Detailed Mechanism Funding and Narrative

Details for Mechanism ID: 5054
Country/Region: Mozambique
Year: 2007
Main Partner: World Vision
Main Partner Program: NA
Organizational Type: FBO
Funding Agency: USAID
Total Funding: $7,925,544

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $415,500

This activity is related to other World Vision activities CT 9157, HBHC 9126 and HKID 9155. WV proposed 4 sites in FY06, but was unable to secure MOH approval for the 4th site, so stayed with 3 PMTCT sites. WV will continue to provide training and technical support to 3 existing PMTCT sites in rural Zambezia province, and will increase program coverage to at least 85% of all first-time antenatal attendees in line with policies and protocols of the MOH. A comprehensive package of integrated PMTCT services, including routine CT, Nevirapine for seropositive mothers and their exposed newborns, couple counseling, family planning, and infant feeding education, will be provided. Seropositive mothers will be referred to mother-to-mother support groups in communities for continuing support and care. All seropositive pregnant women will be referred to the HIV/AIDS care and treatment services site in Mocuba (or eventually the planned new site in Gurue) for appropriate care and treatment. WVI will continue to involve churches and community members in the fight against fear and social stigma which affect seropositive pregnant women and their children. Back-up supplies of gloves, ITN and IPT, and test kits will be procured. In the communities served by these PMTCT service sites, WVI also will work with other USG partners to carry out PMTCT primary prevention campaigns among youth, young people planning to marry, and adult men and women.

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $1,749,000

This funding will support the second year of implementation for World Vision's Mozambique Abstinence and Risk Avoidance (MozARK) community based AB program in Zambezia, a priority province, and Tete province. WV MozARK was the successul awardee for the Mission's FY06 AB RFA for ‘Promoting Abstinence, Faithfulness and Healthy Community Norms and Behaviors'. This activity is linked to World VisionMozARK C&OP_Activty # 12132 for $100,000. This AB activity addresses the gap between knowledge and behavioral practice and aims to increase risk perception among all members of the community. Youth Groups, Parent Groups and District level leadership groups will continue to implement AB prevention activities through WV's existing Community Care Coalitions (CCCs). Youth, especially older youth, single or married, age 15-24, are the primary target of this program and will receive life skills and an age appropriate HIV education. For older and at risk youth, this activity will be complemented with MozARK's C&OP funded activities.

This activity aims to involve all members of the community to create local responses to the epidemic by reducing overall risk. Attention will be placed on youth in the 10-14 year old range, known as the Window of Hope, and more so on the 15-24 year old age group, in which the majority of new infections occur in Mozambique. Programs for adults will expand from focusing on adult's roles as protectors of youth to addressing adult behaviors that increase adult risk (multiple, concurrent partners) and adult behaviors that increase youth risk (transactional or cross generational sex). WV will continue to build on its existing networks and other health and HIV related programs in Zambezia and Tete provinces to rapidly scale up life skills and values-based, gender-sensitive, age-appropriate HIV education programs, and thereby create lasting impact.

The main emphasis area is in Community Mobilization/Participation. Key legislative issues addressed are Gender (Male norms and behavior, reducing violence and coercion and increasing gender equity in HIV programs) and Stigma. This program will weave gender into all programs by raising awareness of the socio-economic and cultural inequalities faced by women and how these inequalities contribute to the spread of HIV. Girls and women will gain skills in building negotiating power in relationships and boys and men will discuss the roles they play in sexual relationships. Stigma will be addressed by creating a greater recognition of stigma, targeting lessons on the youth/community's definition of stigma and identifying ways to address it. PLWHA will also be involved in all activities, including positions of program leadership and facilitation. "B" activities among PLWHA will help address discordant couples and will encourage testing.

This year's funding will also allow for special responsive action in Mopeia district of Zambezia, site of the Zambezi Bridge Construction project. The town of Chimuara, in Mopeia district, is the site for the new Zambezi Bridge construction project, estimated for completion in 2009. The bridge will link Caia, Sofala with Mopeia, Zambezia. Projected studies from Save the Children UK warn of threats of increased child prostitution, rape and other sexual abuse linked to the influx of mobile workers in rural, impoverished districts. "Barracas", the informal and privately managed businesses of sleeping quarters, stores and bars along the river and near the construction, has helped to create a "culture of sexual abuse and exploitation in the form of child prostitution, as well as wide spreak child labor and This AB activity addresses the gap between knowledge and behavioral practice and aims to increase risk perception among all members of the community.

