Drought Situation in Mozambique - WHO



DROUGHT SITUATION IN MOZAMBIQUE :

NUTRITION ,

HEALTH ,

WATER AND SANITATION

Nutrition

Nutrition can be seen as an outcome of access to adequate food, health and care. The immediate causes of malnutrition are related to food intake and disease status of the individual.

The underlying causes of malnutrition have three essential, yet alone insufficient components. One is related to food security, the other to availability of health and sanitation services, and the third is related to how these resources and others are used to care for the mother and child during vulnerable periods of pregnancy and infancy.

Household Food Security is tenuous in Mozambique at the best of times. Using the national poverty line constructed for Mozambique, 69.4% of inhabitants live in a state of absolute poverty, or food insecurity. The situation is worse in rural (71.2%) that urban areas (62%). The impact of the drought on household food security is discussed in Section … of this report.

The provision of Health and Sanitation Services varies considerably across the provinces. The situation of Health and access to Water and Sanitation are discussed later in this report.

Maternal and Child Caring Practices are known to have a significant influence on child nutrition. Of particular concern are feeding practices (such as the low rates of exclusive breast-feeding in the first 6 months and the low frequency of active feeding of infants) and inadequate hygiene practices relating to food preparation. How women are treated and cared for within a society are reflected by indicators such as the percentage of girls in school, the percentage of girls aged 15-19 that are mothers, and the total fertility rate. In general, women are treated better in the south of the country, compared with the centre and north.

1. Nutritional Status in Mozambique

Stunting is a good long-term indicator of the nutritional status of a population as it reflects historic food intake. Acute malnutrition (wasting) indicates recent changes in food intake. Results from the QUIBB published in 2001 show that 43.8% of all Mozambican children are stunted (49.2% in rural areas) and 5.5% are wasted. Although stunting is higher in the rural areas than in the urban areas, almost a third of urban children are stunted. Twenty-six percent of the total under-five population are underweight, i.e. 12 times the level expected in a healthy, well-nourished population.

Data Source: QUIBB, 2001 DHS, 1997

Protein-energy malnutrition, anaemia, endemic goitre resulting from iodine deficiency, vitamin A deficiency and pellagra (a condition resulting from niacin deficiency) constitute the most common health problems associated with nutrition and food security. Immediate causes of malnutrition are inadequate food intake (both quantity and quality) and diseases such as diarrhoea, malaria, IRIA. Lack of access to adequate health services including maternal and childcare and nutrition education programmes, and illiteracy of mothers are major factors which contribute to malnutrition and would explain higher levels of stunting in rural areas.

The Nutrition Programme of MISAU has an ongoing nutrition surveillance system in which growth faltering and low birth weigh indicators are be measured. Growth faltering in Mozambique is defined as a decline in the weight of the child from one weighing to the next. This indicator is difficult to interpret. In 1999, the overall growth-faltering rate was 9.2%. The high prevalence of low birth weight (12.5%) remains a public health problem and reflects the poor nutritional status of mothers.

HIV/AIDS

As AIDS decimates the labour supply, household agricultural production can decrease significantly. The loss of even a few workers at the crucial planting and harvesting periods can significantly reduce the size of harvest, potentially exacerbating malnutrition. Poverty places households at greater risk of becoming even more food insecure if the household suffers a shock such as the death or sickness of a family member.

Nutrition is one of the key components in keeping people living with HIV/AIDS (PLWHA) healthy. A prolonged food shortage will render PLWHA more vulnerable to opportunistic infections, and will augment the mortality rate due to HIV/AIDS. Consequently, this will increase the number of orphans and child headed households, whose diet is generally meagre and will get worse due to the drought. Effective supply of vitamins is advisable to help keep PLWHA healthy. Organisations involved in food distribution should consider the possibility of supplying vitamins and/or micro-nutrients to all their beneficiaries (as it is usually not known who is HIV positive).

The additional burden that can be placed on caregivers because of deaths within the family or as they themselves become sick, places the household at even greater risk of not being able to obtain and prepare food in appropriate hygienic conditions.

2. Main Threats of Drought on Nutrition

Due to the decreasing access to and availability of food, combined with existing poor food preparation and utilisation practices in terms of food frequency, energy density, active feeding and hygiene (especially for young children) there is a severe threat of an increase in malnutrition in the drought-affected areas. The levels of micro-nutrient deficiency are also likely to increase, impacting in particular upon lactating and pregnant women and children under five.

3. Government Policy

In 1999, the Ministry of Health’s Nutrition Programme developed a Strategy to Combat Micro-nutrient Deficiencies. The Micro-nutrient Strategy is an integral component of the National Strategy for Food Security and Nutrition and will be integrated into the inter-sectoral Food and Nutrition Action Plan. Progress has been made in the implementation of the plan of action particularly in the areas of capacity building, nutrition education (breastfeeding promotion, campaign for vitamin A) and interventions aimed at combating micro-nutrient deficiencies.

Similarly, the 5-year National Plan of the Ministry of Health (2000-2004) has a nutrition component with the objective of reducing morbidity and mortality as a consequence of malnutrition particularly among women and children. The Nutrition Programme continues to address malnutrition problems by:

• Developing guidelines for the implementation of nutritional interventions aimed at populations in critical situations;

• Carrying out research activities on micro-nutrient deficiencies (iodine, vitamin A & iron) and other nutritional diseases in the country and develop strategies to combat them;

• Preparing District Food Security and Nutritional Profiles;

• Developing programmes to combat nutritional deficiencies and diseases, and strengthening the links between improved health care (particularly improved immunisation coverage and the prevention and treatment of diarrhoeal diseases) to improved nutrition;

• Promoting infant nutrition practices with the emphasis on breastfeeding and introduction of adequate complementary foods between the age of 4 and 6 months.

