[PDF] A Mining Health Initiative case study: - Kenmare Resources PLC

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1 Kenmare Resources PLC and its health initiatiǀe in

Lessons in Partnership and Process

January 2013

2

FUNDING

The Mining Health Initiative is grateful to the following organisations and foundations for the financial support that made this project and this case study possible.

CONSORTIUM

The Mining Health Initiative is implemented by a consortium comprising the following organisations and institutions. 3

CONTENTS

FUNDING ................................................................................................................................................. 2

CONSORTIUM .......................................................................................................................................... 2

ACRONYMS ............................................................................................................................................. 5

EXECUTIVE SUMMARY ............................................................................................................................ 6

1. BACKGROUND AND PURPOSE OF THE CASE STUDY ....................................................................... 8

2. CASE STUDY METHODOLOGY ......................................................................................................... 9

3. SITUATION ANALYSIS ...................................................................................................................... 9

3.1. Company profile ...................................................................................................................... 9

3.2. Demographic profile ............................................................................................................... 9

3.3. Health status ......................................................................................................................... 11

3.4. Health system: structure, functionality and accessibility ..................................................... 12

3.5. Projects ................................................................................................................................. 14

3.6. MoH Strategic Priorities ........................................................................................................ 14

4. PROGRAMME CHARACTERISTICS .................................................................................................. 14

4.1. Conception process ............................................................................................................... 14

4.2. Description of the health programme (employee and community) .................................... 16

4.3. Plans for wider impact .......................................................................................................... 18

4.4. Partnership (including government): structure and functionality ........................................ 19

4.5 Governance, monitoring and oversight process ......................................................................... 22

4.6 Financing ............................................................................................................................... 22

5. PROGRAMME COSTS ..................................................................................................................... 22

5.1. Employee services ................................................................................................................. 22

5.2. Community services .............................................................................................................. 23

5.3. Cost effectiveness ................................................................................................................. 24

6. PROGRAMME BENEFITS AND IMPACT .......................................................................................... 24

6.1. Employees and families ........................................................................................................ 24

6.2. Communities ......................................................................................................................... 25

6.3. Mining company ................................................................................................................... 26

6.4. Local government and health system ................................................................................... 27

7. STAKEHOLDER PERSPECTIVES ....................................................................................................... 28

4

7.1. Beneficiaries .......................................................................................................................... 28

7.2. Partners (including government) .......................................................................................... 30

8. ANALYSIS OF PROGRAMME STRENGTHS ...................................................................................... 30

8.1. Strategic issues ...................................................................................................................... 30

8.2. Operational issues ................................................................................................................. 32

Annex A: Case study information sources ............................................................................................ 33

Annex B: Further information on findings of a 2008 baseline survey in malaria and maternal health 34

Annex C: How the KMAD programme responds to MoH strategic priorities ....................................... 36

5

ACRONYMS

ANC Antenatal care

ARI Acute respiratory infection

CHW Community health worker

DHS District Health Service

DHT District Health Team

HANSHEP Harnessing non-state actors for better health of the poor

HIV Human immunodeficiency virus

I-SOS International SOS

IPTp Intermittent preventative treatment in pregnancy

IRS Indoor Residual Spraying

KMAD Kenmare Moma Development Association

LLIN Long-lasting Insecticidal Net

MDG Millennium Development Goal

MMR Maternal Mortality Rate

MoH Ministry of Health

MOU Memorandum of Understanding

NGO Non Governmental Organisation

NHS National Health Service

PPP Public-Private Partnership

PSI Population Services International

RDT Rapid diagnostic test

SEDE Health and Development in the Workplace

STI Sexually Transmitted Infection

TB Tuberculosis

TBA Traditional birth attendant

6

EXECUTIVE SUMMARY

Kenmare Resources plc is an international mining company whose primary activity is the operation of the Moma Titanium Minerals Mine in northern Mozambique. The company has been active in Mozambique since the mid-1980s, conducted feasibility studies on the Moma mine area in 2001, commenced construction of the mine in 2004, and turned its first profit in 2011. Kenmare contracts service providers directly to ensure quality preventative and curative care is available to its workforce. International SOS (I-SOS) provides health services to Kenmare employees and contractors through a health centre at the Kenmare accommodation site. Medical evacuation is provided when necessary to South Africa. Employees also receive 2 long-lasting insecticidal nets