Youth Groups, Parent Groups and District level leadership groups will continue to implement AB prevention activities through WV's existing Community Care Coalitions (CCCs). Youth, especially older youth, single or married, age 15-24, are the primary target of this program and will receive life skills and an age appropriate HIV education. For older and at risk youth, this activity will be complemented with MozARK's C&OP funded activities. of physical abuse" in the river crossing area. HIV prevalence in Mopeia district is above 20%. This partner is currently the only USG AB partner in Mopeia. MozARK may also choose to carry out "B" focused messages with individuals involved with the bridge construction, ferry service , local law enforcement and barraca owners to mitigate sexual exploitation and abuse and transactional and transgenerational sex. Certain activities here can be complemented with MozARK's C&OP funded activities for a holistic prevention approach for higher risk youth and individuals.

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $360,000

This activity is a new component for World Vision's MozARK program and is related to USAID_HVAB_World Vision MozARK Activity #9392. MozARK will receive $300,000 in C&OP funding to complement its AB activities, providing a comprehensive ABC approach to prevention for identified older, at risk youth as well as for adults. While MozARK will not provide condom service outlets, it will strategically program these funds to have a large impact in the most at-risk groups and maximize results by integrating with AB activities. This funding will specifically be used in transport corridor districts, for example, Mopeia district, site of the Zambezi bridge construction where there are populations of truck drivers and sex workers, and focus on addressing individual risk perception as well as community norms around the acceptability of multiple concurrent partners, male sexual norms and behaviors and condom usage.

Funding for Care: Adult Care and Support (HBHC): $652,600

This activity is related to MTCT 9143, HKID 9155, HTXS 9168 and HVCT 9157.

World Vision implements their palliative care program in close collaboration with their OVC program. The Community Care Coalitions (CCC) and their selected caregivers called Home Visitors (HV) as well as the Home Based Care Activists (HBCAs) will continue to work to identify chronically ill persons in their respective communities and provide palliative care through home-based care (HBC). This work will be conducted in close coordination with district and provincial offices of the Ministry of Health (MOH). Caregivers will be charged with making home visits to these ill people (PLWHA stages 1&2 - as defined by the World Health Organization), providing them with material, psychosocial and spiritual support, and appropriate nutritional advice and emotional counseling. HBCA will work with the CCCs to help arrange, as needed, higher levels of palliative care for those clients (PLWHA stages 3&4) who are clearly suffering from ailments caused by AIDS, including treatment of OI, pain management, referrals to ART, malaria prevention, etc. In each district a HBC Nurse Supervisor will oversee the HBCAs and provide direct support to the clients when needed. When possible, legal services to help dying patients prepare wills and burial arrangements will be arranged by the HV These activities are being carried out by the HVs as part of their routine work with PLWHA and OVC which also includes protecting the rights of children and promoting the creation of a memory book as a coping mechanism for the client and family members. The project will provide psychosocial support for the bereaved family.

Overall, World Vision will be seeking to improve the quality and scope of PLWHA palliative care. One element in providing for PLWHA support is the sustainability of the community-based organizations (CBOs) leading the effort. Key to World Vision's sustainability strategy is ensuring that the FBOs, CBOs/CCCs and their member have the capacity to carry out their important PLWHA care and support activities in the long term. To this end, World Vision has developed an Organizational Capacity Building (OCB) Guide focused on strengthening the general organizational capacities (as opposed to solely HIV/AIDS-specific technical skills) of CBOs/CCCs. The iterative three stage OCB process begins with organizational self-assessment, followed by selected training based on the results of the assessment, and supplemented with additional follow-up support. World Vision will apply this new strategy to strengthen 2 local organizations and 40 CCCs.

Under COP07, mechanisms will be put in place to improve the community to clinic linkages. Although, NGOs were encouraged to liaise with local clinics, many volunteers were comfortable working at the community level only. In FY07, volunteers will be required to work along with clinics in caring for PLWHA on ART, with TB patients, patients with OI, STI and other conditions. At least 50% of all HBC clients will need to have a clinic record. Treatment adherence also will be supported by a related USG activity to ensure TB and HIV patients are taking their medicines and not experiencing any overt reactions. In addition, volunteers will be trained to further recognize OIs and to refer clients to the clinic for proper follow-up. Coupons for transport or use of bicycle ambulances will be used to ensure clients attendance. Further training will be held to ensure that HBC supervisors, and volunteers have the necessary skills to handle these new activities.

