Patrick J. Leahy War Victims Fund Orthoprosthetic Technical Assessment of POWER’s Program in Mozambique April 2002 Joe Ubiedo Rob Horvath The evaluation report was conducted under the aus￾pices of the U.S. Agency for International Develop￾ment. The evaluation was conducted by the Displaced Children and Orphans Fund and Leahy War Victims Fund Contract (HRN-C-00-98-00037-00). The opin￾ions expressed are those of the author and do not necessarily reflect the views of the U.S. Agency for International Development or Professional Resources Group International, Inc. iii Table of Contents Page Abbreviations v Map of Mozambique vi Executive Summary vii Introduction 1 Country Background 1 Overview of Prosthetics and Orthotics Services 3 Development of Prosthetics and Orthotics Servcics 3 Number of Amputees and Causes of Disability 6 Current and Potential Capacity of Prosthetics and Orthotics Services 6 Existing Human Resources in P/O 7 Causes and Problems of Low Capacity in Prosthetics and Orthotics Activities 8 Patient Accessibility to Prosthetic and Orthotic Services 9 Staff Performance, Motivation, and Oversight 9 Technology Used and Quality of Prosthetics and Orthotics Services 10 HI/France Technology and Its Acceptance by the MISAU 11 SMFR-MISAU Budget 11 Materials, Purchases, Supplies, and Logistics of SMFR/MISAU 11 Conclusions and Recommendations 12 Appendix A—Vice-Minister of Health’s Debriefing on the Assessment of the POWER/Mozambique Program 16 Appendix B—Assessment of POWER’s Program and Feasibility Study on Charitable Not-for-Profit Organization Managing P/O Services 19 Appendix C—Persons Contacted 21 Appendix D—Evaluation Schedule 22 v Abbreviations ADEMO Association of Disabled Mozambican AN National Warehouse of Ministry of Health BSc Bachelor of Science CA National Center for Supplies of Ministry of Health CAD Council for Action on Disability DAG Directorate for Administration & Management of Ministry of Health DAM Department for Medical Assistance, Ministry of Health DNS National Directory of Health DNSA Deputy Director of DNS DPS Provincial Department of Public Health DT Technical Department of Logistics EEC European Economic Community FIN Finances Department of MISAU HI Handicap International ICRC International Committee of the Red Cross JLC-MRCS Jaipur Limb Campaign & Mozambican Red Cross Society LOG Logistics of Ministry of Health LWVF Leahy War Victims Fund MISAU Ministry of Health MMCAS Ministry of Women and Coordination of Social Action MSc Master of Science DPMMCAS Deputy Provincial of MMCAS P/O Prosthetics and Orthotics PAI Program for Institutional Support of MMCAS POWER Prosthetics and Orthotics World Education & Research SIRT System for Identification and referral for Transport of Persons in MMCAS SMFR Section of Physical Medicine and Rehabilitation vi MAP vii Executive Summary The U.S. Agency for International Develop￾ment (USAID) has enjoyed a long and suc￾cessful orthopedic assistance program in Mo￾zambique. The program, which was developed in response to a humanitarian emergency, initially provided essential ser￾vices for thousands of Mozambicans disabled by the war and its lingering after ef￾fectslandmines. In 1994, with peace at hand and the country’s first democratic elections successfully completed, the program shifted its approach and began to focus on increasing the quality and quantity of services in an ef￾fort to develop sustainable practices and methods. In 1998, as a result of the establishment of a new unit within the Ministry of Health (MISAU), the Section of Physical Medicine and Rehabilitation (SMFR), and recommenda￾tions made in a USAID-sponsored evaluation, the program’s focus shifted out of direct in￾volvement in the management and administra￾tion of rehabilitation services and into provid￾ing technical assistance, long-term training opportunities, and support to indigenous dis￾ability advocacy groups. The orthoprosthetic rehabilitation centers became the direct re￾sponsibility of the provincial and district hospi￾tals in which they were located, and oversight was to be provided by the SMFR. Since the reorganization of the program in 1998, the quality and quantity of prosthetic and orthotic services has rapidly declined. Production in the four main orthopedic cen￾ters has dropped by more than 51 percent. In the year 2000, only 309 prostheses were pro￾duced in the country, despite a conservative production capacity of more than 1,000 de￾vices per year. The quality of fittings and workmanship has taken an equally startling turn for the worse. Orthopedic services are the responsibility of the Ministry of Health, but they are given lower priority within the ministry compared to other important preventative and curative health issues. As a result, little interest is paid to these programs, and diminutive resources are allocated for them. The challenges facing the rehabilitation sec￾tor in Mozambique are not unique. Although the MISAU must continue to play a crucial role in this health issue and service, ortho￾prosthetics will never be cost-effective enough for the government to absorb within its current health budget and manage within its existing structure. A number of alternative management, administrative, and financial structures have been attempted in other Afri￾can countries. Several of the more successful options are based on public-private sector partnerships and oversight boards outside of the day-to-day management structure. It is incumbent upon the MISAU to further ex￾plore, and in a controlled pilot program, ex￾amine the potential benefits these models provide. 1 Introduction Through the Leahy War Victims Fund (LWVF), the U.S. Agency for International De￾velopment’s (USAID) mission in Mozambique has been supporting orthopedic assistance since 1989. At that time, civil war continued to rage and civilian casualties from armed attack as well as from landmine accidents continued to mount. In response to the need for prosthetic and orthotic services, USAID began providing support to the International Committee of the Red Cross (ICRC) and later to Handicap Inter￾national (HI) to assist the Ministry of Health (MISAU) in developing and operating pros￾thetic and orthotic workshops in five provinces. Over time, the program’s purpose expanded to include increasing the capacity of nongovern￾mental organizations (NGO) and MISAU to provide mobility as well as social and economic integration services for people with disabilities. Since 1995, Prosthetic and Orthotic Worldwide Education and Relief (POWER) has managed all orthopedic assistance funnelled through USAID. To date, USAID/Mozambique has in￾vested more than $10 million in the rehabilita￾tion sector. POWER’s involvement in the orthopedic sec￾tor under its USAID assistance program ini￾tially focused on providing direct manage￾ment and administrative and technical support to the provincial rehabilitation centers. Under this initial cooperative agreement, the quality and quantity of devices produced and services delivered increased substantially. In 1998, a new cooperative agreement was negotiated. Under this agreement, all technical and mana￾gerial oversight and responsibility was sub￾sumed under the MISAU. POWER’s role be￾came advisory, with a small amount of financial assistance going toward the produc￾tion of orthopedic componentry. Both the de￾mand and delivery of services has declined steadily since the technical responsibility for providing orthopedic services was transferred to the MISAU. Client satisfaction is low and staff morale and motivation is waning. As a result of the declining demand and poor quality of devices delivered, USAID, the LWVF, and POWER determined to conduct an external program evaluation. The evalua￾tion was divided into two parts: (1) an ortho￾prosthetic technical review and (2) a feasibil￾ity study on the possibility of having a charitable not-for-profit organization manage prosthetic and orthetic services. This report represents the orthopedic technical review. Country Background Mozambique has a population of approxi￾mately 18 million (1996 statistics) and