4. Resources

The Government has limited human resources working in the area of nutrition. At the central level there are a small number of staff with advanced degrees in nutrition, and each province has on average only two nutrition technicians. The Governments’ financial resources are also low and the Nutrition Programme relies mainly on external financing for programme implementation. It is hoped that the introduction of sector wide approaches (SWAps) in both health and agriculture will increase resources.

Contingency plan

5. Key Challenges

The key challenges include:

• Increase trained Human Resources: The main challenge facing the nutrition sector is the lack of professional staff to implement the various strategies and policies. The challenge is to increase the number of staff qualified in nutrition. A further challenge is the implementation of nutrition education programmes which are an integral part of the surveillance system but are often neglected again due to the limited qualified staff.

• Status of Women and Girls: The role of women is essential in food production, food access and preparation. Girls’ education is a key factor in longer term improvements in the care and nutrition of the youngest children.

• Community participation and education: Food availability is a necessary but not sufficient condition to improve nutrition, therefore the importance of education programmes to improve knowledge on feeding practices and other care elements, maternal and child health and nutrition is evident.

• Building partnerships: MISAU collaboration with NGOs needs to be strengthened and more information is needed about such organisations. It is also crucial to involve and collaborate with the private sector working in food security and nutrition to implement policies

• Health Service Delivery: Limited access to health services hinders effective coverage of nutrition programmes targeted at women and children, and this increases vulnerability. Improving access to health services by increasing the number and coverage of functioning health facilities, both in terms of improving access to health care as well as specifically looking at improving access to nutritional and food information remains a challenge.

6. Government / UN Response to Current Situation

Assessment and Monitoring

From 4th – 30th June 2002, a series of multi-sectoral assessments will be carried out in the districts identified as being worst affected in terms of food security. These will include a MUAC survey, in which a sample of 900 children per district (30 clusters of 30 / district) will be measured. The assessment will also look at the frequency of diarrhoeal disease in children under five, measles coverage, access to health services, hygiene practices and access to water, and the capacity of the family to respond to threats (child headed versus adult headed households).

Provincial Health staff, with financial and technical support from UNICEF, will participate in the assessments. Data will be collated and analysed at central level with technical assistance being provided by a UNICEF consultant.

To monitor the situation over the longer-term, sentinel sites in the drought-affected districts will be developed, with routine monitoring of weight / height at community or Health Unit level.

Assistance Provided by UN

As part of UNICEF’s normal programme, financial and technical support is being provided to improve management of severe malnutrition and therapeutic feeding centres in the provinces. Increased support will be channelled to those areas identified by the assessments, and in the longer-term additional training will be supported to improve the provincial level’s capacity to manage severe malnutrition programmes.

Expected Areas of Intervention

WHO will provide financial support and technical expertise to the Ministry of Health to update the manual of “Nutrition Interventions During Emergencies” and the training of technicians in its use. Health promotion activities including nutrition education will also be carried out in the affected areas with WHOs technical and financial support. WHO will also participate in further nutrition assessments and surveillance activities in the affected areas with the evolution of the drought.

If the assessment shows the situation in some districts to be critical (MUAC: global malnutrition >10%), supplementary feeding will be started for children under five and pregnant and lactating women, in addition to the WFP food aid programme.

Health

The health status of a population contributes to and depends on the level of development of basic services available within a country. In addition to access to preventative and curative health services, a healthy population depends also on the level of education, access to safe water and sanitation, and access to and availability of adequate food.

1. Health Situation in Mozambique

In general, the health status of the population in Mozambique is a result of the current socio-economic profile of the country. Low education levels, limited access to safe water and sanitation, poor nutritional status and limited access to health care all contribute to the poor health status of the population.

In 1997 the life expectancy was estimated at 42.3 years for both sexes (44.0 years for females and 40.6 years for males). The HIV/AIDS epidemic will have a major impact on this indicator. According to the 1997 census, it was calculated that the life expectancy would increase to 47 years by 2005, but it is now expected to decline to 35.7 years by 2005 due to HIV/AIDS.

According to the 1997 census, the infant mortality rate (IMR) is 146 per 1000 live births but with major differences between sexes (152.9 for boys and 137.8 for girls). The under-5 mortality rate (U5MR) is 246/1000 (251 for boys and 239 for girls). Regional disparities are startling, as are urban and rural disparities (IMR – 101 and 160 and U5MR – 166 and 270 respectively) reflecting the poor levels of health care coverage in rural areas. Maternal mortality is estimated at 1,500 per 100,000 deliveries and the maternal mortality ratio remains one of the highest in the world and is highly influenced by the low position of women in Mozambican society.

The major causes of mortality in the under 5 age group are malaria (18% of deaths), diarrhoea (13%), acute respiratory infections (8%), and measles and neonatal tetanus (3%). Diarrhoea has been found prevalent in 20% of under five-year children.

Mozambique’s epidemiological profile is typical of Sub-Saharan African countries, the main causes of illness and death among adults being common infectious diseases, such as malaria, tuberculosis. Because of the precarious environment, the vulnerability to epidemics such as cholera and dysentery also remains high.

