|1. Project Data:
ICR Review Date Posted:
|Hiv/aids Response Project
Project Costs(US $M)
Loan/Credit (US $M)
|Health, Nutrition and Population
Cofinancing (US $M)
Board Approval Date
|Health (40%), Other social services (35%), Central government administration (20%), Sub-national government administration (5%)|
|HIV/AIDS (29% - P)
Population and reproductive health (29% - P)
Gender (14% - S)
Participation and civic engagement (14% - S)
Social safety nets (14% - S)|
||ICR Review Coordinator:
|Judyth L. Twigg
||Robert Mark Lacey
|2. Project Objectives and Components:|
a. Objectives:According to the Development Grant Agreement (DGA, p. 17), the project’s objectives were “to assist the Recipient in the implementation of its National Strategic Plan through: (i) improving the institutional capacity of the National AIDS Council (CNCS), Participating Ministries, Civil Society Organizations, and the private sector to plan, deliver, and monitor HIV/AIDS response interventions; (ii) supporting Sub-projects aimed at HIV/AIDS prevention, care, and mitigation in local communities; (iii) supporting prevention and care programs for staff in the Participating Ministries and their client base at the regional and national levels; and (iv) strengthening and scaling up of health services for prevention of HIV infection and provision of care and treatment through integrated health networks.”
The Project Appraisal Document (PAD, p. 2) states the objectives in terms of assisting the Government with financing of its National Strategic Plan to Combat Sexually Transmitted Diseases (STDs) and HIV/AIDS. “This strategy is designed to slow the spread of HIV/AIDS infection and mitigate the effects of the epidemic, through prevention, care, treatment, and mitigation activities.”
The objective as stated in the DGA cites assistance with the implementation of the National Strategic Plan as the desired outcome, and then lists in (i) through (iv) a set of outputs intended to achieve that end. The DGA statement does not elaborate on the content of the National Strategic Plan. As the definition stated in the PAD more clearly states the key elements of the National Strategic Plan, this Review will assess achievement of the outcome-oriented objectives elaborated in the PAD: slowing the spread of HIV/AIDS infection, and mitigating the effects of the epidemic.
In June 2007, the project’s objectives were revised to indicate that the Bank was only one player in the fight against HIV/AIDS. The revised objective was “to contribute to slow the spread of HIV/AIDS in Mozambique and mitigate the effects of the epidemic through prevention and care activities” (Project Paper, p. 3).
Both the original and revised objectives point to the same two outcomes: slowing the spread of AIDS and mitigating the effects of the epidemic.
b. Were the project objectives/key associated outcome targets revised during implementation?
If yes, did the Board approve the revised objectives/key associated outcome targets?
Date of Board Approval: 06/27/2007
c. Components:The project contained five components:
1. Community and Civil Society Initiatives (appraisal, US$ 28.0 million; actual, US$ 26.6 million). This component was to empower communities to respond effectively to the epidemic through mobilizing communities, promoting local initiatives, and strengthening the capacity of local actors. A Community and Civil Society Facility held by CNCS was to be created to finance appropriate HIV/AIDS-related activities carried out by eligible applicants, such as community and faith based organizations, non-governmental organizations (NGOs), the private sector, associations, and other organizations. The management of the Facility was to be decentralized to the provincial level.
2. Capacity Building for the Civil Society HIV/AIDS Response (appraisal, US$ 5.5 million; actual, US$ 3.8 million). This component would support efforts to create AIDS-competent communities by improving skills and increasing implementation capacity of implementers, supporters, and target groups active under the Community and Civil Society Initiatives. Activities to be funded included hiring and training “Facilitation Agents” in each province; courses and activities to build awareness and leadership capacity in the public sector, civil society, and private sector; and the formulation and distribution of training modules and packages of information, education, and communication (IEC) materials.
3. Government Multi-Sector Response (appraisal, US$ 7.0 million; actual, US$ 5.1 million). This component would support ministries and subordinate institutions in the development and implementation of HIV/AIDS-related programs directed toward their own personnel (particularly high-risk staff such as soldiers, police, extension agents, teachers, and health workers) and their families, as well as programs directed toward their clients. The program was to concentrate on non-health ministries and other key public sector institutions to respond effectively to the epidemic, with emphasis on prevention and care for infected and affected families. A Focal Point was to be appointed in each ministry. District Administrators were to foster development of District-level HIV/AIDS plans.
