24-Feb-2025 Date: ____________ H.E. Carla Fernandes Loveira Minister of Economy and Finance Ministry of Economy and Finance Avenida 10 de Novembro, No 929 Maputo Caixa Postal No 272 Mozambique Excellency: Re: Republic of Mozambique: Credit Number D265-MZ (Primary Health Care Strengthening Program) Fourth Amendment to the Financing Agreement We refer to the Grant Agreement (the “Agreement”) for the above-captioned Project between the Republic of Mozambique (“Recipient”) and the International Development Association (“Association”) dated February 12, 2018, as amended from time to time. We are pleased to inform you the Association agrees to your request and proposes to amend the Agreement as follows: (a) The table in Section IV.A of Schedule 2 to the Agreement is hereby deleted and replaced with the table in Annex 1 to this amendment letter. All other provisions of the Agreement, except as amended herein shall remain in full force and effect. Please confirm the Recipient’s agreement to the foregoing by signing and dating both copies of this letter of amendment and returning one fully countersigned copy to the Association. This amendment letter shall become effective on the date of its countersignature by the Recipient. [remainder of the page is left intentionally blank] -2- Sincerely, By: _________________________ Idah Z. Pswarayi-Riddihough Country Director for Mozambique Africa Region AGREED: REPUBLIC OF MOZAMBIQUE By: _______________________ Authorized Representative Carla Loveira Name:_____________________ Ministra das Financas Title:______________________ 27-Feb-2025 Date:______________________ -3- Annex Category Disbursement Linked Result Amount of the (including Grant Disbursement Linked (as applicable) Indicator as Allocated Disbursement applicable) (expressed in SDR) Calculation Formula (1) DLI #1: The Previous: Total of SDR FY2018 - No scalability Recipient has The Recipient has 6,779,260, of FY2019 – FY Allocated increased the Number increased the percentage which: Amount x [Actual of districts out of the of Institutional Achievement up to DLR 42 defined as lagging Deliveries in the 42 SDR 2,921,250 is 1.2 – DLR 1.1] / [DLR in the Investment Lagging Districts allocated in FY 1.2 – DLR 1.1] + Case, with at least 85 defined in the 2018; undisbursed amount from percent Institutional Investment Case previous targets met Deliveries. SDR 1,710,000 in DLR#1.1: The Recipient FY 2019; FY2020 - No scalability has increased the SDR 1,353,750 in FY2021 - FY Allocated percentage of FY 2020; Amount x [Actual Institutional Deliveries SDR 285,000 in FY Achievement up to DLR in 42 Lagging Districts 2021; and 1.4 – DLR 1.3] / [DLR to 66.8% 1.4 – DLR 1.3] + [FY 2018] SDR 509,260 in FY undisbursed amount from (Baseline: 66.1%) 2022. previous targets met FY2022 - FY Allocated DLR#1.2: The Recipient Amount x [Actual has increased the Achievement up to DLR percentage of 1.5 – DLR 1.4] / [DLR Institutional Deliveries 1.5 – DLR 1.4] + in 42 Lagging Districts undisbursed amount from to 81% previous targets met. [FY 2019] Revised: The Recipient has increased the number of districts, out of the 42 defined as lagging in the Investment Case, with at least 85 percent Institutional Deliveries DLR#1.3: The Recipient has increased the number of districts with at least 85 percent Institutional Deliveries to 29 [FY 2020] DLR#1.4: The Recipient has increased the number of districts with at least 85 percent -4- Institutional Deliveries to 32 [FY 2021] DLR#1.5: The Recipient has increased the number of districts with at least 85 percent Institutional Deliveries to 37 [FY 2022] (2) DLI #2: The DLR#2.3.1: The Total of SDR FY2020 – No scalability Recipient has Recipient has increased 