Immunisation

In 2001, only 47% of children between 12 and 23 months were fully immunised: 78% against BCG, 59.2% polio (3rd dose), and 67.5% measles. Urban/rural immunisation disparities exist (85% and 36% respectively), but figures desegregated by sex are not easily available. Coverage of tetanus toxoid vaccination for mothers giving birth stands at 34% (urban 58% and rural 27%). The urban-rural divide indicates the problems related to scattered populations still relying on costly mobile teams. The progressive expansion of fixed vaccination posts, cold chain facilities and outreach facilities through the National Expanded Programme on Immunisation (EPI) will reduce this disparity.

Detailed Immunisation Table from WHO Report

HIV/AIDS

HIV/AIDS has a negative impact on the provision of health services. Care of AIDS patients has overwhelmed health services in many countries, both in the number of hospital beds occupied and in the high cost of treatment. In Mozambique, an estimated 40% of hospital beds are occupied by HIV/AIDS patients. AIDS is also decimating the ranks of health workers.

Children infected with HIV are particularly vulnerable. Intensified immunisation campaigns would help to reduce this vulnerability to opportunistic illnesses. The Government is not able to provide prophylactic drugs through clinics and heath units in the rural areas, though some NGO pilot projects are being started in Tete, Gaza and Maputo provinces.

Although hospitals are overloaded with AIDS patients, the vast majority of patients are cared for in their home communities. Extending health care to communities has the double advantage of strengthening communities’ capacity to cope with the impacts of HIV/AIDS and reducing the strain on facility-based care of AIDS patients. Underreporting of AIDS cases and HIV infections by health administrations seriously hinders the realistic design and planning of health care structures, staffing systems and basic support systems.

Health Service Delivery

Only 30% of the population lives in an area within 5Km of a Health Unit. In the central provinces, access is even lower and Health Units often only offer key basic services with staff having received no formal training.

Pharmaceuticals and Medical supplies

The main challenge with regard to pharmaceuticals is the need to increase resources for purchase and internal distribution of drugs. The Government budget allocations for drugs are increasing but there are still imbalances on drug distribution. Procurement of family planning commodities is outside the national procurement system, but distribution is integrated into the distribution plan of the Pharmaceutical Department of MISAU.

Annex 3 of WHO Report

Human Resources

Serious imbalances exist in staff deployment between provinces and between urban and rural areas. MISAU estimates that 23% of the most peripheral health units and health centres have no qualified health personnel. In addition, programme staffing levels do not correlate to output, eg MCH personnel currently constitute 17% of the total health sector workforce but represent at least 40% of the health care delivery output. After a situation analysis, MISAU established several measures for tackling the problem including provincial training of elementary midwives, increasing training of basic MCH nurses and re-deployment of the existing MCH staff to under-staffed areas.

2. Main Health Threats Caused by Drought

Cholera and Other Diarrhoeal Diseases

The incidence of diarrhoeal diseases usually increases during a drought. This is exacerbated by a reduced access to clean drinking water, to sufficient water for personal and household hygiene, and to existing poor sanitation practices. Cholera is endemic in Mozambique and therefore the likelihood of an outbreak can be considered as high.

Table of cholera cases since January

Immunisable Diseases

During the dry season, there is an increased risk of diseases such as Measles and Meningococcal Meningitis. The morbidity and mortality of measles is especially influenced by the nutritional status of a population.

Skin / Eye Infections

A reduced access to sufficient water for personal and household hygiene can lead to escalation in the number of cases of infections relating to cleanliness. Skin irritations and conjunctivitis are the most common of these, and previous experience in Mozambique shows that this is likely to become a significant issue.

Malaria

Accounting for 70% of all paediatric admissions, malaria is also the major cause of anaemia, low birth weight and miscarriages. In Mozambique, malaria creates immense burdens on families and loss of life. It inhibits productivity and reduces school attendance. The National Malaria Control Programme aims to implement an integrated, sustainable malaria control programme to prevent mortality and morbidity.

In dry conditions however, a reduction of malaria transmission could normally be expected. However this can reverse if even reduced rainfall creates mosquito breeding sites. Again, the morbidity and mortality rates will be influenced by the nutritional status of the population.

Thiocyanate Intoxication

There have been several outbreaks of spastic paralysis caused by Thiocyanate Intoxication in Mozambique since the 1980s. These have mostly been associated with the consumption of embittered cassava insufficiently processed during drought periods. Although this has been most frequently reported in the north, there have been some reported cases in Gaza and Manica provinces.

3. Government Policies

The National Integrated Programme for Mother and Child Health, Family Planning, Extended Programme of Immunisation and School/Adolescents Health contributes to the reduction of maternal, child (specifically school children) and adolescent morbidity and mortality. The National Integrated Plan for Contagious Diseases and the five-year National Malaria Control Strategy also work to improve prevention and treatment of a number of diseases.

4. Resources

Presently, annual per capita spending on health is estimated at around USD 8.84. While the Government’s contribution is currently only 22%, it is programmed to increase annually both in real terms and as a share of total expenditure. In 1999, the Government budget for health increased by more than a third from 1998. The Government covers almost all costs for health personnel. Dependence on external funding sources is high. Of total sector resources, 33% comes from international agencies, 19% form households, and 25% from NGOs, employers and other sources. International assistance pays for 92% of medical and surgical supplies and 77% of all investment expenditure.

Within the UN Contingency Plan some additional supplies were pre-positioned with the Ministry of Health (catheters, ORS, Ringer Lactate, Cholera Treatment Centre equipment, disposable syringes, gloves and sterilising materials, and other small items). However, these have mostly been used to respond to cholera outbreaks at the beginning of the year.

