World Bank Gives Low Marks for its HIV/AIDS Programs in Mozambique

*This post is a contribution from HIV/AIDS Monitor research partners in Mozambique, Dirce Costa and Eleásara Antunes, Austral Cowi Ltd

Mozambique's response to HIV/AIDS was weak or deficient throughout the past year. -Susan Hume, the manager of World Bank programs in Mozambique, Sept 2008

This was the unfortunate verdict from a joint review by the World Bank and Government of Mozambique of the performance of World Bank HIV/AIDS programs in the country. The meeting, called a Country Portfolio Performance Review (CPPR), was held from 17 to 18 September in Maputo and reviewed the implementation of all World Bank programs in Mozambique, including the Multi-Country AIDS program (MAP) that began in 2003 and is due to end in December 2009. In the scale used for this review, the MAP program was rated as poor overall due to weak financial management, program implementation (disbursements), procurement and monitoring and evaluation. This represents a worsening of the situation since the previous CPPR in March of 2008, with this program area being the only one in the World Bank's Mozambique portfolio to be rated as a "problem project."The poor progress on HIV/AIDS is not necessarily a surprise to the Bank, as we can see in the last WB Mission Appraisal (not publically available, so we have included excerpts here) undertaken to supervise the HIV/AIDS Response Project conducted in close coordination with the Common Fund partners.

The MAP has been rated unsatisfactory from May 2004 until April 2007, when it was brought back to satisfactory status… However, due to the deterioration in the volume of subprojects, and a near complete stop of the private sector component, compounded by a stalemate of negotiations between CNCS (Mozambique's National AIDS Commission) and the GMA [Grant Management Agent], the project is again back to problem status as from April 2, 2008.- World Bank Aide Memoire, Mozambique - HIV/AIDS Response Project Supervision Mission, May 26-June 6, 2008

While the World Bank has been making many suggestions for how to improve capacity across ministries and in the public and private sectors, including contracting consultants, and fostering learning between ministries, these capacity constraints persist in putting a major dampener on disbursement of funds. Based on the Mission Appraisal it is clear that government disbursement of funds is in decline, spending of disbursed funds is low, and most disturbingly, only a fraction of the funds disbursed has been accounted for.

During the period of January – May, 2008 CNCS disbursed a total of US$ 286,780 to line ministries against a total of US$ 505,000 disbursed during the same period in 2007. To date, cumulative disbursements to the public sector amount to US$ 4.2 million. Of this, line ministries have used only US$ 1.6 million (execution rate of 40%)… Similarly, from January-May, 2008, line ministries used only US$ 0.2 million compared to US$0.8 million during January-May, 2007 (CNCS data)… It is also concerning that although CNCS disbursed close to US$ 250,000 to 24 district and provincial public institutions, only 3 institutions accounted for the use of funds in an amount of US$ 2,600 i.e. 1% of the disbursed amount.- World Bank Aide Memoire, Mozambique - HIV/AIDS Response Project Supervision Mission, May 26-June 6, 2008

In a recent piece of research for the HIV/AIDS Monitor project on the flows of funding from donors into the AIDS response in Mozambique, Austral Cowi presented clear evidence on the lack of capacity of CNCS to disburse and manage the huge amount of funds received from WB and GF.One of the issues addressed by the Austral Cowi research team was the speed and predictability of funding from CNCS to civil society organizations. Two examples presented below from interviews illustrate some of CNCS inefficiencies, and the effect they have one the capacity or organizations to operate:

The process is extremely slow and it is never known when the funds will be disbursed. The first request for disbursement was presented to CNCS in November 2006 and the deposit at FBO account was in April 2007. - Key informant interview, local faith based organization receiving funding through CNCS

The approval of financial reports (FR) and the disbursements are too slow, and it is not possible to predict its availability… This waiting period is very painful; the national NGOs … do not have internal sustainability, their functioning depends on these fund… The life cycle of the project was planned to be one year but with these delays on disbursements it is now the third year of implementation.- Key informant interview, national NGO receiving funding through CNCS

M&E capacity was also seen as a critical challenge to the success of MAP programs in Mozambique. Limitations in CNCS' M&E capacity and performance were found in the research on the interactions of donor funding with health systems and on performance based funding conducted by Austral Cowi for the HIV/AIDS monitor project. One of the main findings of Austral Cowi's study on "Performance Based Funding" summarizes some of the challenges for the M&E of NAC:

Although the government with development partners defined a theoretical M&E system, to measure the performance of the national response, through the calculation of 27 key impact, outcome and program output indicators, the majority of them have not been calculated. These indicators require a number of surveys and studies that have never been undertaken... CNCS just partially monitors the AIDS activities implemented by CSOS, and the public and private sector.- "Tracking the effects of donor funds and operations on the health system in Mozambique, Theme 3: Performance Based Funding," Final Report, Costa D. et al, November 2007, Maputo, Mozambique

Without effective monitoring and evaluation, difficulties accounting for and spending HIV/AIDS money effectively through national institutions will be a continuing issue. But, as we can see in table 1, these limitations extend to even executing trainings to put in place the capacity necessary for M&E.Table 1: Indicators of Capacity Building of Civil Society, Public Sector and Private Sector (Jan- March 2008)Source: Technical Progress Report. 1st Quarter ( January - March 2008) Table 5 p22 This raises an interesting conundrum for World Bank programs. In particular this CPPR has highlighted many problems with financial and operational capacity which are undermining programs which are aimed at least in part at building financial management and operational capacity.