3,135,000, of FY2021 - increased the the percentage of which: Secondary and 2.4.1: FY Allocated percentage of Technical Schools Amount x [Actual Secondary and offering sexual and SDR 712,500 is Achievement up to DLR Technical Schools allocated in FY2020 2.4.1 – DLR 2.3.1] / offering sexual and reproductive health for DLR#2.3.1 [DLR 2.3 – DLR 2.31] + reproductive health services to 19% undisbursed amount from services (information [FY 2020] (Baseline: 0%) previous targets met and contraceptive SDR 997,500 in FY methods) 2021 for 2.4.3: No scalability DLR#2.3.2: The DLR#2.4.1; 2.4.4: No scalability Recipient has completed FY2022 - FY Allocated a gaps identification of Amount x [Actual current training SDR 1,425,000 in FY 2022: Achievement up to DLR materials 2.4 – DLR 2.3] / [DLR [FY 2020] SDR 712,500 for 2.4 – DLR 2.3] + DLR#2.5.1; and undisbursed amount from DLR#2.3.3: The SDR 712,50 for previous targets met Recipient has finalized DLR#2.5.2 the harmonization of 2.5.2: No Scalability M&E Tools 2.5.3: No Scalability [FY 2020] DLR#2.4.1: The Recipient has increased the percentage of Secondary and Technical Schools offering sexual and reproductive health services to 40% [FY 2021] DLR#2.4.2: The Recipient has approved updated training materials [FY 2021] DLR#2.4.3: The Recipient has approved updated Adolescent and -5- Youth-Friendly Services (SAAJ) Guidelines [FY2021] DLR#2.5.1: The Recipient has increased the percentage of Secondary and Technical Schools offering sexual and reproductive health services to 50% [FY 2022] DLR#2.5.2: The Recipient has completed training for health providers and focal points on improved M&E tools [FY2022] (3) DLI#3: The The Recipient has met Total of SDR FY2018 - No scalability Recipient has the following targets for 3,765,740, of FY2019 – FY Allocated increased Couple Couple Years of which: Amount x [Actual Years of Protection Protection. Achievement up to DLR SDR 1,282,500 is 3.2 – DLR 3.1] / [DLR DLR#3.1: 2,135,012 allocated in FY 3.2 – DLR 3.1] + [FY 2018] 2018; undisbursed amount from previous targets met DLR#3.2: 2,336,463 SDR 997,500 in FY [FY 2019] 2019; FY2020 - FY Allocated Amount x [Actual SDR 356,250 in FY DLR#3.3: 3,190,000 Achievement up to DLR 2020; [FY 2020] 3.3 – DLR 3.2] / [DLR SDR 356,250 in FY 3.3 – DLR 3.2] + 2021; and undisbursed amount from DLR#3.4: 3,360,000 [FY 2021] SDR 773,240 in FY previous targets met 2022 FY2021 - FY Allocated DLR#3.5: 3,540,000 Amount x [Actual [FY 2022] Achievement up to DLR 3.4 – DLR 3.3] / [DLR (Baseline: 1,722,692) 3.4 – DLR 3.3] + undisbursed amount from previous targets met FY2022 - FY Allocated Amount x [Actual Achievement up to DLR 3.5 – DLR 3.4] / [DLR 3.5 – DLR 3.4] + undisbursed amount from previous targets met. -6- (4) DLI#4: The DLR#4.1.1: The Total of SDR FY2018 - No scalability. Recipient has Recipient has trained at 4,780,000, of FY2020 - FY Allocated increased the least 6 trainers, 100% of which: Amount x [Actual percentage of district nutrition Achievement up to DLR children between 0- representatives, and 30% 4.3 – Baseline] / [DLR 24 months of age of Community Health SDR 1,137,500 is 4.3 – Baseline] + receiving the Workers, and identified allocated in FY 2018 undisbursed amount from Nutrition 30% of volunteers, in 6 [with SDR 425,000 for DLR#4.1.1, and previous targets met Intervention Package of the 8 targeted provinces on the NIP SDR 712,500 for FY2021 - (NIP) in the 8 [FY 2018] DLR#4.1.2] 4.4.1: FY Allocated Provinces (Cabo Delgado, SDR 1,068,750 in Amount x [Actual Inhambane, Manica, DLR#4.1.2: The FY 2019; Achievement up to DLR Nampula, Niassa, Recipient has finalized SDR 1,253,750 in 4.4.1 – DLR 4.3] / [DLR Sofala, Tete and the Monitoring and FY 2020; 4.4.1 – DLR 4.3] + Zambezia) with the Evaluation System undisbursed amount from SDR 1,177,500 in prevalence stunting [FY 2018] previous targets met FY 2021; and of above 35 percent 4.4.2: FY Allocated DLR#4.3: The Recipient SDR 142,500 in FY Amount x [Actual has ensured that 15% of 2022. Achievement up to DLR children are benefiting 4.4.2 – Baseline] / [DLR from the Modified NIP 4.4.2 – Baseline] + [FY 2020] undisbursed amount from (Baseline: 0) previous targets met FY2022 - FY Allocated DLR#4.4: The Recipient Amount x [Actual has ensured that 30% of Achievement up to DLR children are benefitting 4.5 – DLR 4.4.1] / [DLR from the Modified NIP 4.5 – DLR 4.4.1] + [FY 2021] undisbursed amount from previous targets met DLR#4.5: The Recipient has ensured that 40% of children are benefitting from the NIP [FY 2022] (5) DLI#5: The DLR#5.1: Actual Total of SDR FY2018 - No scalability Recipient has Domestic Health 6,832,500, of which: FY2019 – FY Allocated increased the Expenditure as a Amount x [Actual Domestic Health percentage of total SDR 1,674,375 is Achievement up to DLR Expenditures as a Domestic Government allocated in FY 5.2 – DLR 5.1] / [DLR percentage of total Expenditure at least 2018; 5.2 – DLR 5.1] + Domestic 8.5% undisbursed amount from Government [FY 2018] SDR 1,603,125 in previous targets met Expenditures. (Baseline: 7.9%) FY 2019; FY2020 - FY Allocated SDR 1,603,125 in DLR#5.2: Actual Amount x [Actual FY 2020; and Domestic Health Achievement up to DLR SDR 1,951,875 in 5.3 – DLR 5.2] / [DLR Expenditure as a FY 2021. percentage of total 5.3 – DLR 5.2] + Domestic Government undisbursed amount from Expenditure at least previous targets met 8.5% -7- [FY 2019] FY2021 - FY Allocated Amount x [Actual DLR#5.3: Actual Achievement up to DLR Domestic Health 5.4 – DLR 5.3] / [DLR Expenditure as a 5.4 – DLR 5.3] + percentage of total undisbursed amount from Domestic Government previous targets met Expenditure at least 9% FY2022 - FY Allocated [FY 2020] Amount x [Actual Achievement up to DLR DLR#5.4: Actual 5.5 – DLR 5.4] / [DLR Domestic Health 5.5 – DLR 5.4] + Expenditure as a undisbursed amount from percentage of total previous targets met. Domestic Government Expenditure at least 9.5% [FY 2021] (6) DLI#6: The DLR#6.3.1: Actual Total of SDR FY2020 – Recipient has provincial expenditures 1,515,829, of 6.3.1:No scalability increased health in the Underserved which: Provinces from the Sub- 6.3.2: No scalability expenditures in historically Account Resources 6.3.3:No scalability increased to USD 9 SDR 615,000 is Underserved Areas FY2021 - million allocated in FY 2018 [FY2020] with (SDR200,250 6.4.: No Scalability. (Baseline: 0) for DLR#6.1.1; SDR FY2022 – 315,000 for 6.5.: No scalability DLR#6.3.2: Actual DLR#6.1.2; and district expenditures in SDR 99,750 for the Underserved DLR#6.1.3); Districts from the Sub- Account Resources SDR 385,829 in FY increased to USD 4 2019 with million (SDR300,250 for [FY2020] DLR#6.2.1; SDR (Baseline: 0) 85,579 for DLR#6.2.2); and DLR#6.3.3: Domestic Health Expenditures for the Underserved Areas SDR 515,000 in FY maintained as a share of 2020 with (SDR provincial and district 356,250 for Domestic Health DLR#6.3.1; SDR Expenditures 158,750 for [FY2020] DLR#6.3.2); (Baseline: 32% for Underserved Provinces and 16% in Underserved Districts in 2019) DLR#6.4: The Recipient has signed Results -8- Agreements with eleven provinces [FY 2021] (Baseline: 0) DLR#6.5: The Recipient has disbursed grants to 90% of primary health care facilities with internment in the three Underserved Provinces [FY2022] (Baseline: 0) (7) DLI#7: The The Recipient has met Total of SDR FY2018 - No scalability Recipient has the following 5,182,613, of FY2019 – increased the number