5. Key Challenges

• Increasing access to services to address current disparities in equity of access (particularly in rural areas), staffing , infrastructure and management

• Expanding IEC activities to increase knowledge and to influence positively health seeking behaviour especially in relation to diarrhoeal diseases, complications in pregnancy, to complications in malaria and to sexual behaviour such as increasing the use of condoms

• Development of a Human Resource Development Plan to ensure adequate and appropriate deployment of health personnel

• Acquisition of equipment and additional materials required for the drought related diseases

6. Government / UN Response to Current Situation

Assessment and Monitoring

From 4th – 30th June 2002, a series of assessments will be carried out in the districts identified as being worst affected in terms of food security. The assessment will look at the nutritional status of children under five, the frequency of diarrhoeal disease in children under five, measles coverage, access to health services, hygiene practices and access to water, and the capacity of the family to respond to threats (child headed versus adult headed households).

Provincial Health staff, with financial and technical support from UNICEF, will participate in the assessments. Data will be collated and analysed at central level with technical assistance being provided by a UNICEF consultant.

Assistance Provided by UN

UNICEF and WHO have worked with the Ministry of Health to develop the assessment framework. And technical support is being provided for the compilation and evaluation of the assessment data.

At the provincial level, two consultants have been based in Gaza Health Department and Tete Health Department to assist in the planning and implementation of nutrition and health activities, in particular in response to the drought.

Expected Areas of Intervention

In accordance with the UN Contingency Plan, UNICEF and WHO will provide technical, financial and material support for the implementation of activities in response to the drought. These include activities undertaken to reduce the threat of diarrhoeal diseases including cholera and dysentery, the threat of outbreaks of immunisable diseases, meningitis and plague and the increase of severe cases of anaemia due to malaria. WHO will assist the Ministry of Health with co-ordination efforts and with the planning at central and provincial level with the participation of 10 epidemiologists.

Water and Sanitation

Access to safe water and the practice of safe hygiene behaviours is a major contributing factor to health and development. Lack of these has a negative impact of the health and nutritional status of a population, and subsequently on education levels (in particular girls’ education), and capacities for productive work.

1. Water and Sanitation Situation in Mozambique

Access to Water in Mozambique

It is estimated that in the country there are in total 12,500 water points for safe water supply to the rural population of which 4,500 of them are reported as broken-down. This implies that less than 35% of the rural population has access to a reliable water supply. The major causes of the breakdowns are related to poor community involvement, weak preventive maintenance system, lack of a spare parts network near to the community, and the continued reliance on old pumps. Although coverage has slightly increased, there is strong consensus that a greater focus needs to be placed on community involvement through Demand Responsive Approach (DRA) in all aspects of rural water supply and sanitation in order to ensure sustainability. This is reflected in the Government’s policy and strategies for rural water supply and sanitation, widely viewed as a positive development for the sector.

Coverage Tables from NOA

It is important to note that although coverage or access ratios for urban and rural water supplies have increased to the target levels expressed by the Government, care must be taken in interpreting these figures. Issues of quality, quantity, and availability (i.e. available 24 hours per day, 7 days per week) are not fully considered. For rural areas, for example, coverage is calculated on the basis of one protected water point for every 500 people within a radius of 500 metres. Estimates for rural coverage also assume that all known protected water points are functioning properly which is far from the case. Experience has shown that it is common for about one third of all water points to be malfunctioning while in many sparsely populated rural areas it is often difficult to find 500 people living within a radius of 500 metres of a water point. This infers that coverage is likely to be far lower in real terms than expressed here. The same concepts apply to the sanitation situation.

Hygiene Behaviours and Access to Sanitation

In relation to rural sanitation, very little is known regarding access to improved sanitation facilities. However it is nationally estimated that around 26% of the population has access to improved sanitation facilities.

Inappropriate household water management, excreta disposal, and personal hygiene practices contribute considerably to unhygienic conditions which exist close to communities, creating a breeding ground for disease and the possibility of diarrhoea, dysentery, and cholera. Repeated diarrhoea is a major cause of malnutrition and underweight, leading to susceptibility to other illnesses. Diarrhoea causes 13 percent of under-five deaths. Epidemiological data show high rates of faecal-oral transmitted diseases.

Women, with the major responsibility for collection of water and for childcare at household level, perform a key role in water and sanitation and are potentially significant agents of change.

HIV/AIDS

The provision of safe water and sanitation is essential for the prevention of opportunistic illnesses in people living with HIV and AIDS (PLWHA). The existing poor access to these, compounded by inadequate hygiene practices will have a particularly negative impact on PLWHA, and this will only increase with the effect of the drought on access to water and the ability to implement safe hygiene practices is reduced.

2. Main Threats Caused by the Drought

A significant proportion of the rural population (65%) rely on insecure water sources (shallow hand-dug wells, small streams, ponds, rivers). Those relying on these surface water sources are already experiencing some difficulties in particular in parts of Tete, Inhambane and Gaza provinces (districts habitually dry). If the rainy seasons for the next few years are below average, as predicted, almost all of these sources will be affected.

For boreholes and deep wells, the water tables throughout the country should be currently fairly well charged, having had good rainfall for the past few years. However, little accurate information on rural groundwater conditions in the affected areas exists. As the water table slowly draws down during the dry season, it can be expected that many of these sources will dry partially and some totally.