Under COP07, capacity building of local CBO/FBO will continue with fervor. With a UGS funded AED program, tools and materials will be available for NGOs to use with their nascent CBO in provide quality services and assess and manage outside funding. AED will also provide training on several general topics (on functional organizations, strengthened management, leadership, advocacy, financial management, etc.) which will be open to all NGOs and their partners.

Through this activity, 5,020 PLWHA will receive HIV-related palliative care and 502 per will be trained to deliver HIV-related palliative care.

General Information about HBC in Mozambique: Home-based Palliative Care is heavily regulated by MOH policy, guidelines and directives. USG has supported the MOH Home-Based Palliative Care program since 2004 and will continue with the same basic program structure including continued attempts of strengthening quality of services to chronically ill clients affected by HIV/AIDS. In FY02, the MOH developed standards for home based care and a training curriculum which includes a practicum session. Trainers/supervisors receive this 12 day training and are

then certified as trainers during their first 12 day training of volunteers. A Master Trainer monitors this first training and provides advice and assistance to improve the trainers' skills and certifies the trainer when skill level is at an approved level. All volunteers that work in HBC must have this initial 12 training by a certified trainer and will also receive up-dated training on a regular basis. The first certified Master Trainers were MOH personnel. Then ANEMO, a professional nursing association, trained a cadre of 7 Master Trainers who are now training Certified Trainers, most of whom are NGO staff who provide HBC services in the community. In the next two years, ANEMO will train and supervise 84 accredited trainers who will train 7,200 volunteers, creating the capacity to reach over 72,000 PLWHA.

In addition, the MOH designed 4 levels of "kits" one of which is used by volunteers to provide direct services to ill clients, one is left with the family to care for the ill family member, one is used by the assigned nurse which holds cotrimoxazole and paracetamol and the 4th kit contains opiates for pain management which only can be prescribed by trained doctors. The kits are an expensive, but necessary in Mozambique where even basic items, such as soap, plastic sheets, ointment, and gentian violet are not found in homes. USG has costed the kits and regular replacement of items at $90 per person per year; NGOs are responsible for initial purchased of the kits and the replacement of items once they are used up except for the prescription medicine, which is filled at the clinics for the nurses' kits. An additional $38 per client per year is provided to implementing NGOs to fund all other activities in HBC, e.g. staff, training, transport, office costs, etc.

MOH also developed monitoring and evaluation tools that include a pictorial form for use by all volunteers, many of whom are illiterate. Information is sent monthly to the district coordinator to collate and send to provincial health departments who then send them on to the MOH. This system allows for monthly information to be accessible for program and funding decisions.

In FY06, the initial phase of the assessment of home-based care will be completed. Recommendations from this assessment will inform the MOH on how to improve the palliative care services delivered at community level and what is needed to strengthen the caregivers. Training in psychosocial support is beginning to roll out and is meant to support HBC caregivers as well as the clients and their families. In Zambezia, it was reported that 40% of the HBC clients died during a recent 3 month period. This puts a lot of stress on the volunteer caregiver, who needs support to continue to do his/her job faithfully. A pilot project in three locations will support an integrated care system, strengthening relevant government offices as well as NGOs. The more varied resources, such as food, education, legal and other social services, that are available to the chronically ill, the stronger the overall program.

Funding for Care: TB/HIV (HVTB): $15,688

This activity is related to HBHC activities 9207, 9209,9132, 9133,9139,9126 and HXTS activity 8545.

A new activity, which will be initiated during FY07 addresses the need for a more collaborative processes between clinic based and community based palliative care, especially in relationship to treatment adherence for TB and ARV. Although this has been the focus of community based care since the beginning, improvements can be made in the areas of collaboration and communication with NGO partners that are working in both clinic and community sites. Small amounts of funding will be provided to five partners who offer palliative care under the home-based care (HBC) model. HBC volunteers and their supervisors will receive training on treatment adherence for ARV and TB. Columbia University will develop training materials for ARV adherence under a separate USG supported activity and provide hands-on training to HBC volunteers so that they can assist their HBC clients to adhere to treatment drugs and determine if there is some reaction to the treatment regime. In addition, collaboration will occur with the MOH's TB program to ensure that HBC volunteers are correctly trained concerning the DOTS model and the MOH's vision for improving case detection and treatment success rates.