percentages of Technical which: Health Personnel 7.2.1: FY Allocated of Technical Health assigned to the Primary Amount x [Actual Personnel assigned to the Primary Health Health Care Network: SDR 1,923,750 is Achievement up to DLR allocated in FY 7.2.1 – DLR 7.1] / [DLR Care Network DLR#7.1: 12,205 2018; 7.2.1 – 7.1] + undisbursed [FY 2018] SDR 1,567,500 in amount from previous (Baseline: 11,970) FY 2019; targets met SDR 1,121,363 in FY2020 - DLR#7.2.1: 15,431 FY 2021; and 7.3.1: FY Allocated [FY 2019] SDR 570,000 in FY Amount x [Actual 2022. Achievement up to DLR DLR#7.2.2: The 7.3.1 – DLR 7.2.1] / Recipient has increased [DLR 7.3.1 – DLR 7.2.1] the number of health + undisbursed amount facilities in the primary from previous targets met care network that have at 7.3.2: FY Allocated least two active maternal Amount x [Actual child health (MCH) Achievement up to DLR nurses to 688 7.3.2 – DLR 7.2.2]/[DLR [FY 2019] 7.3.2 – DLR 7.2.2]+undisbursed DLR#7.3.1: 15,566 amount from previous [FY 2020] targets met DLR #7.3.2: The FY2021 - Recipient has increased 7.4.1: FY Allocated the number of health Amount x [Actual facilities in the primary Achievement up to DLR care network that have at 7.4.1 – DLR 7.3.1] / least two active MCH [DLR 7.4.1 – DLR 7.3.1] nurses to 704 [FY 2020] + undisbursed amount from previous targets met DLR#7.4.1: 16,182 7.4.2: FY Allocated [FY 2021] Amount x [Actual Achievement up to DLR DLR#7.4.2: The 7.4.2 – DLR 7.3.2]/[DLR Recipient has increased 7.4.2 – DLR 7.3.2]+ -9- the number of health undisbursed amount from facilities in the primary previous targets met care network that have at FY2022 - least two active MCH 7.5.1: FY Allocated nurses to 728 Amount x [Actual [FY 2021] Achievement up to DLR 7.5.1 – DLR 7.4.1] / DLR#7.5.1: 17,153 [DLR 7.5.1 – DLR 7.4.1] [FY 2022] + undisbursed amount from previous targets met DLR #7.5.2: The Recipient has increased 7.5.2: FY Allocated the number of health Amount x [Actual facilities in the primary Achievement up to DLR care network that have at 7.5.2 – DLR 7.4.2]/[DLR least two active MCH 7.5.2 – DLR 7.4.2]+ nurses to 768 undisbursed amount from [FY 2022] previous targets met (8) DLI#8: The DLR#8.1: The Recipient Total of SDR FY2018 - No scalability Recipient has has designed and piloted 6,021,330, of FY2019 – FY Allocated demonstrated that hospital scorecards in 6 which: Amount x [Actual District/Rural District/Rural Hospitals, Achievement up to DLR Hospitals received which receive SDR 1,603,830 is 8.2 – DLR 8.1] / [DLR performance-based performance-based 8.2 – DLR 8.1] + allocations in allocations according to allocated in FY 2018; undisbursed amount from accordance with a their performance previous targets met minimum of two [FY 2018] SDR 1,781,250 in (Baseline: 0) FY 2019; FY2020 - FY Allocated scorecard assessments Amount x [Actual in the previous Fiscal SDR 855,000 in FY DLR#8.2: The Recipient 2020; Achievement up to DLR Year (FY). Has demonstrated that SDR 890,625 in FY 8.3 – DLR 8.2] / [DLR 29 (30%) of 8.3 – DLR 8.2] + 2021; and undisbursed amount from District/Rural Hospitals received performance- SDR 890,625 in FY previous targets met based allocations in 2022 FY2021 - FY Allocated accordance with a Amount x [Actual minimum of two Achievement up to DLR scorecard assessments in 8.4 – DLR 8.3] / [DLR the previous FY 8.4 – DLR 8.3] + [FY 2019] undisbursed amount from previous targets met DLR#8.3: The Recipient FY2022 – FY Allocated has demonstrated that 29 Amount x [Actual (or 30%) District/Rural Achievement up to DLR Hospitals received 8.5 – DLR 8.4]/[DLR 8.5 allocations based on – DLR 8.4] + undisbursed prioritized action plans amount from previous that respond to scorecard targets met