(LLINs) per year and 1 can of insect repellent per month. Population Services International (PSI) have

recently been contracted to provide HIV education and prevention services to employees. Kenmare conducts indoor residual spraying (IRS) within the Kenmare accommodation site. These employee services benefit an average monthly workforce of around 1,700 at an annual cost of approximately

US$880,980 or US$513 per employee per year.

For the community in the locality immediately adjacent to the mine, called Topuito, Kenmare includes a health component within its wider social responsibility programme that also supports a well-developed livelihoods programme. Activities are run by sub-contractors which are managed by

either Kenmare directly or, as is more often the case, by the not-for-profit independent organisation,

Kenmare Moma Development Association (KMAD). Health services of the programme include: fortnightly medical and dental clinics at five Ministry of Health (MoH) health centres in Moma district; a new health centre currently under construction, which will become a formal MoH health centre and the only one in Topuito locality; community-based HIV awareness and prevention programming and IRS for malaria prevention. While good population data are unavailable, a best approximate cost of per person benefiting, given that all locality residents benefit in some way, is calculated at 20,152 people benefitting at an annual cost of US$16 per person.1 The case study is unable to explore the direct impact of the programme on the health status of those

benefiting given a lack of data on the health of the communities or a sufficiently long period of data

on the workforce. Kenmare plans to improve this data collection. Strategic lessons can be drawn from the success the company has had in building partnerships:

1. The conception and design process should and can be responsive, balance community and

company needs and promote sustainability ƒ Kenmare managed to achieve a balance in its programme design, recognising the need to respond to community and government priorities, yet also to address the likely health needs relevant to the company and assuming responsibility for the effects of the mine on surrounding areas. ƒ Kenmare deliberated carefully prior to finalising its health care programme, wanting to ensure sustainability of interventions through coordination and integration with the national

1 Population figures for Topuito locality are calculated by the Moma District Administration

7 health system (NHS), and in consultation with communities. The new KMAD strategic plan has been an important opportunity to build on and clearly articulate this commitment to sustainability, though exit strategies remain to be defined in existing support and geographical areas. Scale-up needs also must be considered, taking advantage of the considerable lessons learned in the initial three years. ƒ Kenmare has prioritised strengthening the public health system with a view to the most likely route to sustainability. While they have prioritised the need for immediate impact on malaria above the need for sustainability - the IRS programme is not sustainable beyond Kenmare' support - they commit to continuing the IRS as needed as long as they remain operational in the area, which is expected to be in the long term. ƒ Attempting to build co-financing relationships with NGOs and fellow donors has shown some results. More may be shown in the medium term to be an effective way of widening the impact of the programme and improving sustainability of interventions.

2. Strong and effective partnerships can be built through careful fostering of relationships, clearly

defined responsibilities and methods of holding partners to account ƒ In line with their desire for sustainability, Kenmare has forged a strong partnership with government at all levels from the outset. Including provincial and district health and administrative authorities from the planning stage, ensuring clear and mutually acceptable MOUs are in place and maintaining regularly contact shows how strong relationships can be built. Useful lessons for best practice guidance can also be drawn from some of the gaps in Kenmare's approach:

1. Well thought through and designed monitoring and evaluation is important to support the case for

rational and continued funding by the company or others. ƒ Collection of data on the relationship between workforce health and productivity, the health of the workforce and supported communities and the performance of cost-benefit analyses would be hugely valuable to Kenmare, KMAD, the NHS and the wider international health and development community.