This activity was designed in collaboration with the emphasis in COP07 on improving TB/HIV programming. The activity is deemed important because of the recent information of mutated strains of TB found in neighboring countries that can easily cross the boarders.

Directly funding the NGO partners will help to build their own capacity in ARV and TB adherence support, creating a permanent buy-in to the importance of this effort. Thus it is expected that all HBC providers will receive training and that at least half of the HBC beneficiaries will be recipients of this expanded community-based service on treatment adherence.

Funding for Care: Orphans and Vulnerable Children (HKID): $2,527,756

This activity is related to: MTCT 9143; HBHC 9126; HTXS 9168 and HVCT 9157.

World Vision (WV) and sub-partner Aid for Development People to People (ADPP) will continue USG-supported OVC programs in 13 targeted districts in the Province of Zambezia and 3 targeted districts in Sofala Province, building on services started in 2004, expanded in 2005 and 2006. Based on this past experience of providing assistance to over 38,621 OVC, WV will continue to identify and document promising practices in OVC programming in Zambezia and Sofala Provinces. WV will continue to focus on OVC affected by HIV/AIDS within the age brackets of 0-5, 6-12 and 13-18 years of age. As all WV projects, clients will be chosen on the basis of need without regard to religion or ethnic grouping.

World Vision's "RITA" Project will continue to provide care and support to improve the lives of OVC through the provision of a comprehensive package of six quality services. RITA will also continue to strengthen the leadership role of communities through the Community Care Coalitions (CCCs) who will continue to be the primary mechanism for providing care and support to OVC, PLWHA and vulnerable households, as well as for referrals to essential services available in the community and clinical setting.

Through the CCCs and other local organizations, RITA (WV and ADPP), will ensure the provision of the six essential services for OVC, as defined by the USG PEPFAR team in Mozambique and the Ministry of Women and Social Action (MMAS). WV will continue to work closely with the Ministry of Health to provide preventative and clinical care for infants and older children, especially HIV-infected children and with the Ministry of Education to ensure that OVC are attending and advancing in school.

For the most vulnerable OVC and PLWHA and their families, emergency food support will be distributed to ensure food security in the short term. At the same time, interventions will be implemented jointly with WV agriculture/livestock projects and other available resources to move ahead to food self-sufficiency. RITA will continue working to ensure that linkages with existing food-security and micro-finance projects are enhanced. WV will coordinate and collaborate with other NGOs, such us Project Hope, so that CCCs, networks and organizations whose institutional capacity WV will strengthen will have access to small grants to better enable them to carry out and expand community-based activities. Additional training will be given to community-based volunteers (Home Visitors - HV), and WV supervisors and volunteers will work closely with the MOH personnel to ensure that adequate care is provided to infants and young children who are part of this program. Also, an added emphasis will be placed on joining with new projects and organizations to advocate for the needs of OVC and to further build their capacity. The training of all CCCs will be ongoing and continuous, and designed to ensure that CCCs have the capacity needed to be effective as well as the organizational maturity required to function over the long-term.

WV will continue to assess the quality of services provided to OVC. In FY06, they have developed standards that fit with community normative levels. Their assessment tools will now measure if OVC under care are receiving services up to the standard set by the community. They will continue to adopt tools and methodology to determine how OVC benefit from services provided over the years.

One element in providing for OVC/PLWHA support is the sustainability of the community-based organizations (CBOs) leading the effort. Key to RITA's sustainability strategy is ensuring that the FBOs/CBOs/CCCs and their members have the capacity to carry out their important OVC/PLWHA care and support activities in the long term. To this end, WV has developed an Organizational Capacity Building (OCB) Guide focused on strengthening the general organizational capacities (as opposed to HIV/AIDS-specific technical skills) of CBOs/CCCs. The iterative three stage OCB process begins with organizational self-assessment, followed by selected training based on the results of the assessment, and supplemented with additional follow-up support. In COP07, WV will apply this new strategy to strengthen 2 local organizations and 40 CCCs.