covers 799,380 square kilometres. It is one of the poorest countries in world. The gross domes￾tic product (GDP) was estimated at $80 in 1989 and only $133 in 1995 (MRCS 2000). After gaining its independence from Portugal in 1975, Mozambique became embroiled in civil war. With the signature of the “Accords de Rome” in 1992, however, that conflict between the Marxist regimes of Maputo, Patrick J. Leahy War Victims Fund 2 the Frente de Liberta Vão de Mozambique (FRELIMO), and the anti-Communist armed resistance of the Resistencia National Mocam￾bicana (RENAMO) ended. The country has en￾joyed relative peace since that time. Although it has been dominated by President Chissano’s party, FRELIMO, since 1994, Mozambique has been governed as a multiparty democracy. Mozambique demonstrates a strengthen￾ing market economy and good economic growth despite its remaining problems and difficulties. Agriculture production, foreign investment, tourism, access to education and health services, and civic participation in local and national affairs are all on the rise. 3 Overview of Prosthetics and Orthotics Services Development of Prosthetics and Orthotics Services During the period when Mozambique was ruled by Portugal, the country had only one private limb-fitting workshop. This workshop, located in the capitol, Maputo, was aban￾doned after Mozambique gained its independ￾ence in 1975. International organizations, in collaboration and partnership with the MISAU, reinitiated prosthetics and orthotics services in the early 1980s as a direct result of the need generated from the civil war. During the last 20 years, an estimated $25 million has been provided for physical reha￾bilitation assistance programs in Mozam￾bique. Major contributors include USAID (through the LWVF this contribution is more than $10 million), the European Union (EU), and other agencies. During this period, about 14,800 orthopedic appliances were delivered (prostheses and orthoses) through the nine orthopedic centers established and supported by ICRC, HI, and POWER. Following is a brief description of the various programs and projects. The International Committee of the Red Cross Program (1981–1995) In 1981, the International Committee of the Red Cross, in collaboration with the Ministry of Health (MISAU), began offering prosthet￾ics and orthotics services at the central hospi￾tal in Maputo. The program operated for 14 years. During this time, the ICRC developed the process for manufacturing orthopedic ap￾pliances, local production of orthopedic com￾ponents, and patient gait training. Activities included on-the-job training for national staff in the different sections. Early in the program, an 18-month training program was established for prosthetics and orthotics technician’s assistants. Statistics under the ICRC Assistance Program (1981-1995) Maputo (1981–1995) Beira (1986–1995) Quelimane (1986–1995) Nampula (1989–1995) Total Prostheses delivered 4,711 1,728 939 815 8,193 New prostheses patients 2,496 774 648 406 4,324 Orthoses delivered not reported 287 61 not reported 348 New orthoses patients not reported 219 45 not reported 264 Pairs of crutches 25,964 not reported not reported not reported 25,964 Patrick J. Leahy War Victims Fund 4 Using staff trained under this program, ICRC then extended P/O services to the provinces of Beira, Quelimane, and Nampula. Before phas￾ing out its program in 1995, the ICRC pro￾vided a formal three-year training program in orthopedic technology for 24 national ortho￾pedic technicians. Handicap International (1986–2000) Handicap International, in collaboration with the Ministry of Health, set up two small or￾thopedic workshops in Vilanculos and In￾hambane in 1986 and 1987, respectively. In 1990 and 1991, HI set up two more orthope￾dic workshops in Nampula (North), which produced only orthoses, and Tete (North￾west). Two additional workshops were estab￾lished in Pemba (far North) in 1993 and in Lichinga (far Northwest) in 1996. All six workshops were attached to district and pro￾vincial hospitals. As part of the MISAU sys￾tem, the centers experienced administrative problems and HI had difficulty in raising ade￾quate and consistent funding. In 1991, HI received U.S. Agency for Inter￾national Development/Leahy War Victims Fund financing to implement a one-year training course for orthopedic technicians (note: during the team’s visit some of these technicians were wrongly said to have achieved an internationally recognized Category II level). In 1996–1998, HI also implemented training for physiotherapy technicians (assis￾tant level) in Pemba. The French Cupertino and the British High Commission financed this project. Between 1995 and 1996, HI provided technical assistance in the MISAU’s various other projects, i.e., provid￾ing equipment for and installing physiother￾apy sections in 16 provincial hospitals. This effort was funded by the European Economic Community (EEC) and from the Canadian cooperation and also included assistance for patients transit centers and a community￾based rehabilitation (CBR) program, and support to the center for the rehabilitation of Malhangalene children in Maputo. In 1993–1994, HI handed over the responsi￾bility for overseeing its six orthopedic work￾shops to the MISAU. However, HI’s finan￾cial assistance to the MISAU continued. HI also provided support for two technical ad￾visers who were posted at the MISAU office in Maputo. At HI’s initiative, MISAU cre￾ated a department within the ministry to es￾tablish policy for, supervise, and manage the physical rehabilitation programs at the na￾tional and provincial levels. In 1997, an agreement was signed and the SMFR (Sec￾tion of Physical Medical and Rehabilitation) was officially created. Three HI technical advisers were posted full time at the SMFR￾MINSAU office until May 2000. Under the HI structured plan, the SMFR became Statistic Records under HI’s Assistance (1986-2000) Vilanculos (1986– 2000) Inhambane (1987– 2000) Nampula (1990– 2000) Tete (1991– 2000) Pemba (1993– 2000) Lichinga (1996– 2000) Total Prostheses delivered 579 767 0 256 140 14 (*) 1,756 Orthoses delivered 514 316 66 (*) 252 281 5 (*) 1,434 Crutches delivered 2,827 5,541 1,391 (*) 3,443 3,065 250 (*) 9,671 * Some figures for Nampula and Lichinga are either not reported or missing. Orthoprosthetic Technical Assessment of POWER’s Programs 5 responsible for coordinating, overseeing, and establishing policy for orthoprosthetics and rehabilitation activities. However, the SMFR lacked the budget, authority, and credibility to play such a crucial role. These failings persist today. POWER Cooperative Agreement I: 1995–1998 In October 1995, shortly after ICRC phased out its program, POWER and the MISAU signed a three-year technical assistance agree￾ment. The Leahy War Victims Fund and the local USAID mission provided $1,824,276 in financing. During this agreement, POWER oversaw the activities of the four former ICRC orthopedic projects (Maputo, Beira, Nampula, and Quelimane). POWER was directly in￾volved in managing these orthopedic centers, i.e., controlling the quality of prosthetics and orthotics, producing components, managing logistics, providing materials, managing pa￾tient’s services, and arranging for training and education for P/O staff. POWER also super￾vised the ordering and purchasing of imported equipment and materials. POWER Cooperative Agreement II: 1998–ongoing As a result of the establishment of the SMFR as well as the recommendations from a USAID-funded assessment team, a new agreement between POWER and the MISAU was signed in November 1998. The Leahy War Victims Fund provides total funding in the amount of $2,181,024 for this agreement. Under this agreement, the MISAU has full responsibility for managing the four main or￾thopedic centers. POWER’s role under this agreement is advisory (initially done jointly with HI) and is based at the SMFR-MISAU office. Moreover, under the agreement POWER became involved in providing over￾sight visits to all nine orthopedic workshops. In January 1999, POWER recruited a certified prosthetist/orthotist (CPO), Mr. Ronald Doorten, as the advisory monitoring and evaluation officer. Mr. Doorten was retained full time and based at the SMFR-MISAU of￾fice. In addition, POWER’s obligations under the agreement include • Funding the acquisition of necessary ma￾terials for the fabrication of orthopedic appliances, • Managing and administering funds and the use of materials in all limb-fitting workshops of the MISAU, • Managing and collecting statistics for a database of patients, • Conducting regular technical evaluations with the MISAU and national investiga￾tions of the disabled, • Financing training of technical staff, and • Producing regular activities reports. The CPO left Mozambique in 2000 prior to end of his contract because of frustrations with his job and an inability to work produc￾tively within a governmental bureaucracy. Mr. Doorten’s detailed report of findings and recommendations is essential reading if one is trying to understand the difficulties and dis￾satisfaction he experienced. As a result of his departure, some of POWER’s obligations un￾der the cooperative agreement have not, and will not, be met. The present POWER agreement will be com￾pleted at the end of 2001. In collaboration with USAID and the LWVF, POWER would like to determine whether the current status quo will allow for a productive program or whether the MISAU will be receptive to try￾ing a different service delivery approach. One option that has been presented to the govern￾ment is the creation of a charitable not-for￾profit NGO that can manage P/O services out￾side of the direct control of the MISAU. The Jaipur Limb Campaign Project/ Mozambican Red Cross Society In 1998, the Jaipur Limb Campaign Project (JLP) (based in London, UK) and the Patrick J. Leahy War Victims Fund 6 Mozambican Red Cross Society (MRCS) set up a not-for-profit service project for ampu￾tees in Manjacaze, Xai Xai province. This project began in March 2000. Due to the lack of qualified orthopedic technologists and the poor skills of resident staff, services have been limited to below knee prostheses. The newly constructed center has hostel-type accommodations with 18 beds and laundry and kitchen services. It is a pleasant environ￾ment for both staff and clients. Despite the free services and the nice accommodations offered the center has rarely had more than three patients at any one time since it opened. To date, the center has registered 170 and de￾livered 76 prostheses. Follow-up visits to am￾putees are also part of the services the center provides. Eighteen patients have been visited. The majority of the patients visited live fairly close to the center. Follow-up visits to pa￾tients in remote areas are extremely time con￾suming. The JLC-MRCS orthopedic center is not included in the MISAU’s national program. Number of Amputees and Causes of Disability According to various governmental and non￾governmental surveys, Mozambique has ap￾proximately 9,000 amputees. Including other types of physical disability, the total number of persons with disabilities affected is in the range of 25,000. POWER-SMFR statistics from 1997 to 2000 show an average of 950 new patients per year in need of orthopedic appliances. The number of patients is approximately 10 per￾cent higher than the present total capacity output. In 2001, amputations from landmines repre￾sented about 11 percent of all new patients attending the orthopedic centers. This number is sharply down from 29 percent in 1997. Other major amputations reported are either from congenital causes or disease. Few ampu￾tations are as a result of motor vehicle or in￾dustrial accidents. Current and Potential Capacity of Prosthetics and Orthotics Services Ten orthopedic workshops are located in nine provinces (out of the 10 provinces in the country) in Mozambique. Two orthopedic workshops are located in the province of In￾hambane (north of Maputo). Manica province (west central Mozambique) is the only prov￾ince without a P/O workshop. During this evaluation, the team could not visit all of the centers. However, the team vis￾ited the centers in Maputo, Beira, Quelimane, Inhambane, and Manjacaze. The condition in these centers were found to be representative of those in all of the centers. The team had access to detailed information about the other orthopaedic workshops in follow-up reports and statistics from the MISAU and POWER. The country has a sufficient number of ortho￾pedic facilities for the present. Additionally, as noted earlier in this report, over the past 20 years international humanitarian organizations have been committed to assisting in the deliv￾ery of services for people with disabilities. Under the POWER/MISAU partnership from 1995–1998, the number of prostheses deliv￾ered in the four main orthopedic centers aver￾aged nearly 700 limbs per year. This capacity was sustained during the period although near the end it dipped slightly. During this time, orthotic production increased significantly and constantly, from less than 200 appliances delivered per year to an average of 439 per year. Orthotic production peaked in 1998 with 634 orthoses delivered. The output from the other five orthopedic workshops (formerly under HI) during that same time frame averaged only 145 prosthe￾ses per year. In 1998, it reached a peak of 167 limbs per year. Orthoprosthetic Technical Assessment of POWER’s Programs 7 Statistics in 1999 show a quick decline in production, which corresponds and is directly related to the point at which HI transferred the responsibility of the workshops to the MISAU. In 2000, only 142 prostheses were delivered from the five HI-assisted work￾shops. The decline was most dramatic in the four POWER-assisted orthopedic centers. In these centers, production dropped by 51.2 percent. By the end of 2000, only 309 pros￾theses were delivered. Combined output figures from 1994–1998, including both prostheses and orthoses from all nine orthopedic centers, show a constant increase in P/O outputs when POWER was directly involved in the orthopedic activities. This followed a projected 10 percent increase under the POWER/MISAU agreement. How￾ever, during the last period 1999–2000, the total capacity for P/O services dropped by an average of 23.3 percent (see general statistics in Appendix E). Existing Human Resources in P/O A total of 106 people work in the nine ortho￾pedic centers managed by the SMFR-MISAU. The following chart outlines the numbers of, classification for, and salaries of these people. Number Categories Training Salary Range (monthly) 1 Head of O/P SMFR-MISAU O/P technology, Bachelor of Science (BSc) more than: $165 21 (*) Orthopedic technologists Cat. 2 / ISPO three-year diploma O/P technology, ICRC-ISPO minimum: $95 maximum: $165 USD 30 Orthopedic technicians Cat. 3 / ISPO less than two-year certificate on-the-job training ICRC-POWER minimum: $75 maximum: $112 34 Bench workers (Category 3) leather, metal, wood, plastic on-the-job training minimum: $47 maximum: $75 18 Assistants helpers and cleaners within the lowest range 2 Administrators office work within the medium range (*) Presently, five orthopedic technologists are not producing devices. Three are attending a three-year (BSc), Cat.1. course in France and will return in July 2001. Two are attending a four-year (Master of Science [MSc]) degree program for orthopedic engineers in Scotland. They will return in 2003. The developing country norms in P/O ser￾vices suggest that qualified orthopedic tech￾nologists (Category II) assisted by orthopedic technicians (Category III) should have the capacity to deliver at least six prostheses and six orthoses per month. Therefore, the poten￾tial capacity for Mozambique should be about 1,056 prostheses and 1,056 orthoses a year (including one month annual leave for staff and work handled by the five absent tech￾nicians). Time needed to repair ortho￾pedic appliances is not considered in this calculation because orthopedic technicians (Category III) and bench workers can per￾form these duties without lowering the over￾all production numbers. During the last two years, production figures