2. Formal health impact assessments would add validity and assist in cost-benefit predictions.

ƒ As a component of the strategic planning stage, would give robust information to allow rational decision making on the appropriate size of financial commitments to health interventions. 8

Descriptive

components portray how the mining company works to influence health by: (i) fostering understanding of the context in which the programme was conceived and in which day to day practicalities are faced. (ii) documenting the detail of the programme, how it came about, its scope, operational modalities and costs.

Analytical components

explore the process taken and its effects by: (i) examining challenges, barriers and successful responses. (ii) exploring achievements, impact and cost-benefit ratio. (iii) examining the potential of the approach in the short and longer term. Figure 1. Objectives of the descriptive and analytical components of the case studies

1. BACKGROUND AND PURPOSE OF THE CASE STUDY

health of the poor' (HANSHEP) group to build understanding of, and foster agreement on standards for, mining industry public-private partnerships (PPPs) which work to strengthen health services for underserved populations. The Mining Health Initiative will lead to enhanced understanding of on- going mining health PPPs and a set of good practice documentation of mining health programmes for wide dissemination and application. The Mining Health Initiative had conducted a number of case studies of health programmes run by mining companies in sub-Saharan Africa. The purpose of the case studies is to document the reach and impact that has been achieved through such projects and examine the best ways in which these programmes can overcome practical challenges and achieve maximum effectiveness both in terms of costs and efficacy. The case studies have both descriptive and analytical components (Figure 1). There are a number of key audiences for the case studies with varying intended impacts: The Mining Health Initiative and HANSHEP. Intended impact: improved understanding of the scope, potential and most effective approaches for mining health PPPs; to inform the

Mining Health Initiatiǀe's Phase III.

The donor community. Intended impact: increased awareness of the potential for mining health PPPs as approaches to improving the health of hard to reach populations. The mining sector. Intended impact: increased awareness of the range of potential approaches and the opportunities for increasing impact and cost-effectiveness. Other health sector organisations. Intended impact: increased awareness of the opportunities for mining PPPs and of how best such partnerships may work. 9

Box 1. Basic demographic details

2. CASE STUDY METHODOLOGY

This case study was conducted by a team of two international public health experts. Data collection was undertaken through a i) review of documents, ii) review of health data national, local and company health centre, iii) key informant interviews with company and partner and iv) focus group discussions with community representatives. Details are shown in Annex A.

3. SITUATION ANALYSIS

3.1. Company profile

Kenmare Resources plc is a member of the FTSE

250 Index and has a primary listing on the London

Stock Exchange and secondary listing on the Irish

Stock Exchange. Kenmare operates the Moma

Titanium Minerals Mine, located in Topuito

locality, Moma District, Nampula Province, on the north eastern coast of Mozambique (Figure 2).

The mine contains reserves of heavy minerals,

including titanium minerals ilmenite and rutile (used in the production of paint and plastics) and the relatively high-value zirconium silicate mineral, zircon (used in the production of ceramics and tiles). Annex B includes further details on the Kenmare mine production process. Following feasibility studies in 2001 and subsequent negotiations with the Government of Mozambique, Phase I of mine construction began in August 2004. Low capital and operating expenses, due in part to a dedicated port facility immediately adjacent to the mine, have allowed Kenmare to progress rapidly to Phase II, a 50% expansion currently under construction. The expansion is expected to be commissioned in the last quarter of 2012, with expanded capacity coming online during 2013. Phase III pre-feasibility studies are underway. Given the size of the ore reserves and projected production following Phase II, Kenmare could mine in Moma for a further 160 years; no phase out of operations is currently under discussion. In 2011, revenue from the mine was US$167.5 million, with profit after tax of US$23.7 million - Kenmare's first profit on the mine. Howeǀer, due to heavy investment and start-up costs, Kenmare carries extensive current and non-current liabilities. There are considerable monthly fluctuations in staffing levels depending on the number of subcontractors employed. At the end of March 2012, Kenmare's mine staffing levels stood at 1,037 employees, of which 898 were national staff and 139 international staff. A further 678 were employed by sub contractors, most of who are working on the mine expansion project. Small offices are maintained in Maputo (6 staff, including the country manager) and the provincial capital, Nampula (5 staff).