4. Strengthening and Scaling Up Health Sector Services for HIV/AIDS (appraisal, US$ 17.5 million; actual, US$ 19.5 million). This component was to scale up the health sector response to the epidemic and to provide technical leadership on treatment and care for people living with HIV and AIDS (PLWHA). It was to support: (i) strengthening of the Integrated Health Network providing voluntary counseling and testing (VCT) and HIV/AIDS-related services in four central provinces; (ii) increasing the supply of HIV-related drugs and supplies, condoms, drugs for opportunistic infections (OIs), anti-retrovirals for the prevention of parent-to-child transmission (PPTCT) of HIV, and post-exposure prophylaxis; (iii) strengthening clinical laboratory capacity for CD4 monitoring and diagnosis of OIs; (iv) measures to enhance bio-security; (v) measures to enhance blood safety; (vi) training and anti-retroviral drugs for post-exposure prophylaxis for health workers; (vii) improved management of OIs; and (viii) monitoring and evaluation of the component and the overall progress of the epidemic.
5. Institutional Development for Program Management (appraisal, US$ 6.0 million; actual, US$ 4.2 million). This component was to support the Executive Secretariat of the CNCS, strengthening its capacity to lead the country in the campaign against HIV/AIDS.
The components were not revised.
d. Comments on Project Cost, Financing, Borrower Contribution, and DatesProject Cost:
US$ 31.47 million had been disbursed at the time of restructuring.
Actual total project costs are not specified in the ICR. As explained below, there was no actual Borrower contribution, but according to the project team, strong exchange rate gains more than compensated for the loss of that US$ 9 million, so that the project's final costs in US dollar terms were greater than the estimated costs, even without the US$ 9 million from the Government. However, the project team did not specify these final costs, and it is not known whether there were fees that should be added to the sum of the actual component costs (US$ 59.2 million) in order to calculate the total final costs.
Financing: The ICR (p. 23) states that the Bank’s total disbursements were US$ 59.2 million. However, on p. viii of the ICR it is indicated that US$ 60.39 million had been disbursed at the last Implementation Status Report (ISR) on June 29, 2011. The ICR does not explain the difference between the Bank’s planned and actual costs.
Borrower Contribution: There was a US$ 9.0 million planned contribution from the Government. The ICR (p. 23) states that the exact contribution is not known. The project team clarified that the Government contribution was intended to go toward taxes, but because of shortages of funds, the Government requested and was granted an amendment to the Grant Agreement changing the project to 100% Bank financing.
On June 27, 2007 the project was restructured to modify the objectives, introduce a new financing modality in which Bank funds were pooled in a Common Fund with those of other development partners (the Canadian International Development Agency, the Department for International Development (UK), the Danish International Development Agency, the Global Fund, Irish Aid, and the Swedish International Development Cooperation Agency), amend some of the key indicators, and extend the closing date by one year to December 31, 2009.
In October 2009, the project was amended to modify its institutional and governance structure. A new Grant Management Agency (GMA) was established in the Ministry of Health to channel funds and facilitate implementation of project activities in participating ministries, civil society organizations, and sub-project beneficiaries; in effect, this GMA took over some of the roles and responsibilities of the CNCS. In addition, US$ 12 million was reallocated to MOH for scaling up HIV and syphilis testing, expanding condom distribution, strengthening links between HIV and reproductive health, and improving bio-safety and nutrition (explaining the greater-than-planned spending on Component 4). A further US$ 3 million was reallocated to the establishment of a Rapid Results Fund (RRF) for prevention; this RRF was supported by various donors and managed by the United Nations Development Programme, supporting proposals focusing on multiple concurrent sexual partnerships, reproductive health and HIV, HIV and tuberculosis (TB), and male circumcision. According to the ICR, this amendment also extended the project’s closing date by another year, to December 31, 2010.
