proposed Mozambique Development Policy Operation (DPO) for Agricultural Growth and Productivity Enhancement project by improving the health and nutritional status of women who form close to half of the agricultural labor force. 14. The proposed AF will enhance collaboration with other DPs. The Bank will coordinate actions with other DPs active in health and nutrition, including CIDA, DANIDA, USAID, EU, UNICEF, WFP, WHO, Irish Aid, and others. These partners are keen to support the Government’s PAMRDC with technical assistance, program financing, or analytical studies and surveys. The nutrition community coordinates closely with the Department of Nutrition in the National Directorate of Public Health (DNSP/DN), who in collaboration with SETSAN (Food Security and Nutrition Coordination Secretariat) 9 led the PAMRDC’s development and is currently leading a nutrition working group, to ensure consistency and complementarity of the health sector nutrition activities with national objectives. Mozambique has recently joined the global Scaling Up Nutrition (SUN) movement. The Bank’s strengthened engagement in nutrition will complement the efforts of SUN DPs, provide financial resources, and will convene wider support to include nutrition as an important element in the national development agenda. It will complement DANIDA’s recently approved US$30 million allocation for nutrition under their Health, Nutrition and HIV/AIDS Sector Programme Support Phase V (2012-2017) and USAID’s Feed the Future (FTF) initiative, which provides US$50 million over a 5-year period (2012- 2017) for a number of nutrition and related activities. Other DPs, including UNICEF are supporting nationwide Behavioural Change and Communication (BCC) campaigns, training of APEs, and the national food fortification initiative and related activities. The AF will also support capacity development for MOH, thereby contributing to enhanced coordination and more sustainable results in the longer term. II. Background and Rationale for Additional Financing and Alternatives Considered a. Original Project Background 15. The Original Project was approved by the Board of Directors on April 16, 2009 and became effective on June 11, 2010, with a closing date of February 28, 2014. It includes an IDA credit of US$44.6 million and co-financing from 3 DPs – CIDA, US$15.6 million; Russia, US$7.9 million and Swiss Development Cooperation, US$4.3 million. The original Project Development Objectives (PDOs) are to: (a) reduce child mortality; (b) reduce maternal mortality; (c) reduce the burden of malaria; (d) reduce the prevalence of tuberculosis; and (e) reduce inequity in the access of health services in Mozambique. The Original Project is being 9 SETSAN is the GOM multisectoral coordinating body for nutrition and food security. It is a semi-autonomous organ of the Ministry of Agriculture and mandated to organize at national and at provincial level, annual meetings of all government and non-government institutions and donors, with the objective to identify best practices, share programmatic information, define main nutrition and food security interventions, and constraints that must be addressed. 5 implemented by the Ministry of Health in 3 northern provinces, namely Cabo Delgado, Nampula, and Niassa. It is supporting the Government’s strategy in the context of the Health Sector Strategic Plan II (PESS II) and was designed to address major health system needs. The Original Project components were: (i) Improvement in service delivery (US$42.6); (ii) Boosting of national malaria control program (US$13.5); (iii) Preparation of national health sector investment plan (US$0.5); and (iv) Capacity building and Operating Costs (US$15.8). 16. Progress on the Original Project was initially slow, but has picked up pace in the last few months. A Project launch workshop was held in December 2010. Effectiveness was delayed due to the time taken by the Government to recruit essential staff and finalize the Project implementation manual. The first disbursements were made in September 2011, more than a year after project effectiveness. The main reason for the delay was the lack of familiarity of the MOH in World Bank procedures, particularly in disbursement. Slow progress has also been due to: (i) lack of funds at the provincial level; (ii) inadequate staffing at central and provincial levels, including the lack of procurement and financial management specialists with experience in Bank procedures; (iii) slow administrative action from central level to manage project accounts through the Government’s on-line system (e-SISTAFE); and (iv) limited implementation progress on components III and IV. Project execution has improved subsequently and about 25 percent of the Credit has been disbursed, mostly as an advance to the Designated Account. 17. Performance of the Original Project is improving. Steps taken subsequently have improved implementation, with the operation increasingly better managed by the National Directorate of Public Health. The coordination has been moved to the Directorate of Planning with better interface with the Directorate of Administration and Finances (DAF) and Central Medicine and Medical Supplies (CMAM). Experienced financial management and procurement experts have been hired, both at central and provincial levels (Cabo Delgado, Nampula and Niassa) to enhance the coordination unit’s capacity. Although the Original Project was rated Moderately Satisfactory for more than 12 months (through June 2012) on implementation progress, fiduciary aspects, and expected development impact, it was downgraded to Moderately Unsatisfactory for a 4-month period between June-October 2012. Subsequently, in October 2012, the Original Project was upgraded to Moderately Satisfactory upon satisfaction of 4 benchmarks 10 agreed during the Mid-tern Review (MTR). The Government is committed to increase disbursement to over 50 percent by February 2013. With the extensive dialogue, experience, and GOM investment, the HSDP is and will be an integral part of the broader MOH outcome effort, where the restructuring and the addition of the proposed AF are expected to enhance its operational and substantive performance. 18. An in-depth MTR of the Original Project was conducted in June 2012, and an agreement was reached to restructure it by revising the PDO, results framework and components I, III and IV. The original PDO suggests that the Project will reduce mortality rates, 10 (i) Appointment of key staff to strengthen the project implementation unit, namely a procurement specialist, a financial management specialist at central level and a project manager in each province; (ii) Completion of the environment and social assessment for the construction of health centers; (iii) Agreement and confirmation by Government on the new Results Framework; (iv) Collection of data on the new indicators agreed upon including the baseline data, progress to date, and target at completion. 6 which is unlikely, given the length of the Project (5 years) and the scope of activities supported (only health). A new, more realistic PDO in line with the HSDP’s activities is proposed. Upon the restructuring, including reallocation of funds, and addition of the AF, the HSDP will include the following 4 components: (i) Improvement in Service Delivery (US$80.0 million); (ii) Boosting of National Malaria Control Program (US$15.5 million); (iii) Strategic Planning and Capacity Building (US$7.4 million); and (iv) Project Management and Operating Costs (US$6.5 million). The operating costs which until now are limited to 1 component of the project will apply to all project components and will have retroactive effects, i.e. will cover operating expenses made after October 16, 2011. The results framework will be updated to reflect the change in the PDO and to improve relevance to the activities financed by the Original Project and the AF. The HSDP will be extended to December 31, 2016. b. Rationale for Additional Bank Funding 19. The AF will be used to scale up existing nutrition interventions and add new ones, primarily targeted to pregnant and lactating women, adolescent girls and infants and young children. The primary target group remains the same as for the Original Project, thereby increasing the HSDP’s impact and development effectiveness. Currently, the Original Project’s efforts to improve nutrition are limited and are primarily supply driven, resulting in poor coverage of the target beneficiaries. The AF will support the scaling up of additional high impact nutrition interventions and will introduce a more intense community-based service delivery model, which in turn, will generate sustained demand for basic health and nutrition services, contributing to the higher and impact. 20. Furthermore, the AF will mainstream nutrition in Mozambique’s health sector. The HSDP is one of the major health sector projects, and scaling up of nutrition through this existing platform will not only be cost-effective, but will also be increasing the MOH’s ownership and its capacity in nutrition, all of which are necessary elements to position nutrition as one of the key activities of the Ministry. Similar efforts will be made to encourage other sectors to support relevant actions and investments, leading to a multisectoral solution to chronic under nutrition. 21. The GOM considers nutrition as a core responsibility, with investment in this sub- sector is urgently needed to save lives, prevent economic losses, and make progress towards development goals, including MDG 1. As described earlier, the nutrition situation in Mozambique is alarming. In addition to increasing the risk of mortality, under nutrition increases the susceptibility to, duration, and severity of various morbidities, including malaria, which put a heavy burden on the country’s already vulnerable health system. Anemia alone is associated with a 2.5 percent reduction in adult wages 11, and it is estimated that Mozambique may lose approximately US$116 million in GDP annually as a result of anemia alone. Thus, Mozambique’s current effort to scale up investment in nutrition is essential and timely. It supports the attainment of the CPS 2012-15, the first MDG of eradicating extreme poverty and hunger, reductions in child and maternal mortality as well as PARPA II’s human development pillar. Furthermore, this proposed investment is aligned with the Africa Region’s Strategy of 11 Strauss and Thomas (1998); Horton and Ross (2003). 7 reducing vulnerability and building resilience, thereby fostering economic growth and poverty reduction in Mozambique. 22. Although there is strong political commitment and leadership from the MOH and its nutrition agenda partners, serious financing gaps persist. The MOH and its DPs recognize the importance and urgency in addressing the causes of under nutrition, as evident in their active participation in formulating and supporting the PAMRDC. A Bank-supported analysis entitled The Cost of Delivering Priority Nutrition Interventions through the Health Sector in Mozambique estimated that approximately US$60 million would be required annually to implement a set of prioritized high impact nutrition interventions proposed by the PAMRDC. However, to date, only US$20 million per annum is potentially available from all DPs. Further, there is currently no allocation in the national budget for nutrition. The availability of the AF, which is still insufficient to cover the country’s needs, is expected to provide a large-scale demonstration effect, thereby making a compelling case for GOM’s domestic investments in nutrition. 23. The Government’s strategy to bolster community-based structures to deliver basic health services creates an exceptional opportunity to concurrently integrate, complement and scale up nutrition activities. The Original Project is already being implemented in the 3 Northern provinces. This represents an efficient and practical entry point for integrating, complementing and scaling up of Community-based Nutrition (CBN) Service Package. The APEs network is currently being scaled up, which represent a “fourth” and formal element of the Mozambique health systems pyramid – a plan that remains to be fully realized in Cabo Delgado, Nampula, and Niassa 12. While continued support for the APEs program will be intensified under the restructured HSDP 13, the AF will complement this with more intensive social mobilization with support from the CCS, its affiliated Volunteers and other existing structures in the community, as well as the Activistas (hired by the TPPs). TPP-facilitated CBN services under the Community Mobilization Strategy will strengthen the demand-side, while APEs will focus on the supply side, thereby enhancing complementarity between the two inputs. 24. Maximum coverage of high impact nutrition interventions is a key to prevent chronic under nutrition. Preventative interventions have been proven to be the most effective method for the reduction of chronic under nutrition, especially when high coverage has been achieved with at least 80 percent of the target population. The current health system status in Mozambique poses a barrier to reaching this coverage level as only 36 percent of the population having access to a healthcare within 30 minute walk from their homes. Furthermore, the Northern provinces pose the additional constrains with regards to the access and geographical coverage. 25. The proposed AF will complement broader community health efforts and contribute to increased access and utilization of basic health care services through a community-based approach. It will also complement the PMARDC, which recognizes that high coverage can be achieved by extending services to the community level. Bank resources will be targeted to Cabo 12 APEs Program Self-Evaluation FY08-FY11 13 For example, salary of all APEs in Cabo Delgado, Nampula and Niassa will financed through the restructured HSDP. 8 Delgado, Niassa and Nampula and will contribute to increased utilization of basic health services primarily by the poorest and most vulnerable population. This focused attention to nutrition improvement will, over time, reduce morbidity, thus reducing pressure on the health system. Ongoing efforts to mobilize communities and villages will be strengthened and streamlined. Communities and villages will be better informed and their capacity will be enhanced through a “triple-A approach” of assessment, analysis and action. This intensified nutrition approach will complement the broader community health efforts undertaken by APEs and health centers, improving the community’s engagement in health awareness, including prevention, detection and response. 26. Recognizing the adverse impact of chronic under nutrition on the country’s growth and economic productivity, the GOM has formally asked the Bank for technical and financial assistance to implement PAMRDC. The Ministry of Planning and Development (MPD) has made a specific request to support high impact nutrition interventions to reduce stunting and implement them through the health sector. 27. The proposed AF is completely aligned with the revised PDO and consistent with the parameters of OP/BP 13.20 as it will finance ongoing and additional nutrition activities to scale up the HSDP’s impact and development effectiveness. During the design phase of the Original Project, the MOH recognized the need to include nutrition as a cost-effective approach to prevent diseases and improve health, particularly of pregnant women and young children. Subsequently, the Government launched the PAMRDC which calls for a wider scaling up of nutrition interventions, primarily preventive. This requires additional technical assistance and funds. c. Alternatives Considered 28. Four alternatives were considered, for the Bank (a) not engage in nutrition support, (b) develop a separate nutrition project, (c) develop a multisectoral project, or (d) provide incremental financing. Given the situation described above, the Bank intervention is fully warranted and so alternative (a) was not appropriate. Either a stand-alone project (alternative b or c), or an incremental financing (alternative d), would be appropriate. Incremental financing has the advantage that scaling up and integrating nutrition interventions explicitly with the health sector will improve health outcomes in the targeted provinces, avoid Bank portfolio fragmentation, and allow the use of existing HSDP implementation and fiduciary arrangements. Indeed, by giving greater visibility and resources to health sector efforts in nutrition, there is greater likelihood that nutrition will have its proper place in health sector decision making and service provision, and help engage other sectors. A new project, whether a separate new health project, one with another government entity, or a multisectoral project, might allow for somewhat broader scope. However, other sectors, such as agriculture, social protection or education, are not well-equipped to take on maternal and child nutrition, which have closer links to the health sector. Given this capacity gap, pursuing a multisectoral approach would be complex at this stage with big implementation challenges for which the government is not currently prepared. The proposed AF is first phase operations that will help prepare the grounds for a broader multi-sectoral approach in the future, building on the health sector’s experience. Given that the health sector is the one that is now equipped and prepared to take on this task, and 9 given that many of the most cost-effective interventions lie in the health domain, the option of providing additional financing to the MOH is appropriate to undertake this effort. The proposed AF will support health sector delivered evidence-based nutrition interventions and will aim to build the capacity of MOH to engage with other sectors (e.g. agriculture, social protection, education), leading to a multisectoral approach in the longer term. III. The Proposal 29. The PP proposes an AF, including the restructuring of the Original Project, as follows: (a) Change the PDO to better reflect the Original Project and newly added nutrition activities; (b) Revise all Original Project components; (c) Revise Project indicators as follows: increase PDO indicators from 3 to 5 and intermediary indicators from 7 to 11 to reflect the AF; and (d) Reallocate Original Credit proceeds and AF proceeds across the Project components in order to better reflect their contribution to the PDO. 30. A new Operational Risk Assessment Framework has been added which includes risks specific to the AF (See Annex 2, Operational Risk Assessment Framework) (ORAF). 