3.2. Demographic profile

Box 1 shows basic demographics (see Annex C for details).

Figure 2. Location of Kenmare Moma Titanium

Minerals Mine

Population Figures :

Mozambique National: 23.7m

Nampula province: 4.6m

Moma district: 348,101 Topuito locality: 20,152 1

2012 extrapolations from 2007 census

National growth rate: 2.3%

National % urban-dwelling: 28% 2

1Moma District Office; 2UNICEF Mozambique.

10 In Moma district, Macua is the predominant language. Portuguese is taught in schools, but only 7 per cent of women and 28 per cent of men speak it.

Illiteracy remains high, at 64.5 per cent of those aged 15 and older (95 per cent of women and 75 per

cent of men). Of the economically active population, 96 per cent are engaged in informal work or family farming, with only 4 per cent earning a salary. Women comprise only 4 per cent of this salary-earning figure.

Development status

Since peace was established in Mozambique in 1992, political stability and rapid economic growth Nevertheless Mozambique is ranked 184 out of 187 countries on the UNDP Human Development Index2. Reductions in extreme poverty and hunger (Millennium Development Goal or MDG 1) are being achieved, with the proportion of Mozambicans living below the national poverty line dropping from 69 per cent in 1997 to 54.7 per cent in 20093. However, this is lower than the country's 2009 target in its poverty reduction strategy and may mean Mozambique is unlikely to reach the 2015 goal. As measured by the national poverty index, the level of food poverty is slightly below 55% of the population. Nampula province is in line with the national average with 54.7 per cent food poverty. Universal primary education (MDG 2) is unlikely to be achieved nationally4 and in the programme area in 2005 only 21 per cent of the district population was attending or has attended school.5

Transport access and community infrastructure

Moma district relies on the regional road links to the provincial capital and Angoche district, which

are partly tarmac but have not been maintained. All other link roads in the district are non-classified,

in very poor condition and not maintained.

A typical rural house (Figure 3) has a pounded earth floor, thatch roof and walls of reed or sticks and

no electricity.

93.6 per cent of families in Moma district have no access to a latrine, and 74 per cent access water

through open wells. Inequalities in access to basic social services are seen between urban and rural areas, by gender and socio-economic status. Women, children, the elderly, disabled and chronically-

2 UNDP Human Development Indicators. http://hdrstats.undp.org/en/countries/profiles/MOZ.html. Accessed 3 May 2012.

3 Plano de acção para redução da pobreza (PARP) 2011-2014 - Government of Mozambique Poverty Reduction Strategy

Paper; Maputo 3 May 2011. The national poverty line in Mozambique is 18 meticais, or about US$0.50, far lower than the

MDG indicator of less than $1.25/day.

4 UN Mozambique, 2008. http://mz.one.un.org/eng/What-we-do/About-the-Millennium-Development-Goals/MDGs-in-

Mozambique

5 Perfil do Distrito de Moma, Província de Nampula, Ministério de Administração Estatal, República de Moçambique, Edição

2005

Figure 3. Typical rural house in Moma

District

11

Box 2. Selected national health indicators

ill are most at risk.6

3.3. Health status

National and provincial level

Despite significant improvements since 2000

and 3.5 per cent of GDP spent on the NHS, health care in Mozambique remains highly inadequate. The health status of the population is lower than in other countries in the region.