A special emphasis in COP07 will be to coordinate and expand existing programs of non-governmental organizations dealing with child protection and family support in close collaboration with the Child and Family Initiative ($20,000).

COP07 targets include reaching 43,580 OVC with all 6 services and training 2,900 care providers to oversee the OVC activities in the community and report results to their supervisors.

Funding for Testing: HIV Testing and Counseling (HVCT): $300,000

This activity is related to: HBHC 9126; HTXS 9168; HKID 9155 ; HVTB 9130; and MTCT 9143.

In this activity, WV will continue to support 4 CT sites in Zambezia province (in Mocuba, Namacurra, Quelimane and Gile) and their 8 Satellites sites (2 per fixed service site) offering counseling and testing to19,584 people by 12 trained counselors in Zambezia Province. WV will provide supervision and additional training to strengthen the quality of counseling and to promote couple and family counseling and testing. This activity is linked with the development of the HIV care and treatment integrated network, including essential and effective two way referral systems. WV will continue to involve churches, other local partners and community members in the fight against fear and social stigma related to HIV/AIDS as part of the outreach and promotion related to CT services.

A second activity builds on a pilot authorized by the Ministry of Health in July 2006 for the implementation of community-based counseling and testing. World Vision in cooperation with sub-partner, ADPP in Sofala, will implement community based counseling and testing in Sofala and Maputo provinces expanding upon lessons learned from the MOH approved community-based counseling pilot phase. In both provinces one training for 25 counselors will be held and it is expected that 24,000 people will have access to CT services (12,000 in Sofala and 12,000 in Maputo province) within COP07 implementation.

Funding for Treatment: Adult Treatment (HTXS): $1,905,000

This activity is linked to HBHC 9126 and HVTB 9130. This activity involves construction of clinic facilities which will be used by USG partners in providing treatment services. Thus, the counting of the sites in the activity will be duplicative with other treatments services.

In this activity, World Vision will implement two components: Construction and Treatment Adherence

In FY07, World Vision will construct the following facilities for MOH in Zambezia Province: 1) 3 type II MOH health centers to increase support of HIV care and treatment services ($825,000) 2) 3 staff houses related to these health centers and 7 more staff houses related to other USG supported health centers to retain important clinic staff in rural areas ($400,000) 3) a training centre in Quelimane City to support training of basic and middle level health professionals ($300,000)

In addition, World Vision will improve treatment adherence by improving the collaboration between clinic and community-based palliative care partners. This collaboration is considered a fundamental component of the adherence support for HIV treatment and care. Each clinic will have an NGO supported treatment adherence focal person (a community-to-clinic nurse) who can interact and coordinate community-based care providers. The focal point will refer ART and TB patients to a particular person in the patient's barrio for follow-up, care and support. It has been internationally recognized that to achieve the full benefits of ARV, adequate dietary intake is essential and dietary and nutritional assessment is an essential part of comprehensive HIV care. Based on these findings World Vision will collaborate closely with World Food Program tapping into their existing program to target those HBC clients on ART to improve nutrition. It also has been shown that HIV+ patients are lost after they get tested. World Vision will develop better mechanisms to improve the referral from testing to treatment using the clinic focal persons and HBC organizations. Reliable means of transportation is another activity that will assist treatment adherence. Vouchers, motor and bicycle ambulances, and special vans will be used to address this transportation issue. ($380,000)

Zambezia is Mozambique's most populous province. With an estimated HIV prevalence of 18%, it is also the province with the largest estimated number of people living with HIV/AIDS. However, access to treatment is low, and Zambezia accounted for only 5% of all patients on ART as of June 2006. In order to redress geographic inequity, the Ministry of Health has established ambitious treatment targets for Zambezia. Next to trained human resources, infrastructure is the greatest barrier to treatment roll-out. Staff housing is essential for retaining staff in rural areas. World Vision has extensive experience in Zambezia in health and other areas, including rehabilitation and construction. World Vision will coordinate with Columbia University, the primary treatment partner in Zambezia, as well as other treatment partners, to ensure that the rural health infrastructure developed through this activity supports treatment roll-out in the province.

Subpartners Total: $750,000
Humana People to People: $750,000