31. The proposed revised PDO is to increase access to, and utilization of, maternal and child health and nutrition services in target areas in the Recipient’s territory. Additional Financing 32. Component I of the Original Project currently finances a limited number of nutrition activities. The DNSP/DN within MOH is coordinating these activities and providing technical assistance to implement them. The Government has requested additional financing to the Original Project, which will be used to add new nutrition activities in Cabo Delgado, Nampula, and Niassa where the Original Project is being implemented. Detailed design and implementation strategy for this AF were developed in close consultation with the DNSP/DN, Food Security and Nutrition Coordination Secretariat (SETSAN), DPs and NGOs. The MOH agrees with the principles of the design and its implementation at community level. 33. The amended Project components will be as follows: 34. Component I: Improvement in Service Delivery. This will include an additional subcomponent for scaling up nutrition activities (Total US$80.0 million, including US$27 million for nutrition equivalent). The following activities will be financed through this component. 10 1.a. Strengthen management and planning capacities of MOH, including training institutions and health facilities, to improve the quality of health and nutrition services’ provision and enhance acute malnutrition and malaria control activities in the provinces of Cabo Delgado, Nampula and Niassa, including through: (a) Enhancement of capacity of central, provincial and district health staff, including Community Health Workers to deliver health promotion, prevention, and basic health interventions for women of child bearing age, adolescent girls, and children under five years of age in their communities through the carrying out of training; (b) Advisory in the areas of planning, management and monitoring and evaluation for the implementation of the National Human Resources for Health Development Plan; (c) Carrying out of outreach and community-oriented activities, including vaccinations, provision of oral rehydration salts, health education, antenatal care, and basic clinical care; (d) Implementation of the Health Waste Management Plan (HWMP) and Vector Management Plan (VMP); (e) Construction and rehabilitation of health facilities and related staff housing; and (f) Provision of transportation, including vehicles, motorcycles and bicycles for the purpose of paragraph (c) above. 1.b. Implementation of CBN activities targeted to pregnant and lactating women, adolescent girls and children up to 24 months of age, including through: (a) Delivery of a CBN Service Package including the carrying out of: (i) Growth monitoring and promotion activities, including treatment of acute malnutrition; (ii) Promotion of activities of exclusive breastfeeding and appropriate complementary feeding, including the use of micronutrient powder (MNP) and deworming; (iii) Mobilization of pregnant women for ante-natal care services, including provision of iron folic acid (IFA) tablets, and deworming for lactating women; (iv) Provision of IFA tablets and, deworming for adolescent girls; 11 (v) Provision of dispersible zinc tablets and Oral Rehydration Salt (ORS) to treat children with diarrhea; and (vi) Education on safe water, hygiene, sanitation and referral services for infectious disease control, including immunization; (b) Carrying out of advocacy and mass campaign activities to support MOH’s other nutrition initiatives and programs; (c) Provision of nutrition commodities and equipment for prevention and treatment of malnutrition; and (d) Provision of transportation, including vehicles, motor cycles and bicycles for purpose of carrying out the activities under paragraphs (a) and (b) above. 35. Component II: Boosting of National Malaria Control Program (Total US$15.5 million equivalent). This component will strengthen the Recipient’s public health malaria control management program (including vector control) and malaria treatment policy shift from artesunate-sulfadoxine-pyrimethamine to artesunate-lumefantrine while, at the same time, supporting the Recipient’s supply chain, including through the following activities: (a) Design and implementation of a national training program on malaria monitoring and evaluation; (b) Enhance capacity of MOH staff in the implementation of public health operations in the provinces of Cabo Delgado, Nampula and Niassa; (c) Provision of essential drugs, long lasting insecticide treated nets, rapid-diagnostic test kits, equipment and vehicles for malaria control; (d) Rehabilitation of storage facilities throughout the territory of the Recipient; (e) Design of a geographic information system, including hardware and software to capture, store, analyze and display data regarding malaria incidence and prevalence for purposes of calculating the amount of Recipient’s population at risk; (f) Setting up of sentinel sites within health centers and selected hospitals in the provinces of Cabo Delgado, Nampula, and Niassa for surveillance of malaria cases; and (g) Design and dissemination of behavior change communication materials. 36. Component III: Strategic Planning and Capacity Building (Total US$7.4 million, including US$5.0 million for nutrition equivalent). This component will support the MOH to 12 allow it to undertake policy analysis, strengthen its supply chain and improve its capacity for Project management and monitoring activities, including through: (a) Design and implementation of a health sector strategic plan; (b) Enhancement of the capacity of MOH staff and nutrition technicians to design, implement, monitor and evaluate health and nutrition activities; (c) Support for central and provincial level staff for pursuing graduate level nutrition degrees; (d) Operational research studies in nutrition to test innovative community-based nutrition interventions and/or delivery mechanisms; (e) Testing the use of information and communication technologies to strengthen the health and nutrition routine monitoring system; and (f) Support for national and provincial level meetings and workshops to strengthen nutrition coordination mechanism. 37. Component IV: Project Management and Operating Costs (Total US$6.5 million, including US$5.0 million for nutrition equivalent). This component will support the following activities: (a) Support the management capacity of DNSP/DN and DPS to implement Component I.b of the Project in the provinces of Cabo Delgado, Nampula and Niassa; (b) Carrying out of nutrition monitoring and evaluation activities, including baseline, mid-line and end-line surveys and routine CBN monitoring in the provinces of Cabo Delgado, Nampula and Niassa; (c) Establishment of a decentralized regional unit at provincial level to support data processing, filing of key strategic documents, and relevant health research studies; and (d) Provision of Operating Costs for the Project. Further details on each of these components are listed in Annex 4. 38. The CBN Service Package will build on high impact health promotion and nutrition interventions aiming to reduce chronic under nutrition which are already being implemented, 13 in various forms, by NGOs. These interventions are primarily preventive and targeted to women and children. It includes those run by AFRICARE 14 and Save the Children Fund (SCF) 15, each of which was evaluated in mid-2000 and found successful (in addressing chronic under nutrition rates). Lessons have also been learned from other large NGOs active in nutrition and food security, including World Vision, Aga Khan Foundation, Food for the Hungry, FHI360, and Concern. The AF financed CBN Service Package will build on these experienced service providers, coupled with public health sector Provincial and District platforms. The CBN Service Package will also contribute to the Recipient’s strategy on community involvement by strengthening capacity of APEs, CCS and its affiliated Volunteers. 39. While similar efforts have been successfully undertaken in Mozambique by NGOs, the CBN approach has not been implemented on the scale envisioned. The activities will be phased, with outputs projected to significantly increase after the first year in which the CBN Service Package is operational, with flexibility to allocate or reallocate resources across provinces. Implementation arrangements for CBN under Component I.b.: 40. The new Component I.b will primarily support CBN Service Package in Cabo Delgado, Nampula and Niassa. It will also support selected nationwide nutrition campaigns and nutrition specific capacity development activities, including implementation, M&E training and knowledge generation. The intention is to generate widespread community engagement and ownership in improving nutritional well-being of at-risk groups, with greater social mobilization efforts and using a network of trained Volunteers, linked to the CCS. The specific activities will build on the Mozambique National Health Promotion Strategy16. 41. One experienced TPP per province (Provincial TPP) will be contracted as a service provider to facilitate the CBN Service Package implementation. Each such Provincial TPP will facilitate the monitoring and supervision of the CBN Service Package delivery in close collaboration with the District Health, Women and Social Action Services (SDSMAS) and DPS. The TPP engagement is a short-to-medium term strategy addressing the current Health Sector capacity gap and responding to the urgent needs of tackling chronic under nutrition. Given province population size and access challenges, each Provincial TPP may subcontract other TPP/CBOs with local capacity to implement community-based activities. Each Provincial TPP will be responsible for the quality of services, training of its staff and M&E of activities of all its subcontractors and will monitor service delivery regularly. 42. CBN will be built on community mobilization, facilitated by the Provincial TPP. The community mobilization would involve: identification of communities/villages; linking up with the APE; organization of the CCS; identification of Activistas and Volunteers based on agreed 14 John Pielemeier and Lourdes Fidalgo. MEFSI Final Evaluation Report. Maputo, November 2006. 15 Frank Sullivan & Kerry Selvester. Final Evaluation: Coastal Region-Integrated Food Security Program. Submitted to Save the Children/ Mozambique and USAID/ Mozambique. Maputo, September 1, 2006. 16 Ministry of Health. National Strategy for the Promotion of Health, 2010. 14 selection criteria 17 and acceptable to the community; organization of beneficiaries under BGs and building a rapport with them; understanding of the specific local context as relevant to the proposed CBN Service Package; agreement on a suitable location for monthly activities which will be the center of operations. Eventually, the center of operations is expected to become the community forum where women and men will meet regularly and build a community action program, not just for nutrition, but for a broader range of women and child welfare efforts. 43. TPP-facilitated CBN Service Package will include behavioral change and nutrition education, targeted distribution of nutrition commodities, and referral mechanisms for the treatment of acute malnutrition. The TPP will support the community mobilization, training, supervision and monitoring, but the actual nutrition services will be provided to the communities by the Volunteers, in close collaboration with the CCS and the APE. Lessons from this experience, as well as alternative community mobilisation approaches (including APEs, CCS and its affiliated Volunteers) will be applied to future projects. The modalities of CBN Service Package implementation through the existing community mobilisation approach and without the support of the TPP will be defined by each DPS in close collaboration with the DNSP/DN and according to the local capacity. 44. In addition, the AF will strengthen ANC services and enhance Type II health centres’ capacity to treat acute malnutrition, store nutrition commodities, and help APEs and Activistas to supervise the Volunteer. This role will be facilitated by in-service training in nutrition, provided to at least 2 staff in each Type II health centre. 45. CBN activities will be reinforced by various key actions at national level, which include critical Behavioural Change and Communication (BCC) activities to promote Infant and Young Child Feeding (IYCF), including the development and multiplication of IEC/BCC material, but also the promotion of nutrition within hospitals/health centres and the further expansion of the Baby Friendly Hospital Initiative (BFHI); enhancement of the appropriate utilization of key micronutrients, especially iodine, iron, vitamin A and zinc. Staple food products and condiments fortified with vitamins and minerals, including iron, zinc, folic acid and vitamin A will be promoted. MNP will be registered within 6 months after effectiveness date so that the product can be distributed to target children. Zinc will be administered by the Volunteers in conjunction with the use of Oral Rehydration Salts (ORS) therapy in cases of child diarrhea. 46. Under the revised Component III, the AF will finance capacity building, monitoring and evaluation, operational research and use of Information and Communication Technologies (ICTs) to strengthen monitoring and evaluation system. 47. Capacity building. The AF will provide critical capacity building support including training so that national, provincial, district and health center officials can better coordinate, manage (including fiduciary and information management), monitor and evaluate the implementation and effectiveness of the proposed nutrition activities. This would include pre- 17 Belongs to and residing in the same community; 2.Female; 3. 25-59 years old; 4. Has at least one child with good nutritional status; 5. Preferably is able to read and write; 6. Preferably already known in the community as a health care provider. These criteria will be finalized during the Appraisal. 15 and in-service training to the DNSP/DN, Province, District, and Type II Health Center level staff, including nurses and APEs to enhance capacity in nutrition project implementation, monitoring and evaluation. A work program will cover the training of MOH staff working at all levels in the 3 provinces. The training will be coordinated by the Directorate of Human Resources of the MOH. In addition, five health sector staff at central and/or provincial level will receive graduate level nutrition training from reputed academic institutions in Brazil or Europe. 48. Operational research will focus on knowledge generation and fostering innovation. The AF will support coordination, supportive supervision and strengthening nutrition information/surveillance and monitoring and evaluation, concentrating on the CBN Service Package in the 3 Provinces, as well as operational research to evaluate specific service delivery methods, management improvements, and quality assurance aspects. Quality control support for the operational research will be provided by the National Institute of Statistics (INE). 49. The MOH will also test the use of ICT in limited settings, mobile phones to collect data from the Activistas, and disseminate information and IEC messages to them. These new technologies and techniques will potentially enhance citizen engagement in health and nutrition and increase health system capacities to get timely nutrition information from communities delivered to the provincial and national authorities. 50. Under the revised Component IV, the AF will finance operating costs to implement activities under the Project. Beneficiaries 51. Based on the capacity of the MOH and the 3 DPS to lead the scaling up of nutrition efforts, this incremental financing is expected to reach about 28 Districts (Nampula: 12 Districts; Cabo Delgado: 8 Districts; and Niassa: 8 Districts) over the period 2013-2016, for a total of direct beneficiaries of over 317,000 under-2 years of age children, 206,000 pregnant and lactating women, 455,000 adolescent girls (See Annex 4 for more details). Geographic implementation expansion in each province will be phased, according to the capacity of both DPS and the selected TPP. 52. Other direct and/or indirect beneficiaries will include: (i) children aged 2-5 years, (ii) parents and extended families of participating children, in particular through the BG conversations, (iii) community leaders, indigenous health practitioners and other members of the CCS, (iv) health facilities in participating communities, (v) selected TPP (either national or international) to provide community nutrition services in participating provinces, (vi) SETSAN at national and provincial level, (vii) the national nutrition strategy through enhanced data collection and evaluation approaches, and (viii) DNSP/DN and Province Health Directorates through support for capacity building. Costs and Financing 53. A detailed cost estimate has been finalized. The total cost of the AF is estimated at US$37 million. It will be provided through 100 percent IDA financing in accordance with the 16 Country Financing Parameters for social sectors for Mozambique. Decisions with respect to the CBN Service Package, resource allocations between the MOH programs and those to be carried out by the selected Provincial TPPs will be reviewed after two years, based on agreed results, with possibilities for reallocation of funds across provinces depending on meeting targets and quality of service. The financing plan for the Original Project and for the AF is presented below. Additional details on costs are presented in Annex 3 (Revised Estimate of Costs). Financing Plan Original Component Original Revised Project Revised Proposed Total Amount Component Amount Additional (US$ (US$ Financing million) million) (US$ million) I. Improvement in I. Improvement in 42.6 53.0 - 80.0 service delivery Service Delivery I.b. Community- -- 27.0 based Nutrition II. Boosting of II. Boosting of national malaria national malaria 15.5 - 15.5 13.5 control program control program III. Preparation of III. Strategic national health sector Planning and 2.4 5.0 7.4 0.5 investment plan Capacity Building IV. Capacity building IV. Project and Operating Costs Management and 1.5 5.0 6.5 15.8 Operating Costs Total Costs 72.4 72.4 37.0 109.4 Closing Date 54. The HSDP will be extended and the new closing date for the Project will be December 31, 2016, to allow additional time for the implementation of Component I.b of the Project. Monitoring and Evaluation Arrangements 55. The PAMRDC provides the framework for nutrition activities in Mozambique. The focus of proposed activities under Component I.b is on PAMRDC’s strategic objectives 2 & 3. Its strategic objective 2 is to strengthen nutrition activities for children in the first two years of age with the following results: • Result 2.1- Exclusively breastfed children in the first six months of life; • Result 2.2-Receipt of adequate complementary feeding for all children from 6-24 months; and 17 • Result 2.3- Reduced micronutrient deficiencies and anemia in all children from 6 to 24 months of age. 56. The PAMRDC’s strategic objective 3 is to strengthen interventions with impact on health and nutrition of women of reproductive age before and during pregnancy and lactation with the following results: • Result 3.1- Reduced micronutrient deficiencies and anemia before and during pregnancy and lactation; and • Result 3.2- Increased weight gains during pregnancy. 