Maternal, neonatal, infant and child mortality

rates remain high (Box 2). The maternal mortality (MMR) remains amongst the highest ratios in the world, at 500/100,000 and Mozambique is unlikely to meet the 2015 targets for MDG 5, improved maternal health. While Mozambique may achieve its target to halt and reduce the burden from HIV and malaria (MDG 5), it will not achieve MDG 4, reduced childhood mortality, without more substantive progress in malaria control.

According to national statistics, major causes of mortality include malaria, HIV, tuberculosis (nearly

30 per cent of TB-patients are co-infected with HIV), anaemia, sexually transmitted infections (STIs),

intestinal parasites, acute respiratory infections (ARI) and malnutrition. Over a quarter of total deaths are attributed to malaria7 which also accounts for 48 per cent of total outpatient consultations. Nampula province has far lower HIV prevalence than the national average, at 4.6 per cent8.

In children under five, more than 80 per cent of deaths are caused by preventable infectious diseases

- the four main causes are shown in Table 1. As well as being the primary cause of under-five

mortality, malaria causes a massive burden of illness in this age group, with 68 per cent of hospital

admissions in children under five due to malaria. Malnutrition also remains a concern, many children suffer or die due to low birth weight and one in five children under five (41 per cent) are underweight for their age or are chronically malnourished.9 Table 1. Main causes of under-five mortality at national and provincial level

Administrative Level Diarrhoea AIDS Malaria ARI

National 6.7 9.8 33.2 10.1

Nampula 8.0 9.5 33.8 8.1

Source: 2009 National Child Mortality Survey

6 PARP 2011-2014

7 MOH 2011

8 INSIDA survey preliminary report, Institute of Health, Ministry of Health 2009

9 Plano Estratégico Sector da Saúde 2007-2012 (PESS), Ministério da Saúde March 2008

HIV prevalence (14-59y): 11.5% 1 Infant mortality rate: 92/1,000 live births 2 <5 mortality rate: 135/1,000 live births 2 Maternal mortality ratio: 550/1,000 live births 3 Life expectancy at birth: 50y

1INSIDA survey preliminary report, Institute of Health, Ministry

of Health 2009

2UNICEF Mozambique

3Human development report, 2011

12 The Ministry of Health has made significant effort to roll out measures for malaria prevention, including IRS, LLINs and intermittent preventative treatment for pregnant women (IPTp), diagnosis (rapid diagnostic tests or RDTs) and microscopy) and treatment. Good progress is also being made in immunization coverage. The Extended Programme on Immunisation reached 65 per cent of infants from 12-23 months in 2011; in Nampula province 66.3 per cent of children were reached.10

Moma District and Topuito Locality

Data on health indicators specific to Moma and Topuito are scarce, though it is likely that the

mortality and morbidity profile is similar to those at Provincial level, or slightly worse due to the

largely rural population of the District. Data available for Moma District are shown in Table 2. One recent survey, conducted in 2008 to inform Kenmare's malaria intervention11, provides data specific to malaria and maternal health. This survey showed that, among women age 15-49 who had a birth in the last 5 years, only 43.8 per cent made the recommended four or more ante-natal care (ANC) visits, though 75% attended at least twice and 87.6 per cent at least once. Only 37.2 per cent of pregnant women took any medicine during their pregnancy. 25.5 per cent took at least one dose

of IPTp, and 14.6 per cent received two or more doses. In the Topuito area, less than a third (27%) of

women seeking antenatal care reached the health facility within two hours, and 73 per cent needed more than two hours. Only pregnant women in Pilivili (85 per cent) reached ANC in less than an hour.

First Aid Posts at Pilivili and Larde were the most accessed facilities. The major mode of travel to ANC

services was on foot (80.3 per cent) otherwise it was by bicycle. Knowledge of the cause and signs of

malaria were reasonable though understanding of the feasibility and importance of prevention measures was low. Further information on findings is shown in Annex D.