The ICR does not specify when the closing date was extended for the final time, to June 30, 2011. The project team clarified that the second extension of the project's closing date was for eighteen months, not twelve, bringing the closing date from December 31, 2009 to June 30, 2011.
|3. Relevance of Objectives & Design:|
a. Relevance of Objectives:Relevance of the original and revised objectives is rated Substantial. The project’s objectives were substantially relevant to country conditions at the time of appraisal. It was estimated that Mozambique had one of the fastest-growing HIV epidemics in sub-Saharan Africa, with an adult HIV prevalence rate of roughly 12%. Multiple factors converged to create an environment of high vulnerability, including a long and protracted civil war, large population movements, proximity to high-prevalence countries that hosted Mozambique’s refugees, and a deterioration of physical infrastructure and social fabric. The objectives are also substantially relevant to Mozambique’s National HIV Strategic Plan (2005-2009, updated to 2010-2014), with pillars of prevention, treatment, care, coordination of the response, operational research, and monitoring and evaluation. Finally, the project’s objectives are substantially relevant to current Bank strategy. The project was part of the second phase of the Bank’s Multi-Country AIDS Program for the Africa Region (MAP), launched in 2000, whose objectives were to dramatically increase access to HIV/AIDS prevention, care, and treatment programs, with an emphasis on vulnerable groups. The Bank’s Country Partnership Strategy (CPS, 2007-2011), current at project closure, cites HIV/AIDS as “perhaps the single greatest threat to Mozambique’s continuing growth and development” (p. ii). One of the CPS’s three pillars is “Equitable Access to Key Services,” with increased access to information on HIV/AIDS and to treatment as the first listed outcome under that pillar.
b. Relevance of Design:Relevance of Design under the original and revised objectives is rated Substantial. The PAD (pp. 45-50) contains a detailed results framework that plausibly links the project’s activities to its expected outcomes and achievement of development objectives. The PAD (p. 8) identified priority vulnerable groups, at highest risk in terms of both infection and impact: young people (especially girls), soldiers, miners, prisoners, drivers, and commercial sex workers. It also cited three main transport corridors as desirable geographic areas of focus. The PAD (p. 13) cites these groups as target populations, and the project design, particularly Component 3, specifically focuses interventions on these groups. It is not clear, however, that Component 1 contained incentives for community-based subprojects to focus on prevention interventions targeting high-risk groups. The 2009 restructuring, the creation of the RRF, and the allocation of resources toward male circumcision and multiple concurrent sexual partnerships made the design even more substantially relevant, as it incorporated the results of current research on HIV prevention into the project’s activities.
|4. Achievement of Objectives (Efficacy) :|
While the ICR recognizes the contributions of other donors to the fight against HIV/AIDS in Mozambique, particularly after the Bank entered the Common Fund arrangement in 2009, it does not provide information that would aid in an assessment of attribution of observed outcomes specifically to Bank-financed interventions. The Global Fund has made a series of grants to Mozambique: Round 2, 2006-2008, US$ 7.7 million for prevention and care; Round 2, 2005-2010, US$ 88.1 million for treatment and care; Round 6, 2007-2010, US$ 61.3 million for prevention, treatment, and care. The United States Government, through the President’s Emergency Plan for AIDS Relief (PEPFAR), provided US$ 835.6 million in comprehensive support for HIV/AIDS prevention, treatment, and care programs from 2004-2009. The project team clarified that the Bank's major contribution was as a convener, driving the multi-sectoral agenda and mobilizing actors across Government, as well as establishing the National AIDS Council and M&E structures around which all financing was provided. This review therefore assesses, in part, the overall efficacy of the program to which the Bank contributed.
Slow the spread of HIV/AIDS (Original and Revised Objective) is rated Modest. There is no evidence that the project reached high-risk groups most likely to spread infection. The project’s interventions related to male circumcision and multiple concurrent partnerships were well conceived, but took place too late in the project period to have likely contributed to observed outcomes during the project’s time frame. The project team added that prevention activities by the Ministry of the Interior targeting police, and by the Ministry of Education targeting youth, were strong, but specific data are not provided for these programs.