57. The CBN Service Package-related indicators are consistent with the PAMRDC strategic objectives and outcomes relevant to the 3 Northern provinces, and data collection plans. The indicators were chosen because they are: (i) linked in a causal chain to the PDO; (ii) clearly defined; and (iii) easy to collect. The HSDP Indicators, including those added newly to reflect the CBN Service Package, are provided in the Table below. Summary Table of Revisions to the Results Framework Revisions to the Results Framework Comments/ Rationale for Change Current (PAD) Proposed PDO indicators Percentage of Percentage of institutional Revised. Disaggregated by institutional deliveries deliveries in: (a) Cabo each of the target Delegado; (b) Nampula; (c) provinces. Niassa Percentage of health Dropped Currently 100 percent of facilities offering first- facilities are offering first- line treatment for line treatment for malaria malaria New Percentage of children In the original PAD it was vaccinated DPTHepHib3 in the an intermediary indicator first year of life in: (a) Cabo Delgado; (b) Nampula; (c) Niassa Direct Project Continued Core HNP indicator. beneficiaries (number) of which female (percentage) New Percentage of pregnant women In the original PAD it was who received 2nd dose of IPT at an intermediary indicator. antenatal clinics This indicator is used as a proxy of health system performance. New Percentage of children aged 0- To capture Component I.b 18 Revisions to the Results Framework Comments/ Rationale for Change 24 months fed in accordance with all 3 IYCF practices (food diversity, feeding frequency, and consumption of breast milk or milk) Intermediate Results indicators Current (PAD) Proposed change* Number of outreach Outreach teams fully Revised. A definition of teams fully operational operational in Cabo Delgado, “fully operational” is now Nampula, and Niassa provided Number of community Number of Agentes Polivalente Revised. The indicator health workers trained Elementares (APEs) trained refers to a specific cadre (cumulative) (cumulative) of community health workers known as APEs Health Personnel Continued Core HNP indicator and receiving training no additional change (cumulative) proposed New Health facilities constructed, The construction and renovated, and/or equipped to rehabilitation have to standard specifications adhere to a defined (cumulative) standard. Preparation of Dropped Activity cancelled Investment Plan New Pregnant women receiving 1st Captures specific activity ANC visit 18 financed by the project. (a) Cabo Delgado, (b) Nampula (c) Niassa New Children receiving a dose of HNP core indicator. vitamin A 19 Captures specific activity (a) Cabo Delgado, financed by the project. (b) Nampula (c) Niassa. New number of children <1 year fully Captures specific activity immunized 20 financed by the project. 18 This indicator capture the total number of women receiving 1st ante-natal care in health units that have (a) workers that have received training funded by the World Bank or (b) been constructed or substantially renovated with World Bank funding. This is a measure of contribution, and it is not necessary to make a calculation to estimate a pro rata World Bank attribution, based on financial contribution to each health center. This figure is a pro-rata calculation based on the total number of women receiving a1st ante-natal care in the province, and the number of facilities in the province that have received support from the World Bank (i.e. if 75% of health units have received some support, then 75% of the total number of women who received 1st ante-natal care will be counted). Targets were calculated from Demographic Projection – 2011 assuming coverage of 95 percent. 19 Children aged 6-59 months 19 Revisions to the Results Framework Comments/ Rationale for Change (a) Cabo Delgado, (b) Nampula (c) Niassa. Percentage of children Dropped This indicator was revised 12-23 months and included as a PDO vaccinated with BCG; level indicator. DPT3; Polio and measles vaccines in the first year of life. Percentage of pregnant Dropped This indicator was revised women who received at and included as a PDO least 1 dose of IPT level indicator. Long-lasting Dropped Replaced by more relevant insecticide-treated indicator malaria nets purchased and or distributed (number) New Number of Volunteers To capture Component functional (cumulative) I.b New Percentage of children aged 0- To capture Component I.b 24 months who attended at least 1 Growth Monitoring and Promotion session during the preceding 4 months, percentage who are female New Percentage of children aged 6- To capture Component I.b 24 months received at least 60 sachets of micronutrient powder (MNP) during the preceding 4 months, percentage who are female New Percentage of pregnant women To capture Component I.b received a complete dose of IFA tablets 58. Details on the revised baseline and targets for the original indicators and on the additional indicators are presented in Annex 1 (Proposed Change to Results Framework). 59. Monitoring of the CBN Service Package implementation will be carried out based on predetermined indicators, measuring inputs and process as defined in the results framework (Annex 1). Overall responsibility of the CBN Service Package monitoring and evaluation will lie 20 Refers to annual number of children immunized with vaccines purchased with Bank funds, or delivered through programs supported with Bank funds. Children receiving multiple vaccinations are counted once. See note number 2 on data quality issues. 20 with the MOH at the district, province and central levels, following the already established HSDP procedure. Data for routine monitoring will be collected by the respective Provincial TPP through its Activistas in all participating communities. The DPS will be responsible for ensuring that routine monitoring data are properly collected from communities, aggregated at District levels, and progress reports for respective province is submitted to the DNSP/DN. The Provincial TPP will provide the DPS with yearly and quarterly progress reports related to activities undertaken. Ongoing monitoring and evaluation will be conducted through: (a) quarterly meetings at provincial level between the DNSP/DN, DPS Nutrition Focal Point and responsible Provincial TPP; (b) monthly progress reports and meetings at district level between the SDSMAS and the TPP operating in that province; (c) IDA supervision missions, including the mid-term review 21; (d) annual progress reviews; and (e) the midterm CBN implementation quality assessment, conducted by an independent third party. The CBN Service Package will also be continuously monitored by different segments in the community, including the BGs and CCS. A monitoring and evaluation chapter in the Nutrition Implementation Manual (NIM) will define further details. Adoption of the NIM by the MOH will be a condition of effectiveness. 60. Baseline and end-line surveys will be conducted at the provincial level on key process, output and outcome indicators, including IYCF practices, prevalence of under nutrition (stunting, underweight, wasting), micronutrient deficiencies (anemia, vitamin A deficiency), dietary intake, and coverage of selected nutrition commodities, including IFA, vitamin A capsule and deworming in women of reproductive age, adolescent girls and under-2 children in order to establish/validate baseline and target data for the CBN Service Package implementation. The baseline survey will be conducted in the first two quarters of 2013 and the end-line survey will be completed in last quarter of 2016. 61. In addition, in collaboration with the World Bank-supported ECD project (P124729), a randomized phased-in impact assessment has been designed and selected for funding by the Strategic Impact Evaluation Fund (SIEF). Prior to the beginning of the CBN Service Package implementation, a listing of all eligible communities in selected districts and provinces will be carried out. Among the 3 provinces which will receive the community-based integrated ECD interventions (Cabo Delgado, Nampula, and Tete), eligible communities within a given district will be randomly assigned to one of 4 groups, namely: 3 intervention groups (integrated ECD only; nutrition only; and integrated ECD + nutrition) and 1 control group (no intervention). The 3 intervention groups will receive support over time (implementation in years 1, 2, and 3) and 1 group (the control group) will not receive any interventions. III. Institutional Arrangements for Implementation 62. The main institutions and individuals involved in the implementation of Component I.b. of the Project are the DNSP/DN, DPS, including their public health and nutrition focal points and technical specialists, SDSMAS, Type II health centers, APEs, volunteers and e communities/villages. The institutional oversight of the Original Project combined with the AF is provided below. 21 The nutrition partners group will be invited to join and will be followed by regular meetings between the Partners, the World Bank and the MoH. 21 Oversight of HSDP after adding Component I.b Directorate of Planning and Cooperation Solid Line: Formal Authority Department of Projects Dotted line: Technical support/Coordination HSDP Coordination Unit Director of Public Health/ Department of Nutrition Provincial Health Provincial Health Provincial Health Director Niassa Director Nampula Director Cabo Delgado Malaria/HIV/TB/ Nutrition Chief Medical officer Operations Coordinator Executive Coordinator HSDP Assistant (in each province) Head of Provincial M&E Planning Assistant Department Biologist Head of Community malaria Focal Nutrition Health and Medical TPP Provincial Manager Point Focal Point Service Nutrition District Health Director TPP District Nutrition Focal Point and Field Supervisors Officer Nutrition Health Unit Directors Focal Point APE CCS Volunteers TPP Activista Beneficiary Households 22 63. At the national level, the HSDP Coordinator will coordinate all elements of the HSDP, including the AF activities. Financial management will be conducted by the Directorate of Administration and Management (DAF) of the MOH, who will also have the overall responsibility for the financial management of the AF at central, provincial and district level. 64. Technical oversight of Component I.b financed activities will be conducted by the DNSP/DN staff, in close collaboration with the HSDP Coordination Unit. The DNSP/DN will continue to work closely with the DPS in each of the provinces. Implementation arrangements have been designed to provide a balance between supervision at the Project level and reinforcing the management capacity of the provinces, districts, health centers, and community outreach implementers. 65. The DNSP/DN will be responsible for technical oversight, coordination, reporting, and will work with the HSDP Coordination Unit and DPS, in close collaboration with other units of the MOH and DPs. DNSP/DN will undertake technical management of Component I.b financed activities. Furthermore, the DNSP/DN will provide technical oversight during the procurement process of nutrition commodities and their distribution through the MOH system to provinces and then onward to Type II health centers for provision of nutrition commodities. Through the HSDP Coordination Unit, the DNSP/DN will also be responsible for: (a) providing consolidated activity budgets and expenditures, (b) ensuring that contractual and financial arrangements entered into are being implemented as agreed, and (c) monitor and evaluate the CBN Service Package, and report on progress. DNSP/DN shall be supported with resources for the administration of the above mentioned tasks until such time as the Department is sufficiently staffed to do so itself. 66. DNSP/DN in close collaboration with the HSDP Coordination Unit will prepare a NIM in form and substance acceptable to IDA. The Manual will contain (i) each CBN Service Package to be delivered by each Provincial TPP; (ii) a model form of CBN Service Agreement for the provision of CBN services; (iii) the detailed list of functions to be carried out by each level of MOH (central, provincial, district) and the list of training to be received by them in order to effectively carry out these functions; (iv) the indicators to be monitored by the MOH at the district and provincial levels and the template to be used for reporting on these indicators; (v) the TORs for the Provincial TPPs and for the Independent Verification Agent (IVA); and (vi) details on the technical performance indicators that will assess the TPP facilitated CBN Service Package implementation progress, including the size and frequency of disbursements and the quality of reported outputs maintained. 67. At the provincial level, the DPS will be responsible for the implementation in the province and providing oversight at district level. For each of the 3 provinces, a nutrition focal person will oversee province and district activities. The head of the DPS will be responsible for the direct implementation of Component I.b activities in her or his mandated geographic area. Service delivery will rely on the public sector health system with community mobilization, training and assistance provided by Provincial TPP. The DPS or designee will coordinate all Component I.b activities and participate in the selection of the Provincial TPP, in close collaboration with the Central and Provincial SETSAN. The DPS will be assisted by a full time Province Nutrition Focal Point. 23 68. The contracted Provincial TPP and sub-contractor, if appropriate, will identify existing staff or new recruits for contract management, hire and train Activistas. They will form BGs, select Volunteers, build capacity, distribute commodities, and report on implementation progress. The Provincial TPP and its Activistas will provide reports to the health centers and will monitor implementation and provide feedback to strengthen service delivery mechanisms and programmatic content, ensure quality control, supervision and monitoring. Furthermore, in consultation with the SDSMAS and DPS, the Provincial TPP will develop a CBN Services Package expansion plan, which will also include specific targets set for each district, and will submit on a no-objection basis through the DPS to the DNSP/DN and IDA. The Provincial TPP will report to the DPS, and through it, to the DNSP/DN. Quarterly meetings will be organized at the provincial level between the DNSP/DN, DPS Nutrition Focal Point and Provincial TPP to discuss the quarterly province progress reviews and progress towards set targets, based on the Province CBN Service Package Expansion Plan. 69. At the district level, the District Administrator and the SDSMAS will work closely with TPPs and contribute to the District CBN Service Package Expansion Plan. Monthly coordination meetings will be organized between SDSMAS, the TPP District Nutrition Officer and TPP representatives to evaluate the previous month’s activities and discuss the next month’s work plan. The TPP will provide the SDSMAS monthly progress reports, including the data collected and compiled at community level by the Activistas. These data will feed into the monthly progress reports which SDSMAS will share with the DPS. The SDSMAS will also verify TPP progress reports on reaching the output indicators that will be used to justify payments. 70. At the community level, service delivery will be done by Volunteers. Activistas will provide supportive supervision and facilitate the activities of Volunteers, in collaboration with APEs. Each Activista will mobilize, train and supervise 20 BGs, each consisting of 15 households with under-2 children or pregnant/lactating women and served by 1 Volunteer. The Activista will collect monitoring data once a month from Volunteers and summarize the data on the information system forms for the DNO. Furthermore, Activistas will facilitate that the CBN activities are continuously monitored by different segments in the community, including the BGs and CCS. A detailed description of the nutrition activities is presented in Annex 4. 71. The national food and nutrition coordinating body, SETSAN, will be updated through regular report mechanism to the PAMRDC of the National and Province nutrition efforts, and any cross-sectoral work. The nutrition DPs will be informed by DNSP/DN regularly through coordination mechanisms such us GT-PAMRDC and the Nutrition Partners Forum. Those DPs with nutrition or nutrition-related programs in the Northern provinces will be informed more frequently. Nutrition will now be on the agenda during the Joint Annual Reviews of the HSDP with participation from central MOH Directors, the 3 DPS, and health-related DPs. 72. Additional information about the target communities and the CBN Service Package specific organizational structure are presented in Annex 5 (Revised Implementation Arrangements and Support) 24 Risk Assessment 73. The Original Project includes a detailed risk assessment. Nutrition-specific risk ratings are presented below. The nutrition specific risks reflect the fact that, as mentioned earlier, the MOH has had limited management and technical capacity and for the first time the health sector will work with TPPs to deliver the community-based nutrition services. Annex 2 provides a detailed ORAF for the HSDP. Risk Rating Implementation Agency Risks -Capacity Substantial -Governance Moderate AF specific Risk -Design Low -Social and Environmental Low -Program and Donor Moderate -Delivery Monitoring and Sustainability Moderate Overall Implementation Risk Moderate IV. Appraisal Summary a. Economic 74. The Original Project includes an economic analysis of the overall health and nutrition sector in Mozambique. Strengthening nutrition activities will further increase the benefits of the project. The nutrition interventions have been designed in order to achieve the maximum possible outcome at the lowest possible costs. Cost effectiveness considerations have played an important role in the selection of the proposed CBN interventions and their target groups. 75. Under nutrition slows economic growth and perpetuates poverty through 3 routes: direct loss in productivity from poor physical status; indirect loss from poor cognitive function and deficits in schooling; and losses owing to increased health care costs. Reducing vitamin and mineral deficiencies, one of the major contributors to under nutrition, are known to be among the most cost effective public health interventions based on extensive morbidity and mortality clinical and epidemiological evidence, particularly in nutritionally vulnerable countries and localities. Studies have consistently demonstrated this, whether based on average (“unit”) cost per beneficiary, average cost per disability adjusted life years (DALY), or average cost per death averted. 