3.4. Health system: structure, functionality and accessibility

Structure

administrative and public health delivery system consists of a national-level responsible for health

sector policy and strategic direction and a provincial level, providing technical and policy oversight to

the operational level (districts). At district level, basic health programme planning and implementation takes place. The District Health Team is in charge of all health services provided at district and community level. On average, the District serves a population of 100,000 inhabitants, but there are extremes ranging from 10,000 to 400,000. Health services in Mozambique are provided at several levels, both formal and informal: In rural areas, traditional healers and herbalists provide the first link in the chain of access to health care and referral in the country. These are supplemented by community health workers (CHW) and traditional birth attendants (TBAs). Primary - first aid posts and health centres, providing basic diagnosis and care;

10 Moçambique Inquérito Demográfico da Saúde 2011, Relatório Preliminar, Instituto Nacional de Estatística & Ministério

da Saúde

11 Kenmare Resources, Malaria Assessment Report, October 2008

13 Secondary - consisting of rural and district hospitals, the first reference level providing improved diagnostics as well as surgical and obstetric services; Tertiary - second reference level providing improved diagnostic and care service and acting as training centres, and Quaternary - consisting of central hospitals in Maputo, Beira and Nampula; these are the major referral centres for southern, central, and northern Mozambique, respectively. The private sector for health care is not well-developed in Mozambique - the 2003 DHS, which

provides the most recent figures in advance of the release of the 2011 DHS statistics, estimates that

the private sector provides about 16.1 per cent of healthcare nationally.12

Functionality and accessibility

A main reason for poor health outcomes in Mozambique is accessibility to health services. An estimated 36 per cent of the population has access to health services, defined as being within 45 minutes' walk of a health facility. This may be an important factor in the high MMR; institutional deliveries remain low at 54 per cent in 2011, with a marked difference between rural (44 per cent) and urban (80 per cent) areas. The aggregated percentage for institutional births in Nampula province was 55 per cent.13 The referral system does not function well and patients frequently present at any level of health facility. Reasons for this include low staff skills and motivation, staff and drug shortages, poorly

equipped and maintained health facilities and long distances to health facilities. Patients requiring

referral to a higher level of health service are often responsible for covering the cost of their own

transfer.

Although the MoH is committed to increasing access to health services, as well as their efficiency and

quality nationwide, weak health infrastructure and a shortage of healthcare workers are formidable obstacles. The public health sector is by far the largest provider of health services in Mozambique, yet it is estimated only about 50й of the country's population readily accesses these.14 Nationally, the percentage of the population with access to a health facility within 45 minutes on foot increased from 55 per cent to 65 per cent between 2002-3 and 2008-9. Most progress was noted in rural areas, particularly in northern Mozambique. In urban areas, there was rather a reduction in those with access within 45 minutes on foot - a reflection of rapid urban expansion.

Access to health care remains a serious challenge for the population in Moma District. In 2008, there

were 0.41 beds per 1,000 inhabitants and a total of 44 general and 87 maternity beds.15 Nampula central hospital, 250km and >7h travel time away from Topuito, is the reference hospital for Moma district. Moma district has one hospital (75 Km by road from Topuito locality) and 11 health centres serving a population of >340,000. 17 first aid posts will soon be active, manned by MoH trained community volunteers who will provide basic first aid. Topuito locality has two (currently unmanned) first aid posts and no health centres. One village in Topuito has a TBA.

12 Mozambique Demographic and Health Survey, 2003.

13 Ibid.

14 PARP 2011-2014

15 Moma 2008, Estatisticas do Distrito, Instituto Nacional de Estatistica 2010

14 Access to health care in Moma District is also hampered by poor availability of drugs at MoH health facilities. It was not possible to assess the level of stock outs of essential medicines within Moma district or Topuito locality, however, verbal reports suggest significant supply chain problems and periods of stock outs in the district in excess of 3 months in 2011. The MoH has faced increasingly

serious difficulties in its procurement and logistics services, which have resulted in nationwide stock

outs of medicines at different levels of the health system. In 2011, many medicines were discovered stockpiled in Maputo, and others have accumulated at provincial or district level - while direct service providers have faced stock outs.