from all nine centers were 2.5 times (150 percent) lower than Mozambique’s potential production capacity. Mozambique has 122 physiotherapists and physiotherapy assistants operating out of the district and provincial hospitals and distrib￾uted in the nine orthopedic centers and 39 hospitals in the country. Patrick J. Leahy War Victims Fund 8 Causes and Problems of Low Capacity in Prosthetics and Orthotics Activities Many factors have contributed to the decline in overall production quantity and quality: • Five orthopedic technologists left to at￾tend upgrading courses in 1998 and 1999 and three other quit • POWER management support was phased out in 1998 • Floods in 1999 and 2000 affected the sup￾plies of materials and patients access to P/O services However, these factors do not explain all the deficiencies of the current situation. Other significant factors include the following: 1. Structure and Responsibility of the MISAU Understandably, the MISAU’s priority is preventive and curative medicine pro￾grams. It allocates little or no attention or resources to physical rehabilitation pro￾grams. Under current procedures, there is a constant turnover of upper-level manag￾ers and directors at both the hospitals and the ministry. This change of personnel has thwarted the introduction and progress of necessary changes. The sole full-time employee of the SMFR-MISAU, the director, is responsi￾ble for co-ordinating all P/O activities, but he has no real authority. SMFR occupies a small office without adequate staff or budget. Plans of action and recommenda￾tions from oversight visits are often de￾layed or hindered by the complex bu￾reaucracy of the MISAU, under which the SMFR operates. Communication is poor and the system, thus far, has operated in￾efficiently. Although he is obstructed by bureaucracy, even in an optimal environ￾ment the head of SSMFR has neither the leadership skills nor the initiative to effec￾tively co-ordinate the national and provin￾cial hospital P/O workshops. 2. Deficiencies in the Development of P/O Services The team’s discussions with national- and provincial-level players (MISAU, DNSA, DAM, SMFR, and MMCAS) in Maputo, Inhambane, Beira, and Quelimane con￾firmed that P/O services need to be im￾proved. However, such improvements can not and will not be accomplished without additional financial and technical support. The SMFR-MISAU believes that they cannot change the current situation with￾out more external funding. However, the team found that existing problems are sys￾temic and do not necessarily require addi￾tional financial resources. 3. Other Problems • Lack of patients due to transporta￾tion problems. Transportation, under the responsibility and coordination of the Ministry of Women and Coor￾dination of Social Action has been unreliable and not well coordinated. Even when POWER negotiated agreements and payments directly to MMCAS, transportation was not be￾ing provided. • Lack of staff motivation. Some centers experienced high absenteeism and in almost all centers staff members rushed off to second and third jobs as soon as the day was complete (or even before). Staff salaries are low and con￾tribute to low productivity. The work￾ing environment at the centers is poor and in some cases dangerous. These factors all contributed to the poor quality of P/O services. • Low production of components. Machinery has broken down and has not been repaired. As a result, the cen￾ters have not produced enough, feet, knee joints, and crutches. • Lack of human and material resources. The system does not have a cost re￾covery mechanism and the budget al￾location from MISAU is not suffi￾cient. Current staff members do not Orthoprosthetic Technical Assessment of POWER’s Programs 9 have the requisite skills to handle the responsibilities of their positions. Un￾der qualified staff are allowed to treat patients and provide services they do not have the skills to provide. • Lack of proper logistics and supplies. The MISAU central warehouse is un￾derstaffed and transportation to the provinces is lacking. Vehicles pur￾chased for use under the rehabilitation program are used for other medical purposes and their use is not coordi￾nated. • Communication between all depart￾ments and staff is poor. Patient Accessibility to Prosthetic and Orthotic Services One of the crucial problems with Mozam￾bique’s P/O services is the patients’ lack of accessibility to those services. Through it’s provincial branches, the Ministry of Social Affairs (MMCAS) is the office tasked with identifying, registering, transporting, and ac￾commodating the disabled from the districts as well as following up after service delivery. The MMCAS implements the services through its provincial departments (DPAS￾PAI and SIRT units). In Beira and Quelimane, POWER provides $23,000 per year in financial support to MMCAS, which is about $2.5 per patient a day for food and lodging and $25 for transporta￾tion. Little is achieved. In Maputo, Quelimane, Beira, and Inhambane, no vehicles are avail￾able to transport patients and alternative meth￾ods of transportation have not been identified. The team met many patients who had been at the transit center for several weeks but had not yet visited the orthopedic center, despite the fact that the center was less than 5km from the transit center. The car, it was reported, had been broken for one year. MMCAS had not reported this problem to POWER. The transit centers the team visited were far from full capacity. In many places, the rooms were occupied more by poor and destitute people than by disabled people. Some rooms are also rented but there is not a realistic cost recovery system. The ministry (MMCAS-DPAS) does not pro￾vide a budget for or maintenance of the transit centers. The centers are therefore forced to “fundraise” on their own. In Quelimane, for example, where POWER negotiated an agreement to reimburse the transportation and food/lodging costs for people being served at the rehabilitation center, MMCAS uses the money to feed and house all the people at the center, including the poor and elderly. In the Quelimane transit center, the poor and elderly far outnumber the people awaiting services at the orthopedic center. As a result, the disabled report receiving only two meals a day consist￾ing solely of beans and rice. Conditions at this transit center are extremely basic. People re￾port staying up to four months. Coordination between the DPAS-MMCAS and SMFR￾MISAU for transportation and follow-up vis￾its to disabled people appears difficult. In general, patients visited in different transit centers were not satisfied. Staff Performance, Motivation, and Oversight The evaluation team assumed that the P/O technicians working in the workshops were technically acquainted with fabrication meth￾odologies and procedures because they have had many years of experience and most had attended more than one training event. Yet, the team found the quality of job performance was poor in all the places they visited (with exception of Quelimane, where the quality was fair). The team noted careless mistakes, like improperly assembling components, dur￾ing visits. In Maputo, the team saw patients whose pros￾theses had not been fitted properly but who had been discharged and counted as success￾ful outcomes. The team was told that techni￾cian assistants (Category 3, the lowest) are Patrick J. Leahy War Victims Fund 10 permitted to see and treat patients, duties normally assigned only to orthopedic tech￾nologists who are Category 2 and above. The center supervisor indicated that quality con￾trol procedures were in place and imple￾mented. However, the team saw numerous, poor-quality devices being used by patients that had been discharged. The orthopedic workshops the team visited were not busy. Absenteeism and unmotivated staff was often noticed. The orthopedic work￾shop of Inhambane had neither patients nor prostheses. Productivity in general was low in the work￾shops the team visited. In Maputo, six ortho￾pedic technicians who are eligible (and sup￾posed) to retire are permitted to work “moderately” instead. The MISAU’s staff salaries, like those of other government de￾partments, are very low (between $US 75 and $US 165 per month) while salaries in the pri￾vate sector are double for the same level of staff. Staff members note that transportation alone represents a significant expenses (up to $US 10 per month). Regardless of the poor the salaries they re￾ceive, the technician’s practice of discharging patients with poorly fitted prostheses—in some cases so poor as to cause injury—is un￾justifiable. Perhaps the larger question relates to job satisfaction and whether or not the technicians are truly happy coming to their workplace every day. Indeed, most of the technicians the team met are either studying in a different field or working at night in an unrelated position. Although all P/O centers are formally part of the provincial or district hospital system, hos￾pital directors are not involved in the services. The directors state that they are not involved because they have limited time and ortho￾pedics is not a priority. Recommendations and follow-up reports from POWER and SMFR monitoring trips, therefore, receive little or no consideration and, as a result, have no impact. Necessary maintenance for machinery and building is severely lacking. Consequently, workshop conditions are declining rapidly. Technology Used and Quality of Prosthetics and Orthotics Services In the early 1990s, ICRC introduced the tech￾niques and materials necessary to locally pro￾duce polypropylene components. The ortho￾pedic center in Maputo was modified to include a workshop to produce components. The Maputo center produces components for all centers in Mozambique. The Maputo center employs seven bench workers to produce and assemble feet, knee joints, alignment components, crutches, and other small parts. Despite being well equipped and stocked, the center’s present production capacity is only 40 feet, 10 knee joints, and 15 crutches per month—only enough to meet the needs of the Maputo central workshop. The same pattern of negligence and poor con￾ditions the team saw throughout the country were also evident in this workshop. For in￾stance, the injection machine used to produce plastic parts for crutches and prostheses has been out of use for more than three months because the brass nozzle had not been fixed. This is a fairly minor repair. Therefore, in￾jected plastic handles for crutches cannot be produced. Instead of repairing the injection machine, the workshop reverted to producing poor-quality metal crutches. Unnecessarily, this workshop is heavily equipped with tools and machinery (e.g., four different types of lathe machines) from which it is possible to reproduce very sophisticated spare parts. In spite of this fact, the feet pro￾duced are too stiff (they cannot flex when the patient is walking) and badly shaped by hand. Knee joint components are poor: the metal tube supporting the knee axis is too weak and the bushings wear out quickly. Furthermore, the workshop is quite disorganized. Although staff members are allocated to departments Orthoprosthetic Technical Assessment of POWER’s Programs 11 and by level, there is either little division of labor or staff members are used inappropri￾ately and ineffectively. The workshop is costly to maintain and the quality of work￾manship is poor. HI/France Technology and Its Acceptance by the MISAU In the early 1990s, HI/France initiated the use of polyvalent technology in the workshops in Inhambane, Lichinga, Tete, Pemba, and Vilanculos. It was introduced as “appropriate technology.” The principles of this technol￾ogy consist of producing orthopedic appli￾ances at the lowest cost using local materials available and with minimally trained staff. The professional P/O community has not gen￾erally accepted this technology. Under HI advisement, the SMFR-MISAU of￾ficially accepted this standard, adapted it slightly and designated it “improved appro￾priate technology.” By professional standards, this type of limb should only be used as a temporary device or as basic walking aids. The team evaluated an example of this tech￾nique in Inhambane and Manjacase where the Jaipur Limb Campaign, in cooperation with the Mozambique Red Cross, trained workers for three months in India. The devices produced were made by combining a mixture of materi￾als (not well matched) such as aluminium, metal, plastic, wood, and leather with an im￾provised type of foot. The resulting foot ap￾peared to be poor and often inappropriate. Moreover, although this technique was touted as using locally available materials, and thus appropriate technology, in reality about 70 percent of the materials used to produce these devices need to be imported from places such as South Africa, India, China, or Maputo. As a result the cost of such devices and the time needed to fabricate them may be about the same as the cost of and time needed to produce the more durable polypropylene prosthesis. SMFR-MISAU Budget The MISAU’s budget is 70 percent funded by foreign sources and represents only 12 per￾cent of the total national budget. In 2001, the SMFR proposed a budget of $219,015 to cover the cost of imported mate￾rials. This amount represents MISAU’s 30 percent share. The rest of the costs were to be covered by HI (20 percent) and POWER (50 percent). A close look at the budget plan showed an additional $81,237 needed for or￾thopedic and physiotherapy services at the 10 workshops, this amount included running costs of offices, stationery, small items, staff trips within the provinces, and communica￾tion expenditures. The budget did not include salaries or expenditures for the orthopedic workshops, which instead are directly in￾cluded in the respective provincial/district hospital budget. Some orthopedic appliances and crutches are also sold in hospitals for “special attendance patients” as allowed by the MISAU. The selling prices of these items range from $37 to $109 for prostheses, from $2 to $68 for orthoses, and $3 for a pair of crutches. The selling prices are not based on a realistic cost calculation system but are in￾stead viewed as a patient contribution. Based on collected information, the SMFR-MISAU national budget for physical rehabilitation (in￾cluding physiotherapy) can be estimated at between $480,000 and $500,000 per year. Materials, Purchases, Supplies, and Logistics of SMFR/MISAU Since 1998, when POWER’s roles and re￾sponsibilities were changed to advisory, the project has experienced significant difficulties in importing and dispatching materials to the provinces. Customs procedures within the government of Mozambique are extremely long and complicated and even within MISAU several different departments are in￾volved in this process. As a result, consign￾ments of materials often remain in customs Patrick J. Leahy War Victims Fund 12 for several months before they are received at the national MISAU warehouse. The team visited the national MISAU ware￾house where all hospital equipment and sup￾plies are stored and shipped for the entire country. Incredibly, the warehouse has only four employees to handle all stocking func￾tions for the health care needs of the entire country. These employees state that they are overwhelmed. This appears to be a gross un￾derstatement. For the P/O sector, components for orthopedic devices are stored in one small area. Although some stock was visible, several of the provin￾cial centers visited noted that they had been waiting up to six months for supplies. In one center, they stated that they had not received crutches for two years! The management of stock at the warehouse and the coordination with logistics and sup￾plies departments (Directorate for Admini￾stration and Management of Ministry of Health, Logistics of Ministry of Health, Technical Department of Logistics, and Na￾tional Center for Supplies of Ministry of Health) within the MISAU are inefficient. During the grant agreement, POWER occa￾sionally used the services of an independent contractor or other NGO to distribute sup￾plies. On more than one occasion, in order to get supplies moving