As the access to water is reduced, populations will be forced to travel greater distances to find water, and available sources will be put under significant pressure. Experience from the drought of 1992 – 94 showed that available boreholes with hand-pumps often suffered frequent breakdowns due to the increased usage. In the meantime, if the drought continues and there is consequently no aquifer recharge, the water levels will continue to go down resulting in some water points becoming unusable.

The problems described above are likely to impact on the amount of water available within the household for personal and household hygiene. The consequences of this will be seen in an increase in the cases of diarrhoeal diseases, and higher rates of skin and eye infections. This in turn will negatively impact on the health status and coping mechanisms of the members of the household. This contributes to increased human poverty.

3. Government Policy

The Government Policy for the Water Sector focuses on development of infrastructures necessary to ensure access to basic services mainly for the low-income groups in rural and peri-urban areas. This is in line with the National Action Plan for the Reduction of the Absolute Poverty (2001-2005). To ensure sustainability and maximise benefits the set pursues two strategies: effective involvement of the communities and integration of water sanitation and hygiene.

In line with the decentralisation, implementation of water, sanitation and hygiene promotion activities are undertaken by the provinces in co-operation with NGO’s and private sector.

As part of the emergency preparedness the Government has established under the INGC a working group on Shelter Water and Sanitation chaired by MOPH/EC.

4. Resources

While efforts are being made to build capacities of provinces to undertake the new roles and responsibilities, provinces have difficulties in attracting qualified and experienced personal. This is often resulted in weak co-ordination among all stakeholders.

As part of the UN Contingency Plan, various water, sanitation and hygiene supplies have been pre-positioned and most of them could be used in response to the drought emergency. These include Water Treatment Plant, water storage bladders with tap-stands, chlorofloc sachets, jerry cans, buckets, and plastic latrine slabs.

5. Key Challenges

The overall response to water and environmental sanitation conditions should focus on increasing sustainable access for rural and low-income groups and promote improved behavioural change. It is vital to ensure that water, sanitation, and hygiene promotion interventions are planned with communities. However, it is important that the need for community interventions to be technically and financially sustainable does not prevent poorer communities from benefiting from adequate water and sanitation facilities. Furthermore, communities must be made aware of local water issues so that an informed decision is made in agreeing appropriate interventions. Communities must also be supported in obtaining the relevant information in order to allow them to make informed decisions regarding their own development priorities and strategies.

Provision of facilities needs to take place in tandem with hygiene promotion activities in order to maximise interventions and community well-being.

A number of barriers to improving access to water and sanitation exist in the context of the drought, namely:

• Weak co-ordination of the various actors in the sector in particular at the provincial level.

• Lack of updated information on the extent of impact of the drought, on water facilities susceptible to drought conditions, contributions of the various players.

• Lack of involvement of users in design and implementation of projects

• Lack of empowerment of women as powerful change agents in hygiene practices.

• Lack of emphasis by technicians on social issues related to water systems (technicians concentrate on technology);

• Under-utilisation of NGOs and the private sector;

• Strong cultural taboos and beliefs interfering with behaviour change.

• Difficulties in implementing demand responsive approaches in the context of the drought emergency.

6. Government / UN Response to Current Situation

Assessment and Monitoring

From 4th – 30th June 2002, a series of assessments will be carried out in the districts identified as being worst affected in terms of food security. Among other issues, the assessment will look at the frequency of diarrhoeal disease in children under five, access to water, and household sanitation and hygiene practices. Results will be available by the end of June and will be used to finalise the drought emergency response plans.

In the longer-term, support will be provided to the Provincial Departments for Public Works to monitor critical water sources.

Assistance Provided by UN

UNICEF is providing technical and financial assistance to the provinces to undertake the assessment. At the request of the Government and as part of the emergency preparedness, water and sanitation supplies have been ordered and are in position around the country.

Expected Areas of Intervention

UNICEF will work to support the Ministry of Public Works and Housing to plan, implement and monitor response actions to the drought situation. Results from the assessments will define the extent and geographical coverage of interventions, but given the experiences of previous droughts in Mozambique, the actions that will be taken to increase access to water supplies will include:

• Rehabilitation of malfunctioning water facilities through replacement of broken pumps and flushing of old boreholes

• Establishment and capacity building of the community water committees

• Development of new water facilities in rural areas (wells / boreholes)

• Trucking of water

• Provision of water treatment supplies

In addition, some education activities to improve existing hygiene and sanitary conditions will be implemented:

• Promotion of appropriate hygiene and sanitation practices

• Campaign for better use of available water supplies, in particular in urban and peri-urban areas

WHO will provide technical and financial support to RESP (IEC Unit), Ministry of Health at the central and provincial level for the revision of the “Emergency Manual on Health Promotion Activities for Community Volunteers” and the implementation of the hygiene promotion activities.