evaluations [FY 2020] (Baseline: 0) -10- DLR#8.4: The Recipient has demonstrated that 31 (or 70%) District/Rural Hospitals received performance- based allocations in accordance with a minimum of one scorecard assessment in the previous FY [FY 2021] DLR#8.5: The Recipient has demonstrated that 44 (or 100%) District/Rural Hospitals received performance-based allocations in accordance with a minimum of one scorecard assessment in the previous FY [FY2022] (9) DLI#9: The DLR#9.1: The Recipient Total of SDR FY2018 - No scalability Recipient has has designed and piloted 8,372,420, of FY2019 – FY Allocated increased the health center scorecards which: Amount x [Actual number of health with community Achievement up to DLR centers in Priority consultations in at least SDR 2,137,500 is 9.2 – DLR 9.1] / [DLR Districts receiving 64 Rural Health Centers 9.2 – DLR 9.1] + allocated in FY performance-based in Priority Districts, undisbursed amount from 2018; allocations according receiving financial previous targets met to at least one allocations according to SDR 1,781,250 in FY 2019; FY2020 - FY Allocated scorecard assessment their performance [FY 2018] Amount x [Actual with community SDR 1,627,420 in Achievement up to DLR consultations in the (Baseline: 0) FY 2020; 9.3 – DLR 9.2] / [DLR previous FY. SDR 1,825,000 in DLR#9.2: The Recipient FY 2021; and 9.3 – DLR 9.2] + has demonstrated undisbursed amount from that 130 Rural Health SDR 1,001,250 in previous targets met Centers in Priority FY 2022. FY2021 - FY Allocated Districts receive Amount x [Actual performance-based Achievement up to DLR allocations according to 9.4 – DLR 9.3] / [DLR at least two scorecard 9.4 – DLR 9.3] + assessments with undisbursed amount from community consultations previous targets met in the last FY FY2022 - FY Allocated [FY 2019] Amount x [Actual Achievement up to DLR DLR#9.3: The Recipient 9.5 – DLR 9.4] / [DLR has demonstrated that 9.5 – DLR 9.4] + 186 Rural Health undisbursed amount from Centers in Priority previous targets met. Districts receive -11- financial allocations based on prioritized action plans that respond to scorecards evaluations [FY 2020] (Baseline: 0) DLR#9.4: The Recipient has demonstrated that 261 health centers in Priority Districts receive performance-based allocations according to at least one scorecard assessment with community consultations in the last FY [FY 2021] (Baseline: 0) DLR#9.5: The Recipient has demonstrated that 391 health centers in Priority Districts receive performance-based allocations according to at least one scorecard assessment with community consultations in the last FY [FY 2022] (Baseline: 0) (10) DLI#10: The The Recipient has Total of SDR FY2018 - No scalability Recipient has achieved the following 5,343,750 of which: FY2019 – FY Allocated increased the targets: Amount x [Actual number of trained Achievement up to DLR and active DLR#10.1: 4,723 APEs SDR 2,135,000 is trained and active allocated in FY 2018 10.2. – Baseline]/[DLR community health 10.2. – Baseline] + workers (Agentes [FY 2018] undisbursed amount from Polivalentes (Baseline: 3,380) SDR 1,604,375 is previous targets met Elementales - allocated in FY DLR#10.2: 6,523 APEs 2021; and FY2020 – APEs) trained and active 10.3.: FY Allocated [FY 2019] Amount x [Actual SDR 1,604,375 is Achievement up to DLR DLR#10.3: 6,690 active allocated in FY 2022 10.3. – DLR APEs 10.2.1]/[DLR 10.3.1- [FY 2020] DLR 10.2.] + undisbursed amount from previous DLR#10.4: 7,748 active targets met. APEs FY2021- [FY 2021] 10.4. FY Allocated Amount x [Actual Achievement up to DLR -12- DLR#10.5.1: 8,800 10.4. – DLR 10.3.]