25 76. In May 2004, the first Copenhagen Consensus Conference took place. Based on extensive background material prepared by 30 economic specialists, 8 leading international economists (of which 4 were Nobel Prize winners) assessed and prioritized the best solutions to some of the greatest global challenges. The Copenhagen Consensus concluded that nutrition interventions generate returns among the highest of 17 potential development investments. Investments in micronutrients were rated above those in trade liberalization, malaria, and water and sanitation. Community-based programs targeted to children under-two years of age are also cost-effective in preventing under nutrition. Overall, the benefit-cost ratios for nutrition interventions range from 5 to 520 as provided in the Table below. 77. Benefit-cost ratios of selected nutrition interventions 22 Interventions Benefit-cost Breastfeeding promotion in hospitals 5-67 Integrated child care programs 9-16 Iodine supplementation (women) 15-520 Vitamin A supplementation (children 6 years) 4-43 iron fortification (per capita) 176-200 iron supplementation (per pregnant women) 6-14 b. Technical 78. The overall technical design of the proposed CBN Service Package is aligned with the country’s health sector priorities and PAMRDC. It uses lessons learned from similar interventions implemented elsewhere, including in Madagascar, Senegal, Ethiopia and Bangladesh and past interventions in Mozambique undertaken or financed by the Government and other DPs. Under-2 children, pregnant and lactating women and adolescent girls, will receive maximum attention. The CBN Service Package aims to build on GOM existing efforts and implement cost-effective interventions of proven value, provide commodities to vulnerable and high-risk populations, strengthen the health system through capacity building, improve the monitoring and evaluation system, and provide a broader package of nutrition interventions in the 3 provinces. c. Environmental and Safeguard Policies 79. The proposed additional activities will not trigger any new safeguard policies, nor will they involve any major, unprecedented or irreversible negative environmental and social impacts. The Original Project was classified as Category B (and shall be kept for the AF) with respect to environmental and social considerations, having triggered the Environmental Assessment (OP/BP 4.01) and Pest Management (OP 4.09) Safeguard policies. . However, the MOH did not prepare an Environmental and Social Management Plan (ESMP) for the Original 22 Source: Behrman, Alderman and Hoddinon, 2004. 26 Project as eligibility for financing of civil works for the construction and rehabilitation of rural health centers had not been envisaged during preparation of the Original Project and such financing was only decided (and reflected in the negotiations’ package) during negotiations of the Financing Agreement for the Original Project. Notwithstanding, since there was no ESMP, such civil works could not be carried out during implementation of the Original Project. The MOH has now prepared an ESMP, which has been approved by the Bank and disclosed in the MOH’s website on November 15, 2012 and by the InfoShop on November 16, 2012. The final ISDS was also disclosed through InfoShop on November 16, 2012. d. Financial Management 80. The MOH, through DAF, will have the overall responsibility for the financial management of the AF at the central, provincial and district levels. A financial management assessment of the MOH was conducted in 2011 and determined that the Ministry met minimum FM requirements under OP/BP 10.02, with arrangements in place to ensure that funds will be used for the purposes intended, and that financial reports will be prepared in a timely manner, and subjected to auditing arrangements acceptable to the Bank. The MOH will designate a qualified accounting officer for Component I.b activities. 81. However, the MOH’s financial management capacity remains weak, and the AF will provide further resources to DAF, HSDP Coordination Unit and DNSP/DN which will enhance their collective ability to effectively oversee the financial aspects of the HSDP, including its Component I.b activities, consistent with the Government’s Global Strategy for Public Sector Reform (2001-2011). The resources will be utilized to conduct short-term training, including financial management and investment procedures for Bank-financed projects. 82. A number of changes, recently made by the MOH, will lead to an effective implementation of the proposed AF. They include: (i) change in the structure and leadership of DAF, including the appointment of a new Director; (ii) appointment of a full time, experienced and dedicated HSDP Coordinator; and (iii) recruitment of an experienced Financial Management Specialist in DAF who will coach existing staff in the Department on financial management policies and procedures specific to Bank-financed projects. 83. Funds from the AF will be disbursed through the existing Forex Account maintained at the Bank of Mozambique. Disbursements will be Statement of Expenditure-based. On the basis of financial reports received from the relevant implementing agencies at the central, provincial, and district levels, the MOH will submit a consolidated Interim Financial Report (IFR) to IDA within 45 days after the end of each quarter. The IFRs will be the basis of consolidated annual project financial statements, encompassing all sources of financing for the project, which will be audited by an independent auditor acceptable to the Association. 84. The Ministry has been utilizing the government-wide Single Treasury Account mechanism, the Government’s integrated financial management information system (e- SISTAFE), which allows direct bank transfer of all transactions. This system now handles about 90 percent of all transactions and the aim is to reach 100 percent by the end of 2012. 27 85. One TPP per province will be contracted as a service provider to facilitate the CBN Service Package implementation. The Provincial TPPs will receive a mobilization advance from the MOH representing 10 percent of the contract value. This advance payment which will not be reported as expenditure in the Statements of Expenditures (SOEs) submitted to the Association It is recognized that, during the first 2 quarters of the contract, most of the efforts will be in community mobilization and identification Activistas, training of Activistas, APE, members of the CCS and Volunteers. Subsequent payments will focus on actual expenditure and agreed budget. With regard to Component I.b. of the project Disbursement Category 11 of the Financing Agreement the DAF will submit to the Bank SOEs reporting exclusively actual costs paid for Goods, Consulting Services, Operating Costs and Training. The financial and technical reports will be prepared by the Provincial TPPs, which will be validated by the respective SDSMASs and approved by DPS. Several control mechanisms have been put in place to verify technical quality to be claimed by TPPs. In addition to regular supervision of TPP implemented interventions at different levels, 1 IVA will be hired by the MOH to verify semi-annually if the Provincial TPPs followed agreed procedure in preparing routine financial reports and the SDSMAS and DPA verified and approved them based on agreed criteria. Also, the IVA will undertake rapid assessment of the Provincial TPP delivered outputs through field visits. Furthermore, the quality of TPP interventions will be assessed at mid-term based on a set of well-defined technical performance indicators; however the IVA assessment will be de-linked from disbursement and will be carried out only for technical reasons, as the additional financing credit will finance the actual cost incurred by NGOs. The results of the assessment will determine if the TPP contract can be continued, should be terminated, or could conditionally be extended. e. Procurement 86. Procurement activities under the AF would be carried out in accordance with the World Bank's "Guidelines: Procurement of Goods, Works and Non-consulting Services under IBRD Loans and IDA Credits and Grants by World Bank Borrowers" published by the World Bank in January 2011 and the World Bank's "Guidelines: Selection and Employment of Consultants under IBRD Loans and IDA Credits and Grants by World Bank Borrowers," published by the World Bank in January 2011. The MOH procurement unit, UGEA will have overall responsibility for all procurement activities under the AF. 87. The HSDP MTR noted that the procurement capacity of the MOH was low. The main factors contributing to inefficiencies in the implementation of procurement activities are the insufficient qualifications and experience of the staff responsible for procurement activities in all units, and in particular with regard to World Bank requirements. That said, the MOH has improved its management structure, the UGEA has been reshuffled, including the head of UGEA who was brought from UFSA (the central Government procurement authority) and has 4 years of experience in procurement using government procedures, albeit not with the World Bank procurement procedures. The rest of the newly assigned staff has limited or no experience in procurement, using both government and the Bank procedures. In sum, there have been positive steps to revamp MOH procurement, while at the same time concerns remain that the new staff and arrangements have not been tested and will need to significantly and quickly enhance their knowledge of World Bank procedures. In this regard, the MOH is in the process of recruiting a 28 qualified Procurement Specialist on a part time basis with knowledge and experience in the Bank procurement procedures. Furthermore, the MOH has requested additional procurement support for the CMAM and the selection process will start soon. 88. Having on board the full time procurement specialist will be discussed with the MOH as a high priority and urgent matter. Additionally, the MOH will prepare a revised procurement manual, introducing new goods and services specific to the AF. 89. UNICEF will be engaged to procure specialized medical supplies. The National Statistical Institute (INE) will provide technical assistance in conducting research activities under Component IV of the Project. 90. The overall procurement risk for the AF activities is Substantial. f. Anti-Corruption Guidelines: 91. “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants”, dated October 15, 2006 and updated in January 2011, shall apply to this Additional Financing. g. Bank Policy Exceptions 92. The proposed additional credit does not require any exception to the World Bank’s Operational Policy governing Additional Financing for Investment Lending (OP 13.20). 29 ANNEX 1: Proposed Change to Results Framework MOZAMBIQUE HEALTH SERVICE DELIVERY PROJECT Comments/ Rationale for Change PDO The Project Development Objectives Dropped PDO in the original PAD. are to: (a) reduce child mortality; (b) Too broad and not specific to reduced maternal mortality; (c) reduce activities supported by the the burden of malaria; (d) reduce the project. prevalence of tuberculosis; and (e) reduce inequity in the access of health services in Mozambique. To increase access to and utilization of Revised New PDO. More specific to maternal and child health and nutrition activities supported by the services in target areas in the project and captures Recipient’s territory. Component I.b. PDO indicators Percentage of institutional deliveries in: Revised This indicator has been (a) Cabo Delegado; (b) Nampula; (c) disaggregated by Provinces Niassa Percentage of health facilities offering Dropped Currently 100% of facilities first-line treatment for malaria. are offering first-line treatment of malaria. Percentage of children vaccinated New In the original PAD it was an DPTHepHib3 in the first year of life in: intermediary indicator. (a) Cabo Delgado; (b) Nampula; (c) Niassa Direct project beneficiaries (number) of Continued Core HNP indicator. which female (percentage) Percentage of pregnant women who New In the original PAD it was an received 2nd dose of IPT at antenatal intermediary indicator. clinics Percentage of children aged 0-24 New CPS indicator. Included in months fed in accordance with all 3 DHS. A composite indicator IYCF practices (food diversity, feeding causally linked to chronic frequency, and consumption of breast under nutrition. milk or milk) Intermediate Results indicators Outreach teams fully operational in Revised A definition of fully Cabo Delgado, Nampula and Niassa operational is now provided Number of Agentes Polivalente Revised The indicator refer to Elementares (APEs) trained specific cadre of Community 30 (cumulative) Health Workers known as APEs Health personnel receiving training Continued Core HNP indicator and no (cumulative) 23 additional change proposed Health facilities constructed, renovated, New The construction and and/or equipped to standard rehabilitation have to adhere specifications (cumulative) to a defined standard Preparation of an invest plan Dropped Activity cancelled Pregnant women receiving 1st ANC New Captures specific activity visit 24 financed by the project (a) Cabo Delgado, (b) Nampula (c) Niassa. Children receiving a dose of vitamin New Captures specific activity A 25 financed by the project (a) Cabo Delgado, (b) Nampula (c) Niassa. Number of children <1 year fully New Captures specific activity immunized26 financed by the project (a) Cabo Delgado, (b) Nampula (c) Niassa. Percentage of children 12-23 months Dropped This indicator was revised vaccinated with BCG; DPT3; Polio and and included as a PDO level measles vaccines in the first year of indicator. life. Percentage of pregnant women who Dropped This indicator was revised received at least 1 dose of IPT and included as a PDO level indicator. Long-lasting insecticide-treated malaria Dropped Replaced by a more relevant nets purchased and or distributed indicator (number) 23 This figure excludes community health workers (APEs). 24 This indicator capture the total number of women receiving 1st ante-natal care in health units that have (a) workers that have received training funded by the World Bank or (b) been constructed or substantially renovated with World Bank funding. This is a measure of contribution, and it is not necessary to make a calculation to estimate a pro rata World Bank attribution, based on financial contribution to each health center. This figure be a pro-rata calculation based on the total number of women receiving a1st ante-natal care in the province, and the number of facilities in the province that have received support from the World Bank (i.e. if 75% of health units have received some support, then 75% of the total number of women who received 1st ante-natal care will be counted). Targets were calculated from Demographic Projection – 2011 assuming coverage of 95%. 25 Children aged 6-59 months. 26 Refers to annual number of children immunized with vaccines purchased with Bank funds, or delivered through programs supported with Bank funds. Children receiving multiple vaccinations are counted once. See note number 2 on data quality issues. 31 Number of Volunteers functional New To capture Component I.b (cumulative) Percentage of children aged 0-24 New To capture Component I.b months who attended at least 1 Growth Monitoring and Promotion session during the preceding 4 months, percentage who are female Percentage of children aged 6-24 New To capture Component I.b months received at least 60 sachets of micronutrient powder (MNP) during the preceding 4 months, percentage who are female Percentage of pregnant women received New To capture Component I.b a complete dose of IFA tablets 32 ANNEX 1 Revised Results Framework and Monitoring MOZAMBIQUE: HEALTH SERVICE DELIVERY PROJECT Project Development Objective (PDO): To (a) reduce child mortality; (b) reduce maternal mortality; (c) reduce the burden of malaria; (d) reduce the prevalence of tuberculosis; and (e) reduce inequity in the access to health services in Mozambique. Revised Project Development Objective: To increase access to and utilization of maternal and child health and nutrition services in target areas of the Recipient’s territory. D=Dropped Values* C=Continue Core N= New Unit of Baseline YR 1 YR 3 Data Source/ Responsibility for PDO Level Results Indicators* YR 2 Frequency R=Revised Measure (2009) (2011) (2013) Methodology Data Collection (2012) Realized Target Target Indicator One: Percentage of Routine Information System institutional deliveries in: (a) 57 (a) 69 (ACA11 #6) Department of (b) 53 (b) 64 Targets aligned with the latest (a) Cabo Delgado, C % 63% 27 65% Semi-annual Performance Framework for Health Information (b) Nampula (c) 84 (c) 72 the Health Sector (QAD 2012, System (DIS) (c) Niassa. approved in year 2011). Indicator Two: Percentage of children Routine Information System vaccinated DPTHepHib3 in the first (a) 71 (a) 84 (ACA11#1) Department of year of life in: (b) 51 (b) 95 Targets aligned with the latest R % 90% 29 90% Semi-annual Health Information (a) Cabo Delgado (c) 115 28 (c) 84 Performance Framework for the Health Sector (QAD 2012, System (DIS) (b) Nampula (c) Niassa. approved in year 2011). Indicator Three: 30 Percentage of Routine Information System. Department of pregnant women who received 2nd dose R % 18.6% 31 20% 30% 50% Semi-annual (ACA11 #10). National targets Health Information of IPT at antenatal clinics. revised in year 2012. System (DIS) 27 A National figure is given for year 2 and 3 targets, but reporting will be based on actual provincial coverage levels achieved. Provinces also set annual targets for institutional deliveries and vaccination (indicator 2). These are not included here as targets are not set for the outer years of the project. However, project assessments can review performance against annual provincial targets as well as national targets. Provincial targets for year 2012: (a) 70%; (b) 66%; (c) 74%. 28 Coverage >than 100% is due to the quality of routine data for the numerator (risk of double counting). From year 2009, the EPI program has started to train staff at health centers on data quality verification. Up to year 2012 all the provinces were involved and the quality of data is now improving. This might eventually result in an apparent decrease of the actual number of children vaccinated. 29 See footnote 1. Provincial targets aligned with the national ones. 30 This indicator is a proxy for system performance. Bank investments in staff and infrastructure contribute to performance against this target. 31 Preliminary Result from DHS 2011 (referring to pregnancies in years 2009-2010). 