Education

1. Situation of Education in Mozambique

Primary Level

In EP1 schools, 32% of children attend only one shift and not a full school day. In 1999 it required 13.1 years (males 12.7 and females 13.8) for the average pupil to graduate from EP1, rather than the five years were envisaged. Still, this represents significant progress over 1992 when an average of 15.5 years per graduate was recorded (14.5 males and 16.6 females). The pupil: teacher ratio at EP1 is 62.2 with a pupil: class ratio of 46.9. For the large majority of children, the language of instruction is not their mother tongue. Annually, about 30% of all children repeat at least one class, 8% drop out, and only 8% complete the first cycle without repeating. Only 32% who enter the first grade eventually graduate from EP1. 32% of all teachers have no training, and only 24% are women.

|Table 6 Primary Education Indicators |

|EP1 indicators |1997 |Boys |Girls |1999 |Boys |Girls |2000 |Boys |Girls |

|Gross Enrolment Rate (%) |68.2 |79.7 |56.7 |75.6 |86.3 |64.8 |96.6 |102.9 |78.3 |

|Net Enrolment Rate (%) |38.5 |42.9 |34.1 |43.6 |47.4 |39.8 |53.8 |58.1 |49.5 |

|Dropout Rate (%) | | | |18.3 |17.8 |19.1 | | | |

|Repetition Rate (%) | | | |25.0 |24.3 |26.1 | | | |

|% Completing Grade 5 | | | |46.2 |48.9 |42.8 | | | |

Source: MINED

Secondary and Higher Education

As a consequence of the inefficiencies of primary schools, secondary education is also subject to low participation rates and low quality. Only 7% of primary school graduates enter the first cycle of secondary education. The small number of secondary schools, 71 at ESG1 and 18 at ESG2, limits access. Most secondary schools are located in urban centres. Schools in rural areas are boarding schools with few resources for quality education. With a repetition rate of 41.4% (46.5% male and 53.5% female), the efficiency of the secondary level leaves much to be desired.

As with the transition from primary to secondary level, the curriculum and quality of secondary education does not allow for smooth progression to tertiary levels such as university and technical/vocational institutions. Only 1% of students enter higher education institutions; the further and higher education sub-sector is small and under developed and in need of expansion and reform. The World Declaration on Higher Education for the 21st Century suggests that “without adequate higher education and research institutions, no country can assure genuine endogenous and sustainable development.” The Declaration further suggests that “developing countries cannot reduce the gap separating them from the industrially developed ones” without a dynamic higher education sector. A key goal of the new Ministry for Higher Education Science and Technology is an increase in the participation rate for higher education, improved management of state and non-state higher education facilities and a further diversification of the sector to allow for greater provision by non-state entities including the private sector. Additionally, the intention is to facilitate a higher level of research and application of science and technology to allow higher education to contribute to economic and social development goals of the country.

Teachers and Teacher Training

The crisis of teacher supply requires urgent attention. One third of teachers are not trained, with a much larger proportion of untrained teachers outside urban areas. The growth in enrolment, particularly in primary education, is outstripping the capacity of the system to produce sufficient trained teachers, and the ravages of HIV/AIDS will further undermine the supply of teachers in the years ahead. To improve the efficiency and effectiveness of teacher education, a unified teacher training system, linking a wide range of current initiatives, including the use of distance teaching and learning strategies needs to be promoted. Further attention is also required to improve the status of teachers through provision of accommodation and increased salaries.

HIV / AIDS

HIV/AIDS has a multiple, and generally negative impact on education. It affects the demand for education, the supply of educational services, the quality of education, and the management of education. In the context of the drought, this situation is likely to be intensified.

2. Main Threats Caused by the Drought

The drought is expected to cause higher levels of pupil absenteeism and drop-outs mainly due to: (1) an increased need for children to contribute to family labour children - having to spend more time searching for food, fetching water or caring for other family members (younger children / elderly); and (2) a reduction in disposable income for expenditure on the children’s education within the household.

Higher absenteeism will in turn have an impact on the levels of performance, and will ultimately result in even higher repetition rates. If the dry spell continues there is likely to be a negative impact on school enrolment for the next school year (January 2003).

3. Government Policy

Mozambique boasts key right-to-education clauses in its Constitution. It has also formulated and publicised a National Education Policy, and the Education Sector Strategic Plan (ESSP) which has the full support of the donor community. The poverty reduction priority for education is improved access, especially in rural areas, reducing gender disparities in both admissions and school performance. Current admission and enrolment rates are being improved and the school network expanded through the construction of new classrooms, and the recruitment and training of teachers.

MINED has prepared an Action Plan to address the HIV/AIDS pandemic which focuses on providing prevention activities for secondary school pupils, providing life skills training for pupils and teachers, and support for teachers living with HIV. Children affected by HIV/AIDS need to learn in safe, stable environments and gain the knowledge, skills, and values needed to develop together with their peer and communities.

Contingency plans for the drought are being prepared by a working group in the Planning Directorate, following similar procedures used during previous emergencies.

4. Resources

The improvement of quality and the implementation of planned reforms require increasing the allocation of resources to the education sector. In 1997 the Government expenditure on education was 15.4 % of total public expenditure and 2.9% of GDP. The budget of MINED for 2001 is 1,320.2 billion meticais (800.1 billion for salaries and 520.2 for goods and services). This is still below the target set under the mid-term expenditure framework. A declining budget in real terms is a concern, taking into account the opportunities available for additional resources to be released to education under the HIPC arrangements.

Within the UN Contingency Plan, UNICEF will support the Ministry of Education to assess and respond to an emergency situation. Within this plan, a contingency stock of pupil, teacher and school kits have been pre-positioned around the country. The use of these will be reoriented to those areas most affected by the drought.

5. Key Challenges

• Continued expansion of the school network through construction and rehabilitation

• Developing teacher education processes through a unified system under MINED supervision

• Promoting family and community involvement in education

• Expanding the scope of an integrated health programme (including attention to the nutritional needs of pupils through provision of hot meals) for schools, out-of-school youth and communities

• Teacher training as well as parent education on Early Childhood Development delivered via non-formal education channels

• Educating young people about HIV/AIDS – about the causes, risk factors and prevention

• Ensuring continued schooling for HIV/AIDS-affected children and orphans

• Training key personnel at central and provincial level in education planning and financial management, and in pedagogical supervision

6. Government / UN Response to Current Situation

Assessment and Monitoring

The Ministry of Education is working with the Provincial Education Directorates to identify sentinel schools in the drought-affected districts. These schools will collect data on attendance rates and reasons for absenteeism and report back to the provincial authorities on a monthly basis. The Provincial Education authorities will supervise and monitor this process.