3.5. Projects

Prior to Kenmare's moǀe to support community health in Topuito locality the only health proǀider

was the MoH. In the wider District, there are more organisations active, including Save the Children,

Elizabeth Glaser Paediatric AIDS Foundation, and two USAid-funded projects.

3.6. MoH Strategic Priorities

The health sector strategic plan states the central concern of the Government of Mozambique is to improve equitable access to essential health services.16 The guiding principles of the plan are summarized in Box 3.

Box 3. MoH Strategic Priorities

Emphasis on primary health care and community involvement Equity and social protection for vulnerable groups. Focus areas include neonatal and infant care, sexual and reproductive health, infectious diseases, and non-infectious diseases e.g. diabetes, asthma. Universal access to health care and services. Focus areas include HIV transmission prevention, testing and treatment services, malaria prevention and treatment services and

ANC and maternity services.

Community mobilisation and involvement. Standardisation of services provided by CHWs has been prioritised; the primary focus will be on promoting better health at community level, with a focus on prevention and control of infectious diseases, child and reproductive health.

Institutional and human resource development

Promotion of partnerships, local and international collaboration

Development of healthy life styles and behaviours

Advocacy

4. PROGRAMME CHARACTERISTICS

4.1. Conception process

In 2004, prior to construction of the mine and initiation of operations, Kenmare established KMAD, a not-for-profit independent organisation through which its social responsibility programme is run.

16 PESS 2007-2012

15 KMAD supports and contributes to the development of the communities close to the Mine, assisting community members to improve their livelihoods and wellbeing'.17 Prior to 2007, KMAD's health actiǀities in the community were limited to a focus on HIV awareness and prevention (in coordination with the Mozambican NGO Development Aid from People to People) and ad hoc logistical and financial support to the MoH for routine vaccination and other health campaigns in the District. In 2007 KMAD undertook a formal strategic planning process, to develop an implementation plan covering the 2008 - 2013 period. Consultation with the District Health Teams (DHTs) and the communities was undertaken, though there was no formal health impact assessment. During the strategic planning process, KMAD identified two focus areas for activities - economic

livelihoods and well-being. Health falls under the well-being category. However, it is notable that the

livelihoods programme, which includes an agricultural component, also has the potential to impact the nutrition of the local population, though this has not yet been documented. The mine also

brought the electrical grid to Topuito locality, again also likely impacting quality of life for local

residents. Notwithstanding these additional health-related factors, the health component of the strategic plan was developed, as far as possible, in line with the following principles: ƒ Adherence to national MoH strategic priorities (Box 3 in previous section) ƒ This was achieved through a focus on these priorities by the KMAD team and the DHT

ƒ Response to expressed community needs

ƒ Extensive community consultation was included in planning process

ƒ Response to expressed needs of the DHT

ƒ Extensive consultation was included in the planning process and the DHT reviewed drafts of the strategic plan ƒ Response to main health issues likely to impact on Kenmare's work force. Achieving appropriate balance between these principles was sometimes challenging. Malaria was considered highly likely to result in considerable lost work days per year given the high malaria prevalence in the area and the fact that many employees were likely to be drawn from, and live in, the surrounding communities. Malaria control would need to be a key component of the plan despite not being expressed as a priority by communities. The likelihood of the mine's actiǀities increasing the relatively low HIV prevalence in the area, through increased disposable income in surrounding communities and flows of migrant workers meant that HIV control was an important component to minimised the health impact of the programme, despite it not being a current priority for communities.

The most obvious and pressing need in the area was that of health care provision. This was identified

as the priority for the health component of the social responsibility programme and responding to this would address the main community and district priorities, and a number of national MoH

17 Kenmare Company Community Interaction. http://www.kenmareresources.com/responsibilities/company-community-

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