/ [DLR active APEs 10.4. – DLR 10.3.1] [FY 2022] +undisbursed amount from previous targets met DLR#10.5.2: 50% of FY2022 – APEs deliver services 10.5.1: FY Allocated according to quality Amount x [Actual standards Achievement up to DLR [FY 2022] 10.5.1 – DLR 10.4.]/ (Baseline: 28%) [DLR 10.5.1 – DLR 10.4.] + undisbursed amount from previous targets met. 10.5.2: No scalability (11) DLI#11: The The Recipient has Total of SDR FY2018 - No scalability Recipient has achieved the following 3,937,387, of FY2019 - FY Allocated increased the targets: which: Amount x [Actual percentage of deaths Achievement up to DLR certified in health DLR#11.1: 100% of SDR 1,068,750 is 11.2 – DLR 11.1] / [DLR facilities with data hospitals and 50% of allocated in FY 11.2 – 11.1] + on cause of death health centers use 2018; undisbursed amount from coded per ICD 10, MGDH to generate previous targets met reported in SISMA, information on causes of SDR 1,425,000 in death FY 2019; FY2020 - FY Allocated and the death record [FY2018] Amount x [Actual captured in SISMA SDR 873,637 in FY (Baseline: 70% of Achievement up to DLR Hospital Data 2020; hospitals and 0% of 11.3 – Baseline] / [DLR Management SDR 356,250 in FY 11.3 – Baseline] + Module (Módulo de health centers use 2021; and MGDH to generate undisbursed amount from Gestão de Dados SDR 213,750 in FY information on causes of previous targets met Hospitalares – 2022. MGDH). death) FY2021 - FY Allocated Amount x [Actual DLR#11.2: 70% of the Achievement up to DLR health centers use 11.4 – DLR 11.3] / [DLR MGDH to generate 11.4 – DLR 11.3] + information on the cause undisbursed amount from of death previous targets met [FY 2019] FY2022 - FY Allocated Amount x [Actual DLR#11.3.1: 50% of Achievement up to DLR deaths in health facilities 11.5 – DLR 11.4] / [DLR with internment and 11.5 – DLR 11.4] + certified by a doctor or undisbursed amount from qualified clinician with previous targets met the cause of death coded using ICD10, and the death record captured in the SISMA MGDH [FY 2020] (Baseline: 0) -13- DLR#11.3.2: 15% of deaths registered, certified, and captured in the civil registration system (SiRCEV) within one year of their occurrence [FY 2020] (Baseline: 0) DLR#11.4.1: 60% of deaths in health facilities with internment and certified by a doctor or qualified clinician with the cause of death coded using ICD10 or ICD 11, and the death record captured in the SISMA MGDH [FY 2021] DLR#11.4.2: 20% of deaths registered, certified and captured in the civil registration system (SiRCEV) within one year of their occurrence [FY 2021] DLR#11.5.1: 70% of deaths in health facilities with internment and certified by a doctor or qualified clinician with the cause of death coded using ICD10 or ICD 11, and the death record captured in the SISMA MGDH [FY 2022] DLR#11.5.2: 25% of deaths registered, certified, and captured in the civil registration system (SiRCEV) within one year of their occurrence [FY 2022] (12) DLR #12: The The Recipient has Total of SDR FY2021- FY Allocated Recipient has increased achieved the following 1,334,171, of which: Amount x [Actual the average availability targets: of tracer essential -14- maternal and DLR#12.4: Expansion of SDR 712,500 is Achievement up to DLR reproductive health the Sistema de allocated in FY 12.4] medicines at primary Informação, Gestão, e 2021; and FY2022-No scalability health care facilities. Logística das Unidades SDR 621,671 in FY Sanitárias (SIGLUS) to 2022 85% of health facilities [FY 2021] DLR#12.5.1: Approval by the Cabinet of a decree granting the Central de Medicamentos e Artigos Médicos (CMAM) autonomy to enable an optimized single command structure [FY 2022] DLR#12.5.2: Implementation of outsourcing of last mile transportation and distribution of medicines [FY 2022] TOTAL AMOUNT 57,000,000