33 D=Dropped Values* C=Continue Core N= New Unit of Baseline YR 1 YR 3 Data Source/ Responsibility for PDO Level Results Indicators* YR 2 Frequency R=Revised Measure (2009) (2011) (2013) Methodology Data Collection (2012) Realized Target Target Indicator Three: Direct project Department of number 525,295 533,567 beneficiaries (number) of which female C 0 Annual Project Data Projects % (82%) (81%) (percentage). Baseline 2014 2015 2016 (2013) Indicator Four: Percentage of children 3% 6% 10% aged 0-24 months fed in accordance M&E Unit (central, increase increase increase Nutrition-specific baseline with all 3 IYCF practices (food N % 0 Survey provincial, and from from from and endline surveys diversity, feeding frequency, and district) baseline baseline baseline consumption of breast milk or milk 32). INTERMEDIATE RESULTS Intermediate Indicators Indicator One: Outreach teams fully DPS and operational 33 in Cabo Delgado, R number 0 22 54 54 Semi-annual Project data Department of Nampula, and Niassa. Projects Indicator Two: Number of Agentes Polivalente Elementares (APEs) trained R number 0 249 906 1100 Semi-annual Program Reports APE Program (cumulative). Indicator Three: Health personnel Department of receiving training 34 X C number 0 0 180 300 Semi-annual Project data Projects (cumulative). Indicator Four: Health facilities constructed, renovated, and/or equipped Department of X N number 0 0 9 18 Semi-annual Supervision Reports to standard specifications Projects (cumulative). 32 No baseline value is available at appraisal. The target will be set after baseline survey is done. 33 “Fully operational” means; a team comprising of at least 3 staff (1 responsible for vaccination, one responsible for maternal health screening, and one responsible for primary health care level clinical services. Fully operational also means that each village within a district has had access to an outreach team four times in each year (quarterly). Note, that this does not mean that the outreach team has visited every village, but that the team is accessible to villages in the district (which may require some reasonable travel to a selected location). 34 This figure includes all health sector cadres recognized by MOH who have received pre- or in-service training. This includes all formal knowledge or skill transfer activities (e.g. short-courses). This figure excludes community health workers (APEs). 34 D=Dropped Values* C=Continue Core N= New Unit of Baseline YR 1 YR 3 Data Source/ Responsibility for Intermediate Results Indicators* YR 2 Frequency R=Revised Measure (2009) (2011) (2013) Methodology Data Collection (2012) Realized Target Target Indicator Five: Pregnant women receiving 1st ANC visit 35 (a) (a) (a) (a) (a) Cabo Delgado, 118,126 132,096 84,526 85,852 Department of (b) Nampula (b) (b) (b)218, (b) Routine Information X N number Semi-annual Health Information (c) Niassa. 267,517 303,874 502 217,338 System System (DIS) (c) (c) (c) (c) 112,107 97,445 81,701 80,041 Indicator Six: Children receiving a (a) (a) (a) (a) dose of vitamin A 36 178,490 98,710 235,811 240,113 (a) Cabo Delgado, (b) (b) (b) (b) Nutrition N Number Semi-annual Program report (b) Nampula 185,879 575,939 609,797 625,488 Department (c) Niassa. (c) (c) (c) (c) 219,195 114,462 193,178 200,993 Indicator Seven: Number of children (a) (a) (a) (a) <1 year fully immunized 37 62,412 45,176 52,482 54,904 Routine Information Department of (a) Cabo Delgado, (b) (b) (b) (b) X N Number Semi-annual System Health Information (b) Nampula 150,427 123,770 139,436 143,024 (ACA#2 TBC) System (DIS) (c) Niassa. (c) (c) (c) (c) 32,702 37,265 42,993 45,346 35 This indicator capture the total number of women receiving 1st ante-natal care in health units that have (a) workers that have received training funded by the World Bank or (b) been constructed or substantially renovated with World Bank funding. This is a measure of contribution, and it is not necessary to make a calculation to estimate a pro rata World Bank attribution, based on financial contribution to each health center. This figure be a pro-rata calculation based on the total number of women receiving a1st ante-natal care in the province, and the number of facilities in the province that have received support from the World Bank (i.e., if 75% of health units have received some support, then 75% of the total number of women who received 1st ante-natal care will be counted). Targets were calculated from Demographic Projection – 2011 assuming coverage of 95%. 36 Children aged 6-59 months. 37 Refers to annual number of children immunized with vaccines purchased with Bank funds, or delivered through programs supported with Bank funds. Children receiving multiple vaccinations are counted once. See note number 2 on data quality issues. 35 D=Dropped Values* C=Continue Core N= New Unit of Baseline YR 1 YR 3 Intermediate Results Indicators* YR 2 R=Revised Measure (2009) (2011) (2013) Data Source/ Responsibility for (2012) Frequency Realized Target Methodology Data Collection Target Baseline 2014 2015 2016 2013 Indicator Eight: Number of Routine Information M&E Unit (central, Volunteers functional N number 0 7,000 14,000 21,000 Semi-annual System provincial, and (cumulative) (target: 21,000). district) Indicator Nine: Percentage of children aged 0-24 months who attended at least 1 Growth Monitoring and Promotion M&E Unit (central, Routine Information session during the preceding 4 months, N % 0 2014 50% 80% Semi-annual provincial, and System percentage who are female district) (Target: 80% of 0-24 months old children). Indicator Ten: Percentage of children aged 6-24 months received at least 60 M&E Unit (central, sachets of micronutrient powder (MNP) 25% 50% 80% Routine Information N % 0 Semi-annual provincial, and during the preceding 4 months, System district) percentage who are female (target: 80% of 6-24 months old children). Indicator Eleven::Percentage of 20% M&E Unit (central, pregnant women received a complete increase Routine Information N % -- Semi-annual provincial, and dose of IFA tablets. 38 from System district) baseline 38 No baseline value is available at appraisal. The target will be set after baseline survey is done. 36 ANNEX 2: Operational Risk Assessment Framework (ORAF) Project Stakeholder Risks 1.1. Project stakeholder Rating Moderate Description: Risk Management: Communities will misunderstand why pregnant and APEs/Activistas will meet Community Health Committee and Volunteers lactating women and children up to 24 months have periodically to explain benefits of targeting pregnant and lactating women and been chosen as the main target groups. children up to 24 months to reduce stunting. Resp: Stage: Status: Due Date : NA DSP/SDSMAS/TPPs App/Impl Not yet due 1.2. Project stakeholder Rating Moderate Description: Risk Management: Lack of resources to continue the implementation of The Bank’s task team will work closely with the Government and DPs to ensure key activities may frustrate Communities, TPPs and that the project objectives are achieved and that the Government continues (i) to key officials at the District and Type II Health Centers, gradually cover selected programs by the state budget to reduce external which may affect the timely completion of planned dependency and (ii) to involve the provincial and district directors in the decision activities. The current level of GOM’s commitment making process. With the proposed request for this project, the Government will be for nutrition has raised expectations among the main able to continue the support to nutrition. beneficiaries of the programs. Resp: Stage: Status: Due Date : NA DSP/SDSMAS/TPPs App/Impl Not yet due 2 Implementing Agency Risks (including fiduciary) 3.1 Capacity Rating: Substantial Description : Risk Management : Procurement capacity of the MOH remains weak with In conjunction with the HSDP restructuring, any identified MOH management and high level of staff turnover at UGEA. fiduciary perceived needs that require improvement will be addressed by the Bank and MOH team. The national directorate of Public Health introduced weekly coordination meetings with key staff including nutrition and HSDP coordinators. This current arrangement needs to be maintained and will add the DNSP/DN. Resp: Stage: Status: Due Date : MOH Impl Not yet due 37 2.2 Capacity Rating: Moderate Description : Risk Management : New procurement team in place with limited skills in Finalize the recruitment of short term procurement specialist and initiate the procurement. selection process of full time procurement specialist. Resp: Stage: Status: Due Date : MOH Impl Not yet due 2.3 Capacity Rating: Moderate Description : Risk Management : Lack of coordination across different Directorates to Integrate procurement discussion in the weekly coordination meeting headed by the facilitate procurement process. Permanent Secretary to improve the coordination with different departments involved in the implementation of the project. Resp: Stage: Status: Due Date : MOH Impl Not yet due 2.4 Capacity Rating: Substantial Description : Risk Management : The MOH does not maintain its currently adequate In conjunction with the HSDP restructuring, any identified MOH management and commitment including management capacity to fiduciary perceived needs that require improvement will be addressed by the Bank implement the HSDP and the new nutrition and MOH team. component. The national directorate of Public Health introduced weekly coordination meetings with key staff including nutrition and HSDP coordinators. This current arrangement needs to be maintained. Resp: Stage: Status: Due Date : MOH/TPP/Bank Impl Not yet due 2.5 Capacity Rating: Moderate Description : Risk Management : MOH/DNSP/DN and Province Health Directorates DSNP/DN will hire two full time staff with nutrition project management may not have the technical capacity to oversee TPP experience to oversee national level activities. execution of nutrition services. Each DPS will hire one full time staff with nutrition project management 38 experience to oversee Province-level activities. MOH will hire an Independent Verification Agent (IVA) to quality check TPP provided services semi-annually. A third party agent will assess quantity and quality of TPP provided services at mid-term. Resp: Stage: Status: Due Date : MOH/TPP/Bank Impl Not yet due 2.6 Capacity Rating: Moderate Description : Risk Management : MOH/DNSP/DN and Province Health Directorates The MOH will initiate an early selection of TPPs so that the CBN Service Package may not have the adequate capacity to recruit TPPs on can be implemented right after the effective date. time and manage their contracts. The MOH HSDP Coordination Unit will hire one full time Project Management specialist to coordinate with UGEA and manage TPP contracts. Stage: Status: Resp: MOH Due Date : Impl Not yet due 2.7 Capacity Rating: Moderate Description : Risk Management : The newly trained nutrition technicians are not Directorate of Administration and Finance (DAF) and the National Directorate of integrated at the District level of the health system due Human resources will ensure beginning of 2013 budget cycle includes the estimated to financial limitations of the MOH. number of District Nutrition Officers for each province. Stage: Status: Resp: MOH Impl Due Date : Not yet due 39 2.8 Capacity Rating: Low Description : Risk Management : Selected Province TPPs may not have the technical TPPs for each of the Provinces will be selected based on clear and transparent nutrition capacity, nor sufficient fiduciary mechanisms eligibility criteria. Funds will be made available in the contract for the TPP to scale- to effectively perform contracted obligations up to increase staff capacity and adequately train community nutrition promoters. Resp: Stage: Status: Due Date : MOH/TPP/Bank Impl Not yet due 2.9 Capacity Rating: Moderate Description : Risk Management : Limited capacity of the National Institute of Health Provide technical assistance to INS will increase their capacity in monitoring and (INS) to respond to highly demanding monitoring and evaluation activities. evaluation needs. Stage: Status: Resp: MOH/TPP/ Due Date : Impl Not yet due 2.10 Governance Rating: Moderate Description : Risk Management : Limited Province Health Directorate oversight of TPP Emphasis will be placed on regular supportive supervision missions by the activity, may lead to governance issues during DNSP/DN and the MOH fiduciary units to assist Province Health Directorates in implementation effective TPP contract performance oversight. The Bank team will reinforce MOH efforts, particularly during the first project implementation year. Resp: Stage: Status: Due Date : Imp Not yet due MOH 3 Project Risks 3.2 Design Rating: Moderate Description : Risk Management : Scaled –up community based nutrition services In addition to the public health system, community-based nutrition will build on 40 reaching priority target populations through services existing TPP Province efforts. The implementation approach will be discussed provided by the public health system and by TPPs and jointly with DNSP/DN, Province and District Health staff, as well as potential overseen by the public sector, is found to be an overly Province TPPs. The objective will be to agree on streamlined systems to speed complex process, and unworkable. quality service delivery to target populations. The Bank team will be involved in the discussions, as requested, and provide its no-objection. In addition, the government and the Bank team will review the timeframe of the project pre- implementation and at midterm to adjust the design as necessary. Resp: Stage: Status: Due Date : MOH/Bank/TPPs MTR/App/Impl Not yet due 3.3 Social & Environmental Rating: Low Description : Risk Management : There are no significant adverse social or Regular MOH/DNSP/DN supervision, with Bank participation as appropriate, will environmental impacts expected as a result of the include field visits to a random sample of community nutrition beneficiaries. Such proposed project. It does not entail civil works, pest supervision missions will ensure program-related commodities (such as iron-folic management issues, or medical waste management acid supplements, supplementary food) are non-expired, and are in safe, and in the issues case of supplies (such as child weighing scales), are in proper working order. Resp: Stage: Status: Due Date : MOH/Bank/TPP App/Impl Not yet due 3.4 Program & Donor Rating: Moderate Description : Risk Management : Inadequate GOM nutrition coordination could lead to GOM has put in place a national nutrition coordination mechanism (SETSAN) program overlap, different protocols and service which is responsible for consistency in carrying forward the national nutrition delivery, and donor discontinuities. strategy. Further, a strong and active nutrition working group exists with representation from the GOM, the Bank, other major nutrition DPs, UN agencies, and key TPPs. This group will continue to collaborate with its members and coordinate programs in terms of geographic assignments, common nutrition protocols, and data collection in keeping with the national plan. Technical Assistance provided by the AF will strengthen coordination capacity at the central and provincial levels. Resp: Stage: Due Date : Status: MOH/Bank/DPs App/Imp 3.5 Delivery Monitoring & Sustainability Rating: Moderate 41 Description : Risk Management : The financing of the nutrition component will not be The Bank team will work with the GOM and other DPs to monitor financing. They sustainable once the HSDP is complete. will develop a transition plan towards the end of the HSDP if there is need to mobilize new resources for existing Province programs to ensure their sustainability , and possibly expand the approach to other Provinces (if successful). Process to integrate central, provincial and district level newly recruited nutrition staff needs to be initiated through the inclusion in annual GOM budget cycle. Resp: Stage: Status: Due Date : MOH/Bank Imp Not yet due 3.6 Delivery Monitoring and Sustainability Rating: Moderate Description : Risk Management : The community based nutrition intervention efforts in By the end of the project, the overall capacity of the MOH would have increased the three Northern provinces will halt once the with newly trained nutritionists as well as APEs able to work at the Provincial and additional financing is complete and the TPP contracts District levels. In addition, the provincial government plan for nutrition would have terminated (phasing out strategy). been formulated, allowing for the provinces and districts to take ownership of nutrition intervention implementation. Resp: Stage: Status: Due Date : MOH/Bank Imp Not yet due 3.7. Delivery Monitoring & Sustainability Rating: Moderate Description : Risk Management : There is likelihood that there may be delays in the The CBN OM clearly defines financing parameters agreed by MO and contracting releasing of funds by MOH to Province TPPs which TPPs. may affect the speed of implementation of the project. The Bank team and MOH/DN will ensure close monitoring and supervision of TPP performance. Resp: Stage: Status: Due Date : MOH/Bank Imp Not yet due Overall Risk Following Review Implementation Risk Rating: Moderate Comments: The risks described in this ORAF are likely to have a low impact on the achievement of the PDO. 42 ANNEX 3: Revised Estimate of Costs 1. The Original Credit proceeds have been reallocated between the existing categories. (i) US$9.2 million will be added to Component I to cater for incremental costs of: a) payment of salaries for APEs in each district of the 3 provinces; b) strengthening the MOH’s health training institutions in the 3 provinces through the provision of goods, vehicles, and technical assistance; c) provision of technical assistance to the Directorate of Human Resources; d) intensified supervision of HCWM; and e) operating costs; (ii) US$2.0 million will be added to Component II to finance additional malaria commodities and operating costs; (iii) US$2.0 million will be added to Component III to support the process of developing the new health sector strategic plan, operational research and studies in the areas of health care financing and human resources for health, strengthen supply chain management, training of district and provincial staff in management, and operating costs; and (iv) US$14.2 million will be reduced from Component IV and reallocated to Components I, II and III. The remaining amount will finance project management costs. 