at all, POWER of￾fered to pay the costs of shipping supplies to the provinces through an independent con￾tractor. Unfortunately, the SMFR/MISAU declined and the provincial workshop went without necessary orthopedic supplies and materials. Conclusions and Recommendations The situation with regard to P/O services in Mozambique clearly suggests that the MISAU cannot sustain P/O program activities in such a way that the services can meet the needs of the country’s population. Difficulties include poor staff performance, an inefficient system for supplying materials to the workshops, the lack of a cost recovery system, poor to satis￾factory quality prostheses produced, lack of proper communication between the different ministry departments, and no established standard of quality with regard to the fit of prostheses and the delivery of services in gen￾eral. Since the SMFR-MISAU assumed direct responsibility for P/O services in 1999, the capacity for delivering prostheses in the nine orthopedic centers is about 2.5 times (150 percent) lower than the available capacity (451 prostheses delivered versus a capacity to deliver 1,056 per year) and the combined out￾put of prostheses and orthoses dropped by 24 percent. Moreover, the following findings and recommendations are made. 1. Quality of P/O Supplies and Services Patient accessibility to P/O services is poor, and when services are available, they have not generally been of acceptable quality. Although finances and materials have affected in the quality and quantity of services, a number of other factors such as staff motivation, adequate and appro￾priate management, training and technical assistance, and selection of technology have also played a decisive part. The projects in Manjacaze and Quelimane are good examples of the effect of such other factors. The JLC-MRCS project in Manjacaze (Gaza province) is independ￾ent from the MISAU and sufficiently funded. Facilities are new and expansive. However, the quality of devices produced at this site was not any better than those seen at the other centers. On the other hand, in the Quelimane orthopedic work￾shop, part of the MISAU system, the con￾ditions were poor, equipment limited, and supplies sporadic, but the few prostheses provided to amputees were of decent qual￾ity. This success was in great part due to the dedication of the staff; the manage￾ment provided by the workshop manager, Arlindo Setavane; and the oversight given by the hospital director, Dr. Elena F. Mula Chong. Orthoprosthetic Technical Assessment of POWER’s Programs 13 2. Local Production of Orthopedic Com￾ponents in Maputo Local production of components in Ma￾puto has been fraught with problems. The system, as it stands now, is neither efficient nor effective and should be changed. The fabrication process involves extremely technical issues and high expenditures. This process should not be run as simply ancillary to an orthopedic workshop. The 20-year-long experience of the ICRC, as a pioneer in this field, has proven (with the exception of production of crutches) that locally produced components are not the best approach in P/O programs. The ICRC found that the programs failed be￾cause they were not sustainable in quality, quantity, and in cost as compared to the more affordable, centrally fabricated im￾ported components available today. As such, the ICRC has chosen to outsource all production of components for prosthet￾ics, orthotics, and wheelchairs. ICRC has found that it is more efficient and effec￾tive to concentrate solely on the already difficult objective of developing P/O appliances. The team recommends that the Maputo center stop fabricating components. In￾stead, serious consideration should be given to accessing and using the ICRC/Coppet components. In order to best be informed, a cost/benefit analysis should be made comparing the importa￾tion of the ICRC/Coppet components with in-country production. In assessing in￾country production, it should be antici￾pated that any local production would be outsourced to a private facility and not done with the SMFR/MISAU system. 3. POWER’s Proposal for a Not-for￾Profit NGO Managing P/O Services in Mozambique The initiative proposed by POWER for an independent NGO or institution to manage P/O services for disabled people enjoys wide and varied support and should be explored further. The challenge, however, will be great. In the team debriefing with the vice-minister of Health, the govern￾ment of Mozambique expressed optimism that the minister himself would welcome such an initiative. Since POWER has already worked out an alliance with ADEMO (local association of the disabled) and created the Council for Action on Disability (CAD), there are a number different options that POWER could explore. Three options were dis￾cussed with the vice-minister of Health and the evaluation team. There are still many outstanding issues and agreements to be made before engaging. For example, there is the issue of how to deal with staff and donated equipment belonging to the MISAU centers. How will this be re￾solved? What if the recommendation was to sell excess equipment? Could this be done? Other outstanding matters include what type of agreement to create with one (ADEMO) or many local partners and what method to use to build sustainability into the programs. POWER should not have more than two partners or too many different types of ac￾tivities associated with this project, at least until it has made solid roots. If POWER expands this initiative too broadly it will implode with management and administrative problems and will cre￾ate a structure that is difficult to control. 4. Conditions for Sustainability of Future Programs (as proposed in the in￾country debriefing) The following four principles determine the potential sustainability of any project: 1. Patient accessibility to P/O services How: • Refund part or all of the costs of trans￾portation and accommodation for poor disabled • Use available local transportation and accommodation possibilities (pension Patrick J. Leahy War Victims Fund 14 family, church, shelters, etc.) and do not try to create these services within the same P/O activities Who: • Find/Develop an agreement with NGOs, private sources, or insurances companies 2. Existence of cost recovery and in￾come-generating mechanisms How: • Establish real cost calculations of all products supplied and/or services (physiotherapy) • Include small profit (10 percent) and contingencies (9 percent) (to be made by external financial audit) • Making sell prices available for pri￾vate clients and for outsource donors or insurances Who: • Provide services free for disabled war victims and poor disabled, but the costs for these services must be reim￾bursed by NGOs or donors or by small government participation 3. Staff performance under qualification and motivation How: • Improve salaries for qualified and committed staff • Provide advantages for staff transpor￾tation, training, or other possibilities • Improve working conditions and envi￾ronment (clean and attractive set up of facilities) Who: • Implementing agency (POWER) with NGO and donors support 4. Quality of P/O supplies and services How: • Provide choice and satisfaction to all disabled (poor and other) • Do not produce components locally but purchase the most affordable im￾ported quality products (possible deals with manufacturers, suppliers, and in￾ternational agencies or donors) • Establish a database listing informa￾tion on disabled people and collect relevant information for donors • Follow up and survey patients serviced Who: • The implementing agency Three Options for Future POWER/MISAU Collaboration Based on ICRC’s work in Ethiopia and else￾where in Africa the following three options should be considered with regard to collabo￾ration between POWER and the MISAU: 1. P/O services under an independent structure This structure might be an institution or NGO (CAD). It would have a board, a chairman, and representatives from differ￾ent agencies (ADEMO, Private VIP, MRCS, associations, MISAU, MMCAS, etc.). The board would