Assistance Provided by UN

UNICEF has been working with the Ministry of Education to identify the numbers of school children living in the districts considered to be affected in terms of food security due to the drought. Support for planning and co-ordination of their emergency response will also be provided.

Expected Areas of Intervention

Under the UN Contingency Plan, UNICEF will support the Ministry of Education to maintain access to basic education. UNICEF has supplied a contingency stock of pupil, teacher and school kits to be used in case of an emergency situation. As there have been no floods / cyclones this year, the Ministry of Education and UNICEF are planning to reorient the use of this stock for the areas affected by the drought. In addition, support will be channelled to the Provincial Education Departments to enable them to monitor the situation of school attendance.

Special Protection

1. Situation in Mozambique

High level political commitment to women and children has been demonstrated in Mozambique through the ratification of the CEDAW (1993), CRC (1994) and the African Charter on the Welfare and Rights of Children. In addition, policy development took place in the areas of youth, social integration of children and disabled children. Nevertheless, the combined effects of poverty, HIV/AIDS, and social dislocation due to population movements during the civil war mean that the number of children in need of special protection remains high. By end 2002, there will be an estimated 435,000 children in Mozambique who have lost their mother or both parents due to HIV/AIDS. Although exact numbers are not known, there are children involved in exploitative and harmful labour. Problems of abuse, neglect and sexual exploitation exist, and over 50,000 children are living with disabilities

HIV / AIDS

Mozambique has one of the highest HIV prevalence rates in the world. It is estimated that in 2002, more than 1.3 million Mozambicans are infected with HIV – 13.8% of the adult population. Over 57% of the Mozambican adults living with HIV are women. Data from 2000 shows that the epidemic is particularly severe in the central provinces of Tete, Manica and Sofala with the average HIV prevalence exceeding 19%, and in the southern province of Gaza with more than 16% of the population infected. The provinces hardest hit by HIV coincide with the drought-affected areas of the country.

In 2000 there were at least 60,000 new maternal orphans. The number of children in Mozambique aged under 15 and orphaned from their mother is expected to reach 1.12 million by 2006, with the increase due entirely to the impact of HIV, and therefore having a greater impact in the central region. In the past, most orphan children have been absorbed into extended family networks, however, with the advent of AIDS, the extended family has become over burdened, increasing the risk of children loosing out on school opportunities, reduced access to health and other social services, loss of inheritance and putting them in situations of risk such as sexual exploitation, child labour and exposure to HIV.

Child Labour and Sexual Exploitation

Although the Labour Law prohibits the employment of children under 15 (except with the agreement of the Ministries of Labour, Health and Education as well as their legal guardians), children do work in various sectors.

A rapid assessment of the situation of child labour in Mozambique focused on children who work as domestic workers, traders and in agriculture. The results suggest that the worst forms of child labour are in commercial agriculture (cotton), domestic work and child prostitution. For most of the children working hours were long and payment extremely low. Working girls are especially exposed to all forms of abuse, including sexual abuse.

The data indicate that many children started working as a consequence of family break up, through either death or separation of the parents and the subsequent weakened economic power of the family. Most children work in order to contribute to the household income or because school is not affordable. The law prohibits minors from undertaking heavy or dangerous tasks that require significant physical strength, but since most child labour takes place in the informal sector, labour laws are difficult to enforce. More detailed studies are needed to verify if the legal mechanisms are being respected.

Landmines

Landmines in Mozambique are not randomly scattered across the country but were laid tactically to protect villages and infrastructure. However, no reliable maps exist indicating the locations of these mines. This is now hampering development by denying access to the assets they were originally intended to protect. There is an increased presence of landmines around conflict lines, but the nature of the extended conflict blurred these areas to encompass virtually all of the country, including many of its international borders. With the floods in 2000, landmines were washed from higher lying areas to previously cleared areas, causing renewed worries for the population in these areas.

2. Main Threats Caused by the Drought

HIV / AIDS

In many of the drought stricken areas, the impact of HIV/AIDS has already resulted in high numbers of child headed households, households with older caregivers caring for orphans, and other families with a high number of vulnerable children and adults infected and affected by HIV/AIDS. The drought will further stretch the capacities of these safety nets to provide care and protection for vulnerable children. These conditions force children and their families to look for alternative means of survival to ensure livelihoods, that might put children at risk where their rights are violated and/or reduce their access to basic services. Many girls will have to stay home and care for the ill as well as take care of domestic chores, limiting their access to education. As community resources are stretched, discrimination against AIDS orphans or people living with HIV or AIDS could increase, reducing access to support mechanisms for these groups.

It should be noted that HIV prevention initiatives will face an additional challenge among distressed and impoverished populations whose main concern will be immediate survival. The situation is therefore likely to fuel complacency about the HIV epidemic.

Child Labour

Boys and girls may be forced into various forms of child labour to assist with the household income, reducing their educational opportunities and putting them at risk. Young girls may be exposed to sexual and economic exploitation in the search of alternative means of earning an income. This will place them at increased risk of contracting HIV.