43 2. The new allocation to scale up nutrition has been added to Components I, III and IV (Table 1). Table 1: Revised Project Costs by Component Original Revised Original Proposed Revised Total Component Component Project Additional Costs after (US$ million) Financing restructuring (US$ million) (US$ Million) I. Improvement in I. Improvement in Service Delivery Service Delivery 42.6 27.0 80.0 II. Boosting of II. Boosting of national malaria national malaria 13.5 - 15.5 control program control program III. Preparation of III. Strategic national health sector Planning and 0.5 5.0 7.4 investment plan Capacity Building IV. Capacity building IV. Project and Operating Costs Management and 15.8 5.0 6.5 Operating Costs Total Cost 72.4 37.0 109.4 3. Overall costs by Fiscal Year under the AF by budget category are presented in Table 2 below: Table 2: Nutrition Total Fiscal Year Costs by Budget Category FY13-17 Total FY 13 FY 14 FY 15 FY 16 FY 17 (US$) (US$) (US$) (US$) (US$) (US$) TPP contract for community 16,762,62 3,763,931 5,495,607 4,058,191 3,444,933 0 Interventions 1,876,724 504,996 362,897 291,931 291,931 0 Services Goods 8,645,496 1,590,185 7,914,802 1,000,000 00 0 Capacity 4,724,774 1,362,014 833,320 1,083,440 446,000 0 Building Operational 4,555,820 648,972 1,382,150 1,287,150 1,237,550 0 Costs 37,000,000 7,870,098 15,988,776 7,720,712 5,420,414 0 Total 44 ANNEX 4: Detailed Description of the Revised Components and New Activities Revision of Project components: revised Project components will be revised as follows: 1. Component I: Improvement in Service Delivery. This will include an additional subcomponent for scaling up nutrition activities (Total US$80.0 million including 27 million for nutrition equivalent). The following activities will be financed through this component. I.a. Strengthen management and planning capacities of MOH including training institutions and health facilities, to improve the quality of health and nutrition services’ provision and enhance acute malnutrition and malaria control activities in the provinces of Cabo Delgado, Nampula and Niassa, including through: (a) Enhancement of capacity of central, provincial and district health staff, including Community Health Workers to deliver health promotion, prevention, and basic health interventions for women of child bearing age, adolescent girls, and children under five years of age in their communities through the carrying out of training; (b) Advisory in the areas of planning, management and monitoring and evaluation for the implementation of the National Human Resources for Health Development Plan; (c) Carrying out of outreach and community-oriented activities, including vaccinations, provision of oral rehydration salts, health education, antenatal care, and basic clinical care; (d) Implementation of the Health Waste Management Plan (HWMP) and Vector Management Plan (VMP); (e) Construction and rehabilitation of health facilities and related staff housing; and (f) Provision of transportation, including vehicles, motorcycles and bicycles for the purpose of paragraph (c) above. I.b. Implementation of CBN activities targeted to pregnant and lactating women, adolescent girls and children up to 24 months of age, including through: (a) Delivery of a CBN Service Package including carrying out of: (i) Growth monitoring and promotion activities, including treatment of acute malnutrition; (ii) Promotion activities of exclusive breastfeeding and appropriate complementary feeding, including the use of micronutrient powder (MNP) and deworming; 45 (iii) Mobilization of pregnant women for ante-natal care services, including provision of iron folic acid (IFA) tablets, and deworming for lactating women; (iv) Provision of IFA tablets and, deworming for adolescent girls; (v) Provision of dispersible zinc tablets and Oral Rehydration Salt (ORS) to treat children with diarrhea; and (v) Education on safe water, hygiene, sanitation and referral services for infectious disease control, including immunization. (b) Carrying out of advocacy and mass campaign activities to support MOH’s other nutrition initiatives and programs; (c) Provision of nutrition commodities and equipment for prevention and treatment of under nutrition; and (d) Provision of transportation including vehicles, motor cycles and bicycles for purpose of carrying out the activities under paragraphs (a) and (b) above. 2. Component II: Boosting of National Malaria Control Program (Total US$15.5 million equivalent). This component will strengthen the Recipient’s public health malaria control management program (including vector control) and malaria treatment policy shift from artesunate-sulfadoxine-pyrimethamine to artesunate-lumefantrine while at the same time supporting the Recipient’s supply chain, including through the following activities: (a) Design and implementation of a national training program on malaria monitoring and evaluation; (b) Enhance capacity of MOH staff in the implementation of public health operations in the provinces of Cabo Delgado, Nampula and Niassa; (c) Provision of essential drugs, long lasting insecticide treated nets, rapid-diagnostic test kits, equipment and vehicles for malaria control; (d) Rehabilitation of storage facilities throughout the territory of the Recipient; (e) Design of a geographic information system, including hardware and software to capture, store, analyze and display data regarding malaria incidence and prevalence for purposes of calculating the amount of Recipient’s population at risk; (f) Setting up of sentinel sites within health centers and selected hospitals in the provinces of Cabo Delgado, Nampula, and Niassa for surveillance of malaria cases.; and 46 (g) Design and dissemination of behavior change communication materials. 3. Component III: Strategic Planning and Capacity Building (Total US$7.4 million including US$5.0 million for nutrition equivalent). This component will support the MOH to allow it to undertake policy analysis, strengthen its supply chain and improve its capacity for Project management and monitoring activities, including through: (a) Design and implementation of a health sector strategic plan; (b) Enhancement of the capacity of MOH staff and nutrition technicians to design, implement, monitor and evaluate health and nutrition activities; (c) Support for central and provincial level staff for pursuing graduate level nutrition degrees; (d) Operational research studies in nutrition to test innovative community-based nutrition interventions and/or delivery mechanisms; (e) Testing the use of information and communication technologies to strengthen the health and nutrition routine monitoring system; and (f) Support for national and provincial level meetings and workshops to strengthen nutrition coordination mechanism. 4. Component IV: Project Management and Operating Costs (Total US$6.5 million including US$5.0 million for nutrition equivalent). This component will support the following activities: (a) Support the management capacity of DNSP/DN and DPS to implement Component I.b. of the Project in the provinces of Cabo Delgado, Nampula and Niassa; (b) Carrying out of nutrition monitoring and evaluation activities, including baseline, mid-line and end-line surveys and routine CBN monitoring in the provinces of Cabo Delgado, Nampula and Niassa; (c) Establishment of a decentralized regional unit at provincial level to support data processing, filing of key strategic documents, and relevant health research studies; (d) Provision of Operating Costs for the Project, including office administration costs, office equipment and supplies, reasonable communications expenses, office and temporary warehouse rental, Project’s vehicles operation and maintenance; Project related insurance costs, travel expenses and per diems for official Project staff, stipends for APEs and interviewers under Component 1.b of the Project, non-monetary incentives for volunteers under Component 1.b of the Project 47 (excluding salaries of Recipient’s civil servants), and bank charges pertaining to the Designated Account for the Project. Additional Financing details: 5. With the objective to expand key nutrition activities as defined in the Multisectoral Action Plan for the Reduction of Chronic Under Nutrition (PAMRDC), and in particular, to prevent and reduce the high levels of chronic undernutrition in infants and young children, the Government of Mozambique (GOM) requested the support of the World Bank for further support of nutrition activities. The GOM seeks to leverage existing nutrition strategies and activities, especially at community level, improve their quality and coverage, and strengthen the capacity of the MOH to plan and manage nutrition interventions at central, provincial and district levels. The approach will build on a strategic framework for maternal and child nutrition as follows 39: Offer quality Integrate essential services- Improve nutrition actions in managerial skills existing health system DEVELOP CAPACITY IN NUTRITION Measure changes in Advocacy and nutrition-increase awareness rising knowledge actions at all levels Population Coverage and Criteria 6. While the intention is to be as inclusive as possible in serving the population in Cabo Delgado, Nampula and Niassa, the CBN Service Package will need to be focused on a more limited number of districts due to the relatively short financing period and the need for continuing community support to assure regular participation of mothers and the application of good nutrition practices. Further, TPP field experience in Mozambique strongly recommends initial limited geographical coverage, given the heterogeneous nature of the provinces in terms of malnutrition prevalence and difficulty in accessing remote areas, thereby requiring more intensive human resource, time and effort. Therefore, the AF financed CBN Service Package will only cover part of the population and in selected districts. The final choice of districts will be determined during the bidding process for TPP, based on the following criteria: • Prevalence of low birth weight • Population density; • Existing of community nutrition interventions (to prevent overlap) 39 Adapted from: Mwadime,R.- Health sector Activities to improve nutrition: challenges and opportunities in sub- Saharan Africa; African Journal of Food and Nutrition Sciences, Vol1, nº1 – August 2001) 48 7. Projections based on the above indicators provide the basis for determining the expected CBN Service Package coverage for each province. It is expected that the Province TPP will subcontract local TPPs and CBOs already operational in the districts and which have local capacity to implement the CBN Service Package in their respective districts. The optimal scenario will be for existing TPPs to start in districts where they (or their subcontracted partners) already have ongoing programs (ensuring the maintenance of coverage), and gradual expansion of activities to additional districts. 8. Because start-up operations in any new province and for a new substantive program requires an adaptation period of several months, Niassa Province, with relatively lower malnutrition prevalence among the 3 provinces and a limited number of functional TPPs (and none specific working in nutrition), will have the least coverage at community level. CBN Service Package Activities 9. CBN Service Package is a model which has proven its effectiveness in the Mozambique context as the basic “Care Group“ model has been functioning in the country for some time, both in other Provinces and Districts, as well as having been piloted in the northern Provinces. It has been evaluated and found to have significant positive effect on child health and nutrition. The approach involves identifying and selecting Volunteers who will preferably be chosen by the community from those considered with the best infant and child feeding practices, e.g. positive deviant (PD) mothers who will lead by example. Further description of the Care Group model is provided in Attachment 1. The proposed approach also builds upon the Strategy for Community Involvement of the MOH and experiences in supporting the roll out of the APE and CCS. 10. The AF will thus support implementation of the CBN Service Package in Cabo Delgado, Nampula and Niassa. The intention is to generate widespread community engagement and ownership in improving nutritional well-being of at risk groups, using community-based, trained unpaid Volunteers who are linked to the CCS. The specific activities will build on the Mozambique Community Involvement Strategy and the “Basic Nutrition Packet” which was primarily designed for health facilities, but includes community nutrition, and ongoing operational activities of the selected Province TPPs which can be expanded incrementally to cover the activities described below. 11. CBN Service Package will encompass behavioral change and nutrition education, the supply of essential nutrition commodities to specific target populations, and referral mechanisms for the treatment of acute malnutrition. As mentioned above, selected CBN activities have been identified for the various target populations. 12. To address micronutrient deficiencies in under-2 children, the promotion of MNP will be introduced. It is a relatively new WHO recommended nutrition intervention which delivers a range of micronutrients including iron and zinc and caregivers use to fortify complementary food cooked at home. It is a mix of 1 gram micronutrient powder packed in a single serve sachet and used once a day, primarily to treat and prevent iron deficiency anemia. Inspired by global 49 evidence 40, the WHO published a guideline on the use of MNP 41. MNP will be duly registered in accordance with the laws of Mozambique within 6 months after effectiveness. 13. Volunteers (or an APE where available) will assure acutely malnourished children are sent to Type II health center for treatment, and follow thereafter. The treatment will be done according to the existing MOH’s protocol and will be financed by the AF. 14. At the national level, support will include: (i) procurement and distribution of nutrition commodities to be used in health center and by APE and Volunteers, (ii) development, reproduction and distribution of training and BCC materials, (iii) critical nationwide BCC activities to promote IYCF including BFHI and enhance the appropriate utilization of key micronutrients, especially iodine, iron, vitamin A and zinc; (iv) reinforcement of regulation and procedures to prohibit the production or distribution of salt that is not iodized, or inadequately iodized; (v) promotion campaigns for staple food products and condiments fortified with vitamins and minerals, including iron, zinc, folic acid and vitamin A; (vi) efforts to register MNP so that community-based workers including Volunteer can distribute them; and (vii) pre-and in- service training of health staff at all levels to manage, implement and monitor better nutrition and planned interventions. Contracting TPPs 15. To achieve quick and effective results, and ensure that a significant number of communities and population are covered, 3 Provincial TPPs will be contracted by the MOH as third party service providers to facilitate the implantation of the CBN Service Package. To facilitate the process of managing TPPs’ services and considering the limited availability of MOH staff to oversee multiple contracts, each province will contract with only 1 Provincial TPP. Given the province population size and access challenges, the Provincial TPP will organize a consortium or subcontract with other TPPs/CBOs that have local capacity to implement the CBN activities. The Provincial TPP will be responsible for the quality of services offered by its subcontractors. 16. The contracted Provincial TPP or its subcontracted TPPs/CBOs will work directly at community level with community groups of mothers and fathers using mother group models, as the organizational approach for the community interventions. In addition, and based on the existing experience of TPPs with ongoing health/nutrition projects in the northern provinces, the CCS will be organized and its members coached to ensure validation of the nutrition activities in the communities, and as a means to reduce community resistance to innovation. The engagement of the members of the CCS will be essential for future sustainability of the activities after the AF have been disbursed. 40 Zlotkin SH, Schauer C, Christofi des A, Sharieff W, Tondeur MC, Hyder Z. (2005) Micronutrient Sprinkles to control childhood anemia. PLoS Med 2(1): e1. 41 Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6–23 months of age. ISBN 978 92 4 150204 7 (NLM classification: WH 160). World Health Organization, 2011. 50 17. To effectively implement the CBN Service Package, the Provincial TPP will have an organizational structure, which is capable of implementing the program. Details will be described in the NIM and the Provincial TPP TOR, which will be prepared by the MOH. Key TPP staff to support the interventions at district and community level and interact on a regular basis with the Type II health centers will be the District Nutrition Officer (DNO) and the Activista. DNOs will be based in each one of the districts, will support the Activista , APE and Volunteer and will coordinate the CBN Service Package implementation with the SDSMAS and district medical chief (if one exists), and with the Type II health center staff in its intervention areas. The DNO will also control distribution of the commodities from the Type II health center to the APE and Volunteers. Each Activista will mobilize, train and supervise approximately 20 Volunteers, and facilitate their collaboration with APEs, where available. They will also provide the initial training and provide in-service refresher training to the APE, CCS members and the Volunteers during monthly meetings. The Activista will collect the data from the Volunteers and summarize them on an information system form for the DNO. Importantly, the Activista will ensure regular weekly contacts and coordination with Type II health center staff in the Activista’s catchment area. 18. Capacity Building. The Provincial TPP will be responsible to ensure that its staff and the staff of its consortium members have the necessary skills to deliver services and will be accountable for training and supervising these workers. Special attention will be provided to the training of the Activista, which constitute the core Provincial TPP staff at community level and who will receive a 10 days initial training as well as 2 times per year 2-day refresher training. Each Activista will receive training in community interventions, CBN Service Package activities such as growth monitoring and promotion, breast feeding and complementary feeding, use of micronutrients including MNP and deworming, based in the Essential Nutrition Activities (ENA) and on interventions encompassing the community Integrated Management of Childhood Illnesses (IMCI). DNOs will receive a 15-day initial training in nutrition, including the CBN Service Package activities. Before the new harmonized training material is available, the Provincial TPP will use the existing APE and Volunteer approach manuals and training materials available to them. Once the new harmonized training materials are available, training will be organized to update the skills of all persons involved in delivering such training. 