appoint a director and administrator for the orthopedic center. In the orthopedic center, the person in charge, the chief, should be a Category 1 prosthetist/orthotist. This person would be in charge not only of services, but also of quality assurance/control in all respective departments. All P/O activities and ser￾vices should contain a cost-recovery ele￾ment and an income-generation mecha￾nism based on real cost calculations. The Ministry of Defence, insurance companies, NGO, or other donors would reimburse the real costs to the center for P/O services. CAD Æ Board Æ P/O Center: Director/Administrator 2. P/O services remain under the respon￾sibility of the MISAU but with full autonomy Under this option, the center has its own board (chairman and representatives of MISAU, MMCAS, MRCS, and others). The orthopedic center has a director and administrator appointed by the board. Orthoprosthetic Technical Assessment of POWER’s Programs 15 The MISAU will guarantee national standards and a minimum salary to the staff and all P/O activities. Services pro￾vided must contain cost recovery and in￾come-generation elements sufficient, at least, to cover salaries and maintenance. The Ministry of Defence, insurance com￾panies, NGO, or other donors would re￾imburse the real costs to the center for P/O services. MISAU Æ P/O Center Board: Director/Administrator 3. P/O services are entirely under the commercial private sector This option could be developed in addition to or in combination with options 1 and 2. This option should not be excluded as it of￾fers particular advantages, especially for difficult cases. MISAU is encouraged to permit and support the private sector’s par￾ticipation in the delivery of P/O services. In all cases, small units of P/O services should remain under the responsibility of MISAU hospitals for medical purpose. These P/O units should be attached to physiotherapy departments and be limited to delivering small orthopedic appliances, such as temporary prostheses. Orthoprosthetic Technical Assessment of POWER’s Programs 16 Appendix A – Vice-Minister of Health’s Debriefing on the Assessment of the POWER/Mozambique Program 1. Context of the Visit (Leahy War Vic￾tims Fund [LWVF]) a. Began in 1989. It is a program within USAID that provides a dedicated source of financial and technical as￾sistance for civilian victims of war. “Victims” are persons who suffer from mobility related injuries, includ￾ing those injured by land-mines and those who suffer from polio as a re￾sult of interrupted immunization cam￾paigns. b. LWVF supports programs that pro￾vide for the improved mobility of people with disabilities by providing accessible, appropriate orthopros￾thetic services. Focus is on quality, availability, accessibility, and sus￾tainability. The Fund also supports rehabilitation-related services such as orthopedic surgery and physiotherapy and works to improve the social and economic integration of people with disabilities. c. In the last 12 years, the LWVF has provided more than $70 million in more than 16 countries. 2. The LWVF and Rehabilitation in Mozambique a. Mozambique was one of the first countries supported under the LWVF. The program of assistance began in 1989 through support to the ICRC. In addition to providing support to the ICRC, the Fund has provided support to Handicap International (HI), Save the Children (for the construction of the transit centers in Maputo and Beira), and POWER. The total LWVF investment in the rehabilitation sector in Mozambique is approximately $10.2 million. b. The POWER program in Mozambique began in 1996. In collaboration with the ministry, it was decided that POWER would assist four centers for￾merly supported by the ICRC. Namely, Maputo, Beira, Quelimane, and Nampula. c. As a result of work done by Handicap International to centralize services and recommendations by a USAID team, the activities were fully handed over to the Ministry of Health in 1998/1999. Since that time, within its partnership with the Ministry of Health, POWER has played only a cursory advisory role and provided fi￾nancial assistance for the manufacture of orthoprosthetic components. d. The current partnership between POWER and the Ministry of Health (and other partners) ends at the end of the year. With the end of the program Orthoprosthetic Technical Assessment of POWER’s Programs 17 close at hand, this assessment was de￾vised to (1) evaluate project impact since 1998; (2) help develop a close￾out and sustainability plan; (3) deter￾mine what assistance, if any, the LWVF could/should provide in the fu￾ture for rehabilitation in Mozambique; and (4) suggest/recommend possible options for such an assistance pack￾age, if determined appropriate. 3. Assessment Team and Itinerary a. The team consisted of the following individuals: i. Health economist from the U.K., looking at feasibility of pub￾lic/private sector involvement ii. Joe Ubiedo, CPO and ICRC Technical Director. iii. Rob Horvath, LWVF iv. Donna Carpenter, USAID/Mozam￾bique v. Max Denu, POWER vi. Francisco Baptista, Head of SMFR vii. Representative, with PAI at the MMCAS b. The team visited the following sites: i. Maputo Orthopedic Center and general hospital ii. Manjance Orthopedic Center, sup￾ported by Mozambique Red Cross iii. Inhambane Orthopedic Center and general hospital, formerly sup￾ported by Handicap International. Also visited the MMCAS transit center. iv. Beira Orthopedic Center and gen￾eral hospital (and MMCAS transit center) v. Quelimane Orthopedic Center and general hospital (and MMCAS transit center) vi. Also met with Dr. Candido, Dr. Mengele, and Dr. Tomo (deputy director of the Dept. of Planning and Cooperation) 4. Starting point: Miller/Whitson and the status of activities in 1997/98 a. Country moved from emergency/hu￾manitarian relief to development b. Recommendations were that the MOH assume responsibility for services. This has been done and the MOH cur￾rently pays all recurring cost. Finances come from within the hospital’s budg￾ets. POWER (donor) pays only the costs of materials. In a sense, the pro￾gram has reached a level of financial sustainability. However, as findings indicate there is little or no managerial and/or technical sustainability in most centers. c. The centralization of services has led to a large decline in both quality and quantity of services. 5. General Findings. Joe provide more details depending on Vice-Minister’s wishes. a. Materials purchased and/or fabri￾cated with outside resources are not getting to the centers. Sometimes cen￾ters wait more than six months from time of order. In one center, no crutches were available for almost two years. b. With the exception of one center (Quelimane), the quality of the de￾vices produced was poor to very bad. The lack of materials had an affect on the quantity of services. However, quality issues were more directly re￾lated to staff, despite seemingly ade￾quate skill levels and the existence of supervision. c. Although supervision and oversight visits were made, the visits and subse￾quent reports have had little or no ef￾fect on service delivery. d. Hospitals take little or no interest in the delivery of quality services. There are many higher priority issues. Staff prob￾lems/issues are not addressed. Mainte￾nance is not done. Existing space is in- Patrick J. Leahy War Victims Fund 18 adequate and often what does exist is reallocated for departments. e. Many trained staff members have de￾parted. Those at the centers work half￾heartedly. f. Work and service delivery environ￾ment is unappealing and depressing. g. Production had declined by more than 40 percent. h. Demand for services has declined, as much to do with poor service as with accessibility. 