Landmines

The threat of exposure to landmines might be further increased due to especially children and women being forced to forage for water and food by venturing into areas, which have not previously been cleared of landmines.

3. Government Policy

HIV / AIDS

Approved in 2000, the Government’s Nation Strategic Plan (2201 – 2003) out lines the following priorities: (1) Prevention activities focusing on young people and highly mobile population and their sexual partners; (2) Improvement in the quality and coverage of VCT, care and treatment; (3) Impact reduction through support to activities aimed at people living with AIDS and children infected by AIDS; and (4) Focus on the Development Corridors.

Beyond the health sector, the Ministries of Education and Youth have developed and are currently implementing programmes to equip young people in- and out-of-school with information and life skills to protect themselves and facilitate their access to youth-friendly health services. The Ministry of Social Action, through their sectoral plan on HIV/AIDS, have finalised their strategies for the care and protection of children made vulnerable by HIV/AIDS and implementation is underway in collaboration with NGOs and community based organisations.

Child Labour

Following a rapid assessment carried out in 2000, a national strategy on child labour was elaborated and approved by the Consultative Council of the Ministry of Labour which set the stage for a national seminar on child labour in which a draft plan of action to address the worst forms of child labour was drawn up. UNICEF is working to support the development of legislation on child domestic labour, as it was one of the three worst forms of child labour identified.

Landmines

The government created the National De-mining Institute to co-ordinate all mine actions and mine awareness campaigns in the country and this institution has now developed a 5 year plan of action to address landmines in Mozambique.

4. Resources

HIV / AIDS

The National Strategic Plan remains largely unfunded. According to the revised budget presented by the National AIDS Council in 2000, the implementation of the National Strategic Plan is costed at $253 Million for the period of 2001-2003. However, these figures do not reflect key new interventions, such as Home Based Care; ARV treatment, PMTC, and others which were not included at the time of the formulation of the NSP in 1999. Over USD 100 million were pledged by donors in December 2000 but very little has been disbursed. The AIDS Common Fund, launched in Nov. 2001, aims to pool additional external funds primarily to support CVOs. Procedures and systems for the management of the funds are been established but pledged donor funds have yet to be disbursed. Funding for the sectoral plans on HIV/AIDS are also limited. Mozambique is preparing a funding proposal for the Global Fund (2nd round) and has also officially requested a World Bank loan to address HIV/AIDS.

Child Labour

UNICEF is currently finding the dissemination of the findings of the rapid assessment and the draft national plan of actions, as well as the development of legislation and action in the area of child domestic work. However, few other bilateral and multilateral partners are involved in this area.

Landmines

Landmines awareness campaigns have been supported by UNICEF through Handicap International who has been the co-ordinating institution in the area of mine awareness. This responsibility was late 2000 handed over to the IND. Currently, IND have not been able to fill the vacuum created by Handicap international in co-ordinating the area of landmine risk awareness and education.

5. Key Challenges

HIV / AIDS

• Level of awareness and life skills development: strategies to develop increased knowledge and skills to address and cope with the issues relating to HIV/AIDS, and supported by shifts in social and economic relations between men and women. This may be increasingly difficult during the drought period, as more immediate concerns are likely to draw attention away from this issue.

• Stigma: characterised by silence, fear, discrimination and denial, stigma is a major factor fueling the spread of HIV/AIDS in Mozambique. A new legislation was passed to protect HIV positive workers from dissemination in the workplace, but there are still no clearly articulated strategies to address this important issue, although there is recognition of the potential role of PLWAs and religious organisations.

• Access of Children Affected by HIV/AIDS to Basic Social Services: Strategies to ensure the care and protection of orphans and other children made vulnerable by HIV/AIDS need to be better articulated and implemented. Many of these children lack food, shelter, medical care, school fees, protection from neglect and abuse, economic support and emotional care. Many find themselves at high risk of HIV infections due to their living conditions. These children may suffer increased discrimination as a result of the additional pressures placed on communities by the drought. Many find themselves at high risk of HIV infections due to their living conditions.

Child Labour

• Finalise the draft National Plan of Action, ensure multi-sectoral participation and action for its implementation in all parts of the country.

Landmines

• Building the capacity of IND and its partners in the area of mine risk education and awareness, and strengthening local NGOs to build on the work already done in the country in this area.

6. Government / UN Response to Current Situation

Louise I am not sure about what to write here …. The rapid assessment will more clearly identify what needs to be done, but key would be that any intervention needs to take into consideration vulnerable groups and their capacity, and would need to address rights violations if they are directly related to the drought (i.e. increased exploitative child labour, prostitution etc.)., strengthening work in the area of OVCs and HIV/AIDS …

Assessment and Monitoring

From 4th – 30th June 2002, a series of assessments will be carried out in the districts identified as being worst affected in terms of food security. These will collect data on critical household status due to the drought.

Assistance Provided by UN

WHO is already providing financial and technical support to Sofala, Gaza, Manica and Tete particularly in Counselling and Voluntary Testing, Home Based Care and treatment of opportunistic infections. In the above named provinces WHO supports training of district health staff, provision of drugs and supervision.

Youth friendly health services?

Expected Areas of Intervention

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% of male rural children aged 7 – 14 years working

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% of female rural children aged 7 – 14 years working

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Under 5 Mortality Rates

Source: 1997 Census

% of children 0 – 14 years who are maternal orphans

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Maternal AIDS Orphans

Child Labour in Mozambique: Results of 2000 Survey

Under 5 Mortality Rates

Source: 1997 Census

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