19. The actual CBN activities will thus be facilitated by the APE (where available) and the CCS linked Volunteers, who will be trained to undertake growth monitoring and promotion, identification and mobilization of pregnant women for ante-natal care services, provide oral rehydration therapy and zinc for the treatment of diarrhea, semi-annual deworming, water purification, prevention of malaria including distribution of bed nets, as well as female education including avoidance of risky sexual behavior, family planning, promote early and maintained breast feeding, complementary feeding with the use of nutritious foods and micronutrient powder, improve hygienic behaviors such as stool disposal, washing hands, and increasing the capacity of families to recognize the early danger signs of some common diseases so to as search for help in early stages of disease. They also will receive training in the basics of interpersonal communication and mobilization skills to convey their nutrition education messages more accurately. 51 20. Each Volunteer will be provided with an essential equipment kit that will include: Spring type scale with weighing pants for children, height/length scale, MUAC tapes, cooking demonstration kit, registry forms, pens and pencils and growth charts for children. Each Volunteer will also receive a laminated set of nutrition education sheets or a flip chart book with the essential nutrition and hygiene messages that will be utilized in discussions with the group members about the needed behaviors to improve nutrition based in the Essential Nutrition Activities approach. 21. Each Volunteer will work directly with up to 15 beneficiary households with children under 2 years old and/or pregnant/lactating women and adolescent girls, providing education at group meetings, but also ensuring household visits for those mothers in greater need, and providing training on the use of nutritious foods and care of the child. Adolescent girls living in these 15 households will also be provided IFA supplements and deworming tablets along with age specific health and nutrition education. 22. For supervision and training purposes, each Volunteer will be associated with up to 5 other Volunteers who will constitute a Volunteer Group, receiving direct support from the Activista and the APE during monthly organizational meetings. These meetings will also include selected members of the CCS and will be used for refresher training, distribution of nutrition commodities per monthly work plan, discussion of the monthly activities, and collection of data on the results of past activities, namely: number of meetings held with beneficiary households, number of cooking demonstration sessions held, number of children participating in growth monitoring and promotion sessions, number of children with acute malnutrition referred to a nearby Type II health center, number of pregnant women referred to prenatal care, number of adolescent girls received IFA supplements and deworming tablets, number of children with expected weight gain as plotted on growth charts and activities related to distribution of IFA, vitamin A and deworming tablets as well as zinc tablet/ORS distribution. It will also be an opportunity to receive reports related to difficulties and constraints identified by the Volunteers and APE, identify good practices and reposition day-to-day operational strategies. 23. This type of deepened community engagement will make a significant contribution to the smooth implementation and sustainability of the process. Experience has shown that with active engagement of the CCS, there is greater adherence to the group, and maintenance of the group after external support diminishes, and as such is critical to successful outcomes. Thus the Activista is expected to train the members of the CCS (or facilitate its creation if it does not exist yet) according the guidelines described in the Community Involvement Strategy. The CCS often includes the chief of the village, some prominent people in the village, traditional healers and midwifes as well as the Volunteers. Members of the CCS will receive a training provided by the Activista and meet with the Activista and the APE once a month to discuss the process of implementation of nutrition activities in the community. More detailed CBN monitoring sessions will be organized at least every 4 months. 24. The MOH, through the respective province authorities, will provide the Provincial TPP with the necessary inputs to implement the CBN Service Package, including: (i) sufficient standardized IEC/BCC materials such as flyers, posters, and also flip charts and laminated images which promote the key family practices such as the use of nutritious foods, exclusive 52 breast feeding, use of micronutrients, including MNP, growth monitoring, among other nutrition- related messages; (ii) relevant available information about facilities, nutrition status of the target population, results of surveys and special studies, and other factors; (iii) copies of standard reporting and recording forms; and (iv) existing technical guidelines and training material, as well as new ones developed during the agreement period. 25. The existing reporting system of the MOH, applied by HSDP will also be used to report the project implementation. The Provincial TPP will report to the DPS, and through it, to the DNSP/DN. As such, the Provincial TPP will provide the DPS with yearly and quarterly reports related to activities undertaken in fulfillment of its agreement with the MOH. The report requirements will be further defined in a monitoring and evaluation plan, which will be incorporated in the NIM and finalized before effectiveness. General IEC/BCC Interventions 26. The IEC/BCC materials will be designed and reproduced centrally by the DNSP/DN. While the TPPs and district health facility staff will implement IEC/BCC activities in their districts, they will need standardized IEC/BCC materials such as flyers, posters, and also flip charts and laminated images which promote the key family practices such as the use of nutritious foods, exclusive breast feeding, use of micronutrients, growth monitoring, among other nutrition- related messages. The AF will support the revision and adaptation of IEC/BCC materials, and the printing and distribution of them to the contracted Province TPP and its consortium members, and also to Type II health centers. At national level the DNSP/DN will contract services to prepare messages and spots to be transmitted twice a year on specific health days, ion national TV and radio, and also at provincial, district, and local radios. Micronutrients and Other Nutrition Commodities, Equipment and Goods 27. The AF will support the procurement of nutrition commodities and equipment, including vitamin A capsules for children 6 to 59 months and pregnant/lactating women; dispersible zinc tablets and ORS for children under 2 years of age with diarrhea; IFA tablets for pregnant and lactating women and adolescent girls; deworming tablets for children, pregnant and lactating women and adolescent girls; MNP for children 6-24 months of age; MUAC Tapes; and height and weighing scales It also includes commodities which will only be used in Type II health centers for the treatment of acute malnutrition, such as RUFT, F75 Nutrition Milk and F100 Nutrition milk. This procurement will be done through the HSDP Coordination Unit in coordination with UGEA and distributed through existing MOH channels down to the province and district levels. Whenever possible such commodities, nutrition equipment and products (for example, scales and MUAC tapes and micronutrient MNP), will be procured through UN supply systems, mainly UNICEF, to take advantage of lower costs and shorter delivery times. Additional efforts will be made to ensure that goods procured centrally by CMAM are distributed from province to each health center on time. 28. As mentioned, the distribution of commodities to the Provinces and the Type II health centers will be done by the MOH, according to its existing distribution channels applied also by 53 the Community Promotion Department for the APE program. Based on monthly needs, Type II health centers will distribute the commodities to the Activistas and APE, where available. During monthly meetings between Activista, APE, CCS and Volunteers, the prior month’s distribution of nutrition commodities will be discussed and the requirements for the next month identified, based on the monthly work plan. Following this work plan, the APE or Volunteer will provide the nutrition commodities to children, adolescent girls and pregnant and lactating women in their communities as needed and during their monthly sessions and household visits. 29. Additionally, the Provincial TPP will be responsible for the procurement and the distribution of the basic equipment which are not already provided through the Type II health centers. This relates to cooking demonstration kits, back packs, gum boots, raincoats, computers, printers and basic stationery, as well as bi-cycles including extra tires for Activista, motor cycles for DNO as well as 4x4 and other vehicles to implement the CNB. These items will be included in TPP contract. Flow of Funds 30. The AF will consider two options for flow of funds. The first flow will be for the payments to 3 experienced TPPs (1 for each province). The TPPs will be selected based on well- defined criteria set by a committee consisting of national and provincial authorities. TPPs will be contracted at national level as Third Party Service Providers to the MOH and will be paid based on actual expenditure and agreed budget, and not according to fixed time-based schedule. Details will be provided in the NIM. Several control mechanisms will be put in place to secure effective delivery of outputs. First, the Provincial TPP’s financial and progress reports will be validated by the respective District and Provincial Health authorities. One experienced Independent Verification Agent (IVA) will be hired by the MOH no later than 6 months after Effective Date on the basis of terms of reference satisfactory to IDA. The IVA will perform twice a year assessments of the quality of services provided by the Provincial TPPs and will verify that the payments were done according to agreed procedures. The team of this IVA should comprise experienced finance and nutrition experts. The IVA will conduct independent verifications of the delivery of CBN Service Packages by each TPP, including through interviews with consumers of CBN Service Packages, inspections of the TPP’s documentation and facilities and employment of community organizations, whose terms of reference, qualifications and experience and terms and conditions of employment shall be satisfactory to IDA, to carry out satisfaction surveys of consumers of the CBN Service Packages being delivered under Component I.b of the Project. 31. Furthermore, the performance of the Provincial TPP will also be assessed at mid-term by a third party based on a set of well-defined technical performance indicators which will be included in the TPP contract. The outcome of this performance evaluation will advise if the TPP contract can be continued, should be terminated or could conditionally be extended. Details will be provided in the NIM. 32. The second flow of funds line will be for all other nutrition national and provincial approved activities, e.g. treatment of acute malnutrition, capacity strengthening/training, knowledge generation/operational research, supportive supervision, monitoring and evaluation as 54 well as the development, multiplication and distribution of the IEC/BCC material. Such activities will be defined in annual Plans of Action that the DPS, SDSMAS and the DNSP/DN will prepare and which will be integrated in the MOH planning and budgeting process. These second flow of funds line will be made available using the HSDP-Bank procedures and through the government- wide Single Treasury Account mechanism. 33. Disbursement Arrangements: taking into consideration the Financial Management rating – Marginally Unsatisfactory – the delays in the submission of IFRs, the recently identified ineligible expenditures and the potential for accountability issues, the Original Project and the AF will use transaction-based disbursements. An amendment to the original credit disbursement letter will be issued. 34. Except for the already mentioned conversion from report-based disbursements to transaction-based disbursements, no significant departure is expected from the financial management arrangement of the original credit, with exception of use TPPs to be engaged as service providers for implementation of CBN Service Package in participating districts. The necessary changes expected are: (i) appointment of an IVA to review payments to the TPPs and assess quality of services provided; (ii) revision of formats and contents of interim unaudited financial reports by negotiations; and (iii) preparation of simplified financial guidelines for distribution to participating districts to be finalized and incorporated in the NIM before Effectiveness Date. Strengthening MOH Capacity 35. As described below, and in addition to other HSDP efforts, the AF will also support the MOH’s overall capacity including CBN specific implementation training, monitoring and evaluation, knowledge generation and fostering innovation under Component III. Improving Human Resources Skills in Nutrition 36. Training will be provided so that national, provincial, district, health center officials and existing APEs can better coordinate, manage (including fiduciary and information management), monitor and evaluate the implementation and effectiveness of the proposed CBN Service Package. This would include pre- and in-service training to the DNSP/DN, Province, District, and type II health center level staff to enhance capacity in nutrition project implementation, monitoring and evaluation. 37. A major MOH constraint in ensuring the implementation of any nutrition program, including the PAMRDC, is the near total lack of trained nutritionists at central, provincial and district levels. For example in Cabo Delgado, only 2 districts have a nutrition technician with mid-level training; and in Nampula only 1 of the districts has a trained nutrition technician (a “nutrition technician” is one who received 2.5 years of training in the Institute of Health Sciences in Maputo, the only school providing regular training in nutrition in coordination with the DNSP/DN). 55 38. A 4-year, Bachelors level, nutrition training program is now available at Lúrio University in Nampula. It will only produce its first batch of graduates this year and it is not clear how these graduates will be integrated into the MOH ranks. (There is some indication that many of these graduates are likely to be hired by private sector hospitals, thus limiting district level benefits and impact). 39. Nutrition activities are normally the responsibility of nurses or other health technicians who have received short term training in nutrition, mostly focusing on clinical approaches in responding to acute malnutrition cases and managed at type II health centers. To improve the overall capacity of the MOH in the planning and implementation of nutrition program activities, the AF will support a multipronged strategy, summarized in the table below. Table 3: Summary of nutrition specific training activities under the AF Level Intervention Comments Central A) Graduate level training in A) The MOH will use its nutrition in universities in Europe and/or normal process of recruiting Brazil to candidates from the MOH at candidates. The DN will any level of the system. identify and contact recognized international schools that will be interested in teaming up with local universities to provide the training in a “sandwich” model if possible. B) Pre-service training: Providing B) The pre-service 2.5-year nutrition training for 90 training will utilize existing Nutrition Technicians (30 per province- training curricula in use in to be implemented under central the Maputo Health Science supervision in each province) Institute, and the DNSP/DN, will work with the DPS in each province to ensure that the course could be provided in each one of the provinces Provinces A) 10 days training of 20 master A) The training will be trainers in the new IYCF guidelines provided jointly by DNSP/DN and TPP personnel. B) 5 days training of existing district health directors (SDSMAS) and nutrition B) Training provided by technicians in Infant and Young Child master trainers with support Feeding. Total 54 SDSMAS and 2 from central level and TPP persons per DPS (60 total). nutrition specialists if needed. 56 C) Training on data management to C) The training on data include nutrition data, and HMIS for 54 management is expected to SDSMASs and 2 per DPS (60 total) draw in the experience of Cabo Delgado DPS, with the TPP- Medicos Mundi. D) 2 days refresher training on D) Training provided by nutrition interventions every year for the master trainers with support 54 SDSMAS. from central level and TPP nutrition specialists. District A) 5 days training in IYCF, for 413 This training will be carried health professionals (Nurses, Medicine out by the master trainers of Technicians or health agents). 1 per the province. It is also Health Center level. expected that TPP nutrition technical staff will provide B) Annual 2 days refresher training support specially in the for each one of the health professionals refresher training process in charge of nutrition at the HC. C) 15 days initial training in nutrition and community interventions for 28 DNOs. Community A) 10 days initial training for 525 A) These (A & B) Activistas and APEs (if available) on the training activities, especially CBN Service Package the DNO and Activista training, will be done by the B) 3 times a year 2 days refresher TPP senior team in close training for 165 Activistas and APEs (if collaboration and with the available). direct support of trainers from the DNSP/DN and the C) 1-week initial training of 21,000 DPS in each province. Volunteers in the CBN Service Package, followed by monthly half-day refresher B) These (C & D) training. training activities will be conducted by Activistas. D) 2-day nutrition training for 2,788 members of CCS 40. Clearly it is important to build capacity and increase the numbers of fully trained nutritionists. The approach planned is to expand pre-service training of mid-level nutrition technicians in Cabo Delgado, Nampula and Niassa. A mid-level nutrition technician requires 2.5 years of training, and those who are already in the pipeline are being trained in Maputo, in limited numbers. Mozambique has an extensive experience in training and utilizing this type of cadres and the MOH already decided to have as soon as possible, a mid-level nutrition technician in each district. The AF will provide funding early-on for such training to happen in the 3 57 provinces, and under the coordination of the MOH’s DNSP/DN and the Directorate of Human Resources. 