3,771 community-based subprojects were funded. The project provided capacity building for NGOs and civil society organizations, primarily through the hiring of Facilitating Agents. After the mid-2009 restructuring, two proposals were funded involving multiple concurrent partnerships, and two involving male circumcision, meeting the target. Overall, however, according to the ICR (p. 24), the community-based subprojects had limited focus on prevention, with the exception of “some targeting” of geographic areas with a high risk of HIV transmission (border areas and truck stops). The ICR does not provide information on what specific services were provided through the community-based subprojects, nor on their coverage. It does not discuss any prevention activities that were targeted specifically at high-risk groups most likely to spread HIV infection. The project team confirmed that most of the community-based subprojects were targeted at the general population.
According to the project team, after the mid-term review there was more discussion of the drivers of the epidemic, and therefore there was more interest in scaling up activities directed at high-risk groups: truck drivers, commercial sex workers, injection drug users, and men having sex with men. There was promotion of female condoms and treatment of sexually transmitted infections (clinics were opened in high-risk areas, aimed at truck drivers and sex workers, so that they could receive treatment when symptoms appear). The ICR provides no specific data for these efforts, however, and the project team confirmed that there is a need now to scale up these efforts.
557 private sector subprojects were funded, surpassing the target of 450, reaching an estimated 45,000 workers and family members. Most of these subprojects focused on IEC, peer education, distribution of condoms, and VCT.
Focal points were selected in 18 ministries and 20 public or para-statal agencies such as the National Institute of Health and the national airline. According to the ICR (p. 28), disbursements for activities were often late, and the focal points were part-timers who did not receive additional payment for their work on HIV/AIDS. The ICR states that this public sector component “did not consider the strategic role a ministry could play in the national response,” with activities relating only to AIDS in the workplace.
Multiple behavior change communication (BCC) sessions were organized through radio, television, and community theater in all provinces.
10,000 community leaders and 9,162 religious leaders were trained and/or reached through HIV/AIDS awareness interventions, against a target of 500 national leaders and 5,000 provincial leaders.
66.5 million condoms were distributed, exceeding the target of 30 million. The project team explained that condom distribution was primarily through health facilities, with coverage at health facilities almost universal, from the district to provincial level, and special attention to distribution to women of childbearing age. Distribution also took place at bars, kiosks, and markets, where condoms were sold at very low prices. Condoms were also made universally available at entrances to public institutions. Population Services International engaged in condom social marketing, through radio, TV, and other media.
359 voluntary counseling and testing centers were in place, exceeding the target of 100.
Blood banks received training in bio-safety. 100% of blood for transfusion was screened for HIV by 2008, meeting the target, but only 35.5% of blood units were tested under conditions of adequate quality control.
The project team added that the project engaged the Government in continuous policy dialogue on the prevention of transmission of HIV from parents to children (PPTCT), and financed training of staff, procurement of HIV tests, and other inputs to improve provision of PPTCT services.
100% of secondary and tertiary health facilities had the capacity to diagnose and treat sexually transmitted infections by 2007, reaching the target one year early. The ICR does not provide information on the actual use of that capacity to diagnose and treat these infections. The project team later provided the following data on numbers of cases of sexually transmitted infections notified by the Ministry of Health:
These data indicate overall downward trends in reporting of genital ulcers and urethral discharge, which could indicate effective use of installed capacity to treat infections. However, as the project team points out, these data should be interpreted with caution, as they represent only those individuals who sought care in health facilities, and a reduction in cases could represent a reduction in incidence or a reduction in utilization of services.
The project team also later added the following information regarding outreach efforts to high-risk groups (data drawn from the National AIDS Council's 2011 Joint Annual Evaluation Report). No information is provided on the coverage represented by these interventions.
- In November 2007, the Government adopted a plan to accelerate prevention, prioritizing high-risk groups such as commercial sex workers, truckers, prisoners, members of the armed forces, and police. Interventions aimed at these groups were implemented by NGOs, with funding coming from bilateral partners and from the National AIDS Council, whose Common Fund was financed by the Bank until 2009.