6. Options a. Components i. Continue to manufacture in coun￾try – quality and quantity produced are inadequate. Maputo center should not continue to manufac￾ture and deliver services. They are unable to do this effectively. ii. Purchase/import – Coppet or others iii. Need to conduct a full cost analysis iv. Comment on Manjacaze (and HI approach); supposedly “local” components. In reality, they im￾port as much as any other center. b. Service Delivery – regardless of deliv￾ery mechanism, LWVF can and will only support quality services that are delivered in reasonable quantity. i. Services remain totally integrated within the hospital and MOH sys￾tems. From centers visited, only Quelimane would be eligible for LWVF assistance. ii. Orthopedic center managed by separate board but still within MOH perview. iii. Management contract outsourced to NGO/association/foundation. iv. Privatization. 7. Next Steps a. Decision taken on possible options. May be more than one option. b. If new option, bring team back to de￾velop detailed business and implemen￾tation plan. Initial visit of one to two weeks, followed by individual visits. c. Selection of implementation site and development of phase-in plan. May take up to six months. i. Includes negotiation of roles and responsibilities with all players, fi￾nancial commitments, exit plan should be built in from the begin￾ning, etc. Orthoprosthetic Technical Assessment of POWER’s Programs 19 Appendix B – Assessment of POWER’s Program and Feasibility Study on Charitable Not-for-Profit Organization Managing P/O Services Term of reference for Orthoprosthetic Technical Evaluation Purpose: Evaluate POWER’s accomplishments under the two cooperative agreements funded by USAID. Provide recommendations on how to ensure sustainability of prosthetics services in Mozambique after the end of USAID assistance in December 2001. I. Responsibilities a. The CPO technical expert will work in coordination with the team b. The CPO technical expert will collect the technical information described below. c. The CPO technical expert will present to the team a technical report, which shall include the final evaluation re￾sults and recommendations. 2. Assessment of current situation a. Production statistics i. Capacity ii. Actual iii. Changes with handback to MOH iv. Reasons b. Human resources issues i. In-country capacity ii. Motivation, career path, salary issues c. Service delivery issues i. Patient awareness of service avail￾ability ii. Patient access: transit centres, transport iii. Patient satisfaction iv. Service quality v. Costs d. Production, appropriate technology, and technical quality issues e. MOH preferences i. History (ICRC and HI) ii. Polyvalent technology (proposed by MOH) iii. Current technology used (manu￾facture of components and appli￾ances) f. Implications of patient satisfaction i. Comments on product offered by MISAU (ADEMO, ADEMIMO, etc.) ii. Comments on service the delivery g. Implications for sustainability i. Local production of components ii. New products to be locally devel￾oped Patrick J. Leahy War Victims Fund 20 iii. Local production vs. importation of products h. Volume i. Production capacity and real pro￾duction ii. Need for the future i. Logistics and supplies management i. Current system in place/ MISAU’s system ii. Control of supplies consumption (central, provincial level) j. Supervision, monitoring and evaluation i. Central and Provincial levels ii. Implementation of Recommenda￾tion 3. Proposals for the future a. Potential models per Miller and Whitson i. Workshop to serve production and repair of medical equipment for entire hospital system ii. Turn workshop over to private sector iii. Retain within MOH iv. Orthoprosthetics Implementing Agency v. Foundation b. Other possible models in Mozambique and elsewhere i. Advantages and disadvantages 4. Recommendations a. The recommendations will cover the above-mentioned sections and will re￾flect an independent technical judg￾ment. Orthoprosthetic Technical Assessment of POWER’s Programs 21 Appendix C – Persons Contacted MMCAS • Duarte Joaquim, National Director • Arthur Nhantumbo • Cristina Matsinhe, PAI-MMCAS MISAU • Dr. Aida Libombo, Vice-Minister of Health • Dr. Candido, Deputy National Director of Health (DNSA) and Head of Medical As￾sistance (DAM) • Dr. Menguele, DAM Dept. • Francisco Baptista, Head of SMFR-MISAU • Dr. Jorge Fernando M. Tomo, Deputy Na￾tional Director, Directorate of Planning and Co-operation USAID • David W. Hess, Deputy Director • Donna Carpenter, Special Projects Coor￾dinator Mozambican Red Cross Society • Texeira Fernanda, General Secretary Maputo Central Hospital • Dr. Langa, head of Orthopaedic Department • Carlos Passe, head of orthopaedic workshop ADEMO • Farida Gulamo, General Secretary of ADEMO Handicap International France • Nicolas Bordet, Director • Cristina Vera Beira (Province) • Dr. Americo Assane, Hospital Director of Beira • Antonia S. P. Charre, Director DPMMCAS • Moises Pedro Vilanculos, Head of orthopaedic centre Inhambane (Province) • Dr. Celia Gonçalves, Director DPS • Dr. Ana Paula, Hospital Director • Atanazio Pitore, Director DPMMCAS • Ricardo Romeu, Head of orthopaedic workshop Manjacaze (Province) • Luis Sautiane, Head of orthopaedic center and staff. • Jeronimo Ntimane, Administrator Quelimane (Province) • Dr. Helena Fernando Mula Chong, Hospi￾tal Director • Joana Simiao, Director DPMMCAS • Aarlindo Setavane, Head of orthopaedic workshop Orthoprosthetic Technical Assessment of POWER’s Programs 22 Appendix D – Evaluation Schedule Date Time Action 04/10/01 8:30 pm Arrival Joe Ubiedo in Maputo 04/11/01 8:30 am Meeting POWER office with Max Deneu and Malcolm Murray 10:00 am Meeting SMFR office with Francisco Baptista and Mal￾colm Murray 11:00 am Visit of the CRIM (Children Project in Malanghalene, Maputo) 2:30 pm Meeting with Texeira Fer￾nanda, MRCS office 04/12/01 8:00 am Visit of the orthopaedic center of Maputo Hospital 10:00 am Meeting with Francisco Bap￾tista 1:00 pm Meeting with Duarte Joaquim and Cristina Matsinhe, MMCAS office 4:00 pm Meeting with H.I. 04/13/01 8:00 am Discussions with Max Deneu and Malcolm Murray, POWER office 12:00 am Lunch with Donna Carpenter USAID, Max Deneu and Mal￾colm Murray 04/14/01 Arrival of Rob Horvath in Maputo, USAID 04/15/01 Day off 04/16/01 8:00 am Briefing meeting POWER office with the team 04/16/01 11:30 am Meeting with Dr Candido and Dr Menguele, at MISAU office 2:00 pm Meeting with team POWER office 04/17/01 6:00 am Departure to Manjacase by road 10:30 am Visit of the JLC-MRCS ortho￾paedic center 7:30 pm Arrival in Maputo 04/18/01 8:30 am Meeting at orthopaedic center of Maputo Hospital 1:00 pm Evaluation visit of the ortho￾paedic center, Maputo Hospital continued Date Time Action 2:00 pm Continuation of meeting with Carlos Passa, Head of ortho￾paedic center 4:00 pm POWER office 04/19/01 8:00 am Meeting with David W. Hess and Donna Carpenter, USAID office 12:30 pm Meeting with Francisco Bap￾tista at SMFR office 4:30 pm POWER office 04/20/01 8:00 am Flight to Inhambane 9:30 am Meeting with Celia Gonçalves, DPS, and visit of the ortho￾paedic workshop and physio￾therapy at hospital of Inham￾bane 2:00 pm Meeting with Director at office of DPMMCAS and visit of tran￾sit center of Inhambane 6:00 pm Arrival in Maputo 04/21/01 Day off 04/22/01 2:00 pm Departure to Beira by air 5:00 pm arrival to Beira 04/23/01 7:30 am Visit of the orthopaedic center and physiotherapy at Beira hospital 2:00 pm Meeting with Antonia Charre, DPMMCAS, office 2:30 pm Visit of transit center in Beira 4:00 pm Meeting with Dr Americo Assan, Director of Beira Hospital 04/24/01 7:00 am Departure to Quelimane 9:30 am Visit of the orthopaedic work￾shop in Quelimane 11:00 am Meeting with Helena F. Mula Chong, Director of Quelimane Hospital 2:30 pm Visit of the transit center in Quelimane 4:00 pm Meeting with Johana Simao, Director of DPS in Quelimane 4:30 pm Meeting at orthopaedic work￾shop continued Orthoprosthetic Technical Assessment of POWER’s Programs 23 Date Time Action 10:30 pm Arrival in Maputo 04/25/01 9:00 am Meeting with Donna Carpen￾ter, USAID office 10:00 am Visit of the national warehouse of the MISAU 11:00 am Visit of the transit center in Maputo 2:00 pm Meeting with Dr. Langa, Maputo hospital 3:00 pm Meeting with Dr Jorge Fer￾nando, Deputy Director of Cupertino and Plan of MISAU 04/26/01 11:30 am Meeting with Dr Menguele, MISAU office 3:00 pm Meeting with Dr Aida Libombo, Vice Minister of MISAU