41. While these mid-level nutrition technicians are being trained, the short-term strategy is to guarantee that each of the districts in the 3 Northern provinces has a nurse or medicine technician who will receive in-service training in nutrition, provided under the direction of the DNSP/DN, supported by the TPP senior nutritionist and the DPS training school. After completing this training, these health professionals will serve as the nutrition focal points at district level, until the mid-level, fully trained, nutrition technicians are on board in 2016 and thereafter. 42. The AF will also provide training to at least 1 health staff in each Type II health center in essential nutrition actions. Such training will be done utilizing the MOH materials and curricula, specifically the new IYCF materials, under the direct supervision and preparation of the DNSP/DN at central level. However, the execution of the training will only be done after the master training-of-trainers has been done by the MOH. 43. At central level, there will be opportunities for health professionals to receive graduate level training from recognized schools aboard, preferably in Europe and/or Brazil, and at the same time allow for exchange of knowledge and experience with other countries in the region, for professionals implementing nutrition actions. 44. All training activities will require the existence of appropriate teaching and learning materials, as well as the existence of job aids in nutrition. Over the years the DNSP/DN and TPPs have developed a significant number of guidelines, job-aids and manuals, but they are often out of stock for long periods. To assure that the training activities have the needed materials, the AF will cover costs of the DNSP/DN at central level (coordinating with the assistance of contracted specialists and TPP partners), the updating, adapting and printing of manuals and job aids in nutrition to ensure that in the 3 provinces each district health facility has the needed manuals, guidelines in ENA and IYCN. Further, the DNSP/DN will be responsible meeting the needs in nutrition training and education at community level for Volunteers in terms of printing sufficient copies, and distribution through the contracted Provincial TPP. Technical Assistance 45. The DNSP/DN will play the key role in the implementation of the CBN activities. The DNSP/DN has only two persons with specialized training in nutrition; thus the AF will provide technical assistance to strengthen central level capacity in the following areas: planning, budgeting and follow-up of the annual plan and budget; definition of standards and guidelines; preparing methodological documents about the organization of the nutrition services at hospital, health center and community levels; organize workshops; support the revision of the training curricula in nutrition for the provincial health schools; develop and adapt nutrition to the MOH routine information system, providing the indicators needed to improve monitoring and follow- up. 46. The AF will finance the contracting at central level of 1 Nutrition Project Management Specialist with extensive African experience in the management of nutrition programs as well as 58 1 Monitoring and Evaluation specialist. Both these experts will work in the DNSP/DN, providing direct support to the Head of the DNSP/DN and the DN Team. It is also expected that the HSDP team will be strengthened by an administrative person who will be in charge of following up the administrative and managerial procedures related to the AF activities. 47. Considering the provinces of Cabo Delgado, Nampula and Niassa have very limited capacity to coordinate, plan and control nutrition activities, it is expected these will be supported by the Provincial TPPs at community level, the implementation of formative supervision at the district level, as well as support for training of nutrition professionals. In this regard, the AF will contract 1 Nutrition Specialist per province with a university degree who has sound technical background in nutrition with at least 5 years of experience in public health nutrition interventions in Mozambique, or similar African country. This nutrition specialist will provide support to the DPS, Community Health- Nutrition section which is tasked with providing nutrition technical expertise to the HSDP focal point in each province. 48. Each Provincial SETSAN in Cabo Delgado, Nampula and Niassa will be supported by a short term consultant to provide technical assistance during the mapping phase of nutrition interventions in the province and to support the development of a multi-sectoral action plan. Technical assistance for each of the three provinces will be provided to undertake the following activities to harmonize and coordinate interventions with other sectors and partners and will work under SETSAN’s guidance: (i) Mapping of nutrition interventions under the PAMRDC that are currently implemented/planned at provincial level (who, where, when and how?); (ii) The creation / strengthening of provincial GT-PAMRDCs; and (iii) The development of provincial PAMRDCs 49. Further, there is need to revise and adapt nutrition IEC, teaching and learning materials as well as graphic presentations of these materials. These will be funded under the AF through funding the services of short term consultants to do these activities under the direct coordination of the DNSP/DN. Knowledge Creation and Monitoring and Evaluation 50. The AF will provide resources to finance needed surveys that will give the basic data on nutrition status, coverage, and operational situation in the districts in each of the 3 provinces. A baseline and a final evaluation survey will be implemented during the first semester of the AF approval, and its final semester, respectively. 51. It is not enough to have information on the nutrition status of children in the 3 provinces and specifically in the areas of community nutrition interventions. Knowing the reasons why mothers and communities use certain kinds of food, cultural determinants as well as socio- economic determinants of feeding practices and behaviors, child care and care seeking practices, will help to better adjust the community interventions and the messages to be designed in order 59 to help mothers to improve nutrition of their children. In this regard, funding will be provided for qualitative and quantitative surveys and operational research activities in Cabo Delgado, Nampula and Niassa. The DNSP/DN, at central level, will define with its technical staff, SETSAN and donor partners the type of surveys and research. Such research will also provide better evidence of the reasons for success or failure of the supported nutrition interventions, and highlight best practices. 52. The National Statistical Institute (INE) will support the DNSP/DN to ensure quality control of surveys, including the base-line and end line. Depending on the availability of the INE team, it will be encouraged to apply for specific research activities, either alone or in partnership with recognized international academia schools known for their work in nutrition, specifically in sub-Saharan Africa. 53. Supportive supervision activities will be carried out at all levels. The DNSP/DN will ensure that there are at least quarterly supervision field visits to each province. A similar process will be carried out from the DPS to the districts receiving support through the AF. Monthly supervision from the SDSMAS to the health facilities will complete the supervision process. The supportive supervision activities will be financed through the Component IV of the Project. Fostering Innovation 54. Difficulties in linking the health information system and nutrition surveillance are highlighted by the lack of updated information about the nutrition situation at district, and community level. This absence of frequent and reliable data jeopardizes the capacity to provide timely answers and to focus attention on areas in greater need. In sub-Saharan Africa there are new methods and experience with Information and Communication Technologies (ICT), such as mobile phone, that are beginning to be operational and of benefit in both urban and rural areas. These new technologies and techniques could improve the capacity of health systems to have timely and quality information on nutrition at community level, delivered to the health authorities. The AF will support the MOH in testing in a limited setting in selected districts, in one of the provinces, the use of ICT – mobile phones to collect data from the Activistas and disseminate information and IEC messages to them. Organizational Arrangements 55. At each level, as with other elements of the HSDP, the MOH will be responsible for coordinating and controlling the AF activity implementation. All existing central level structures of the HSDP will be utilized in the carrying out the implementation. 56. At the Central level: The DNSP/DN will be the technical focal point at the central level responsible to define the strategy and annual implementation plan for nutrition activities to be financed by the AF, integrated in the overall MOH programmatic activities. The DNSP/DN will work in close coordination with the Department of Promotion of the MOH. The DNSP/DN in coordination with all stakeholders will prepare guidelines and standards to be set in a NIM that must guide interventions to be implemented by the TPP at community level but also guide activities aimed to increase the capacity and to generate knowledge and innovation within the 60 MOH at all levels. The DNSP/DN will ensure that annual programmatic meetings will be held at national level, and also that at provincial level; similar meetings will be held to monitor the nutrition activities implementation and prepare annual plans. The DNSP/DN will also have the overall responsibility to ensure that the information system to monitor the CBN Service Package implementation will be in place and linked to the existing HMIS. 57. At the Provincial Level: The DPS will have the overall responsibility to plan and supervise Component I.b implementation. The Provincial SETSAN will provide necessary coordination support to ensure its alignment with other sectoral activities. The activities will be coordinated through the Provincial Chief Medical Officer (CMO) which will have the direct support of the DPS HSDP focal point, and assure all administrative and programmatic activities are carried out as planned. For nutrition technical matters, the Provincial CMO will work through the nutrition section of the community health sector that is under his responsibility. The nutrition section will have the responsibility to: coordinate (with the support of a technical assistant) preparation and execution of supervision activities in the districts, and into the TPP areas; and the collection of data (already being done) provided by the districts and by the TPPs. The CMO will be responsible for coordinating and overseeing the training and refresher training of the health facility staff, and in coordinating with the contracted Provincial TPP team, the training activities and supportive supervision of the districts. 58. At the District Level: The SDSMAS staff will receive basic training in nutrition for them to be able to support the nutrition interventions. One health staff member in the district health facility will be trained to be the district nutrition focal point until arrival of a full time district nutrition officer. The district is the most critical juncture point at which the MOH will coordinate Component I.b implementation. At this level, the TPP responsible for the CBN Service Package delivery in the district will be the main operational partner and the DNO of the TPP will have to integrate his/her activities within the health systems. The SDSMAS will hold monthly meetings with the DNO and TPP representatives to evaluate the previous month’s activities, receive the data collected at community level by the Activistas, and action and intervention plans for the next month. 61 Attachment A The Care Group Approach 59. Care Groups thrive on nurturing relationships between project staff, beneficiaries, health facility staff and the community in general. The model was mentioned by UNICEF in their 2008 Report on the State of the World’s Children and even though there are some variations in the way it is applied, there are 13 required criteria and 4 suggested criteria, proposed by World Relieve and Food for the Hungry, as the best practices for the Care Group Approach: Required Criteria Suggested criteria 1. Be based in peer to peer health promotion, by community positive 1. Conduct formative deviant (PD) or Care Group Leaders (Volunteers), which lead the research, focusing promotion of healthy behaviors. in the key 2. The work load of these Volunteers must be limited-15 to 20 behaviors households per PD mother. promoted. 3. The group of PD mothers must also have a limited number of 2. Care Group Leader members, 15 to 20, and attendance is monitored (best if more than Group (about 5 70% mothers are always present). volunteers in 1 4. The mothers of households meet with the Volunteers at least once group) ratio to per month, better twice a month. . Mothers are regrouped in Care Activista should be Groups (Beneficiary Groups). Volunteers meet between them around 1:9 (social and with the Activista at least monthly. channel capacity 5. The households of the target groups must be visited to reinforce for 1 person is messages given in group meetings and to reach people other than estimate to be the mothers (grandparents, sisters, daughters, husbands etc.). around 150 6. Volunteers collect data on vital events in their communities, birth, people). death, pregnancies. 3. Results indicators 7. The majority of promotion and BCC activities are directed to should be reduce maternal and child mortality through Essential Nutrition measured regularly Actions and Essential Hygiene Actions. at minimum once a 8. The Volunteers use visual teaching tools such flip charts, year to allow for laminated images etc., to do health promotion with groups and at responses to lack the households. of performance. 9. Nutrition promotion activities are done using participatory BCC 4. Social/educational methods. differences 10. Meetings with beneficiary households should be limited to two between Activista hours, to improve attendance and limit requests for compensation. and Volunteers 11. Activistas and Volunteers must receive regular supportive should not be supervision at least monthly. extreme – because 12. All Volunteers must live close (less than 1 hour walking) to their of believes, and beneficiaries and also from the meeting point with the Activista. language barriers 13. Beneficiary Groups must foster respect for women as an explicit for example. part of the project 62 ANNEX 5: Revised Implementation Arrangements and Support A. Expected Beneficiaries 1. The data below and projections provide the basis for determining the possible CBN Service Package coverage for each Province The optimal scenario will be for existing TPPs to bid for Provinces where they already have ongoing programs (ensuring the maintenance of coverage), and expanding activities to additional Districts. Because start-up operations in any new Province and for a new substantive program requires an adaptation period of several months, Niassa Province, with the lowest malnutrition prevalence of the 3 provinces and a limited number of functional TPPs (and none specifically working in nutrition), will have the least coverage at community level. Future Districts and Provinces will similarly require an adaptation period. Expected Number of beneficiaries per province Province Total Total Districts Children < Pregnant Adolescent Population Beneficiaries covered 2years Women Girls 2012 /year Cabo Delgado 8 1,797,335.00 71,893.40 46,730.71 103,346.76 221,970.87 Niassa 8 1,472,387.00 58,895.48 38,282.06 84,662.25 181,839.79 Nampula 12 4,647,841.00 185,913.64 120,843.87 267,250.86 574,008.36 Total Project 28 7,917,563.00 316,702.52 205,856.64 455,259.87 977,819.03 63 B. Organizational Diagrams 2. Below are the organizational frameworks for the entirety of the incremental financing effort and a separate framework for the CBN Service Package implementation effort. 1. CBN Service Package Activity Specific Organizational Framework Director of Public Health MOH- Nutrition Unit HSDP Unit Provincial Health Provincial Health Provincial Health Director Director Director Head of Community SETSAN Health and Medical TPP Program Service Manager Solid Line – Formal Authority District Health Dotted line: Technical support TPP District Director Nutrition Officer Type II Health Center TPP Activista Head Volunteers CCS APEs Beneficiary HHs 64 2. CBN Service Package Implementation Framework Type II Health Center Head TPP-District Nutrition Officer TPP Activista APE 20 Volunteers CCS 15 beneficiary households per Volunteers 300 Households 65 IBRD 33451R1 30° E 35° E 40° E 10° S 10° S Lake La ke TA N Z A N I A To Mtwara Malawi Mocimboa MOZAMBIQUE Mueda da Praia a end Lug Metangula CABO ssa lo DELGADO Pemba NIASSA Me Lichinga Lichinga ue Montepuez MA LAWI ALAWI Marrupa q Catur bi u io To m a Lúr Chipata To a e ZAMBIA Lilongwe oz t Mualadzi To M Pla Nacala To Petauke Mangoche Cuamba NAMPULA Furancungo Ribáu Ribáuè 15° S To 15° S To Zomba Lusaka Fíngo Fíngoè Montes Namule Nampula Moçambique Lago de TETE Zam (2,419 m) Cahora Bassa be Gurué Guru Zumbo Songo ze To Alto Molócue Blantyre Ligo Moatize Milange n ha Tete Angoche un ZAMBÉZIA Lic go Changara Mocuba To Mutoko Namacurra Pebane Sena Za mb Quelimane ZIMBABWE Catandica ez e Gorogosa Inhaminga To Harare SOFALA Chimoio INDIA N O CE AN in To Masvingo MANICA a Pl Monte Binga (2,436 (2,438 m) Beira 20° S 20° S u e i To Bu z Masvingo i q Espungabera m b Nova Mambone e z a Sav Inhassôro To Rutenga M o Vilanculos Chicualacuala 0 50 100 150 200 Kilometers Machaíla To Messina INHAMBANE 0 50 100 150 Miles Chigubo Mapai GAZA Ch a Lim po M O Z A M B I QUE ngane SOUTH po Massingir Inhambane AFRICA Panda SELECTED CITIES AND TOWNS Guija Inharrime Chibito PROVINCE CAPITALS 25° S MAPUTO NATIONAL CAPITAL 25S To Xai-Xai Nelspruit This map was produced by RIVERS Manhica the Map Design Unit of The World Bank. The boundaries, MAIN ROADS Moamba colors, denominations and Matela MAPUTO any other information shown RAILROADS on this map do not imply, on To the part of The World Bank Mbabane Group, any judgment on the PROVINCE BOUNDARIES legal status of any territory, SWAZILAND Zitundo or any endorsement or acceptance of such INTERNATIONAL BOUNDARIES boundaries. 30° E 35° E JANUARY 2007