- The following interventions took place among commercial sex workers in provinces prioritized because they had high HIV prevalence rates and/or were major transport corridors or areas where major investment projects existed (coal extraction, major road/bridge construction, natural gas).
|Year||Number of contacts between peer educators and CSW||Number of information, education, and communication materials distributed||Number of male condoms distributed||Number of female condoms distributed|
- In 2011, nearly 5,000 men who gave sex with men were reached by prevention interventions including condom distribution, peer education, and provision of water-based gel. Clinical referral services were provided to nearly 500 individuals.
- In 2011, 7,200 long-distance truckers on main transport corridors were reached with condom distribution, counseling, promotion of HIV testing, and treatment of sexually transmitted infections. In 2008, 33,446 truckers received information on HIV prevention.
- In 2011, 23,364 prisoners were reached with face-to-face counseling, distribution of information, education, and communication materials, peer education, and/or referral to health services.
The ICR provides information on the following indicators:
- The percentage of 15-24-year olds who had sex before age 15 was 27.7% in 2006, and 25% for females and 24.8% for males in 2011, against a target of less than 20%.
- The percentage of 15-24-year olds who had sex with a non-marital, non-cohabiting partner in the last 12 months declined from 60% in 2002 to 4.2% for females and 16.4% for males in 2011, against a target of 50%.
- The percentage of 15-24-year olds who used a condom the last time they had sex with a non-regular partner was 31% in 2002, and 33.1% for females and 37.2% for males in 2011, against a target of 37.2%.
In reporting on these indicators, the ICR relies on source material that should have been scrutinized more carefully, and it does not seek verification of baseline and endline data points that do not seem reasonable or that seem contradictory with one another. Also, more reliable and comparable data are readily available. Mozambique Demographic and Health Surveys (DHS) and AIDS Surveys from 2003 and 2009 show the following:
- The percentage of females who know that using a condom prevents HIV transmission increased from 53% to 71%, and men from 71% to 74%. The percentage of females who know that having one exclusive sexual partner prevents transmission of HIV increased from 53% to 73%, and males from 73% to 76%. This is very limited improvement among men, and indicates that 25-30% of adults remain unaware of basic facts about HIV transmission.
- The percentage of 15-19-year-olds who had sex before age 15 has declined slightly (from 28 to 23% for girls, and 31 to 27% for boys). The percent of never-married 15-19-year-olds who had sex in the past 12 months was nearly unchanged for women (from 48 to 47%) and declined slightly for men (from 61 to 55%). The percent of this group who used condoms in the last sexual encounter increased but was still less than half, from 34 to 45% for women, and 31 to 37% for men.
- The percent of men who paid for sex in the past 12 months declined only slightly (from 13 to 9%) and condom use in last paid sex was still low at 28%, compared with 21% in 2003.
- Among adults with 2 or more partners, condom use improved but was still was still low: 24% for women (up from 14% in 2003) and 22% for men (up from 19% in 2003).
These results show modest change in some areas, but levels of knowledge and behavior that indicate still-high risk of spread of infection. The ICR also reports no data on many high-risk groups most likely to spread HIV infection.
The project team later added that the percentage of HIV-positive pregnant women receiving PPTCT services increased from 14.2% in 2006 to 66.4% in 2011.
Mitigate the effects of the epidemic (Original and Revised Objective) is rated Substantial.
The Bank’s Treatment Acceleration Program (US$ 59.8 million, 2004-2008) had a Mozambique component, and therefore the project under review here was designed only to fund procurement of drugs for OIs, PPTCT, and post-exposure prophylaxis. However, the dramatic price drop for ARV allowed procurement of ARV for general purposes under the HARP project, albeit on a small scale. The ICR (p. 30) states that ART is now available in all districts, but it does not provide information on what treatment was specifically provided through the HARP project.
Of the 3,771 funded community-based subprojects, according to the ICR (p. 24), “many focused on mitigation of the impact of HIV infection and thus turned into income-generating projects.” Over 20% of the community-based subprojects “dealt with orphans” (ICR, p. 14). However, no further information is provided in the ICR. The project team later added that the specific activities implemented in all provinces of the country through the community-based subprojects included home-based care, provision of nutrition support and school materials for orphans and vulnerable children (OVCs), and provision of seed money to initiate income-generating activities to families (hammer mills, chicken rearing, small-scale farming, tailoring). According to this additional information, in 2007 455 subprojects supported 428,299 orphans and vulnerable children (an estimated one-third of OVCs in the country), 28,845 people living with HIV/AIDS, and 19,191 households (foster families, and households headed by the elderly).
The ICR (p. 28) states that, through the public sector component, the Ministry of Women and Coordination of Social Action supported orphans and vulnerable children and income-generating projects for women affected by HIV, but it does not provide details.
In 2011, 96.2% of HIV-infected tuberculosis patients received cotrimoxazole, against a target of 100%. In 2011, 10% of HIV-infected persons received isoniazide preventive therapy, against a target of 40%.
The project team provided additional information that the coverage of those eligible for treatment with ARV increased from less than 5% n 2004-2005 to 40% (nearly 290,000 individuals) in 2012. According to the project team, the main contribution of the HARP project was not directly in the procurement of ARV, but in the assistance provided to strengthen laboratory services through procurement of HIV tests, syphilis tests, and general equipment fo improve biosafety, and through the training of staff that provide clinical and preventive services throughout the country.
Efficiency is rated Substantial.
The PAD (pp. 26-28, 80-81) cites an economic analysis specific to Mozambique performed in mid-2001, showing an economic loss in the country due to HIV/AIDS of between US$11 million and US$ 37 million in 2002, rising gradually in subsequent years as the population and GDP increase. These losses would stem from reduced productivity growth, reduced population growth and human capital accumulation, and reduced physical capital accumulation. This analysis also indicated that successful HIV prevention policies could significantly impact economic growth, justifying large expenditures on prevention. However, there is little evidence on whether the project was as effective as the assumptions made in the PAD; a fresh economic analysis was not carried out for the ICR.
According to the project team, there were no overruns in any category of expenditure of the project. In addition, despite the project having been extended nearly three years beyond its original closing date, administrative costs were not substantially increased, in part because of the merging of project funds with the National AIDS Council Common Fund.
The ICR (p. 12) states that the community-based subprojects focused on alleviating the difficult conditions of people living with HIV and AIDS “showed how a small amount of money can go a long way” to provide relief to needy individuals and communities, but it provides no further information about the content of these subprojects or their cost-effectiveness. The project later provided information on the activities funded by the subprojects, but still no analysis of their cost-effectiveness.
The financial management procedures put in place proved to be overly complicated, as two special accounts (one each for the Ministry of Health and the National AIDS Council) resulted in 33 project accounts at the provincial level. Payment procedures were too complex for the provinces and the small community organizations that were sometimes unable to open a bank account. This complexity resulted in delays in implementation of community-based subprojects.
The ICR acknowledges (p. 12) that efficiency would have been enhanced through a greater focus on geographic areas and population groups with the highest risk of transmitting HIV infection. Efficiency of the public sector component was diluted by the large number of ministries involved (ICR, p. 13). After the mid-2009 restructuring, efficient targeting of resources improved through the selection of larger organizations to implement community-based subprojects and by the targeting of some of those subprojects in areas most likely to prevent the spread of infection (multiple concurrent partnerships, male circumcision).
Integration of HIV and TB services during the latter half of the project led to efficiency gains, though the ICR does not provide evidence to demonstrate that this was the case. The project team stated that these efficiency claims are based on the cross-screening of patients. Screening is no longer done along vertical lines, so that a TB worker now knows that HIV status should be checked, and vice versa. The project team later provided additional information from the 2009 UNGASS report on the integration of HIV and TB services, indicating an increase over time in the percentage of TB patients screened for HIV and vice versa. This increase, according to the project team, stemmed largely from a 2008 Government decision to scale up screening of TB among HIV positive patients receiving care in health facilities.
|Year||% of TB patients HIV tested||% of TB patients HIV+||% HIV + TB patients receiving cotrimoxazole||% TB patients on ARV therapy|
|Year||Number of HIV+ individuals screened for TB||Number of HIV+ individuals diagnosed with TB||Number of HIV+ individuals provided with Isoniazid prophylaxis|
a. If available, enter the Economic Rate of Return (ERR)/Financial Rate of Return at appraisal and the re-estimated value at evaluation:
* Refers to percent of total project cost for which ERR/FRR was calculated